You are on page 1of 9

2030

Effect of health education on dietary behavior:


the Stanford Three Community Study1-3
Stephen P. Fortmann, M .D., Paul T. W illiams, M .S., Stephen B. Hulley, M .D., M .P.H.,
W illiam L. Haskell, Ph.D., and John W . Farquhar, M .D.
ABSTRACT A 2-yr mass media cardiovascular health education program in two communities
was followed by a 3rd, maintenance yr of reduced effort. In each community, a representative
cohort reported its dietary behavior annually to an interviewer using a questionnaire which
estimated daily consumption of cholesterol and fat. Relative weight and plasma cholesterol were
also measured annually. Both men and women in the treatment towns reported reductions in
dietary cholesterol (23 to 34% ) and saturated fat (25 to 30% ) which were significantly larger than
those reported in a 3rd, control community. Relative weight was increased in the control community
when compared to the treatment towns, perhaps as a result of the aging of the cohorts. Similar
patterns were observed for plasma cholesterol changes. The 2-yr changes were maintained or
increased during the 3rd, maintenance yr. The changes in individual values for plasma cholesterol
showed low level correlations with dietary cholesterol and saturated fat, but the association with
weight change was more important. These results suggest that mass media health education can
achieve lasting changes in diet, obesity, and plasma cholesterol on a community level. Am. J.
Clin. Nutr. 34: 2030-2038, 1981.
KEY W ORDS Coronary heart disease, nutrition, health education, preventive medicine
The Stanford Three Community Study in-
cluded extensive dietary information during
an experiment to determine if a community
health education program could reduce the
risk of cardiovascular disease (CVD). The
hypothesis was that behavioral changes re-
sulting in reduced CVD risk would occur if
the residents of a community were educated
about CVD and subsequently trained in spe-
cific skills to reduce CVD risk factors. The
design, educational strategy, and early results
have been reported earlier (1-7). There was
a reduction in overall risk of about 20% when
population cohorts from treated and un-
treated communities were compared after 2
yr.
The Three Community Study used a mu!-
tifactor risk reduction approach, but because
of the importance of dietary factors, Stern et
a!. (3) reported separately the dietary changes
observed after 2 yr. In this paper we again
concentrate on dietary change, reporting the
results after a 3rd, maintenance yr of the
campaign. M ore importantly, we extend
Sterns analysis by examining the dietary
change data in relation to changes in plasma
cholesterol and relative weight, by examining
changes in alcohol intake, and by using an
analysis technique which recognizes the com-
munity as the unit of intervention.
M ethods
The Stanford Three Community Study
Three northern California communities-W atson-
ville, Gilroy, and Tracy-were selected for study. These
towns were semirural with mainly agricultural economies
and populations in 1970 between 13,000 and 15,000. In
each community, a multistage random sample of men
and women between 35 and 59 yr of age was invited to
participate in the base-line survey during the fall of 1972,
and in subsequent annual surveys through 1975. Each
survey included interviews about CVD-related k.nowl-
From the Stanford Heart Disease Prevention Pro-
gram and the Department of M edicine, Stanford Uni-
versity, Stanford, CA.
2 Supported by Grants HL 14174 and HL 21906 of
the National Heart, Lung, and Blood Institute. S. P. F.
was supported in part by NIH Training GrantS T32 HL
07034 and the Robert W ood Johnson Clinical Scholars
Program.
3Address reprint requests to: Stephen P. Fortmann,
M .D., Stanford Heart Disease Prevention Program, Stan-
ford University, 730 W elch Road, Stanford, CA 94305.
The American Journal of Clinical Nutrition 34: OCTOBER 1981, pp. 2030-2038. Printed in U.S.A.
1981 American Society for Clinical Nutrition

