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Effec t o f hea lth education on d ietary behavio r:

the S tanford Three C om m unity S tudy 3S tep hen P . F o rtm ann , M .D ., P aul T . W illia m s, M .S ., Steph en B . H u lley , M .D ., M .P .H .,

W illiam L . H a skell, Ph.D. and Jo hn W . F a rqu har, M .D .

S T R C T 2-yr m ass m edia cardiovascular health education program in tw o com m unities

w as follow ed by a 3rd, m aintenance yr of reduced effort. In each com m unity , a representative

cohort reported its die tary behavior annually to an interview er using a questionnaire w hich

es tim ated daily consum ption of cholesterol and fat. Relative w eight and plasm a cholesterol w ere

also m easured annually . B oth m en and w om en in the treatm ent tow ns reported reductions in

dietary cholesterol (23 to 34% ) and saturated fa t (25 to 30% ) w hich w ere significantly larger than

those reported in a 3rd , control com m unity . Relative w eight w as increased in the control com m unity

w hen com pared to the trea tm ent tow ns, perhaps as a result of the aging of the cohorts. S im ilar

patterns w ere observed for plasm a cholesterol changes. T he 2-yr changes w ere m aintained or

increased during the 3rd, m aintenance yr. The changes in individual values for plasm a cholesterol

show ed low level correlations w ith dietary cholesterol and saturated fat, but the association w ith

w eight change w as m ore im portant. These results suggest that m ass m edia health education can

achieve lasting changes in die t, obesity, and plasm a cholesterol on a com m unity level.Am . J.

C lin . N utr. 34: 2030-2038, 1981.

K E Y W O RD S C oronary heart disease, nutrition, health education, preventive m edicine

The Stanford Three Com m unity Study in-

c luded extensive dietary inform ation duringan experim ent to determ ine if a com m unityhealth education program could reduce the

risk of cardiovascular disease (C VD ). The

hypothesis w as that behavioral changes re-sulting in reduced C V D risk w ould occur if

the residents of a com m unity w ere educatedabout CV D and subsequently trained in spe-

cific skills to reduce C V D risk factors. The

design, educational stra tegy, and early results

have been reported earlier (1-7). There w as

a reduction in overall risk of about 20% w hen

population cohorts from treated and un-

treated com m unities w ere com pared after 2

yr .

The Three C om m unity Study used a m u -

tifac tor risk reduction approach, but because

of the im portance of die tary factors, Stern et

a . (3) reported separate ly the dietary changesobserved after 2 yr. In this paper we again

concentrate on dietary change, reporting the

results after a 3rd, m aintenance yr of the

cam paign. M ore im portantly , w e extend

Sterns analysis by exam ining the dietary

change data in re la tion to changes in plasm a

cholesterol and rela tive w eight, by exam ining

changes in alcohol in take, and by using ananalysis technique w hich recognizes the com -

m unity as the unit of intervention.

Methods

T he S tanford Three C om m unity S tudy

T hree northern C alifornia com m unities-W atson-

ville, G ilroy, and Tracy-w ere selected for s tudy. T hese

tow ns w ere sem irural w ith m ainly agricultural econom ies

and popula tions in 1970 betw een 13,000 and 15,000. In

each com m unity , a m ultistage random sam ple of m en

and w om en betw een 35 and 59 yr of age w as invited to

partic ipate in the base-line survey during the fall of 1972,

and in subsequent annual surveys through 1975. Each

survey included interview s about CV D -related k.now l-

From the Stanford H eart D isease Prevention Pro-

gram and the D epartm ent of M edicine, S tanford U ni-

vers ity , Stanford , C A .2 S upported by G rants H L 14174 and H L 21906 of

the N ational H eart, Lung, and B lood Ins titu te. S . P . F .

w as supported in part by N IH Training G rantS T 32 H L

07034 and the Robert W ood Johnson C linica l Scholars

Program.

3A ddress reprint requests to : S tephen P . Fortm ann,

M .D ., S tanford H eart D isease Prevention P rogram , S tan-

ford U niversity, 730 W elch Road, S tanford,C 94305.

