Health Behaviour Change: Nutrition and Computers to Assess Nutritional Intake of Learners Self Direc

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Health Behaviour Change Nutrition and Computers
to Assess Nutritional Intake of Learners Self
Directed learning
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Most Teens Aren't Getting Preventive Health Care

• University of California, San Francisco,
  researchers analyzed data gathered from almost
  8,500 adolescents, ages 10 to 17, who took part
  in the Medical Expenditure Survey
• Most American teens don't receive the appropriate
  amount of preventive health services

March 30, 2009 in the journal Pediatrics
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Need to develop new strategies

• First author Dr. Charles Irwin, director of the
  Division of Adolescent Medicine at UCSF
  Children's Hospital said
• "The results were pretty shocking to us. With so
  many adolescents not receiving the recommended
  preventive care, it is clear we need to develop
  new strategies that will help increase the
  delivery of services."

university news release
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AreAS OF CONCERN

• dental care, healthy eating, regular exercise,
  wearing a seat belt, wearing a bicycle helmet,
  and being exposed to second hand smoke
• Less than half of the teens who had a preventive
  health visit were counseled about at least one of
  these issues, and only 10 percent were counseled
  about all six

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STAR

• Health education and health promotion have a
  tradition of using information and communication
  technology (ICT). In recent years, the rapid
  growth of the Internet has created innovative
  opportunities for Web-based health education and
  bebehaviour change applicationstermed eHealth
  promotion. However, many eHealth promotion
  applications are developed without an explicit
  model to guide the design, evaluation, and
  ongoing improvement of the program. The spiral
  technology action research (STAR) model was
  developed to address this need. The model
  comprises five cycles (listen, plan, do, study,
  act) that weave together technological
  development, community involvement, and
  continuous improvement. The model is illustrated
  by a case study describing the development of the
  Smoking Zine (www.SmokingZine.org), a youth
  smoking prevention and cessation Web site.

Skinner, H. A. (., Maley, O. (., Norman, C. D.
(. (2006). Developing internet-based eHealth
promotion programs The spiral technology action
research (STAR) model. Health Promotion Practice,
7(4), 406-417.
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Computer Nutrition Modules

• Prompted almost half of the study group to
  independently pursue relevant nutrition-related
  information.
• This inexpensive, collaborative, multi-department
  effort to design a computer-based nutrition
  curriculum positively impacted both participant
  knowledge and attitudes.

Roche, P. L., Ciccarelli, M. R., Gupta, S. K.,
Hayes, B. M., Molleston, J. P. (2007).
Multi-school collaboration to develop and test
nutrition computer modules for pediatric
residents.
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Abstract

• Describes the context created by students as they
  worked in groups on a nutrition computer-assisted
  instruction (CAI) program. Observational methods
  were used to collect data from students in 2
  6th-grade classrooms that were part of an
  experimental program designed to restructure the
  educational process. 32 students, from 12 groups,
  were observed as they completed the program. The
  objectives of the program were to change
  children's knowledge structure of basic nutrition
  concepts and to increase children's critical
  thinking skills related to nutrition concepts.
  Observational data focused on three domains were
  collected (1) student-computer interaction, (2)
  student-student interaction, and (3) students'
  thinking and learning skills. Five styles of
  student interaction were defined. These included
  (1) dominant directors, (2) passive actors, (3)
  action-oriented students, (4) content-oriented
  students, and (5) problem solvers. The "student
  style" groups were somewhat gender specific. The
  problem solvers group was mixed gender.
  Children's responses to computer-based nutrition
  education are highly variable. Based on the
  results of this research, nutrition educators may
  recommend that nutrition CAI programs be
  implemented in mixed gender groups.

