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A Multicomponent Program for Nutrition and Physical Activity Change in Primary Care
PACE+ for Adolescents
Kevin Patrick, MD, MS;
James F. Sallis, PhD;
Judith J. Prochaska, MS;
David D. Lydston, MS;
Karen J. Calfas, PhD;
Marion F. Zabinski, BA;
Denise E. Wilfley, PhD;
Brian E. Saelens, PhD;
David R. Brown, PhD
Arch Pediatr Adolesc Med. 2001;155:940-946.
ABSTRACT
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Background Most adolescents do not meet national recommendations for nutrition
and physical activity. However, no studies of physical activity and nutrition
interventions for adolescents conducted in health care settings have been
published. The present study was an initial evaluation of the PACE+ (Patient-centered
Assessment and Counseling for Exercise plus Nutrition) program, delivered
in primary care settings.
Participants Adolescents aged 11 to 18 years (N = 117) were recruited from 4 pediatric
and adolescent medicine outpatient clinics. Participants' mean (SD) age was
14.1 (2.0) years, 37% were girls, and 43% were ethnic minorities.
Intervention Behavioral targets were moderate physical activity, vigorous physical
activity, fat intake, and fruit and vegetable intake. All patients completed
a computerized assessment, created tailored action plans to change behavior,
and discussed the plans with their health care provider. Patients were then
randomly assigned to receive no further contact or 1 of 3 extended interventions:
mail only, infrequent telephone and mail, or frequent telephone and mail.
Measures Brief, validated, self-report measures of target behaviors were collected
at baseline and 4 months later.
Results All outcomes except vigorous physical activity improved over time, but
adolescents who received the extended interventions did not have better 4-month
outcomes than those who received only the computer and provider counseling
components. Adolescents who targeted a behavior tended to improve more than
those who did not target the behavior, except for those who targeted vigorous
physical activity.
Conclusions A primary care–based interactive health communication intervention
to improve physical activity and dietary behaviors among adolescents is feasible.
Controlled experimental research is needed to determine whether this intervention
is efficacious in changing behaviors in the short- and long-term.
INTRODUCTION
BECAUSE patterns of nutrition and physical activity can impact the current
and future health of young people, the US Public Health Service1
has issued national guidelines. High rates of risk factors for cardiovascular
disease among youth2 and the rapid increase
in the prevalence of obesity3 have brought
new urgency to the need to improve health behaviors among young people.
Only about two thirds of adolescent boys and one half of adolescent
girls in the United States meet the recommendation for vigorous physical activity.4, 5 Most high school–age youth do
not meet the recommendation that young people should accumulate 60 minutes
per day of moderate to vigorous physical activity.6
Likewise, most young people do not meet dietary guidelines for fruits and
vegetables and fat intake.7, 8, 9
The Centers for Disease Control and Prevention10, 11
estimated that only 15% of adolescents met the recommendation for total fat
intake (<30% of energy) and only 24% reported eating 5 or more servings
of fruits and vegetables per day. Because unhealthful eating and physical
activity patterns are so common among young people, effective interventions
are needed.
Although dietary and physical activity interventions have been evaluated
in schools,12 such interventions have been
neglected in primary health care. About 80% of children and adolescents visit
a physician in any given year, with an estimated 76 million annual contacts.13 Thus, most young people could be impacted by prevention
interventions in primary care.
At least 10 national and international agencies have recommended that
providers assess and counsel young people about dietary habits and physical
activity behaviors.13 Even though 30% to 40%
of primary care physicians indicate they provide counseling about physical
activity and nutrition to young people during general medical examinations,13 the quality of this counseling is unknown. Critical
barriers to counseling appear to be an expectation that it is not effective,
limited time available during clinical encounters, and lack of reimbursement.13
Two sets of guidelines exist to assist providers as they counsel young
people about physical activity and nutrition: the American Medical Association's
"Guidelines for Adolescent Preventive Services" (GAPS),14
and "Bright Futures" produced by the National Center for Education in Maternal
and Child Health under contract from the US Public Health Service Health Services
and Resources Administration.15, 16
However, neither of these programs has been evaluated. The growing literature
on practice-based interventions to change adult physical activity and nutrition17 contrasts with the lack of studies targeting young
people.
