The internet and nutrition education: challenges and opportunities

Eight-month follow-up of physical activity and central adiposity: results from an Internet-delivered randomized control trial intervention

BACKGROUND

Less than half of U.S. adults engage in the recommended amount of physical activity (PA). Internet-delivered PA programs increase short-term PA but long-term adherence is largely equivocal.

PURPOSE

To determine whether increased PA following the 16-week Internet-delivered Active Living Every Day (ALED-I) program is maintained 8 months later in sedentary and overweight rural adults.

METHODS

In our previous randomized controlled trial (N = 32; 18 intent-to-treat controls, 14 ALED-I interventions), the ALED-I group increased PA (+1384 steps/day; E.S. = 0.95) and reduced central adiposity. Nine original intervention participants and ten delayed intent-to-treat control participants completed ALED-I and an 8-month followup. Pedometer-measured PA, anthropometric variables, and cardiometabolic disease risk factors were assessed at baseline, postintervention, and at 8 months.

RESULTS

Control crossover participants increased PA (+1337 steps/ day; P = .04). Eight months following completion of ALED-I (N = 19), PA levels relapsed (-1340 steps/day) and were similar to levels before the intervention (6850 +/- 471 steps/day vs. 6755 +/- 543 steps/day; P = .89). Total cholesterol and triglycerides improved, -9.9% and -18.2%, respectively, and reductions in central adiposity were maintained (97.1 +/- 2.2 cm vs. 97.2 +/- 2.2 cm; P = .66).

CONCLUSIONS

The ALED-I intervention was efficacious in the short-term but did not produce longer-term adherence to PA. Future theory-based internet-delivered interventions that produce habituation of increased PA are warranted.

Computer-tailored physical activity behavior change interventions targeting adults: a systematic review

BACKGROUND

Increasing physical activity is important in the promotion of better health. Computer-tailored behavior change programs have shown promise in changing lifestyle risk factors.

PURPOSE

To provide a narrative systematic review describing the range of evidence on 'second' and 'third' generation computer-tailored primary prevention interventions for physical activity, to determine their effectiveness and key characteristics of success. Unlike previous reviews, this review used specific criteria to measure the external validity of studies, was exclusive to primary prevention interventions in which tailoring was generated through an expert system, and excluded first generation computer-tailored interventions.

METHODS

Computer-tailored intervention studies published from January 1996-2008 were identified through a search of five databases: Medline; Embase; PsycINFO; CINAHL; and All EBM Reviews and by examining reference lists of relevant articles.

RESULTS

Seventeen articles were included, describing the evaluation of 16 interventions, ten of which found significant positive effects of the computer-tailored interventions on physical activity or weight reduction outcomes.

CONCLUSION

The evidence of effectiveness for computer-tailored physical activity interventions is inconclusive. They have potential to reach large groups of people however there is uncertainty whether reported effects are generalizable and sustained.

Use of the internet for health purposes: trends in Norway 2000-2010

AIM

The aim of this work is to study the 10 year trends in the use and projected use of internet for health purposes in Norway. This includes more detailed analyses of changes in latter years, current uses, valuation as source of health information, reported effects and projected developments.

METHOD

Surveys on the use of the internet for health purposes have been conducted in Norway in the years 2000, 2001, 2003, 2005 and 2007. Representative samples were drawn from the population, and interviews were conducted by poll agencies using telephone (CATI).

RESULTS

Internet use for health purposes in the Norwegian population has increased dramatically over the last 7 years from 19% in 2000 to 67% in 2007. If this trend continues, we estimate that 84% of the Norwegian population will be using internet for health purposes by the year 2010. Reading about health or illness is the most common activity, and the rated importance of the internet as a source of health information is increasing. The internet is also used more for ordering medicines and other health-related products. Forty-four per cent of those having used the internet for health purposes reported having searched for lifestyle-related information, and 40% reported having felt inspired to change health behaviour.

CONCLUSIONS

The internet is an important source of health information, which is likely to increase in importance in the years to come. This study further underlines the potential of internet use for health promoting purposes, as well as the potential for exacerbating social disparities in health.

