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Beverage intake improvement by high school students in Saskatchewan, Canada
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Nutrition Research 28 (2008) 144 – 150 www.elsevier.com/locate/nutres
Beverage intake improvement by high school students in Saskatchewan, Canada Elisabeth Lo a , Renee Coles a , M. Louise Humbert b , Joyce Polowski c , Carol J. Henry a,⁎, Susan J. Whiting a a
College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada S7N 5C9 b College of Kinesiology, University of Saskatchewan, Saskatoon, SK, Canada S7N 5C9 c College of Education, University of Saskatchewan, Saskatoon, SK, Canada S7N 5C9 Received 19 June 2007; revised 28 December 2007; accepted 16 January 2008
Abstract Certain beverages contribute energy, protein, vitamins, and minerals. North American adolescents have shifted their beverage intake from predominantly milk to predominantly sugary beverages. Intake of these sugary beverages, in sufficient quantity, may increase the risk of bone fractures, may contribute to obesity, and may lead to tooth decay. This study evaluated the effectiveness of a schoolnutrition education program (Fluids Used Effectively for Living) on nutrition knowledge, attitude, and self-reported behavior of grade 9 students in Saskatchewan, Canada. Two classes of grade 9 students, 1 (n = 33) in a high school in Saskatoon (n = 33) and 1 (n = 24) in a large high school in Prince Albert, Saskatchewan, received the peer educator intervention. Two other classes in the 2 cities (n = 24 and n = 24, respectively) were controls. Six sessions of Fluids Used Effectively for Living nutrition education were delivered by using 2 peer educator models (multiple and single), and the intervention was delivered in a 45-minute weekly class session over a 6-week period. After the intervention, students in these 2 peer educator classes decreased their sugary beverage intake significantly, which was sustained for 3 months. Students in the control self-taught class increased their juice intake at the end of the year. The significant decrease of juice and sugary beverage intakes in the single model peer educator class disappeared after Bonferroni correction. Carbonated sugary beverage intake of students in the control self-taught classes declined, but it was not sustainable at the 3-month follow-up. A peer educator school-based nutrition education approach can lead to a decrease in sugary beverage intake in high school children. © 2008 Elsevier Inc. All rights reserved. Keywords: Abbreviations:
Peer education; Adolescents; Health education; Soft drinks; Sugary beverages; School-based nutrition education BFQ, beverage frequency questionnaire; CSD, carbonated soft drink; FUEL, Fluids Used Effectively for Living; NSD, noncarbonated sugary drink.
1. Introduction Adolescents need greater amounts of nutrients than adults to support their growth and development and to prevent chronic disease that may subsequently occur during adulthood [1,2]. Adolescents often do not have ⁎ Corresponding author. Tel.: +1 306 966 5833; fax: +1 306 966 6377. E-mail address: [email protected] (C.J. Henry). 0271-5317/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.nutres.2008.01.005
enough knowledge and experience to make appropriate decisions and tend to develop unhealthy eating habits. These include skipping breakfast, replacing lunch meal with snack food, and increasing soft drink intake, all of which can lead to inadequate nutrient intake [1]. Furthermore, adolescents' decision-making processes may be influenced by commercial activities, peers, and environmental factors [3,4], placing adolescents in a nutritionally vulnerable position. Healthy behaviors, including consum-
E. Lo et al. / Nutrition Research 28 (2008) 144–150 Table 1 Summary of intervention sessions for nutrition education programs Session
Training curriculum
1
The ABCs of nutrition Increasing student knowledge of human nutrition Helping students make nutritious food and beverage choices using accurate and current nutrition information Understanding nutritional value of beverages Nutritional content of various beverages Health impact of beverage choices Healthy bones Calcium content of beverages/foods Simple ways to incorporate calcium-rich food and beverages in the diet Making fast foods fit Integrating nutrition principles of variety and moderation in daily food habits Ways to reduce sugar, fat, and salt in their fast food Vitality Important role of physical activity and health Social and emotional benefits of active living Importance of healthy weight Simple ways to include physical activity in the daily lifestyle Take a peek Skill development, label reading, and changing behaviors
2
3
4
5
6
ing nutritious beverages, are important for adolescents to improve their school performance, growth, and developmental tasks [5-8]. Over the past 25 years, adolescents have changed their beverage intake patterns by doubling their sugary drink intake and decreasing their milk intake [9-11]. This shift has had a negative impact on health by lowering nutritional quality and decreasing micronutrient intake. Consumption of high sugary drink intake may place children at risk for not getting the nutrient they need for optimal health [12] and may contribute to increased risk of bone fractures [12-16], obesity [17,18], and tooth decay [19]. School-based nutrition education represents an important strategy for improving the beverage choices of children and youth. Several interventions using a school-based approach have successfully led to significant or moderate changes in adolescents' dietary habits [20,21]. Studies continue to confirm the influence of peers on adolescent health behaviors [22]. Much of the research in Canada on the impact of sugary drink consumption on the health of adolescents has placed emphasis on bone health. Two of the most influential studies conducted on Saskatchewan children [23,24] provided insights on aspects of adolescent's beverage intake [23] and the relationship between carbonated sugary drinks (CSDs) and bone health [24]. This investigation presents the results of a pilot nutrition education resource Fluids Used Effectively for Living (FUEL), including the program's impact on changing the beverage consumption practices of grade 9 students in Saskatchewan, Canada. The FUEL program intended to decrease students' sugary beverage intake.
