22 annotated bibliographies AMA style

Research Brief

Interactive Introductory Nutrition Course Focusing on Disease Prevention Increased Whole-Grain Consumption by College Students Eun-Jeong Ha, PhD; Natalie Caine-Bish, PhD, RD, LD

Family and Address fo Studies, Ke 2194; E-ma �2011 SO doi:10.1016

Journal of

ABSTRACT

Objective: To estimate current consumption of whole grains in college students and determine whether there would be an increase in whole-grain consumption after the students completed an interactive introductory nutrition course focusing on disease prevention. Methods: Eighty college students, 18–24 years old, participated in the study. Grain and whole-grain con- sumption, whole-grain food sources, and energy intake were measured before and after the nutrition course. Repeated-measures analysis of variance was performed. Results: After the study, whole-grain intake significantly increased from 0.37 ounces (oz) to 1.16 oz (P < .001), whereas total grain intake remained the same (3.07 oz). The number of whole-grain food sources increased from 7 to 11 food items after the intervention. Conclusions and Implications: A general nutrition course can be used as an avenue to increase whole- grain intake by college students. KeyWords: young adults, college students, class-based nutrition, whole grains, food habits (J Nutr Educ Behav. 2011;43:263-267.)

INTRODUCTION

The prevalence of diet-related chronic diseases has steadily increased over the past few decades. Research has revealed that a plant-based diet, spe- cifically the regular consumption of whole grains, aids in weight mainte- nance1,2 and reduces the risk of type 2 diabetes,3 heart disease,3,4 and certain cancers.5 The MyPyramid food guidance system recommends that at least half the dietary grain intake should comprise whole-grain products, that is, 3 ounces (oz) per day for a 2,000-kcal diet.6 The average intake of whole grains in American adults, however, is reported at less than 1 oz per day, with only 8% of Americans meeting the recommenda- tion.7

The college years are a period of significant change in the lifestyles of young adults. Food patterns estab-

Consumer Studies, Kent State Uni r correspondence: Eun-Jeong Ha, Ph nt State University, Kent, OH 442 il: [email protected] CIETY FOR NUTRITION EDUC /j.jneb.2010.02.008

Nutrition Education and Behav

lished during college are likely to be maintained for life and may have long-lasting influences on college stu- dents’ future health and that of their families.8 Previous research has demonstrated that college students consume only 0.7 servings per day, which is less than the recommended amount of whole-grain products.1 In spite of accumulating evidence dem- onstrating the physiological benefits of whole grains, nutrition interven- tion promoting whole-grain intake has been very limited among college students. The purpose of the present investigation was to estimate their current consumption of whole grains, identify their whole-grain food sour- ces, and determine whether whole- grain consumption would increase after completing an interactive intro- ductory nutrition course focusing on disease prevention in college students.

versity, Kent, OH D, 130 Nixson Hall, Family and Consumer 42; Phone: (330) 672-2701; Fax: (330) 672-

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DESCRIPTION OF THE INTERVENTION AND EVALUATION

A sample of 90 healthy college stu- dents (between 18 and 24 years old) participated in the study. This group was enrolled in an introductory, sophomore-level nutrition class at a university in the midwestern United States during spring 2006. Written in- formed consent was obtained from the students before they participated in the study. Procedures for this re- search were reviewed and approved by the Institutional Review Board at the university.

A pre- and posttest non-experi- mental design was used in this research. Data were collected during the first 2 weeks and the last week of spring semester. Body weight was measured in kg to the nearest 0.1 kg on an electronic scale in light clothing without shoes. Standing height was recorded without shoes on a portable stadiometer to the nearest 0.1 cm with mandible plane parallel to the floor. Each subject’s body mass index was calculated as weight (kg)/height (m2). A researcher with a degree in exercise science completed anthropo- metric measurements.

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A 3-day dietary record was col- lected to assess dietary intake. On the first day of class, participants were instructed to complete the 3- day dietary record on the typical 2 weekdays and 1 weekend day prior to the interview. To obtain typical die- tary intake information, participants were advised not to include holidays, exam days, or any day that included a special event, such as a birthday party or wedding reception. After completion of the 3-day dietary re- cord, each participant was scheduled for an individual interview with a pri- mary investigator to review the die- tary information provided in the food log. During the interview, a vari- ety of tools and techniques was used to increase the validity and reliability of the data. To estimate proper por- tion sizes, food models and standard measuring cups and spoons were used, and participants were also asked to bring their own household utensils and tableware to quantify actual intakes.

