Research Brief

Impact of a Behavioral Intervention on Diet, Eating

Patterns, Self-Efficacy, and Social Support
Matthew Lee Smith, PhD1,2,3; Shinduk Lee, DrPH1; Samuel D. Towne Jr, PhD1,2,4,5;
Gang Han, PhD6; Cindy Quinn, MS1; Ninfa C. Pen~ a-Purcell, PhD1,2,7;
Marcia G. Ory, PhD1,2

ABSTRACT
Objective: To examine the effectiveness of a structured multimodal behavioral intervention to change die-
tary behaviors, as well as self-efficacy and social support for engaging in healthier diets.
Methods: A quasi-experimental design was used to assign sites into intervention and comparison groups.
Data were collected at baseline, 3 months, and 6 months. The intervention group participated in Texercise
Select, a 12-week lifestyle enhancement program. Multiple mixed-effects models were used to examine
nutrition-related changes over time.
Results: For the intervention group, significant improvements were observed for fast food consumption
(P = .011), fruit/vegetable consumption (P = .008), water consumption (P = .009), and social support (P < .001)
from baseline to 3 months. The magnitude of these improvements was significantly greater than changes in the
comparison group.
Conclusions and Implications: Findings suggest the intervention’s ability to improve diet-related out-
comes among older adults; however, additional efforts are needed to maintain changes over longer periods.
Key Words: healthy diet, evidence-based program, program evaluation, lifestyle, intervention (J Nutr Educ
Behav. 2020; 52:180−186.)
Accepted June 7, 2019. Published online September 17, 2019.

INTRODUCTION Furthermore, many adults consume caloric intake.5 Dietary habits are
diets that exceed the recommended influenced by individual characteris-
The 2015−2020 Dietary Guidelines limits for saturated fats, sodium, and tics (eg, sociodemographics), interper-
for Americans call for increasing fruit added sugars.2 Consequently, fast sonal interactions (eg, social support),
and vegetable intake while simulta- food consumption (including sugar- and settings that individuals visit in
neously reducing the intake of satu- sweetened beverages) is associated a community (eg, facilities hosting
rated fats, salt, and sugars.1 However, with obesity and cardiovascular risk.4 health-promoting programs).6−9 An
a substantial proportion of adults Small steps can be beneficial to mod- individual’s perceived confidence (ie,
do not consume the recommended ify dietary behavior as well as create self-efficacy) to change dietary patterns
servings of fruits and vegetables.2,3 balance in food choices and total can be influenced.10
Based on a multimodal interven-
tion approach, this quasi-experimental
1
Center for Population Health and Aging, Texas A&M University, College Station, TX study examined the effectiveness of
2
Department of Environmental and Occupational Health, School of Public Health, Texas a structured behavioral intervention
A&M University, College Station, TX to change diet, eating patterns, self-
3
Department of Health Promotion and Behavior, College of Public Health, The University of efficacy, and social support among
Georgia, Athens, GA middle-aged and older adults. The
4
Department of Health Management & Informatics, University of Central Florida, Orlando, intervention, Texercise Select, has been
FL shown to improve fruit and vegetable
5
Aging & Technology Faculty Cluster Initiative, University of Central Florida, Orlando, FL consumption, self-efficacy to improve
6
Department of Epidemiology & Biostatistics, School of Public Health, Texas A&M Univer- nutrition, and general social support
sity, College Station, TX for lifestyle/behavior using a single-
7
Family and Community Health, AgriLife Extension Service, Texas A&M University, Col- group, pretest/post-test design.11
lege Station, TX The current study builds upon these
Conflict of Interest Disclosure: The authors have not stated any conflicts of interest. findings by using a more rigorous
Address for correspondence: Matthew Lee Smith, Center for Population Health and Aging, study design to examine initial and
Texas A&M University, 212 Adriance Lab Rd, College Station, Texas 77843; E-mail: sustained diet-related outcomes. It is
matthew.smith@tamu.edu hypothesized that significant initial
Ó 2019 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights and sustained improvements will be
reserved. observed among Texercise Select par-
https://doi.org/10.1016/j.jneb.2019.06.008 ticipants relative to participants in

