- Email: [email protected]
Integrating the Glycemic Index into Clinical Practice: Written Education Materials and Perceptions of Utility
Can J Diabetes 36 (2012) 54e57
Contents lists available at SciVerse ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Practical Diabetes
Integrating the Glycemic Index into Clinical Practice: Written Education Materials and Perceptions of Utility Katherine M. Southgate BASc, RD, Thomas M.S. Wolever DM, PhD * Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
Background Over the past 15 years (1), interest in the Glycemic Index (GI) has increased among the scientific, clinical and public communities. Through numerical classification, the GI simply describes how different carbohydrate foods affect our bodies’ postprandial blood glucose levels (2). Despite strong evidence supporting the efficacy of the GI as a strategy to improve glycemic control in diabetes (3,4), disagreement among international associations (5e10) and practice-based health professionals regarding its clinical use persists. At the practice level, many dietitians admit to finding the GI difficult to teach with a lack of suitable teaching tools being a primary reason (11,12). Those dietitians who choose to use the GI often teach the concept verbally, while also providing written materials to facilitate the learning process. Many dietitians report using free-of-charge materials provided by health organizations and professional associations for their client education (13). However, these materialsdincluding those used for teaching the GIdmay be problematic, as their suitability for clients as effective education tools is often not assessed by a formal evaluation. Investigation into the barriers causing disagreement among health professionals’ opinions as to the use of the GI has been recommended (14). Looking at the quality of currently available written GI education tools is an important piece to this puzzle. If warranted, improvement of these materials may help to promote the acceptance and use of the GI among practice-based health professionals. Therefore, this commentary uses a formal evaluation tool to assess the suitability of 5 free-of-charge GI education handouts provided by national professional associations.
readability and also usability characteristics, including layout and design elements, of a written material. Because it was designed for quick and easy use by health professionals during their daily practices, and has been validated among healthcare professionals from several countries, the Suitability Assessment of Materials (SAM) instrument developed by Doak et al. (15) was used in this commentary. When using the SAM, a selected piece of written material is evaluated for suitability against 6 categories (content, literacy demand, graphics, layout and typography, learning stimulation and motivation and cultural appropriateness) containing a total of 22 factors (15). Each factor is given a rating of “Not Suitable” (score ¼ 0); “Adequate” (score ¼ 1); “Superior” (score ¼ 2); or “Not Applicable” (15). Approximate reading grade level is assessed via the Fry formula, calculated by plotting the average number of sentences and syllables from 3, 100-word passages contained in the handout (15). The total suitability score (expressed as a percentage) for each material is then calculated and a corresponding overall rating is given (15). Of note, 3 SAM factors (reading grade level, match in cultural logic, language and experience; and cultural image and examples) are considered by its authors to be “goeno/go” factors (15). If any one is found to be unsuitable, a written material is considered to have an overall rating of Not Suitable irrespective of the ratings it obtains in the other 19 factors (15). Once suitably designed, user opinion and comprehension level of the written material should then be assessed through pilot testing among a sample of the material’s intended audience (17).