The purposes of the present study were to (1) develop and test a primary
care–based intervention to improve young people's physical activity
and nutrition behaviors, (2) assess the feasibility and acceptability of program
components among patients and providers, (3) assess the feasibility of conducting
extended interventions after the clinical contact via telephone and mail,
and (4) assess the effectiveness of those interventions in producing longer-term
behavioral change. The design provides a randomized, controlled evaluation
of 4 protocols for extended intervention. Continued intervention is believed
to be essential for long-term changes in nutrition18
and physical activity,19 but the type and frequency
of interventions rarely have been investigated. This pilot study was conceived
as the first step in an effort to create effective programs that can be implemented
in primary care settings to improve the nutrition and physical activity behaviors
of young people.
PARTICIPANTS AND METHODS
PARTICIPANTS
We recruited patients from 3 pediatric or adolescent medicine outpatient
clinics in San Diego, Calif, and 1 in Pittsburgh, Pa. Each clinic served a
diverse population and was staffed by 4 to 9 pediatricians. Recruitment was
conducted by (1) contacting patients who were scheduled for an examination
and their parents, asking them to complete consent forms prior to the appointment;
and (2) approaching adolescents and parents when they arrived for a well-care
visit. The inclusion criteria were that the adolescent be between the ages
of 11 and 18 years, be well enough to complete the initial assessment, and
agree to participate in the 4-month extended contact trial. Parents signed
an informed consent agreement, and adolescents signed an assent form prior
to the initial assessment. All participants who completed the 4-month follow-up
assessment were paid $10.
We attempted to recruit 262 patients. Of these, 191 agreed to be in
the study, yielding a 73% recruitment rate. However, 74 of these 191 could
not be used in the final analyses: 33 did not complete the computer program
(due to time constraints or technical problems), 5 were referred for further
evaluation of disordered eating, 5 were siblings of current participants,
and 31 did not complete the follow-up assessment. Based on the 148 who were
assigned to an intervention group, the attrition rate was 21% (31/148) over
the 4 months. Study dropouts were significantly more likely to be African
American ( 2 = 20.79, P<.001) (Table 1) and from the Pittsburgh site,
probably reflecting lower socioeconomic status and more frequent residential
moves. Participants' sex was not associated with dropout rates (2 = 1.39, P = .24). Other factors that contributed
to dropping from the study included changing from school to summer schedules
and summer jobs.
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Table 1. Demographic Characteristics of Participants and Dropouts
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STUDY DESIGN
All participants completed a computerized assessment in the waiting
room and received physical activity and nutrition counseling from their health
care provider. Each participant was randomly assigned to receive 1 of 4 types
of extended intervention: no contact control, frequent mail, infrequent mail
and telephone, or frequent mail and telephone (Table 2). The duration of all extended contact was 4 months from
the date of the initial assessment. Postintervention surveys were administered
by telephone interviews.
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Table 2. Study Design and Intervention Components in Each Condition
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INTERVENTION RATIONALE AND DEVELOPMENT
The multicomponent intervention called PACE+ (Patient-centered Assessment
and Counseling for Exercise plus Nutrition) was designed to be practical for
use in primary care and to support long-term behavioral change. Intervention
design was based on literature review; consultation with experts in pediatrics,
adolescent medicine, interactive health communications, and health behavioral
change; our previous experience with behavioral change in primary care20, 21, 22; and extensive focus
groups with adolescents, parents, and providers.23
PACE+ was designed to improve 4 nutrition and physical activity behaviors:
moderate physical activity, vigorous physical activity, fat intake, and fruit
and vegetable intake.
All PACE+ components were based on a unified theoretical and empirical
framework. Consistent with the Transtheoretical Model,24
adolescents selected 1 nutritional and 1 physical activity behavior that they
were most ready to change or maintain. Based on Social Cognitive Theory25 and the Transtheoretical Model, adolescents were
then guided by the computer to identify motivators and to develop a specific
self-change plan that incorporated goal setting, social support, and problem
solving. Health care providers, believed to possess substantial credibility
and authority,25 then gave their verbal and
written endorsement of the action plan. Because of the consensus that long-term
interventions are needed for long-term behavioral change in nutrition18 and physical activity,19
we used the Relapse Prevention Model26 to design
the extended interventions. PACE+ helped patients anticipate barriers to change
and make plans to overcome those barriers. Because previous physical activity19 and nutrition18, 27
interventions conducted via mail and telephone have been effective, we adopted
this low-cost strategy.
Because parents can influence adolescents' health behaviors,28 all intervention components encouraged parental involvement.