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2. Methods and materials 2.1. Design The overall design was to compare changes in nutrition knowledge, attitude, and self-reported beverage consumption behaviors in a self-administered questionnaire for students who received the FUEL nutrition education resource and for those who did not receive the intervention. 2.2. Participants A total of 113 grade 9 students (average age, 14 years) from 4 high school classes participated in the study. Students from the 2 Saskatoon classes (n = 33 and n = 20, respectively) were selected from ethical living classes in 2 schools in Saskatoon, Saskatchewan, Canada, a large urban center with a population of 206 900 [25], and were assigned as classes A and B. Students (n = 24 and n = 24, respectively) from 2 English classes in a large school in Prince Albert, Saskatchewan, Canada, a suburban center with a population of 41 460 [26], were assigned as classes C and D. Both the ethical living class and the English classes were identified by classroom teachers as appropriate venues for integrating nutrition education into the curriculum. Classes in Saskatoon were assigned as a multiple (older, cross-age, and same age) peer educator class (A) and as self-taught (control) (B). Schools in Prince Albert were assigned as a single (older) peer educator class (C) and as self-taught (control) (D). A purposeful sampling technique was used to select the 3 schools. Schools were selected according to neighborhoods and socioeconomic status, meaning that the classes were made up of students from middle-income households from the Directory of Saskatchewan schools [27] in consultation with the appropriate school divisions. The schools were also chosen because of their diversity and large student population. Approval for human subjects was obtained from the University of Saskatchewan's Committee on Ethics in Behavioral Science Research. Written permission was obtained from the school divisions; principals of participating schools; teachers, parents, and guardians of eligible participants; and all student participants. Principals, teachers, consenting parents, and students were sent an information package describing the study and protocols. The identity of the participants was not recorded, except to characterize participants by class treatment and to allow sequential recalls and for questionnaires to be tracked. The 1 student who did not participate in the intervention was given alternate activities. 2.3. The FUEL intervention The FUEL program is a 6-session multifactorial nutrition education resource designed to be highly focused and interactive. The intervention was also developed taking into account constructivist theory of learning [28], which is predicated on the assumption that students construct
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knowledge from a variety of interactions such as knowledge, social learning, and linking new knowledge. The framework for the intervention included concepts from Canada's Food Guide for Healthy Eating [29]. The modules aimed to enhance knowledge and understanding about the importance of variety, balanced, and moderation in making wise beverage choices (fruit juice 100%, milk, and water) instead of sugary drinks and CSDs. Each module included a lesson plan, activities (student worksheets, games, experiments, and quiz), background information for users (teachers, health professionals, and students), handout materials, and evaluation activities (Table 1). The lesson plans were delivered weekly in six 45-minute classroom sessions over a 6-week period. Teachers (other than those whose from the participating classes) and public health nutritionists contributed to the development of the resource package by reviewing the package to ensure that it was age, sex, and culturally appropriate. 2.4. The FUEL delivery During the implementation, class A multiple peer educator model in Saskatoon received full presentations from the FUEL nutrition education resource package. Crossage peers (5 undergraduate nutrition students from the University of Saskatchewan) and 6 same-age peers (grade 9 students from selected classrooms where the intervention was carried out) assisted 2 older peers, recent nutrition graduates, in carrying out the intervention. Both cross-age and same-age peers received a 2-week intensive training that was intended to build teamwork among them and orient them to the materials/content of the resource package. In addition, cross-age peers were linked with same-age peers for guidance and support. The control class (class B) in Saskatoon received only the student handout materials from the resource package. The 2 classes (experimental and control) in Prince Albert were located in the same high school. In this school, a single model (an older peer, a registered dietitian) delivered the FUEL nutrition education to the intervention class (class C). The FUEL delivery was similar to that in class A; however, there was no recipe demonstration and beverage tasting in this class. A priority for the research team was to develop a resource that could be used by both researchers and nutrition providers in the delivery of FUEL; hence, there was a need to compare the 2 techniques, one using a range of peer educators and one using an older peer only. The use on an older-peer technique mirrored the use of a trained classroom teacher and may not be able to incorporate recipe demonstration and tasting into their own curricula delivery. The control class (class D) was treated similar to class B and received the handout materials from the lessons for the 6 classroom sessions. In classes B and D (control), the teachers in the 2 classes were permitted to respond to questions from students. However, these teachers did not receive the FUEL nutrition education resource until the study finished. Students in classes B and D self-taught (control)
were promised that they would receive the full intervention after the completion of the study. 