Part D. Chapter 3: Individual Diet and Physical Activity Behavior Change
Needs for Future Research
Develop a standard methodology to collect and characterize various types of eating venues.
Rationale: This recommendation is fundamental to conducting rigorous research, evaluating findings from multiple studies, and developing policies to promote healthy eating among people who frequent eating out venues and/or consume take away meals.
Conduct rigorously designed research to examine the longitudinal impact of obtaining or consuming meals away from home from various types of commonly frequented venues on changes in food and beverage intakes (frequency, quantity, and composition), body weight, adiposity, and health profiles from childhood to adulthood in diverse (racial/ethnic, socioeconomic, cultural, and geographic) groups of males and females.
Rationale: Most groups in the U.S. population regularly consume meals that are prepared away from home and the landscape of fast food and other types of food procurement and consumption venues is increasingly complex. The potential for eating out and/or take away meals to influence diet quality, energy balance, body mass and composition, and the risks of health-related morbidities across the lifespan among our diverse population underscores the importance of understanding this issue.
Family Shared Meals
Conduct studies in diverse populations that assess not only frequency of family shared meals, but also quality of family shared meals.
Rationale: Our understanding of the importance of family shared meals in terms of how they contribute in a positive way to body weight and overall health and well-being requires a rigorous examination of the dietary quality of these meals compared to other meals consumed by family members.
Conduct RCTs to isolate the effect of interventions that increase the frequency of family meals from other health and parenting behaviors that may be associated with dietary intake and weight status.
Rationale: Family shared meals are commonly implemented as one component of lifestyle interventions that include an array of other behavioral and parenting strategies for weight management. To improve our understanding of the causal pathway of how family shared meals contributes to maintaining or achieving a health weight, the specific contribution of family shared meals to weight outcomes independent of other behavioral strategies needs to be ascertained.
Develop improved and better standardized and validated tools to assess sedentary behaviors and activities that children, adolescents, and adults regularly engage in.
Rationale: Our understanding of the impact of sedentary behaviors on diet, energy balance, body mass, adiposity, and health is currently compromised by reliance on subjective assessments, including self-reports of daily activity patterns, and by inadequate techniques to document and quantify the array of sedentary activities people engage in (beyond TV viewing and (or) computer screen time). It also would be beneficial for researchers to document the potential benefits and implications of reducing one type of sedentary behavior (e.g. screen time) on other sedentary behaviors (e.g., reading for leisure, arts and crafts, listening to music) and indices of health (e.g. sleep quality and duration).
Conduct prospective research to examine the effects and mechanisms of the quantity, patterns, and changes of sedentary behaviors on diet quality, energy balance, body weight, adiposity, and health across the life span in groups within the U.S. population with diverse personal, cultural, economic, and geographic characteristics.
Rationale: Emerging, but limited, evidence implicates sedentary behaviors with adverse health-related outcomes, especially in children and adolescents as they transition into adulthood. However, an improved understanding of why these relationships exist will help in developing appropriate and effective approaches and policies to reduce the amount of time people spend engaging in sedentary behaviors.
Evaluate the impact of different types, modalities, and frequencies of self-monitoring on body weight outcomes during both the weight loss intervention and maintenance periods.
Rationale: Self-monitoring is associated with improved weight management. However, the current practice of recommending daily self-monitoring may represent a barrier to its implementation and/or continued use. Hence, it is important to determine whether lower frequencies of self-monitoring can produce beneficial effects on weight outcomes.
Evaluate the comparative effectiveness of performance feedback from self-monitoring delivered through automated systems versus personal interactions with a counselor.
Rationale: Automated feedback derived from self-monitoring data and delivered electronically can produce beneficial changes on weight outcomes. However, the comparative effectiveness and cost efficiency of feedback delivered through non-personal modalities versus personal interactions has yet to be determined.
Test the effectiveness of self-monitoring on weight outcomes in understudied groups, including ethnic/racial minorities, low education, low literacy, and low numeracy populations, males, and subjects younger than age 30 years and older than age 60 years.
Rationale: Evidence regarding the effectiveness of self-monitoring has been derived largely from research conducted on well educated, middle-class, white women. Hence, it is important to determine whether the beneficial effects of self-monitoring on weight outcomes are generalizable to understudied groups.
Conduct RCTs based on sound behavioral change theories that incorporate self-monitoring, employ heterogeneous populations, and are powered for small effect sizes and high attrition rates, to test the short- (e.g., 3 months) and long-term (e.g., 12 months) effects of mobile health technologies on dietary and weight outcomes.