b
y

g
u
e
s
t

o
n

S
e
p
t
e
m
b
e
r

1
0
,

2
0
1
4
a
j
c
n
.
n
u
t
r
i
t
i
o
n
.
o
r
g
D
o
w
n
l
o
a
d
e
d

f
r
o
m

EFFECT OF HEALTH EDUCATION ON DIET
2031
edge. attitudes, and behavior and measurements of CVD
risk factors. Plasma cholesterol was measured using the
Lipid Research Clinics methods as described elsewhere
(8). Relative weight was defined as actual weight divided
by ideal weight determined according to the mean of the
weight-for-height ranges given in the M etropolitan Life
Insurance Company Ideal W eight Table (9).
W atsonville and Gilroy are separated by a range of
low hills, but they share a television station and so were
selected to receive the educational program. This pro-
gram began in January 1973 and continued through the
summer of 1975. During the fall of each year, when the
annual surveys were conducted, the educational effort
was suspended. During the last year of the campaign
( 1975) the intensity of the media effort was reduced to
about half of its former level.
The campaign was bilingual (English and Spanish)
and delivered through various media, including televi-
sion, radio, newspapers, and billboards. Pamphlets,
cookbooks, and other informational items were distrib-
uted by direct mail to the base-line survey participants.
In addition to the mass media and direct mail campaigns,
some of the base-line survey participants in W atsonville
received personal, small group intensive instruction on
risk factor reduction (7). This group consisted of a ran-
dom two-thirds of those base-line participants who fell
into the upper quartile of risk after stratification for age,
and their spouses. The W atsonville reconstituted
group to be reported on here excludes these individuals
and compensates for their removal by appropriately
weighting the remaining one-third of the high risk indi-
viduals (1).
D ie ta ry q u e s tio n n a ire
The dietary questionnaire was a shortened dietary
history designed to characterize the usual dietary behav-
ior of participants concerning certain foods, rather than
their total food intake over some brief, specified time
period. There were 47 preceded questions that concen-
trated on cholesterol, saturated and unsaturated fat, re-
fined sugar, and alcohol intake; no reliable estimate of
total caloric intake was possible. The trained interviewers
used food models to assist in estimating portion sizes. A
computer program later converted questionnaire data
into estimates of the daily consumption of cholesterol,
saturated and polyunsaturated fat, and alcohol using the
food composition data published by Fetcher et al. (10).
Stern et al. (3) previously reported on the reproduci-
bility of this dietary questionnaire. In brief, Pearson
correlation coefficients on between-survey estimates of
cholesterol and saturated fat intake of subjects in the
control community ranged between 0.48 and 0.SS. T abl e
I shows the results of a comparison between the Stanford
questionnaire and a 3-day food record in a group of 79
volunteers who received both assessments within a
month of each other. The two dietary assessment meth-
ods are reasonably comparable in their mean estimates
of saturated fat and cholesterol intake but there is a
considerable difference in their estimates 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
more valid estimate of the usual habits of the community,
we have chosen the most conservative course and do not
report here the results for calories or polyunsaturated
T A BL E 1
Comparison of Stanford short form diet q
with 3-day food record in 79 subjects
uestionnaire
M ean daily intake
Nutrient
Questionnaire Food record
Correlation
across individ.
ual.st
Calories
(kcal) 1,676.6 2,075.6
Cholesterol
(mg) 450.9 406.9
Saturated fat
0.58
(g) 32.5 33.5
Polyunsatu-
rated fat (g) 8.2 18.1
0.S7
0.35
* Subjects were volunteers from the control commu-
nity who completed 3-day food records within 2 to 4 wk
of completing the questionnaire.
t Pearson correlation coefficients.
fat. The correlations across individuals are high given
the limitations on reproducibility of both techniques.
This limitation will also attenuate correlations between
dietary variables and physiological variables, thus tend-
ing to obscure some important relationships. Such atten-
uation must be considered when interpreting the corre-
lations presented below.
A n a ly s is
Except where noted, we use logarithmic transforma-
tions of the variables in these analyses ( 1 1). For these
data, this transformation appears to result in more nor-
mally distributed variables, stabilizes the variance, and
aids in achieving additivity in linear models. W e also use
schematic plots ( 1 1) since they better represent the data
then do plots of the mean and SD. In these schematic
plots, the central 50% of the distribution (the interquar-
tile range) is represented by a box which contains a
horizontal bar to indicate the location of the median.
Dashed lines above and below the box show the range
of the remaining observations, excluding points which
lie more than 1.5 times the interquartile range beyond
the end of the box. These extreme poi nt s are shown as
dots.
All analyses are limited to those members of the initial
sample who also completed the final survey. Seventy-
eight percent of the people eligible for the initial survey
agreed to attend; the subsequent dropout rate was 34%
of the base-line sample. Base-line differences between
towns are tested by analysis of variance after adjusting
for age and sex differences (12).
The longitudinal results are analyzed by two ap-
proaches. First we ignore the nonrandom assignment of
individuals to towns, and treat the observed changes
from base-line in a classical experimental framework
using as the error term the standard pooled variances for
estimating the precision of between-group comparisons.
Second, we use a regression analysis that is much less
powerful than the first approach for detecting true re-
ductions in risk factors, but which recognizes the town
as the appropriate unit of intervention (6). In this ap-
proach we assume that the changes in dietary factors are
linear over the duration of the study and fit separate
slopes and intercepts to each town based on the means