2.5. Assessments The unit of analysis for the evaluation was the class because class was the unit of intervention for FUEL. Beverage intake, knowledge, and attitude were assessed by an expanded self-administered questionnaire, which included a beverage frequency questionnaire (BFQ) with sections for nutrition knowledge, attitude, and behavior questions. The BFQ was pretested by high school students not participating in the study and was revised accordingly. The BFQ section included 19 questions on specific types of beverages consumed weekly, 4 questions about beverage intake habits at school, 6 questions about the student's attitude toward beverages, 11 questions about knowledge regarding healthy foods and beverages, and 3 questions on demographic characteristics. The baseline and postintervention questionnaires were all identical. The questionnaires were conducted as class exercises lasting 10 to 15 minutes and were supervised by trained research assistants. Responses on the attitude and knowledge questions were in the expression of agree, somewhat agree, and disagree. Questions on beverage intake habits were answered using the expressions more than once per day, once per day, once per week, and seldom or never as 3, 2, or 1. When the questions were expected to be answered in the negative, the score was 1, 2, or 3, respectively. Knowledge and attitude questions were scored separately. The score of each expression in knowledge and attitude questions depended on the answer and the questions. For example, for the incorrect statement “fruit drink has the same nutrient content as fruit juice,” the answers agree, somewhat disagree, or disagree would be coded 1, 2, or 3. Knowledge and attitude questions were scored separately and totaled. In the postintervention questionnaires, we asked students about their satisfaction level for the programs. The satisfaction level was rated using a 5-point scale, where 1 = poor and 5 = excellent. In the postintervention questionnaires, satisfaction with course content and delivery was rated using a 5-point scale, where 1 = poor and 5 = excellent. Each participating student was asked to complete 3 sets of BFQ, one at the beginning of the study (pretest), one 1 week after the delivery of the nutrition program (posttest), and one 3 months after the intervention delivery (3-month followup). The final set of questionnaires was administered 1 year later (1-year follow-up) for classes A and B only when students were in grade 10. Process evaluation was also conducted to assess participants' satisfaction with the content and delivery of the nutrition education resource. 2.6. Statistical analysis Results from the BFQ for beverage intake were grouped into categories of milk, 100% juice, noncarbonated sugary drinks (NSDs), CSDs, total sugary drinks, and other drinks. The intake of NSDs included tea and coffee (with added
E. Lo et al. / Nutrition Research 28 (2008) 144–150 Table 2 Characteristics of each class at baseline Saskatoon Peer educator (class A) Class Ethical living (grade 9) Students 33 Female 9 Male 24 Intake a Milk Median 15 Mean (SE) 15 (2) Interquartile 7 range Juice Median 9 Mean (SE) 10 (2) Interquartile 14 range NCD Median 9 Mean (SE) 11 (1) Interquartile 12 range CSD Median 7 Mean (SE) 5 (1) Interquartile 6 range Other Median 2 Mean (SE) 6 (1) Interquartile 14 range Knowledge score b Median 13 Mean (SE) 13 (3) Interquartile 4 range Attitude score b Median 14 Mean (SE) 14 (2) Interquartile 3 range
Prince Albert
Self-taught (class B)
Peer educator (Class C)
Self-taught (class D)
Ethical living 24 10 14
English
English
20 12 8
24 8 16
13 11 (1) 9
11 12 (1) 9
15 16 (2) 15
7 6 (1) 7
7 11 (3) 7
8 11 (2) 8
6 8 (1) 14
3 7 (2) 12
8 11 (1) 13
7 5 (1) 6
8 8 (2) 13
2 4 (2) 6
1 3 (1) 6
12 7 (2) 7
8 8 (2) 13
13 13 (2) 3
14 15 (2) 14
9 10 (3) 9
10 10 (2) 3
10 13 (2) 2
9 12 (3) 2
NCD indicates noncarbonated drink. a In serving per week. b Full score was 18.
sugar only), sweetened ice tea, sport drinks, fruit drinks, and fruit punch. Carbonated sugary drink intake included intake of beverages such as Coke, Pepsi, Seven-Up, and their generic equivalents. Total sugary drink intake was the addition of NSD and CSD intakes. The “other drinks” category consisted of bottled water, hot tea, and black coffee. For coding purposes, the expression of seldom or never in the BFQ was considered as zero serving per week; that of about once per week was 1 serving per week; that of once per day was 7 servings per week; and that of more than once per day was 14 servings per week.
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Data were analyzed using SPSS (version 13.0, Chicago, Ill). Cronbach α was determined to find out the internal reliability of the data. A normality test, Shapiro-Wilk test, to assess the data distribution was run first. Because our data were found to be not normally distributed, nonparametric tests were used to analyze the data. To determine significant differences among the beverage assessments, we performed the Friedman test. The Wilcoxon test was used as a multiple comparison test, with the α level corrected using Bonferroni correction, according to the number of comparisons: .008 for classes A and B and .017 for classes C and D [30]. 3. Results and discussion The internal reliability of the questionnaire was acceptable (Cronbach α = .68). Overall, students in all classes drank similar amounts of beverages (milk, juice, CSDs, NSDs, and other beverages). Students in Prince Albert classes drank significantly higher amount of other beverages than students in Saskatoon classes before the intervention. Students' characteristics at baseline are shown in Table 2. Table 3 describes the beverages that were usually consumed by students at schools. The favorite beverage at school was water, followed by sugary drinks. Students drank milk in the smallest amount than any other beverages. Furthermore, 76% of students in class A and B and 96% of students in class C and D never consumed milk at school. After the intervention, students in class A (Saskatoon peer educator class) showed a significant decrease in sugary beverage intake, which was sustained for 3 months (Fig. 1) and which was due to changes in carbonated and noncarbonated soft drink intake. The students in class B (self-taught class in Saskatoon) increased their juice intake at the end of the study (Fig. 1). Intakes of milk and of other beverages (latter not shown in the figure) did not change. In class C, after the other peer educator (older peer only), there was an apparent decrease in juice and sugary beverage intakes, but this was not significant. However, the trend was similar to class A (Fig. 1). Carbonated sugary beverage intake of students in class D significantly declined at 1 week postintervention, but it returned to the baseline condition at 3 months follow-up. Students' knowledge and
Table 3 The percentage of students that consumed soft drinks, 100% fruit juice, milk, and water at the schools ≥ once per day (%)
Soft drinks 100% fruit juice Milk Water a
Classes A and B a
Classes C and D b
29.8 23.2 7.3 78.6
25.0 28.1 2.3 70.5
A and B: experimental and control classes in Saskatoon High School. C and D: experimental and control classes in Prince Albert High School. b
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E. Lo et al. / Nutrition Research 28 (2008) 144–150
Fig. 1. Beverage intake of students (number of servings per week) in 4 grade 9 classes before and after the classroom nutrition education intervention. Intake is presented in mean and SE. A different letter indicates significant differences among beverage intake, P b .02. TSD indicates all sugary beverages. The first intervention was class A (multiple strategy), n = 33 at pretest, and class B (single strategy), n = 24 at pretest. The intervention was repeated in class C (multiple strategy), n = 20 at pretest, and class D (single strategy), n = 24 at pretest.
