author: erickson, amy m an evaluation of beneficial bites ... · 2 erickson, amy m. an evaluation...

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Author: Erickson, Amy M

Title: An Evaluation of Beneficial Bites: A Nutrition Education Program for

Older Adults

The accompanying research report is submitted to the University of Wisconsin-Stout, Graduate School in partial

completion of the requirements for the

Graduate Degree/ Major: MS Food & Nutritional Sciences

Research Adviser: Dr. Kerry Peterson, RD

Submission Term/Year: August, 2012

Number of Pages: 73

Style Manual Used: American Psychological Association, 6th

edition

I understand that this research report must be officially approved by the Graduate School and

that an electronic copy of the approved version will be made available through the University

Library website

I attest that the research report is my original work (that any copyrightable materials have been

used with the permission of the original authors), and as such, it is automatically protected by the

laws, rules, and regulations of the U.S. Copyright Office.

My research adviser has approved the content and quality of this paper.

STUDENT:

Amy M. Erickson DATE: 7/27/2012

ADVISER: (Committee Chair if MS Plan A or EdS Thesis or Field Project/Problem):

Kerry D. Peterson, PhD, RD DATE: 7/27/2012

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This section for MS Plan A Thesis or EdS Thesis/Field Project papers only

Committee members (other than your adviser who is listed in the section above)

1. CMTE MEMBER’S NAME: Carol Seaborn, PhD, RD DATE: 7/27/2012

2. CMTE MEMBER’S NAME: Elizabeth Levaro, PhD DATE: 7/27/2012

3. CMTE MEMBER’S NAME: DATE:

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This section to be completed by the Graduate School This final research report has been approved by the Graduate School.

Director, Office of Graduate Studies: DATE:

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Erickson, Amy M. An Evaluation of Beneficial Bites: A Nutrition Education Program for

Older Adults

Abstract

The purpose of this study was to determine the effectiveness of Beneficial Bites, a

comprehensive nutrition education program for older adults in Barron County, Wisconsin. A

survey was administered to 63 male and female attendees of the February Beneficial Bites

presentation and data were analyzed for changes in learning about and attitudes toward food and

healthy eating as related to program participation rates and relevant sociodemographic variables.

Participants ranged in age from 47 to 93 years, were predominantly White, female, retired,

married, and high school educated. Findings in support of program effectiveness were as

follows: 1) significantly more females than males reported increased confidence in healthy

cooking, confidence in making dietary changes, and motivation to make dietary changes; 2)

approximately two-thirds of participants reported increases in learning and positive attitudes

regardless of the number of presentations attended; 3) approximately three-fourths or more of

those attending five or more Beneficial Bites presentations reported increases in all learning and

attitude parameters; and 4) positive comments about the presentations, presenters, and program

content and design outweighed any other suggestion for improvement. Based on these findings,

Beneficial Bites was effective in enhancing participants’ nutrition knowledge and promoting

positive attitudes toward food and healthy eating.

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The Graduate School

University of Wisconsin Stout

Menomonie, WI

Acknowledgments

First and foremost, I would like to thank my committee chair, Dr. Kerry Peterson, for her

dedication, guidance, encouragement, expertise, and patience throughout this process. Much

gratitude is also owed to my graduate program advisor and committee member, Dr. Carol

Seaborn, for her continued support, extraordinary commitment, and guidance throughout this and

my entire graduate experience. I would also like to thank Dr. Elizabeth Levaro, for graciously

lending her knowledge and experience. To all of my committee members, I extend my profound

appreciation for the time you dedicated on my behalf.

I also want to thank two people without whom this would not have been possible—Leslie

Fijalkiewicz, Nutrition Program Manager at the Barron County Government Center, and Susan

Greene of UW-Stout. To Leslie, thank you for your guidance, expertise, input, and enthusiasm.

To Susan, thank you for all of your help with my data analysis and interpretation—I could not

have done this without you!

Words cannot express how grateful I am to my parents. To my dad, your support has

meant the world to me. To my mom, thank you for listening, and for simply being the person

that you are—selfless, caring beyond compare, and resilient—your strength inspires me.

Without even realizing it, you teach me and everyone around you how to be a better person.

Last, but not least, I would like thank Nick for believing in me when I did not, for

building up my confidence when I was unsure, for reassuring me in times of stress, and for

pretending to be happy with takeout.

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Table of Contents

............................................................................................................................................. Page

Abstract ...................................................................................................................................... 2

Acknowledgements ..................................................................................................................... 3

List of Tables .............................................................................................................................. 6

Chapter I: Introduction ............................................................................................................... 7

Statement of the Problem ............................................................................................... 11

Purpose of the Study ...................................................................................................... 12

Assumptions of the Study .............................................................................................. 12

Definition of Terms ................................................................................................................... 13

Chapter II: Literature Review .................................................................................................... 15

Healthful Aging and Nutrition Education ....................................................................... 15

Perceptions of and Attitudes toward Nutrition................................................................ 16

Nutrition Education Evaluations .................................................................................... 19

Barriers .............................................................................................................. 20

Successful strategies .......................................................................................... 21

Chapter III: Methodology .......................................................................................................... 28

Subject Selection and Description .................................................................................. 28

Instrumentation.............................................................................................................. 28

Data Collection Procedures ............................................................................................ 30

Data analysis ...................................................................................................... 30

Limitations .................................................................................................................... 32

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Chapter IV: Results ................................................................................................................... 34

Characteristics of the Sample ......................................................................................... 34

Frequency of Beneficial Bites Attendance and Use of Information Provided .................. 38

Figure 1. Frequency distribution for the total number of presentations attended ............. 38

Relation of Program Participation and Changes in Learning and Attitudes Regarding

Food and Healthy Eating ....................................................................................... 39

Comparison of Learning and Attitudes for Limited and Frequent Attendees .................. 41

Changes in Learning and Attitudes across Gender, Marital Status, Educational

Attainment, and Income Level .............................................................................. 43

Barriers to Participation, Areas of Improvement, and Future Topics .............................. 48

Chapter V: Discussion ............................................................................................................... 50

Limitations .................................................................................................................... 50

Conclusions ................................................................................................................... 52

Recommendations ......................................................................................................... 58

References ................................................................................................................................ 61

Appendix A: Institutional Review Board Approval ................................................................... 65

Appendix B: Evaluation Tool .................................................................................................... 67

Appendix C: Informed Consent ................................................................................................. 72

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List of Tables

Table 1: Sociodemographic Characteristics of the Sample ............................................................ 37

Table 2: Proportions Reporting Changes in Learning and Attitudes as a Result of

Attending 5 or more Beneficial Bites Presentations............................................................ 40

Table 3: Frequency of Learning and Attitude Changes by Limited (8 Presentations or Fewer)

and Frequent Attendance ................................................................................................... 42

Table 4: Frequency of Learning and Attitude Changes by Limited (12 Presentations or Fewer)

and Frequent Attendance ................................................................................................... 43

Table 5: Frequency of Learning and Attitude Changes by Gender ................................................ 45

Table 6: Frequency of Learning and Attitude Changes by Marital Status ...................................... 46

Table 7: Frequency of Learning and Attitude Changes by Educational Attainment ....................... 47

Table 8: Frequency of Learning and Attitude Changes by Income Level ...................................... 48

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Chapter I: Introduction

Coinciding with the dramatic increase in the older adult population is the need for health

promotion and nutrition services for this unique group. As the baby boomers (those born

between 1946 and 1964) begin to turn 65, the number of older persons will continue to grow

significantly over the next couple decades, increasing from 40 million in 2010 to 72 million in

2030, representing nearly 20% of the total U.S. population (Federal Interagency of Aging-

Related Statistics, 2008; United States Census Bureau, 2012). This aging population constitutes

the greatest consumers of health care resources; thus the need for primary prevention strategies

involving nutrition interventions to address the anticipated corresponding increases in health care

expenditures cannot be overemphasized (Krondl, Coleman, & Lau, 2008).

The nutritional concerns for older adults are multifactorial and unique. In general, due to

a host of factors, the probability of experiencing poor nutrition status increases with age (Kamp,

Wellman, & Russell, 2010; Kuczmarski & Weddle, 2005; Manilla, Keller, & Hedley, 2010).

Decreases in appetite and early onset of satiety can change eating patterns and frequency, which

in turn may decrease energy intake and lead to nutrient deficiencies, frailty, more frequent

hospital admissions and longer lengths of stays, increased falls and fractures, and increased

morbidity and mortality rates (Kamp et al., 2010). Declines in olfaction, taste sensitivity, and

chewing and swallowing ability are common and may contribute to reduced interest in cooking

and consuming a variety of foods (Kuczmarski & Weddle, 2005; Savoca et al., 2010). Similarly,

eating alone is a recognized risk factor for declining eating behaviors (McClelland, Bearon,

Fraser, Mustian, & Velazquez, 2001). Greater risk of malnutrition among older adults can be

attributed to all of the former as well as problems in the oral cavity causing food avoidance and

loss of functionality which affects 42% of people aged 65 years and older (Bandayrel & Wong,

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2011; Kamp et al., 2010). In particular, the effects of oral health problems have been related to

eating fewer fruits, vegetables, and nuts, causing lower intakes of many vitamins and minerals,

and to eating more foods high in cholesterol and sodium (Savoca et al. 2010). Loss of

functionality can also greatly impact the ability to do the physical tasks necessary for grocery

shopping and food preparation (Kamp et al., 2010).

Medications can have a profound effect on nutritional status, especially among older

adults who tend to suffer from more chronic medical conditions; as a result, medication use tends

to increase with advancing age. In a recent study examining polypharmacy and nutritional status

in older adults, Heuberger and Caudell (2011) found that increased medication use was

associated with decreased fiber intake and increased sodium, glucose, and cholesterol intakes.

Furthermore, declining physical health was associated with decreasing intake of major vitamins,

minerals, and electrolytes.

At the other end of the spectrum, obesity and overweight are also common, with obesity

affecting nearly 30% of older adults (Kamp et al., 2010). Convenient, single-serving foods

requiring minimal preparation are particularly attractive to this population but are notoriously

less nutrient-dense and higher in energy, often exacerbating preexisting conditions. Indeed, age-

related physical and metabolic changes necessitate certain dietary modifications (Sahyoun, Pratt,

& Anderson, 2004). While sarcopenia is known to cause problems for this population,

sarcopenia coupled with obesity can be even more severe, and both are associated with

immobility in addition to increasing age (Kuczmarski & Weddle, 2005).

Nutritional status is affected not only by the physiological changes associated with aging,

but by psychosocial issues and mental and cognitive changes as well. Potential effects of these

changes include undernutrition, overnutrition, and food insecurity (Kamp et al., 2010; Krondl,

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Coleman, & Lau, 2008). An often overlooked problem among the aging population is

depression, which can be caused by social isolation, loss of spouse, financial difficulties, loss of

autonomy, impaired cognition, or any combination of the former (Kamp et al., 2010). Such

constraints can also contribute to decreased interest in food and often precede the loss of

motivation to eat or to eat healthful foods.