b
y

g
u
e
s
t

o
n

S
e
p
t
e
m
b
e
r

1
0
,

2
0
1
4
a
j
c
n
.
n
u
t
r
i
t
i
o
n
.
o
r
g
D
o
w
n
l
o
a
d
e
d

f
r
o
m

2032 FORT M ANN ET AL .
199.
t Test of statistical significance o mi t t e d because of skewed distribution.
of each of the four annual surveys. The significance of
the difference between the average rate of change in the
two treatment towns versus the rate of change in the
control town is therefore based in the t distribution with
only 6 df.
W e used packaged computer programs for much of
the analysis. One way analysis of variance and covari-
ance, t tests, and frequency distributions were obtained
through the Statistical Package for the Social Sciences
and regression analysis was performed using the BM DP
Statistical Package. Since the educational program was
attempting to achieve unidirectional changes in the fac-
tors discussed in this paper (i.e., reductions), we use one-
tailed t tests throughout when testing the significance of
these changes. Two-tailed tests are used to describe cross-
sectional patterns at baseline and other fmdings where
the direction of the difference was not predicted. Signif-
icance levels above 0.1 are indicated as not significant.
Results
Table 2 shows the distribution of reported
dietary variables, relative weight, and plasma
cholesterol by sex for each community at
base-line.
There are considerable differences for all
the variables among the three communities.
Table 2 shows that this variance among towns
is statistically significant for dietary choles-
terol and saturated fat even after adjusting
for sex and age effects. However, the variance
within towns for these variables (not shown)
is two orders of magnitude larger than the
between-town variance. Table 2 also shows
the distribution of alcohol intake by town.
The highly skewed nature of this distribution
is evident; in all communities and in both
sexes a high proportion of respondents re-
ported no alcohol intake.
Longitudinal analysis, 1972 to 1975
Figures 1 and 2 show the percent change
in dietary cholesterol, dietary fatty acids, re!-
ative weight, and plasma cholesterol after 3
yr in each community. The declines in re-
ported dietary cholesterol and saturated fat
intake are uniformly larger in the two edu-
cation communities than in the control com-
munity. The differences in relative weight are
less striking. Plasma cholesterol increased in
all communities, but the increase appears
larger in the control town.
T ABL E 2
Base-line distributions by sex and community for reported dietary variables, relative weight, and plasma
cholesterol*
Percentile
M en women Significance of
the variation
among towns 25 50 75 25 50 75
Dietary cholesterol (mg/day)
W atsonville 413 516 717 336 429 527
Gilroy 443 580 855 313 418 567 p<O.O2
Tracy 437 570 750 284 374 516
Dietary saturated fat (g/day)
W atsonville 28 36 49 23 29 39
Gilroy 32 43 56 21 30 38 p <0.001
Tracy 30 40 49 20 25 33
Dietary alcohol (oz/day)
W atsonville 0 0.35 0.91 0 0 0.27
Gilroy 0.06 0.45 1.10 0 0.06 0.40 t
Tracy 0 0.27 0.93 0 0 0.26
Relative weight
W atsonville 1.10 1.17 1.29 1.05 1.15 1.33
Gilroy 1.10 1.21 1.31 1.08 1.19 1.34 p<O.l
Tracy 1.10 1.21 1.33 1.07 1.19 1.39
Plasma cholesterol (mg/dl)
W atsonville 187 212 240 181 210 237
Gilroy 186 208 240 184 206 232 p <0.08
Tracy 182
* Sample sizes: W atsonville-men
207
167, women 2
236 179
18; Gilroy-men 160, w
198
omen 203;
231
Tracy-men 166, women