180 Journal of Nutrition Education and Behavior  Volume 52, Number 2, 2020
Journal of Nutrition Education and Behavior  Volume 52, Number 2, 2020
the comparison group (ie, those not
receiving the intervention).
METHODS
Participants and Procedures
This study used longitudinal data col-
lected from nonequivalent groups in a
quasi-experimental design (ie, inter-
vention and comparison groups) from
May 2015 to September 2017. This
study included 9 intervention and 14
comparison sites, which were recruited
through local partnerships with multi-
ple organizations in the aging and
healthcare sectors. More comparison
sites were recruited to account for
greater participant attrition within the
comparison group. Between 13 and 26
participants were recruited from each
intervention site, and between 8 to 41
participants were recruited from each
comparison site. All sites were either
exposed to the intervention or treated
as comparison sites. There was no mix-
ing in terms of treatment arm within a
particular site location. Sites were
assigned to the intervention or compar-
ison condition using nonrandomized
methods based on the organizations’
comparability in terms of size, client
base, and their readiness to offer the
intervention.
The intervention group participa-
ted in Texercise Select, a 12-week life-
style enhancement program offered in
a small group education format in
community settings. The comparison
group did not receive the intervention
during the study period but were invi-
ted to join an evidence-based health
promotion program after the end of
the study. Examples of topics covered
in the sessions include components of
a healthy diet; components of a bal-
anced diet; portion sizes; food labels;
cooking modifications to maximize
nutritional intake; and healthy choices
when eating outside the home. Exam-
ples of session activities include keep-
ing a nutrition log, making action
plans, brainstorming about ways to
change their diet, creating healthy
meals/menus, and staying committed
to nutritional goals and healthy eat-
ing. Specific details on program activi-
ties are described elsewhere.12
Study participants were recruited
using convenience sampling methods
by community partners in multiple
locations across Texas who work with
middle-aged or older adults. The
inclusion criteria for the study partici-
pants were: (1) being at least 45 years
old; (2) agreeing to participate in the
study (consent given by way of an
information sheet); and (3) complet-
ing and returning the baseline survey
to the research team. For the inter-
vention group, participants were
excluded from the study if they did
not attend the first or second session
of the Texercise Select workshop. To be
ethical and accommodate community
partners’ needs, those who did not
attend the first or second session
were still allowed to participate in
the workshops; however, their data
were excluded from analyses. A total
of 9 Texercise Select workshops were
hosted in community settings, includ-
ing senior centers, faith-based facilities,
senior housing facilities, and all-pur-
pose community centers. Data were
collected from participants at baseline,
3 months, and 6 months. Instruments
at all 3-time points included items
related to self-reported dietary behav-
iors, self-efficacy related to engaging in
a healthy diet, and perceived social
support for engaging in a healthy diet.
This study was approved by the Texas
A&M University Institutional Review
Board.
Primary Outcome Measures
Dietary behavior. Using slightly modi-
fied measures of dietary behavior from
the Starting the Conversation diet
instrument,13 participants were asked
about the following dietary behaviors
over the past 7 days: number of times
consumed a fast food meal or snack;
number of soda and sugar-sweetened
drinks (regular, not diet) consumed
each day; number of fruit or vegetable
servings consumed each day. For
each of these items, responses were: 1,
2, 3, 4, and 5 or more. Participants
were also asked to report how many
cups of water they drink on an average
day. For this item, responses were: 0, 1,
2, 3, 4, 5, 6, 7, and 8 or more.
Self-efficacy. Participants were asked
to indicate their degree of confidence
using a 4-point Likert scale to (1) set a
healthy eating goal; (2) read food
labels; (3) identify recommended por-
tion size for different foods, and (4)
Smith et al 181
identify social services for obtaining
healthy foods. The valid response
range for this self-efficacy scale was 4
to 16, with higher scores indicating
greater self-efficacy related to keeping
a healthy diet. The internal reliability
for this scale was strong for the com-
parison (Cronbach’s alpha = 0.87) and
intervention (Cronbach’s alpha = 0.88)
group.14
Social support. Participants were asked
how frequently they received social
support for the following at baseline
and 3 months using a 4-point Likert
scale: (1) planning dietary goals; (2)
keeping dietary goals; (3) reducing bar-
riers to healthy eating; and (4) eating
healthy meals. The valid response
range for this scale was 4 to 16, with
higher scores indicating greater per-
ceived social support to keep a healthy
diet. The internal reliability for this
scale was good for the comparison
(Cronbach’s alpha = 0.80) and inter-
vention (Cronbach’s alpha = 0.77)
group.14
Other covariate measures. The baseline
survey included sociodemographic
information (eg, age, sex, race/ethnic-
ity, and education) and self-reported
chronic conditions (ie, from a list of
9 conditions). Participants who self-
reported ≥2 conditions were identified
as having disease comorbidity. Race/
ethnicity was collapsed into 2 groups:
non-Hispanic White and Other. Three
levels of education were defined: high-
school graduate or lower; some college
or technical school; and college gradu-
ate or higher.
Statistical Analyses
Bivariate analyses were used to compare
the participants’ sociodemographic
and baseline characteristics among
the study participants between the
comparison and intervention groups.
Pearson’s chi-squared tests were used
for categorical variables, indepen-
dent sample t tests were used for
interval variables, and Wilcoxon-
Mann Whitney tests were used for
ordinal variables. Multiple mixed-
effects models (ie, linear for interval
variables; ordinal logistic for ordinal
variables assuming proportional odds)
were used to examine the changes in
outcome variables from baseline to
182 Smith et al Journal of Nutrition Education and Behavior  Volume 52, Number 2, 2020

