final paper.docx - web viewresults indicating common unhealthy dietary trends including sweet and...

Running Head: Nutrition in Lao Nadi

Nutrition in Lao Nadi

Lucy Aranda, Michael Marino, Mackenzie O’Brien, Veronica Thao, Elsa Weltzien

Khon Kaen University

Running head: Nutrition in Lao Nadi

Abstract

Thailand and other countries in Southeast Asia have recently undergone a nutritional

transition, resulting in changes in dietary trends to more similar to a Western diet.

Consequently, there have been increases in the rates of chronic degenerative diseases

including hypertension, diabetes mellitus and heart disease. Research in the form of semi-

structured interviews was performed in the Lao Nadi slum community of urban Khon Kaen,

Thailand to explore: What are the top five dietary trends among the Lao Nadi community;

(2) How do they affect villagers’ nutritional status; (3) What are some factors in diet that

contribute to hypertension, diabetes, and obesity? Results indicating common unhealthy

dietary trends including sweet and oily food consumption and lack of formal nutritional

education were used to create a culturally sensitive nutrition intervention for the community

that was attended by 24-26 participants. Topics covered were portion size, the Thai Nutrition

Flag, and balanced meal planning. Evaluation demonstrates a successful intervention with an

increase in participant knowledge but a need to research and address more specific

community nutritional needs.

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1. Introduction

Over the past few decades, Asian countries including those in Southeast Asia have

experienced rapid socio-economic development resulting in increased urbanization and

Westernization and leading to changes in dietary patterns. There has been a shift from a

more traditional diet based on starches and low in fat to a diet “characterized by increased

consumption of animal products, fats and sugars and decreasing consumption of complex

carbohydrate foods” (Kosulwat, 2002). As an example, Malaysia has seen degenerative

diseases including coronary heart disease, hypertension, diabetes, and obesity become

prominent (Noor, 2002). It has been projected that by 2020, chronic diseases will account for

three-quarters of all deaths worldwide, in both developed and developing/middle-income

nations (WHO, 2002). In Thailand, when considering the overall causes of death, the leading

causes are diet-related chronic degenerative diseases (Kosulwat, 2002). This is comparable

to the highly developed United States. As of 2010, heart disease, stroke, and diabetes graced

the top 10 causes of death of both countries (CDC, 2010).

The location for this research project was Lao Nadi, a railroad slum community with

a population of 238 people located in Khon Kaen, Thailand, existing on one main road.

Research was guided by the goals of understanding community members’ nutritional status

and their knowledge on healthy eating. These goals were guided by three main research

questions (1)What are the top five dietary trends among the Lao Nadi community; (2) How

do they affect villagers’ nutritional status; (3) What are some factors in diet that contribute

to hypertension, diabetes, and obesity? Data collected in the form of semi-structured

interviews was then used to create and implement a nutrition intervention in Lao Nadi.

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As illustrated by previous studies, health problems in Thailand are influenced by a variety

of factors including socioeconomic changes, cultural ties, and limited access to resources and

education. Research has found significant connections between nutrition and chronic illness in

Thailand. Previous campaigns and interventions have focused mainly on screening and

management of nutrition-related chronic diseases, lacking a focus on primary prevention and

basic nutritional behaviors. Therefore, the research and intervention initiatives made in Lao Nadi

have the purpose to use basic nutritional information to encourage community members to find

solutions to improve the nutritional health status of their community and to increase their access

to healthier food choices.

2. Literature Review

According to the World Health Organization (1990), “nutrition is coming to the fore as a

major modifiable determinant of chronic non-communicable disease (NCD), with scientific

evidence increasingly supporting the view that alterations in diet have strong effects, both

positive and negative, on health throughout life” (p. 1). The risk of developing a NCD is

compounded by “motorized transportation, labor-saving devices in the home, the phasing out of

physically demanding manual tasks in the workplace, and leisure time that is devoted to

physically undemanding pastimes” (WHO, 2003). These fairly recent changes in dietary and

lifestyle patterns have caused “chronic NCDs to become significant causes of disability and

premature death in both developing and newly developed countries” (WHO, 2003). Third,

(WHO, 2003) also says “one of the problems is that in many developing countries, food policies

remain focused only on undernutrition and are not addressing the prevention of chronic disease.”