attitudes in both classes did not change significantly (data not shown). Students in class A expressed a higher level of satisfaction (P b .05) than class B. Overall, 71% of students said the program was fun, informative, interesting, and helped them to learn. Furthermore, 77% of the students would suggest this program to others. Students indicated that they appreciated learning about nutrition and healthy eating, participating in the recipe demonstrations, or trying the recipes at home. The level of satisfaction of the intervention in class C and D was not significantly different. Overall, 73% of students from classes C and D would suggest the FUEL to others. Furthermore, 57% class C and 33% class D students stated that the intervention was fun, informative, and helped them to eat and drink healthier. The study was designed to deliver nutrition education focusing specifically on beverage consumption to high school students in 3 Saskatchewan schools. The study provided a forum for students to increased knowledge so that young people are empowered to make informed decisions or so that they will change their behavior and increase healthy beverage consumption habits. The study was based on the assumption that students needed to construct knowledge, and by using the information pre-
sented, they were expected to assimilate information that would help change they pattern of beverage choices. Students in our study reported drinking more noncarbonated beverages than carbonated beverages before the intervention. The noncarbonated beverages included ice tea, coffee with sugar, sport drinks, and fruit drinks. Some of these noncarbonated beverages are fortified with vitamins and minerals. This finding is comparable to the literature. In recent years, fruit-flavored drinks, often made up of only 5% to 19% real juice, have emerged as a growing component of children's and adolescents' diets [31]. Hampl et al [32] reported that despite a higher sugar content, compared to 100% fruit juices, fruit-flavored (fruit drinks) drinks provide about 16% vitamin C in the diet of adolescents. However, the consumption of high intake of sweetened beverage may compromise overall nutrient intake [33]. The results showed that the most popular beverage consumed every day at school was plain water, followed by soft drink, fruit juice, and milk, although milk was the least consumed of all the beverages. The study did not solicit information about reasons for consumption, or nonconsumption, but attitude of the school staff toward healthy beverage environment [34], availability of beverage choices [35], and
E. Lo et al. / Nutrition Research 28 (2008) 144–150
promotion of beverages at school [36] likely help to shape adolescents' beverage intake. After the intervention, the 2 classes with the peer educator multiple and single strategy format showed a reduction in sugary beverage intake. This may be attributable to the peer educators, a finding that was also evident in the TEENS [37] and Trying Alternative Cafeteria Options in Schools studies [38]. The peer delivery format in these classes also combined the use of visual, auditory, tactile, group, and individual teaching styles. These results confirm the results of the study by Sovyanhadi and Cort [39]. Sovyanhadi and Cort [39] combined role-playing, video presentation, and visual display teaching styles, which were effective in the food pyramid session. Each student may have a different style of learning that is influenced by several dimensions such as (1) the type of information (sensory or intuitive), (2) through which modality is sensory information most effectively perceived (visual or verbal), (3) the way students process the information (actively or reflectively), and (4) the order in which they receive it (sequentially or globally) [40]. Students in class A and C returned to their baseline behaviors at 1-year follow-up; again, this trend to return to baseline was also found in the TEENS study [37]. Thus, maintenance sessions may be needed to remind students to keep their new behaviors. Furthermore, students may need additional support from parents and school to sustain their new healthier behavior [37]. Using a different peer approach for classes A (multiple) and C (single) was a strong point for comparison for the study. Participants came from the same socioeconomic background and received the FUEL nutrition education resource in a peer educator teaching approach (older peer assisted by cross-age and same-age peers and older peers only). Nonetheless, both classes showed the same tendency after the intervention, which was a reduction of sugary beverage intake. Although the recipe-tasting sessions were well received by class A, it did not appear to influence the participant's decision to increase nutritious beverage intake. The results in class A showed significant decrease in sugary beverage intake after the Bonferroni correction. The decrease in this class could be lower than in class C. The use of crossage, same-age, and older-peer educators in class A may have influenced the results. The number of peer educators who participated in the delivery of the intervention meant a broader reach. The use of same-age peers may also contribute to the outcome. The arrangement of the FUEL nutrition education resource in a user-friendly mode was another advantage in the intervention. The user-friendly FUEL nutrition education resource provided all the handouts needed to be distributed to students; furthermore, it also contained other appropriate reading resources. Students, especially in classes B and D, were attracted to reading the handouts from FUEL. There are several limitations to the study. One was the use of the expanded self-administered questionnaire BFQ, which
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included the beverage intake assessment tool. Although the beverage frequency section of the questionnaire was developed to ask about most kinds of beverages usually consumed by adolescents, a misclassification might have happened. For example, several fruit juice companies also produce fruit drinks. Although the companies labeled the drinks, students might be inattentive to their beverages and classified them as fruit juice when the beverages were fruit drinks. The fact that the questionnaire was a self-administered questionnaire could lead students to under- or overestimate their intake. Another was the presence of nutrition graduate students at the time when the instrument was administered, which could be found intimidating to students. They might not fill out the questionnaire as they were expected to. The number of subjects in the FUEL study was also a limitation. The FUEL study has a small number of subjects because it was a pilot project. Therefore, after conducting the study in classes A and B, another confirmation study was done in class C and D. The intervention in class C was slightly different than in class A in that only an older peer delivered the intervention. Despite these shortcomings, the study showed that the peer educator approach can be an important strategy for changing children's beverage behaviors. Although it was originally designed for the 2 urban area schools, this FUEL nutrition education resource has received wide circulation throughout the province and has been adopted as a learning resource package in 3 subject areas in the Saskatchewan Education curricula by Saskatchewan Department of Learning for use in the classrooms [41]. The resource is currently being used by provincial public health nutritionists as a training tool to assist teachers in promoting healthy beverage choices for high school children. Acknowledgment We would like to thank the Dairy Farmers of Canada and the Dr Stirling Foundations on Research in Teaching and Learning for the funding for the study. We also acknowledge the help provided by the school divisions, principals, teachers, and students. References [1] Spear BA. Adolescent growth and development. J Am Diet Assoc 2002;102(3):S23-9. [2] Story M, Neumark-Sztainer D. School-based nutrition education programs and services for adolescents. Adolesc Med 1996;7(2): 287-302. [3] O'Dea JA. Why do kids eat healthful food? Perceived benefits of and barriers to healthful eating and physical activity among children and adolescents. J Am Diet Assoc 2003;103(4):497-507. [4] McKinley MC, Lowis C, Robson PJ, Wallace JMW, Morrissey M, Moran A, et al. It's good to talk: children views on food and nutrition. Eur J Clin Nutr 2005;59:542-51. [5] Massey-Stokey M. Adolescent nutrition: needs and recommendation for practice. Clearing House 2002;75(6):286-91.