b
y

g
u
e
s
t

o
n

S
e
p
t
e
m
b
e
r

1
0
,

2
0
1
4
a
j
c
n
.
n
u
t
r
i
t
i
o
n
.
o
r
g
D
o
w
n
l
o
a
d
e
d

f
r
o
m

E F F E C T O F H E AL T H E DUC AT I O N O N DI E T 2033
-J
>
-J
2
U)
4
0
LU
Q
4
z
LU
C.)
LU
10
io
I
i o
i-
1 a
$. ..4
i a 9
-
- - .: 4
io5 io ia9 io
FI G. 1. Change i n reported di etary chol esterol and saturated f at f rom 1972 to 1975 i n each of the three towns f or
men and women. The one-tai l ed p val ues f or tests of si gni f i cant di f f erences between the control communi ty and each
treatment communi ty are shown at the bottom of the f i gure.
.J
>
z
.J
LU
U)
4
0
4
z
C.)
182
150
122
100
82
67
55
MAL ES FEMAL ES
i P. CHOL ESTER0 L i REL ATI VE
L SP. CHOL ESTEROL d REL ATI VE
WEI GHT WEI GHT
L .H

t
0 . 8 2 8 . 1 9 8 . 0 6 0 . 8 5
I I.-.--.-4 i-.-----4
1
8.17 0.25
..
iO
..
0.02
800
MALES
5D. CHOLESTEROL 5O. SATURATED
FEMALES
1D. CHOLESTEROL D. SATURATED
FAT FAT
400
. #{149}
:
- -

WATSONVI L L E (treatment)
GI L ROY (treatment)
D TRACY (control )
D WATSONVI L L E (treatment)
GI L ROY (treatment)
TRACY (control )
FI G. 2. Change i n pl asma chol esterol and rel ati ve wei ght f rom 1972 to 1975 i n each of the three towns f or men
and women. The one-tai l ed p val ues f or tests of si gni f i cant di f f erences between the control communi ty and each
treatment communi ty are shown at the bottom of the f i gure.
I f we i gnore the vari ance at basel i ne among
towns, we may use a t test of the si gni f i cance
of these di f f erences. Both men and women i n
the educati on towns showed a si gni f i cantl y
greater decl i ne i n di etary chol esterol and sat-
urated f at when compared to the control
town. A l so, whi l e the combi ned sampl e of
mal es and f emal es i n Tracy experi enced an
average i ncrease of 1% i n rel ati ve wei ght,
W atsonvi l l e and Gi l roy showed essenti al l y
no change i n rel ati ve wei ght. Si mi l arl y, Tracy
experi enced a si gni f i cantl y l arger i ncrease i n
pl asma chol estero! .
The regressi on anal ysi s of these data i s