Our research sought to address this gap in health policy by trying to identify the nutrition-related

causes of chronic disease in the Lao Nadi community. Our intervention also focused on the lack

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of chronic disease prevention policy by educating the community about the three most prevalent

NCDs in Lao Nadi.

Taechangam et al. (2008) center the discussion of nutrition-related chronic illnesses

specifically on Thailand, explaining that: “Thai staples, which are rich in complex carbohydrates,

are being replaced by diets containing a higher proportion of fats and animal meat which can be

critically harmful for health” (p. 1). Thailand’s recent “dietary shift towards processed, calorie

dense foods” comes with the territory of being a “rapidly developing nation” and this

“contributes to Thailand’s double burden of disease” (Kelly et al., 2010, p. 1). When a country is

facing a double burden of disease, it simply means that there are health threats from both non-

communicable diseases as well as communicable infectious diseases.

Clearly, nutrition is a key factor in the discussion of diet-related chronic illnesses. To

provide guidelines for proper diets, Thai Food Based Dietary Guidelines (FBDG) and a Thai

Nutritional Flag were developed by the Food and Agricultural Organization and World Health

organization. These tools are intended to help address nutritional transition based health issues

regarding undernutrition and overnutrition. The FBDGs include the recommendations that an

individual should “eat a variety of foods from each of the five food groups and maintain proper

weight, eat adequate rice or alternate carbohydrates, eat plenty of vegetables and fruits regularly,

eat fish/lean meats/eggs/legumes/pulses regularly, drink a sufficient amount of milk every day,

eat moderate amounts of fat, avoid excessive intake of sweet and salty foods, eat clean and

uncontaminated foods, and avoid or reduce consumption of alcoholic beverages (Sirichakwal et

al., 2011, p. 477).” Sirichakwal et al. emphasize that, “FBDGs have been considered as one of

the most important tools for nutrition education, communication for promotion of desirable of

eating habits, and nutritional well being and good health” (p. 477). FBDGs can also be used for

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“setting up food and nutritional policy and strategy in health, education, and agriculture because

they create demand for healthy diets which will lead to the supply of appropriate nutritious and

safe food in various settings (p. 477).” Overall, FBDGs have the potential to help guide

communities in making healthier food choices.

The article by Sirichakwal et al. (2011) helped us to shape our nutrition intervention in

Lao Nadi. For example, the intervention was designed so that each component included simple

health tips and guidelines. Each of the Thai FBDGs were addressed and additional tips were also

provided to the participants. Furthermore, a 3’x5’ Thai Nutritional Flag was hung in the center

of the community and each participant received a miniature Thai Nutritional Flag.

While limited nutritional health information affects many communities of Thailand,

culture also perpetuates food-induced health problems. More specifically, the cultural importance

of certain foods has an effect on nutritional health status. Leedom Lefferts (2005) discusses the

complicated relationship between poor food choices and the challenge of eliminating these foods

due to their cultural significance in Thailand. More specifically, in the Northeast region of

Thailand, “Isaan culture has a long-rooted history of consuming traditional foods high in

unhealthy salts, fats, and sugars” (p. 247). For example, “one staple food in the Isaan diet

includes sticky rice, which is typically consumed by people on a daily basis” (Lefferts, 2005, p.

247). Ultimately, “sticky rice is a symbol of unity and identity for Isaan people and it is difficult

to totally eliminate it from people’s diets because it is significant to Isaan culture and tradition”

(Lefferts, 2005, p. 247). The sticky rice example highlights the larger conflict that results from

the strong cultural attachment to certain Thai foods.

