EAL

FNOA: Aging Programs (2012)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To document the Eat Better Move More (EBMM) program's effectiveness in a variety of community sites.

Inclusion Criteria:

OAA Nutrition Program Sites to be awarded grants were those that had:
- No existing physical activity program
- The ability to recruit 50 to 100 participants
- The capacity to collect and electronically submit data to the Administration on Aging.
Inclusion criteria for individual participants at selected program sites were
- 60 years or older (50 years or older at the Native American Site)
- Ability to walk with or without assistive devices
- Completion of a consent form.

Exclusion Criteria:

OAA sites:
- Those that did not meet the inclusion criteria
- Those not awarded a grant to participate in the program
Individual participants:
- Those who could not walk
- Those not 60 years old (50 years old for Native American groups)
- Those who were unwilling or unable to complete a consent form.

Description of Study Protocol:

Recruitment

OAA sites were recruited via the US Administration on Aging's website, the center's five Aging Network listservs and through state Unit on Aging nutritionists. 10 sites were selected from 106 sites that applied. Those sites that were accepted received a $10,000 grant and their staff were trained on implementation of the EBMM program.
Individuals at the 10 sites were recruited but methods of recruitment and enrollment were described as "self-selected volunteers." Participating sites screened potential participants using the EBMM Guidebook screening questionnaire and encouraged to seek medical approval before participating if one of more questions were answered yes.

Design

Before-and-after study:

Those individuals who enrolled in EBMM completed an enrollment form. Data on functional ability and a Nutrition Screening Initiative checklist were obtained when possible. A nutrition and physical activity questionnaire that included a "stages of change" question were included as part of the data collection.
Pre-intervention data and post-intervention data on nutrition and physical activity were completed to assess changes in behavior. These assessments focused on nutrition and physical activity, stages of change, self-reported health status, dietary intakes and program satisfaction.

Intervention

12 weekly sessions that incorporated mini-talks and activities for group nutrition and physical activity sessions were attended. Step counters were provided to participants, as were weekly "Tips and Tasks" sheets that reviewed each weeks nutrition and physical activity mini-talks.

Statistical Analysis

A Chi-square test and T-test were used to assess the differences between participants who completed the program and those who did not
A paired-samples T-test was used to assess pre-intervention and post-intervention differences
The Wilcoxon signed rank test was used for some analysis, including the number of servings of fruits and vegetables consumed
The McNemar test was used when dichotomous variables were present.

Data Collection Summary:

Timing of Measurements

Data were collected before and after the 12-week intervention.

Dependent Variables

Physical activity per day as measured by step counters and self-reported activity and Timed Up and Go scores
Changes in daily food intake as measured by self-reported intake.

Independent Variables

Completion of 12-week session of the EBMM program.

Description of Actual Data Sample:

Initial N: 999 participants at 10 sites around the country
Attrition (final N): 620 participants ("completers") who had both pre-intervention and post-intervention data on nutrition, physical activity or both
Age: Mean age of completers was 74.6 years
Ethnicity: 59% of completers were white, 25% African American, 4% Hispanic/Latino, 6% Native American and 7% Asian/Pacific Islander
Other relevant demographics: Completers were 18% male and 82% female
- 11% had a first- to eighth-grade education, 45% had ninth- to 12th-grade education, 28% had some college, 7% had a bachelor's degree and 9% had graduate school
- 12% of completers lived at or below the poverty level, while 88% were above the poverty level
Anthropometrics:
- 51% had a low nutrition risk score, 34% had a moderate nutrition risk score and 15% had a high nutrition risk score
- 92% had no assistance with Activities of Daily Living (ADL) while 8% had some assistance with ADLs
Location: 10 Older American Act Nutrition Program locations around the country. They included sites in:
- Meadville, PA
- Oakland, CA
- Shawnee ,OK
- Detroit, MI
- East St. Louis, IL
- Tampa, FL
- Dorchester, MA
- Mukiltea, WA
- Brookefield, WI
- Waynesboro, VA.

Summary of Results:

Key Findings

Nutrition outcomes:
- 31% of participants increased the number of servings of fruit they consumed by one or more servings. 37% increased their vegetable consumption by one or more servings. 33% increased their fiber consumption by one or more servings and 42% increased thier intake of calcium-rich foods by one or more servings. 31% increased their fluid intake by one to three glasses per day.
- In all categories there were also decreases in consumption by some of the completers
Physical activity outcomes:
- Number of blocks walked per day increased by 45% and flights of stairs per day increased 24%. Number of days walked per week increased 9%.
- Timed Up and Go scores increased from 11.7 seconds to 10. 6 seconds.