Th e Am erican Journ al of C lin ica l Nu trition 4: OCTOBER 1981, pp 2030-2038. P rin ted in U .S.A . 1981 A m erican S ociety for Clinical N utrition


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EF FE CT O F H EA LT H E D U C A T IO N O N D IET 2031

edge. attitudes , and behavior and m easurem ents of C V D

risk factors. P lasm a cholesterol w as m easured using the

Lipid Research C linics m ethods as described elsew here

(8). R elative w eight w as defined as actual w eight divided

by ideal w eight determ ined according to the m ean of the

w eight-for-height ranges given in the M etropolitan Life

Insurance Com pany Ideal W eight T able (9).

W atsonville and G ilroy are separa ted by a range of

low hills , but they share a televis ion station and so w ere

selected to receive the educational program . T his pro-

gram began in January 1973 and continued through the

sum m er of 1975. D uring the fa ll of each year, w hen the

annual surveys w ere conducted, the educational effort

w as suspended. D uring the last year of the cam paign

1975) the intens ity of the m edia effort w as reduced to

about half of its form er level.

The cam paign w as bilingual (English and Spanish)

and delivered through various m edia, including televi-

s ion, radio, new spapers, and billboards. P am phlets,

cookbooks, and other inform ational item s w ere distrib-

uted by direct m ail to the base-line survey partic ipants .

In addition to the m ass m edia and direct m ail cam paigns ,

som e of the base-line survey partic ipants in W atsonvillereceived personal, sm all group intensive instruction on

risk factor reduction (7). T his group consisted of a ran-

dom tw o-thirds of those base-line partic ipants w ho fell

in to the upper quartile of risk after stra tification for age,

and their spouses . T he W atsonville reconstitu ted

group to be reported on here excludes these individuals

and com pensates for their rem oval by appropria tely

w eighting the rem aining one-third of the high risk indi-

viduals (1).

D ie ta ry q u es tio nn a ire

T he dietary questionnaire w as a shortened die tary

his tory designed to characterize theusu l dietary behav-

ior of partic ipants concerning certa in foods , rather than

their total food intake over som e brief, specified tim e

period. There w ere 47 preceded questions that concen-

trated on choles terol, saturated and unsaturated fa t, re-

fined sugar, and alcohol in take; no reliable estim ate of

tota l caloric intake w as possible. T he trained interview ers

used food m odels to assis t in estim ating portion sizes. A

com puter program later converted questionnaire data

into estim ates of the daily consum ption of cholesterol,

sa tura ted and polyunsaturated fat, and alcohol using the

food com position data published by F etcher e t al. (10).

Stern et al. (3) previously reported on the reproduci-

bility of this dietary questionnaire . In brief, Pearson

correlation coefficients on betw een-survey estim ates of

cholesterol and satura ted fat intake of subjects in the

control com m unity ranged betw een 0.48 and 0.SS .TableI show s the results of a com parison betw een the S tanford

questionnaire and a 3-day food record in a group of 79

volunteers w ho received both assessm ents w ithin a

m onth of each other. The tw o die tary assessm ent m eth-

ods are reasonably com parable in their m ean estim ates

of saturated fa t and cholesterol intake but there is a

considerable difference in their estim ates of caloric and

polyunsaturated fat intake. W hile there is no basis for

choosing one of these sets of results over the other as the

m ore valid estim ate of the usual habits of the com m unity ,w e have chosen the m ost conservative course and do not

report here the results for calories or polyunsaturated

T A BL E 1

C om parison of Stanford short form diet qw ith 3-day food record in 79 subjects

uestionnaire

M ean d aily intake

Nutr ient

Q uestionn aire Foo d reco rd

Correla t ion

a cr os s i nd iv id .

ual.st

Calories

(kcal) 1,676.6 2,075.6

Cholesterol

(m g) 450.9 406.9

S aturated fat

0.58

(g) 32.5 33.5

Polyunsatu-

ra ted fa t (g) 8.2 18.1

0.S7

0.35

Subjects w ere volunteers from the control com m u-

nity w ho com pleted 3-day food records w ithin 2 to 4 w k

of com pleting the questionnaire.

t Pearson correlation coeffic ients.

fat. The correlations across individuals are high given

the lim itations on reproducibility of both techniques .

This lim itation w ill also attenuate corre lations betw een

die tary variables and physiological variables, thus tend-

ing to obscure som e im portant re lationships. Such atten-

uation m ust be considered w hen interpreting the corre-

lations presented below .