About evidence based and beyond: a discourse-analytic study of stakeholders' talk on involvement in the early development of personalized nutrition

This paper draws on discourse analysis to examine how Dutch stakeholders in health education, health care, health insurance, social science, the food industry and the media make sense of innovations in the field of 'personalized nutrition' and their own role and significance in an early stage of technology development. Previous research has focused on factors that help or hinder collaboration between stakeholders, and on the development, management and implementation of joint programs. However, no attention has been paid to how stakeholders themselves handle issues of responsibility and initiative in relation to early technology development and collaborative interactions. The present study shows how such stakeholders establish themselves as gatekeepers of innovation by displaying authority on what consumers 'want' and 'cannot do', while avoiding a proactive role. Uncertainty in scientific knowledge, fixed roles and responsibilities and dependency on incompetent or biased others are drawn upon to account for a wait-and-see policy.

Design and evaluation of a computer game to promote a healthy diet for young adults

This article reports the development and evaluation of a computer game (RightWay Café) as a special medium to promote a healthy diet for young adults. Structural features of computer games, such as interactive tailoring, role playing, the element of fun, and narrative, were operationalized in the RightWay Café game to afford behavior rehearsal in a safe and entertaining way. Theories such as the health belief model, social cognitive theory, and theory of reasoned action guided the content design of the game to influence mediators of behavior change, including self-efficacy, perceived benefits, perceived barriers, and behavior change intention. A randomized controlled evaluation study with pretest, posttest, and follow-up design demonstrated that this game was effective in teaching nutrition and weight management knowledge and increasing people's self-efficacy and perceived benefits of healthy eating, as well as their intention to be on a healthy diet. Limited long-term effects were also found: participants in the game-playing group had greater self-efficacy than participants in the control group after 1 month. This study validates the computer game-based approach to health promotion for young adults. Limitations and implications are also discussed.

Diet and nutrition advice from the Cochrane Library: is it useful for the consumers and family physicians?

BACKGROUND

The role of nutrition in public health is well established. This raises the need for reliable and up to date evidence and its ready accessibility for health professionals and consumers.

OBJECTIVES

The principal objectives are to evaluate whether nutrition-related Cochrane Systematic Reviews contain clear guidance on nutritional aspects that may be applicable to individual patient care.

METHODS

We screened and searched the Cochrane reviews of Issue 3, 2007 of the Cochrane Library. The abstracts were assessed to identify nutrition-relevant reviews which are applicable in the consulting room. All irrelevant studies were excluded and a questionnaire was filled in for each review by the consumers and a Nutrition specialist.

RESULTS

The screening and search of the Cochrane Library Issue 3, 2007 retrieved overall 270 reviews. After excluding the irrelevant results, from the remaining reviews, 17 reviews were about the nutrition and feeding of infants, 44 of the reviews were on diet and nutrition and 78 on nutritional supplementations. From the 38 reviews on nutrition, seven did not have clear translation for the consulting room.

CONCLUSIONS

Our study provided an overview of the number of Cochrane reviews on diet and nutrition in Issue 3, 2003 of the Cochrane Library and highlighted the need for more clear and understandable evidence-based information in the field of nutrition.

Desenvolvimento e aplicação de um questionário semiquantitativo de freqüência alimentar on-line para estimar a ingestão de cálcio e ferro

OBJETIVO: Desenvolver um questionário semiquantitativo de freqüência alimentar on-line para a avaliação de ingestão de cálcio (Ca) e de ferro (Fe). METODOLOGIA: O site de acesso à pesquisa foi o jornal eletrônico Folha Online. Trinta internautas, de ambos os sexos, residentes no estado de São Paulo, com idades de 21 a 45 anos foram selecionados. Informações obtidas de Registros Alimentares de 4 dias em dois meses consecutivos foram comparadas com as do questionário semiquantitativo de freqüência alimentar preenchido pelos participantes no terceiro mês. Para a análise estatística foram calculados coeficientes de correlação de Pearson. Os dados dietéticos foram ajustados pela energia e pela variância. RESULTADOS: O coeficiente de correlação entre os resultados obtidos por meio dos dois métodos, após o ajuste pela energia e da correção pela variância, foi de 0,52 para Ca e r = -0,02 para Fe. CONCLUSÃO: Os resultados indicam que o QSFA on-line pode ser utilizado para avaliar médias de ingestão de Ca nesse grupo. No entanto, as condições (n, nível de ingestão) não foram adequadas para a avaliação da média de ingestão de Fe.

