Fulfilling the Potential of Cancer Prevention and Early Detection (2003) / Chapter Skim
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4. Modifying Health Risk Behaviors
4. Modifying Health Risk Behaviors
Pages 87-155
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From page 87... ...
The Effectiveness of Interventions to Assist in Weight Loss, by Suzanne Phelan and Rena Wing; and (3) Provider, System and Policy Strategies to Enhance the Delivery of Cancer Prevention and Control Activities in Primary Care, by Judy Ockene, Jane Zapka, Lori Pebert, Suzanne Brodney, and Stephanie Leman (www.iom.edu/ncpb)
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From page 88... ...
An overview is then provided of conceptual frameworks and intervention paradigms that underlie much of the reviewed behavioral research. Next, treatment-outcome research is summarized for tobacco cessation and prevention, physical activity, and diet (weight loss interventions and modification of eating patterns)
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From page 89... ...
This section describes three models that guide assessments of behavioral interventions relating to tobacco use, diet, and physical activity: value expectancy theories, the social cognitive theory, and the transtheoretical or stages of change model. Value Expectancy Theories Value expectancy theories emphasize cognitive factors that are associated with motivation for behavior change.
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From page 90... ...
Perceived susceptibility and severity are based largely on an individual's knowledge of a disease and its potential outcome. The HBM also recognizes the potential importance of "cues to action" in starting the process of behavior change.
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From page 91... ...
Transtheoretical Model The transtheoretical mode! is widely applied in studies of the determinants of behavioral risk factor modification as well as in randomized intervention trials in the areas of smoking cessation, dietary change, and physical activity (Velicer et al., 1999; Kristal et al., 2000a; Peterson and Aldana, ~ .
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From page 92... ...
; 4. action (made the target behavior change within the past six months)
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From page 93... ...
mec Cation; · advice to quit from physicians and other creclible professionals; · programs implemented through community channels such as worksites, churches, and health care settings; and · broaci, multicomponent, multichannel programs such as statewide programs to prevent smoking and encourage smoking cessation. Smoking cessation has the advantage of a well-clefineci, single outcome measure (abstinence from tobacco)
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From page 94... ...
There is a similar trend when the data are disaggregated by the number of formats used. These analyses demonstrate an important feature of smoking cessation: the number of different formats used in cessation interventions may be more important than the nature of the formats used.
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From page 95... ...
12.3 (10.9, 13.6) Proactive telephone counseling 26 1.2 (1.1, 1.4)
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From page 96... ...
, and personalized feedback added to a self-help manual (Curry et al., 1991; Becona and Vazquez, 2001~. Physician Advice A physician's advice or brief counseling for smoking cessation often includes a presentation of the risks individualized by symptoms or family history, provision of accompanying cessation materials, and follow-up (Kottke et al., 1988; Ockene et al., 1991a; Rose and Hamilton, 1978; Russell et al., 1979~.
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From page 97... ...
Proactive services provide outreach telephone counseling to smokers, usually in conjunction with written self-help materials. The 2000 PHS Clinical Practice Guidelines concluded that telephone counseling is an effective approach to smoking cessation counseling (US DHHS, 2000a, p.
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From page 98... ...
Pharmacological Interventions Pharmacotherapies for smoking cessation that have been approved by the Food and Drug Administration (FDA) and recommended in the PHS Guidelines include several forms of nicotine replacement (gum, patch, nasal spray, and inhaler)
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From page 99... ...
concluded that nicotine replacement is best viewed as an adjunct to counseling or other smoking cessation programs and efforts. The 1996 Agency for Health Care Policy and Research (AHCPR)
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From page 100... ...
Reductions in smoking have been reported through workplace programs aimed at smoking alone or at multiple risk factors (Gome! et al., 1993, 1997; Emmons et al., 1999~.
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From page 101... ...
Insurance Coverage of Smoking Cessation Interventions The provision and acceptance of smoking prevention services are enabled when they are covered insurance benefits. A lack of reimbursement affects both patients and physicians (Frame, 1992; Tacn et al., 1994; Kottke et al., 1993~.
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From page 102... ...
Among participants in smoking cessation services, those who haci to pay for some portion of costs achieved higher quit rates than those who received them at no cost. This reflects the commonly expressed opinion that offering services for free is counterproductive because recipients will not value services for which they clo not have to pay.