A n a l y s i s

E xcept w here noted, w e use logarithm ic transform a-

tions of the variables in these analyses 1 1). For these

data, this transform ation appears to resultin m ore nor-

m ally dis tributed variables, s tabilizes the variance, and

aids in achieving additivity in linear m odels. W e also use

schem atic plots 1 1) since they better represent the data

then do plots of the m ean and SD . In these schem atic

plots, the central 50% of the dis tribution (the interquar-

tile range) is represented by a box w hich contains a

horizontal bar to indicate the location of the m edian.

D ashed lines above and below the box show the range

of the rem aining observations, excluding points w hich

lie m ore than 1.5 tim es the interquartile range beyond

the end of the box. T hese extrem epoints are show n as

dots.

A ll analyses are lim ited to those m em bers of the initia l

sam ple w ho also com pleted the final survey. S eventy-

e ight percent of the people eligib le for the initia l survey

agreed to attend; the subsequent dropout ra te w as 34%

of the base-line sam ple. Base-line differences betw een

tow ns are tes ted by analysis of variance after adjus ting

for age and sex differences (12).

The longitudinal results are analyzed by tw o ap-

proaches . F irs t w e ignore the nonrandom assignm ent of

individuals to tow ns, and trea t the observed changes

from base-line in a classical experim enta l fram ew ork

using as the error term the standard pooled variances for

estim ating the precis ion of betw een-group com parisons.

S econd, w e use a regression analys is that is m uch less

pow erful than the first approach for detectingtrue re-ductions in risk factors, but w hich recognizes the tow nas the appropriate unit of intervention (6). In this ap-

proach w e assum e that the changes in dietary factors are

linear over the duration of the study and fit separate

slopes and intercepts to each tow n based on the m eans


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E F F E C T O F H E A L T H E D U C A T I O N O N D I E T 2033

-J

>

-J

2

U)4

0LUQ

4

LUC.)

LU 10

ioI

ioi-

1a. .4

i a 9- .:

io5 io ia9 io

FIG. 1. Change in reported dietary cholesterol and saturated fat from 1972 to 1975 in each of the three towns for

men and w omen. The one-tai l ed p values for tests of si gni f icantdi f ferences betw een the control communi ty and eachtreatment community are show n at the ot to of the f igure.

.J

>

.JLUU)4

0

4

C.)

182

150

122

100

82

67

55

MALES FEMALES

P CHOL ESTER0 L REL ATI VEL SP CHOL ESTEROL d REL ATI VE

WEI GHT WEI GHT

L .H t

0 82 8 19 8 06 0 85I I.-.--.-4 i-.-----4

1

8.17 0.25..iO

..0.02

800 MALES 5D . CH OLESTE R O L 5 O. S AT UR AT ED

FEMALES

1 D . C H O LE S TE R OLD . SATU RATEDFAT FAT

400 . {149}

:- -

WATSONVI LLE (treatment) GI LROY (treatment)

D TRACY (control)

D WATSONVI LLE (treatment)

G IL RO Y ( tr eatm ent)

TRACY (control)

FIG. 2. Change in pl asma cholesterol and relati ve w eight from 1972 to 1975 in each of the three towns for menand w omen. The one-tai led p values for tests of si gni f icant differences between the control communi ty and each

treatment communi ty are shown atth e ot to of the f igure.

If w e ignore the variance at basel ine among

tow ns, w e may use at test of the signif icanceof these differences. B oth men and w omen inthe education tow ns show ed a signif icantlygreater decl ine in dietary cholesterol and sat-

urated fat w hen compared to the controltow n. A lso, w hile the combined sample of

males and females in Tracy experienced anaverage increase of 1% in relative w eight,W atsonvil le and Gilroy show ed essential lyno change in relative w eight. Similarly, Tracyexperienced a signif icantly larger increase inpl asm a chol ester o .

The regression analysis of these data is


5/9

55 0

45 0

.