3 months and baseline to 6 months. In
these models, nesting within sites
(using a site ID variable) and individu-
als over time (using unique partici-
pant IDs) were incorporated in the
model. Statistical independence was
assumed at the participant-level, and
over-time effects were assumed to be
nested within the subject effect.
Despite the low intra-class correlations
within each site (ranged from <0.001
to 0.059), the random effects from sites
were incorporated in the models.
Given the nonlinear trend of the
changes over time (ie, baseline, 3
months, and 6 months), time was
included in the model as a categori-
cal variable instead of a continuous
variable. All models included time,
group (intervention or comparison),
and the interaction between time and
group. Additionally, all models were
performed after controlling for age,
sex, race/ethnicity, education, and
disease comorbidity. For each mixed-
effect model, all participants with
outcome data at ≥1 time points
were included in the analyses.
However, only participants with
complete data for all independent
and control variables were included
in the analyses.
RESULTS
A CONSORT diagram depicting partic-
ipant flow for this study is published
elsewhere.15 A total of 430 study-
eligible participants were recruited (ie,
intervention group = 163 [37.9%];
comparison group = 267 [62.1%]). In
the intervention group, about 77% of
study-eligible participants completed
the 3-month follow-up, and 45%
completed the 6 months follow-up. In
the comparison group, about 65% of
study-eligible participants completed
the 3-month follow-up, and 40% com-
pleted the 6-month follow-up.
Table 1 reports participants’ sociode-
mographic characteristics and baseline
values for outcome variables by treat-
ment group. On average, participants
were age 74.49 (standard deviation,
8.95). Most of the study participants
were female (77.4%), had ≥2 comorbid
conditions (66.4%), and had cardiovas-
cular risk (72.6%). About half (47.3%)
of participants were non-Hispanic
white, and 61.3% had more than a
high-school education. Relative to the
comparison group, the intervention
group had a significantly larger pro-
portion of non-Hispanic white partici-
pants (34.7% vs. 67.7%). At baseline,
the comparison group consumed sig-
nificantly more sugar-sweetened bev-
erages relative to the intervention
group (P < .005). On average, interven-
tion group participants attended 14.8
(§5.47) of the 20 workshop sessions.
Program Effects
Table 2 presents outcomes from the
adjusted models for all study-eligible
participants. For the intervention
group, significant improvements were
observed for fast food consumption
(P = .011), fruit/vegetable consump-
tion (P = .008), water consumption
(P = .009), and social support (P < .001)
from baseline to 3 months. For the
comparison group, no statistically

Table 1. Baseline Characteristics of the Study Participants

Mean (SD), Median [IQR], or Frequency (%)