More importantly, Lefferts’ article highlights a serious issue of how the culture

complicates behavioral changes related to food choice and nutritional health status. Therefore,

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“when addressing health problems that can arise from eating traditional Thai foods, it is

important to ensure that Thai culture and tradition are kept in consideration” (Lefferts, 2005, p.

258). Overall, Lefferts’ findings indicate a need for the “distribution of more comprehensive

nutritional information to communities in the Northeast region of Thailand while remaining

culturally sensitive” (p. 248). Related to his suggestions is the research of Gibson and Ferguson.

According to Gibson and Ferguson (1998), “to implement effective dietary strategies,

knowledge of the local dietary patterns, food beliefs, preferences and taboos is required, as well

as the ability to change attitudes and practices” (p. 123)

These two articles were particularly useful in helping researchers to develop an effective

and successful nutrition-related intervention in Thailand. It was not difficult for the researchers

to respect Thai culture and tradition because of our unique position as CIEE study abroad

students. To elaborate, over the course of the student group’s four months in Thailand, they had

multiple opportunities to live in the Lao Nadi community. We were able to glean a lot of

important information about Lao Nadi’s culture and traditions from these homestays through

observing ceremonies, helping to cook, and conducting research interviews, to name a few. Each

of the semi-structured interview questions were chosen specifically to obtain information about

Lao Nadi’s local dietary patterns, food beliefs, preferences, and taboos, as recommended by

Gibson and Ferguson (1998). In addition, building personal relationships with members of the

potential intervention audience allowed us to integrate into the Isaan culture.

According to Davis et al. (2012), “there is evidence that group programs can be more

effective than individual or self help approaches to weight management” (p. 176). Davis et al.

also cite a study by Heshka et al. (2003) stating that “one trial found that a multi-component

commercial group program (Weight Watchers) was more effective in terms of weight loss and

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weight control over a 2-year period than individualized or self help programs.” Finally, Davis et

al. cite Waleekhachonloet et al., (2007) who compared group behavior therapy with individual

behavior therapy for promoting healthy dieting behavior and weight control in overweight and

obese women in a rural community in Thailand. The group behavior therapy was found to be

“practical, cost and time effective and not inferior to individual therapy in terms of

effectiveness” (p. 230). The added bonus of Waleekhachonloet et al.’s (2007) research is that it

is applicable to obese women in rural Thailand. “The most promising programs are those that

address the needs and concerns of the target communities using culturally appropriate methods

and messages” (Doak, 2002).

Colleen Doak’s (2002) journal article further validates the need for research and

subsequent nutrition interventions, stating that, “early prevention is a necessary, cost-effective

means of avoiding the high social, biological and economic costs of a treatment-based approach

to nutrition-related chronic diseases” (p. 275). According to Doak (2002), “assessment of the

extent of overweight, obesity and nutrition-related chronic diseases is critical to addressing the

problem” (p. 275). This assessment should be the responsibility of the Lao Nadi village health

volunteers (VHVs), however the responses gathered from our semi-structured interviews indicate

that VHVs in the Lao Nadi community are not as accessible as they should be.

Doak (2002) also relates to our survey question about nutrition education in school. “A

school-based program began in Thailand in September, 2001. This program, in regional primary

and secondary schools, focuses on physical activity and a healthy diet” (p. 275). This statement

validates the “yes” responses to the survey question “is nutrition education provided in schools?”

For adults, “the workplace is ideal for interventions reaching adults and the promotion of

physical activity in Thailand in the workplace is among the strategies of health promotion in the

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National Plan, although implementation of this varies by region” (Doak, 2002, p. 276). This

statement supports the need for our nutrition intervention because even if health promotion exists

in workplaces, there is a lack of health promotion in the community. Finally, “national

campaigns in Thailand for nutrition-related chronic disease prevention focus on screening and

management of nutrition-related chronic diseases such as hypertension and diabetes” (Doak,

2002, p. 277). The presence of these chronic disease campaigns is promising; however, while

screening is a form of secondary prevention, there is a gap in primary prevention. Our

intervention addresses this gap in policy by focusing completely on prevention instead of

management.