How Do Current Written GI Education Materials Fare? Suitability
Assessment of Written Materials Various tools have been developed to formally evaluate the appropriateness of written education materials. These tools range from simple text readability formulas, which determine how easy or difficult a given material is to read (15), to more comprehensive evaluations such as those developed by Doak et al. (15) and Hill-Briggs et al. (16). These comprehensive tools assess the * Address for correspondence: Thomas M.S. Wolever, Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Fitzgerald Building, 150 College Street, Room 427, Toronto, Ontario, Canada M5S 3E2. E-mail address: [email protected] (T.M.S. Wolever). 1499-2671/$ e see front matter Ó 2012 Canadian Diabetes Association doi:10.1016/j.jcjd.2012.05.002
Using SAM, 5 free-of-charge GI education materials were formally evaluated for suitability as effective client education tools. These included those produced by Diabetes Australia (18), The British Dietetic Association (BDA) (19), the Baker IDI Heart and Diabetes Institute (20), the Canadian Sugar Institute (21) and The Canadian Diabetes Association (CDA) (22). Table 1 lists the primary focus of each material. Using the operational criteria for scoring defined by the authors of the SAM, one of us (KMS) assessed the materials against all 22 factors. Table 2 shows the individual SAM factor and total ratings for all materials assessed. The Baker IDI and Canadian Sugar Institute education materials had the highest and lowest overall scores respectively. Three of the 5 materials were
K.M. Southgate, T.M.S. Wolever / Can J Diabetes 36 (2012) 54e57
found to have a SAM rating of Adequate with 2 of the materials being assessed as Not Suitable. However, when considering the goeno/go factors, 4 of the materials were found to have a Fry reading grade level of 9 or higher and thus, were given a final rating of Not Suitable. The majority of materials were assessed as Not Suitable in 5 of the SAM factors: having a clear purpose; including behaviour related content; including a summary or review; being an appropriate reading level; and using relevant illustrations. These results indicate that the suitability of written GI client education materials can be improved. Most of the materials assessed lacked an explicitly stated purpose in their title or introduction, and all were lacking concluding summaries. Also, much of the materials were heavily fact-based, with inadequate information provided on specific, desirable dietary GI behaviours and interactive learning stimulation. The Diabetes Australia and Baker IDI written materials provide specific recommendations for the incorporation of low GI foods into one’s diet. Both advise readers to include 1 low or lower GI food at each meal and/or snack time per day (18,20). The remaining written education materials offer only abstract behavioural advice to “choose medium and low GI foods more often” (22), or that “a diet based mainly on low GI foods may improve insulin sensitivity” (19). Furthermore, only the CDA material provides individuals with interactive stimulation in the form of an area to write down their intended changes. Consistent with previous literature examining the readability of printed sources of diet and health information (23), the reading level for 4 of 5 materials was at a 9th grade level or higher. This is much higher than the 5th grade level found comprehensible by most individuals (24). Poor graphic utilization was displayed among all of the materials. Although research has shown that, when included, proper use of illustrations can provide significant benefits in client attention, comprehension, recall and adherence (25), none of the materials assessed displayed relevant illustrations. Graphics should present key messages visually with no distracting features, through simple, adult-appropriate line drawings familiar to the intended audience (15). For example, Table 1 notes that the primary focus of the CDA written material is how to incorporate lower GI foods into one’s diet. Therefore, instead of the current broccoli graphic used, a more useful illustration might be a simple line drawing of a person adding a lower GI option to their lunch or dinner plate. Pilot testing No published pilot testing involving the materials assessed here could be found during a Scopus literature search. Although not directly examining the tool itself, in 2009 the written education material developed by the CDA was used during the low GI education component of a study involving the First Step, First Bite Program (26). Results indicate a positive significant behavioural change for participants in the low GI group, who significantly increased their daily consumption of low GI foods from baseline to follow-up at 16 weeks by 2 servings (baseline ¼ 50.6, followup ¼ 70.8, p ¼ 0.01) (26). However, as subjects in this study were also exposed to a low GI presentation, sample meal plans, and recipes and snacks incorporating low GI foods, it is impossible to determine the effects that the CDA written material alone may have had on the positive behaviour change observed. Conclusions When provided alone, client recall of verbal health information is poor (27,28). However, providing verbal and written education together has been found to improve knowledge and behaviour change (27). When incorporated into client education practices, written education materials offer a host of additional benefits
55
Table 1 The primary focus of each written education material Written education material
Professional association
Primary focus of the material
Talking diabetes No. 17: the Glycemic Index: http:// www.australiandiabetes council.com/Resources/ PDFs/NDSS-InformationSheets/GLYCEMIC-INDEX2010.aspx Food Facts: Glycemic Indexdis it just hype?: http://www.bda.uk.com/ foodfacts/GIDiet.pdf
Diabetes Australia
-How using the GI can help in diabetes -How to incorporate lower GI foods into one’s diet
BDA
Carbohydrates and Glycemic Index (GI): http:// www.bakeridi.edu.au/ Assets/Files/CHO%20 &%20GI%20(2011)[1].pdf Clips on Sugars: understanding the Glycemic Index: http:// www.sugar.ca/english/ pdf/healthprofessionals/ Clip9.pdf The Glycemic Index: http:// www.diabetes.ca/files/ GlycemicIndex_ 09_Boehringer.pdf
Baker IDI
-How the GI may help with weight control and be an effective part of a weight loss plan -How to use the GI in one’s diet -The health benefits of lower GI foods -How to incorporate lower GI foods into one’s diet
Canadian SI
-General information on the GI such as the definition, why the GI was created, limitation of the GI and the GI of various foods
CDA
-How to incorporate lower GI foods into one’s diet
BDA, British Dietetic Association; BG, blood glucose; CDA, Canadian Diabetes Association; GI, Glycemic Index; SI, sugar institute.