Overall Intervention Comparison P Values

(n = 430) (n = 163) (n = 267) (Intervention vs Comparison)
Demographic Characteristics
Age (years) 74.49 (8.95) 74.84 (7.70) 74.28 (9.65) .505
Female 333 (77.4%) 129 (79.1%) 204 (76.4%) .510
Non-Hispanic white 192 (47.3%) 105 (67.7%) 87 (34.7%) <.001
Education
High-school graduate or lower 166 (38.7%) 56 (34.4%) 110 (41.4%) .058
Some college 134 (31.2%) 62 (38.0%) 72 (27.1%)
College graduate or higher 129 (30.1%) 45 (27.6%) 84 (31.6%)
Disease comorbitity 277 (66.4%) 111 (68.5%) 166 (65.1%) .471
Cardiovascular risk 312 (72.6%) 119 (73.0%) 193 (72.3%) .871
Baseline diet behavior
Fast food consumption (times in the 2 [1, 3] 2 [1, 3] 2 [1, 3] .509
past 7 days)
Fruit/vegetable consumption (serv- 3 [2, 4] 3 [2, 5] 3 [2, 4] .553
ings per day in the past 7 days)
Soda/sugar drink consumption 0 [0, 2] 0 [0, 1] 1 [0, 2] .005
(drinks per day in the past 7 days)
Water (drinks per day) 5 [4, 7] 5 [4, 7] 5 [4, 7] .940
Baseline social support 9.93 (3.39) 9.75 (3.30) 10.03 (3.45) .414
Baseline self-efficacy 12.23 (2.53) 12.30 (2.59) 12.19 (2.50) .682
Workshop characteristics
Number of attended sessions — 14.83 (5.47) — —
(max = 20)
IQR indicates interquartile range; SD, standard deviation.
 Journal of Nutrition Education and Behavior  Volume 52, Number 2, 2020
Table 2. Adjusted Immediate and Sustained Program Effects Among the Overall Study Participants

P Values
Adjusted Differences (D) or (Changes From Baseline
Adjusted Means Adjusted ORa to Immediate Post or 6-Month
(95% CI) (95% CI), Changes From Baseline Post-Test)

Immediate Sustained
Program Program
Immediate Program Sustained Program Effects: Effects: P Values
T2. 3-Month T3. 6-Month Effects: Compare Effects: Compare Compare Compare (“group x time”
Variables T1. Baseline Follow-Up Follow-Up T1 vs T2 T1 vs T3 T1 vs T2 T1 vs T3 Interaction)
Fast Food Consumption .046b,c
(times in the past 7 days) .184d
Comparison − − − OR = 1.04 (0.77−1.40) OR = 0.97 (0.66−1.42) .820 .886
Intervention − − − OR = 0.66 (0.48−0.91) OR = 0.65 (0.42−1.02) .011 .062
Fruit/Vegetable Consumption .006b,c
(servings in past 7 days) .656d
Comparison − − − OR = 0.83 (0.60−1.15) OR = 0.74 (0.50−1.09) .263 .123
Intervention − − − OR = 1.68 (1.15−2.47) OR = 0.84 (0.53−1.35) .008 .483
Soda/Sugar Drink .393c
(drinks in past 7 days) .710d
Comparison − − − OR = 1.09 (0.82−1.44) OR = 0.82 (0.58−1.16) .567 .267
Intervention − − − OR = 0.88 (0.60−1.30) OR = 0.73 (0.45−1.19) .524 .209
Water consumption .204c
Comparison − − − OR = 1.14 (0.89−1.47) NA .299 NA
Intervention − − − OR = 1.46 (1.10−1.94) .009
Social support .002b,c
Comparison 9.78 10.27 NA D = 0.49 (0.06−1.04) NA .079 NA
(9.31−10.25) (9.72−10.83)
Intervention 10.08 11.87 NA D = 1.79 (1.16−2.42) <.001
(9.53−10.63) (11.27−12.48)
Self-Efficacy .167c
Comparison 12.23 (11.86−12.59) 12.24 (11.81−12.67) NA D = 0.01 ( 0.46−0.48) NA .957 NA
Intervention 12.43 (11.97−12.89) 12.95 (12.44−13.47) NA D = 0.52 ( 0.03−1.07) .063