Matheson, D., Achterberg, C. (2001). Ecologic
study of children's use of a computer nutrition
education program. Journal of Nutrition
Education, 33(1), 2-2.
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Abstract

• To support student learning in a large Metabolism
  and Nutrition class, we have introduced a
  web-based package, using a commercially available
  program, WebCT. The package was developed at a
  minimal cost and with limited resources. In
  addition to downloadable (PDF) versions of
  lecture Powerpoint presentations, tutorial
  outlines and a practical class exercise,
  web-based self-directed learning exercises were
  included to reinforce and extend lecture material
  in an active learning environment. The web-site
  also contained a variety of formative and
  summative assessment tasks that examined both
  factual recall and higher order thinking.
  Detailed course information, timetables and a
  bulletin board were also readily accessible.
  Student usage of the site was generally high, but
  varied widely between individual students.
  Students who achieved a high overall score for
  the course completed on average three times as
  many formative assessment items and achieved a
  higher score for all tests than students who did
  poorly. Student feedback about the site was very
  positive with the majority of students reporting
  that the course material and assessment items
  that were available were useful to their
  learning. Administration of the course was also
  facilitated.

Henly, D. C. (., Reid, A. E. (. (2001). Use of
the web to provide learning support for a large
metabolism and nutrition class. Biochemistry and
Molecular Biology Education, 29(6), 229-233.
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Abstract

• In 2002, an integrated basic science course was
  introduced into the Bachelor of Dental Sciences
  programme at the University of Queensland,
  Australia. Learning activities for the Metabolism
  and Nutrition unit within this integrated course
  included lectures, problem-based learning
  tutorials, computer-based self-directed learning
  exercises and practicals. To support student
  learning and assist students to develop the
  skills necessary to become lifelong learners, an
  extensive bank of formative assessment questions
  was set up using the commercially available
  package, WebCT. Questions included short-answer,
  multiple-choice and extended matching questions.
  As significant staff time was involved in setting
  up the question database, the extent to which
  students used the formative assessment and their
  perceptions of its usefulness to their learning
  were evaluated to determine whether formative
  assessment should be extended to other units
  within the course. More than 90 of the class
  completed formative assessment tasks associated
  with learning activities scheduled in the first
  two weeks of the block, but this declined to less
  than 50 by the fourth and final week of the
  block. Patterns of usage of the formative
  assessment were also compared in students who
  scored in the top 10 for all assessment for the
  semester with those who scored in the lowest 10.
  High-performing students accessed the Web-based
  formative assessment about twice as often as
  those who scored in the lowest band. However,
  marks for the formative assessment tests did not
  differ significantly between the two groups. In a
  questionnaire that was administered at the
  completion of the block, students rated the
  formative assessment highly, with 80 regarding
  it as being helpful for their learning. In
  conclusion, although substantial staff time was
  required to set up the question database, this
  appeared to be justified by the positive
  responses of the students.

Henly, D. C. (2003). Use of web-based formative
assessment to support student learning in a
metabolism/nutrition unit. European Journal of
Dental Education Official Journal of the
Association for.Dental Education in.Europe, 7(3),
116-122
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Abstract

• Problem-based learning (PBL), a case-driven,
  student-centered educational approach, has been
  shown to foster critical thinking, problem
  solving, and self-directed learning skills, and
  enhance knowledge base acquisition and retention.
  PBL has been recommended by dietetic educators,
  but has not been formally evaluated. The purpose
  of this study was to describe dietetic student
  response to a PBL format. Subjects were 32
  undergraduate dietetic students (UDS) in a
  lifecycle nutrition class and 52 dietetic interns
  (DI) from five Midwestern intern sites. The
  research design was a descriptive and evaluative
  case study with an embedded experimental design
  (generalized randomized block factorial). The UDS
  were randomly assigned to study the infant and
  elderly units using PBL or a lecture-based
  method. Data from the UDS and DI were obtained
  with ten instruments that assessed knowledge,
  attitude, learning style, sensation seeking
  traits, and opinions. Findings from the
  experimental component were analyzed with a
  three-way analysis of variance. PBL students were
  more apt to use articles, books, and
  professionals to study than lecture notes.
  Interpretation of knowledge acquisition results
  was confounded by significant treatment
  interactions Only PBL UDS who started with the
  elderly unit scored higher than LBC UDS. Tenets
  that PBL enhances retention, self-directed
  learning skills, and motivation level were not
  supported for the UDS. PBL use was associated
  with a change in motivating factors from self and
  achievement to the group and knowledge. Use of
  memorization decreased for PBL UDS and DI
  reflective thinking increased for PBL UDS, but
  confidence in problem solving skills did not
  increase. Self-directed learning skills and
  confidence in problem solving skills increased
  for DI DI reported less frustration and stress
  with PBL than the UDS, rating PBL more positively
  on the Positive Learning Experience Scale and
  expressing a high desire to experience PBL