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From page 105... ...
The pattern of results from mass media approaches to smoking cessation shows a striking parallel to the pattern of results from clinical approaches: the more channels of influence that support cessation, the greater the impact (Kottke et al., 1988~. Thus, televised programs achieve greater impacts when they are accompanied by printed materials distributed to viewers (Flay, 1987; Warnecke et al., 1992)
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From page 106... ...
06 CANCER PREVENTION AND EARLY DETECTION SOURCE: Centers for Disease Control and Prevention.
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From page 107... ...
By the third year of the program, local community boards had assumed the burden of responsibility for program planning and implementation. Relative to the counties used for comparison, the two counties achieved significantly greater levels of smoking cessation and lower smoking prevalences (Secker-Walker et al., 2000~.
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From page 108... ...
Aciclitionally, health promotion programs should reflect the emphasis on family founci among members of African-American and other minority groups (Ness et al., 1997; Stolley and Fitzgibbon, 1997~. Efforts at the promotion of smoking cessation among African Americans and other minorities have used churches, schools, lay health advisers, mass media, and community-baseci approaches.
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From page 109... ...
Declines in the prevalence of smoking exceeded those in comparison neighborhoods. PREVENTION OF TOBACCO USE Because of the time course of exposure and disease incidence, reductions in cancer-related morbidity and mortality over the next two decades will result from smoking cessation rather than prevention of smoking initiation.
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From page 110... ...
This intervention included booklets mailed to families to help them prevent smoking among adolescents and follow-up telephone contacts by health educators (Bauman et al., 2001~. Evaluations of mass media and community-based approaches to the prevention of smoking have, as a group, achieved mixed results (Biglan et al., 2000; Sowden and Arblaster, 2000a,b)
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From page 111... ...
This section of the chapter summarizes evidence for interventions to promote adherence to national guidelines for physical activity and for physical activity interventions as part of multicomponent treatments for weight loss. Distinctions between physical activity, exercise, and physical fitness are useful in understanding intervention research.
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From page 112... ...
2 CANCER PREVENTION AND EARLY DETECTION SOURCE: Corbis Corporation. ous exercise, moderate physical activity, occupational physical activity, physical activity performed in school physical education classes, or lifestyle physical activity.
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From page 113... ...
As defined in a recent review (Simons-Morton et al., 1998) , physical activity interventions in health care settings fall into four categories: 1.
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From page 114... ...
Physicians delivered the majority of the physical activity interventions, with two delivered by nurses and two delivered by allied health care specialists. Of the seven randomized controlled studies, five reported significant increases in physical activity, but only two of these five reported significant long-term effects.
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From page 115... ...
identified the characteristics of successful physical activity interventions in health care settings. These included long-term interventions, multiple contacts, supervised exercise, provision of equipment, and the use of behavioral approaches.
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Several interventions have been successful in increasing moderate-intensity physical activity during physical education classes (e.g., the CATCH study)
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In study of Hispanic and African-American youth in middle school, students reported positive effects from an aerobic dance-based physical education intervention (Flores, 1995~. Also, Hopper and colleagues (1992, 1996)
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From page 118... ...
The Stanford Five-City Study, the Minnesota Heart Health Project, and the Pawtucket Heart Health Project have all tested community-based approaches to promoting physical activity. In the Stanford Five-City Study, the only significant findings were from cross-sectional analyses indicating that the men in the treatment cities increased their daily energy expenditures and rates of participation in vigorous exercise.
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From page 119... ...
described a significant difference in knowledge and self-reported rates of exercise in a school-based intervention geared toward Navajo and Pueblo youth. In a study with Hispanic and African-American youth in a middle school, students reported positive effects from an aerobic dance-based physical education intervention (Flores, 1995~.
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From page 120... ...
INTERVENTIONS TO ACHIEVE WEIGHT LOSS Weight-loss treatments aim to modify eating habits and levels of physical activity. Decreasing energy intake, increasing energy expenditure, or a combination will result in decreases in body fat levels.
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From page 121... ...
VLCDs produce mean weight losses of about 20 kg (44 Ib) in women and about 30 kg (66 Ib)
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From page 122... ...
Thus, reducing fat intake may help produce weight loss (Instill et al., 1990; Kendall et al., 1991~. Randomized control trials evaluating the effects of low-fat diets
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From page 123... ...