An emerging body of evaluation literature suggests that nutrition interventions made at

later ages can improve health status and quality of life (Sahyoun et al., 2004). Although some

physiological age-related declines are unavoidable, nutritional issues can be addressed to help

promote healthful aging, including the ability to maintain low risk of disease and disease-related

disability, maintaining high mental and physical function, and promoting active engagement in

life (Krondl et al., 2008; Kuczmarski & Weddle, 2005, p. 616). Even later in life, optimal

nutrition can help with retaining independence, deterring long-term care, and improving overall

quality of life (Bandayrel & Wong, 2011). For example, supplementation of antioxidant

vitamins, certain minerals, and omega-3 fatty acids have been shown to reduce factors of

cognitive decline in the elderly, such as inflammation and the vascular disease marker

homocysteine (Williams & Kemper, 2010). In a review of nutrition education program

outcomes, Higgins and Barkley (2003) report that, while print materials and lectures can be

effective in increasing nutrition knowledge, a majority of research indicates that the use of a

combination of complementing nutrition education techniques furthers outcome improvements

such as attitudes, dietary practices, and physiologic factors.

Beneficial Bites is a nutrition education program that is composed of multiple

components. Implemented in January 2010, this community-based nutrition education program

was developed by the Registered Dietitian/Nutrition Program Manager at the Barron County

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Government Center, Wisconsin. The purpose of the program is to deliver relevant, practical,

research-based nutrition information emphasizing both why-to and how-to knowledge, all

without intimidation or reprimand (L. Fijalkiewicz, personal communication, June 6, 2012). By

featuring one functional or “powerhouse” food per month, the program emphasizes the value of

targeting small changes in the pursuit of long-term behavior change, with an ultimate goal of

increasing healthful dietary behaviors and promoting a greater understanding of the health

benefits that certain foods can provide. The featured functional foods are described by the

creator as those that provide health benefits above and beyond the usual vitamins, minerals,

protein, etc., and those with the power to prevent or improve health problems, as established by

the scientific literature and other reliable sources.

Although intended for older adults and catered to the older adult learner, the mission of

Beneficial Bites is to provide nutrition education to adults of all ages, reaching younger seniors,

as well as the broader aging community as well. Because funding for older adult nutrition

programs has not and will not keep pace with the aging population, it is an effort to promote

healthful aging and postpone the need for nutrition services later on in life among those nearing

older adulthood (L. Fijalkiewicz, personal communication, June 6, 2012).

A well-supported feature of the Beneficial Bites program is its comprehensive approach

to learning. This includes monthly nutrition education presentations involving a cooking

demonstration, food tasting, and user-friendly recipes adjusted for one or two servings, as well as

various forms of educational print materials—all focused on a functional food or specific

nutrition related topic. Each month, presentations are given by either the Nutrition Program

Manager (Registered Dietitian) or the head cook at each of five congregate meal sites or

community/senior centers in Wisconsin, including Barron, Cameron, Chetek, Cumberland, and

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Rice Lake; a bimonthly presentation is also given at the Almena Town Hall. The educational

print materials corresponding to the monthly presentations include table tents displayed at each

of the centers, take-home recipes provided at each presentation, puzzles or games, and flyers

packaged with Meals on Wheels for delivery to homebound seniors.

Advertising for the program and presentation dates, times, and locations appear every

month in the free Barron County Senior Review newspaper, along with a Beneficial Bites article

on the topic to be presented. Participation in Beneficial Bites is free, requires no prior

registration, and provides entry into a prize drawing at each presentation, with the added

incentive of an additional entry for bringing a new participant. Although a brief, 5-item survey is

handed out to participants periodically, no formal evaluation of the program has been completed.

Statement of the Problem

Nutrition education plays an important role in promoting healthful aging by empowering

and teaching older adults how to make healthier dietary choices, strategies for cooking and

grocery shopping for just one or two, and easy, user-friendly recipes. Furthermore, participation

in community-based nutrition education programs provides increased opportunities for valuable

social interaction. Beneficial Bites is a multifaceted, community-based nutrition education

program utilizing several well-supported strategies tailored to the unique learning needs of older

adults. In the two years since its inception, no formal evaluation has been implemented to assess

the effectiveness of the program. By evaluating changes in attitudes toward food and healthy

eating and the extent of learning that has occurred among participants the Beneficial Bites staff

can make modifications to the program to increase its effectiveness.

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Purpose of the Study

The purpose of this evaluation of the multi-component nutrition education program,

Beneficial Bites, was to determine the effectiveness of the program for enhancing participants’

knowledge of healthy eating and promoting positive attitudes toward food for better health. The

specific objectives were as follows:

1. Determine the relationship between learning about and attitudes toward food and

healthy eating and frequency of attendance at Beneficial Bites presentations

2. Compare the learning and attitude ratings between limited and frequent attendees

3. Examine the differences in learning and attitudes across gender, income level, marital

status, and educational attainment

4. Identify the prominent barriers to regular participation

5. Identify salient areas of improvement to the program

Assumptions of the Study

Several assumptions inherent to this research warrant comment. First, it was assumed

that the participants understood the survey and answered the questions truthfully. It was also

assumed that the survey respondents could reliably recall which Beneficial Bites presentations

they attended. In addition, certain survey questions aimed at measuring changes in attitudes

toward food and healthy eating were assumed to indicate changes in learning: namely, “My

confidence in healthy cooking has…”, “The belief that what I eat affects my health has…”, and

“My confidence in making changes to my diet has…” Correspondingly, it was also assumed that

nutrition knowledge and perceived benefits of dietary changes or healthy eating habits positively

influence food intake, though intake was not quantified in this research.

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Definition of Terms

The following terms are defined here for the purpose of a better understanding of their

intended meaning for this paper.

Aging adults. To include the full range of Beneficial Bites participants and to recognize

the intent of the program, aging adults will refer to those aged 45 to 64 years, also referred to as

“younger” seniors.

Congregate nutrition sites. Community/senior centers or similar venues that serve

meals to adults aged 60 and over as provided for by the national Congregate Meal Program

(McClelland et al., 2001).

Malnutrition. A condition that occurs when the body does not receive adequate amounts

of nutrients due to a variety of reasons, including but not limited to inadequate or unbalanced

diet, problems with digestion or absorption, and certain medical conditions; both undernutrition

and overnutrition are examples (Krahn, Lengyel, and Hawranik, 2011; Zieve & Eltz, 2011).

Older adults. Most of the literature, as well as the U.S. Census Bureau, define older

adults as those aged 65 and older.

Paraprofessional. An employee trained by a professional to extend the delivery of

education and health promotion (McClelland, Irving, Mitchell, Bearon, & Webber, 2002).

Process evaluation. Data collected during implementation to support improvement of the

program (Keller, Hedley, Hadley, Wong, & Vaderkooy, 2005).

Sarcopenia. “The age-related loss of skeletal muscle mass … most often associated with

underweight” (Kuczmarski & Weddle, 2005, p. 465).

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Successful/healthful aging. “The ability to maintain … low risk of disease and disease-

related disability, high mental and physical function, and active engagement of life” (Kuczmarski

& Weddle, 2005, p. 616; Rowe & Kahn, 1987).

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Chapter II: Literature Review

This chapter will begin with a discussion of nutrition for successful aging, the importance

of nutrition education for older adults, and the need to evaluate those interventions. Older

adults’ perceptions of nutrition education efforts, their attitudes toward food and healthy eating,

and potential barriers to learning and participation in such programs will also be examined.

Lastly, various nutrition intervention evaluations will be described, highlighting specific

nutrition education strategies that have shown promise for older adult populations.

Healthful Aging and Nutrition Education

Nutrition plays a role in every step of disease prevention, contributing to successful aging

(Kuczmarski & Weddle, 2005; Rowe & Kahn, 1987). In primary prevention strategies, nutrition

helps to promote health and functionality. In secondary and tertiary prevention, medical

nutrition therapy is an integral part of disease management to reduce chronic disease risk, deter

disease progression, and alleviate disease symptoms. Even towards the end of the life cycle, the

goal of nutrition is to make later years healthful, enjoyable, and productive by preventing or

effectively managing chronic diseases.

Particularly for older adults, nutritional status affects functionality, independence, and

quality of life (Kamp et al., 2010). The corresponding increases in nutritional risk that occur

with aging, illnesses and chronic diseases, physical, cognitive, and social challenges, racial and

ethnic differences, and low socioeconomic status, can further complicate a situation. For these

reasons, the beneficial effects of nutrition for health promotion, risk reduction, and disease

management warrant emphasis among older adults (Krahn et al., 2011). Appropriate food and

nutrition programs including nutrition education and intervention services, adequately-funded

food assistance and meal programs, screening, assessment, counseling, therapy, monitoring,

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evaluation, and outcomes documentation provide avenues to improve nutritional status and

ensure more healthful aging (Kamp et al., 2010). Additionally, reducing the number of risk

factors that can be avoided or modified through primary prevention and nutrition education

among middle-aged or “younger” older adults increases the probability of better health at more

advanced ages (Krondl et al., 2008).

An important component of successful aging is deterring age-related cognitive decline.

As mentioned in Chapter I, nutrition may play a role in this endeavor. In a randomized, double-

blind, placebo-controlled study by Wouters-Wesseling (2005), providing an enriched beverage

with moderate doses of all essential micronutrients to frail, elderly subjects for six months

produced significant increases in cognitive functioning, as measured by a word-learning test and

category fluency. Improvements in factors implicated in cognitive decline were also seen,

including an increase in plasma vitamin B12 concentration and a decrease in homocysteine

concentration. These data suggest that consuming foods rich in vitamins and minerals can

improve cognitive functioning even in the oldest old, providing greater impetus for designing

and promoting nutrition education for this population.

Perceptions of and Attitudes toward Nutrition

As with any intervention, it is of vital importance to assess the wants and needs of the

target audience. To explore the healthy eating perceptions of older adults in rural and northern

communities in Manitoba, Canada, Krahn et al. (2011) utilized a focus group approach. A

trained moderator conducted five focus groups of eight participants each, beginning with several

preplanned, open-ended questions posed to generate discussion for the purposes of establishing

the healthy eating perceptions of older adults and the factors influencing their food choices.

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Findings indicated discrepancies between abstract and concrete nutrition knowledge.

Although all respondents reported that healthy eating was important and seemed to have limited

understanding of what it entails, knowledge deficits were observed regarding label reading,

understanding and visualizing portion sizes, as well as vitamin D recommendations and sources

(Krahn et al., 2011). Despite reported rates of nutritional risk of up to 68.7%, the use of food

assistance programs was minimal due to lacks of availability, transportation, or knowledge of

their existence, or individual resistance. These results indicate that there are inconsistencies

between the healthy eating perceptions and actions of older adults among this sample,

highlighting a need for nutrition education programs. This study also corroborates contentions

that information about community-based meal and nutrition education programs needs to be

more effectively communicated.