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Nutrition Research 28 (2008) 144 – 150 www.elsevier.com/locate/nutres
Beverage intake improvement by high school students in Saskatchewan, Canada Elisabeth Lo a , Renee Coles a , M. Louise Humbert b , Joyce Polowski c , Carol J. Henry a,⁎, Susan J. Whiting a a
College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada S7N 5C9 b College of Kinesiology, University of Saskatchewan, Saskatoon, SK, Canada S7N 5C9 c College of Education, University of Saskatchewan, Saskatoon, SK, Canada S7N 5C9 Received 19 June 2007; revised 28 December 2007; accepted 16 January 2008
Abstract Certain beverages contribute energy, protein, vitamins, and minerals. North American adolescents have shifted their beverage intake from predominantly milk to predominantly sugary beverages. Intake of these sugary beverages, in sufficient quantity, may increase the risk of bone fractures, may contribute to obesity, and may lead to tooth decay. This study evaluated the effectiveness of a schoolnutrition education program (Fluids Used Effectively for Living) on nutrition knowledge, attitude, and self-reported behavior of grade 9 students in Saskatchewan, Canada. Two classes of grade 9 students, 1 (n = 33) in a high school in Saskatoon (n = 33) and 1 (n = 24) in a large high school in Prince Albert, Saskatchewan, received the peer educator intervention. Two other classes in the 2 cities (n = 24 and n = 24, respectively) were controls. Six sessions of Fluids Used Effectively for Living nutrition education were delivered by using 2 peer educator models (multiple and single), and the intervention was delivered in a 45-minute weekly class session over a 6-week period. After the intervention, students in these 2 peer educator classes decreased their sugary beverage intake significantly, which was sustained for 3 months. Students in the control self-taught class increased their juice intake at the end of the year. The significant decrease of juice and sugary beverage intakes in the single model peer educator class disappeared after Bonferroni correction. Carbonated sugary beverage intake of students in the control self-taught classes declined, but it was not sustainable at the 3-month follow-up. A peer educator school-based nutrition education approach can lead to a decrease in sugary beverage intake in high school children. © 2008 Elsevier Inc. All rights reserved. Keywords: Abbreviations:
Peer education; Adolescents; Health education; Soft drinks; Sugary beverages; School-based nutrition education BFQ, beverage frequency questionnaire; CSD, carbonated soft drink; FUEL, Fluids Used Effectively for Living; NSD, noncarbonated sugary drink.
1. Introduction Adolescents need greater amounts of nutrients than adults to support their growth and development and to prevent chronic disease that may subsequently occur during adulthood [1,2]. Adolescents often do not have ⁎ Corresponding author. Tel.: +1 306 966 5833; fax: +1 306 966 6377. E-mail address: [email protected] (C.J. Henry). 0271-5317/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.nutres.2008.01.005
enough knowledge and experience to make appropriate decisions and tend to develop unhealthy eating habits. These include skipping breakfast, replacing lunch meal with snack food, and increasing soft drink intake, all of which can lead to inadequate nutrient intake [1]. Furthermore, adolescents' decision-making processes may be influenced by commercial activities, peers, and environmental factors [3,4], placing adolescents in a nutritionally vulnerable position. Healthy behaviors, including consum-
E. Lo et al. / Nutrition Research 28 (2008) 144–150 Table 1 Summary of intervention sessions for nutrition education programs Session
Training curriculum
1
The ABCs of nutrition Increasing student knowledge of human nutrition Helping students make nutritious food and beverage choices using accurate and current nutrition information Understanding nutritional value of beverages Nutritional content of various beverages Health impact of beverage choices Healthy bones Calcium content of beverages/foods Simple ways to incorporate calcium-rich food and beverages in the diet Making fast foods fit Integrating nutrition principles of variety and moderation in daily food habits Ways to reduce sugar, fat, and salt in their fast food Vitality Important role of physical activity and health Social and emotional benefits of active living Importance of healthy weight Simple ways to include physical activity in the daily lifestyle Take a peek Skill development, label reading, and changing behaviors
2
3
4
5
6
ing nutritious beverages, are important for adolescents to improve their school performance, growth, and developmental tasks [5-8]. Over the past 25 years, adolescents have changed their beverage intake patterns by doubling their sugary drink intake and decreasing their milk intake [9-11]. This shift has had a negative impact on health by lowering nutritional quality and decreasing micronutrient intake. Consumption of high sugary drink intake may place children at risk for not getting the nutrient they need for optimal health [12] and may contribute to increased risk of bone fractures [12-16], obesity [17,18], and tooth decay [19]. School-based nutrition education represents an important strategy for improving the beverage choices of children and youth. Several interventions using a school-based approach have successfully led to significant or moderate changes in adolescents' dietary habits [20,21]. Studies continue to confirm the influence of peers on adolescent health behaviors [22]. Much of the research in Canada on the impact of sugary drink consumption on the health of adolescents has placed emphasis on bone health. Two of the most influential studies conducted on Saskatchewan children [23,24] provided insights on aspects of adolescent's beverage intake [23] and the relationship between carbonated sugary drinks (CSDs) and bone health [24]. This investigation presents the results of a pilot nutrition education resource Fluids Used Effectively for Living (FUEL), including the program's impact on changing the beverage consumption practices of grade 9 students in Saskatchewan, Canada. The FUEL program intended to decrease students' sugary beverage intake.