However, because developing autonomy is an important task for adolescents,
each patient determined the extent of his/her parents' involvement. The computer
program encouraged the adolescent patients to allow their parents to participate
in the assessment and action-planning process. Providers were encouraged to
include parents in the clinical discussion if the adolescent agreed. During
the extended intervention, adolescents were encouraged to share all materials
with their parents. At the end of each counseling telephone call, adolescents
were asked whether a counselor could give an update of their progress to a
parent.
INTERVENTION COMPONENTS
PACE+ has 3 primary components: the interactive computer program, provider
counseling, and extended follow-up by telephone and/or mail. We considered
the computer-based assessment and action-planning program to be the only feasible
method of conducting multiple behavioral assessments, interpreting the results,
and developing a behavior change program within a busy clinic. After an introductory
section, the computer assessed disordered eating to identify adolescents with
a need for further evaluation and referral. Then the computer assessed all
4 behaviors, compared participants' data with health recommendations, and
fed this information back to the adolescent. On the basis of this feedback,
adolescents were instructed to choose 1 physical activity and 1 dietary target
behavior for which they developed a behavior change plan. These tailored action
plans were printed out. Adolescents were encouraged to target a behavior that
was not at the recommended level. If they were meeting goals for multiple
behaviors, they were encouraged to have their action plan address behavior
maintenance. These plans included the desired benefits of change; specific
goals and strategies, including the time(s) and place of behavioral change;
identification of a social supporter; and anticipated barriers. If the adolescent
declined to target any behaviors for change, this information was reflected
in their "provider summary" to initiate a discussion that would include brief
motivational information. This provider summary, highlighting any areas in
need of further evaluation (eg, disordered eating), was printed for the provider
and placed in the medical chart prior to the clinical encounter.
The provider counseling component centered around a discussion of the
2 printouts. Providers (physicians or nurse practitioners) reviewed action
plans with their patients to assess whether they were appropriate and realistic.
Providers also reviewed the provider summary for any special issues that needed
attention. Providers received brief training in interpreting the printouts,
making modifications as needed, and delivering motivational information related
to the adolescents' personal health status.
The extended intervention by mail and telephone supported the adolescent
in beginning behavioral change and maintaining gains. Except for the control
group, extended intervention began 1 week after the clinical encounter. Telephone
calls and mailings were handled by research staff who received training and
frequent supervision. The same counselor was assigned to an adolescent for
the entire 4-month intervention, and counselors identified themselves as their
PACE+ counselor and not as doctor's office staff.
Mail intervention packets contained a cover letter, a postage-paid mail-back
postcard, and age-appropriate tip sheets appropriate to the adolescents' goals.
Tip sheets were divided into 4 categories: nutrition, physical activity, behavioral
change, and parental support. Every mailing contained at least 1 physical
activity and 1 nutrition tip sheet, and adolescents could request specific
topics.
Telephone intervention counseling calls, about 10 minutes in length,
were structured to assess participants' goal achievements since the last call,
praise their progress, develop solutions to barriers, and revise goals if
necessary. Participants were asked to name a person to support them (eg, a
friend or parent) and specify how that person could help. Usually the focus
of calls alternated between nutrition and physical activity targets. Mailings
sent after each call related to topics covered during the telephone call.
Adolescents in the group receiving infrequent contact were scheduled
for 3 calls at 6-week intervals. Those in the frequent contact group received
8 biweekly counseling calls alternated with 8 "prompt" calls to achieve the
goal of some contact each week. Prompt calls lasted 1 to 3 minutes and were
reminders to continue with the changes suggested the prior week. Prompt calls
were considered completed if a message was left because of findings that the
frequency of calls was more important than content.29
MEASUREMENTS
We created or adapted physical activity and nutrition self-report measures
for this study. We conducted assessments at baseline by computer program23 and at 4-month follow-up by trained telephone interviewers.
The follow-up questions were identical to the ones used on the computer, but
were asked over the telephone. Reliability and validity of all measures were
assessed in separate psychometric studies.30
We evaluated reliability in a diverse group of 250 adolescents with a 1-week
interval between test and retest, using 1-way model intraclass correlations
(ICCs). We based validity data on an assessment of 60 adolescents using 7
days of accelerometer monitoring as the physical activity criterion and 3
days of dietary records as the nutrition criterion.