The efficacy of Web-based and print-delivered computer-tailored interventions to reduce fat intake: results of a randomized, controlled trial

OBJECTIVE

To test and compare the efficacy of interactive- and print-delivered computer-tailored nutrition education targeting saturated fat intake reduction.

DESIGN

A 3-group randomized, controlled trial (2003-2005) with posttests at 1 and 6 months post-intervention.

SETTING

Worksites and 2 neighborhoods in the urban area of Rotterdam.

PARTICIPANTS

A convenience sample of healthy Dutch adults (n = 442).

INTERVENTIONS

An interactive, computer-tailored intervention delivered on a CD-ROM (interactive-tailored condition); a print-delivered, computer-tailored intervention (print-tailored condition); and print-delivered, generic information.

MAIN OUTCOME MEASURES

Total and saturated fat intake (grams/day and percentage-energy) and energy intake per day assessed with validated food frequency questionnaires at 1 and 6 months post-intervention.

ANALYSIS

Multilevel linear regression analyses.

RESULTS

Mean total fat, saturated fat, and energy intakes were significantly lower in both tailored conditions compared to the generic condition at 1-month follow-up. These differences were still significant for the print-tailored condition at 6-months follow-up. Effects were most pronounced among participants with unfavorable fat intakes at baseline. There were no significant differences between the 2 tailoring conditions.

CONCLUSIONS AND IMPLICATIONS

The results indicate that interactive and print-delivered computer-tailored interventions can have similar short-term effects on fat intake and that the effects of the print-delivered tailored feedback are maintained in the longer term.

Comparison of use and appreciation of a print-delivered versus CD-ROM-delivered, computer-tailored intervention targeting saturated fat intake: randomized controlled trial

Background

Computer-tailored health education, a promising health education technique, is increasingly being delivered interactively, for example, over the Internet. It has been suggested that there may be differences in use and appreciation between print and interactive delivery of computer-tailored interventions, which may influence information processing. This may especially be the case for women, older people, and people of lower socioeconomic status. Knowledge about differences in use and appreciation could help in choosing the appropriate delivery mode for a particular target audience.

Objective

The study investigates a content-identical, computer-tailored intervention addressing saturated fat intake delivered via print or CD-ROM. We analyzed consumer use and appreciation of the feedback information and explored whether possible differences exist among gender, age, and education subgroups.

Methods

Healthy Dutch adults (18-65 years), none of whom were under treatment for hypercholesterolemia, were randomly allocated to receive a computer-tailored program on CD-ROM (n = 151) or in print (n = 141). At baseline, data were collected on gender, age, and education level. One month post-intervention, data were collected on the use (feedback information read, saved, discussed) and appreciation (trustworthiness, perceived individualization, perceived personal relevance, and user-friendliness) of the feedback. Statistical analyses on the use and appreciation items were performed using chi-square tests and independent-samples t tests.

Results

After exclusion of individuals with missing values, a total of 257 and 240 respondents were included in the analyses of the use outcomes of feedback read and saved, respectively. The results indicate that among the total population, the print feedback was read more often than the CD-ROM feedback (95% vs 81%; P = .001) and saved more often than the CD-ROM feedback (97% vs 77%; P < .001). Similar results were found among the gender, age, and education subgroups. After exclusion of individuals who did not read the information and those with missing values, a total of 208-223 respondents were included in the analyses of the use outcome of feedback discussed and the appreciation items. The personal relevance of the print feedback was rated higher than for the CD-ROM-delivered feedback (0.97 vs 0.68; P = .04), but the effect size was small (0.28). These differences in personal relevance were also seen among women (1.06 vs 0.67; P = .04) and respondents aged 35-49 years (1.00 vs 0.58; P = .03), with moderate effect sizes (0.38 and 0.44, respectively).