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2. Methods and materials 2.1. Design The overall design was to compare changes in nutrition knowledge, attitude, and self-reported beverage consumption behaviors in a self-administered questionnaire for students who received the FUEL nutrition education resource and for those who did not receive the intervention. 2.2. Participants A total of 113 grade 9 students (average age, 14 years) from 4 high school classes participated in the study. Students from the 2 Saskatoon classes (n = 33 and n = 20, respectively) were selected from ethical living classes in 2 schools in Saskatoon, Saskatchewan, Canada, a large urban center with a population of 206 900 [25], and were assigned as classes A and B. Students (n = 24 and n = 24, respectively) from 2 English classes in a large school in Prince Albert, Saskatchewan, Canada, a suburban center with a population of 41 460 [26], were assigned as classes C and D. Both the ethical living class and the English classes were identified by classroom teachers as appropriate venues for integrating nutrition education into the curriculum. Classes in Saskatoon were assigned as a multiple (older, cross-age, and same age) peer educator class (A) and as self-taught (control) (B). Schools in Prince Albert were assigned as a single (older) peer educator class (C) and as self-taught (control) (D). A purposeful sampling technique was used to select the 3 schools. Schools were selected according to neighborhoods and socioeconomic status, meaning that the classes were made up of students from middle-income households from the Directory of Saskatchewan schools [27] in consultation with the appropriate school divisions. The schools were also chosen because of their diversity and large student population. Approval for human subjects was obtained from the University of Saskatchewan's Committee on Ethics in Behavioral Science Research. Written permission was obtained from the school divisions; principals of participating schools; teachers, parents, and guardians of eligible participants; and all student participants. Principals, teachers, consenting parents, and students were sent an information package describing the study and protocols. The identity of the participants was not recorded, except to characterize participants by class treatment and to allow sequential recalls and for questionnaires to be tracked. The 1 student who did not participate in the intervention was given alternate activities. 2.3. The FUEL intervention The FUEL program is a 6-session multifactorial nutrition education resource designed to be highly focused and interactive. The intervention was also developed taking into account constructivist theory of learning [28], which is predicated on the assumption that students construct
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knowledge from a variety of interactions such as knowledge, social learning, and linking new knowledge. The framework for the intervention included concepts from Canada's Food Guide for Healthy Eating [29]. The modules aimed to enhance knowledge and understanding about the importance of variety, balanced, and moderation in making wise beverage choices (fruit juice 100%, milk, and water) instead of sugary drinks and CSDs. Each module included a lesson plan, activities (student worksheets, games, experiments, and quiz), background information for users (teachers, health professionals, and students), handout materials, and evaluation activities (Table 1). The lesson plans were delivered weekly in six 45-minute classroom sessions over a 6-week period. Teachers (other than those whose from the participating classes) and public health nutritionists contributed to the development of the resource package by reviewing the package to ensure that it was age, sex, and culturally appropriate. 2.4. The FUEL delivery During the implementation, class A multiple peer educator model in Saskatoon received full presentations from the FUEL nutrition education resource package. Crossage peers (5 undergraduate nutrition students from the University of Saskatchewan) and 6 same-age peers (grade 9 students from selected classrooms where the intervention was carried out) assisted 2 older peers, recent nutrition graduates, in carrying out the intervention. Both cross-age and same-age peers received a 2-week intensive training that was intended to build teamwork among them and orient them to the materials/content of the resource package. In addition, cross-age peers were linked with same-age peers for guidance and support. The control class (class B) in Saskatoon received only the student handout materials from the resource package. The 2 classes (experimental and control) in Prince Albert were located in the same high school. In this school, a single model (an older peer, a registered dietitian) delivered the FUEL nutrition education to the intervention class (class C). The FUEL delivery was similar to that in class A; however, there was no recipe demonstration and beverage tasting in this class. A priority for the research team was to develop a resource that could be used by both researchers and nutrition providers in the delivery of FUEL; hence, there was a need to compare the 2 techniques, one using a range of peer educators and one using an older peer only. The use on an older-peer technique mirrored the use of a trained classroom teacher and may not be able to incorporate recipe demonstration and tasting into their own curricula delivery. The control class (class D) was treated similar to class B and received the handout materials from the lessons for the 6 classroom sessions. In classes B and D (control), the teachers in the 2 classes were permitted to respond to questions from students. However, these teachers did not receive the FUEL nutrition education resource until the study finished. Students in classes B and D self-taught (control)