Participants reported the number of days a week they participated in
at least 20 minutes of vigorous physical activity (reliability ICC = 0.67;
validity r = 0.31, P = .02)
and the number of days a week they participated in at least 30 minutes of
moderate-intensity physical activity (reliability ICC = 0.55; validity r = 0.20, P = .16). Participants
were provided with examples of each class of physical activity. The number
of servings of fruits and vegetables that participants ate on a typical day
were assessed by separate items, and then summed (reliability ICC = 0.57;
validity r = 0.33, P = .10).
Common serving sizes were described.
We modified a brief food frequency survey of commonly eaten high-fat
foods31 to better reflect the intake patterns
of ethnically diverse adolescents. Scores were transformed to reflect average
servings of high-fat foods per day (reliability ICC = 0.64; validity r = 0.36, P = .006), including
common meats, fried foods, high-fat dairy foods, and added fats.
We telephoned adolescents 1 week after the clinical encounter and asked
them to rate their satisfaction with the PACE+ computer program and provider
counseling. We scored satisfaction questions on a 5-point Likert-type scale
from 1 (not at all helpful) to 5 (very helpful). At the 4-month assessment,
adolescents provided similar ratings of satisfaction with mail and telephone
components.
To assess the process of implementation, we counted the number of telephone
contacts and the number of mailings sent per subject by condition.
ANALYSES
A preliminary analysis determined the baseline comparability of the
4 groups on demographic variables and on each dependent variable. We assessed
the normality of the variables by interpreting histograms and homogeneity
of variance. Moderate physical activity, vigorous physical activity, and fruit
and vegetable intake were all within normal skewness range. The fat variables
exceeded a skewness of ±2 and therefore were adjusted for outliers
using the windsorizing technique. (In windsorizing, the extreme values are
not eliminated from the data set but replaced by the value of the cutoff criterion,
in this case, 2.) Because demographic variables among the 4 groups did not
differ, we did not include demographic covariates in outcome analyses. We
then calculated the percentage of participants meeting the guidelines for
each behavior at baseline.
We conducted 2 sets of primary analyses. First, we used 4 x 2
x 2 (condition x time x sex) repeated-measures of analysis
of variance (ANOVA) to determine the effect of extended interventions on each
of the outcomes. Because these primary analyses underestimated the effects
of the extended interventions—inasmuch as participants only tried to
change 2 of the 4 outcomes—a second set of analyses determined the differential
effect of targeting a behavior for change. Targeting
was defined as making an action plan for that behavior and discussing it with
the provider. We then compared subsequent changes in that behavior among adolescents
who targeted the behavior with those who did not with a 2 x 2 (targeted/not-targeted
x time) repeated-measures ANOVAs on each of the 4 dependent variables.
Effect sizes were calculated to give a more accurate estimate of the effect
of targeting a behavior with a PACE+ action plan. We calculated effect sizes
(d) by creating change scores (postintervention score minus preintervention
score) and subtracting the mean change for the group that did not target the
behavior from the mean change for those who did target the behavior, then
dividing by the SD for the change score pooled across all groups.32
We next described participants' satisfaction ratings of the computer
program, provider interaction, and extended follow-up interventions and, finally,
examined the extent of delivery of follow-up contacts.
RESULTS
There were no significant differences between extended intervention
conditions at baseline for moderate physical activity (F3,113 =
0.31, P = .82), vigorous physical activity (F3,113 = 1.60, P = .19), fruit and vegetable
intake (F3,113 = 0.67, P = .57), or fat
intake (F3,113 = 0.56, P = .65). At baseline,
39% of participants reported meeting the guidelines for moderate physical
activity (30 minutes,  5 days a week), 74% for vigorous physical activity
(20 minutes, 3 days a week), 17% for fat intake ( 3 servings a day
of high-fat foods), and 42% for fruit and vegetable intake (5 servings
per day).
PRIMARY ANALYSES: BEHAVIORAL OUTCOMES AT 4 MONTHS
We found no significant 3-way interactions (condition x time x
sex), or any significant interaction effects between participants' sex and
their intervention group. This indicates that neither the sex of the participants
nor their participation in an extended intervention was associated with measurable
improvements in behavior beyond those provided by PACE+ computer and provider
counseling alone. For all behaviors except vigorous physical activity, PACE+
participants generally improved over time: moderate physical activity (F1,115 = 6.35, P = .01), vigorous physical activity
(F1,115 = 3.41, P = .07), fruit and vegetable
intake (F1,115 = 9.81, P = .002), and
fat intake (F1,115 = 5.20, P = .02). Put
another way, following the PACE+ intervention, fat consumption decreased by
12%, fruit and vegetable consumption increased by 18%, vigorous activity increased
by 10%, and moderate physical activity increased by 17%.