A similar study by Patacca, Rosenbloom, Kicklighter, and Ball (2004) used focus groups

to determine older adults’ opinions and attitudes toward a nutrition education program and

identify potential improvements. In this study, the nutrition education program consisted of

three nutrition lesson plans based on the Food Guide Pyramid and how to meet protein and fiber

needs, as well as self-assessment of current eating habits, a goal-setting activity, food tasting,

take-home handouts, and a question and answer session. Pre- and post-tests assessed changes in

nutrition knowledge. Six months after completion of the nutrition education program, six 45-

minute focus groups addressed opinions toward nutrition education, reasons for participating,

outcomes following the program, and suggestions for future programs.

Findings demonstrated that the majority of participants expressed a desire to learn more

about nutrition, which led to their participation in the program (Patacca et al., 2004). All

participants indicated an intent to participate in nutrition education in the future and most

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reported wanting to participate because they found the lessons interesting and informative. A

majority reported a sustained change in their diet as a result of the nutrition education program,

with the most common changes including increased fruit and vegetable consumption and

decreased portion sizes.

Although the participants responded positively toward nutrition education, they tended to

view foods as “good” or “bad” and nutrition guidelines as “rules” or “orders” (Patacca et al.,

2004). This suggests that, in future nutrition education efforts for older adults, it may be

important to emphasize all foods can fit into a healthy diet in moderation. Despite these

connotations, most participants agreed that they would be more likely to set goals and follow

through with them if they were held accountable; in fact, the most common suggestion was to

include more goal-setting and subsequent monitoring as part of the nutrition education. Some

expressed that they would be more likely to make healthier choices if they knew a follow-up

session was ahead of them.

In a unique longitudinal study by Keller et al. (2006), a community-organized approach

was employed in the development of a nutrition education program for seniors. In this approach,

members of the target group were directly involved in the planning and delivery process to

ensure that activities and curriculum content met participant needs. Program activities included

monthly interactive food demonstrations or workshops, supplemented by a display board with

handouts and recipes, and a column in the center’s monthly newsletter. Other program

provisions included nutrition education resources for the center library and affordable fresh

produce at the center. Individual nutrition counseling, a cooking group for men, and a support

group for seniors with diabetes were added per participants’ requests.

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To determine the impact of the program as measured by the extent of behavior change,

follow-up surveys were compared to baseline survey results from 3 years prior to the

intervention (Keller et al., 2006). Of the 251 survey respondents, 64.5% reported some level of

participation in the program, and 51% reported frequent participation in two or more activities.

From baseline to follow-up, findings demonstrated a significant decline in risk of low fruit and

vegetable intake and improved frequency of eating. Food workshops positively influenced food

practices more so than print materials, and program participants reported healthier nutrition

attitudes and beliefs compared to nonparticipants. These findings illustrate the importance of

assessing the unique needs, interests, and characteristics of each target population and

incorporating them into the planning and design of nutrition education programs to make the

content more relevant.

Nutrition Education Evaluations

Nutrition education efforts are frequently evaluated in an effort to demonstrate that

interventions made at a later age can improve health status and quality of life among older adults

(Sahyoun et al., 2004). To improve knowledge and consumption of more nutrient-dense foods

among older adults, Ellis, Johnson, Fischer, and Hargrove (2005) conducted a nutrition education

intervention directed at behaviors related to whole grain foods among congregate meal recipients

in senior centers in north Georgia. Based on the health belief model, key concepts of the

conceptual framework included perceived susceptibility to health conditions associated with low

intake of whole grains, perceived severity of these conditions that are common among older

people, perceived benefits of decreasing disease risk, perceived barriers to consuming more

whole grains, cues to action, and self-efficacy. Participants completed a pretest questionnaire

which included whole grain food consumption patterns and barriers to consumption,

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anthropometrics, and other nutrition and health variables. Five lessons emphasized three main

messages: how to identify a whole grain food; whole grains protect against diseases; and “three

are key”—based on the MyPyramid recommendation to consume at least 3 ounces of whole

grains per day (Center for Nutrition Policy and Promotion, 2005).

Within three months after the last lesson, a post-test was administered to ascertain

knowledge and behavior changes related to whole grain foods (Ellis et al., 2005). Participants

demonstrated increased recognition of whole grain foods, increased intakes of whole grain bread,

whole grain cereal, and whole wheat crackers, as well as a stronger belief that whole grains

would reduce the risk of chronic disease. Additionally, barriers to increasing consumption were

more related to cost more so than taste or knowledge about the health benefits of whole grain

foods. Although the use recommended strategies was evident, particularly, the use of theory in

the framework of the intervention, notable limitations included self-reported outcome data,

limited information on potential barriers to whole grain food consumption, a primarily female,

Caucasian sample, and cognitive impairment among some participants.

Barriers. Just as nutritional status is subject to age-related effects, so are learning

characteristics. Besides the physical limitations experienced by older adults that may affect

learning, adult learning theory states that life-experience perceptions and social support can also

influence readiness and openness to changing behavior and motivation to learn new concepts

(Taylor-Davis et al., 2000). Using this theory Taylor-Davis et al. (2000) designed a nutrition

newsletter specifically for older adults and evaluated its effectiveness on cognitive, affective, and

behavioral domains. Two treatment groups received five biweekly nutrition newsletters. In

addition, one group received educator interaction by participating in structured process

evaluation interviews via telephone 10 to 14 days after newsletter distribution. A control group

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completed the pretest and posttest surveys to ascertain differences in learning from the newsletter

and from the combined newsletter and telephone interviews. The telephone interviews focused

on newsletter use patterns, preferences for certain sections or topics, and short-term knowledge

gain. Pre- and post-tests assessed nutrition knowledge, willingness to answer items on a

nutrition knowledge test, perceived nutrition knowledge, interest in nutrition, food behavior, and

stages of change for dietary fat and fiber intake.

As a result of the intervention, treatment groups showed significant improvement in both

cognitive measures, both affective measures, and two behavioral measures as compared to the

control group (Taylor-Davis et al., 2000). Both treatment groups exhibited greater nutrition

knowledge, more willingness to answer nutrition knowledge test items, and greater perceived

nutrition knowledge and interest in nutrition than the control group. Furthermore, the group

receiving follow-up phone calls scored significantly better than the group receiving only

newsletters on both cognitive variables and perceived nutrition knowledge. Treatment groups

also performed better than the control on readiness to change dietary fiber intake and stages of

change to avoid dietary fats. These findings provide further evidence that older adults are not

only receptive to and benefit from nutrition education but may also experience greater benefits

still when proximal follow-up strategies are employed.

Successful Strategies. Reviews of research have identified salient program strategies

for effective nutrition education programs for aging populations (Higgins & Barkley, 2004;

Sahyoun et al., 2004). These strategies include: limiting educational messages to one or two

practical topics; emphasizing “how to” information; using interactive formats; providing hands-

on activities, incentives, cues, and frequent access to health professionals; and building upon

appropriate theories of behavior change. These strategies showed the most success in terms of

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positive outcomes in nutrition knowledge. Notably, age was not a limiting factor in increasing

knowledge, suggesting the potential for beneficial effects of nutrition education even for the

oldest participants (Sahyoun et al., 2004).

Consistent with the Health Belief Model and increased chance of ill health among older

adults, interventions that targeted specific needs such as a health condition, provided nutrition

education to motivated persons, or addressed older adults’ unique health concerns were usually

more successful (Sahyoun et al., 2004). Other promising components consistent with those

identified in reviews by Bandayrel and Wong (2011) and Higgins and Barkley (2004) include

frequent collaboration between program participants and health professionals, individual

assessment of readiness to change, setting of achievable goals and a health plan, and the

promotion of self-efficacy. Additionally, a time frame of approximately 30 minutes for

educational sessions has been well-received in previous studies (McClelland et al., 2001).

Notably, goal-setting activities and corresponding follow-up activities that hold participants

accountable for knowledge gained and intentions to change may encourage initiation and long-

term maintenance of more healthful behaviors, as indicated in the study by Patacca et al. (2004).

Furthermore, using formative research in the initial phases of a nutrition intervention allows for

better matching of participants’ needs with the goals of the program and helps to identify

participants’ readiness to change (Sahyoun et al., 2004).

A study by Keller et al. (2005) examined the use of food workshops over a three-year

period in the Evergreen Action Nutrition Program as a useful method for providing cooking and

nutrition education for older adults. Workshops were highly interactive and involved a cooking

demonstration of a five-or-more-course menu, food tasting, and discussion of the food products,

their nutritional value, and preparation and storage techniques. Participants also received two

23

corresponding handouts—one with recipes and one with relevant nutrition and cooking

information. Two types of workshops following the aforementioned format were implemented:

single-session or stand-alone workshops and three-session series workshops following a central

theme. Process evaluation data were collected on each to determine the respective influences on

behavior change.

Several positive outcome measures were noted. A significant proportion of participants

reported an intention to change dietary behavior after attendance at a single-session workshop.

In the third year of programming, 81.5% of the participants were able to describe at least two

new things that they had learned (Keller et al., 2005). Participants of three-part series workshops

reported increased nutrition knowledge, interest in trying new foods, motivation to make dietary

changes, confidence in healthy cooking and making dietary changes, importance of healthy

eating, and increased belief that diet influences health.

Additionally, focus group data identified several program components as instrumental to

the success and empowerment of behavior change. These key components included: interactive

format, social experience, consistent high-quality education, and a small group size of less than

10 participants (Keller et al., 2005). Focus group participants also reported that the

demonstration and tasting helped to reinforce what they had learned by promoting use of the

recipes at home to ultimately change their eating behavior. Furthermore, the recipes provided

were thought to be essential to learning and relevant as they incorporated the new nutrition

information and supported concepts which included: sizing for one or two servings,

modifications for common health conditions such as diabetes and hypertension, consideration of

food cost and minimizing waste, and simplified food preparation techniques (Higgins & Barkley,

2004).

24

Another study examining the use of food tasting as a part of the larger Evergreen Action

Nutrition Program was that by Manilla et al. (2010). In an effort to promote continued interest in

food and enjoyment of eating, the purpose of this pilot study was to integrate a food-tasting

component into a nutrition education display designed for community-living older adults.

Monthly nutrition displays, which focused on practical and relevant nutrition information based

on previous feedback from senior center members and furnished recipes specific to the monthly

theme, provided the vehicle for the food-tastings. Once a month for three months during lunch at

the senior center, visitors who passed by the nutrition display were asked to sample two food

items, and those who sampled a food item were immediately asked to complete an anonymous

feedback form, for which they received a chance to win a meal at the senior center cafeteria.