were promised that they would receive the full intervention after the completion of the study. 2.5. Assessments The unit of analysis for the evaluation was the class because class was the unit of intervention for FUEL. Beverage intake, knowledge, and attitude were assessed by an expanded self-administered questionnaire, which included a beverage frequency questionnaire (BFQ) with sections for nutrition knowledge, attitude, and behavior questions. The BFQ was pretested by high school students not participating in the study and was revised accordingly. The BFQ section included 19 questions on specific types of beverages consumed weekly, 4 questions about beverage intake habits at school, 6 questions about the student's attitude toward beverages, 11 questions about knowledge regarding healthy foods and beverages, and 3 questions on demographic characteristics. The baseline and postintervention questionnaires were all identical. The questionnaires were conducted as class exercises lasting 10 to 15 minutes and were supervised by trained research assistants. Responses on the attitude and knowledge questions were in the expression of agree, somewhat agree, and disagree. Questions on beverage intake habits were answered using the expressions more than once per day, once per day, once per week, and seldom or never as 3, 2, or 1. When the questions were expected to be answered in the negative, the score was 1, 2, or 3, respectively. Knowledge and attitude questions were scored separately. The score of each expression in knowledge and attitude questions depended on the answer and the questions. For example, for the incorrect statement “fruit drink has the same nutrient content as fruit juice,” the answers agree, somewhat disagree, or disagree would be coded 1, 2, or 3. Knowledge and attitude questions were scored separately and totaled. In the postintervention questionnaires, we asked students about their satisfaction level for the programs. The satisfaction level was rated using a 5-point scale, where 1 = poor and 5 = excellent. In the postintervention questionnaires, satisfaction with course content and delivery was rated using a 5-point scale, where 1 = poor and 5 = excellent. Each participating student was asked to complete 3 sets of BFQ, one at the beginning of the study (pretest), one 1 week after the delivery of the nutrition program (posttest), and one 3 months after the intervention delivery (3-month followup). The final set of questionnaires was administered 1 year later (1-year follow-up) for classes A and B only when students were in grade 10. Process evaluation was also conducted to assess participants' satisfaction with the content and delivery of the nutrition education resource. 2.6. Statistical analysis Results from the BFQ for beverage intake were grouped into categories of milk, 100% juice, noncarbonated sugary drinks (NSDs), CSDs, total sugary drinks, and other drinks. The intake of NSDs included tea and coffee (with added
E. Lo et al. / Nutrition Research 28 (2008) 144–150 Table 2 Characteristics of each class at baseline Saskatoon Peer educator (class A) Class Ethical living (grade 9) Students 33 Female 9 Male 24 Intake a Milk Median 15 Mean (SE) 15 (2) Interquartile 7 range Juice Median 9 Mean (SE) 10 (2) Interquartile 14 range NCD Median 9 Mean (SE) 11 (1) Interquartile 12 range CSD Median 7 Mean (SE) 5 (1) Interquartile 6 range Other Median 2 Mean (SE) 6 (1) Interquartile 14 range Knowledge score b Median 13 Mean (SE) 13 (3) Interquartile 4 range Attitude score b Median 14 Mean (SE) 14 (2) Interquartile 3 range
Prince Albert
Self-taught (class B)
Peer educator (Class C)
Self-taught (class D)
Ethical living 24 10 14
English
English
20 12 8
24 8 16
13 11 (1) 9
11 12 (1) 9
15 16 (2) 15
7 6 (1) 7
7 11 (3) 7
8 11 (2) 8
6 8 (1) 14
3 7 (2) 12
8 11 (1) 13
7 5 (1) 6
8 8 (2) 13
2 4 (2) 6
1 3 (1) 6
12 7 (2) 7
8 8 (2) 13
13 13 (2) 3
14 15 (2) 14
9 10 (3) 9
10 10 (2) 3
10 13 (2) 2
9 12 (3) 2
NCD indicates noncarbonated drink. a In serving per week. b Full score was 18.
sugar only), sweetened ice tea, sport drinks, fruit drinks, and fruit punch. Carbonated sugary drink intake included intake of beverages such as Coke, Pepsi, Seven-Up, and their generic equivalents. Total sugary drink intake was the addition of NSD and CSD intakes. The “other drinks” category consisted of bottled water, hot tea, and black coffee. For coding purposes, the expression of seldom or never in the BFQ was considered as zero serving per week; that of about once per week was 1 serving per week; that of once per day was 7 servings per week; and that of more than once per day was 14 servings per week.
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Data were analyzed using SPSS (version 13.0, Chicago, Ill). Cronbach α was determined to find out the internal reliability of the data. A normality test, Shapiro-Wilk test, to assess the data distribution was run first. Because our data were found to be not normally distributed, nonparametric tests were used to analyze the data. To determine significant differences among the beverage assessments, we performed the Friedman test. The Wilcoxon test was used as a multiple comparison test, with the α level corrected using Bonferroni correction, according to the number of comparisons: .008 for classes A and B and .017 for classes C and D [30]. 3. Results and discussion The internal reliability of the questionnaire was acceptable (Cronbach α = .68). Overall, students in all classes drank similar amounts of beverages (milk, juice, CSDs, NSDs, and other beverages). Students in Prince Albert classes drank significantly higher amount of other beverages than students in Saskatoon classes before the intervention. Students' characteristics at baseline are shown in Table 2. Table 3 describes the beverages that were usually consumed by students at schools. The favorite beverage at school was water, followed by sugary drinks. Students drank milk in the smallest amount than any other beverages. Furthermore, 76% of students in class A and B and 96% of students in class C and D never consumed milk at school. After the intervention, students in class A (Saskatoon peer educator class) showed a significant decrease in sugary beverage intake, which was sustained for 3 months (Fig. 1) and which was due to changes in carbonated and noncarbonated soft drink intake. The students in class B (self-taught class in Saskatoon) increased their juice intake at the end of the study (Fig. 1). Intakes of milk and of other beverages (latter not shown in the figure) did not change. In class C, after the other peer educator (older peer only), there was an apparent decrease in juice and sugary beverage intakes, but this was not significant. However, the trend was similar to class A (Fig. 1). Carbonated sugary beverage intake of students in class D significantly declined at 1 week postintervention, but it returned to the baseline condition at 3 months follow-up. Students' knowledge and
Table 3 The percentage of students that consumed soft drinks, 100% fruit juice, milk, and water at the schools ≥ once per day (%)
Soft drinks 100% fruit juice Milk Water a
Classes A and B a
Classes C and D b
29.8 23.2 7.3 78.6
25.0 28.1 2.3 70.5
A and B: experimental and control classes in Saskatoon High School. C and D: experimental and control classes in Prince Albert High School. b
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Fig. 1. Beverage intake of students (number of servings per week) in 4 grade 9 classes before and after the classroom nutrition education intervention. Intake is presented in mean and SE. A different letter indicates significant differences among beverage intake, P b .02. TSD indicates all sugary beverages. The first intervention was class A (multiple strategy), n = 33 at pretest, and class B (single strategy), n = 24 at pretest. The intervention was repeated in class C (multiple strategy), n = 20 at pretest, and class D (single strategy), n = 24 at pretest.
