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


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

Health Behaviour Change Nutrition and Computers
to Assess Nutritional Intake of Learners Self
Directed learning
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
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
  • 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

  • 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 (, 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.
Computer Nutrition Modules
  • Prompted almost half of the study group to
    independently pursue relevant nutrition-related
  • 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
  • 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.
  • 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

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.
  • 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),
  • 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
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
  • 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
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
Two Internet Diet Analysis Programs (US)
  • http//

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
  • 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.

Implementing American Heart Association Pediatric
and Adult Nutrition Guidelines,
Implementing American Heart Association Pediatric
and Adult Nutrition Guidelines,
  • 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
Approaches to Implementation of Effective Diet
  • 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
Guidelines, p 1166
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
  • 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
  • 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
  • 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
Principals for Teaching or facilitating nutrition
behaviour chANGE
Guidelines, p 1166
How does Computer Diet analysis Facilitate these
  • 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

  • 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
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
  • 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
  • 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

Community Research
  • significant limitation of this discussion is
    inadequate research in populations other than
    school-aged children on community-based
  • Another limitation is that for many
    community-based interventions, measurement of
    health outcomes is difficult because of
    impracticality or insufficient resources to make
  • 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
  • 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.
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
  • 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
  • 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

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
  • 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,

  • 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
  • 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

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

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.

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

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

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

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

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

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

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