EFFECTS OF TARGETING A BEHAVIOR
No significant 3-way or 2-way interactions involving condition were
discovered in the analyses of the effects of targeting a behavior on outcome.
However, we found evidence that participants who targeted a behavior for change
improved more over time than participants who did not target the behavior
for change. Participants who targeted moderate physical activity showed significant
improvement; those who targeted either fruit and vegetable intake or fat intake
showed near-significant improvement. Improvement was not significant for those
targeting vigorous physical activity (Table
3). Considering that effect sizes (d) can be interpreted as small
(d0.20) and medium (d0.50), this represents a medium effect of targeting
on moderate physical activity and small effects on both nutrition outcomes.
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Table 3. Comparison of Adolescents Targeting vs Not Targeting Each
Behavior
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SATISFACTION AND FEASIBILITY DATA
Adolescents expressed generally high satisfaction with all components
of the intervention, between 3 and 4 on a 5-point scale (Table 4). They rated the computer program and provider counseling
components as most helpful in making behavioral changes, and the mailed materials
as least helpful. About 75% of the adolescents were satisfied with the frequency
of both the mailed materials and telephone calls, and only 10% stated that
contacts should be more frequent. Eighty percent of the adolescents stated
they discussed some or all of the mailed materials with friends or family.
Seventy-five percent reported they discussed their counseling calls with friends
or family. Parents gave very high overall ratings of satisfaction, and 98%
said that PACE+ should be offered at the clinic on an ongoing basis.
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Table 4. Adolescent and Parent Ratings of Intervention Components*
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All mailings were sent as planned, regardless of whether telephone contact
was made. Of the 3 planned telephone calls to those in the infrequent contact
group, a mean of 2.04 (SD = 0.9) or 68% were completed. Of the 8 planned counseling
calls to those in the frequent contact group, a mean of 4.55 (SD = 3.0) or
57% were completed.
COMMENT
The PACE+ intervention was successfully implemented in primary care
settings and was associated with changes in dietary and moderate-intensity
physical activity behaviors over a 4-month period. However, without a control
group, it is impossible to determine whether these changes were due to the
intervention, to other unmeasured factors, or to chance. Levels of vigorous
physical activity did not appear to change, but this may have been due to
the high levels of vigorous activity reported at baseline in this group.
Our results support the feasibility of PACE+, but they also identified
areas in need of improvement. Some patients could not complete the computer
program before they were called in for their provider encounter, suggesting
a need to shorten the computer program or find another means of administering
it before the office visit. Technical problems (eg, computer "crashes") prevented
others from completing the program or printing their action plans, but those
difficulties mainly occurred early in the study. The mailings were reliably
delivered, but it is not clear what percentage of the materials was read.
Adolescents were generally pleased with the frequency of contact they received.
Although the moderate completion rates for telephone calls limited the
comparison between the planned 3 and 8 calls, adolescents in the frequent
contact group still received twice as many calls as those in the infrequent
call group. The lack of differences in results between these groups suggests
that all the extended interventions may have had too low an intensity to be
effective. However, we tend to believe that the content of the extended interventions
was too limited. We targeted several empirically supported mediators for behaviors,
including praise for successes, social support by telephone counselors, and
problem solving to overcome barriers. It may, however, have been more efficacious
to use the mail and telephone contacts to systematically teach behavior change
strategies, as suggested by Social Cognitive Theory,25
and to tailor the teaching of strategies to the stage of change, as recommended
by the Transtheoretical Model.24 Although others29 have found that frequency of contact was more important
than content, present results suggest otherwise. Because creating long-term
change may be the biggest challenge for those seeking to change health behaviors,26 more studies evaluating the mode, frequency, and
content of behavior change communications are needed.
The lack of differences in outcomes associated with the various extended
interventions suggests that the computer and provider intervention alone may
be producing whatever effect we are seeing with this intervention. However,
as is the case with our overall findings, because we did not conduct a separate
experimental evaluation of the initial 2 components of PACE+ (computer program
and provider counseling), we can draw no conclusion about their effectiveness.
The possibility that the computer program and provider counseling per se were
effective was partially supported by the analysis of targeting. Those who
targeted moderate physical activity improved significantly more in this area
than those who did not, and the effect size was medium. Targeting fat and
fruit and vegetable consumption produced small effect sizes that were not
statistically significant. If validated through further experimentation, these
results support the utility of computer-based behavior change programs combined
with provider counseling as a promising strategy for intervening with adolescents
in primary care.
The apparent effects of "targeting" patient-selected behaviors must,
however, be interpreted cautiously. The computer program encouraged patients
who did not meet a particular behavioral guideline to choose that behavior
for change. After the intervention, some of the targeted behavior means approached
the recommended levels. However, some of this change could be due to regression
to the mean. We interpreted the selection of a target behavior as an indication
of the patient's readiness to change, consistent with the Transtheoretical
Model,24 so target selection was an integral
part of the behavior change strategy. The efficacy of this approach needs
to be compared with random assignment of target behaviors, selecting a standard
sequence of target behaviors, and working on multiple targets simultaneously.
Another limitation of this study was the quality of the self-report
measures of behavioral outcomes. The brief self-report measures were developed
to be clinical assessments in the PACE+ computer program, but we applied them
as measures of behavioral outcomes. A psychometric study provided support
for the reliability and validity of most measures, but none performed as well
as desired. Another concern in this study relates to the social desirability
of responses in that measures of outcome were collected via telephone, while
baseline measures were collected via computer. Although valid, we do not think
this is a major concern because staff who collected final measures were different
from intervention staff, and methods were the same for those who targeted
behaviors and those who did not. Nonetheless, the difficulty of measuring
physical activity and diet in young people is well known, and we encourage
future researchers to use objective and previously validated measures.
To our knowledge, this is the first evaluation of a physical activity
and dietary behavior change intervention for adolescents that combines (1)
a computerized expert system based on behavior change theory, (2) health care
provider counseling that is informed by the results of the expert system,
and (3) postvisit telephone and mail counseling also tailored to an individual
patient's behavioral stage and goals. Results of this study indicated that
this type of intervention is feasible in primary care settings. Participants
were highly satisfied with all components of the intervention and there was
relatively good participation in extended intervention by mail and telephone
over a 4-month period. Even so, more effective approaches to long-term interventions
need to be developed and evaluated. A randomized trial of the PACE+ intervention,
currently under way, will help determine if this intervention is efficacious.
AUTHOR INFORMATION
What This Study Adds
Most adolescents engage in insufficient physical activity and have poor
dietary habits. The increasing incidence of overweight and obesity in adolescents
and young adults is a result of these behavioral patterns. Counseling by health
care providers may help improve these behaviors but methods to enable brief,
systematic, and tailored health behavior counseling have not been reported.
This study evaluates the feasibility of a theory-based multicomponent
intervention designed to improve the effectiveness of health care provider
counseling for physical activity and dietary behaviors. It also explores the
impact of different versions of this intervention on behavioral outcomes.
Results of this study indicate that this intervention is feasible and provide
background for its evaluation through controlled trials.
Accepted for publication March 16, 2001.
This project was made possible by funding from the Centers for Disease
Control and Prevention, Atlanta, Ga, through their cooperative agreement with
The Association of Teachers of Preventive Medicine.
We would like to acknowledge the input of the following colleagues as
this research progressed: Barbara J. Long, MD, MPH, Sheri Thompson, PhD, and
Joan Rupp, MS, RD. We also express our appreciation to the study providers
at Kaiser Permanente, San Diego (John Cella, MD), Scripps Clinic, La Jolla
(Richard Buchta, MD), University of California–San Diego Medical Center
(Larry Friedman, MD, Lynn Rice, NP, Edward Epstein, MD, Cindy M. Fujii, MD,
and Wilma Wooten, MD), the US Naval Medical Center, San Diego (CDR Sanders
Anderson, MC, USN), and the Children's Hospital in Pittsburgh for their contribution
to this project.
From the Graduate School of Public Health (Dr Patrick) and Student
Health Services (Drs Patrick and Calfas) and Department of Psychology (Drs
Sallis, Calfas, Wilfley, and Saelens and Mr Lydston), San Diego State University,
San Diego, Calif; San Diego State University/University of California, San
Diego Joint Doctoral Program in Clinical Psychology, San Diego State University
(Mss Prochaska and Zabinski); and Division of Nutrition and Physical Activity,
Centers for Disease Control and Prevention, Atlanta, Ga (Dr Brown).
Corresponding author: Kevin Patrick, MD, MS, or James Sallis, PhD,
PACE Project, San Diego State University, 5500 Campanile Dr, San Diego, CA
92182-4701 (e-mail: kpatrick{at}mail.sdsu.edu).
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