Conclusions

Despite the possible advantages of interactive feedback, the present study indicates that interactive-delivered feedback was used less and perceived as less personally relevant compared to the print-delivered feedback. These differences in use and appreciation of delivery modes should be taken into consideration when selecting a delivery mode for a specific subgroup in order to optimize exposure.

Trial Registration

ISRCTN 01557410; http://www.webcitation.org/5XMylWleH

An exploration of factors related to dissemination of and exposure to internet-delivered behavior change interventions aimed at adults: a Delphi study approach

Background

The Internet is an attractive medium for delivering individualized, computer-tailored behavior change interventions to large numbers of people. However, the actual numbers of people reached seem to fall behind the high expectations. Insight into factors that determine use of and exposure to these Internet interventions is important to be able to increase the reach and improve exposure.

Objective

The aim was to identify potentially important factors that determine whether adults visit an Internet-delivered behavior change intervention, extend their visit, and revisit the intervention.

Methods

A systematic, three-round Delphi study was conducted among national and international experts from Internet intervention research and practice, e-marketing/e-commerce, Web design, and technical website development. In the first round, 30 experts completed a structured, open-ended online questionnaire assessing factors that were, in their opinion, important for a first visit, an extended visit, a revisit and for effective promotion strategies. Based on the responses in this first questionnaire, a closed-ended online questionnaire was developed for use in the second round. A total of 233 experts were invited to complete this questionnaire. Median and interquartile deviation (IQD) scores were computed to calculate agreement and consensus on the importance of the factors. The factors for which no consensus was obtained (IQD > 1) were included in the third-round questionnaire. Factors with a median score of six or higher and with an IQD ≤ 1 were considered to be important.

Results

Of the 62 experts invited for the first round, 30 completed the questionnaire (48% response rate); 93/233 experts completed the second-round questionnaire (40% response rate), and 59/88 completed the third round (67% response rate). Being motivated to visit an Internet intervention and perceiving the intervention as personally relevant appeared to be important factors related to a first visit. The provision of tailored feedback, relevant and reliable information, and an easy navigation structure were related to an extended visit. Provision of regular new content and the possibility to monitor personal progress toward behavior change were identified as important factors to encourage a revisit. Primarily traditional promotion strategies, like word-of-mouth by family and friends, a publicity campaign with simultaneous use of various mass media, and recommendation by health professionals, were indicated as effective ways to encourage adults to visit an Internet intervention.

Conclusions

This systematic study identified important factors related to the dissemination of and exposure to Internet interventions aimed at adults. In order to improve optimal use of and exposure to Internet interventions, potential users may need to be motivated to visit such an intervention and the information provided needs to be personally relevant. Furthermore, several (technical) aspects of the intervention itself need to be taken into account when developing Internet interventions.

Efficacy and use of an internet-delivered computer-tailored lifestyle intervention, targeting saturated fat intake, physical activity and smoking cessation: a randomized controlled trial

BACKGROUND

Although experts claim that computer-tailored interventions provided over the Internet have great potential to promote health behavior change, few studies have tested the efficacy of computer-tailored lifestyle interventions online-delivered over the Internet.

PURPOSE

To evaluate the short-term (1 month) efficacy of an Internet-delivered, computer-tailored lifestyle intervention targeting saturated fat intake, physical activity (PA), and smoking cessation, and to evaluate exposure to the intervention.

METHODS

A pretest-posttest randomized controlled trial with an intervention group and a no intervention waiting list control group was conducted. Self-reported behavior and determinants were assessed at baseline and 1 month follow-up. Exposure to the intervention was monitored through server registrations. The data were analyzed using multiple linear and logistic regression analysis.

RESULTS

The intervention resulted in a significantly lower self-reported saturated fat intake (b = -0.76, p < 0.01) and a higher likelihood of meeting the PA guidelines among respondents who were insufficiently active at baseline (OR = 1.34, 95%CI = 1.001-1.80). No significant intervention effects were found for self-reported smoking status. Of the participants, 81% actually visited the website.