b
y

g
u
e
s
t

o
n

S
e
p
t
e
m
b
e
r

1
0
,

2
0
1
4
a
j
c
n
.
n
u
t
r
i
t
i
o
n
.
o
r
g
D
o
w
n
l
o
a
d
e
d

f
r
o
m

550
450
0
.
E
240 A
200
160
250
1.28
1.24
1.20
1.16
1 1 )
E
E
0
0
E
0 1 2 3
RELATI VE WEI GHT (p = 0.04)
_ ____ 0
A. A A
0 1 2 3
PLAS MA CHOLES TEROL (p = 0.02)
225
215
205
195 -
1 2 3
YEARS
0 1 2 3
YEARS
2034 FORT M A NN ET A L .
shown in Figure 3 and the rates of change in
each community 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 are
based on one-tailed t tests with 6 df). Dietary
cholesterol and saturated fat show almost
identical declines in the two educated com-
munities and little change in the control town.
Relative weight increased in Tracy but was
DI ETARY CHOLES TEROL (p = 0 . 0 1 )
A
350 .
stable in the two treated towns. Plasma cho-
lesterol increased in all communities, but sig-
nificantly less in Gilroy and W atsonville than
in Tracy.
Alcohol consumption (not shown) tended
to decrease in all three communities during
the study, but the pattern of change for the
treatment towns was not substantially differ-
ent from the contro!. W e e!ected not to dis-
play these data due to the highly skewed
DIETARY SATURATED FAT (p = 0.03)
REGRESSION
LINE MEAN
0
A
0
W ATSONVI LLE (treatment)
GILROY (treatment)
TRACY (control)
FI G. 3. Change in the four risk factors analyzed by the regression method (see text). The one-tailed p value for
testing whether the average of the slopes for the two treatment communities is significantly different from the slope
in the control community is given at the top of each regression plot.
T A BL E 3
Re g r e s s i o n a n a l y s i s wh i c h r e c o g n i z e s t o wn s a s t h e e x p e r i me n t a l u n i t
Variable
Average annual percentage change in
mean
the geometric
Significance test p values for the difference in the rate of change in
the treatment communities vs the rate of change in the control
community
Community
W atsonville vs Average of W atson
Gilroy vs Tracy vile and Gilory vs
Tracy Tracy
W atsonville Gilroy Tracy
Dietary cholesterol -11.2 -11.0 -2.8 0.01 0.05 0.01
(mg/day)
Dietary saturated fat
(g/day) -9.4 -10.3 -0.9 0.05 0.04 0.03
Plasma cholesterol
(mg/100 ml) 1.0 0.5 1.7 0.08 0.02 0.02
Relative weight 0.0 0.0 0.3 0.07 0.06 0.04
* One tailed test.

b
y

g
u
e
s
t

o
n

S
e
p
t
e
m
b
e
r

1
0
,

2
0
1
4
a
j
c
n
.
n
u
t
r
i
t
i
o
n
.
o
r
g
D
o
w
n
l
o
a
d
e
d

f
r
o
m

Log dietary -0.07
saturated fat NS
0.04
-0.07
NS
-0.03
0.07
0.03
-0.02
0.06
0.06
T ABL E 5
M ultiple regression associating changes in log plasma
0.16 cholesterol with changes in relative weight and dietary
0.001 variables after 3 yr
* Pearson correlation coefficients and their one-sided
significance levels are reported.
t NS is specified if p > 0.1.
Significance levels are not provided for alcohol
because of its skewed distribution.
EFFECT OF H EAL T H EDUCAT I ON ON DI ET
2035
distribution of alcohol intake and the number
of potentially confounding variables.
Reported diet and plasma cholesterol
Table 4 shows correlations between re-
ported nutrient intake, relative weight, and