In addition, to increase the accu- racy of the dietary data, research asso- ciates visited local restaurants and campus cafeterias where the majority of participants ate to gain accurate in- formation about ingredients and por- tion sizes. When dietary intake information was insufficient and/or was not publicly available, food items were purchased for estimation of in- gredients or portion sizes. In addition, all food labels and the packaging for products that participants consumed during the data collection period were gathered. Grain and whole- grain intakes were categorized and quantified in ounces as defined by MyPyramid. Whole-grain products were defined as those with whole grains listed as the first ingredient on the food labels. Whole-grain status of each grain item was verified by its food label. Dietary analysis was per- formed by the primary investigator using NutriBase IV Clinical (version IV, CyberSoft, Inc., Phoenix, AZ, 2002).

A unique approach was adopted to allow participants to understand their current dietary practices. In tradi- tional introductory nutrition classes, students typically fill out and analyze their dietary records by themselves. In the current study, food logs were re- viewed and analyzed by the primary

investigator during the interview session. Each student sat down with the researcher and discussed his or her dietary intake with the researcher (ie, correct portion sizes, types of food consumed). The students also re- ceived the results of their completed analysis from the primary investiga- tor. Then the students were asked to bring their results to each class to compare their intake to Dietary Refer- ence Intake, dietary guidelines, and MyPyramid recommendations. To re- inforce dietary recommendations, the participants completed a personal assessment of their dietary logs at the conclusion of the semester by stating the strengths and weaknesses of their diet and any dietary changes that could be made.

The class met in 50-minute ses- sions 3 times a week. Lectures empha- sized the following: increasing consumption of fruit, vegetables, and whole-grain products; encouraging the consumption of low-fat dairy products; discouraging over-reliance on dietary supplements; and promot- ing active lifestyles. This study em- phasized the role of a healthful lifestyle by stressing dietary habits, ex- ercise, and disease screening in pre- venting chronic diseases instead of by emphasizing food choice modifica- tion as the only mechanism related to disease prevention. For example, to encourage whole-grain intake, the participants were asked to consider their risk for heart disease in a risk- assessment activity. In a subsequent lecture, the physiological benefits of whole grains were introduced to en- courage participants to increase over- all diet quality by including whole grains. Another lecture that involved food-label contents, ‘‘What’s in a food label other than calories?’’ was followed to help participants identify whole-grains products and possibly to result in an increase of actual intake of whole-grain products. A whole- grain tasting activity was then con- ducted to reduce students’ biases against the taste and texture of whole-grain products compared to refined-flour products, a major barrier to increasing whole-grain intake.7,9,10

Approximately 4 hours of total lecture time were spent on whole grains and related topics.

In the present study, traditional lectures were combined with interac-

tive feedback and ‘‘hands-on’’ activi- ties (Table 1) that incorporated concepts from the Social Cognitive Theory (SCT). The SCT is based on the interaction of environment (ie, factors that affect a person’s behav- ior), personal factors (cognitive, affec- tive, and biological events), and the behaviors that an individual per- forms.11 Many of the activities and class lectures in the current study were tied to SCT whereby the students used their own dietary behaviors and lifestyle choices as a framework to learn the course materials. For exam- ple, one of the class activities, ‘‘May I take your order?’’ was based on social constructs including behavioral capa- bility and environment. Another ac- tivity, ‘‘Happy Body Log,’’ reflected constructs from SCT such as self- control and expectation. Lectures were piloted for 3 semesters prior to delivery in the current program to de- termine whether they met the study objectives by assessing students’ suc- cess on projects, classroom activities, and exams.

SPSS (version 14.0, SPSS, Inc., Chi- cago, IL, 2005) was used for all analy- ses. Data were entered into SPSS, and the lead investigator randomly veri- fied data entry by checking accuracy between the data file and a hard copy. Means and standard deviations were calculated for all the variables analyzed. Repeated-measures analysis of varince was performed to deter- mine changes in grain, whole-grain product fiber, and energy intake with respect to sex. Significance was set a priori at P # .05.

FINDINGS

Among 90 students, 80 of them com- pleted the study. Exclusions included students older than 25 years of age and those with preexisting medical conditions limiting the intake of cer- tain foods (ie, celiac disease), illnesses affecting food intake during data col- lection period (ie, flu), or incomplete or unreliable data.

Because no significant differences in overall grain consumption were demonstrated between males and fe- males (P ¼ .48) at pre- and posttest measures, the data were pooled (ie, all participants included). On aver- age, both grain and whole-grain

Table 1. Examples of Class Activities and Demonstrations for a Basic Nutrition Course

Title of Activity Class Topic Lesson Plan Food label hunt: What’s on

a food label besides calories? Food label Students learn how to interpret information on food labels,

including the ingredient list. This activity provides important tips (ie, bread that comes in ‘‘brown bag’’ is not necessarily ‘‘whole-grain bread’’).