including ease of portability for future reference (29); repetition and reinforcement of concepts (27); flexibility of information delivery (27,30); and accessibility of information to family and friends who may positively influence desired behavioural changes (27). Patients’ desire for written materials during healthcare education sessions has been reported (31,32), with a subsequent increase in satisfaction being found when written materials are supplied (32). Thus, dietitians frequently use written materials as an adjunct to dietary education. One study found that 87% of dietitians use 1 to 3 printed pieces per client with 97% “sometimes, almost always, or always” using free-of-charge materials (13). Those dietitians surveyed also reported a heavy reliance on health organizations, professional associations and commodity groups for the written materials used within their practices (13). With this in mind, use of written materials during client education sessions focused on the GI is arguably critical to the successful incorporation of this concept into an individual’s dietary behaviours. Yet despite the proven efficacy of the GI, dietitians continue to have conflicting views regarding its use in clinical practice. Often choosing not to incorporate the GI into client care, dietitians cite the lack of suitable teaching materials as a primary reason. These perceptions are supported here by the formal assessment of 5 freeof-charge GI education materials. Using the SAM, all of the handouts assessed were found to have a final suitability rating of Not Suitable. Thus, less than superior GI teaching materials may be negatively affecting health professionals’ perceptions regarding the use of the GI, and ultimately the frequency they choose to use this concept with their clients. In conclusion, although this assessment was based on a review by only 1 individual, the results suggest a need for the development of simple written GI education materials, proven to be both suitable by formal evaluation tools and effective through pilot testing. Raynor indicates that the success of written materials hinges on 3 factors: “1) how they are delivered to the client, 2) the design and layout, and 3) the content” (27). Both a comprehensive assessment of and revision to these components are vital in maximizing the
56
K.M. Southgate, T.M.S. Wolever / Can J Diabetes 36 (2012) 54e57
Table 2 SAM ratings for all 5 free-of-charge glycemic index handouts assessed* SAM category and factor 1. Content Purpose is evident Content about behaviours Scope is limited Summary or review included 2. Literacy demand Fry reading grade level Writing style, active voice Vocabulary uses common words Context is given first Learning aids via “road signs” 3. Graphics Cover graphic shows purpose Type of graphics Relevance of illustrations List, tables, etc. explained Captions used for graphics 4. Layout and typography Layout factors Typography Subheadings used 5. Learning stimulation, motivation Interaction used Behaviors are modeled and specific Motivationdself-efficacy 6. Cultural appropriateness Match in logic, language, experience Cultural image and examples Total SAM scorey Percent scorey Ratingy Are any goeno/go factors considered unsuitable?z Final rating with suitability of goeno/go factors considered
Diabetes Australia
BDA
Baker IDI
Canadian SI
CDA
0 0 N/A 0
1 0 1 0
0 2 N/A 0
0 0 N/A 0
1 2 2 0
0 0 1 2 2
1 1 1 2 2
0 2 1 2 2
0 1 1 2 1
0 2 1 2 2
N/A 2 0 1 2
N/A 1 0 0 0
N/A 1 0 2 1
N/A 0 0 0 1
N/A 1 0 1 0
2 2 2
1 1 1
2 1 2
2 1 0
2 2 1
1 1 2
0 0 1
1 2 2
0 0 1
2 1 2
N/A 1 21 55.3 Adequate Yes Not suitable
N/A 1 15 37.5 Not suitable No Not suitable
N/A 1 24 65 Adequate Yes Not suitable
N/A 1 11 29 Not suitable Yes Not suitable
N/A 1 25 62.5 Adequate Yes Not suitable
BDA, British Dietetic Association; CDA, Canadian Diabetes Association; IDI, International Diabetes Institute; N/A, Nonapplicable; SAM, suitability assessment measure; SI, Sugar Institute. * Individual factor ratings are as follows; 2 ¼ Superior; 1 ¼ Adequate; 0 ¼ Not Suitable; N/A ¼ Not applicable. Interpretation is as follows; 0%e39% score ¼ Not Suitable; 40%e 69% score ¼ Adequate; 70%e100% score ¼ Superior. y Nonapplicable items were not figured into total scores, percent scores or overall material interpretation. z If any of the 3 goeno/go factors (reading grade level; match in cultural logic, language and experience; and cultural image and examples) are found to be unsuitable, the entire material is considered to have a final SAM suitability rating of Not Suitable, irrespective of the ratings obtained in the other 19 factors.