Over three tasting events, 54 feedback forms were completed, representing 40% of those

who sampled the foods (Manilla et al., 2010). The number of copies of recipes taken differed

significantly for the two tasting foods at each display, suggesting that palatability or food

preference was an unavoidable factor despite preliminary recipe testing. Although 27.8%

reported that they might have made the recipe without tasting the food, 42.6% responded that

they would not have made these foods without tasting them. Among all respondents, 75.9%

indicated that they intended to prepare the sample food at home. These findings indicate that

including food tastings in nutrition education may increase the likelihood that participants will

prepare it themselves, which may in turn increase their interest in food and cooking, leading to

healthier eating behaviors and supporting autonomy. Tastings may also help to translate

nutrition messages into food behavior by promoting eating enjoyment as people age and

providing opportunities to try new foods and experiment with different flavors.

25

As nutrition educators, congregate nutrition site managers have the benefit of working

closely with the target population and being recognized as knowledgeable, caring, and willing to

help (McClelland et al., 2002). The use of such indigenous networks may prove advantageous in

nutrition education efforts involving the training of laypersons to extend the reach of health

promotion. Specifically, this established recognition may facilitate acceptance of trained

laypersons assuming an authoritative role in education by the constituency targeted for health

promotion. Based on this idea, a train-the-trainer approach, in which professionals train

paraprofessionals, may be useful in extending the reach of nutrition education programming.

To investigate this, four congregate nutrition site managers received 4 hours of training

over 2 days on an 8-week nutrition education module, “Meals on a Budget”, as well as record

keeping, survey administration, adult learning styles, and educational delivery methods

(McClelland et al., 2002). Pre- and post-tests were used to assess the level of confidence each

site manager attained in ability to teach the module. As a result of training, all site managers

reported positive changes in confidence and ability. Congregate nutrition site participants

indicated comfort with the site managers delivering the program and the majority reported high

levels of satisfaction with the nutrition information they received. Not only do these findings

suggest that trained laypersons can be effective in delivering health promotion, but also, that

nutrition program participants are receptive to education delivered by paraprofessionals.

However, this interpretation necessitates the consideration of several study limitations. As self-

report measures were subjective, focusing on participant satisfaction and comfort level, data

cannot be taken to reflect actual behavior change leading to improved nutritional status.

Correspondingly, while a rapport between educator and learner is important, relationships and

frequent contact may influence biased responses. Perhaps most importantly, observational

26

fidelity checks to determine whether the managers were implementing modules as intended were

limited to two out of eight occasions.

It is thought that congregate nutrition sites constitute an effective means of reaching older

adults and provide a convenient location for nutrition education programs (McClelland et al.,

2001). Traffic through these sites includes older adults who are likely to attend on a regular

basis, and follows a fairly predictable cycle providing some down time between arrival and

departure, usually before lunch is served. Also, the provision of meals is thought to create a

“ready audience” with a primed mindset of food and nutrition issues. Important considerations

to be made in planning the use of congregate nutrition sites as nutrition education venues include

background noise, interruptions, and other distractions.

The body of evidence describing meaningful changes in nutrition knowledge among

older adults as a result of interventions and education is growing. Optimal nutrition is integral to

successful aging and older adults have proven to be a more captive audience to this information

than previously thought. Ongoing evaluative research on nutrition education programs is needed

to further determine the most efficacious strategies for reaching this expanding population.

Therefore, the purpose of the present study was to determine the effectiveness of the

comprehensive nutrition education program, Beneficial Bites, in enhancing participants’

nutrition knowledge and promoting positive attitudes toward food and healthy eating. The

objectives were as follows: 1) to determine the relationship between learning and attitudes

regarding food and healthy eating and frequency of attendance at Beneficial Bites presentations;

2) to compare the learning and attitude ratings between limited and frequent attendees; 3) to

examine differences in learning and attitudes across gender, income level, marital status, and

27

educational attainment; 4) to identify the prominent barriers to regular participation; 5) to

describe salient areas of improvement to the program.

28

Chapter III: Methodology

This study was designed to determine the effectiveness of Beneficial Bites, a multi-

component nutrition education program, in enhancing older adults’ nutrition knowledge and

promoting positive attitudes toward food and healthy eating. In addition to assessing differences

in learning among participants, this study also sought to reveal prominent barriers to

participation, frequency of attendance at program presentations, general changes in eating

behaviors of previously unfamiliar targeted foods since participating, usefulness and interest in

the information presented, and areas of improvement. Prior to beginning, all procedures were

approved by the University of Wisconsin-Stout Institutional Review Board for the Protection of

Human Subjects (Appendix A).

Subject Selection and Description

Participants of this study included 63 attendees, aged 47 to 93, of the February Beneficial

Bites nutrition education presentation at each of five local community/senior centers in Barron

County, Wisconsin, including: Barron, Cameron, Chetek, Cumberland, and Rice Lake. To

ensure more accurate participation data, the only exclusion criterion was the incidence of short

term memory loss, or participation in the Adult Day Program at the Rice Lake Senior Center as

determined by the survey administrator/presenter for that location who was familiar with the

participants.

Instrumentation

The evaluation tool used in this study was a 13-item pen and paper survey (Appendix B),

developed by the researcher in collaboration with the Nutrition Program Manager/creator of

Beneficial Bites, and research adviser and committee member from UW-Stout. Intended to be

used for the purpose of this study only, questions were designed to gather data on Beneficial

29

Bites attendance, barriers to attendance, behavioral and attitudinal changes as a result of

participation, areas for improvement, and participant demographics.

Preliminary questions in the instrument determined the participant’s age and gender.

Additionally, to differentiate respondents who can actively use the presentation information and

those who attend but may rely on a caretaker for meals, questions regarding cooking and grocery

shopping responsibilities were included. To ascertain the number of presentations attended,

Question 1 included a list of the first two years of Beneficial Bites presentation topics to aid in

memory recall for respondents to indicate if they had attended. The second part of Question 1

was used to establish the prominent barriers to attendance. Respondents were asked to report, if

they had attended fewer than 5 presentations, what has prevented them from attending, and were

then asked to skip to Question 5.

Questions 2 through 4 were intended for those who had attended five or more Beneficial

Bites presentations. To determine the frequency of use of information and materials among this

sample, Question 2 asked about use of the featured recipes while Question 3 asked about

consumption and use of the featured foods/ingredients. Question 4 was modeled after an

evaluation study by Keller et al. (2005) that assessed changes in cooking/eating behavior as a

result of attending food workshops similar in design to the Beneficial Bites program. This

question contained 7 items to assess learning and attitudinal changes—such as knowledge of

nutrition and confidence and motivation to make dietary changes—which were recorded as

“increased”, “decreased”, or “not changed”.

Questions 5 and 6 were opened-ended questions aimed at collecting participant feedback.

All respondents were asked to provide their thoughts on how Beneficial Bites presentations

30

and/or attendance could be improved, as well as suggestions for topics or foods to be covered in

the future.

The remaining questions were modeled after a more detailed participant profile designed

to describe demographics for older adults (E. Levaro, personal communication, January 10,

2012). Relevant sociodemographic data including perceived health status, current employment

status, educational attainment, marital or partner status, living situation, and income were

gathered in Questions 7 through 13. A question regarding race or ethnicity was not included as

the vast majority (96.1%) of Barron County residents are Caucasian (United States Census

Bureau, 2012).

Data Collection Procedures

Survey procedures took place prior to the Beneficial Bites presentation at each location to

avoid missing potential participants due to early departure. Beginning with a short introduction

and explanation of the study, participants were familiarized with the purpose and procedures of

this research, as well as the hope to use the information gathered to improve the Beneficial Bites

program. Informed consent (Appendix C) was provided prior to survey administration and

participants were assured that involvement in the study was completely voluntary, that their

surveys would remain anonymous, and that they could withdraw at any time. Participants were

also encouraged to be as honest as possible in their answers, and to address any questions they

had along the way to the survey administrator.

Data analysis. A number of statistical analyses were used in this study to evaluate the

effectiveness of the Beneficial Bites program, as determined by differences in learning and

attitudes regarding food and healthy eating based on frequency of attendance at Beneficial Bites

presentations. The Statistical Program for Social Sciences (SPSS) version 17.0 was used to

31

analyze the data. A standard of p < 0.05 determined significance for all statistical analyses

conducted.

Frequencies were determined and reported for sociodemographic variables (age, gender,

health status, employment status, education level, marital status, household status, income level,

and income comfort level); cooking and grocery shopping responsibilities; presentations

attended; barriers to regular attendance at Beneficial Bites presentations; use of the featured

recipes and featured foods/ingredients; and changes in learning and attitudes as a result of

participating in Beneficial Bites. Similar written-in responses regarding barriers to participation,

areas of improvement, and future foods or topics were categorized and frequencies were used to

establish any patterns.

To determine if a relationship occurred between the number of presentations attended and

changes in learning and attitudes regarding food and healthy eating (increased, decreased, or no

change), Spearman’s Rho correlation was used for each of the following learning and attitude

measures: knowledge of nutrition, confidence in healthy cooking, personal value of healthy

eating, the belief that foods consumed affect health, confidence in making dietary changes, and

motivation to make dietary changes, as well as overall health compared to similarly aged

persons.

To determine differences in learning or attitudes among those who attended at least five

presentations, respondents were separated into low and high attendee groups. Low attendance

was defined in two ways: those who had attended eight or fewer of the monthly presentations in

two years, and those who had attended twelve or fewer presentations total. To obtain sufficient

observations for statistical analyses, the original rating scale for each learning and attitude

measure was collapsed into two categories: 1) increased and 2) decreased or no change.

32

Cross tabulation and Chi-square analyses were used to compare differences in the

frequencies of learning and attitude changes and overall health changes among participants who

had attended five or more presentations. Learning and attitude changes were compared for

limited and frequent attendees using Fisher’s Exact test, with limited attendance defined as eight

or fewer presentations and as twelve or fewer presentations, and frequent attendance defined as

nine or more presentations and as thirteen or more presentations.

To further determine differences in the frequency of learning and attitude changes, Cross

tabulation and Chi-square analyses with Fisher’s Exact test for statistical significance were also

conducted for each of the following sociodemographic variables: gender, marital status,

educational attainment, and income level. To obtain adequate observations, marital status,

educational attainment, and income level were each collapsed into two categories: married or

living with partner and widowed, divorced, separated, or single; high school diploma or less and

some vocational training or more; and $29,999 or less and $30,000 or more, respectively. The

same statistical analyses were attempted for income comfort level as well, however, the test

could not be performed due to a limited distribution of the data.

Limitations

The first limitation of this study was the lack of a pre/post design. In addition to the

process evaluation data presented, baseline nutrition knowledge, food frequency, and health

status data for each participant would have provided more concrete measures of the effectiveness

of the program and would have allowed absolute changes to be determined.

An additional limitation was the sampling procedure. The population for this study was

limited to participants of the Barron County Beneficial Bites presentations in February 2012. As

such, it is possible that some regular participants were unable to attend this particular month’s

33

presentation. Also, the total number of attendees was not recorded at every location, which

would have allowed the participation rate to be calculated.

The self-reported data collected by the survey was a limitation in several ways. As

alluded to in the aforementioned assumptions of this investigation, because the survey required

respondents to accurately recall which Beneficial Bites presentations they had attended,

inaccurate responses may have limited the data on survey items that depended on a certain

number of attended presentations, namely, the question regarding barriers to participation and

those aimed at measuring changes in learning and attitudes regarding food and healthy eating.