May I take your order? Carbohydrate and fiber Students pretend to go out for lunch and are asked to choose fiber-rich, low-fat food items from a provided menu. Answers are given in the order of fiber/fat contents.

Whole-grain product sampling MyPyramid Low-cost whole-grain products are introduced, and opinions are shared. Most students cite their negative bias against whole-grain products, believing their taste and texture to be poor and their cost high, but they change their attitudes after taste tests.

Let’s try something new: Best recipe contests

Why do we eat? MyPyramid, energy balance, vitamins, and minerals

For homework students try new food items, such as ethnic food, seafood, dry beans, calcium-rich and low-sodium food, and vegetables. Contests are held for the best recipes, and winners receive coupons/gift certificates for whole-grain products or whole-grain baguettes from local bakeries.

Dining out quizzes Energy balance Sample quiz: Which McDonald’s sandwich contains the fewest calories, a Chicken McGrill or a cheeseburger? Students usually choose Chicken McGrill over the cheeseburger, reflecting the popular assumption that chicken is a healthful choice.

Happy body log Fitness Students list good things that they do for their bodies in a daily log. The key to this activity is to start with small behavior changes, such as not eating while watching TV, reducing portions of single condiments, and choosing skim milk over 2% milk.

How much risk do I have? Lipid and calcium Students assess their risks for heart disease and osteoporosis by completing risk assessment forms. These activities help students realize that they are not free from chronic disease risks merely because they are young or currently disease free.

Be an advocate! Cancer and cardiovascular diseases

As a class assignment, students choose at least 3 people from their family/friends and teach them about the protective effects of healthful diet and prevention of chronic diseases. Experiences are shared with a group.

Journal of Nutrition Education and Behavior � Volume 43, Number 4, 2011 Ha and Caine-Bish 265

consumption was low at the begin- ning of the study. At baseline, total mean grain consumption was 3.07 oz, and mean whole-grain consump- tion was 0.37 oz. After the study, mean consumption of whole-grain products significantly increased to 1.16 oz (P < .001), but total mean grain intake remained same (3.06 oz). On average, only 12% of the total grain intake was whole grains at the pretest, well below the MyPyramid recommendation; however, by the conclusion of the study, whole-grain consumption increased to 38%. Only 49% of the class consumed some whole-grain products at the be- ginning of the semester, but at the end, 80% of the participants con- sumed whole-grain products. Only

1% of participants consumed the rec- ommended 3 oz of whole grains at pretest, whereas at the conclusion of the study, 13% of individuals con- sumed at least 3 oz of whole grains. Average fiber intake at baseline also increased significantly from 15.37 � 6.82 g to 18.37 � 7.88 g after the study (P ¼ .007), whereas total energy intake had decreased after the study period (P < .001). Body mass index at pretest was 26.3 � 5.63 kg/m2 and 25.93 � 5.91 kg/m2 at posttest, respectively (P ¼ .44). Participants’ characteristics and pre- and posttest means and standard deviations for dependent variables are presented in Table 2.

At the beginning of the interven- tion, 7 food items were identified as

sources of whole grains. The major sources of whole-grain consumption that were identified at baseline were granola bars (36%), ready-to-eat ce- reals (22%), yeast breads (18%), and hot cereals (12%), with minor whole-grain contributions from snacks (8%), bagels (2%), and cooked whole grains (1%). At posttest, major food sources for whole-grain con- sumption included yeast breads (39%), bagels (14%), granola bars (13%), and ready-to-eat cereals (11%), and cooked whole grains, snacks, and hot cereals made up 21% of total whole-grain intake. Pasta, popcorn, pancakes, and other cereals (ie, bulgur/barley) were new additions to whole-grain food sour- ces in this population.

Table 2. Participants’ Information and Pre- and Posttest Variables of Total Grain, Whole-grain, and Energy Intakes (n ¼ 80)

Pretest Posttest P Value Age, y (mean � SD) 20 � 1.4 . . Female (%) 88 . . White (%) 71 . . Energy, kcal (mean � SD) 2,270 � 763.7 1,764 � 551.4 < .001a Total grain, oz (mean � SD) 3.1 � 3.1 3.1 � 3.0 .97 Whole grain, oz (mean � SD) 0.4 � 0.6 1.2 � 1.0 < .001a Whole grain as percentage

of total grain (%) 12 38 .

aDemonstrates significant difference (P # .05).