benefits that written materials have to offer. However, it has been reported that although 96% of the dietitians surveyed “almost always or always” previewed their materials before providing them to clients, 82% “never or almost never” performed this evaluation with a formal tool (13). A growing body of literature focused on practical advice for the incorporation of the GI into current dietary practices exists (2,33e35) and should be used in the development of such resources. When applied correctly, the GI can be an important tool for dietary empowerment and should no longer be overlooked as a component to comprehensive care. Author Disclosures There was no financial or material support for this work. Author Contributions KMS conceived and designed this study, including acquisition, analysis and interpretation of the data. KMS also drafted the manuscript, played a major part in the critical revision process and gave final approval of the version to be published. TMSW contributed to the conception and design of the manuscript, critically revised it and gave final approval of the version to be published. References 1. Wolever TMS. Historical introduction. In: Wolever TMS, editor. The Glycaemic Index: A Physiological Classification of Dietary Carbohydrate. Cambridge (MA): CABI North American Office; 2006. p. 10.
2. Small P, Brand-Miller J. From complex carbohydrate to glycemic index: tracing the controversy. Nutr Today 2009;44:236e43. 3. Thomas D, Elliott EJ. Low glycaemic index, or low glycaemic load, diets for diabetes mellitus (Review). Cochrane Database Syst Rev 2009;21:CD006296. 4. Thomas DE, Elliott EJ. The use of low-glycaemic index diets in diabetes control. Br J Nutr 2010;104:797e802. 5. Dyson PA, Kelly T, Deakin T, et al, on behalf of Diabetes UK Nutrition Working Group. Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes. Diabet Med 2011;28:1282e8. 6. The Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD). Recommendations for the nutrition management of patients with diabetes mellitus. Eur J Clin Nutr 2000;54: 353e5. 7. Vorster HH, ANell T. Make starchy foods the basis of most meals. S Afr J Clin Nutr 2001;14:S17e24. 8. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2008; 32(suppl 1):S1e201. 9. American Diabetes Association. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care 2008;31(suppl 1):S61e78. 10. Franz MJ, Powers MA, Leontos C, et al. The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. J Am Diet Assoc 2010;110: 1852e89. 11. GI Master Class 2002 Group. The glycaemic index in practicedconsensus statement of a small group of South African dietitians. S Afr J Clin Nutr 2005; 18:260e4. 12. Kalergis M, Pytka E, Yale JF, et al. Canadian dietitians’ use and perceptions of glycemic index in diabetes management. Can J Diet Pract Res 2006;67:21e7. 13. Tagtow AM, Amos RJ. Extent to which dietitians evaluate nutrition education materials. J Nutr Educ 2000;32:161e8. 14. Grant S, Wolever TMS. Perceived barriers to application of glycaemic index: valid concerns or lost in translation? Nutrients 2011;3:330e40. 15. Doak CC, Doak LG, Root JH. Assessing suitability of materials. In: Doak CC, Doak LG, Root JH, editors. Teaching Patients with Low Literacy Skills. 2nd ed. Philadelphia (PA): J.B. Lippincott; 1996. pp. 41e60.