Raiha et al., (2012) evaluated the effects of a nutritional health intervention on student’s

nutrition knowledge and eating habits from grade seven to grade nine. The researchers suggest

that “more attention should be paid to the importance of actively involving parents in the effort”

(Raiha et al., 2012, p. 280). More specifically, Raiha et al. cite Woolfe & Stockley (2005)

stating that “attention should be paid to committing parents to the intervention and promoting

nutritional health within the entire school community including political decision-makers in the

local community.” Our intervention mimicked this strategy by involving the parents of children

as well as the village headman.

As illustrated by scholars and organizations alike, health problems in Thailand are

influenced by a variety of factors including socioeconomic changes, cultural ties, and limited

access to resources and education. It is important that research efforts continue to explore these

topics to better understand and address these nutrition-related health problems in Thailand.

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Taken as a whole, previous research has made it evident that there are significant

connections between nutrition and chronic illness in Thailand. Therefore, the nutritional status

of the railroad slum community, Lao Nadi, was of interest to researchers and community alike.

While communities may understand the basic connection between their food choices and the

potential increased risk of disease, many do not fully understand the extent to which their food

choices and poor eating habits can negatively impact their overall health status. Therefore, it is

important that research initiatives are made to better educate communities about nutrition and to

increase their access to healthier food choices.

3. Methods

3.1 Sample population

The target population of interest for the pre-intervention data collection period was adults

aged 30 and up, both males and females. The age of 30 was selected as a minimum age because

people within this age range are more likely to be the ones doing the majority of the food

preparation and purchasing for the family. No target gender was selected in consideration of the

small population size of Lao Nadi, to avoid difficulties in finding participants. The sample size

for data collection was 30 individuals, aged 30 or older, from the Lao Nadi community.

Convenience sampling was used because of the restricted size of Lao Nadi and available time

allotted for data collection. Participants were selected by random, by the researchers walking

down the single street of the community and asking whoever was available that met the age

criteria if they would be willing to partake in the survey. Data collection was conducted during a

weekend to allow a potentially wider selection of available participants, as opposed to

conducting research during a workday where it was likely that many people would not be home.

Although the target population for the pre-intervention period was restricted to 30 and older, the

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target population for the intervention was open to any and all ages, along with all genders. The

reason for this was again based on Lao Nadi’s small community size, but also because the

students did not want to limit the pool of participants.

3.2 Measurements

In order to collect data about the dietary habits of community members and their

knowledge on proper nutrition, the students conducted semi-structured interviews with the

sample population in Lao Nadi community. A list of basic questions regarding individuals’

general eating behaviors, current health status, and their access to nutrition information was

asked to gain a sense what should be addressed during the intervention. Information gathered

was both qualitative and quantitative. A total of 10 questions were asked, covering a few

different topics. Students began each interview with an introduction of themselves as U.S.

international students studying public health at Khon Kaen University and presented their

research purpose as gathering information on nutrition with the Lao Nadi community. They then

asked for the individuals’ consent to partake in a questionnaire to contribute to their research.

The questionnaire included questions asking for the individuals age, gender, whether or not they

had any existing chronic diseases, what types of foods they typically ate and drinks they drank

for breakfast, lunch, dinner and snacks, how these meals were prepared and where the

ingredients were purchased from. In order to gain a better perspective on participants’ knowledge

on nutrition, the questionnaire also asked where the individual received their nutrition

information from along with if they believed their community was doing enough to fill this part.

3.3 Budget

The student group requested a total of 9,997 B for the nutrition intervention in Lao Nadi as

described above. The majority of funds went to the translator and translations, and materials for

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the actual intervention. The total translations/translator cost came out to be 2120 B. The total

materials cost came out to be 4,089 B. The cost for transportation was 782 B. The total cost for

the remaining expenses, including the headman’s gift and miscellaneous printing came out to be

1,508 B. The budget was provided by CIEE.

