Title: Health Behaviour Change: Nutrition and Computers to Assess Nutritional Intake of Learners Self Direc
1Health Behaviour Change Nutrition and Computers
to Assess Nutritional Intake of Learners Self
Directed learning
2Most 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
3Need 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
4AreAS 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
5STAR
- 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.
6Computer 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.
7Abstract
- 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.
8Abstract
- 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.
9Abstract
- 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
10Abstract
- 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)
11Two 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
12Two 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
13Two 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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17Canadian 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
18Implementing American Heart Association Pediatric
and Adult Nutrition Guidelines,
http//circ.ahajournals.org/cgi/content/full/119/8
/1161/DC1
19Implementing American Heart Association Pediatric
and Adult Nutrition Guidelines,
http//circ.ahajournals.org/cgi/content/full/119/8
/1161/DC1
20- 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
21Approaches 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
22Guidelines, p 1166
23Effective 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
24Principals for Teaching or facilitating nutrition
behaviour chANGE
Guidelines, p 1166
25How 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
26- 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
27http//www.realage.com/ralong/entry5.aspx?cbrNEXS
6_P
28Example of Computer analysis program
- Diet Master Example menu screens
- How can this be used?
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32Diet 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
33Community 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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35Computers 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.
36Research 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
37Is 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,
38- 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
39Health 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
40US 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.
41- 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
42Community 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
43Workplace 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
44Summary 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
45Summary 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
46Summary and Recommendations for Computerized
Approaches to Implementation of Dietary Advice
Are Needed
47Food 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
48Computer 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