attitudes in both classes did not change significantly (data not shown). Students in class A expressed a higher level of satisfaction (P b .05) than class B. Overall, 71% of students said the program was fun, informative, interesting, and helped them to learn. Furthermore, 77% of the students would suggest this program to others. Students indicated that they appreciated learning about nutrition and healthy eating, participating in the recipe demonstrations, or trying the recipes at home. The level of satisfaction of the intervention in class C and D was not significantly different. Overall, 73% of students from classes C and D would suggest the FUEL to others. Furthermore, 57% class C and 33% class D students stated that the intervention was fun, informative, and helped them to eat and drink healthier. The study was designed to deliver nutrition education focusing specifically on beverage consumption to high school students in 3 Saskatchewan schools. The study provided a forum for students to increased knowledge so that young people are empowered to make informed decisions or so that they will change their behavior and increase healthy beverage consumption habits. The study was based on the assumption that students needed to construct knowledge, and by using the information pre-
sented, they were expected to assimilate information that would help change they pattern of beverage choices. Students in our study reported drinking more noncarbonated beverages than carbonated beverages before the intervention. The noncarbonated beverages included ice tea, coffee with sugar, sport drinks, and fruit drinks. Some of these noncarbonated beverages are fortified with vitamins and minerals. This finding is comparable to the literature. In recent years, fruit-flavored drinks, often made up of only 5% to 19% real juice, have emerged as a growing component of children's and adolescents' diets [31]. Hampl et al [32] reported that despite a higher sugar content, compared to 100% fruit juices, fruit-flavored (fruit drinks) drinks provide about 16% vitamin C in the diet of adolescents. However, the consumption of high intake of sweetened beverage may compromise overall nutrient intake [33]. The results showed that the most popular beverage consumed every day at school was plain water, followed by soft drink, fruit juice, and milk, although milk was the least consumed of all the beverages. The study did not solicit information about reasons for consumption, or nonconsumption, but attitude of the school staff toward healthy beverage environment [34], availability of beverage choices [35], and
E. Lo et al. / Nutrition Research 28 (2008) 144–150
promotion of beverages at school [36] likely help to shape adolescents' beverage intake. After the intervention, the 2 classes with the peer educator multiple and single strategy format showed a reduction in sugary beverage intake. This may be attributable to the peer educators, a finding that was also evident in the TEENS [37] and Trying Alternative Cafeteria Options in Schools studies [38]. The peer delivery format in these classes also combined the use of visual, auditory, tactile, group, and individual teaching styles. These results confirm the results of the study by Sovyanhadi and Cort [39]. Sovyanhadi and Cort [39] combined role-playing, video presentation, and visual display teaching styles, which were effective in the food pyramid session. Each student may have a different style of learning that is influenced by several dimensions such as (1) the type of information (sensory or intuitive), (2) through which modality is sensory information most effectively perceived (visual or verbal), (3) the way students process the information (actively or reflectively), and (4) the order in which they receive it (sequentially or globally) [40]. Students in class A and C returned to their baseline behaviors at 1-year follow-up; again, this trend to return to baseline was also found in the TEENS study [37]. Thus, maintenance sessions may be needed to remind students to keep their new behaviors. Furthermore, students may need additional support from parents and school to sustain their new healthier behavior [37]. Using a different peer approach for classes A (multiple) and C (single) was a strong point for comparison for the study. Participants came from the same socioeconomic background and received the FUEL nutrition education resource in a peer educator teaching approach (older peer assisted by cross-age and same-age peers and older peers only). Nonetheless, both classes showed the same tendency after the intervention, which was a reduction of sugary beverage intake. Although the recipe-tasting sessions were well received by class A, it did not appear to influence the participant's decision to increase nutritious beverage intake. The results in class A showed significant decrease in sugary beverage intake after the Bonferroni correction. The decrease in this class could be lower than in class C. The use of crossage, same-age, and older-peer educators in class A may have influenced the results. The number of peer educators who participated in the delivery of the intervention meant a broader reach. The use of same-age peers may also contribute to the outcome. The arrangement of the FUEL nutrition education resource in a user-friendly mode was another advantage in the intervention. The user-friendly FUEL nutrition education resource provided all the handouts needed to be distributed to students; furthermore, it also contained other appropriate reading resources. Students, especially in classes B and D, were attracted to reading the handouts from FUEL. There are several limitations to the study. One was the use of the expanded self-administered questionnaire BFQ, which
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included the beverage intake assessment tool. Although the beverage frequency section of the questionnaire was developed to ask about most kinds of beverages usually consumed by adolescents, a misclassification might have happened. For example, several fruit juice companies also produce fruit drinks. Although the companies labeled the drinks, students might be inattentive to their beverages and classified them as fruit juice when the beverages were fruit drinks. The fact that the questionnaire was a self-administered questionnaire could lead students to under- or overestimate their intake. Another was the presence of nutrition graduate students at the time when the instrument was administered, which could be found intimidating to students. They might not fill out the questionnaire as they were expected to. The number of subjects in the FUEL study was also a limitation. The FUEL study has a small number of subjects because it was a pilot project. Therefore, after conducting the study in classes A and B, another confirmation study was done in class C and D. The intervention in class C was slightly different than in class A in that only an older peer delivered the intervention. Despite these shortcomings, the study showed that the peer educator approach can be an important strategy for changing children's beverage behaviors. Although it was originally designed for the 2 urban area schools, this FUEL nutrition education resource has received wide circulation throughout the province and has been adopted as a learning resource package in 3 subject areas in the Saskatchewan Education curricula by Saskatchewan Department of Learning for use in the classrooms [41]. The resource is currently being used by provincial public health nutritionists as a training tool to assist teachers in promoting healthy beverage choices for high school children. Acknowledgment We would like to thank the Dairy Farmers of Canada and the Dr Stirling Foundations on Research in Teaching and Learning for the funding for the study. We also acknowledge the help provided by the school divisions, principals, teachers, and students. References [1] Spear BA. Adolescent growth and development. J Am Diet Assoc 2002;102(3):S23-9. [2] Story M, Neumark-Sztainer D. School-based nutrition education programs and services for adolescents. Adolesc Med 1996;7(2): 287-302. [3] O'Dea JA. Why do kids eat healthful food? Perceived benefits of and barriers to healthful eating and physical activity among children and adolescents. J Am Diet Assoc 2003;103(4):497-507. [4] McKinley MC, Lowis C, Robson PJ, Wallace JMW, Morrissey M, Moran A, et al. It's good to talk: children views on food and nutrition. Eur J Clin Nutr 2005;59:542-51. [5] Massey-Stokey M. Adolescent nutrition: needs and recommendation for practice. Clearing House 2002;75(6):286-91.
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