Table 1. Budget for Nutrition Intervention

Budget Item Quantity Amount Sub-Total

a Translations/translator

Intervention Translator 1 520 THB

Translation of Materials 1,600 THB

Total translations/translator cost

2120 THB

b Materials

Cooked White Rice 6 orders 60 THB

Fruit Platters 2 500 THB

Poster and Mini Food Flag Printing

1 Poster, 40 Mini Flags

1,160 THB

Instant Coffees from 7/11 30 930 THB

Highlighters 6 95 THB

Ink Pens 40 240 THB

Napkins for Intervention 1 pack of 50 5 THB

Hooks for hanging large poster 4 47 THB

Bags of seaweed crisps 4 120 THB

Water for intervention 4 packs of 12 104 THB

Coffee from Tesco Lotus 10 290 THB

Paper cups 5 115 THB

Coffee stirring spoons 1 pack of 50 25 THB

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Plate 1 39 THB

Rice serving spoon 1 15 THB

Plastic gift bags 1 pack 29 THB

Sugar 1 pack 22 THB

Creamer 1 pack 39 THB

Bowls 2 packs 58 THB

Sunflower granola bars 2 bars 26 THB

Pumpkin chips 1 box 44 THB

Mixed Nut and pumpkin seed granola bars

4 72 THB

Uncooked White Rice 1 bag 34 THB

Roll of tape 1 20 THB

Total Material Cost 4089 THB

c Transportation Cost

Taxi to and from Tesco Lotus 132 THB

Songtaew rides 650 THB

Total Transportation Cost 782 THB

Miscellaneous printing 118 THB

Village Headman’s Gift: Gas Stove

1 1390 THB

Total Other Cost 1508 THB

Total Cost 8499 THB

Total Request: 10000 THB

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3.4 Timeline

3.4.1 Research and Intervention: November 21-December 3, 2013

Length of task

Day 1 Nov 21

Day 2 Nov 23

Day 3 Nov 24

Day 4 Nov 25

Day 5 Nov 26

Day 6 Nov 29

Day 7 Dec 2

Day 8 Dec 3

Consultation with Aj. Pattara

2

X

X

Data Collection

2 X X

Consultation with Aj. Jen and P. Fac

1

X

Materials Translated and Printed

1

X

Materials Purchased

1 X

Intervention Run-Through

1

X

Intervention 1 X

Debriefing 1 X

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3.4.2 Intervention Day Timeline: December 3, 2013

15:00 Meet at CIEE and brief translator

16:00 Leave for community

16:30 Arrive and set-up intervention space

17:00 Begin intervention

17:00-17:30 Disease, Portion Size, Nutrition Lecture

17:30-17:40 Snack Break

17:40-17:55 Daily Food Activity

17:55-18:00 Question and Answer Session and Discussion

18:00-18:30 Clean up and talk with community members

3.5 Outcome Measurements

In order to measure the success of the intervention and the knowledge that was learned by

the participants through this intervention, questions were asked directly post-intervention. These

questions related back to the information that was taught during the nutrition education section.

● What is the maximum servings of rice should one eat daily?

● What are healthy snack options?

● What did you learn throughout this presentation?

These questions correlate to the success because the participant’s correct answers show

that the information was well taught and knowledge was retained even after the intervention. If a

participant stated a false answer this would have meant that the information was not presented

clearly or correctly. Thankfully, all of the participants answered the questions correctly and even

provided valuable information when discussing what they had learned. One participant stated

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that they learned breakfast was the most important meal of the day and should not be skipped.

This truly shows the intervention was successful as that was a point that was continuously

stressed throughout. Others learned the importance of portion control and nutrition balance. This

post-intervention discussion allowed participants to talk freely. Many even asked questions of

their own, further showing that they learned and desired to learn more from the student

presenters. Furthermore, participants talked amongst themselves as they were leaving the

meeting area, collecting extra daily nutrition guides and Thai nutrition flags for their family and

friends. In conclusion, the participation that was evident throughout the entire intervention shows

a successful intervention. Their continued desire for more information and the successful

discussion towards the end is a true measure of the participant’s gained knowledge.

