CVD Nutrition Education
To conduct a randomized, controlled trial of cardiovascular disease nutrition education
using a cluster design with two conditions, special intervention (SI) and usual care (UC).
Progress in educating those with low literacy levels about CVD risk factors related to
nutrition had been hampered by the lack of appropriate materials and programs. It was
questionable whether the traditional methods of education used with literate, middle-income
populations were generalizable to low literate, lower-income populations. While past work
had demonstrated significant associations between dietary practices and risk for CVD--in the
form of hypercholesterolemia, obesity, and hypertension--as well as alterations in risk when
dietary practices were changed, effective educational methods for low literate populations
who were at high risk for CVD were still in their infancy in 1991.
The study was part of an NHLBI initiative on "CVD Nutrition Education for Low Literacy
Skills". The initiative originated within the Prevention and Demonstration Branch of the
DECA, was approved by the September 1988 National Heart, Lung, and Blood Advisory Council,
and released in July 1990.
The two clusters were comprised of small groups of multi-ethnic, low-income individuals who
were predominantly women aged 20-35 with low-literacy levels. The source of these groups was
the Expanded Food and Nutrition Education Program (EFNEP), a program of the USDA and
Cooperative Extension Services of the University of California. EFNEP provided basic,
non-CVD specific nutrition information to approximately 1000 low-income families in Santa
Clara County, California annually in conjunction with job training programs and specialty
schools for low-literate individuals. Twenty-four groups were matched in pairs for group
size and type of setting and one of each pair was allocated randomly to receive the UC or
SI. The UC group received an eight one-hour classroom curriculum covering nutrition
information on the basic food groups, meal planning and food purchasing, delivered primarily
through lecture and print materials. The Sl involved designing an innovative CVD nutrition
program, composed of distinct education modules, that used face-to-face, participatory
education and mediated materials for low-literate adults. Participants learned to modify
their own family menus, select and prepare low cost foods obtained from the USDA or food
stamps, and received specially adapted and newly developed materials that relied little on
written communication that were sensitive to cultural dietary beliefs.
Summative evaluation involved testing whether the SI groups had a greater change in CVD
nutrition knowledge and behavior (as measured by self-report) 24 hour diet recalls, and
serum cholesterol) from baseline to an eight week post-test, and through a five month
maintenance period. The generalization phase of the research tested a revised version of the
program in a non-classroom setting with Head Start families, and intervened at the community
level to modify the food selection and preparation practices of organizations (such as soup
kitchens, food banks, and homeless shelters) that provide food to low-income/low-literate
groups. As the concluding aspect of the study, the feasibility was explored of disseminating
the nutrition program and education modules to local and national groups serving
Cardiovascular Diseases, Heart Diseases
Stanford University, National Heart, Lung, and Blood Institute (NHLBI)
Howard-Pitney B, Winkleby MA, Albright CL, Bruce B, Fortmann SP. The Stanford Nutrition Action Program: a dietary fat intervention for low-literacy adults. Am J Public Health. 1997 Dec;87(12):1971-6.
Winkleby MA, Howard-Pitney B, Albright CA, Bruce B, Kraemer HC, Fortmann SP. Predicting achievement of a low-fat diet: a nutrition intervention for adults with low literacy skills. Prev Med. 1997 Nov-Dec;26(6):874-82.