CI indicates confidence interval; NA, not available; OR, odds ratio; T1, baseline; T2, 3-month follow-up; T3, 6-month follow-up.
a
The likelihood of having a higher response category (ie, more fast food, more fruit/vegetables, more soda, or more water) were modeled; bIntervention group showed

Smith et al
greater improvement over time than the control group; cStatistical significance of differences in changes from the baseline to 3-month follow-up between the intervention
and control groups; dStatistical significance of differences in changes from the baseline to 6-month follow-up between the intervention and control groups.
Note: All models were controlled for age, sex, race/ethnicity, education, and disease comorbidity

183
184 Smith et al
significant changes were observed.
Relative to the comparison group, the
magnitude of change was significantly
greater for the intervention group
in terms of fast food consumption
(odds ratio [OR] = 1.04 vs. OR = 0.66;
P = .046), fruit/vegetable consumption
(OR = 0.83 vs. OR = 1.68; P = .006), and
social support (D = 0.49 vs. D = 1.79;
P = .002) from baseline to 3 months.
DISCUSSION
Texercise Select has the potential to
improve diet-related outcomes among
older and potentially at-risk adults.
Relative to comparison group partici-
pants, those in the intervention group
significantly improved in terms of
their fast food and fruit/vegetable
consumption, and social support
from baseline to 3 months. Texercise
Select participants reduced their fast
food consumption from baseline to
3 months. Fast food and dining out
are common challenges for individu-
als wanting to engage in a healthier
diet.16 Findings suggest that Texercise
Select sessions addressing these topics
were influential in helping partici-
pants change the frequency of their
fast food consumption.
Of particular note, Texercise Select
participants as a group reduced their
fast food consumption from baseline
to 3 months. Fast food and dining
out are common challenges for
individuals wanting to engage in a
healthier diet.16 Findings suggest
that Texercise Select sessions address-
ing these topics were influential
in helping participants change the
frequency of their fast food con-
sumption. Foods that are most con-
veniently purchased are not always
those that are most healthy. While
fast food restaurants may be easily
available, accessible, and afford-
able,4,17 they are not the only food
option. Despite perceptions that pur-
chasing healthy foods is inconve-
nient or cost-prohibitive,18,19 dietary
recommendations support the con-
sumption of fresh, frozen, or canned
fruits and vegetables,20 which makes
having healthy foods “on-hand” eas-
ier because of widespread purchasing
locations and the ability to store
foods in the home for longer periods.
However, it should be acknowledged
that many fast food restaurants now
Journal of Nutrition Education and Behavior  Volume 52, Number 2, 2020
carry healthier options (eg, milk, bot-
tled water, apple slices instead of
French fries), thus individuals can
better control their dietary intake
despite the existing negative stigma
around fast food consumption.21,22
Although most of the initial diet-
related improvements were not sus-
tained at 6 months, the overall find-
ings are encouraging. The general
tapering effect of improvements
observed in this study suggests that
participants could benefit from addi-
tional or ongoing intervention. Strat-
egies to sustain initial gains can
include hosting brief booster sessions
(eg, one hour, once a month), initiat-
ing telephone or text communica-
tion, and creating social media
groups for participants after the work-
shop concludes. Another strategy to
maintain program effects could be to
sequentially enroll Texercise Select par-
ticipants into other evidence-based
disease prevention and health promo-
tion interventions.23,24
These findings have implications
for participant recruitment to
enhance intervention effectiveness
by enrolling at-risk, older adults.
Recruitment efforts could focus on
engaging community organizations
that serve older adults (eg, senior
centers, residential facilities, area
Agencies on Aging) or healthcare
facilities that serve heart disease or
diabetes patients (eg, hospitals and
dialysis clinics). While these sites
may or may not be able to adopt and
host the workshops themselves, a
referral protocol could be created to
ensure eligible participants are aware
of, and able to access, the interven-
tion. Prior to introducing an inter-
vention into a community, a variety
of key stakeholders (eg, community
leaders, representatives from poten-
tial delivery sites, potential leaders,
potential participants) should be
approached to learn more about their
needs and what they value as suc-
cesses.25 This may include tailoring
marketing material to the target pop-
ulation, being responsive to unique