Furthermore, consistent with an inherent problem with survey methodologies, some respondents

failed to report answers to all questions for unknown reasons, limiting the data on some survey

items. Also, as surveys were administered prior to presentations to avoid missing early

departures, there may have been a perceived time constraint among respondents that prevented

them from contributing responses to open-ended questions.

An additional limitation was identified in the researcher’s instrument. Prior to Question

2, the survey instructed participants to skip to Question 5 if they had attended fewer than five

Beneficial Bites presentations, but to proceed to the following questions if they had attended

more than 5 presentations. The latter statement should have read, “If you have attended 5 or

more presentations,” to include those who had attended five presentations in the instructions to

answer the subsequent questions regarding use of the featured recipes and foods and changes in

learning and attitudes. Of the three participants who attended five presentations, only one

followed the errant survey instructions and skipped to Question 5; data collected from the other

two were included in the analyses of resulting behaviors and learning and attitudes changes of

those who had attended more than five presentations.

34

Chapter IV: Results

This chapter summarizes the results of the research study designed to evaluate the

effectiveness of Beneficial Bites, a comprehensive nutrition education program for aging and

older adults. Effectiveness of this program was determined by positive changes in learning and

attitudes regarding food and healthy eating. This research was completed to achieve the

following objectives: 1) determine the relationship between learning and attitudes regarding food

and healthy eating and frequency of attendance at Beneficial Bites presentations; 2) compare the

learning and attitude ratings between limited and frequent attendees; 3) examine differences in

learning and attitudes across gender, income level, marital status, and educational attainment; 4)

identify the prominent barriers to regular participation; and 5) describe salient areas of

improvement to the program.

This chapter presents the characteristics of the survey respondents. Findings on the

frequency of Beneficial Bites attendance, participant use of the featured foods and recipes, and

the relationship between program participation and changes in six measures of learning and

attitudes regarding food and healthy eating as well as perceived health status will be discussed.

Subsequently, analyses of changes in learning and attitudes and perceived health status in

relation to sociodemographic characteristics of the sample are examined. Lastly, the prominent

barriers to attendance are summarized, and suggestions for improvement and future foods and

topics are presented.

Characteristics of the Sample

Participants of this study included 63 attendees of the February Beneficial Bites nutrition

education presentation at each of five local community/senior centers in Barron, Cameron,

Chetek, Cumberland, and Rice Lake, of Barron County, Wisconsin. The majority (82.5%) were

35

female (n = 52) and 12.7% were male (n = 8), ranging in age from 47 to 93 years, with a mean

and median age of 74 and 75 years, respectively. The most common ages were 72 and 81 (n = 4

for each). Of the 63 survey respondents, three failed to report gender, another three failed to

report age, and one person responded with “60+”, which was removed from the age statistics.

Similarly throughout the survey, some participants failed to report answers for other

sociodemographic questions as well. However, because different sections of the survey were

sampled from to answer the research questions, all data were included in the following analyses,

regardless of survey completion.

Ten respondents failed to indicate whether they are the primary meal preparer and 14

failed to indicate whether they are the primary grocery shopper for their household. Out of 53

responses about meal preparation responsibilities, 86.8% (n = 46) reported being the primary

meal preparer. Similarly, out of 49 responses, 87.8% of (n = 43) reported being the primary

grocery shopper for their household. Fifteen participants failed to report that number of persons

they cook for; of those that did, more than half (52.1% or n = 25) reported cooking for two

people, while 37.5% (n = 18) reported cooking for one (N = 52). Two participants indicated that

they cook for three people and one subject each answered 1-2, 4-6, and 2-8 people.

A majority of participants were retired (76.2% or n = 48). Six indicated some form of

employment—part time, full time, or self-employed and two reported that they were unemployed

but looking for work.

Table 1 presents a frequency distribution of other sociodemographic characteristics of the

sample. More than half of the participants (57.1%) had completed high school or less, while

31.7% had completed some college or vocational school. Nearly half were married (47.6%)

while 27.0% were widowed, 11.1% were divorced, and 3.2% were separated. A portion (36.5%)

36

reported living alone, while 25.4% indicated one other person in their household (usually the

spouse) and 7.9% still had a child living with them. Most participants (19.0%) reported an

income under $20,000; 11.1% reported an income between $20,000 and $29,999 and $40,000

and $49,999 each. Regarding ability to get along on their income, most participants reported

having enough with a little extra sometimes, followed by having just enough and no more,

always having money left over, and unable to make ends meet.

37

Table 1

Sociodemographic Characteristics of the Sample (N = 63)

Characteristic Frequency

(n)

Percentage

(%)

Educational attainment

8th

grade or less

Attended high school

Completed high school

Vocational school

Attended college

Completed college

Advanced or graduate degree

No response

Marital/partner status

Married

Widowed

Divorced

Separated

Living with partner

No response

Other person(s) living in household

7

5

24

8

6

5

1

7

30

17

7

2

1

6

11.1

7.9

38.1

12.7

9.5

7.9

1.6

11.1

47.6

27.0

11.1

3.2

1.6

9.5

No 23 36.5

Child 5 7.9

Other relative 4 6.3

Friend 1 1.6

Other 16 25.4

No response 14 22.2

Income level

Under $10,000

$10,000-$19,999

$20,000-$29,999

$30,000-$39,999

$40,000-$49,999

$50,000-$59,999

$60,000-$69,999

$70,000 or more

3

12

7

6

7

1

3

2

4.8

19.0

11.1

9.5

11.1

1.6

4.8

3.2

No response 22 34.9

Income comfort level

Can’t make ends meet

Have just enough, no more

Have enough with a little extra sometimes

Always have money left over

1

14

27

11

1.6

22.2

42.9

17.5

No response 10 15.9

38

Frequency of Beneficial Bites Attendance and Use of Information Provided

Participants were asked to indicate, on a list of all Beneficial Bites presentations in the

first two years of programming, which presentations they had attended. Frequencies for the total

number of presentations attended are shown in Figure 1. The mean number of presentations

attended was 9.9 and the median 8.5. The greatest frequencies of participants (14%) attended

nine total presentations, followed by four presentations (12% of participants), six presentations

(10% of participants), nineteen and two total presentations were each attended by 8% of

participants. Thirteen participants were either first time attendees of Beneficial Bites at the time

the survey was administered, or could not remember which presentations they had attended.

Figure 1. Frequency distribution for the total number of Beneficial Bites presentations attended

by older and aging adults in Barron County.

0

1

2

3

4

5

6

7

8

2 3 4 5 6 7 8 9 11 13 16 17 19 20 21 23 24

Nu

mb

er o

f P

arti

cip

ants

Total Number of Presentations Attended

39

Although the survey intended to measure featured recipes and food use of participants

who had attended five or more Beneficial Bites presentations, some participants answered

regardless. Of the 33 that responded to recipe use, the largest number reported using the featured

recipes once a month (n = 21), followed by once a week (n = 7). One person reported using the

recipes three times a week and four reported never using the recipes. Use of the featured

foods/ingredients followed a similar pattern. Of the 36 that responded to the question, most

reported eating or cooking with the featured foods/ingredients once a month (n = 17), followed

by once a week (n = 10). Two people reported eating or cooking with the foods three times a

week and seven reported never consuming the featured foods.

Relation of Program Participation and Changes in Learning and Attitudes Regarding Food

and Healthy Eating

Six survey questions assessed changes in learning and attitudes regarding food and

healthy eating as a result of participating in Beneficial Bites. An additional question assessed

any change in overall health. Table 2 presents the proportions of participants reporting changes.

A majority of participants—nearly two thirds or more—reported increases in every category.

The greatest proportions of participants reported increases in nutrition knowledge, motivation to

make dietary changes, importance of healthy eating, and belief that what one eats affects one’s

health. More respondents consistently chose “no change” over “decreased”. Overall health,

confidence in making dietary changes, and confidence in healthy cooking showed the greatest

proportions of participants reporting no change at 33.3%, 23.8%, and 16.3%, respectively.

40

Table 2

Proportions Reporting Changes in Learning and Attitudes as a Result of Attending 5 or more

Beneficial Bites Presentations (N= 63)

Learning and attitude measures Increased

(%)

Decreased

(%)

Unchanged

(%)

Knowledge of nutrition (n = 42) 88.1 2.4 9.5

Confidence in healthy cooking (n = 43) 79.1 4.7 16.3

Importance of healthy eating in my life (n = 43) 86.0 14.0

Belief that what I eat affects my health (n = 40) 85.0 15.0

Confidence in making dietary changes (n = 42) 73.8 2.4 23.8

Motivation to make dietary changes (n = 42) 88.1 11.9

Overall health (n = 42) 61.9 4.8 33.3

Note. Percentages are out of those who responded (n).

This study aimed to examine the relationship between the frequency of Beneficial Bites

participation and learning and attitude ratings (increased, decreased, or unchanged). Spearman’s

Rho correlation analyses showed no significant association between the total number of

presentations attended and any of the following learning or attitude ratings: nutrition knowledge

(rs = 0.04, p > 0.05), confidence in healthy cooking (rs = 0.01, p > 0.05), personal importance of

healthy eating (rs = 0.08, p > 0.05), belief that foods consumed affect health (rs = -0.01, p >

0.05), motivation to make dietary changes (rs = 0.05, p > 0.05), or overall health (rs = -0.08, p >

0.05).

41

Comparison of Learning and Attitudes for Limited and Frequent Attendees

Another objective of this study was to compare changes in learning and attitudes for

limited and frequent attendees. Of those who attended five or more Beneficial Bites

presentations and answered the questions regarding learning and attitude changes (n = 40-43),

limited attendance in two years of programming was defined as one-third or fewer presentations,

and one-half or fewer presentations. To acquire adequate observations in learning and attitude

ratings, the categories were collapsed to increased and decreased or unchanged for analyses and

reporting of results. Because no precedent was found for defining limited attendance for a

similar ongoing nutrition education program, frequencies for learning and attitude changes were

compared twice for limited and frequent attendees in two years of programming, with limited

and frequent attendance defined as 8 or fewer presentations and 9 or more (Table 3) and 12 or

fewer presentations and 13 or more (Table 4). Greater differences were expected between the

groups attending half or less and more than half of the presentations as the most frequent

attendees were assumed to acquire more nutrition knowledge. Per Fisher’s Exact test, no

significant differences were observed in learning or attitude changes between limited and

frequent attendees—either with limited defined as eight or fewer presentations, or twelve or

fewer—as evaluated by Cross tabulation and Chi-square analyses.