E

24 0 A

20 0

16 0

25 0

1.28

1.24

1.20

1.16

1 1

E

E00

E

0 1 2 3

RELATI VE WEI GHT (p 0.04)

_ ___

A. A A

0 1 2 3

P LAS MA CHOL ES TE ROL (p 0.02)

22 5

21 5

20 5

19 5 -1 2 3

YEARS

0 1 2 3

YEARS

2034 FO RT M A NN ET A L .

show n in Figure 3 and the rates of change in

each com m unity are given in Table 3. This

conservative analytic approach supports the

above conclusions both graphically and sta-

tistically (the p values shown in the figure arebased on one-ta iled t tests w ith 6 df). D ietary

choles terol and satura ted fat show alm ost

identica l declines in the tw o educated com -

m unities and little change in the control tow n.

Rela tive weight increased in Tracy but w as

DI ETARY CHOLES TEROL (p 0 0 1

A35 0 .

stable in the two treated tow ns. Plasm a cho-

lesterol increased in all com m unities, but sig-

nificantly less in G ilroy and W atsonville than

in T racy.

A lcohol consum ption (not show n) tendedto decrease in all three com m unities during

the study, but the pattern of change for the

treatm ent towns w as not substantia lly differ-

ent from the contro . W e e ected not to dis-

play these data due to the highly skew ed

D IETARY SATUR ATED FAT (p 0.03)

R E G R E SS I ON

LIN E M EAN0

0

WAT S O N V I LLE ( t reatment)

G ILR O Y (treatm ent)

TR A CY (control)

FI G . 3. Change in the four risk factors analyzed by the regression m ethod (see text). The one-tailed p value fortesting w hether the average of the slopes for the tw o treatm ent com m unities is significantly different from the slope

in the control com m unity is given at theto p of each regression plot.

T A BL E 3

eg r es s i o n n l y s i s wh i c h r ec o g n i z e s t own s s t he e x p e r i me n t l u n i t

Variable

A verag e annual percentag e change in

mean

t he g eo m et ri cS ignifican ce test p values for the differen ce in the rate of change in

th e treatm ent com m un ities vs the rate of chan ge in the control

community

CommunityW atsonville vs A verage ofWatson

G ilroy vs Tracy vile an d G ilory vsTracy Tracy

Watsonvi l le G ilroy T racy

D ietary cholesterol -11.2 -11.0 -2.8 0.01 0.05 0.01

(mg/day)

D ietary saturated fat

(g/day) -9 .4 -10.3 -0.9 0.05 0.04 0.03

P lasm a ch ole ste rol

(m g/100 m l) 1 .0 0.5 1.7 0.08 0.02 0.02

R ela tive w eight 0.0 0.0 0.3 0.07 0.06 0.04

* O ne tailed test.


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L og dietary -0 .07

satura ted fa t N S

0.04

-0.07

N S

-0.03

0.07

0.03

-0.02

0.06

0.06

T A BL E 5

M ultiple regression associa ting changes in log plasm a0.16 choles terol w ith changes in rela tive w eight and dietary

0.001 variables after 3 y r

P earson correlation coefficients and their one-sided

significance levels are reported.

t N S is specified if p> 0.1. S ignificance levels are not provided for alcohol

because of its skew ed distribution.

E FF E C T O F H E A L T H E D U C A T I O N O N D I E T 2035

distribution of alcohol intake and the num ber

of potentia lly confounding variables.

Reported diet and plasma cholesterol

Table 4 show s corre lations between re-

ported nutrient intake, rela tive w eight, and

plasm a cholesterol level by com m unity. The

top half of Table 4 represents the cross-sec-

tional analys is a t base-line and show s signifi-

cant corre la tions between plasm a cholesterol

and die tary factors in only one of the three

com m unities. In contrast, rela tive weight w as

significantly correla ted w ith plasm a choles-

terol in all three com m unities .

The lower portion of Table 4 presents the

longitudinal analysis corre la ting change in

plasm a choles terol w ith change in die tary

nutrients and rela tive w eight. C hanges in di-

e tary cholesterol and satura ted fat are s ignifi-

cantly corre lated w ith changes in plasm a cho-

les terol and the longitudinal corre la tions for

T A BL E 4

Correlations betw een reported nutrient intake, relative

w eight, and plasm a cholesterol level by com m unity*

Community

Nutr ient

W atsonv ille G ilroy T racy

Base-line nutrient intake corre lated w ith base-line log

plasm a choles terol level (cross-sectional)