needs of target delivery sites (eg, liter-
acy and language), and engaging
community members to volunteer as
facilitators to lead programs in their
community. Further, identifying and
engaging key stakeholders early in
the planning process will increase
community buy-in, improve organi-
zational adoption, and ultimately
promote intervention scalability and
sustainability.26
Texercise Select was able to reach
and retain individuals in need of sus-
tainable interventions targeted at
improved nutrition, a key component
in overall health. The intervention
effects suggest Texercise Select is a repli-
cable, successful strategy to modify
health behaviors into sustainable
healthy lifestyles. Although only lim-
ited areas throughout Texas have
received the program thus far, the suc-
cesses of the program set the stage for
wider implementation and dissemina-
tion across the state (and beyond),
thereby seeking to ameliorate adverse
health linked to poor nutrition facing
millions of middle-aged and older
adults across the US.
Limitations
Data used in these analyses were self-
reported. Thus, actual food consump-
tion or changes in social support could
not be verified through observation or
other objective measures. However,
many of the items have been used in
other research and practice settings
and reflect the pragmatic nature of
this study.27,28 Although this study
examined 2 positive (ie, fruit/vegeta-
ble and water) and 2 negatives (ie, fast
food and sugar-sweetened beverages)
measures of diet, including more diet-
related measures, may have allowed
for a more robust assessment of partic-
ipants’ eating patterns over time.
Although the measures for self-effi-
cacy and social support showed strong
internal reliability (Cronbach’s alpha),
intra- and interrater reliabilities were
not examined. This design was quasi-
experimental, which represents an
improvement over a 1-group, pre-post
design. However, because there was
no randomization, group assignment
was imperfect and resulted in some
baseline differences between the
groups. To minimize baseline differen-
ces, the adjusted models control for
age, sex, race/ethnicity, education,
and disease comorbidity, as well as
including a random effect for site
differences. Future studies should
consider using propensity score or
frequency matching methods for
analyses. Because of the realities of
Journal of Nutrition Education and Behavior  Volume 52, Number 2, 2020
pragmatic community-based interven-
tion research, the overall sample size
was modest. Therefore, some analyses
may have been underpowered to
detect meaningful changes. Although
the socioecological model29 pro-
vided a guiding framework for iden-
tifying different intervention touch
points, in no way was the full model
or spheres of influence included or
measured.
IMPLICATIONS FOR
RESEARCH AND PRACTICE
Texercise Select is a structured interven-
tion that draws upon multiple spheres
of the socioecological framework.29 At
the individual level, the intervention
content provides participants with
practical knowledge about food
choices, raises awareness about com-
mon barriers/pitfalls, and teaches skills
to identify local resources to promote
a healthy diet. Concurrently, the inter-
vention enables participants to prac-
tice problem solving and goal setting
week after week. This iterative trial-
and-error process is skill building and
improves self-efficacy in a safe envi-
ronment. At the interpersonal level,
intervention activities (eg, identifying
resources) and the small group format
(including lay leader facilitators) pro-
vide social support. Often participants
in community-based interventions
begin to form friendships and func-
tion as an informal support group or
buddy systems, even after the interven-
tion ends.30,31 Furthermore, the infor-
mation gained during the intervention
and the participants’ dietary goals are
often shared with others (eg, family
members, co-workers, healthcare pro-
viders), which further garners support.
At the organization/setting level, intro-
ducing and embedding interventions
in communities can begin to change
organizational policy, inter-agency
partnership, and social/cultural norms
and values.1 In short, Texercise Select
adheres to the 2015−2020 Dietary
Guidelines for Americans in that it
delivers “information in a way that is
compelling, inspiring, empowering,
and actionable for individuals. . .”
and focuses “on individuals where
they are making food and beverage
choices.”1
ACKNOWLEDGMENTS
The authors recognize the Texas Health
and Human Services Commission, for
supporting the creation and evaluation
of Texercise Select, and the Texas A&M
School of Public Health for helping to
standardize and implement Texercise
Select. We thank the delivery sites, class
facilitators, and participants for their
role in the study.
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