42

Table 3

Frequency of Learning and Attitude Changes by Limited (8 Presentations or Fewer) and

Frequent Attendance

Learning and attitude measures Total number of presentations attended

8 or fewer 9 or more

Nutrition knowledge (n = 41)

No change or decreased

Increased

1 (5.9)

16 (94.1)

3 (12.5)

21 (87.5)

Confidence in healthy cooking (n = 42)


Increased

4 (23.5)

13 (76.5)

5 (20.0)

20 (80.0)

Importance of healthy eating in my life (n = 42)


Increased

2 (11.8)

15 (88.2)

4 (16.0)

21 (84.0)

Belief that what I eat affect my health (n = 39)


Increased

2 (12.5)

14 (87.5)

4 (17.4)

19 (82.6)

Confidence in making dietary changes (n = 41)


Increased

6 (35.3)

11 (64.7)

5 (20.8)

19 (79.2)

Motivation to make dietary changes (n = 41)


Increased

2 (11.8)

15 (88.2)

3 (12.5)

21 (87.5)

Overall health (n = 42)


Increased

6 (33.3)

12 (66.7)

10 (41.7)

14 (58.3)

Note. Numbers in parentheses are percentages of respondents (n).

Although there were no statistically significant differences between the limited and

frequent attendees, some interesting patterns arose. With limited attendance defined as eight or

fewer presentations over the course of 2 years (Table 3), 79% of frequent attendees indicated an

increase in confidence in making dietary changes compared to 65% of limited attendees. The

same trend occurred when limited attendance was defined as twelve or fewer presentations

(Table 4): 87% of frequent attendees reported an increase in confidence in making dietary

changes compared to 65% of the limited attendees. Conversely, 71% of frequent attendees

43

indicated increased overall health compared to 57% of limited attendees only when limited

attendance was defined as 12 or fewer presentations.

Table 4

Frequency of Learning and Attitude Changes by Limited (12 Presentations or Fewer) and

Frequent Attendance

Learning and attitude measures Total number of presentations attended

12 or fewer 13 or more



Increased

3 (11.1)

24 (88.9)

1 (7.1)

13 (92.9)



Increased

6 (22.2)

21 (77.8)

3 (20.0)

12 (80.0)



Increased

4 (14.8)

23 (85.2)

2 (13.3)

13 (86.7)

Belief that what I eat affects my health (n = 39)


Increased

4 (16.0)

21 (84.0)

2 (14.3)

12 (85.7)



Increased

9 (34.6)

17 (65.4)

2 (13.3)

13 (86.7)



Increased

3 (11.1)

24 (88.9)

2 (14.3)

12 (85.7)



Increased

12 (42.9)

16 (57.1)

4 (28.6)

10 (71.4)


Changes in Learning and Attitudes across Gender, Marital Status, Educational

Attainment, and Income Level

An additional aim of this study was to examine the differences in learning and attitude

changes regarding food and healthy eating based on gender, marital status, educational

attainment, and income level. Because of a limited sample distribution across five categories for

marital status, seven for educational attainment, and eight for income level, the categories for

44

each variable were collapsed as follows: married or living with partner, and widowed, divorced,

separated, or single; high school or less and vocational training or more; and $29,999 or less and

$30,000 or more.

Table 5 presents the frequency of learning and attitude changes by gender. Cross

tabulation and Chi-square analyses showed significant differences between males and females in

three learning and attitudes parameters: confidence in healthy cooking [p = 0.016, Fisher’s Exact

test (FET)], confidence in making dietary changes (p = 0.028, FET), and motivation to make

dietary changes (p = .019, FET). More specifically, 85% of females reported increased

confidence in healthy cooking compared to 33% of males. Similarly, 79% of females reported

increased confidence in making dietary changes compared to 33% of males. Motivation to make

dietary changes showed similar results, with 91% of females reporting increases compared to

50% of males.

45

Table 5

Frequency of Learning and Attitude Changes by Gender

Learning and attitude measures Male (n = 6) Female (n = 34)

Nutrition knowledge

Decreased or no change

Increased

2 (33.3)

4 (66.7)

2 (5.9)

32 (94.1)

Confidence in healthy cooking


Increased

4 (66.7)

2 (33.3)

5 (14.7)

29 (85.3)

Importance of healthy eating in my life


Increased

2 (33.3)

4 (66.7)

4 (11.8)

30 (88.2)

Belief that what I eat affects my health


Increased

2 (33.3)

4 (66.7)

4 (11.8)

27 (79.4)

Confidence in making dietary changes


Increased

4 (66.7)

2 (33.3)

6 (17.6)

27 (79.4)

Motivation to make dietary changes


Increased

3 (50.0)

3 (50.0)

2 (5.9)

31 (91.2)

Overall health Decreased or no change

Increased

3 (50.0)

2 (33.3)

12 (35.3)

22 (64.7)

Note. Numbers in parentheses are percentages.

No significant differences were observed between changes in learning and attitudes and

any of the other sociodemographic variables as evaluated by Cross tabulation and Chi-square

analyses. The frequency of learning and attitude changes by marital status, educational

attainment, and income level are each presented in Tables 6, 7, and 8, respectively.

Albeit nonsignificant, some notable differences arose between the coupled and single

groups in learning and attitude changes (Table 6). Although more of those who were married or

living with a partner indicated increases in the belief that foods consumed affect health and

overall health compared to cohorts, more of those who were widowed/widowers, divorced,

separated, or single indicated increases in confidence about making dietary changes.

46

Table 6

Frequency of Learning and Attitude Changes by Marital Status

Learning and attitude measures Married or living

with partner

Widowed, divorced,

separated, or single



Increased

1 (5.9)

16 (94.1)

2 (10.0)

18 (90.0)



Increased

4 (23.5)

13 (76.5)

5 (23.8)

16 (76.2)



Increased

2 (11.8)

15 (88.2)

4 (19.0)

17 (81.0)



Increased

1 (6.3)

15 (93.8)

4 (21.1)

15 (78.9)



Increased

5 (29.4)

12 (70.6)

3 (15.0)

17 (85.0)



Increased

2 (11.8)

15 (88.2)

2 (10.0)

18 (90.0)



Increased

5 (31.3)

11 (68.8)

9 (45.0)

11 (55.0)


Despite the lack of statistical significance, educational attainment seemed to have an

effect on some learning and attitude measures, (Table 7). Namely, slightly greater proportions of

participants with a high school education or less reported increases in nutrition knowledge (96%

versus 86%), the belief that foods consumed influence health (91% versus 79%), and overall

health (71% versus 42%) compared to their more educated cohorts.

47

Table 7

Frequency of Learning and Attitude Changes by Educational Attainment

Learning and attitude measures High school or less Vocational training

or more



Increased

1 (4.3)

22 (95.7)

2 (14.3)

12 (85.7)



Increased

6 (25.0)

18 (75.0)

3 (21.4)

11 (78.6)



Increased

4 (16.7)

20 (83.3)

2 (14.3)

12 (85.7)



Increased

2 (9.5)

19 (90.5)

3 (21.4)

11 (78.6)



Increased

6 (26.1)

17 (73.9)

2 (14.3)

12 (85.7)



Increased

3 (13.0)

20 (87.0)

1 (7.1)

13 (92.9)



Increased

7 (29.2)

17 (70.8)

7 (58.3)

5 (41.7)


Consistent with the other sociodemographic variables, although none of the learning or

attitude differences between income categories was statistically significant, some interesting

patterns emerged (Table 8). Greater proportions of participants with less income reported a

decrease or no change in all learning and attitude variables. Notably, 80% of those with more

income indicated an increase in overall health since participating in Beneficial Bites, compared

to 59% of those in the lesser income category.

48

Table 8

Frequency of Learning/Attitudinal Changes by Income Level

Learning/attitudinal change $29,999 or less $30,000 or more



Increased

3 (16.7)

15 (83.3)

0 (0)

10 (100)



Increased

5 (29.4)

12 (70.6)

2 (20.0)

8 (80.0)



Increased

4 (23.5)

13 (76.5)

0 (0)

10 (100)



Increased

3 (20.0)

12 (80.0)

0 (0)

10 (100)



Increased

4 (25.0)

12 (75.0)

2 (20.0)

8 (80.0)



Increased

3 (18.8)

13 (81.3)

0 (0)

10 (100)



Increased

7 (41.2)

10 (58.8)

2 (20.0)

8 (80.0)


Barriers to Participation, Areas of Improvement, and Future Foods/Topics

Respondents who had attended fewer than five presentations were asked to indicate what

prevented them from participating in the Beneficial Bites presentations. Of those that responded

(n = 31), the majority (51.6%) indicated that the dates/times conflicted with their schedules. The

second most frequent response (19.4%) was that they did not know when or where it was

occurring; a corresponding written-in response was that the subject had not paid attention to the

featured newspaper article. Some respondents gave a combination of answers: one subject

indicated no transportation and date/time conflicts; another indicated not knowing when or where

it was occurring and no interest in/distaste for the featured food; and two participants indicated

49

date/time conflicts and no interest in/distaste for the featured food. The most frequent written-in

response was “I forgot” (n = 4, 12.9%), followed by “I wasn’t living here at the time” (n = 2,

6.5%).

Regarding participant suggestions for improvement to the program, four major themes

emerged from the 22 written-in responses. The majority of responses (36.4%, or n = 8) were not

suggestions but positive comments about the presentations, recipes, and/or presenters. Six

participants (27.3%) identified the need for more advertising, such as in the local newspapers

rather than just the Barron County Senior Review. Three participants commented on distracting

background noise from the kitchen and dining room staff, two of which suggested that the

presenter use a microphone. Three participants made suggestions regarding presentation times:

one proposed changing the time from morning or afternoon to evening and two suggested

scheduling them close to other senior/community center activities.

Suggestions for future topics or foods were varied. The greatest number of requests (n =

11) were for specific vegetables, five of which were specifically for potatoes. The second

greatest request (n = 8) was for fruits, followed by spices/herbs (n = 4) and tips for eating out (n

= 4). Specialty diets, desserts, hotdishes, proteins, and breakfast items were each requested three

times, followed by dairy products, which were requested twice. Five participants wrote in

“anything” or “everything”.

50

Chapter V: Discussion

This study was conducted to appraise the effectiveness of Beneficial Bites—a

comprehensive nutrition education program for older and aging adults—for the purpose of

further program development. This chapter will discuss limitations throughout the research

process—particularly as related to the findings and conclusions of the study, summarize notable

findings and conclusions of the present study in correlation to previous findings in nutrition

education evaluations, and propose recommendations for future nutrition education evaluation

research as well as for the Beneficial Bites program in particular.

Limitations

The limitations of this study have been previously discussed in detail in Chapter III.

Several methodological limitations have particular relevance to the interpretations and

conclusions drawn from this study. The first limitation of this study was the lack of a pre/post

design. In addition to the process evaluation data presented, baseline nutrition knowledge, food

frequency, and health status data for each participant would have provided more objective

measures of the effectiveness of the program and would have allowed identification of absolute

changes. Food frequency data in particular would have provided a more objective measure of

dietary changes.

An additional limitation was in the sampling procedure. The population for this study

was limited to participants of the Barron County Beneficial Bites presentations in February 2012.