Greater decreases in the number of calories from dietary fat have been associated with greater short- and long-term weight losses (Harris et al., 1994; Teffery et al., 1993b)
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From page 124... ...
Physical Activity Interventions to Promote Weight Loss and Maintenance Many reviews and recommendations on the role of physical activity in the management of obesity have been published (Donnelly et al., 1991; Gleim, 1993; National Heart, Lung, and Blood Institute, 1998; Wing, 1999~. Published research suggests that exercise alone (i.e., without adjunct dietary restriction)
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From page 125... ...
Thus, although the combination of a reduced-calorie diet and increased physical activity produced greater weight loss, the effect was modest. However, given the modest increase in weight loss and the significantly greater improvements in cardiorespiratory health, the combination of a reduced-calorie diet and physical activity is the recommended treatment for obesity (National Heart, Lung, and Blood Institute, 1998~.
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From page 126... ...
. After 18 months, the short- and longbout exercise groups had similar weight losses and improvements in cardiorespiratory fitness, again suggesting the comparable benefits of short- and long-bout exercises.
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From page 127... ...
evaluated the effects of a supervised group exercise program versus those of a home-based exercise program. At 12 months, participants who had been randomly assigned to home-based exercise had better rates of adherence to exercise and greater weight losses.
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As a result, weight losses nearly doubled (Brownell and Wadden, 1986~. Today, treatment programs result in an average weight loss of 8.5 kg (18.7 Ib)
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From page 129... ...
Even at 5 years, however, 43 percent of the participants maintained weight losses of >5 percent compared with their weight at the time of entry into Weight Watchers and 70 percent were below their weight at the time of entry into Weight Watchers. The Trevose program is another self-help Program with a different treatment approach (Latner et al., 2000~.
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From page 130... ...
This study raises the possibility that the Internet and e-mail can be useful in increasing the audience for weight-loss programs and helping these individuals achieve modest weight losses. Pharmacological Treatments of Obesity Obesity-related medications are recommended for use only by persons with BMIs of 230 kg/m2 with no concomitant obesity-related risk factors or
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From page 131... ...
By contrast, orlistat is a gastric and pancreatic lipase inhibitor that works by blocking absorption of about one-third of the fat contained in a meal; the undigested fat is excreted in the stool. Both medications in conjunction with dietary therapy promote weight losses of 5 to 13 kg (11 to 29 Ib)
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From page 132... ...
Weight losses appear to be modest. Teffery and colleagues (1985 .
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From page 133... ...
In the Stanford Five-City Study (Taylor et al., l991b) , mass media, community organizations, and educational classes were used to increase knowledge and teach behavioral change skills related to changing diet and levels of physical activity.
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From page 134... ...
For example, taxes on high-fat foods, limiting food advertising during children's television programs, and building more bike paths have all been suggested, but they have not been empirically evaluated. Programs to Reach Underserved and Minority Populations African Americans often achieve less weight loss than whites in standard treatment programs (Kumanyika et al., 1991; Wing and Anglin, 1992; Yanovski et al., 1994~.
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From page 135... ...
Overall, dietary interventions designed to be culturally relevant appear to be as effective as those designed for the general population. As with other programs for the general population, behavioral interventions for underserved groups are most effective when they are developed with input from the target population and are implemented within organizations respected and valued by the target community.
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From page 136... ...
Moreover, a recent study showed that overweight children who were instructed to decrease the amount of time that they spend doing sedentary activities (watching television and playing video
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From page 137... ...
After 3 years of intervention, positive changes were reported in the school environment (cafeteria foods had lower levels of total and saturated fats) and children spent more time participating in moderate and vigorous levels of activity during physical education classes; there were also positive changes in the children's self-reported eating behaviors and physical activity levels.
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From page 138... ...
Behavioral Interventions to Improve Eating Patterns This section of the chapter reviews the effectiveness of behavioral interventions designed to improve fruit, vegetable, and fat intakes as defined by
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From page 139... ...
A primary source for this review is the AHRQ Evidence Report on the Efficacy of Interventions to Modify Dietary Behavior Rented to Cancer Risk: Final Evidence Report (hereafter referred to as the AHRQ Diet Report) (Agency for Healthcare Research and Quality, 2001a)
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From page 140... ...