K.M. Southgate, T.M.S. Wolever / Can J Diabetes 36 (2012) 54e57 16. Hill-Briggs F, Smith AS. Evaluation of diabetes and cardiovascular disease print patient education materials for use with low-health literate populations. Diabetes Care 2008;31. 667e1. 17. Hoffmann T, Worrall L. Designing effective written health education materials: considerations for health professionals. Disabil Rehabil 2004;26:1166e73. 18. The National Diabetes Services Scheme (NDSS) administered by Diabetes Australia. Talking diabetes: the glycemic index. Diabetes Australia: Diabetes Information Sheets site. (available online at http://www.australiandiabetescouncil.com/ Resources/PDFs/NDSS-Information-Sheets/GLYCEMIC-INDEX-2010.aspx). Updated August 2010. Accessed October 3, 2011. 19. Govindji A. Food facts: Glycaemic Indexdis it just hype? The British Dietetic Association: Food Facts Sheets site. (available online at http://www.bda.uk. com/foodfacts/GIDiet.pdf). Published April 2004. Accessed October 3, 2011. 20. Carbohydrates and Glycaemic Index. Baker IDI Heart and Diabetes Institute: resources and fact sheets site. (available online at http://www.bakeridi.edu.au/ Assets/Files/CHO%20&%20GI%20(2011)[1].pdf). Published 2011. Accessed October 3, 2011. 21. Clips on SugarseFor Up-to-Date Information on Sugars in Healthy Eating: Understanding the Glycemic Index. Canadian Sugar Institute: educators and students site. (available online at http://www.sugar.ca/ english/pdf/ healthprofessionals/Clip9.pdf). Updated 2008. Accessed October 3, 2011. 22. The Glycemic Index. Canadian Diabetes Association: for professionals resources. (available online at http://www.diabetes.ca/files/GlycemicIndex_ 09_Boehringer.pdf). Updated September 2009. Accessed October 3, 2011. 23. Dollahite J, Thompson C, McNew R. Readability of printed sources of diet and health information. Patient Educ Couns 1996;27:123e34. 24. Estey A, Musseau A, Keehn L. Comprehension levels of patients reading health information. Patient Educ Couns 1991;18:165e9.
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25. Houts PS, Doak CC, Doak LG, et al. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns 2006;61:173e90. 26. Cheong SH, McCargar LJ, Paty BW, et al. The first step first bite program: guidance to increase physical activity and daily intake of low-glycemic index foods. J Am Diet Assoc 2009;109:1411e6. 27. Raynor DK. The influence of written information on patient knowledge and adherence to treatment. In: Myers LB, Midence K, editors. Adherence to Treatment in Medical Conditions. Amsterdam, Netherlands: Overseas Publishers Association; 1998. pp. 83e111. 28. Wilson M, Robinson EJ, Blenkinsopp A, et al. Customers’ recall of information given in community pharmacies. Int J Pharm Pract 1992;1:152e9. 29. Ley P. The use of written information for patients. In: Marcer D, editor. Communicating with Patients: Improving Communication, Satisfaction and Compliance. New Fetter Lane, London: Croom Helm Ltd; 1988. pp. 110e24. 30. Bernier MJ. Developing and evaluating printed education materials: a prescriptive model for quality. Orthop Nurs 1993;12:39e46. 31. Weinman J. Providing written information for patients: psychological considerations. J R Soc Med 1990;83:303e5. 32. Tang PC, Newcomb C. Informing patients: a guide for providing patient health information. J Am Med Inform Assoc 1998;5:563e70. 33. Davis M, Miller CK. Educational needs regarding the glycemic index in diabetes management. Topics Clin Nutr 2006;21:17e25. 34. Brand-Miller J, Foster-Powell K. Diets with a low glycemic index: from theory to practice. Nutr Today 1999;34:64e72. 35. Slabber M. Complexities of consumer understanding of the glycaemic index concept and practical guidelines for incorporation in diets. S Afr J Clin Nutr 2005;18:252e6.
Contents lists available at SciVerse ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Practical Diabetes
Integrating the Glycemic Index into Clinical Practice: Written Education Materials and Perceptions of Utility Katherine M. Southgate BASc, RD, Thomas M.S. Wolever DM, PhD * Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
Background Over the past 15 years (1), interest in the Glycemic Index (GI) has increased among the scientific, clinical and public communities. Through numerical classification, the GI simply describes how different carbohydrate foods affect our bodies’ postprandial blood glucose levels (2). Despite strong evidence supporting the efficacy of the GI as a strategy to improve glycemic control in diabetes (3,4), disagreement among international associations (5e10) and practice-based health professionals regarding its clinical use persists. At the practice level, many dietitians admit to finding the GI difficult to teach with a lack of suitable teaching tools being a primary reason (11,12). Those dietitians who choose to use the GI often teach the concept verbally, while also providing written materials to facilitate the learning process. Many dietitians report using free-of-charge materials provided by health organizations and professional associations for their client education (13). However, these materialsdincluding those used for teaching the GIdmay be problematic, as their suitability for clients as effective education tools is often not assessed by a formal evaluation. Investigation into the barriers causing disagreement among health professionals’ opinions as to the use of the GI has been recommended (14). Looking at the quality of currently available written GI education tools is an important piece to this puzzle. If warranted, improvement of these materials may help to promote the acceptance and use of the GI among practice-based health professionals. Therefore, this commentary uses a formal evaluation tool to assess the suitability of 5 free-of-charge GI education handouts provided by national professional associations.
