NC: Behavior Change Strategies (2007-2008)

Study Design:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

The purposes of the study were

  1. To identify individuals who expressed a desire to improve their nutrition practices and examine their degree of success
  2. To examine the impact of goal-setting instruction on nutrition-related behaviors when the emphasis is on free goal choice.
Inclusion Criteria:
  1. Enlisted military personnel working at Walter Reed Army Medical Center (e.g., private, corporal, specialist, sergeant)
  2. Answers on a Life-Style Assessment Questionaire identified individuals who desired to make one or more changes in dietary habits.
Exclusion Criteria:
  • Non-military personnel
  • Army officers (initially recruited, but later excluded due to low response rate)
  • Army weight control program participants
  • Answers to Life-Style Assessment questionaire did not indicate desires to change any nutrition behaviors.
Description of Study Protocol:


Study publicized via administrative meetings and classes and the Walter Reed Medical Center newspaper.


  • Subjects were randomly assigned to three groups with different levels of intervention: Goal-Setting/Goal Attanment (GSGA) group, the Goal-Setting (GS) group and the Control group
  • At the end of six months, change scores for nutrition-related goals were evaluated and the groups were compared.

Blinding Used

  • Participants knew that they were enrolled in an employee wellness study
  • They were unaware that change in nutrition-related behaviors were the only things actually being studied
  • Raters evaluated changes in all areas and were blinded to the fact that just nutrition changes were being studied. 


  • The GSGA group received eight group sessions and four individual sessions to learn goal-setting and goal-attainment techniques
  • The GS group received one group session and one individual session to learn how to set goals (purpose was to evaluate the effects of goal-setting alone
  • The control group received no intervention.

Statistical Analysis

  • The Statistical Package for the Social Sciences was used to data analysis
  • Analysis included descriptive statistical information on the three treatment groups and analysis of variance (ANOVA) on mean Change Scores for the three groups
  • Inter-rater reliability was also computed for a comparison of the subjects; self-scoring of the change with the raters' Change Scores.
Data Collection Summary:

Timing of Measurements

  • Recruitment and screening took place over the first three months, the work-site health promotion program was administered in the following two months and evaluation occurred during the sixth month
  • The screening questionaire was given to individuals as they were recruited during the first three months
  • The follow-up questionaire was given during the sixth month (one month after the intervention ended).

Dependent Variables

Change score for nutrition-related behaviors

  • -1: Behavior worse than before
  • 0: No change
  • +1: Expected level of success
  • +2: More than expected success
  • +3: Best anticipated success.

Independent Variables

Group assignment.

Control Variables


Description of Actual Data Sample:
  • Initial N: 77 (number of men and women not reported)
  • Attrition (final N): 60 (42 women). Seven dropped out of the study and 10 did not complete final questionnaires.
  • Age
    • GSGA group: 25±4.7 years
    • GS group: 24±6.2 years
    • Control group: 24±3.8 years.
  • Ethnicity: Not given
  • Other relevant demographics: Not given
  • Anthropometrics: Not given
  • Location: Walter Reed Army Medical Center.
Summary of Results:


GSGA Group

GS Group

Control Group

Statistical Significance of Group Difference

Nutrition Change Score Self-Rating





GSGA vs. Control: P<0.05
GS vs. Control: NS

Nutrition Change Score Composite Rating (Average of Rater's and Counselor's Scores)




GSGA vs. Control: P<0.05

Other Findings

  • The inter-rater reliability between change score ratings of the independent rater and counselor was 0.95, as was the reliability between the two raters. This indicates a high degree of consistency between raters as to what constitutes "desirable nutrition change."
  • The composite change scores compared to the self-change scores showed a correlation coefficient of 0.55. This was due to self-ratings of what participants perceived as "improvements," but were considered undesirable by counselors and raters (e.g., one subject described as improvement, "I skip lunch; I work through the lunch break five times a week." Both counselor and rater agreed this was nutritionally undesirable and rated it -1).
  • Frequency data indicate that dietary improvements were attained (change score of +2 or +3) by 84% of the GSGA group, 64% of the GS group and only 37% of the control group.
Author Conclusion:
  • If a patient chooses goals that he can see himself achieving, he is much more apt to be successful, rather than working toward a goal that a health professional set for himThe use of self-set goals in health promotion presents problems with evaluation, as there is not always a physiologic outcome to measure as an indicator of success
  • For this study, the Goal Attainment Scaling system ("Change Scores") was quite flexible and relevant for evaluating nutrition-related behaviors
  • The high level of agreement between the raters in this study suggests that the Goal Attainment Scaling tool is useful for quantifying and documenting diet-related behavioral change
  • Further research into goal-setting, goal commitment and motivations, as it relates to goals, is necessary in order to refine our effectiveness as health and nutrition counselors
  • The interpretation of these findings is limited because there was a small sample and the groups did not have the same frequency of contact
  • The trends observed, however, suggest several interesting areas for future study:
    1. Further evaluation of various goal-setting approaches is recommended, as are further studies in the area of free goal choice
    2. Goal Attainment Scaling offers new possibilities for documenting and evaluating dietary change. The development and evaluation of Goal Attainment Scales in other research endeavors is encouraged.
  • The comparison of Goal Attainment Scale ratings with corresponding physiological measures is recommended to examine associations between self-reports of behavior and physiological outcomes.
Funding Source:
Government: US Army
University/Hospital: University of Pittsburg, Virgina Commonwealth University, Pennsylvania State University
Reviewer Comments:
  • This is a simple study that shows that motivated individuals, who set their own nutrition goals and receive instruction in both goal-setting and goal attainment can be very successful
  • The author points out the limitations of this particular study, which I think increases its value
  • The findings of this 19-year-old study go along with later research in the area of motivational interviewing, which has been shown to be a very good method of helping individuals to establish and work toward health-related goals.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? N/A
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? No
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) ???
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? No
  4.4. Were reasons for withdrawals similar across groups? ???
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? Yes
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? Yes
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? No
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? No
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes