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1.  Why do people fail to turn good intentions into action? The role of executive control processes in the translation of healthy eating intentions into action in young Scottish adults 
BMC Public Health  2008;8:123.
Despite the significant health benefits associated with eating healthily, diet is extremely difficult to change, with the majority of people who intend to eat more healthily failing to do so. Recent evidence has suggested that the ability to turn intentions into actions may be related to individual differences in one facet of executive control – cognitive inhibition (i.e. the ability to inhibit irrelevant information and suppress prepotent responses). The present study investigates the role of this and other executive processes (inhibition, task switching, planning and cognitive flexibility) in the translation of dietary intentions into action. In addition, as the literature suggests that weak executive control may be associated with hyper-responsivity to cues to action, the role of executive processes in susceptibility to environmental food cues and responses to If-Then plans designed to cue intended behaviour are investigated.
Future intentions about consumption of fruits and vegetables and snack foods will be measured in a sample of young adults. Actual consumption of the target foods will be recorded with computerised diaries over a subsequent 3-day period. Performance on a battery of established executive control tasks (Go-NoGo, Tower task, Verbal Fluency task and Trail-Making) will be used to predict the discrepancy between intended and actual dietary behaviour. In addition, executive control scores will be used to predict reported susceptibility to environmental food cues and benefit derived from the use of 'If-Then plans' designed to cue intended behaviour.
Our findings will add to understanding about the role of executive control in translating intentions into actions and may demonstrate potential for future public health interventions. If participants with weak executive control are found to be less likely to eat as they intend than those with strong executive control, then interventions that reduce the load on these executive processes may increase chances of successful intention-behaviour translation. If those with weak executive control are found to be more responsive to cues to action they may also benefit more from the use of If-Then plans designed to cue intended behaviour.
PMCID: PMC2346472  PMID: 18423026
2.  Food Pricing Strategies, Population Diets, and Non-Communicable Disease: A Systematic Review of Simulation Studies 
PLoS Medicine  2012;9(12):e1001353.
A systematic review of simulation studies conducted by Helen Eyles and colleagues examines the association between food pricing strategies and food consumption and health and disease outcomes.
Food pricing strategies have been proposed to encourage healthy eating habits, which may in turn help stem global increases in non-communicable diseases. This systematic review of simulation studies investigates the estimated association between food pricing strategies and changes in food purchases or intakes (consumption) (objective 1); Health and disease outcomes (objective 2), and whether there are any differences in these outcomes by socio-economic group (objective 3).
Methods and Findings
Electronic databases, Internet search engines, and bibliographies of included studies were searched for articles published in English between 1 January 1990 and 24 October 2011 for countries in the Organisation for Economic Co-operation and Development. Where ≥3 studies examined the same pricing strategy and consumption (purchases or intake) or health outcome, results were pooled, and a mean own-price elasticity (own-PE) estimated (the own-PE represents the change in demand with a 1% change in price of that good). Objective 1: pooled estimates were possible for the following: (1) taxes on carbonated soft drinks: own-PE (n = 4 studies), −0.93 (range, −0.06, −2.43), and a modelled −0.02% (−0.01%, −0.04%) reduction in energy (calorie) intake for each 1% price increase (n = 3 studies); (2) taxes on saturated fat: −0.02% (−0.01%, −0.04%) reduction in energy intake from saturated fat per 1% price increase (n = 5 studies); and (3) subsidies on fruits and vegetables: own-PE (n = 3 studies), −0.35 (−0.21, −0.77). Objectives 2 and 3: variability of food pricing strategies and outcomes prevented pooled analyses, although higher quality studies suggested unintended compensatory purchasing that could result in overall effects being counter to health. Eleven of 14 studies evaluating lower socio-economic groups estimated that food pricing strategies would be associated with pro-health outcomes. Food pricing strategies also have the potential to reduce disparities.
Based on modelling studies, taxes on carbonated drinks and saturated fat and subsidies on fruits and vegetables would be associated with beneficial dietary change, with the potential for improved health. Additional research into possible compensatory purchasing and population health outcomes is needed.
Please see later in the article for the Editors' Summary
Editors' Summary
For the first time in human history, non-communicable diseases (NCDs) are killing more people than infectious diseases. Every year, more than 35 million people die from NCDs—nearly two-thirds of the world's annual deaths. More than 80% of these deaths are in developing countries, where a third of NCD-related deaths occur in people younger than 60 years old. And NCDs are not just a growing global public health emergency. They are also financially costly because they reduce productivity and increase calls on health care systems worldwide. Cardiovascular diseases (conditions that affect the heart and circulation such as heart attacks and stroke), cancers, diabetes, and chronic respiratory diseases (long-term diseases that affect the lungs and airways) are responsible for most NCD-related illnesses and death. The main behavioral risk factors for all these diseases are tobacco use, harmful use of alcohol, physical inactivity, and unhealthy diets (diets that have a low fruit and vegetable intake and high saturated fat and salt intakes).
Why Was This Study Done?
Improvements in population diets and reductions in salt intake are crucial for the control and prevention of NCDs, but how can these behavioral changes be encouraged? One potential but poorly studied strategy is food pricing—the introduction of taxes on unhealthy foods (for example, foods containing high levels of saturated fat) and subsidies on healthy foods (for example, foods high in fiber). However, although a tax on soft drinks, for example, might decrease purchases of these high-sugar drinks, it might also increase purchases of fruit juices, which contain just as much sugar and energy as soft drinks (“compensatory purchasing”), and thus undermine the intended health impact of the tax. Because randomized controlled trials of the effects of food pricing strategies are difficult to undertake, many researchers have turned to mathematical models (sets of equations that quantify relationships between interventions and outcomes) to provide the evidence needed to inform policy decisions on food taxes and subsidies. In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), Helen Eyles and colleagues investigate the association between food pricing strategies and food consumption and NCDs by analyzing the results of published mathematical modeling studies of food pricing interventions.
What Did the Researchers Do and Find?
The researchers identified 32 studies that met their predefined inclusion criteria, which included publication by researchers in a member country of the Organisation for Economic Co-operation and Development (a group of largely developed countries that promotes global development). Most of the studies were of low to moderate quality and provided uncertain and varying estimates of the impact of pricing on food consumption. Where three or more studies examined the same pricing strategy and consumption or health outcome, the researchers calculated the average change in demand for a food in response to changes in its price (“own-price elasticity”). For taxes on carbonated soft drinks, the average own-price elasticity was −0.93; that is, the models predicted that a 1% increase in the price of soft drinks would decrease consumption by 0.93%. The modeled reduction in the proportion of energy intake from saturated fat resulting from a 1% increase in the price of saturated fats was 0.02%. Finally, although the researchers' analysis suggested that for each 1% reduction in the price of fruits and vegetables, consumption would increase by 0.35%, they also found evidence that such a subsidy might result in compensatory purchasing, such as a reduction in fish purchases.
What Do These Findings Mean?
These findings suggest that pricing strategies have the potential to produce improvements in population diets, at least in developed countries, but also highlight the need for more research in this area. Notably, the researchers found insufficient data to allow them to quantify the effects of pricing strategies on health or to analyze whether the effect of pricing strategies is likely vary between socio-economic groups. Given their findings, the researchers suggest that future modeling studies should include better assessments of the unintended effects of compensatory purchasing and should examine the potential impact of food pricing strategies on long-term health and NCD-related deaths. Finally, they suggest that robust evaluations should be built into the implementation of food pricing policies to answer some of the outstanding questions about this potential strategy for reducing the global burden of NCDs.
Additional Information
Please access these websites via the online version of this summary at
The US Centers for Disease Control and Prevention provides information on all aspects of healthy living, on chronic diseases and health promotion, and on non-communicable diseases around the world
The Global Noncommunicable Disease Network (NCDnet) aims to help low- and middle-income countries reduce NCD-related illnesses and death through implementation of the 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases (also available in French); NCDnet's Face to face with chronic disease webpage is a selection of personal stories from around the world about dealing with NCDs
The American Heart Association and the American Cancer Society provide information on many important risk factors for non-communicable diseases and include some personal stories about keeping healthy
PMCID: PMC3519906  PMID: 23239943
3.  Diet and Physical Activity for the Prevention of Noncommunicable Diseases in Low- and Middle-Income Countries: A Systematic Policy Review 
PLoS Medicine  2013;10(6):e1001465.
Carl Lachat and colleagues evaluate policies in low- and middle-income countries addressing salt and fat consumption, fruit and vegetable intake, and physical activity, key risk factors for non-communicable diseases.
Please see later in the article for the Editors' Summary
Diet-related noncommunicable diseases (NCDs) are increasing rapidly in low- and middle-income countries (LMICs) and constitute a leading cause of mortality. Although a call for global action has been resonating for years, the progress in national policy development in LMICs has not been assessed. This review of strategies to prevent NCDs in LMICs provides a benchmark against which policy response can be tracked over time.
Methods and Findings
We reviewed how government policies in LMICs outline actions that address salt consumption, fat consumption, fruit and vegetable intake, or physical activity. A structured content analysis of national nutrition, NCDs, and health policies published between 1 January 2004 and 1 January 2013 by 140 LMIC members of the World Health Organization (WHO) was carried out. We assessed availability of policies in 83% (116/140) of the countries. NCD strategies were found in 47% (54/116) of LMICs reviewed, but only a minority proposed actions to promote healthier diets and physical activity. The coverage of policies that specifically targeted at least one of the risk factors reviewed was lower in Africa, Europe, the Americas, and the Eastern Mediterranean compared to the other two World Health Organization regions, South-East Asia and Western Pacific. Of the countries reviewed, only 12% (14/116) proposed a policy that addressed all four risk factors, and 25% (29/116) addressed only one of the risk factors reviewed. Strategies targeting the private sector were less frequently encountered than strategies targeting the general public or policy makers.
This review indicates the disconnection between the burden of NCDs and national policy responses in LMICs. Policy makers urgently need to develop comprehensive and multi-stakeholder policies to improve dietary quality and physical activity.
Please see later in the article for the Editors' Summary
Editors' Summary
Noncommunicable diseases (NCDs)—chronic medical conditions including cardiovascular diseases (heart disease and stroke), diabetes, cancer, and chronic respiratory diseases (chronic obstructive pulmonary disease and asthma)—are responsible for two-thirds of the world's deaths. Nearly 80% of NCD deaths, close to 30 million per year, occur in low- and middle-income countries (LMICs), where they are also rising most rapidly. Diet and lifestyle (including smoking, lack of exercise, and harmful alcohol consumption) influence a person's risk of developing an NCD and of dying from it. Because they can be modified, these risk factors have been at the center of strategies to combat NCDs. In 2004, the World Health Organization (WHO) adopted the Global Strategy on Diet, Physical Activity and Health. For diet, it recommended that individuals achieve energy balance and a healthy weight; limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids; increase consumption of fruits, vegetables, legumes, whole grains, and nuts; limit the intake of free sugars; and limit salt consumption from all sources and ensure that salt is iodized. For physical activity, it recommended at least 30 minutes of regular, moderate-intensity physical activity on most days throughout a person's life.
Why Was This Study Done?
By signing onto the Global Strategy in 2004, WHO member countries agreed to implement it with high priority. A first step of implementation is usually the development of local policies. Consequently, one of the four objectives of the WHO Global Strategy is “to encourage the development, strengthening and implementation of global, regional, national and community policies and action plans to improve diets and increase physical activity.” Along the same lines, in 2011 the United Nations held a high-level meeting in which the need to accelerate the policy response to the NCD epidemic was emphasized. This study was done to assess the existing national policies on NCD prevention in LMICs. Specifically, the researchers examined how well those policies matched the WHO recommendations for intake of salt, fat, and fruits and vegetables, as well as the recommendations for physical activity.
What Did the Researchers Do and Find?
The researchers searched the Internet (including websites of relevant ministries and departments) for all publicly available national policies related to diet, nutrition, NCDs, and health from all 140 WHO member countries classified as LMICs by the World Bank in 2011. For countries for which the search did not turn up policies, the researchers sent e-mail requests to the relevant national authorities, to the regional WHO offices, and to personal contacts. All documents dated from 1 January 2004 to 1 January 2013 that included national objectives and guidelines for action regarding diet, physical exercise, NCD prevention, or a combination of the three, were analyzed in detail.
Most of the policies obtained were not easy to find and access. For 24 countries, particularly in the Eastern Mediterranean, the researchers eventually gave up, unable to establish whether relevant national policies existed. Of the remaining 116 countries, 29 countries had no relevant policies, and another 30 had policies that failed to mention specifically any of the diet-related risk factors included in the analysis. Fifty-four of the 116 countries had NCD policies that addressed at least one of the risk factors. Thirty-six national policy documents contained strategies to increase fruit and vegetable intake, 20 addressed dietary fat consumption, 23 aimed to limit salt intake, and 35 had specific actions to promote physical activity. Only 14 countries, including Jamaica, the Philippines, Iran, and Mongolia, had policies that addressed all four risk factors. The policies of 27 countries mentioned only one of the four risk factors.
Policies primarily targeted consumers and government agencies and failed to address the roles of the business community or civil society. Consistent with this, most were missing plans, mechanisms, and incentives to drive collaborations between the different stakeholders.
What Do These Findings Mean?
More than eight years after the WHO Global Strategy was agreed upon, only a minority of the LMICs included in this analysis have comprehensive policies in place. Developing policies and making them widely accessible is a likely early step toward specific implementation and actions to prevent NCDs. These results therefore suggest that not enough emphasis is placed on NCD prevention in these countries through actions that have been proven to reduce known risk factors. That said, the more important question is what countries are actually doing to combat NCDs, something not directly addressed by this analysis.
In richer countries, NCDs have for decades been the leading cause of sickness and death, and the fact that public health strategies need to emphasize NCD prevention is now widely recognized. LMICs not only have more limited resources, they also continue to carry a large burden from infectious diseases. It is therefore not surprising that shifting resources towards NCD prevention is a difficult process, even if the human cost of these diseases is massive and increasing. That only about 3% of global health aid is aimed at NCD prevention does not help the situation.
The authors argue that one step toward improving the situation is better sharing of best practices and what works and what doesn't in policy development. They suggest that an open-access repository like one that exists for Europe could improve the situation. They offer to organize, host, and curate such a resource under the auspices of WHO, starting with the policies retrieved for this study, and they invite submission of additional policies and updates.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Stuckler and Basu
The WHO website on diet and physical activity contains links to various documents, including a diet and physical activity implementation toolbox that contains links to the 2004 Global Strategy document and a Framework to Monitor and Evaluate Implementation
There is a 2011 WHO primer on NCDs entitled Prioritizing a Preventable Epidemic
A recent PLOS Medicine editorial and call for papers addressing the global disparities in the burden from NCDs
A PLOS Blogs post entitled Politics and Global HealthAre We Missing the Obvious? and associated comments discuss the state of the fight against NCDs in early 2013
The NCD Alliance was founded by the Union for International Cancer Control, the International Diabetes Federation, the World Heart Federation, and the International Union Against Tuberculosis and Lung Disease; its mission is to combat the NCD epidemic by putting health at the center of all policies
The WHO European Database on Nutrition, Obesity and Physical Activity (NOPA) contains national and subnational surveillance data, policy documents, actions to implement policy, and examples of good practice in programs and interventions for the WHO European member states
PMCID: PMC3679005  PMID: 23776415
4.  Promoting the Avoidance of High-Calorie Snacks: Priming Autonomy Moderates Message Framing Effects 
PLoS ONE  2014;9(7):e103892.
The beneficial effects of gain-framed vs. loss-framed messages promoting health protective behaviors have been found to be inconsistent, and consideration of potential moderating variables is essential if framed health promotion messages are to be effective. This research aimed to determine the influence of highlighting autonomy (choice and freedom) and heteronomy (coercion) on the avoidance of high-calorie snacks following reading gain-framed or loss-framed health messages. In Study 1 (N = 152) participants completed an autonomy, neutral, or heteronomy priming task, and read a gain-framed or loss-framed health message. In Study 2 (N = 242) participants read a gain-framed or loss-framed health message with embedded autonomy or heteronomy primes. In both studies, snacking intentions and behavior were recorded after seven days. In both studies, when autonomy was highlighted, the gain-framed message (compared to the loss-framed message) resulted in stronger intentions to avoid high-calorie snacks, and lower self-reported snack consumption after seven days. Study 2 demonstrated this effect occurred only for participants to whom the information was most relevant (BMI>25). The results suggest that messages promoting healthy dietary behavior may be more persuasive if the autonomy-supportive vs. coercive nature of the health information is matched to the message frame. Further research is needed to examine potential mediating processes.
PMCID: PMC4117640  PMID: 25078965
5.  Adolescents demonstrate improvement in obesity risk behaviors following completion of Choice, Control, and Change, a curriculum addressing personal agency and autonomous motivation 
The rapid increase of obesity and diabetes risk beginning in youth, particularly those from disadvantaged communities, calls for prevention efforts.
To examine the impact of a curriculum intervention, Choice, Control, and Change (C3), on the adoption of the energy balance related behaviors of decreasing sweetened drinks, packaged snacks, fast food, and leisure screen time, and increasing water, fruits and vegetables, and physical activity, and on potential psychosocial mediators of the behaviors.
Ten middle schools in low-income New York City neighborhoods were randomly assigned within matched pairs to either intervention or comparison/ delayed control conditions during the 2007–2008 school year.
562 inner city seventh grade students in the intervention condition, and 574 in the comparison condition.
Students received the 24 C3 lessons that used science inquiry-based investigations to enhance motivation for action, and social cognitive and self-determination theories to increase personal agency and autonomous motivation to take action.
Main outcome measures
Self-report instruments to measure energy balance related behaviors targeted by the curriculum, and potential psychosocial mediators of the behaviors.
ANCOVA with group (intervention/control) as a fixed factor and pre-test as covariate.
Students in intervention schools compared to the delayed intervention controls reported consumption of significantly fewer sweetened drinks and packaged snacks, smaller sizes of fast food, increased intentional walking for exercise, and decreased leisure screen-time, but showed no increases in their intakes of water, fruits, and vegetables. They showed significant increases in positive outcome expectations about the behaviors, self-efficacy, goal intentions, competence, and autonomy.
The C3 curriculum was effective in improving many of the specifically targeted behaviors related to reducing obesity risk, indicating that combining inquiry-based science education and behavioral theory is a promising approach.
PMCID: PMC3016947  PMID: 21111093
6.  Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study 
PLoS Medicine  2008;5(1):e12.
There is overwhelming evidence that behavioural factors influence health, but their combined impact on the general population is less well documented. We aimed to quantify the potential combined impact of four health behaviours on mortality in men and women living in the general community.
Methods and Findings
We examined the prospective relationship between lifestyle and mortality in a prospective population study of 20,244 men and women aged 45–79 y with no known cardiovascular disease or cancer at baseline survey in 1993–1997, living in the general community in the United Kingdom, and followed up to 2006. Participants scored one point for each health behaviour: current non-smoking, not physically inactive, moderate alcohol intake (1–14 units a week) and plasma vitamin C >50 mmol/l indicating fruit and vegetable intake of at least five servings a day, for a total score ranging from zero to four. After an average 11 y follow-up, the age-, sex-, body mass–, and social class–adjusted relative risks (95% confidence intervals) for all-cause mortality(1,987 deaths) for men and women who had three, two, one, and zero compared to four health behaviours were respectively, 1.39 (1.21–1.60), 1.95 (1.70–-2.25), 2.52 (2.13–3.00), and 4.04 (2.95–5.54) p < 0.001 trend. The relationships were consistent in subgroups stratified by sex, age, body mass index, and social class, and after excluding deaths within 2 y. The trends were strongest for cardiovascular causes. The mortality risk for those with four compared to zero health behaviours was equivalent to being 14 y younger in chronological age.
Four health behaviours combined predict a 4-fold difference in total mortality in men and women, with an estimated impact equivalent to 14 y in chronological age.
From a large prospective population study, Kay-Tee Khaw and colleagues estimate the combined impact of four behaviors--not smoking, not being physically inactive, moderate alcohol intake, and at least five vegetable servings a day--amounts to 14 additional years of life.
Editors' Summary
Every day, or so it seems, new research shows that some aspect of lifestyle—physical activity, diet, alcohol consumption, and so on—affects health and longevity. For the person in the street, all this information is confusing. What is a healthy diet, for example? Although there are some common themes such as the benefit of eating plenty of fruit and vegetables, the details often differ between studies. And exactly how much physical activity is needed to improve health? Is a gentle daily walk sufficient or simply a stepping stone to doing enough exercise to make a real difference? The situation with alcohol consumption is equally confusing. Small amounts of alcohol apparently improve health but large amounts are harmful. As a result, it can be hard for public-health officials to find effective ways to encourage the behavioral changes that the scientific evidence suggests might influence the health of populations.
Why Was This Study Done?
There is another factor that is hindering official attempts to provide healthy lifestyle advice to the public. Although there is overwhelming evidence that individual behavioral factors influence health, there is very little information about their combined impact. If the combination of several small differences in lifestyle could be shown to have a marked effect on the health of populations, it might be easier to persuade people to make behavioral changes to improve their health, particularly if those changes were simple and relatively easy to achieve. In this study, which forms part of the European Prospective Investigation into Cancer and Nutrition (EPIC), the researchers have examined the relationship between lifestyle and the risk of dying using a health behavior score based on four simply defined behaviors—smoking, physical activity, alcohol drinking, and fruit and vegetable intake.
What Did the Researchers Do and Find?
Between 1993 and 1997, about 20,000 men and women aged 45–79 living in Norfolk UK, none of whom had cancer or cardiovascular disease (heart or circulation problems), completed a health and lifestyle questionnaire, had a health examination, and had their blood vitamin C level measured as part of the EPIC-Norfolk study. A health behavior score of between 0 and 4 was calculated for each participant by giving one point for each of the following healthy behaviors: current non-smoking, not physically inactive (physical inactivity was defined as having a sedentary job and doing no recreational exercise), moderate alcohol intake (1–14 units a week; a unit of alcohol is half a pint of beer, a glass of wine, or a shot of spirit), and a blood vitamin C level consistent with a fruit and vegetable intake of at least five servings a day. Deaths among the participants were then recorded until 2006. After allowing for other factors that might have affected their likelihood of dying (for example, age), people with a health behavior score of 0 were four times as likely to have died (in particular, from cardiovascular disease) than those with a score of 4. People with a score of 2 were twice as likely to have died.
What Do These Findings Mean?
These findings indicate that the combination of four simply defined health behaviors predicts a 4-fold difference in the risk of dying over an average period of 11 years for middle-aged and older people. They also show that the risk of death (particularly from cardiovascular disease) decreases as the number of positive health behaviors increase. Finally, they can be used to calculate that a person with a health score of 0 has the same risk of dying as a person with a health score of 4 who is 14 years older. These findings need to be confirmed in other populations and extended to an analysis of how these combined health behaviors affect the quality of life as well as the risk of death. Nevertheless, they strongly suggest that modest and achievable lifestyle changes could have a marked effect on the health of populations. Armed with this information, public-health officials should now be in a better position to encourage behavior changes likely to improve the health of middle-aged and older people.
Additional Information.
Please access these Web sites via the online version of this summary at
The MedlinePlus encyclopedia contains a page on healthy living (in English and Spanish)
The MedlinePlus page on seniors' health contains links to many sites dealing with healthy lifestyles and longevity (in English and Spanish)
The European Prospective Investigation into Cancer and Nutrition (EPIC) study is investigating the relationship between nutrition and lifestyle and the development of cancer and other chronic diseases; information about the EPIC-Norfolk study is also available
The US Centers for Disease Control and Prevention provides information on healthy aging for older adults, including information on health-related behaviors (in English and Spanish)
The UK charity Age Concerns provides a fact sheet about staying healthy in later life
The London Health Observatory, which provides information for policy makers and practitioners about improving health and health care, has a section on how lifestyle and behavior affect health
PMCID: PMC2174962  PMID: 18184033
7.  Psychosocial correlates of eating behavior in children and adolescents: a review 
Understanding the correlates of dietary intake is necessary in order to effectively promote healthy dietary behavior among children and adolescents. A literature review was conducted on the correlates of the following categories of dietary intake in children and adolescents: Fruit, Juice and Vegetable Consumption, Fat in Diet, Total Energy Intake, Sugar Snacking, Sweetened Beverage Consumption, Dietary Fiber, Other Healthy Dietary Consumption, and Other Less Healthy Dietary Consumption in children and adolescents.
Cross-sectional and prospective studies were identified from PubMed, PsycINFO and PsycArticles by using a combination of search terms. Quantitative research examining determinants of dietary intake among children and adolescents aged 3–18 years were included. The selection and review process yielded information on country, study design, population, instrument used for measuring intake, and quality of research study.
Seventy-seven articles were included. Many potential correlates have been studied among children and adolescents. However, for many hypothesized correlates substantial evidence is lacking due to a dearth of research. The correlates best supported by the literature are: perceived modeling, dietary intentions, norms, liking and preferences. Perceived modeling and dietary intentions have the most consistent and positive associations with eating behavior. Norms, liking, and preferences were also consistently and positively related to eating behavior in children and adolescents. Availability, knowledge, outcome expectations, self-efficacy and social support did not show consistent relationships across dietary outcomes.
This review examined the correlates of various dietary intake; Fruit, Juice and Vegetable Consumption, Fat in Diet, Total Energy Intake, Sugar Snacking, Sweetened Beverage Consumption, Dietary Fiber, Other Healthy Dietary Consumption, and Other Less Healthy Dietary Consumption in cross-sectional and prospective studies for children and adolescents. The correlates most consistently supported by evidence were perceived modeling, dietary intentions, norms, liking and preferences. More prospective studies on the psychosocial determinants of eating behavior using broader theoretical perspectives should be examined in future research.
PMCID: PMC3224918  PMID: 19674467
8.  Planned development and evaluation protocol of two versions of a web-based computer-tailored nutrition education intervention aimed at adults, including cognitive and environmental feedback 
BMC Public Health  2014;14:47.
Despite decades of nutrition education, the prevalence of unhealthy dietary patterns is still high and inequalities in intake between high and low socioeconomic groups still exist. Therefore, it is important to innovate and improve existing nutrition education interventions. This paper describes the development, design and evaluation protocol of a web-based computer-tailored nutrition education intervention for adults targeting fruit, vegetable, high-energy snack and fat intake. This intervention innovates existing computer-tailored interventions by not only targeting motivational factors, but also volitional and self-regulation processes and environmental-level factors.
The intervention development was guided by the Intervention Mapping protocol, ensuring a theory-informed and evidence-based intervention. Two versions of the intervention were developed: a basic version targeting knowledge, awareness, attitude, self-efficacy and volitional and self-regulation processes, and a plus version additionally addressing the home environment arrangement and the availability and price of healthy food products in supermarkets. Both versions consist of four modules: one for each dietary behavior, i.e. fruit, vegetables, high-energy snacks and fat. Based on the self-regulation phases, each module is divided into three sessions. In the first session, feedback on dietary behavior is provided to increase awareness, feedback on attitude and self-efficacy is provided and goals and action plans are stated. In the second session goal achievement is evaluated, reasons for failure are explored, coping plans are stated and goals can be adapted. In the third session, participants can again evaluate their behavioral change and tips for maintenance are provided. Both versions will be evaluated in a three-group randomized controlled trial with measurements at baseline, 1-month, 4-months and 9-months post-intervention, using online questionnaires. Both versions will be compared with a generic nutrition information control condition. The primary outcomes are fruit, vegetable, high-energy snack and fat intake.
The evaluation study will provide insight into the short- and long-term efficacy of both intervention versions in adults. Additionally, differences in the efficacy among high- and low-educated people will be examined. If these interventions are effective, two well-developed interventions will become available for the implementation and promotion of healthy dietary patterns among both high- and low-educated adults in the Netherlands.
Trial registration
Dutch Trial Registry NTR3396.
PMCID: PMC3915224  PMID: 24438381
Environmental feedback; Self-regulation; Computer tailoring; Nutrition education; Fruit intake; Vegetable intake; Fat intake; Snack intake
9.  Social Cognitive Determinants of Nutrition and Physical Activity Among Web-Health Users Enrolling in an Online Intervention: The Influence of Social Support, Self-Efficacy, Outcome Expectations, and Self-Regulation 
The Internet is a trusted source of health information for growing majorities of Web users. The promise of online health interventions will be realized with the development of purely online theory-based programs for Web users that are evaluated for program effectiveness and the application of behavior change theory within the online environment. Little is known, however, about the demographic, behavioral, or psychosocial characteristics of Web-health users who represent potential participants in online health promotion research. Nor do we understand how Web users’ psychosocial characteristics relate to their health behavior—information essential to the development of effective, theory-based online behavior change interventions.
This study examines the demographic, behavioral, and psychosocial characteristics of Web-health users recruited for an online social cognitive theory (SCT)-based nutrition, physical activity, and weight gain prevention intervention, the Web-based Guide to Health (WB-GTH).
Directed to the WB-GTH site by advertisements through online social and professional networks and through print and online media, participants were screened, consented, and assessed with demographic, physical activity, psychosocial, and food frequency questionnaires online (taking a total of about 1.25 hours); they also kept a 7-day log of daily steps and minutes walked.
From 4700 visits to the site, 963 Web users consented to enroll in the study: 83% (803) were female, participants’ mean age was 44.4 years (SD 11.03 years), 91% (873) were white, and 61% (589) were college graduates; participants’ median annual household income was approximately US $85,000. Participants’ daily step counts were in the low-active range (mean 6485.78, SD 2352.54) and overall dietary levels were poor (total fat g/day, mean 77.79, SD 41.96; percent kcal from fat, mean 36.51, SD 5.92; fiber g/day, mean 17.74, SD 7.35; and fruit and vegetable servings/day, mean 4.03, SD 2.33). The Web-health users had good self-efficacy and outcome expectations for health behavior change; however, they perceived little social support for making these changes and engaged in few self-regulatory behaviors. Consistent with SCT, theoretical models provided good fit to Web-users’ data (root mean square error of the approximation [RMSEA] < .05). Perceived social support and use of self-regulatory behaviors were strong predictors of physical activity and nutrition behavior. Web users’ self-efficacy was also a good predictor of healthier levels of physical activity and dietary fat but not of fiber, fruits, and vegetables. Social support and self-efficacy indirectly predicted behavior through self-regulation, and social support had indirect effects through self-efficacy.
Results suggest Web-health users visiting and ultimately participating in online health interventions may likely be middle-aged, well-educated, upper middle class women whose detrimental health behaviors put them at risk of obesity, heart disease, some cancers, and diabetes. The success of Internet physical activity and nutrition interventions may depend on the extent to which they lead users to develop self-efficacy for behavior change, but perhaps as important, the extent to which these interventions help them garner social-support for making changes. Success of these interventions may also depend on the extent to which they provide a platform for setting goals, planning, tracking, and providing feedback on targeted behaviors.
PMCID: PMC3221350  PMID: 21441100
Internet users; dietary habits; physical activity; psychosocial aspects; self-efficacy; social support; self-regulation
10.  Dietary behaviours during pregnancy: findings from first-time mothers in southwest Sydney, Australia 
Limited prevalence data are available for nutrition related health behaviours during pregnancy. This study aimed to assess dietary behaviours during pregnancy among first-time mothers, and to investigate the relationships between these behaviours and demographic characteristics, so that appropriate dietary intervention strategies for pregnant women can be developed.
An analysis of cross-sectional survey was conducted using data from 409 first-time mothers at 26-36 weeks of pregnancy, who participated in the Healthy Beginnings Trial conducted in southwestern Sydney, Australia. Dietary behaviours, including consumption of vegetables, fruit, water, milk, soft drinks, processed meat products, fast foods/take away and chips, were assessed using the New South Wales Health Survey questionnaire through face-to-face interviews. Factors associated with dietary behaviours were determined by logistic regression modeling. Log-binomial regression was used to calculate adjusted risk ratios (ARR).
Only 7% of mothers reported meeting the recommended vegetable consumption and 13% reported meeting the recommended fruit consumption. Mean and median intakes per day were 2.3 (SD 1.3) and 2 serves of vegetables, and 2.1 (SD 1.4) and 2 serves of fruit respectively. About one fifth of mothers (21%) reported drinking 2 cups (500 ml) or more of soft drink per day and 12% reported consuming more than 2 meals or snacks from fast-food or takeaway outlets per week. A small percentage of mothers (5%) had experienced food insecurity over the past 12 months. There were significant inverse associations between water and soft drink consumption (Spearman's ρ -0.20, P < 0.001), and between fruit and fast food/takeaway consumption (Spearman's ρ -0.16, P = 0.001). The dietary behaviours were associated with a variety of socio-demographic characteristics, but no single factor was associated with all the dietary behaviours.
There were low reported levels of vegetable and fruit consumption and high reported levels of soft drink and takeaway/fast food consumption among pregnant women. Dietary interventions to prevent adverse health consequences need to be tailored to meet the needs of pregnant women of low socio-economic status in order to improve their own healthy eating behaviors. Increasing water and fruit consumption could lead to reduced consumption of soft drink and takeaway/fast food among pregnant women.
Trial Registration
HBT is registered with the Australian Clinical Trial Registry (ACTRNO12607000168459)
PMCID: PMC2830165  PMID: 20181084
11.  Exploratory Study of Web-Based Planning and Mobile Text Reminders in an Overweight Population 
Forming specific health plans can help translate good intentions into action. Mobile text reminders can further enhance the effects of planning on behavior.
Our aim was to explore the combined impact of a Web-based, fully automated planning tool and mobile text reminders on intention to change saturated fat intake, self-reported saturated fat intake, and portion size changes over 4 weeks.
Of 1013 men and women recruited online, 858 were randomly allocated to 1 of 3 conditions: a planning tool (PT), combined planning tool and text reminders (PTT), and a control group. All outcome measures were assessed by online self-reports. Analysis of covariance was used to analyze the data.
Participants allocated to the PT (meansat urated fat 3.6, meancopingplanning 3) and PTT (meansaturatedfat 3.5, meancopingplanning 3.1) reported a lower consumption of high-fat foods (F 2,571 = 4.74, P = .009) and higher levels of coping planning (F 2,571 = 7.22, P < .001) than the control group (meansat urated f at 3.9, meancopingplanning 2.8). Participants in the PTT condition also reported smaller portion sizes of high-fat foods (mean 2.8; F 2, 569 = 4.12, P = .0) than the control group (meanportions 3.1). The reduction in portion size was driven primarily by the male participants in the PTT (P = .003). We found no significant group differences in terms of percentage saturated fat intake, intentions, action planning, self-efficacy, or feedback on the intervention.
These findings support the use of Web-based tools and mobile technologies to change dietary behavior. The combination of a fully automated Web-based planning tool with mobile text reminders led to lower self-reported consumption of high-fat foods and greater reductions in portion sizes than in a control condition.
Trial Registration
International Standard Randomized Controlled Trial Number (ISRCTN): 61819220; (Archived by WebCite at
PMCID: PMC3278104  PMID: 22182483
Implementation intentions; mobile text reminders; saturated fat
12.  The relationship between healthy behaviors and health outcomes among older adults in Russia 
BMC Public Health  2014;14(1):1183.
Worldwide, populations are aging and the health of elderly individuals is deteriorating. Healthy habits may slow the process of health deterioration, but research investigating relationships between health and various health behaviors is lacking. This study aimed to investigate the relationships between health and health behaviors (alcohol consumption, smoking, dietary behavior, and physical activity) among older men and women in Russia.
Wave 1 Study on Global AGEing and Adult Health data (2007–2010) collected in the European portion of the Russian Federation, southern federal districts of the European portion of Russia and from the Asian portion of the country were used for this study. Relationships between self-rated health and four risk behavior measures [physical activity, alcohol consumption, smoking, and dietary behavior (fruit and vegetable consumption)] were examined. Analyses controlled for several socioeconomic factors: gender, age, marital status, educational level, area of residence, ethnicity, and employment status. To estimate the effect of healthy behavior on the probability that participants rated their health as very good/good/moderate/bad/very bad, the ordered logit model and average marginal effects were used.
Sufficient physical activity affected self-rated health most significantly in both genders, whereas excessive alcohol consumption had no significant effect. Smoking had explanatory power (being a current smoker decreased the probability of a very good health assessment and increased the probability of a very bad rating compared with being a non-smoker) among men, but not women. Fruit and vegetable consumption had a strong effect on self-rated health among women, but not men.
The results of this study indicate that health behaviors, especially physical activity, are important for the health of Russia’s older population. Smoking behavior had a strong impact on the health of men, whereas fruit and vegetable consumption was a relevant factor for women. Policies promoting smoking reduction and healthy diet should thus target older men and women, respectively.
PMCID: PMC4251861  PMID: 25410349
Healthy behavior; Self-rated health; Physical activity; Dietary behavior; Alcohol; Smoking; Older population; Russia
13.  Oh baby! Motivation for healthy eating during parenthood transitions: a longitudinal examination with a theory of planned behavior perspective 
Transitioning to parenthood is a major life event that may impact parents’ personal lifestyles, yet there is an absence of theory-based research examining the impact of parenthood on motives for dietary behaviour. As a result, we are unaware of the social cognitive variables that predict eating behaviour among those transitioning to parenthood. The purpose of the study was to examine eating behaviour motives across 12 months within the framework of the theory of planned behavior (TPB) and compare these across groups of new parents, non-parents, and established parents.
Non-parents (n = 92), new parents (n = 135), and established parents (n = 71) completed TPB questionnaires assessing attitudes, subjective norms, perceived behavioral control (PBC), and intentions and three day food records at baseline, and 6- and 12-months post-delivery (for parents) and 6- and 12-months post-baseline (for non-parents).
Repeated measures ANOVAs revealed that among men, new- and established-parents had greater intentions to eat healthy compared to non-parents, F(2) = 3.59, p = .03. Among women, established parents had greater intentions than new- and non-parents, F(2) = 5.33, p = .01. Among both men and women during the first 6-months post-delivery, new-parents experienced decreased PBC, whereas established parents experienced increased PBC. Overall, affective attitudes were the strongest predictor of intentions for men (β = 0.55, p < .001) and women (β = 0.38, p < .01). PBC predicted changes in fruit and vegetable consumption for men (β = 0.45, p = .02), and changes in fat consumption for men (β = −0.25, p = .03) and women (β = −.24, p < .05), regardless of parent status.
The transition to parenthood for new and established parents may impact motivation for healthy eating, especially PBC within the framework of TPB. However, regardless of parental status, affective attitudes and PBC are critical antecedents of intentions and eating behaviour. Interventions should target affective attitudes and PBC to motivate healthy eating and may need to be intensified during parenthood.
PMCID: PMC3706269  PMID: 23829582
Theory of planned behaviour; Nutrition; Dietary behaviour; Parenthood
14.  Protection Motivation Theory in Predicting Intention to Engage in Protective Behaviors against Schistosomiasis among Middle School Students in Rural China 
Among millions of people who suffer from schistosomiasis in China, adolescents are at increased risk to be infected. However, there is a lack of theory-guided behavioral prevention intervention programs to protect these adolescents. This study attempted to apply the Protection Motivation Theory (PMT) in predicting intentions to engage in protective behaviors against schistosomiasis infection.
The participants were selected using the stratified cluster sampling method. Survey data were collected using anonymous self-reported questionnaire. The advanced structural equation modeling (SEM) method was utilized to assess the complex relationship among schistosomiasis knowledge, previous risk exposure and protective measures in predicting intentions to engage in protective behavior through the PMT constructs.
Principal Findings
Approximately 70% of participants reported they were always aware of schistosomiasis before exposure to water with endemic schistosomiasis, 6% of the participants reported frequency of weekly or monthly prior exposure to snail-conditioned water. 74% of participants reported having always engaged in protective behaviors in the past three months. Approximately 7% were unlikely or very unlikely to avoid contact with snail-conditioned water, and to use protective behaviors before exposure. Results from SEM analysis indicated that both schistosomiasis knowledge and prior exposure to schistosomiasis were indirectly related to behavior intentions through intrinsic rewards and self-efficacy; prior protective behaviors were indirectly related to behavior intentions through severity, intrinsic rewards and self-efficacy, while awareness had an indirect relationship with behavior intentions through self-efficacy. Among the seven PMT constructs, severity, intrinsic rewards and self-efficacy were significantly associated with behavior intentions.
The PMT can be used to predict the intention to engage in protective behaviors against schistosomiasis. Schistosomiasis intervention programs should focus on the severity, intrinsic rewards and self-efficacy of protection motivation, and also increase the awareness of infection, and enrich the contents of schistosomiasis education.
Author Summary
In China, millions of population suffer from schistosomiasis infection and adolescents tend to have higher infection rates than adults. The Knowledge-Attitude-Practice (KAP) Theory has traditionally been used as guidance to schistosomiasis prevention in China. However, despite increases in knowledge among residents in the epidemic areas due to KAP theory-based schistosomiasis health education, no significant reduction in water-contact behavior was evident. Therefore, it is of crucial importance to seek alternative health behavior change theories/models that are more effective than the KAP theory to promote purposeful behavioral change. The Protection Motivation Theory (PMT) as a social cognitive model may be an alternative to the KAP theory. In this study, we found that the PMT can be used to predict intention to engage in protective behaviors against schistosomiasis infection among middle school students in rural China. Based on the PMT, in addition to enhancing awareness of schistosomiasis infection, intervention programs should focus on the severity, intrinsic rewards and self-efficacy of protection motivation.
PMCID: PMC4199519  PMID: 25329829
15.  Multiple Health Behaviors in an Ethnically Diverse Sample of Adults with Risk Factors for Cardiovascular Disease 
The Permanente Journal  2011;15(1):12-18.
Background: Health behaviors of adults living with cardiovascular disease (CVD) risk factors affect additional risk, where lifestyle behavioral choices become even more important in controlling disease and preventing additional negative health outcomes. In addition, both lifestyle behaviors and CVD risk factor prevalence can vary by ethnicity.
Objective: We compared multiple health behaviors of adults with diabetes, hypertension, high cholesterol, and obesity to the behaviors of adults without those conditions in a diverse ethnic sample to determine if significant differences existed between groups.
Methods: Data were obtained from 30-minute random-digit-dial telephone surveys in 2007 (n = 3607). All data were self-reports. Healthy behaviors included meeting recommendations for intake of fruits and vegetables; consuming low or very low amounts of dietary fat; eating breakfast six or seven days per week; having a healthy diet; and meeting recommendations for walking, moderate, and vigorous physical activity. Unhealthy behaviors included frequent consumption of soda and fast food, smoking, binge drinking, and high stress.
Results: More than 6% of respondents had diabetes, 15.9% had hypertension, 16.4% had high cholesterol, and 18.5% were obese. Significantly fewer healthy and more unhealthy behaviors were reported for those who had CVD risk factors than were reported by those who did not have such conditions. Ethnic differences in CVD risk factor prevalence and health behaviors existed as well (p < 0.001). Logistic regression models indicated that not eating a healthy diet (odds ratio [OR] = 1.82) was a significant predictor for diabetes; not eating a healthy diet (OR = 1.52) and not doing vigorous physical activity (OR = 1.79) were significant predictors for hypertension; consumption of high amounts of dietary fat (OR = 1.70) and of fast food (OR = 1.51) were significant predictors for high cholesterol levels; and not eating a healthy diet (OR = 1.52), high consumption of dietary fat (OR = 2.20), not eating breakfast (OR = 1.33) and not performing vigorous physical activity (OR = 1.63), but less consumption of fast food (OR = 0.64) were significant predictors for obesity.
Conclusions: Specifically tailored and culturally sensitive interventions that address multiple health behaviors may be necessary for these high-risk populations.
PMCID: PMC3048627  PMID: 21505612
16.  Development and Preliminary Evaluation of an Internet-Based Healthy Eating Program: Randomized Controlled Trial 
The HealthValues Healthy Eating Programme is a standalone Internet-based intervention that employs a novel strategy for promoting behavior change (analyzing one’s reasons for endorsing health values) alongside other psychological principles that have been shown to influence behavior. The program consists of phases targeting motivation (dietary feedback and advice, analyzing reasons for health values, thinking about health-related desires, and concerns), volition (implementation intentions with mental contrasting), and maintenance (reviewing tasks, weekly tips).
The aim was to examine the effects of the program on consumption of fruit and vegetables, saturated fat, and added sugar over a 6-month period.
A total of 82 females and 18 males were recruited using both online and print advertisements in the local community. They were allocated to an intervention or control group using a stratified block randomization protocol. The program was designed such that participants logged onto a website every week for 24 weeks and completed health-related measures. Those allocated to the intervention group also completed the intervention tasks at these sessions. Additionally, all participants attended laboratory sessions at baseline, 3 months, and 6 months. During these sessions, participants completed a food frequency questionnaire (FFQ, the Block Fat/Sugar/Fruit/Vegetable Screener, adapted for the UK), and researchers (blind to group allocation) measured their body mass index (BMI), waist-to-hip ratio (WHR), and heart rate variability (HRV).
Data were analyzed using a series of ANOVA models. Per protocol analysis (n=92) showed a significant interaction for fruit and vegetable consumption (P=.048); the intervention group increased their intake between baseline and 6 months (3.7 to 4.1 cups) relative to the control group (3.6 to 3.4 cups). Results also showed overall reductions in saturated fat intake (20.2 to 15.6 g, P<.001) and added sugar intake (44.6 to 33.9 g, P<.001) during this period, but there were no interactions with group. Similarly, there were overall reductions in BMI (27.7 to 27.3 kg/m2, P=.001) and WHR (0.82 to 0.81, P=.009), but no interactions with group. The intervention did not affect alcohol consumption, physical activity, smoking, or HRV. Data collected during the online sessions suggested that the changes in fruit and vegetable consumption were driven by the motivational and maintenance phases of the program.
Results suggest that the program helped individuals to increase their consumption of fruit and vegetables and to sustain this over a 6-month period. The observed reduction in fat and sugar intake suggests that monitoring behaviors over time is effective, although further research is needed to confirm this conclusion. The Web-based nature of the program makes it a potentially cost-effective way of promoting healthy eating.
PMCID: PMC4210956  PMID: 25305376
social values; diet; fruit; vegetables; saturated fat; added sugar; motivation; Internet; health promotion; psychology
17.  The SNAPSHOT study protocol: SNAcking, Physical activity, Self-regulation, and Heart rate Over Time 
BMC Public Health  2014;14(1):1006.
The cognitive processes responsible for effortful behavioural regulation are known as the executive functions, and are implicated in several factors associated with behaviour control, including focussing on tasks, resisting temptations, planning future actions, and inhibiting prepotent responses. Similar to muscles, the executive functions become fatigued following intensive use (e.g. stressful situations, when tired or busy, and when regulating behaviour such as quitting smoking). Therefore, an individual may be more susceptible to engaging in unhealthy behaviours when their executive functions are depleted. In the present study we investigate associations between the executive functions, snack food consumption, and sedentary behaviour in real time. We hypothesise that individuals may be more susceptible to unhealthy snacking and sedentary behaviours during periods when their executive functions are depleted. We test this hypothesis using real-time objective within-person measurements.
A sample of approximately 50 Scottish adults from varied socio-economic, working, and cultural backgrounds will participate in the three phases of the SNAcking, Physical activity, Self-regulation, and Heart rate Over Time (SNAPSHOT) study. Phase one will require participants to complete home-based questionnaires concerned with diet, eating behaviour, and physical activity (≈1.5 hours to complete). Phase two will constitute a 2-3 hour psychological laboratory testing session during which trait-level executive function, general intelligence, and diet and physical activity intentions, past behaviour, and automaticity will be measured. The final phase will involve a 7-day ambulatory protocol during which objective repeated assessments of executive function, snacking behaviour, physical activity, mood, heart rate, perceived energy level, current context and location will be measured during participants’ daily routines. Multi-level regression analysis, accounting for observations nested within participants, will be used to investigate associations between fluctuations in the executive functions and health behaviours.
Data from the SNAPSHOT study will provide ecologically valid information to help better understand the temporal associations between self-regulatory resources (executive functions) and deleterious health behaviours such as snacking and sedentary behaviour. If we can identify particular periods of the day or locations where self-regulatory resources become depleted and produce suboptimal health behaviour, then interventions can be designed and targeted accordingly.
PMCID: PMC4196005  PMID: 25261200
Snack; Food choice; Executive function; Self regulation; Intentions; Physical activity; Ecological momentary assessment; Accelerometer; GPS; PRO-Diary; Actiheart
18.  Cardiovascular risk profile: Cross-sectional analysis of motivational determinants, physical fitness and physical activity 
BMC Public Health  2010;10:592.
Cardiovascular risk factors are associated with physical fitness and, to a lesser extent, physical activity. Lifestyle interventions directed at enhancing physical fitness in order to decrease the risk of cardiovascular diseases should be extended. To enable the development of effective lifestyle interventions for people with cardiovascular risk factors, we investigated motivational, social-cognitive determinants derived from the Theory of Planned Behavior (TPB) and other relevant social psychological theories, next to physical activity and physical fitness.
In the cross-sectional Utrecht Police Lifestyle Intervention Fitness and Training (UP-LIFT) study, 1298 employees (aged 18 to 62) were asked to complete online questionnaires regarding social-cognitive variables and physical activity. Cardiovascular risk factors and physical fitness (peak VO2) were measured.
For people with one or more cardiovascular risk factors (78.7% of the total population), social-cognitive variables accounted for 39% (p < .001) of the variance in the intention to engage in physical activity for 60 minutes every day. Important correlates of intention to engage in physical activity were attitude (beta = .225, p < .001), self-efficacy (beta = .271, p < .001), descriptive norm (beta = .172, p < .001) and barriers (beta = -.169, p < .01). Social-cognitive variables accounted for 52% (p < .001) of the variance in physical active behaviour (being physical active for 60 minutes every day). The intention to engage in physical activity (beta = .469, p < .001) and self-efficacy (beta = .243, p < .001) were, in turn, important correlates of physical active behavior.
In addition to the prediction of intention to engage in physical activity and physical active behavior, we explored the impact of the intensity of physical activity. The intentsity of physical activity was only significantly related to physical active behavior (beta = .253, p < .01, R2 = .06, p < .001). An important goal of our study was to investigate the relationship between physical fitness, the intensity of physical activity and social-cognitive variables. Physical fitness (R2 = .23, p < .001) was positively associated with physical active behavior (beta = .180, p < .01), self-efficacy (beta = .180, p < .01) and the intensity of physical activity (beta = .238, p < .01).
For people with one or more cardiovascular risk factors, 39.9% had positive intentions to engage in physical activity and were also physically active, and 10.5% had a low intentions but were physically active. 37.7% had low intentions and were physically inactive, and about 11.9% had high intentions but were physically inactive.
This study contributes to our ability to optimize cardiovascular risk profiles by demonstrating an important association between physical fitness and social-cognitive variables. Physical fitness can be predicted by physical active behavior as well as by self-efficacy and the intensity of physical activity, and the latter by physical active behavior.
Physical active behavior can be predicted by intention, self-efficacy, descriptive norms and barriers. Intention to engage in physical activity by attitude, self-efficacy, descriptive norms and barriers. An important input for lifestyle changes for people with one or more cardiovascular risk factors was that for ca. 40% of the population the intention to engage in physical activity was in line with their actual physical active behavior.
PMCID: PMC3091554  PMID: 20929529
19.  Psychosocial predictors of eating habits among adults in their mid-30s: The Oslo Youth Study follow-up 1991–1999 
The predictive value of the psychosocial constructs of Theory of Planned Behaviour (TPB) on subsequent dietary habits has not been previously investigated in a multivariate approach that includes demographic factors and past dietary behaviour among adults. The aim of this study was to investigate to what extent TPB constructs, including intention, attitudes, subjective norms, perceived behavioural control, and perceived social norms, measured at age 25 predicted four eating behaviours (intake of fruits and vegetables, whole grains, total fat and added sugar) eight years later.
Two hundred and forty men and 279 women that participated in the Oslo Youth Study were followed from 1991 to 1999 (mean age 25 and 33 years, respectively). Questionnaires at baseline (1991) included the constructs of the TPB and dietary habits, and at follow-up (1999) questionnaires included demographic factors and diet. For the assessment of diet, a food frequency questionnaire (FFQ) with a few food items was used at baseline while an extensive semi-quantitative FFQ was used at follow-up.
Among men, attitudes, subjective norms and previous eating behaviour were significant predictors of fruit and vegetable intake, while education and past eating behaviour were predictive of whole grain intake in multivariate analyses predicting dietary intake at follow-up. For women, perceived behavioural control, perceived social norms and past behaviour were predictive of fruit and vegetable intake, while subjective norms, education and past eating behaviour were predictive of whole grain intake. For total fat intake, intention was predictive for men and perceived behavioural control for women. Household income and past consumption of sugar-rich foods were significant predictors of added sugar intake among men, while past intake of sugar-rich foods was a significant predictor of added sugar intake among women.
After adjusting for potential confounding factors, all psychosocial factors assessed among young adults appeared predictive of one or more eating behaviours reported eight years later. Results point to the influence of psychosocial factors on future eating behaviours and the potential for interventions targeting such factors.
PMCID: PMC1208934  PMID: 16076386
20.  Predicting fruit consumption: the role of habits, previous behavior and mediation effects 
BMC Public Health  2014;14:730.
This study assessed the role of habits and previous behavior in predicting fruit consumption as well as their additional predictive contribution besides socio-demographic and motivational factors. In the literature, habits are proposed as a stable construct that needs to be controlled for in longitudinal analyses that predict behavior. The aim of this study is to provide empirical evidence for the inclusion of either previous behavior or habits.
A random sample of 806 Dutch adults (>18 years) was invited by an online survey panel of a private research company to participate in an online study on fruit consumption. A longitudinal design (N = 574) was used with assessments at baseline and after one (T2) and two months (T3). Multivariate linear regression analysis was used to assess the differential value of habit and previous behavior in the prediction of fruit consumption.
Eighty percent of habit strength could be explained by habit strength one month earlier, and 64% of fruit consumption could be explained by fruit consumption one month earlier. Regression analyses revealed that the model with motivational constructs explained 41% of the behavioral variance at T2 and 38% at T3. The addition of previous behavior and habit increased the explained variance up to 66% at T2 and to 59% at T3. Inclusion of these factors resulted in non-significant contributions of the motivational constructs. Furthermore, our findings showed that the effect of habit strength on future behavior was to a large extent mediated by previous behavior.
Both habit and previous behavior are important as predictors of future behavior, and as educational objectives for behavior change programs. Our results revealed less stability for the constructs over time than expected. Habit strength was to a large extent mediated by previous behavior and our results do not strongly suggest a need for the inclusion of both constructs. Future research needs to assess the conditions that determine direct influences of both previous behavior and habit, since these influences may differ per type of health behavior, per context stability in which the behavior is performed, and per time frame used for predicting future behavior.
PMCID: PMC4223379  PMID: 25037859
Fruit consumption; Habit; Previous behavior; SRHI
21.  Cross-National Analysis of the Associations among Mental Disorders and Suicidal Behavior: Findings from the WHO World Mental Health Surveys 
PLoS Medicine  2009;6(8):e1000123.
Using data from over 100,000 individuals in 21 countries participating in the WHO World Mental Health Surveys, Matthew Nock and colleagues investigate which mental health disorders increase the odds of experiencing suicidal thoughts and actual suicide attempts, and how these relationships differ across developed and developing countries.
Suicide is a leading cause of death worldwide. Mental disorders are among the strongest predictors of suicide; however, little is known about which disorders are uniquely predictive of suicidal behavior, the extent to which disorders predict suicide attempts beyond their association with suicidal thoughts, and whether these associations are similar across developed and developing countries. This study was designed to test each of these questions with a focus on nonfatal suicide attempts.
Methods and Findings
Data on the lifetime presence and age-of-onset of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) mental disorders and nonfatal suicidal behaviors were collected via structured face-to-face interviews with 108,664 respondents from 21 countries participating in the WHO World Mental Health Surveys. The results show that each lifetime disorder examined significantly predicts the subsequent first onset of suicide attempt (odds ratios [ORs] = 2.9–8.9). After controlling for comorbidity, these associations decreased substantially (ORs = 1.5–5.6) but remained significant in most cases. Overall, mental disorders were equally predictive in developed and developing countries, with a key difference being that the strongest predictors of suicide attempts in developed countries were mood disorders, whereas in developing countries impulse-control, substance use, and post-traumatic stress disorders were most predictive. Disaggregation of the associations between mental disorders and nonfatal suicide attempts showed that these associations are largely due to disorders predicting the onset of suicidal thoughts rather than predicting progression from thoughts to attempts. In the few instances where mental disorders predicted the transition from suicidal thoughts to attempts, the significant disorders are characterized by anxiety and poor impulse-control. The limitations of this study include the use of retrospective self-reports of lifetime occurrence and age-of-onset of mental disorders and suicidal behaviors, as well as the narrow focus on mental disorders as predictors of nonfatal suicidal behaviors, each of which must be addressed in future studies.
This study found that a wide range of mental disorders increased the odds of experiencing suicide ideation. However, after controlling for psychiatric comorbidity, only disorders characterized by anxiety and poor impulse-control predict which people with suicide ideation act on such thoughts. These findings provide a more fine-grained understanding of the associations between mental disorders and subsequent suicidal behavior than previously available and indicate that mental disorders predict suicidal behaviors similarly in both developed and developing countries. Future research is needed to delineate the mechanisms through which people come to think about suicide and subsequently progress from ideation to attempts.
Please see later in the article for Editors' Summary
Editors' Summary
Suicide is a leading cause of death worldwide. Every 40 seconds, someone somewhere commits suicide. Over a year, this adds up to about 1 million self-inflicted deaths. In the USA, for example, where suicide is the 11th leading cause of death, more than 30,000 people commit suicide every year. The figures for nonfatal suicidal behavior (suicidal thoughts or ideation, suicide planning, and suicide attempts) are even more shocking. Globally, suicide attempts, for example, are estimated to be 20 times as frequent as completed suicides. Risk factors for nonfatal suicidal behaviors and for suicide include depression and other mental disorders, alcohol or drug abuse, stressful life events, a family history of suicide, and having a friend or relative commit suicide. Importantly, nonfatal suicidal behaviors are powerful predictors of subsequent suicide deaths so individuals who talk about killing themselves must always be taken seriously and given as much help as possible by friends, relatives, and mental-health professionals.
Why Was This Study Done?
Experts believe that it might be possible to find ways to decrease suicide rates by answering three questions. First, which individual mental disorders are predictive of nonfatal suicidal behaviors? Although previous studies have reported that virtually all mental disorders are associated with an increased risk of suicidal behaviors, people often have two or more mental disorders (“comorbidity”), so many of these associations may reflect the effects of only a few disorders. Second, do some mental disorders predict suicidal ideation whereas others predict who will act on these thoughts? Finally, are the associations between mental disorders and suicidal behavior similar in developed countries (where most studies have been done) and in developing countries? By answering these questions, it should be possible to improve the screening, clinical risk assessment, and treatment of suicide around the world. Thus, in this study, the researchers undertake a cross-national analysis of the associations among mental disorders (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV]) and nonfatal suicidal behaviors.
What Did the Researchers Do and Find?
The researchers collected and analyzed data on the lifetime presence and age-of-onset of mental disorders and of nonfatal suicidal behaviors in structured interviews with nearly 110,000 participants from 21 countries (part of the World Health Organization's World Mental Health Survey Initiative). The lifetime presence of each of the 16 disorders considered (mood disorders such as depression; anxiety disorders such as post-traumatic stress disorder [PTSD]; impulse-control disorders such as attention deficit/hyperactivity disorder; and substance misuse) predicted first suicide attempts in both developed and developing countries. However, the increased risk of a suicide attempt associated with each disorder varied. So, for example, in developed countries, after controlling for comorbid mental disorders, major depression increased the risk of a suicide attempt 3-fold but drug abuse/dependency increased the risk only 2-fold. Similarly, although the strongest predictors of suicide attempts in developed countries were mood disorders, in developing countries the strongest predictors were impulse-control disorders, substance misuse disorders, and PTSD. Other analyses indicate that mental disorders were generally more predictive of the onset of suicidal thoughts than of suicide plans and attempts, but that anxiety and poor impulse-control disorders were the strongest predictors of suicide attempts in both developed and developing countries.
What Do These Findings Mean?
Although this study has several limitations—for example, it relies on retrospective self-reports by study participants—its findings nevertheless provide a more detailed understanding of the associations between mental disorders and subsequent suicidal behaviors than previously available. In particular, its findings reveal that a wide range of individual mental disorders increase the chances of an individual thinking about suicide in both developed and developing countries and provide new information about the mental disorders that predict which people with suicidal ideas will act on such thoughts. However, the findings also show that only half of people who have seriously considered killing themselves have a mental disorder. Thus although future suicide prevention efforts should include a focus on screening and treating mental disorders, ways must also be found to identify the many people without mental disorders who are at risk of suicidal behaviors.
Additional Information
Please access these Web sites via the online version of this summary at
The US National Institute of Mental Health provides information about suicide in the US: statistics and prevention
The UK National Health Service provides information about suicide, including statistics about suicide in the UK and links to other resources
The World Health Organization provides global statistics about suicide and information on suicide prevention
MedlinePlus provides links to further information and advice about suicide and about mental health (in English and Spanish)
Further details about the World Mental Health Survey Initiative and about DSM-IV are available
PMCID: PMC2717212  PMID: 19668361
22.  The role of action planning and plan enactment for smoking cessation 
BMC Public Health  2013;13:393.
Several studies have reemphasized the role of action planning. Yet, little attention has been paid to the role of plan enactment. This study assesses the determinants and the effects of action planning and plan enactment on smoking cessation.
One thousand and five participants completed questionnaires at baseline and at follow-ups after one and six months. Factors queried were part of the I-Change model. Descriptive analyses were used to assess which plans were enacted the most. Multivariate linear regression analyses were used to assess whether the intention to quit smoking predicted action planning and plan enactment, and to assess which factors would predict quitting behavior. Subsequently, both multivariate and univariate regression analyses were used to assess which particular action plans would be most effective in predicting quitting behavior. Similar analyses were performed among a subsample of smokers prepared to quit within one month.
Smokers who intended to quit smoking within the next month had higher levels of action planning than those intending to quit within a year. Additional predictors of action planning were being older, being female, having relatively low levels of cigarette dependence, perceiving more positive and negative consequences of quitting, and having high self-efficacy toward quitting. Plan enactment was predicted by baseline intention to quit and levels of action planning. Regression analysis revealed that smoking cessation after six months was predicted by low levels of depression, having a non-smoking partner, the intention to quit within the next month, and plan enactment. Only 29% of the smokers who executed relatively few plans had quit smoking versus 59% of the smokers who executed many plans. The most effective preparatory plans for smoking cessation were removing all tobacco products from the house and choosing a specific date to quit.
Making preparatory plans to quit smoking is important because it also predicts plan enactment, which is predictive of smoking cessation. Not all action plans were found to be predictive of smoking cessation. The effects of planning were not very much different between the total sample and smokers prepared to quit within one month.
PMCID: PMC3644281  PMID: 23622256
Smoking cessation; Action planning; Preparatory planning; Plan enactment; Planned quit attempts
23.  Towards an Effective Health Interventions Design: An Extension of the Health Belief Model 
Online Journal of Public Health Informatics  2012;4(3):ojphi.v4i3.4321.
The recent years have witnessed a continuous increase in lifestyle related health challenges around the world. As a result, researchers and health practitioners have focused on promoting healthy behavior using various behavior change interventions. The designs of most of these interventions are informed by health behavior models and theories adapted from various disciplines. Several health behavior theories have been used to inform health intervention designs, such as the Theory of Planned Behavior, the Transtheoretical Model, and the Health Belief Model (HBM). However, the Health Belief Model (HBM), developed in the 1950s to investigate why people fail to undertake preventive health measures, remains one of the most widely employed theories of health behavior. However, the effectiveness of this model is limited. The first limitation is the low predictive capacity (R2 < 0.21 on average) of existing HBM’s variables coupled with the small effect size of individual variables. The second is lack of clear rules of combination and relationship between the individual variables. In this paper, we propose a solution that aims at addressing these limitations as follows: (1) we extended the Health Belief Model by introducing four new variables: Self-identity, Perceived Importance, Consideration of Future Consequences, and Concern for Appearance as possible determinants of healthy behavior. (2) We exhaustively explored the relationships/interactions between the HBM variables and their effect size. (3) We tested the validity of both our proposed extended model and the original HBM on healthy eating behavior. Finally, we compared the predictive capacity of the original HBM model and our extended model.
To achieve the objective of this paper, we conducted a quantitative study of 576 participants’ eating behavior. Data for this study were collected over a period of one year (from August 2011 to August 2012). The questionnaire consisted of validated scales assessing the HBM determinants – perceived benefit, barrier, susceptibility, severity, cue to action, and self-efficacy – using 7-point Likert scale. We also assessed other health determinants such as consideration of future consequences, self-identity, concern for appearance and perceived importance. To analyses our data, we employed factor analysis and Partial Least Square Structural Equation Model (PLS-SEM) to exhaustively explore the interaction/relationship between the determinants and healthy eating behavior. We tested for the validity of both our proposed extended model and the original HBM on healthy eating behavior. Finally, we compared the predictive capacity of the original HBM model and our extended model and investigated possible mediating effects.
The results show that the three newly added determinants are better predictors of healthy behavior. Our extended HBM model lead to approximately 78% increase (from 40 to 71%) in predictive capacity compared to the old model. This shows the suitability of our extended HBM for use in predicting healthy behavior and in informing health intervention design. The results from examining possible relationships between the determinants in our model lead to an interesting discovery of some mediating relationships between the HBM’s determinants, therefore, shedding light on some possible combinations of determinants that could be employed by intervention designers to increase the effectiveness of their design.
Consideration of future consequences, self-identity, concern for appearance, perceived importance, self-efficacy, perceived susceptibility are significant determinants of healthy eating behavior that can be manipulated by healthy eating intervention design. Most importantly, the result from our model established the existence of some mediating relationships among the determinants. The knowledge of both the direct and indirect relationships sheds some light on the possible combination rules.
PMCID: PMC3615835  PMID: 23569653
Health Belief; Models; Health Behavior; Health Interventions; Theories; Determinants
24.  Racial/Ethnic Disparities in Exercise and Dietary Behaviors of Middle-Aged and Older Adults 
Differences in health behaviors may be important contributors to racial/ethnic disparities in the health status of adults. Studies to date have not compared whether there are health behavior differences in exercise and dietary behaviors among middle-age and older adults in the four largest racial/ethnic categories.
To investigate racial/ethnic differences in exercise and dietary behaviors of middle-aged and older adults.
We used data from the 2007 California Health Interview Survey. Multivariable logistic regression was used to examine interactions between age and race/ethnicity in predicting two categories of health behaviors. Analyses were conducted adjusting for sociodemographic characteristics, health insurance status, and healthcare utilization.
A population-based sample of 33,189 California adults 45 years old and older: 26,522 non-Hispanic whites, 1,686 African American/blacks, 2,565 Asian/Pacific Islanders (1,741 English-proficient; 824 limited English-proficient), and 2,416 Latinos (1,538 English-proficient; 878 limited English-proficient).
Self-report leisure-time physical activity (moderate and vigorous) and daily consumption of fruits and vegetables.
Racial/ethnic minorities generally engaged in less healthy exercise and dietary behaviors than whites, with differences more pronounced in middle adulthood. The disparities were the greatest among English-proficient minorities. Specifically, among middle-aged respondents, all racial/ethnic minorities engaged in less vigorous physical activity than whites (ORs range = 0.28 to 0.73; 95% CI range = 0.16-1.00). Additionally, middle-aged, English-proficient minorities engaged in less moderate physical activity compared to whites (ORs range =0.57 to 0.67; 95% CI range = 0.45-0.79). Furthermore, middle-aged, English-proficient Latinos had a poorer diet than whites (OR = 0.54; 0.39-0.75). Few significant racial/ethnic differences emerged in the exercise and dietary behaviors of older adults.
Racial/ethnic disparities in exercise and dietary behaviors are most notable among middle-aged, acculturated minorities. Results highlight the need to promote positive exercise and dietary behaviors during critical preventive ages, when racial/ethnic disparities are large and the potential to prevent chronic disease is great.
PMCID: PMC3043172  PMID: 20865342
diet; exercise; older adults; racial and ethnic disparities; California Health Interview Survey
25.  Drinking Patterns, Gender and Health III: Avoiding vs. Seeking Healthcare 
Addiction research & theory  2010;18(2):160-180.
Inability to predict most health services use and costs using demographics and health status suggests that other factors affect use, including attitudes and practices that influence health and willingness to seek care. Alcohol consumption has generated interest because heavy, chronic consumption causes adverse health consequences, acute consumption increases injury, and moderate drinking is linked to better health while hazardous drinking and alcohol-related problems are stigmatized and may affect willingness to seek care.
A stratified random sample of health-plan members completed a mail survey, yielding 7884 respondents (2995 male/4889 female). We linked survey data to 24 months of health-plan records to examine relationships between alcohol use, gender, health-related attitudes, practices, health, and service use. In-depth interviews with a stratified 150-respondent subsample explored individuals’ reasons for seeking or avoiding care.
Quantitative results suggest health-related practices and attitudes predict subsequent service use. Consistent predictors of care were having quit drinking, current at-risk consumption, cigarette smoking, higher BMI, disliking visiting doctors, and strong religious/spiritual beliefs. Qualitative analyses suggest embarrassment and shame are strong motivators for avoiding care.
Although models included numerous health, functional status, attitudinal and behavioral predictors, variance explained was similar to previous reports, suggesting more complex relationships than expected. Qualitative analyses suggest several potential predictive factors not typically measured in service-use studies: embarrassment and shame, fear, faith that the body will heal, expectations about likelihood of becoming seriously ill, disliking the care process, the need to understand health problems, and the effects of self-assessments of health-related functional limitations.
PMCID: PMC3686530  PMID: 23795149
Alcohol Drinking; Health Services Utilization; Gender; Health Status; Health Behavior; Health-related Attitudes

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