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DISCUSSION

The average consumption of whole grains among college students partici- pating in this study was 0.37 oz, 10% of total grain intake, which is well be- low the MyPyramid recommenda- tions of 3 oz for a 2,000-calorie intake. By the conclusion of the study, whole-grain intake significantly in- creased to 38% of the total grain intake (1.16 oz). In addition, the total number of sources of whole-grain food at baseline was limited to 7 items, and the 2 major sources—gra- nola bars and ready-to-eat cereals— constituted 58% of total whole-grain intake. Intake of these 2 items with high-sugar content was reduced to 26% by the end of the program. After the study, whole-grain food sources expanded to 11 items, with yeast bread and bagels as the top choices. These findings suggest that course topics that focused on bal- anced, healthful eating may have helped the participants make health- conscious decisions concerning whole grains.

Several factors may explain the suc- cess of the procedures used in this study in helping participants increase their consumption of whole grains. First, lectures linking whole-grain intake and disease prevention may have increased awareness of the importance of whole-grain products as part of a healthful diet. Second, training in reading food ingredient lists may have helped students correctly identify whole-grain products. A body of evidence suggests that major barriers to increasing whole-grain intake in- clude a low awareness of whole-

grain products and their unique physiological benefits,12,13 consumer confusion,14,15 texture, and taste.7,9,10

In this study, participants often consumed products they believed to be whole-grain products but in actual- ity were not. For example, many indi- viduals recorded their consumption of ‘‘whole-wheat bread’’ in food logs, but food labels submitted along with the dietary record listed ‘‘enriched wheat flour’’ as the first ingredient. Many stu- dents also reported that they consid- ered ‘‘wheat bread’’ as a whole-grain product, particularly when it came in a brown bag. These findings suggest that whole-grain confusion may result from an inability to interpret food la- bels and a ‘‘marketing trend adding whole grain claims on labels although their products have more refined flour than whole grain.’’16 Finally, frequent class meetings (3 times a week), com- pared to traditional nutrition interven- tions, which meet only once a week, more frequently exposed participants to health messages.

A major strength of the present study is its focus on obtaining accurate dietary data using various methods. Although dietary assessment is subject to error, the current investigation used a 3-day dietary record to interview in- dividuals to help them correctly iden- tify whole-grain products and to estimate accurate portion sizes by us- ing various tools, such as food labels, food packages, and household uten- sils; interviewing managers of local restaurants and the campus cafeteria; and purchasing food items actually consumed by the participants. In addi- tion, previous researchers considered ‘‘wheat bread’’ a whole-grain bread,1

likely resulting in overestimation of whole-grain intake. This finding helps to explain the lower baseline intake re- ported in this study compared to that in the previous research, which adop- ted self-reported whole-grain intake either through a food frequency ques- tionnaire or dietary record, without verification specific to whole-grain items.17

This study was limited, first, be- cause of the use of a convenience sample and self-reported dietary log. Second, a control group was not cre- ated. Furthermore, in this study, whole grains were considered only when whole grain was listed as the first ingredient in the food label. Therefore, overall whole-grain consumption may have been underestimated by ignoring food items containing smaller amounts of whole grains. Finally, follow-up assessments were not made to determine whether changes in whole-grain consumption were sus- tained. Future studies are recommen- ded to investigate long-term effects of nutrition intervention on college students’ dietary behavior.

IMPLICATIONS FOR RESEARCH AND PRACTICE

The present study showed that an in- teractive introductory nutrition class can be an effective tool in increasing whole-grain intake by college stu- dents. General nutrition knowledge focused on the role of a healthful diet for prevention of disease, and in- teractive activities may be an effective way to modify eating habits in this population. These approaches require minimal manpower and financial re- sources. Based on the results of this study, an introductory nutrition class may serve as a cost-effective means of providing nutrition education to students on campus.

REFERENCES

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2. Koh-Banerjee P, Franz M, Sampson L, Liu S, et al. Whole grain and weight

Journal of Nutrition Education and Behavior � Volume 43, Number 4, 2011 Ha and Caine-Bish 267

maintenance: Changes in whole grain, bran, and cereal fiber consumption in relation to 8-y weight gain among men. Am J Clin Nutr. 2004;80:1237- 1245.

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13. Adams JF, Engstrom A. Helping con- sumers achieve recommended intakes of whole grain foods. J Am Coll Nutr. 2000;19(suppl 3): 339S–344S.

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16. Look for ‘‘The Whole (Grain) Truth’’ in Nutrition Action Health- letter. Center for Science in the Pub- lic Interest Web site. http://cspinet. org/new/200604261.html. Published April 26, 2006. Accessed June 13, 2010.

17. Harnack L, Walters SH, Jacobs DR. Dietary intake and food sources of whole grains among US children and adolescents: data from the 1994–1996 continuing survey of food intakes by individuals. J Am Diet Assoc. 2003;103:1015-1019.