3.6 Data Analysis

Prior to the intervention the data that was collected was qualitative for the most part. The

majority of the questions in the semi-structured interview relied on open-ended answers such as

varying food that was consumed. In contrast, the quantitative information that was collected was

age, gender, history of disease, and whether nutrition was learned in the community or in

schools. This information is quantitative because it is objective, but is helpful when separating

the backgrounds of each participant.

Due to the purpose of the research, the best data analyzing came from the qualitative

answers. This is because answers could remain subjective to each individual participant.

Nonetheless, each answer was collected and categorized into qualitative versus quantitative

sections. From this point the answers were broken up question by question to see if there was a

correlation between the data that was received. Correlations were noted and the quantitative data

was placed in charts and tables for better representation. Though they are useful in analyzing

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separate styles of data, using both tools together is helpful in getting an overall understanding of

the answers the interviewee provided.

Post-intervention there was no data to be collected as there was no formal post-test or

questionnaire. The answers that were collected after the intervention were simply observations of

the intervention participants made by the students. Similarly, when asked what the participants

learned their answers are not necessary to be analyzed.

3.7 Ethics

As the intervention began, there was an introduction to explain who the students were, as

well as, the purpose of the intervention itself. It was set up as a voluntary meeting in the common

area, so individuals were invited but not forced to participate. No names, ages, or genders were

recorded at any point in the intervention to remain anonymity and encourage all to participate.

No personal information was asked of any participants. At the end of the intervention,

participants were thanked for their voluntary service towards our own personal education. There

has been no contact with the participants post-intervention day, maintaining the anonymity of all.

4. Results

Prior to our intervention, the results of our research include: demographic information

about the sample population, access to nutritional information in the community, top foods

consumed for breakfast, lunch, and dinner, and a total of thirty community members from Lao

Nadi were recruited in our study. The demographics of our sample population include gender

and age. 66.6% of the participants were female, while 33.3% of the participants were males

(Table 1). The lower number of male participants may be due in part to the fact that many males

were not available at the time of our interviews. Additionally, there is a larger female presence

among Lao Nadi community. This may be reflective of the actual gender distribution of Lao

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Nadi community. All participants were required to be thirty years or older to participate in our

study, the average of all participants was 49 years of age (Table 2). The age distribution among

our sample population is reflective of Thailand’s growing elderly population. According to the

United Nation’s Population Fund’s study titled Population Ageing in Thailand: Prognosis and

Policy Response, “[Thailand] has now moved up to be the second most aged country in the

region (next to Singapore), with older persons constituting more than 10 per cent of the

population (UNFPA, p. 2).”

Table 1. Distribution of Participants by Gender

Male Female Total10 20 30

% Male % Female % Total33.33333333 66.66666667 100

Table 2. Distribution of Participants by Age

Youngest Oldest Average Age32 76 49.3809524

Our thirty semi-structured interviews with Lao Nadi community indicate that there was little

nutritional information available to Lao Nadi community. As displayed in Figure 1, of the thirty

participants, who responded to the question, “Do you learn about nutrition in Lao Nadi?” 53% of

all participants answered “no” (Figure 1).

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Figure 1.

Community Members Learn about Nutrition in Lao Nadi

YesNoI Don't Know

While we assessed community members’ access to nutritional information in Lao Nadi, we

further discussed other options for accessing nutritional information. Many community members

received health information from their health care providers, such as nurses and doctors.

However, sixteen participants answered that “nobody” taught them about proper nutrition

(Figure 2).

Figure 2

19


Nobody

TV

VHV

School

Nurse

0 2 4 6 8 10 12 14 16 18

Resources for Learning about Nutri-tion in Lao Nadi Community

Number of VillagersIndi

vidu

als t

hat V

illag

ers L

earn

Fro

m

Additionally, we focused on learning about the different types of foods that are

commonly eaten by community members. In Figure 3, the top answers for ‘What do you

typically eat for breakfast?’ include: 1) white rice 2) nothing 3) stir-fried vegetables 4) omelets,

fish, stir-fried pork, sticky rice, bread, 5) boiled vegetables, boiled egg, steamed vegetables,

sweet bun, soups and noodles, fried rice, oatmeal. The most popular drink option for breakfast is

3 in 1 coffee, as displayed in Figure 4.