Rationale: Mobile health technologies have the potential to reach larger portions of the populations than face-to-face interventions, but the effect sizes of mobile technologies may be small and the attrition rates may be large. Larger, more representative study populations and longer study periods will permit an assessment of the generalizability and sustainability of mobile health technologies.
Food and Menu Labeling
Develop novel labeling approaches to provide informative strategies to convey caloric intake values on food items consumed at home and in restaurant settings.
Rationale: Menu labels can include different types of information in addition to calories. These include physical activity equivalents, and daily caloric needs. Very few studies have been designed to examine the optimal combination of menu label information to prevent excessive caloric intake. This will be very valuable evidence to inform the calorie label policy that has just been enacted by the FDA.
Compare labeling strategies across various settings, such as restaurants, stores, and the home to determine their efficacy in altering food selection and health outcomes, including weight.
Rationale: The great majority of menu labeling RCT's have been conducted under laboratory conditions. Given the recent FDA regulations, future studies will be able to impact the effectiveness of these polices across settings as accessed by diverse free living populations.
Evaluate the process and impact of recent FDA menu labeling regulation.
Rationale: The new FDA regulation provides a unique opportunity to understand the impact of menu labeling on consumers dietary behaviors in "real world" settings.
Household Food Insecurity
Conduct prospective cohort studies that cover a wide age range and include children, families, older adults, and ethnically/racially diverse populations and describe potential effect modifiers such as gender, ethnic and cultural factors, family structure, area of residence (i.e., urban vs. rural), employment, and use of social support systems while examining the relationship between household food insecurity, dietary intake, and body weight.
Rationale: Understanding the temporal process of when and how long food insecurity occurs within a family/individuals lifetime and their response to this economic stressor is critical to conducting rigorous research and comparing finding across studies in order to develop and implement intervention studies and policies to alleviate this public health problem.
Standardize research methodology, including developing a consistent approach to measuring food insecurity and use of measured height and weight to reduce the likelihood of responder bias.
Rationale: The measurement error issues related to the use of self-reported weight have been well documented in the literature. In order to conduct rigorous studies in this area that can be compared and evaluated as to the causal nature of the role of food insecurity on body weight, standard methodology is warranted both in the measurement of the exposure as well as the outcome.
Conduct prospective longitudinal studies including those that start in early childhood to track dietary intake, sedentary behaviors, body weight, and chronic disease outcomes across the lifespan. Include the diversity of ethnic/racial groups in the United States, including individuals and families of diverse national origins. Include comparison groups in countries of origin to rule out, among other things, the potential confounding by internal migration from rural to urban area within the country of origin.
Rationale: Acculturation is a time-dependent life course process that requires longitudinal studies to be properly understood. Because the impact of acculturation on dietary, weight and health outcomes can be expected to be modified by the life course stage of life when individuals migrate to the United States, prospective acculturation studies need to start following individuals from very early childhood.
Develop a standard tool to measure acculturation or validation of multidimensional acculturation scales in different immigrant groups and in different languages.
Rationale: Acculturation is a complex construct that is seldom measured with multidimensional scales that can capture the different paths that migrant scan take with regards to the acculturation process, including assimilation, integration, segregation, and marginalization. Although research in acculturation measurement has been conducted among Hispanic/Latinos, it has been predominantly based on Mexican American populations and little acculturation measurement research has been conducted among other groups, including individuals from Asia, Africa, Europe, and the Middle East.
Conduct prospective studies that start in childhood (including transition to adulthood), to investigate the longitudinal effect of sleep patterns on diet and body weight outcomes while accounting for confounders, mediators, and moderators including: physical activity, socioeconomic variables (such as education, employment, household income), sex, alcohol intake, smoking status (including new smoker, new non-smoker), media use/screen time, and depression.
Rationale: While research associates short sleep duration and disordered sleep patterns with adverse differences and changes in food and beverage consumption, body weight, and indices of metabolic and cardiovascular health, less is known about the impact of potential modifying lifestyle factors. This research will help delineate the role of sleep patterns, duration and quality, i.e., mediator or moderator, on diet and weigh-related outcomes. Research in children shows that sleep deprivation and weight are related but this relationship is not apparent in adult studies. This may be due to the fact that energy intake increases during transition to short sleep duration, but levels off when short sleep duration becomes consistent.
Conduct studies to assess the effects of diet on sleep quality to examine the mechanism by which dietary intake, energy intake, and energy expenditure may impact sleep.
Rationale: Most research has focused on sleep quality and duration as modifying factors on diet, body weight, and health. A paucity of research exists on the potential impact of diet on sleep-related outcomes. This line of research would use diet as the means to improve indices of sleep, which in turn may subsequently improve health-related outcomes.