As such, it is possible that some regular participants were unable to attend this particular month’s

presentation. Data collection should have continued over the subsequent months to obtain a

more inclusive sample of Beneficial Bites participants.

51

The self-reported data collected by the survey was a limitation in several ways. Because

the survey required respondents to accurately recall which Beneficial Bites presentations they

had attended, inaccurate responses may have limited the data on survey items that depended on a

certain number of attended presentations, namely, the question regarding barriers to participation

and those aimed at measuring changes in learning and attitudes regarding food and healthy

eating. A desire to look good, or give the “right” answer also may have influenced positive

responses to learning and attitude measures. Despite assurances that responses would be kept

anonymous, participants may have responded positively in an effort to please the researcher,

survey administrator, or program coordinator.

Correspondingly, consistent with an inherent problem with survey methodologies, failure

to report answers to all questions for unknown reasons limited the data on some survey items.

The multiple categories for several of the sociodemographic questions, numbering up to eight for

income level, may have overwhelmed the respondents, making choosing more difficult. Thus,

rather than describing the sample in more detail as intended, too many choices may have led

respondents to skip the question. Using a consistent number of options for each

sociodemographic variable would not only have streamlined the survey, facilitating readability,

but it may have also increased the data collected from each question, which in turn may have

contributed to variability in responses.

An additional limitation was identified in the researcher’s instrument (Appendix B).

Prior to Question 2, the survey instructed participants to skip to Question 5 if they had attended

fewer than five Beneficial Bites presentations; those who had attended more than 5 presentations

were instructed to proceed through the subsequent questions. The latter statement should have

read, “If you have attended 5 or more presentations,” to specifically include those who had

52

attended five presentations in the instructions to answer the subsequent questions regarding use

of the featured recipes and foods and changes in learning and attitudes. Of the three participants

who attended five presentations, only one followed the errant survey instructions and skipped

Questions 2 through 4; data collected from the other two participants were included in the

analysis of resulting behaviors and learning and attitude changes of those who had attended more

than five presentations.

Final blanket limitations were the lack of a pilot study and use of the specific population.

First, direction of a pilot study may have allowed for improvements to the research design and

corrections to the aforementioned limitations, which may have strengthened the statistical

significance of results. Second, the convenience sampling methodology, small sample size, and

primarily White female sample limit the ability to generalize findings to other nutrition education

initiatives.

Conclusions

Despite the limited statistical significance of many of the study findings, interesting

patterns emerged warranting further discussion. Patterns in learning and attitudes regarding food

and healthy eating related to frequency of Beneficial Bites attendance are discussed, followed by

further discussion of patterns observed in learning and attitudes changes for limited versus

frequent attendees. Changes in learning and attitudes across gender, marital status, educational

attainment, and income level will follow. Finally, conclusions regarding prominent barriers to

regular participation and corresponding areas of improvement will be discussed.

No relationship was established between changes in learning or attitudes and frequency

of program participation. It should be noted, however, that most participants (nearly two thirds

or more) reported increases in learning about and positive attitudes toward food and healthy

53

eating, regardless of the amount of presentations attended. Similarly, reported knowledge gains

are common in the literature, despite varied attendance rates for other nutrition education

presentations, lessons, or food workshops (Ellis et al., 2005; Keller et al., 2005). Ellis et al.

(2005) found similar increases in positive attitudes and behavior changes after a five-lesson

pre/post intervention. As a result of 51% of participants attending three or more lessons, at least

75% reported trying to follow a healthier diet, eating more whole grain foods with the belief that

they were good for them, and/or feeling more strongly than before that eating whole grain foods

would reduce the risk of chronic disease.

In the present study, no significant differences were observed in learning or attitude

changes between limited and frequent attendees. As mentioned previously, this was likely due to

the limited variation observed in responses, namely, most participants reported increases in

learning and attitudes. However, an interesting pattern occurred when limited attendance was

defined as 12 presentations or fewer compared to 8 or fewer. A greater proportion of frequent

attendees participating in 13 or more presentations tended to report increased confidence in

making dietary changes—a trend that did not change when frequent attendance was decreased to

9 or more presentations. This may suggest that greater confidence in making dietary changes is

possible with even moderate participation in nutrition education programs. Similarly, Keller et

al. (2005) found increases in confidence in making dietary changes, as well as motivation to

make dietary changes and confidence in healthy cooking when participants attended only one of

a three-session series food workshop (44.3% compared to 31.4% attending all three sessions and

24.3% attending two sessions). Notably, nutrition knowledge, interest in trying new foods,

importance of healthy eating, and increased belief that diet influences health also increased.

54

In a review evaluating nutrition education intervention results, Sahyoun et al. (2004)

found that knowledge gains were the most frequently reported outcome. Correspondingly,

Taylor-Davis et al. (2000) demonstrated the use of theory-based nutrition education newsletters

and follow-up telephone interviews in increasing nutrition knowledge, willingness to answer

nutrition knowledge test items, confidence in nutrition knowledge, and interest in nutrition.

Treatment groups also performed better than the control on readiness to change dietary fiber

intake and stages of change to avoid dietary fats. Lesson plans incorporating self-assessment of

current eating habits, goal-setting activities, food tasting, take home handouts, and question-and-

answer with a nutrition educator have also shown success in increasing nutrition knowledge and

positive dietary changes (Patacca et al., 2004).

Increases in overall health may require more regular participation in nutrition education.

A greater proportion of frequent attendees participating in 13 or more Beneficial Bites

presentations reported increased overall health; however, the same trend did not uphold for 9 or

more presentations. This is consistent with the more varied evidence for behavior change and

positive nutrition-related biochemical and anthropometric outcomes as a result of nutrition

education (Bandayrel & Wong, 2011; Sahyoun et al., 2004).

Findings of the present research established significant differences in learning and

attitude changes according to gender. Specifically, more females than males reported increased

confidence in healthy cooking, confidence in making dietary changes, and motivation to make

dietary changes. This may be explained by differences in the austerity of gender roles that older

cohorts are accustomed to, particularly those involving meal preparation and grocery shopping

responsibilities. From this perspective, women, especially older adult women, may have more

experience with selecting and preparing food. Moreover, consistently more females than males

55

in the present study were also found to report increases in their nutrition knowledge, personal

value for healthy eating, belief that foods consumed affect health, and overall health compared to

cohorts. These collective findings appear to agree with the observation by Krondl et al. (2008)

that recent widowers exhibit greater nutritional risk with subsequent impact on their health

compared to women living alone.

In discussion of this finding of gender differences in learning and attitudes, it should also

be noted that a majority of the sample was female (83%). A majority also reported being the

primary meal preparer (86%) and primary grocery shopper (88%). Approximately one-third of

Beneficial Bites presentation content is devoted to the selection, storage, handling, cooking, and

serving of the featured food. Additionally, an assortment of take-home recipes featuring the

food/ingredient of the month is always provided at each presentation. Thus, participants who

remain actively engaged in meal preparation and food selection and procurement at home may

constitute a more captive audience; as a result, they may ultimately become better equipped (i.e.

more confident and motivated) to actively make and maintain behavioral changes such as diet

modifications and cooking healthier meals.

Although no significant differences were observed in learning or attitude changes as

related to marital status, some interesting patterns surfaced. More of those who were married or

living with a partner tended to report increases in the belief that foods consumed affect health as

well as increases in overall health compared to cohorts. In contrast, more of those who were

widowed/widowers, divorced, separated, or single reported increases in confidence regarding

dietary changes. While the former trend seems to coincide with previous research, the latter does

not. Varying forms of social isolation have been consistently linked to negative changes in

eating habits among the elderly: bereavement of spouse, depression due to an array of factors,

56

lack of transportation, rural residences, and disability or loss of functionality may all limit an

older adult’s interaction with others (Kamp et al., 2010; Krondl et al., 2008; Kuczmarski &

Weddle, 2005). Furthermore, elderly adults living alone experience greater rates of food

insecurity (Kuczmarski & Weddle, 2005).

No significant differences were established between educational attainment and learning

and attitude changes. An unexpected pattern occurred in that greater proportions of those who

completed high school or less tended to indicate increased overall health, nutrition knowledge,

and belief that foods consumed influence health compared to those who had vocational training

or more. This may be due to the limited variation observed in educational attainment—namely,

that most had only a high school education or less. Contrary to this pattern, Krondl et al. (2008)

have proposed that the younger generation of the future elderly population is likely to be more

health conscious and better educated, and as such may be more receptive to knowledge-based

interventions and nutrition education. As mentioned in Chapter I, Beneficial Bites targets not

only older adults, but also “younger” seniors, or the future older adult population in an effort to

promote healthful aging and postpone the need for nutrition services later on in life. This is not

only in recognition of the need for primary and secondary prevention of chronic disease among

this subgroup, but also in recognition of an aging population that continues to outpace funding

for its respective nutrition programs.

Other interesting patterns occurred in the frequency of learning and attitude changes by

income category. Namely, more participants with less income tended to report a decrease or no

change in each learning and attitude measure, as well as in overall health. This corroborates the

previous findings by Ellis et al. (2005) suggesting that barriers to increasing healthful behaviors

regarding whole grain foods consumption are more likely to include financial constraints than

57

knowledge about the respective health benefits. Krondl et al. (2008) also recognize that older

adults on fixed incomes may be forced to limit allocations for nutritious food. Because a

majority of the sample in the present study was retired, fixed incomes may explain the lack of

changes in attitudes toward food and healthy eating. Although data on income comfort level

were insufficient for statistical analysis, most participants indicated having either “no more than

just enough” or “enough with a little extra sometimes”.

A major theme identified in participant suggestions for improvement to Beneficial Bites

was the need for more advertising; this was consistent with the second most prominent barrier to

participation—not knowing when or where the presentations were occurring. Further, 13 of the

63 participants were possible first-time attendees, as concluded from no recalled presentations

attended, which may suggest that as much as 21% of participants only recently became aware of

the program. Judging from this perspective, a majority of the potential target audience may be

unaware of the program. This was consistent with findings from Manilla et al. (2010) in which

14.8% of participants in an educational food tasting activity had learned of the activity from the

monthly newsletter compared to 42% who had no prior knowledge of the activity, suggesting

that advertising strategies relying chiefly on monthly newsletters are insufficient for attracting

larger scales of older adult audiences.

The purpose of this study was to evaluate the effectiveness of Beneficial Bites—a

comprehensive nutrition education program featuring well-supported strategies for teaching

older adults. Several findings support the conclusion that Beneficial Bites is effective at

promoting nutrition knowledge gains and positive attitudes toward food and healthy eating

among the target audience. Significantly more females than males reported increased confidence

in healthy cooking, confidence in making dietary changes, and motivation to make dietary

58

changes. Most participants (nearly two thirds or more) reported increases in knowledge and

positive attitudes regarding food and healthy eating regardless of the amount of presentations

attended. Of those who did attend five or more Beneficial Bites presentations, approximately

three-fourths or more reported increases in nutrition knowledge, confidence in healthy cooking

and making dietary changes, motivation to make dietary changes, the personal value of healthy

eating, and the belief that foods consumed affect health. Additionally, positive comments about

the presentations, presenters, and program content and design outnumbered any other suggestion

for improvement.