Figure 3.

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Bread

Cereal

Grilled Pork

Soup/Noodle

Stir Fried Prk

Sweet Bun

Steamed Veg

Boiled Veg

White Rice

0 1 2 3 4 5 6 7 8 9

Common Foods Eaten for Breakfast in Lao Nadi Community

Number of Villagers

Food

s Eat

en fo

r B

reak

fast

Figure 4.

CoffeeWaterMilk

Soy MilkWhiskey

Beer

0 2 4 6 8 10 12 14 16

Common Drink Options for Breakfast in Lao Nadi Community

Number of Villagers

Dri

nks f

or B

reak

fast

We also looked at the snack options among the community members and found that these

include: 1) fruit, 2) nothing, 3) breads, 4) potato chips, 5) crackers, chocolate, cookies, and

sandwiches (Figure 5).

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Figure 5.

VietnameseGrilled Pork

Cake Yogurt

SandwichCookie

ChocolateCrackers

Potato Chips

BreadsNothing

Fruit

0 1 2 3 4 5 6 7 8 9

Common Snacks for Lao Nadi Community

Number of Villagers

Food

s

We continued to look at the top foods for all meals: breakfast, lunch, and dinner, as well as

snacks. For lunch, som tam, sticky rice, white rice, and soups/noodles were popular dishes

among Lao Nadi community members. These options are reflective of the high consumption of

rice, that is staple to the Asian diet (Kiple, Ornelas).

Figure 6.

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Sticky RiceWhite RiceFried Rice

Fresh VeggiesStirfried VeggiesSteamed veggies

ChickenBoiled Chicken

Stirfried ChickenGrilled Chicken

Fried ChickenPork

Boiled PorkStirfried PorkGrilled Pork

Fried PorkFish

Steamed FishBoiled FishGrilled Fish

Fried FishFried Egg

Noodles and SoupsGreen Salads

FruitsSom Tam

0 2 4 6 8 10 12 14 16 18

Common Foods for Lunch in Lao Nadi Community

For dinner, white rice, sticky rice, stirfried vegetables, stirfried pork, and soups and noodles were

some of the top foods that community members choose (Figure. Again, rice is consumed in high

numbers. Therefore, we concluded that it was important to limit rice intake and incorporate this

into our intervention nutritional information session.

Figure 7.

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Sticky RiceWhite Rice

Boiled RiceStirfried VeggiesSteamed Veggies

Boiled ChickenFried Chicken

Grilled ChickenStirfried Chicken

Boiled PorkFried Pork

Grilled PorkStirfried Pork

FishSteamed Fish

Boiled FishFried Fish

Stirfried FishFried Egg

Soups/NoodlesGreen Salad

FruitsSom Tam

0 2 4 6 8 10 12 14 16 18 20

Common Foods for Dinner in Lao Nadi Comunity

Number of Villagers

Food

s for

Din

ner

In regard to meal trends, we found 53.8% declared dinner as their biggest meal of the

day. After collecting all of our data, we found that a significant number of participants did not

list foods for breakfast, and discovered that 30% of the participants did not eat breakfast

altogether (Figure 5).

Figure 9.

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Breakfast

Lunch

Dinner

0 2 4 6 8 10 12 14 16

Biggest Meal of the Day among Lao Nadi Com-

munity Members

Number of Villagers

Mea

ls

In our research, we also explored issues of access and affordability of healthy food

options, as well access to processed foods. Therefore, we asked participants where they typically

shop for groceries. As displayed in Figure 10, we found that 73% shop at the downtown market,

13% shop at Tesco Lotus, 4% shop at 7-11 convenient store, and 3% shop at Tops Super Market,

3% shop at Ton Tann market, and 3% prefer to go fishing for their own fresh fish.