Bayard, B. L. (1995). Problem-based learning in
dietetic education A descriptive and evaluative
case study and an analytical comparison with a
lecture-based method. ProQuest Information
Learning). Dissertation Abstracts International
Section A Humanities and Social Sciences, 55
(7-A)
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Two Internet Diet Analysis Programs (US)

• With the use of computers and the Internet
  steadily increasing, information on nutrition and
  health is becoming more accessible to the general
  public.1
• In accordance with this growing trend, the
  Nutrition Analysis Tool (NAT) and the Energy
  Calculator (EC) were created

James E. Painter, Ph.D., R.D., Department of
Food Science and Human Nutrition, Division of
Nutritional Sciences, University of Illinois
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Two Internet Diet Analysis Programs (US)

• The NAT was developed as a free and easy way to
  analyze the nutrient content of meals.
• The EC determines an individuals caloric needs
• Handbook 8 database to provide nutrient
  composition for over 5200 foods

James E. Painter, Ph.D., R.D., Department of
Food Science and Human Nutrition, Division of
Nutritional Sciences, University of Illinois
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Two Internet Diet Analysis Programs (US)

• http//www.nat.uiuc.edu/mainnat.html

James E. Painter, Ph.D., R.D., Department of
Food Science and Human Nutrition, Division of
Nutritional Sciences, University of Illinois
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Canadian Nutrient File

• The Canadian Nutrient File (CNF) is the standard
  reference food composition database reporting the
  amount of nutrients in foods commonly consumed in
  Canada. This nutrition research tool is integral
  to many activities within Health Canada such as
  setting policies, standards and regulations, risk
  assessment studies and food consumption surveys.
• Other government users include Agriculture and
  Agri-Food Canada (AAFC), Statistics Canada and
  the Canadian Food Inspection Agency (CFIA). In
  addition, the CNF is utilized by a large spectrum
  of external users, including hospitals,
  universities, food manufacturers and the general
  public.
• A combination of expanding information linking
  diet habits to health and disease, as well as the
  boom in personal computer technology, has
  resulted in a large number of individuals and
  organizations that are now seeking and utilizing
  Canadian food nutrient data.

http//www.hc-sc.gc.ca/fn-an/nutrition/fiche-nutri
-data/cnf_aboutus-aproposdenous_fcen-eng.php
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Implementing American Heart Association Pediatric
and Adult Nutrition Guidelines,
http//circ.ahajournals.org/cgi/content/full/119/8
/1161/DC1
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Implementing American Heart Association Pediatric
and Adult Nutrition Guidelines,
http//circ.ahajournals.org/cgi/content/full/119/8
/1161/DC1
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• Two recent reviews of the obesity intervention
  literature have concluded that at present there
  is no significant evidence for the efficacy of
  current strategies in children.68,69
• Current Canadian clinical practice guidelines
  concluded that the evidence for recommending diet
  intervention for obesity is excellent but the
  evidence for efficacy of specific strategies is
  generally lacking

Implementing American Heart Association Pediatric
and Adult Nutrition Guidelines, P. 1165
http//circ.ahajournals.org/cgi/content/full/119/8
/1161/DC1
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Approaches to Implementation of Effective Diet
Counseling