readability and also usability characteristics, including layout and design elements, of a written material. Because it was designed for quick and easy use by health professionals during their daily practices, and has been validated among healthcare professionals from several countries, the Suitability Assessment of Materials (SAM) instrument developed by Doak et al. (15) was used in this commentary. When using the SAM, a selected piece of written material is evaluated for suitability against 6 categories (content, literacy demand, graphics, layout and typography, learning stimulation and motivation and cultural appropriateness) containing a total of 22 factors (15). Each factor is given a rating of “Not Suitable” (score ¼ 0); “Adequate” (score ¼ 1); “Superior” (score ¼ 2); or “Not Applicable” (15). Approximate reading grade level is assessed via the Fry formula, calculated by plotting the average number of sentences and syllables from 3, 100-word passages contained in the handout (15). The total suitability score (expressed as a percentage) for each material is then calculated and a corresponding overall rating is given (15). Of note, 3 SAM factors (reading grade level, match in cultural logic, language and experience; and cultural image and examples) are considered by its authors to be “goeno/go” factors (15). If any one is found to be unsuitable, a written material is considered to have an overall rating of Not Suitable irrespective of the ratings it obtains in the other 19 factors (15). Once suitably designed, user opinion and comprehension level of the written material should then be assessed through pilot testing among a sample of the material’s intended audience (17).
How Do Current Written GI Education Materials Fare? Suitability
Assessment of Written Materials Various tools have been developed to formally evaluate the appropriateness of written education materials. These tools range from simple text readability formulas, which determine how easy or difficult a given material is to read (15), to more comprehensive evaluations such as those developed by Doak et al. (15) and Hill-Briggs et al. (16). These comprehensive tools assess the * Address for correspondence: Thomas M.S. Wolever, Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Fitzgerald Building, 150 College Street, Room 427, Toronto, Ontario, Canada M5S 3E2. E-mail address: [email protected] (T.M.S. Wolever). 1499-2671/$ e see front matter Ó 2012 Canadian Diabetes Association doi:10.1016/j.jcjd.2012.05.002
Using SAM, 5 free-of-charge GI education materials were formally evaluated for suitability as effective client education tools. These included those produced by Diabetes Australia (18), The British Dietetic Association (BDA) (19), the Baker IDI Heart and Diabetes Institute (20), the Canadian Sugar Institute (21) and The Canadian Diabetes Association (CDA) (22). Table 1 lists the primary focus of each material. Using the operational criteria for scoring defined by the authors of the SAM, one of us (KMS) assessed the materials against all 22 factors. Table 2 shows the individual SAM factor and total ratings for all materials assessed. The Baker IDI and Canadian Sugar Institute education materials had the highest and lowest overall scores respectively. Three of the 5 materials were
K.M. Southgate, T.M.S. Wolever / Can J Diabetes 36 (2012) 54e57
found to have a SAM rating of Adequate with 2 of the materials being assessed as Not Suitable. However, when considering the goeno/go factors, 4 of the materials were found to have a Fry reading grade level of 9 or higher and thus, were given a final rating of Not Suitable. The majority of materials were assessed as Not Suitable in 5 of the SAM factors: having a clear purpose; including behaviour related content; including a summary or review; being an appropriate reading level; and using relevant illustrations. These results indicate that the suitability of written GI client education materials can be improved. Most of the materials assessed lacked an explicitly stated purpose in their title or introduction, and all were lacking concluding summaries. Also, much of the materials were heavily fact-based, with inadequate information provided on specific, desirable dietary GI behaviours and interactive