The median difference for percent of energy from fat of -15.7 represents an estimated 7.3% reduction in percentage of calories from fat. The majority of behavioral interventions to modify dietary patterns have been conducted within health care settings.
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From page 141... ...
These settings also allowed ongoing monitoring of at-risk groups. A paper published subsequent to publication of the literature review in the AHRQ Diet Report extended these findings by showing both reduced levels of dietary fat intake and increased levels of fruit and vegetable consumption after an individualized intervention delivered by personalized mailings, standard dietary information, and personalized phone calls (Kristal et al., 2000a)
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From page 142... ...
The Working Well stucly inclucleci interactive activities and contests plus multiple environmental changes, such as altering fooci choices in vencling machines, with significant effects on the levels of both fruit and vegetable consumption and fat intake (Sorensen et al., 1996~. The Next Step Trial targeted both fruit and vegetable consumption and fat intake for change.
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From page 143... ...
Significant improvements in fruit and vegetable consumption were observed at the 2-year follow-up point (Beresford et al., 2001~. School-Based Interventions Schools have been the setting for population-based interventions designed to lower the levels of fat intake and improve the levels of fruit and vegetable consumption of elementary and middle school children.
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From page 144... ...
can result in significant improvements in the levels of fruit and vegetable consumption by children and reductions in the levels of fat intake. The need to create innovative programs that encourage additional parental involvement and environmental changes at home continues to be important for future work.
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From page 145... ...
Several studies that have addressed fruit and vegetable consumption and fat intake combined have examined more intensive interventions, such as home visits with newsletters (Knutsen and Knutsen, 1991) and weekly classes or sessions (Fitzgibbon et al., 1996; Hartman et al., 1997)
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From page 146... ...
Programs to Reach Underserved and Minority Populations Among African Americans, diet may be an area of special vulnerability (WorId Cancer Research Fund and American Institute for Cancer Research, 1997~. African Americans, particularly those living in rural communities, report poorer dietary intakes (Baranowski et al., 2000; Johnson et al., 1994; Lillie-Blanton et al., 1996; Schonfeld-Warden and Warden, 1997~.
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From page 147... ...
recruited Hispanic families from literacy training programs and offered a culturally specific curriculum over 12 weeks designed to improve both fat intake and fruit and vegetable consumption (Fitzgibbon et al., 1996~. Stolley and Fitzgibbon (1997)
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From page 148... ...
Workers from informal networks were trained to provide program interventions for their colleagues in those networks. The intervention included various print media and information sessions conducted by peer educators for large and small groups and included ethnically specific messages that encouraged the participants to increase their levels of fruit and vegetable consumption.
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From page 149... ...
The type of visit affects the rate of smoking intervention, with more interventions occurring during well visits than during acute care visits and with more interventions occurring for smokers with chronic tobacco-related illnesses than for smokers with non-tobaccorelated illnesses (Jacn, 1997; Jacn et al., 1997,1998; Sesney et al., 1997; Stange et al., 1994; Thorndike et al., 1998; Frame, 1995~. The general infrequency of well visits and patients not being ready to stop smoking may help explain the less than desirable rates of smoking cessation interventions by physicians.
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From page 150... ...
. , , How a clinical practice is organized, its de" ivery capacity, and its manual and computerized administrative sunnort systems can greatly affect a orovider's ability to deliver preventive health care in general and address behavioral risk factors specifically.
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From page 151... ...
These guidelines include six strategies for systems-level interventions, modified here to encompass multiple behavioral risk factors: 1. implement a behavioral risk factor identification system in every clinic; 2.
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From page 152... ...
of ambulatory care visits made by adults in 1998 were to a patient's primary care provider. · Counseling about risk behaviors such as smoking cessation or describing the pros and cons of screening procedures can be time-consuming, yet most adult patients (63 percent)
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From page 153... ...
The Medicare program, for example, does not provide reimbursement for smoking cessation services. Other barriers to the provision of prevention services are more subtle.
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From page 155... ...
The greatest barriers to providers' delivery of smoking cessation counseling are lack of education and training, limitations of time and practice setting systems, poor reimbursement levels, and a perceived lack of success with patients who smoke. For diet and physical activity, an additional critical barrier is the lack of clear guidelines regarding recommendations for cancer control.
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