Despite the lack of an established, statistically significant relationship between the

frequency of Beneficial Bites attendance and changes in learning and attitudes regarding food

and healthy eating, similar findings of varied nutrition education attendance rates producing

overall knowledge gains have also been reported. Further comparisons of limited and frequent

attendees revealed a trend such that greater proportions of frequent attendees tended to report

increased confidence in making dietary changes.

The lack of significant findings may be explained by the lack of a pre/post design and

small sample size. Also, participants with lower incomes tended to report a decrease or no

change in each learning and attitude measure, as well as in overall health, suggesting that a

barrier to increasing healthful behaviors in this sample may relate to financial constraints. This

may be explained by the greater proportion of retirees within the sample, who may be limited by

a fixed income.

Recommendations

Nutrition education is especially important to older adults who are, for a multitude of

reasons, uniquely susceptible to nutritional risk. Because so many factors may contribute to this

59

risk, ongoing nutrition education programs for older adults require regular assessment or

evaluations to ensure that the needs of the target population are being met and to further program

development. Thus, regular formative evaluations or assessments of Beneficial Bites

programming are recommended to continue to identify potential areas for improvement.

Furthermore, nutritional risk and eating habits could be assessed using a validated tool to identify

priorities for programming.

This study was unable to establish a significant relationship between changes in learning

and attitudes and frequency of attendance. A recommended approach for future nutrition

education evaluation research is a pre/post research design in which baseline and follow-up

nutrition knowledge, food frequency, health status, and nutritional risk for each participant are

measured. This would provide more objective measures of knowledge and behavioral changes

as a result of program participation.

A prominent barrier to regular participation, corresponding with a common suggestion

for improvement, was the need for more advertising of presentation dates, times, and locations.

Although Beneficial Bites is advertised monthly in the free Barron County Senior Review, which

has a circulation of 4,500, only about 100 are actually mailed out. Subscriptions are available to

those who are unable to pick one up where they are normally distributed throughout the county

(grocery stores, banks, senior apartment buildings, senior centers, etc.), or to those who do not

automatically receive one as a recipient of Meals on Wheels, however, many are to those who no

longer live in the area. A recommended advertising resource recognized by current attendees is

local newspapers in the respective towns where Beneficial Bites presentations take place. Other

advertising for Beneficial Bites occurs in the form of flyers and postings at local

community/senior centers; however, the reach of this strategy is limited to those who visit the

60

centers. Posting flyers in public spaces in each locality may increase access to the broader

potential audience for which the program is intended. Further investigation of specific barriers

to participation in this and other ongoing nutrition education programs is needed to determine

strategies for reaching more of the potential audience.

With respect to future research, it is recommended that the survey used for data collection

in the present study be revised in several ways. Given the varied response rate, the number of

choices for sociodemographic questions should be consistent and limited to four to facilitate

readability and reduce respondent burden. This population may also require more detailed

instructions during survey administration to address any points of confusion. A further

recommendation would be to evaluate the potential sociodemographic factors of nutritional

risk—such as income and living situation—separately, using a reliable, validated tool.

61

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http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001441/

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Appendix A: Institutional Review Board Approval Letter

January 25, 2012

Amy Erickson

Food and Nutrition Department

UW-Stout

Title: “An evaluation of Beneficial Bites: A nutrition education program for older adults”

Subject: Protection of Human Subjects

Dear Amy,

In accordance with Federal Regulations, your project, “An evaluation of Beneficial Bites: A

nutrition education program for older adults” was reviewed on January 25, 2012, by a member

of the Institutional Review Board and was approved under Expedited Review through January

24, 2013.

If your project involves administration of a survey or interview, please copy and paste the

following message to the top of your survey/interview form before dissemination:

If you are conducting an online survey/interview, please copy and paste the following message to

the top of the form:

“This research has been approved by the UW-Stout IRB as required by the Code of

Federal regulations Title 45 Part 46.”

Responsibilities for Principal Investigators of IRB-approved research:

1. No subjects may be involved in any study procedure prior to the IRB approval date or

after the expiration date. (Principal Investigators and Sponsors are responsible for

initiating Continuing Review proceedings.)

2. All unanticipated or serious adverse events must be reported to the IRB.

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3. All protocol modifications must be IRB approved prior to implementation, unless they

are intended to reduce risk.

4. All protocol deviations must be reported to the IRB.

5. All recruitment materials and methods must be approved by the IRB prior to being used.

6. Federal regulations require IRB review of ongoing projects on an annual basis.

Thank you for your cooperation with the IRB and best wishes with your project.

Should you have any questions regarding this letter or need further assistance, please contact the

IRB office at 715-232-1126 or email [email protected].

Sincerely,

Susan Foxwell

Research Administrator and Human Protections Administrator,

UW-Stout Institutional Review Board for the Protection of Human Subjects in Research (IRB)

*NOTE: This is the only notice you will receive – no paper copy will be sent.

mailto:[email protected]

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Appendix B: Evaluation tool

Beneficial Bites Evaluation

Thank you for taking a moment to fill out this evaluation.

1. Please check which Beneficial Bites presentations you have attended:

___ Rosemary ___ Dark Chocolate ___ Dry Beans

___ Kiwifruit ___ Flaxseed ___ Garlic

___ Yogurt ___ Tomatoes ___ Basil

___ Squash ___ Cranberries ___ Cinnamon

___ Cabbage Family ___ Walnuts & Almonds ___ Reading the

Food Label

___ Whole Grains ___ Asparagus ___ Apricots

___ Green Peas ___ Corn ___ Bell Peppers

___ Apples ___ Sweet Potatoes ___ Healthy

Holiday Foods

Age _____

Gender ____

Are you the primary meal preparer for your household? ______

If so, how many people do you cook for? ______

Are you the primary grocery shopper for your household? ______

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If you have attended fewer than 5 presentations, what has prevented you from

participating? (Circle the most common reason)

a. Illness

b. Lack of transportation

c. I didn’t know when or where it was occurring

d. Dates/times did not work for me

e. I didn’t like or wasn’t interested in the featured food

f. Other (please explain):

___________________________________________________________

___________________________________________________________

___________________________________________________________

If you have attended less than 5 Beneficial Bites presentations, please skip to

question 5.

If you have attended more than 5 Beneficial Bites presentations, please answer the

following questions:

2. How often do you use the featured recipes?

NEVER ONCE A MONTH ONCE A WEEK 3 TIMES A WEEK

3. Of the featured foods/ingredients that you were unfamiliar with, how often do you

eat or cook with them now?

NEVER ONCE A MONTH ONCE A WEEK 3 TIMES A WEEK

4. As a result of participating in Beneficial Bites, indicate if any of the following have

changed:

a. My knowledge of nutrition has:

INCREASED DECREASED NOT CHANGED

b. My confidence in healthy cooking has:


c. The importance of healthy eating in my life has:

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d. The belief that what I eat affects my health has:


e. My confidence in making changes to my diet has:


f. My motivation to make changes to my diet has:


g. My overall health, compared to other persons my age has:


5. What would you suggest to improve the presentations or attendance?

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

__________________________________________________________________

6. What topics or foods would you like to be covered in the future?

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

7. Compared to other persons your age, would you say that your health is

___ excellent ___ good ___fair ___ poor

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8. What is your employment status?

___ retired

___ not employed but looking for work

___ not employed and not looking

___ employed part-time (34 or fewer hours per week)

___ employed full-time (35 or more hours per week)

___ self-employed part-time or full-time (circle one)

9. What is the highest grade in school that you completed?

___ completed 8th grade or less

___ attended high school

___ completed high school

___ vocational training after high school

___ attended college

___ completed college

___ completed advanced or graduate degree

10. What is your current marital or partner status?

___ married, living with spouse

___ widowed

___ divorced

___ separated

___ single, never married

___ living with a partner

11. Is there anyone else besides you currently living in your household?

___ no, I live alone

___ child/children or stepchild/children

___ grandchild/children or step grandchild/children

___ other relative(s)

___ friend(s)

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___ other person(s) (please explain) ________________________________

12. Which of the following represents your total combined household income before

deductions during the last 12 months?

___ Under $10,000

___ $10,000 - $19,999

___ $20,000 - $29,999

___ $30,000 - $39,999

___ $40,000 - $49,999

___ $50,000 - $59,999

___ $60,000 - $69,999

___ $70,000 or more

13. Which of the following best describes your ability to get al.ong on your income?

___ I can’t make ends meet

___ I have just enough, no more

___ I have enough with a little extra sometimes

___ I always have money left over

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Appendix C: Consent form

Consent to Participate In UW-Stout Approved Research

Title: An evaluation of Beneficial Bites: A nutrition education program for older adults

Investigator: Amy Erickson

[email protected]

218-343-0241

Research Sponsor: Dr. Kerry D. Peterson

Food and Nutrition Department, UW-Stout

220 Heritage Hall

[email protected]

Description: This study is intended to evaluate the effectiveness of the Beneficial Bites nutrition education

program by gathering information on attendance and participants, as well as gaining insight on

areas of improvement. It is hoped that the results will be used to increase the usefulness of

programming, and increase participation and regular attendance.

Risks and Benefits: There are no major risks associated with participating in this study. When completing the

demography portion of this survey you may feel minor emotional discomfort or personal

feelings. There are no direct benefits for participating in this study. However, by completing

this survey you will help us to improve future Beneficial Bites presentations by identifying

barriers to attendance and areas for further development.

Time Commitment: It is expected that the survey for this study should take you no more than 10 minutes to complete.

Confidentiality: Your name will not be included on any documents and therefore you cannot be identified from

any of the information gathered for this study.

Right to Withdraw: Your participation in this study is entirely voluntary. You may choose not to participate without

any adverse consequences to you. You have the right to stop the survey at any time. However,

should you choose to participate and later wish to withdraw from the study, there is no way to

identify your anonymous document after it has been turned into the investigator. If you are

participating in an anonymous online survey, once you submit your response, your data cannot

be identified for withdrawal.

IRB Approval: This study has been reviewed and approved by The University of Wisconsin-Stout's Institutional

Review Board (IRB). The IRB has determined that this study meets the ethical obligations

required by federal law and University policies. If you have questions or concerns regarding this

study please contact the Investigator or Advisor. If you have any questions, concerns, or reports

regarding your rights as a research subject, please contact the IRB Administrator.

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Investigator: IRB Administrator Amy Erickson Sue Foxwell, Director, Research Services

218-343-0241 152 Vocational Rehabilitation Bldg.

[email protected] UW-Stout

Menomonie, WI 54751

Advisor: 715-232-2477

Kerry D. Peterson [email protected]

715-232-1408

[email protected]

Statement of Consent: By completing the following survey you agree to participate in the project entitled, “An

evaluation of Beneficial Bites: A nutrition education program for older adults