learning stimulation. The Diabetes Australia and Baker IDI written materials provide specific recommendations for the incorporation of low GI foods into one’s diet. Both advise readers to include 1 low or lower GI food at each meal and/or snack time per day (18,20). The remaining written education materials offer only abstract behavioural advice to “choose medium and low GI foods more often” (22), or that “a diet based mainly on low GI foods may improve insulin sensitivity” (19). Furthermore, only the CDA material provides individuals with interactive stimulation in the form of an area to write down their intended changes. Consistent with previous literature examining the readability of printed sources of diet and health information (23), the reading level for 4 of 5 materials was at a 9th grade level or higher. This is much higher than the 5th grade level found comprehensible by most individuals (24). Poor graphic utilization was displayed among all of the materials. Although research has shown that, when included, proper use of illustrations can provide significant benefits in client attention, comprehension, recall and adherence (25), none of the materials assessed displayed relevant illustrations. Graphics should present key messages visually with no distracting features, through simple, adult-appropriate line drawings familiar to the intended audience (15). For example, Table 1 notes that the primary focus of the CDA written material is how to incorporate lower GI foods into one’s diet. Therefore, instead of the current broccoli graphic used, a more useful illustration might be a simple line drawing of a person adding a lower GI option to their lunch or dinner plate. Pilot testing No published pilot testing involving the materials assessed here could be found during a Scopus literature search. Although not directly examining the tool itself, in 2009 the written education material developed by the CDA was used during the low GI education component of a study involving the First Step, First Bite Program (26). Results indicate a positive significant behavioural change for participants in the low GI group, who significantly increased their daily consumption of low GI foods from baseline to follow-up at 16 weeks by 2 servings (baseline ¼ 50.6, followup ¼ 70.8, p ¼ 0.01) (26). However, as subjects in this study were also exposed to a low GI presentation, sample meal plans, and recipes and snacks incorporating low GI foods, it is impossible to determine the effects that the CDA written material alone may have had on the positive behaviour change observed. Conclusions When provided alone, client recall of verbal health information is poor (27,28). However, providing verbal and written education together has been found to improve knowledge and behaviour change (27). When incorporated into client education practices, written education materials offer a host of additional benefits
55
Table 1 The primary focus of each written education material Written education material
Professional association
Primary focus of the material
Talking diabetes No. 17: the Glycemic Index: http:// www.australiandiabetes council.com/Resources/ PDFs/NDSS-InformationSheets/GLYCEMIC-INDEX2010.aspx Food Facts: Glycemic Indexdis it just hype?: http://www.bda.uk.com/ foodfacts/GIDiet.pdf
Diabetes Australia
-How using the GI can help in diabetes -How to incorporate lower GI foods into one’s diet
BDA
Carbohydrates and Glycemic Index (GI): http:// www.bakeridi.edu.au/ Assets/Files/CHO%20 &%20GI%20(2011)[1].pdf Clips on Sugars: understanding the Glycemic Index: http:// www.sugar.ca/english/ pdf/healthprofessionals/ Clip9.pdf The Glycemic Index: http:// www.diabetes.ca/files/ GlycemicIndex_ 09_Boehringer.pdf
Baker IDI
-How the GI may help with weight control and be an effective part of a weight loss plan -How to use the GI in one’s diet -The health benefits of lower GI foods -How to incorporate lower GI foods into one’s diet
Canadian SI
-General information on the GI such as the definition, why the GI was created, limitation of the GI and the GI of various foods
CDA
-How to incorporate lower GI foods into one’s diet
BDA, British Dietetic Association; BG, blood glucose; CDA, Canadian Diabetes Association; GI, Glycemic Index; SI, sugar institute.