• Diet counseling has historically been information
  based, more like teaching than counseling, with
  physicians and nutritionists providing factual
  information. The underlying assumption is that
  simply by learning the facts, patients and
  clients will change bebehaviour. There are
  significant limitations to this strategy. First,
  counseling may not include an assessment of the
  patients interest in making dietary change.
• Second, primary care providers have a notoriously
  low estimate of self-efficacy with regard to
  nutrition counseling.
• Third, providers are unwilling to confront
  patients with regard to weight issues.
• Finally, time constraints and restrictions on
  reimbursement impose important limitations on
  traditional medical office visits. Written
  material is often provided, but these materials
  may not be easily adapted by patients to their
  specific circumstances. The patients literacy
  level may be too low to comprehend the material.
• The familys eating pattern, determined by
  diverse economic and social factors, may not
  easily adapt to the recommended changes. Easy
  access to recommended foods may not exist

Guidelines cont
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Guidelines, p 1166
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Effective Behaviour Change

• Improved outcomes to any intervention approach
  may beobtained by the use of general principles
  of bebehaviour change theory, that is, by
  intervening at levels 1 and 2 of the Figure
  simultaneously.74
• The following discussion provides a summary of
  the sequential steps, which are summarized in
  Table 8.
• First, an assessment of readiness to change, a
  critical component of an intervention to change
  bebehaviour, needs to occur. Concomitant with
  that assessment is the need for a self-evaluation
  by the patient of the bebehaviour(s) targeted for
  change, which happens through, self-monitoring or
  keeping records over multiple days. The patient
  gets ready to make the change by understanding
  how frequently he or she does the targeted
  bebehaviour.
• Second, goals are established for changing the
  target bebehaviour over a defined period of time
  (eg, 1 week). Goals should be realistic, should
  be agreed on by the patient, and should allow
  success.
• Third, the goal is attempted while the patient
  monitors the target bebehaviour. Continued
  monitoring is critical for bebehaviour change.
  Finally, there is a repeat self-evaluation with
  goal review and reinforcement and adjustments up
  or down in goal setting, depending on the
  patients success in meeting prior goals.
• Effective counseling should generally reward
  bebehaviours that are considered satisfactory and
  ignore bebehaviours that are unsatisfactory.

Guidelines, p 1166
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Principals for Teaching or facilitating nutrition
behaviour chANGE
Guidelines, p 1166
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How does Computer Diet analysis Facilitate these
guideline

• It provides self-evaluation of eating patterns,
  nutrient intakes, calorie distribution and
  identifies what areas need improvement
• This avoids an expert criticism but allows the
  individuals to evaluate themselves
• It provides critical reflection about what they
  are doing right and where they may be going wrong
• You are their to facilitate this learning a
  type of self-directed learning

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• Critical to success is helping the patient
  maintain favorable self-esteem and maintaining
  self efficacy
• Computer analysis does not lecture or scold but
  programs should give positive - Real Age website
  is somewhat like that, also

Guidelines, p 1166
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http//www.realage.com/ralong/entry5.aspx?cbrNEXS
6_P
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Example of Computer analysis program

• Diet Master Example menu screens
• How can this be used?

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Diet analysis motivates by giving immediate
feedback and provides Self-Directed needs
assessment

• An important question for promoting bebehaviour
  change is the extent to which individuals and
  families are motivated and ready to change.
• Motivational interviewing is a series of clinical
  assessment strategies stemming from the drug and
  addiction field but more recently extended to the
  field of nutrition and pediatric weight
  control.75
• Those who do not perceive a problem or are too
  overwhelmed with other life challenges may not be
  receptive to prescriptions for dietary
  bebehaviour change.
• The overarching aim of motivational interviewing
  is to help set the stage for bebehaviour in
  individuals who are defensive or resistant to
  change by avoiding active prescriptions for
  bebehaviour change or authoritatively telling
  patients what to do.
• Motivational interviewing uses strategies such as
  open-ended questions, reflective listening,
  rephrasing of statements, and identification of
  discrepant beliefs to raise motivation level.
  Motivational interviewing may help to ease the
  frustrations or power struggles between health
  professionals and patients and is an important
  area for future research

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Community Research

• significant limitation of this discussion is
  inadequate research in populations other than
  school-aged children on community-based
  interventions
• Another limitation is that for many
  community-based interventions, measurement of
  health outcomes is difficult because of
  impracticality or insufficient resources to make
  measurements.81
• Newer research is starting to overcome these
  barriers an example is the National Cancer
  Institute Black Churches Initiative.82