plasma cholesterol level by community. The
top half of Table 4 represents the cross-sec-
tional analysis at base-line and shows signifi-
cant correlations between plasma cholesterol
and dietary factors in only one of the three
communities. In contrast, relative weight was
significantly correlated with plasma choles-
terol in all three communities.
The lower portion of Table 4 presents the
longitudinal analysis correlating change in
plasma cholesterol with change in dietary
nutrients and relative weight. Changes in di-
etary cholesterol and saturated fat are signifi-
cantly correlated with changes in plasma cho-
lesterol and the longitudinal correlations for
T ABL E 4
Correlations between reported nutrient intake, relative
weight, and plasma cholesterol level by community*
Community
Nutrient
W atsonville Gilroy Tracy
Base-line nutrient intake correlated with base-line log
plasma cholesterol level (cross-sectional)
Log dietary -0.02 0.08 -0.03
cholesterol NSt 0.03 NS
Log dietary
alcohol
Log relative 0.18
weight 0.001
3-yr changes in nutrient intake correlated with 3-yr
changes in log plasma cholesterol (longitudinal)
SLog dietary 0.08 0.10 0.10
cholesterol 0.03 0.02 0.01
i Log dietary
saturated fat
0.12
0.003
0.13
0.004
0.07
0.03
SLog dietary -0.05 0.14 -0.04
alcohol*
SLog relative 0.30 0.22 0.16
weight 0.001 0.001 0.001
relative weight are general!y larger than the
cross-sectional correlations. The correlations
for dietary cholesterol and saturated fat are
low, but consistently present in all towns. The
correlations in the treatment towns tend to be
larger. Table 4 presents Pearsons correlation
coefficients; similar results were obtained us-
ing Spearmans p and Kendalls T.
Adjustment of the change in plasma cho-
lesterol for change in relative weight does not
eliminate the association with change in di-
etary cholesterol (p < 0.005) or change in
dietary saturated fat (p < 0 . 0 3 ) in the treat-
ment communities. However, as shown in
Table 5, in a multiple regression model con-
taining all of these elements relative weight
achieves the greatest significance. In this
model, changes in dietary cholesterol make
no significant contribution once all other fac-
tors are known, though change in dietary
saturated fat still remains marginally signifi-
cant. The model explains 8% of the variance
in plasma cholesterol reduction.
Discussion
Techniques for changing the eating habits
of populations are important for implement-
ing public health approaches to heart disease
prevention (13-17). This paper presents evi-
dence that such large-scale dietary changes
are possible in the context of a community-
wide mass media hea!th education program.
Significant reductions in cholesterol and sat-
Independent variables
Standard regression
Coefficients Significance
Change log relative 0.4724 p = 10_b
weight
Change log dietary -0.0139 NSt
cholesterol
Change log dietary 0.0328 p = 0.02
saturated fat
Change log dietary 0.0029 NS
polyunsaturated
fat
Change log dietary 0.0012 NS
alcohol
R2 = 0.08
* one-tailed significance levels.
t p>0.1.