CONCLUSIONS

The Internet-delivered, computer-tailored lifestyle intervention was effective in reducing self-reported saturated fat intake and in increasing self-reported PA among participants who completed the study.

Website-delivered physical activity interventions a review of the literature

BACKGROUND

Evidence-based physical activity interventions that can be delivered to large numbers of adults at an acceptable cost are a public health priority; website-delivered programs have this potential. The purpose of this study was to systematically review the research findings and outcomes of website-delivered physical activity interventions and to identify relationships of intervention attributes with behavioral outcomes.

METHODS

A structured search of PubMed, Medline, PsycInfo, and Web of Science was conducted for intervention studies published up to July 2006. Studies included in the review were those that (1) used websites or e-mail, (2) had physical activity behavior as an outcome measure, (3) had randomized controlled or quasi-experimental designs, (4) targeted adults, and (5) were published in English.

RESULTS

Of the fifteen studies reviewed, improvement in physical activity was reported in eight. Better outcomes were identified when interventions had more than five contacts with participants and when the time to follow-up was short (</=3 months; 60% positive outcomes), compared to medium-term (3-6 months, 50%) and long-term (>6 months, 40%) follow-up. There were no clear associations of outcomes with other intervention attributes.

CONCLUSIONS

A little over half of the controlled trials of website-delivered physical activity interventions have reported positive behavioral outcomes. However, intervention effects were short lived, and there was limited evidence of maintenance of physical activity changes. Research is needed to identify elements that can improve behavioral outcomes, the maintenance of change and the engagement and retention of participants; larger and more representative study samples are also needed.

Evaluation of an interactive computer-tailored nutrition intervention in a real-life setting

BACKGROUND

Studies testing Web-based computer-tailored education in real-life settings are now needed.

PURPOSE

The aim of this study is to examine the effectiveness and applicability of an interactive computer-tailored fat reduction intervention, which was previously tested as efficacious in a controlled setting, delivered to a broader population by local health promotion services. The impact of the computer-tailored intervention is compared with a generic intervention and with a no-intervention control group.

METHODS

A quasi-experimental design was used assigning 6 companies randomly to (a) the computer-tailored intervention condition, (b) the generic intervention condition, and (c) the no-intervention control condition. Participants (N = 337) completed validated baseline and posttest questionnaires and received the personal feedback immediately through the company's intranet. A structured interview with the project coordinators assessed the process that the companies had passed through to disseminate the fat intake intervention.

RESULTS

Six months postbaseline, the results showed that the computer-tailored intervention to reduce fat intake implemented through worksites was more effective in decreasing employees' fat intake compared with a generic intervention, F = 23.5, p < .001, or no intervention, F = 28.1, p < .001. Moreover, the dissemination strategy used is feasible for local health promotion services.

CONCLUSIONS

This study can be regarded as an effective "real-life" trial with an implementation strategy that can be used for large scale dissemination.

A systematic review of randomized trials on the effectiveness of computer-tailored education on physical activity and dietary behaviors

BACKGROUND

Although computer-tailored promotion of dietary change and physical activity has been identified as a promising intervention strategy, there is a need for a more systematic evaluation of the evidence.

PURPOSE

This study systematically reviews the scientific literature on computer-tailored physical activity and nutrition education.

METHODS

Intervention studies published from 1965 up to September 2004 were identified through a structured search in PubMed, PsycInfo, and Web of Science and an examination of reference lists of relevant publications. Studies were included that applied a pretest-posttest randomized-controlled trial design, were aimed at primary prevention among adults, used computer-tailored interventions to change physical activity and dietary behaviors, and were published in English. The search resulted in 30 publications-11 on physical activity behaviors and 26 on nutrition behaviors, some studies investigated multiple behaviors.

RESULTS

Three of 11 of the physical activity studies and 20 of 26 of the nutrition studies found significant effects of the tailored interventions. The evidence was most consistent for tailored interventions on fat reduction.

CONCLUSIONS

Overall, there seems to be potential for the application of computer tailoring for promoting healthy diets, but more research is needed to test computer-tailored interventions against other state-of-the-art intervention techniques and to identify the mechanisms underlying successful computer tailoring.