Guidelines, p. 1167
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Computers in African American nutrition church
interventions

• African Americans have higher than average rates
  of morbidity and mortality for numerous health
  conditions despite the improvements in overall
  health in the United States over the past
  century. Despite the proliferation of material on
  health promotion and health disparities concerns
  related to diet and health care for African
  Americans persist. In the present paper, the
  authors describe a computer-based nutrition
  education program designed for use with African
  American adults. Specific features of the program
  that qualify it as culturally-tailored are
  presented and preliminary results demonstrating
  success in improving nutrition in a church-based
  sample of 82 adults are provided.

Goodman, J., Blake, J. (2005). Nutrition
education A computer-based education program.
Journal of Health Care for the Poor and
Underserved, 16(4), 118-127.
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Research in Schools and Other Influences on
Childrens Eating Behaviour

• Although some school-based programs have had
  favorableeffects on body mass index (BMI),8387
  several have not.8890
• Where findings show minimal effects,
  interventions may suffer from insufficient doses,
  barriers to effective implementation, and the
  inability to effectively target children at
  highest risk in addition, the bebehaviours
  targeted by interventions may not relate directly
  to body weight or other cardiovascular risk
  factors.
• In general, these programs have produced modest
  and only short-term reductions (_5) in
  percentage overweight.88,9196 Several
  school-based programs have attempted to improve
  cardiovascular disease risk factors in grade
  school children.89,90,97101 Other studies have
  investigated the impact of such initiatives on
  BMI.83,84,86,102
• To date, the results of these studies are mixed.
  Findings across interventions suggest that those
  that adopt a multifaceted integrated approach,
  ie, those that intervene in many components of
  the school environment simultaneously, are more
  likely to be successful.83,84,86,102

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Is BMI the only measure we need?

• Arkansas was the first state to implement BMI
  screening in schools. The Arkansas Center for
  Health Improvement, an independent entity,
  developed and validated a BMI measurement
  protocol, trained school staff on conducting BMI
  assessment
• The efficacy of BMI screening may be difficult to
  assess. In Arkansas and Pennsylvania, screening
  was only part of a more comprehensive
  intervention that included increased access to
  healthier foods and physical activity
  initiatives. Although the Arkansas initiative met
  with early success, parents have raised concerns
  about labeling children as obese,

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• In the last few years, strengthening nutrition
  standards for foods sold in schools has been
  undertaken. The Institute of Medicine recently
  developed science-based nutrition standards for
  foods and beverages.105 Putting these standards
  into practice will require significant policy
  work at the state and federal levels, industry
  reformulation of products, and a willingness to
  adopt standards such as these by communities,
  local school boards, school administrators, and
  staff.
• Substantial resistance to implementing the
  Institute of Medicine guidelines has emerged from
  sectors of industry, with legislation at the
  federal or state level preempting stricter
  standards in smaller jurisdictions. In 2006, the
  Alliance for a Healthier Generation (a
  partnership between the AHA and the William J.
  Clinton Foundation) negotiated with industry to
  establish voluntary nutrition standards for foods
  and beverages in schools

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Health Promoting Schools

• The Child Nutrition and WIC Women, Infants, and
  Children Reauthorization Act of 2004 required
  schools to develop policies around nutrition
  education, physical activity, and overall school
  wellness and outline an implementation plan for
  these policies.
• The law required parents, students, school food
  service staff, school administrators, and members
  of local school boards to participate in the
  process through school wellness councils.
• School wellness councils or school health
  advisory councils are critical in creating a
  coordinated approach to a healthy school
  environment periodic assessment of implementation
  and accountability for implementation

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US vs Canada Are we on the same page- China and
South Africa

• reduce cardiovascular risk exposure,
• including reduction of poor-nutritional-quality
  foods in vending machines,
• reduction in presentation of deep fried potatoes,
  
• increased recess, and
• creation of smoke-free environments.