L og die tary -0.02 0.08 -0 .03

cholesterol N St 0.03 N S

L og d ieta ry

alcohol

L og relative 0.18

w eight 0.001

3-yr changes in nutrient in take correlated w ith 3-yr

changes in log plasm a cholesterol (longitudinal)

SLog dietary 0.08 0.10 0.10

cholesterol 0.03 0.02 0.01

iLog dietary

satura ted fa t

0.12

0.003

0.13

0.004

0.07

0.03

S Log dietary -0.05 0.14 -0.04

alcohol*

S Log rela tive 0.30 0.22 0.16weight 0.001 0.001 0.001

re la tive w eight are general y larger than the

cross-sectional correla tions. The corre la tions

for die tary cholesterol and saturated fat are

low , but consistently present in all tow ns. The

correla tions in the treatm ent towns tend to belarger. Table 4 presents Pearsons corre la tion

coeffic ients; sim ilar results w ere obta ined us-

ing Spearm ans p and Kendalls T

Adjustm ent of the change in plasm a cho-

lesterol for change in re lative w eight does not

elim inate the associa tion w ith change in di-

etary cholesterol (p< 0.005 or change indie tary satura ted fat (p< 0 . 0 3 in the treat-m ent com m unities. However, as show n in

Table 5 in a m ultip le regression m odel con-

ta ining all of these elem ents rela tive w eight

achieves the greatest s ignificance. In this

m odel, changes in dietary choles terol m ake

no significant contribution once all other fac-tors are know n, though change in die tary

satura ted fat still rem ains m arginally signifi-

cant. The m odel expla ins 8% of the variance

in plasm a choles terol reduction.

Discussion

Techniques for changing the eating habits

of popula tions are im portant for im plem ent-

ing public health approaches to heart disease

prevention (13-17). This paper presents evi-

dence that such large-scale die tary changes

are possible in the context of a com m unity-

w ide m ass m edia hea th education program .Significant reductions in cholesterol and sat-

In dep en de nt v aria bles

S ta nd ard r eg ressio n

Coeff ic ients Signif icance

C hange log re lative 0.4724 p = 10_b

weight

C hange log dietary -0.0139 N St

cholesterol

C hange log die tary 0.0328 p = 0.02

saturated fat

Change log die tary 0.0029 N S

polyunsaturated

fa t

Change log dietary 0.0012 N S

alcoholR2 = 0.08

one-tailed significance levels .

t p>0.1.


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2036 FO R T M A N N E T A L

urated fat in take w ere reported during both

the 2 yr of m ajor effort and during the 3rd,

m aintenance year.

Obesity is a lso a m ajor health problem in

this country. O besity tends to increase w ithage, w hich m ay explain the significant in-

crease in re la tive weight over just 3 yr in the

control com m unity . The fact that this in-

crease w as not observed in the treatm ent

com m unities suggests that the m ass m edia

can be effective in controlling this public

health problem as w ell. Future efforts should

perhaps concentra te on preventing the w eight

gain w hich accom panies aging for m any in-

dividuals. Since our die tary his tory cannot

es tim ate tota l caloric in take, w e cannot deter-

m ine w hether the effect on w eight gain w as

due to change in caloric in take or physical

activity.W hen analyzing the results of studies such

as this one, it is tem pting to use a standard

approach, com paring each m em ber of the

sam ple cohort to him self a t base-line. Such

an approach can be m is eading, how ever,

since it ignores varia tion am ong tow ns at

base-line. In fact, w e did fm d significant vari-

a tion am ong towns (about tw o orders of m ag-

nitude sm aller than the within-tow n vari-

ance). W e therefore used the regression ana -yses presented in this paper w hich support

the conclusion that real differences betw een

treatm ent and control com m unities w ere pre-

sent.C ross-cultura l associa tions betw een die tary

and blood cholesterol have been strong (18).

How ever, several large studies in the U nited

States have found zero (19, 20) or low order

(21, 22) corre lations betw een die tary and

blood choles terol. Jacobs et a . (17) argue

persuasively that the well-es tablished rela-

tionship between die t and blood cholesterol

in m etabolic ward studies can be obscured by

the low precision of die tary m easurem ents.