b
y

g
u
e
s
t

o
n

S
e
p
t
e
m
b
e
r

1
0
,

2
0
1
4
a
j
c
n
.
n
u
t
r
i
t
i
o
n
.
o
r
g
D
o
w
n
l
o
a
d
e
d

f
r
o
m

2036 FORT M ANN ET AL .
urated fat intake were reported during both
the 2 yr of major effort and during the 3rd,
maintenance year.
Obesity is also a major health problem in
this country. Obesity tends to increase with
age, which may explain the significant in-
crease in relative weight over just 3 yr in the
control community. The fact that this in-
crease was not observed in the treatment
communities suggests that the mass media
can be effective in controlling this public
health problem as well. Future efforts should
perhaps concentrate on preventing the weight
gain which accompanies aging for many in-
dividuals. Since our dietary history cannot
estimate total caloric intake, we cannot deter-
mine whether the effect on weight gain was
due to change in caloric intake or physical
activity.
W hen analyzing the results of studies such
as this one, it is tempting to use a standard
approach, comparing each member of the
sample cohort to himself at base-line. Such
an approach can be mis!eading, however,
since it ignores variation among towns at
base-line. In fact, we did fmd significant vari-
ation among towns (about two orders of mag-
nitude smaller than the within-town vari-
ance). W e therefore used the regression ana!-
yses presented in this paper which support
the conclusion that real differences between
treatment and control communities were pre-
sent.
Cross-cultural associations between dietary
and blood cholesterol have been strong (18).
However, several large studies in the United
States have found zero (19, 20) or low order
(21, 22) correlations between dietary and
blood cholesterol. Jacobs et a!. (17) argue
persuasively that the well-established rela-
tionship between diet and blood cholesterol
in metabolic ward studies can be obscured by
the low precision of dietary measurements.
In this study, we also fmd few significant
correlations between diet and blood choles-
terol at base-line, but the longitudinal data
demonstrate small but significant correlations
between changes in plasma cholesterol and
both dietary cholesterol and dietary saturated
fatty acid change.
This study provides further evidence that
weight change is an independent and impor-
tant determinant of blood cho!esterol (23).
W e find highly significant correlations be-
tween relative weight and plasma cholesterol
both at base-line and longitudinally. In ad-
dition, relative weight is the strongest factor
in a multiple regression model associating the
reduction in plasma cholseterol with changes
in relative weight and dietary factors. It re-
mains possible that dietary composition was
as strong a determinant of plasma cholesterol
as weight, but that this was masked in the
regression by the lower precision of the di-
etary assessment.
Although there is evidence that plasma
cholesterol levels are slowly faffing in this
country (24), the cross-sectional association
between plasma cholesterol and age suggests
that the former should rise in a population
followed longitudinally. In fact, we did ob-
serve a smal! rise in plasma cholesterol in all
three communities over time, but the rise was
significantly less in the two treatment towns
(about 2% compared to about 5% ). The other
results presented here suggest that this differ-
ence in plasma cholesterol change was due to
differences in dietary intake and weight gain.
One would predict a fall in cholesterol from
the dietary changes. In addition to the possi-
ble effects of aging, we may have observed a
rise because of subtle laboratory drift (despite
standardization) or some other time effect.
For example, plasma cholesterol did decrease
between the 1st and 3rd surveys (1). Interest-
ingly, the difference between treatment and
control is constant at all surveys.
The most prominent threat to the validity
of these conclusions is the possibility of bias
in self-reported dietary behavior. It is reason-
able to suggest that the members of the treat-
ment community cohort were especially
likely to bias their response to the dietary
questionnaire in the direction that the exper-
imenters desired. W hile this possibility can-
not be dismissed, the existence of real differ-
ences between towns is implied by the sig-
nificant differences in weight change, an ob-
jective measure. The questionnaire data are
also partly validated by our observation that
changes in reported diet were correlated with
changes in plasma cholesterol.
The dietary history used in this study ap-
pears to estimate adequate!y group dietary
cholesterol and saturated fat. Furthermore,
the imprecision of this history would tend to
obscure the fmdings reported. Nevertheless,
the conclusions of future similar studies