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• However, it is important to keep in mind that not
  all
• foods and beverages consumed by children
  throughout the
• day are derived from school sources themselves.63
  Concurrently,
• children and adolescents are influenced by food
• advertising and marketing strategies. Young
  people see
• _40 000 advertisements per year on television
  alone.78
• They also are targeted by carefully crafted
  marketing
• tactics for unhealthy foods used in multiple
  environments
• such as the Internet, magazines, schools, product
  placement,
• incentive programs, video games, social
  networking
• sites, podcasts, and cell phones, all designed to
  improve
• brand recognition and increase sales.107,108
  Children tend to
• spend their discretionary income on high-calorie,
  lownutrient-
• dense foods, and advertising certainly leads them
• in this direction.109

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Community Food Access P.1168

• For people in disadvantaged areas, the grocery
  gap phenomenon
• lack of access to supermarkets is negatively
  associated with low-income residents health and
  economic well-being
• Computerized programs in supermarket
• Now Canadian Medical Association is asking that
  restaurants provide calorie information

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Workplace Interventions

• Web-based programs were more effective than print
  materials, and long-term and interactive
  intervention efforts were proven to have more
  sustainable outcomes than 1-time, temporary, and
  passive efforts
• AHA recommends Trainers who should learn basic
  nutrition, interpretation of the food label,
  portion size, recommendations for physical
  activity, principles of bebehaviour change, and
  how to encourage self-efficacy

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Summary and Recommendations for Computerized
Approaches to Implementation of Dietary Advice
Are Needed

• Computer programs for diet analysis should
  incorporate effective behaviour change and
  motivational interviewing strategies that are
  incorporated into all educational programs and
  reinforced by computer programs .
• Efficacy should be encouraged by the computer
  programs and by health care professionals fromm
  physicians to dietitians
• Computer programs should be sensitive to clients
  readiness to change eating bebehaviours,
  customary food preferences, literacy level,
  ethnic preferences, and social constraints that
  affect dietary patterns.130,131
• It may be more important for computer programs to
  focus on barriers to implementation before
  providing specific nutrition counseling.
• Because of time constraints , healthcare
  providers should deliver simple positive messages
  directed at the major causes of poor nutrition
  which is confirmed by computer analysis

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Summary and Recommendations for Computerized
Approaches to Implementation of Dietary Advice
Are Needed

• Programs should allow the learner to self reflect
  and self direct learning to focus on specific
  individual eating problems Examples include
• eating breakfast
• eating fruits,
• vegetables, and
• whole grains
• limiting intake of sugar-containing beverages to
  _12 oz/d limiting snacks to once a day
• Eating smaller portions
• weighing regularly and
• adjusting dietary intake based on weight

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Summary and Recommendations for Computerized
Approaches to Implementation of Dietary Advice
Are Needed
47
Food and Nutrition literate society

• American Heart Association 5 community-based
  implementation strategies that should be
  evaluated for efficacy (Table 11).
• Create a healthy food environment means serving
  items of high food quality in schools and at work
  places. Collaboration with the various components
  of industry responsible for the food supply will
  be critical to achieving this goal.
• Subsidize AHA-recommended food choices means
  creating financial and other incentives for
  consumers to purchase and food producers to
  generate nutritious foods.
• Market nutrition means using media to
  counterbalance unhealthy food messages.
• Empower consumers means providing more
  comprehensive labeling of
• food and portion size.
• Train professionals in nutrition means improving
  the skill level of healthcare practitioners
  commonly consulted for nutrition advice and
  enlarging the pool of individuals qualified to
  provide nutrition advice.
• The net result of these strategies is to produce
  a food- and nutrition- literate society

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Computer Diet Analysis Creates an Awareness of

• undesirable trends in eating patterns and the
  need to improve.
• consumption of sugar-containing beverages and
  salty snacks ad a need to reduce, along with
• a reduction in portion size and,
• Eating frequency.
• Nutrient density of foodchoices in supermarkets
  and restaurants
• The next era in nutrition research will be
  defined by the degree of success in this
  endeavor.133