In this study, w e also fm d few significant

correla tions betw een die t and blood choles-

terol a t base-line , but the longitudinal data

dem onstra te sm all but significant corre la tionsbetw een changes in plasm a cholesterol and

both dietary cholesterol and die tary saturated

fatty acid change.

This study provides further evidence that

weight change is an independent and im por-

tant determ inant of blood cho esterol (23).

W e find highly significant corre la tions be-

tw een relative weight and plasm a cholesterol

both at base-line and longitudinally . In ad-

dition, rela tive weight is the s trongest factor

in a m ultiple regress ion m odel associa ting the

reduction in plasm a cholseterol w ith changesin rela tive weight and die tary factors . It re-

m ains possible that die tary com position w as

as strong a determ inant of plasm a cholesterol

as w eight, but that this w as m asked in the

regress ion by the low er precision of the di-

eta ry as ses sm ent.

A lthough there is evidence that plasm a

cholesterol levels are slow ly faffing in this

country (24), the cross-sectional associa tion

betw een plasm a choles terol and age suggests

that the form er should rise in a popula tion

followed longitudinally. In fact, w e did ob-

serve a sm al rise in plasm a cholesterol in all

three com m unities over tim e, but the rise wassignificantly less in the tw o treatm ent tow ns

(about 2% com pared to about5 ). The otherresults presented here suggest that this differ-

ence in plasm a choles terol change w as due to

differences in die tary intake and w eight gain .

One w ould predic t a fall in cholesterol from

the die tary changes . In addition to the possi-

ble effects of aging, w e m ay have observed a

rise because of subtle laboratory drift (despite

standardization) or som e other tim e effect.For exam ple , plasm a cholesterol did decrease

betw een the 1st and 3rd surveys (1). Interes t-

ingly , the difference betw een treatm ent and

control is constant at a ll surveys .The m ost prom inent threat to the validity

of these conclus ions is the possibility of bias

in self-reported die tary behavior. It is reason-

able to suggest that the m em bers of the treat-

m ent com m unity cohort were especia lly

likely to bias their response to the die tary

questionnaire in the direction that the exper-

im enters desired. W hile this poss ibility can-

not be dism issed, the existence of real differ-

ences betw een tow ns is im plied by the sig-

nificant differences in w eight change, an ob-jective m easure . The questionnaire data are

also partly validated by our observation that

changes in reported die t w ere corre lated w ithchanges in plasm a cholesterol.

The die tary his tory used in this study ap-

pears to estim ate adequate y group die tary

cholesterol and saturated fat. Furtherm ore ,

the im precision of this history would tend to

obscure the fm dings reported. Nevertheless,the conclusions of future sim ilar studies


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E F F E C T O F H E A L T H E D U C A T IO N O N D IE T 2037

would be strengthened by unobtrusive dietary

measures such as food sales and a moreprecise diet measure.

I t is also important to note that the changes

which occurred in the two treatment townsmay have occurred by chance. W hile the

regression analysis strengthens the conclusion

that real differences between treatment andcontrol towns existed, it does not eliminatethe possibility that the changes in the two

treatment towns were independent of the in-tervention. If two of the three towns weredestined to display the observed changes,

there is one chance in three that the twowould both be treatment communities, thatis p = 0.33. Only random allocation of at

least eight study communities would solve

this problem 2 5 , a strategy that is both

financially and practically infeasible. The co-hort analyzed here does not accurately rep-resent the three communities because of drop-

outs from the cohort during the 3 yr of thestudy and because it was surveyed. However,we have repeated these analyses using various

assumptions about the behavior of the drop-outs without altering the results unpublishedanalysis , and the results from Tracy make itclear that surveying itself has at most a tran-sient effect. N evertheless, future replications

of this study would be strengthened by theaddition of repeated independent samples ofthe com muni ty.

I t is likely that several of the chronic dis-eases that currently plague the developedworld-hypertension, coronary heart disease,

diabetes, cancer-are related to diet and obe-sity. The results presented here offer encour-agement that large groups of people are ableto apply information on health and behavior

obtained from mass media to make changesin dietary practices and obesity. Thus com-munity health education may become a pow-

erful, cost-effective tool for improving thepublic health.

The authors thank Professor Byron W . Brown for

reviewing this manuscript and M s. Patti M athis, M s.

Susan M ellen, and M s. A nn V arady for technical assist-ance.

References

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