b
y

g
u
e
s
t

o
n

S
e
p
t
e
m
b
e
r

1
0
,

2
0
1
4
a
j
c
n
.
n
u
t
r
i
t
i
o
n
.
o
r
g
D
o
w
n
l
o
a
d
e
d

f
r
o
m

E F F E C T O F H E AL T H E DUC AT I O N O N DI E T 2037
would be strengthened by unobtrusive dietary
measures (such as food sales) and a more
precise diet measure.
I t is also important to note that the changes
which occurred in the two treatment towns
may have occurred by chance. W hile the
regression analysis strengthens the conclusion
that real differences between treatment and
control towns existed, it does not eliminate
the possibility that the changes in the two
treatment towns were independent of the in-
tervention. I f two of the three towns were
destined to display the observed changes,
there is one chance in three that the two
would both be treatment communities, that
is 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 the
study 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 (unpublished
analysis), and the results from Tracy make it
clear that surveying itself has at most a tran-
sient effect. Nevertheless, future replications
of this study would be strengthened by the
addition of repeated independent samples of
the community.
I t is likely that several of the chronic dis-
eases that currently plague the developed
world-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 able
to apply information on health and behavior
obtained from mass media to make changes
in dietary practices and obesity. Thus com-
munity health education may become a pow-
erful, cost-effective tool for improving the
public 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. Ann V arady for technical assist-
ance.
References
1. Farquhar JW , M accoby N, W ood P D, et al. Com-
munity education for cardiovascular health. Lancet
l977;l:l 192-5.
2. M accoby N, Farquhar JW , W ood P D, Alexander
J K . Reducing the risk of cardiovascular disease:
effects of a community-based campaign on knowl-
edge and behavior. J Comm Health 1976;3: 100-14.
3. Stern M P, Farquhar J W , M accoby N, Russel SH .
Results of a two year health education campaign on
dietary behavior: Stanford Three Community Study.
Circulation l976;54:826-33.
4. Stern M P, Brown BW , Haskell W L, Farquhar JW ,
W ood P D. Cardiovascular risk and the use of estro-
gens or estrogen-progestogen combinations: Stan-
ford Three Community Study. JAM A l976;235:81 1-
5.
5. Stern M P, Haskell W L, W ood P D, Osonn K E , K in g
AB, Farquhar JW . Affluence and cardiovascular risk
factors in M exican-Americans and other whites in
three northern California communities. J Chron Dis
1975; 28:623-36.
6. W illiams PT, Fortmann SP, Farquhar JW , V arady
A, M ellen S. A comparison of statistical methods for
evaluating risk factor changes in community-based
studies: an example from the Stanford Three Com-
munity Study. J Chron Dis (in press).
7. M eyer AJ, Nash JD, M cAlister AL, M accoby N,
Farquhar JW . Skills training in a cardiovascular
health education campaign. J Consult Clin Psych
1980;48: 129-42.
8. United States Department of Health, Education and
W elfare. Lipid research clinics manual of laboratory
operations, vol 1. Lipid and lipoprotein analysis.
(DH E W Pub. no. (NI H) 75-6281. W ashington, DC :
Government Printing Office, 1974.
9. M etropolitan Life I nsurance Company. New weight
standards for men and women. Stat Bull M etropol
Life I ns Co l959;40:1.
10. Fetcher ES, Foster N, Anderson iT , Grande F, Keys
A. Quantitative estimation of diets to control serum
cholesterol. Am i Chin Nutr 1967;20:475-84.
11. Tukey JW . Exploratory data analysis. New Y ork:
Addision-W esley, 1977.
12. Snedecor GE, Cochran W G. Statistical methods. 6th
ed. Ames, I A: I owa State University Press, 1967:291-
4.
13. Glueck Ci, Connor W E. Diet-coronary heart disease
relationships reconnoitered. Am J Clin Nutr 1978;31:
727-37.
14. Primary prevention of the atherosclerotic diseases:
report of the I ntersociety Commission for Heart
Disease Resources. Circulation l970;42:A55-95.
15. Glueck CJ, M attson F, Bierman EL. Diet and cor-
onary heart disease: another view. N Engl J M ed
l978;298: 1471-4.
16. Stamler i. Lifestyles, major risk factors, proof, and
public policy. Circulation 1978;58:3-19.
17. iacobs ir DR. Anderson iT , Bla ck b u r n H . Diet and
serum cholesterol: do zero correlations negate the
relationship? Am J Epidemiol 1979;hlO:77-86.
18. Keys A. Seven countries. A multivariate analysis of
death and coronary heart disease. Cambridge, M A:
Harvard University Press, 1980.
19. Kannel W B, Gordon T (eds). The Framingham
Study-an epidemiological investigation of cardio-
vascular disease. Section 24: The Framingham Diet
Study: Diet and the regulation serum ch olest er oL
W ashington, DC : US Dep a r t m en t of H ea lt h , Edu-
cation and W elfare, 1970.
20. Nichols AB, Ravenscroft C, Lamphiear DE. Daily

b
y

g
u
e
s
t

o
n

S
e
p
t
e
m
b
e
r

1
0
,

2
0
1
4
a
j
c
n
.
n
u
t
r
i
t
i
o
n
.
o
r
g
D
o
w
n
l
o
a
d
e
d

f
r
o
m

2038 FORT M ANN ET AL .
nutritional intake and serum lipid levels. The Tec-
umseh Study. Am i Chin Nutr 1976;29: 1384-92.
21. Kato H, Tillotson i, Nichaman M Z, Rhoads GG,
Hamilton HB. Epidemiologic studies of coronary
heart disease and stroke in Japanese men living in
Japan, Hawaii and California: serum lipids and diet.
Am J Epidemiol l973;97:372-85.
22. Garcia-Palmieri M R, Tillotson J, Cordero E, et al.
Nutrient intake and serum lipids in urban and rural
Puerto Rican men. Am J Cliii Nutr l977;30:2092-
100.
23. M RFIT Research Group. W eight loss and choles-
terol lowering. Circulation 1977;56(suppl 3):III-45.
24. Stern M P. The recent decline in ischemic heart
disease mo r t a l i t y . An n Intern M ed 1979; 91:630-40.
25. Sherwin R. Controlled trials in the diet-heart hy-
pothesis: some comments on the experimental unit.
Am i Ep i d e mi o l 1 9 7 8 ; l 0 8 : 9 2 - 9 .

b
y

g
u
e
s
t

o
n

S
e
p
t
e
m
b
e
r

1
0
,

2
0
1
4
a
j
c
n
.
n
u
t
r
i
t
i
o
n
.
o
r
g
D
o
w
n
l
o
a
d
e
d

f
r
o
m