including ease of portability for future reference (29); repetition and reinforcement of concepts (27); flexibility of information delivery (27,30); and accessibility of information to family and friends who may positively influence desired behavioural changes (27). Patients’ desire for written materials during healthcare education sessions has been reported (31,32), with a subsequent increase in satisfaction being found when written materials are supplied (32). Thus, dietitians frequently use written materials as an adjunct to dietary education. One study found that 87% of dietitians use 1 to 3 printed pieces per client with 97% “sometimes, almost always, or always” using free-of-charge materials (13). Those dietitians surveyed also reported a heavy reliance on health organizations, professional associations and commodity groups for the written materials used within their practices (13). With this in mind, use of written materials during client education sessions focused on the GI is arguably critical to the successful incorporation of this concept into an individual’s dietary behaviours. Yet despite the proven efficacy of the GI, dietitians continue to have conflicting views regarding its use in clinical practice. Often choosing not to incorporate the GI into client care, dietitians cite the lack of suitable teaching materials as a primary reason. These perceptions are supported here by the formal assessment of 5 freeof-charge GI education materials. Using the SAM, all of the handouts assessed were found to have a final suitability rating of Not Suitable. Thus, less than superior GI teaching materials may be negatively affecting health professionals’ perceptions regarding the use of the GI, and ultimately the frequency they choose to use this concept with their clients. In conclusion, although this assessment was based on a review by only 1 individual, the results suggest a need for the development of simple written GI education materials, proven to be both suitable by formal evaluation tools and effective through pilot testing. Raynor indicates that the success of written materials hinges on 3 factors: “1) how they are delivered to the client, 2) the design and layout, and 3) the content” (27). Both a comprehensive assessment of and revision to these components are vital in maximizing the
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K.M. Southgate, T.M.S. Wolever / Can J Diabetes 36 (2012) 54e57
Table 2 SAM ratings for all 5 free-of-charge glycemic index handouts assessed* SAM category and factor 1. Content Purpose is evident Content about behaviours Scope is limited Summary or review included 2. Literacy demand Fry reading grade level Writing style, active voice Vocabulary uses common words Context is given first Learning aids via “road signs” 3. Graphics Cover graphic shows purpose Type of graphics Relevance of illustrations List, tables, etc. explained Captions used for graphics 4. Layout and typography Layout factors Typography Subheadings used 5. Learning stimulation, motivation Interaction used Behaviors are modeled and specific Motivationdself-efficacy 6. Cultural appropriateness Match in logic, language, experience Cultural image and examples Total SAM scorey Percent scorey Ratingy Are any goeno/go factors considered unsuitable?z Final rating with suitability of goeno/go factors considered
Diabetes Australia
BDA
Baker IDI
Canadian SI
CDA
0 0 N/A 0
1 0 1 0
0 2 N/A 0
0 0 N/A 0
1 2 2 0
0 0 1 2 2
1 1 1 2 2
0 2 1 2 2
0 1 1 2 1
0 2 1 2 2
N/A 2 0 1 2
N/A 1 0 0 0
N/A 1 0 2 1
N/A 0 0 0 1
N/A 1 0 1 0
2 2 2
1 1 1
2 1 2
2 1 0
2 2 1
1 1 2
0 0 1
1 2 2
0 0 1
2 1 2
N/A 1 21 55.3 Adequate Yes Not suitable
N/A 1 15 37.5 Not suitable No Not suitable
N/A 1 24 65 Adequate Yes Not suitable
N/A 1 11 29 Not suitable Yes Not suitable
N/A 1 25 62.5 Adequate Yes Not suitable
BDA, British Dietetic Association; CDA, Canadian Diabetes Association; IDI, International Diabetes Institute; N/A, Nonapplicable; SAM, suitability assessment measure; SI, Sugar Institute. * Individual factor ratings are as follows; 2 ¼ Superior; 1 ¼ Adequate; 0 ¼ Not Suitable; N/A ¼ Not applicable. Interpretation is as follows; 0%e39% score ¼ Not Suitable; 40%e 69% score ¼ Adequate; 70%e100% score ¼ Superior. y Nonapplicable items were not figured into total scores, percent scores or overall material interpretation. z If any of the 3 goeno/go factors (reading grade level; match in cultural logic, language and experience; and cultural image and examples) are found to be unsuitable, the entire material is considered to have a final SAM suitability rating of Not Suitable, irrespective of the ratings obtained in the other 19 factors.
benefits that written materials have to offer. However, it has been reported that although 96% of the dietitians surveyed “almost always or always” previewed their materials before providing them to clients, 82% “never or almost never” performed this evaluation with a formal tool (13). A growing body of literature focused on practical advice for the incorporation of the GI into current dietary practices exists (2,33e35) and should be used in the development of such resources. When applied correctly, the GI can be an important tool for dietary empowerment and should no longer be overlooked as a component to comprehensive care. Author Disclosures There was no financial or material support for this work. Author Contributions KMS conceived and designed this study, including acquisition, analysis and interpretation of the data. KMS also drafted the manuscript, played a major part in the critical revision process and gave final approval of the version to be published. TMSW contributed to the conception and design of the manuscript, critically revised it and gave final approval of the version to be published. References 1. Wolever TMS. Historical introduction. In: Wolever TMS, editor. The Glycaemic Index: A Physiological Classification of Dietary Carbohydrate. Cambridge (MA): CABI North American Office; 2006. p. 10.
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