Percentage Change in Numbers of Daily Servings Consumed from Prentervention to Postintervention by Food Category

Category and Number of Servings Pre-intervention	Increased Two or More (Percent)	Increased One (Percent)	No Change (Percent)	Decreased One (Percent)	Decreased Two or More (Percent)
Fruit (N=590)
0	1.4	1.9	0.2	....	....
1	2.2	15.6	10.5	0.8	....
2	....	9.5	23.1	5.4	0.0
3	....	....	17.8	10.5	1.2
Total	3.6	27.0	51.6	16.7	1.2
Vegetable (N=512)
0	1.	1.7	0.0	....	....
1	3.4	14.8	8.1	0.2	....
2	....	15.3	24.2	4.6	0.2
3	....	....	17.5	7.0	1.2
Total	4.9	31.8	50.0	11.8	1.4
Fiber (N=544)
0	1.7	1.7	0.2	....	....
1	6.1	10.1	9.9	6.0	....
2	....	13.4	23.0	7.4	0.2
3	....	....	17.6	7.2	1.7
Total	7.8	25.2	50.7	14.6	1.9
Calcium (N=586)
0	2.3	5.1	1.4	....	....
1	3.4	15.5	13.1	0.7	....
2	....	15.4	18.3	5.8	0.2
3	....	....	11.8	5.8	1.2
Total	5.7	36.0	44.6	12.3	1.4
Water (N=541)
0	1.1	0.0	0.0	....	....
1	1.0	3.5	2.0	0.2	....
2	1.8	12.4	14.0	1.1	0.0
3	....	11.5	19.4	7.4	1.0
≥7	....	....	15.0	6.7	2.1
Total	3.9	27.4	50.4	15.4	3.1

.... indicates data is not available.

P<0.001 (change from pre-intervention to post-intervention).

Pre-intervention to Post-intervention Changes in Mean Physical Activity Indicators

Physical Activity Indicator	No.	Preintervention, Mean (SD)	Postintervention Mean (SD)	P-value
Steps walked	320	3,110 (2,448)	4,183 (3,257)	<0.001
Blocks walked	390	10.0 (12.3)	14.5 (16.2)	<0.001
Flights of stairs climbed	467	4.6 (9.0)	5.7 (9.0)	0.021
Days walked per week	320	5.7 (1.4)	6.2 (1.4)	0.008
Timed Up and Go score	449	11.7 (5.3)	10.6 (4.3)	<0.001
Exertion level*	475	4.9 (1.4)	5.4 (1.2)	<0.001

*Degree of effort expended when exercising in your usual fashion (one = none, nine = very, very strong).

Other Findings

There was significant movement of participants through the nutrition stages of change. 73% made an advance of one or more stages toward maintenance.

Author Conclusion:

The authors conclude that The Eat Better Move More (EBMM) intervention significantly improved nutrition and physical activity behavior among the 620 individuals who completed the program.

Funding Source:

Government:

US Dept of Health and Human Services Administration on Aging

Reviewer Comments:

The reviewer noted that some potential participants may have opted not to participate because they were encouraged to seek medical approval if they answered yes to one or more questions on the screening questionnaire. This may have eliminated participants who had medical or physical issues and could have affected the outcome.
The completers in the study were well-educated, living above the poverty level, female and mostly Caucasian. Results may have been different for a different subset of the population. Differences in results for the various population groups in the study were not reported.
Changes in food intake were self-reported changes rather than measured. Some changes in physical activity were self-reported, but step-counters were used to quantify changes in physical activity behaviors. Self-reporting may have skewed the results.
The reported Ns in all of the reporting categories for diet and physical activity did not total the number of completers in the study. It is unclear to the reviewer why, when the number of completers was 620, many of the "Ns" for physical activity and dietary changes were much lower. For example, only 320 participants had reporting for steps walked both pre-intervention and post-intervention.
A decrease in intake for all food categories was reported from pre-intervention to post-intervention for 11.8% to 16.7% percent of completers, depending on the food category. It is unclear to the reviewer if this has statistical or clinical significance.

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?		No
	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?	Yes
	2.4.	Were the subjects/patients a representative sample of the relevant population?	No
3.	Were study groups comparable?		N/A
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	N/A
	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.)	N/A
	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?		???
	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?	???
	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?		???
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	N/A
	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.)	???
	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?	N/A
	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?		???
	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?	???
	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?		???
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	No
	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)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	No
	8.6.	Was clinical significance as well as statistical significance reported?	No
	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