Figure 10.

Dwntwn Mkt71%

Seven-Eleven3%

Comm. Mkt3%

Tesco Lotus13%

Ton Tann3%

Fishing 3%

Topps3%

Places where Lao Nadi Community Members Buy Food

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Furthermore, we asked participants “Do you have any health problems or illnesses?” Of the 30

participants, 14 mentioned that they were diagnosed with one, two, or three of the following

diseases: diabetes, hypertension, and heart disease. These three diseases are likely linked to poor

dietary habits ( Bumrungrad International Hospital).

Figure 11.

DiabetesHypertension

AsthmaMuscle/JointHeart Disease

HeadachesGout

HeartburnAllergies

0 1 2 3 4 5 6 7 8

Disease and Health Problems in Lao Nadi Community

Number of Villagers

Hea

lth P

robl

em

Post-intervention results were based on the events that occurred during our intervention.

More specifically, we base our post intervention results largely on responses from the attendees,

participation, perceived interest among the attendees, and perceived engagement from the

attendees. Our intervention focused on the research findings. At our intervention, approximately

24 community members attended the nutritional information session. We found that most

community members in attendance were adult females and children, while only one adult male

was present but not involved in the intervention session. Therefore, it is evident that there is a

gender gap regarding interest in health among Lao Nadi community. There needs to be more

emphasis on drawing in male community members to get involved with health-related

opportunities.

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The community members were engaged in the nutritional information session, especially

during the rice portion control session and during the meal planning activity. In order to evaluate

the audience interests and assess the audience’s gained knowledge, we organized a discussion

session following the intervention. Some community members stated that they learned about

how many servings of rice to eat and how to navigate the nutrition flag. Additionally, during this

time, the audience asked the following questions: “How many eggs should I eat per day as I get

older? What is a good body weight? What is a good substitute for salt? What is a good substitute

for sugar?” These questions ultimately conveyed the community members’ further interest on the

topic of nutrition and their desire to learn more about nutrition for the benefit of their own health.

Overall, the results convey that the community members in attendance gained knowledge from

the basic information that student researchers provide during the intervention. More importantly,

the discussion confirmed that many community members were highly interested in the topics

covered during the intervention session and wanted to seek out more information in the future.

5. Discussion

Overall, our research results and intervention process indicate that there is a lack of

adequate nutritional information available to Lao Nadi community members. In Lao Nadi, the

only efforts to promote healthy eating habits come from the few available village health

volunteers that usually only tend to community elders. While there are intentions to improve Lao

Nadi’s access to health information and provide community members with healthy outlets, there

are little efforts being made to implement these opportunities. Therefore, the community could

greatly benefit from more nutrition-based information sessions and the increase of access to

education resources. .

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The high consumption of white rice, sticky rice, stir-fried dishes, noodles/soups, som

tam, pork, omlettes, and 3-1 coffee are all are dishes that are core to the Thai diet (source). While

these foods cannot be completely eliminated, we discussed the idea to educate community

members on using portion control and meal planning methods to lesson their intake of these

foods. We also used the Thai nutritional guidelines and Thai food flag as a guide to help

community members understand what food groups were important to eat and in what quantities.

These food choices are not only rooted in Thai cultural attachment certain dishes , but also relate

to the nutritional transition that has occurred in Thailand. The consumption of animal proteins

and processed foods is quite common as more and more community members shop at super

markets and are consuming a lot of meat. While we did not discuss the different options of

protein outside of pork and red meats, our research findings indicate that chicken and fish are

common food choices within the Lao Nadi community. In our observational study at Thalad

Lampoon, we found that there is substantial access to fish, chicken, tofu and soy products—all

which are forms of protein. Perhaps the discussion of other protein options could have been

beneficial to our intervention session.

To address the issue of 3-1 coffee, we offered an instant coffee alternative sample, which

is higher in coffee and lower in sugar. However, community members were largely opposed to

the taste of the coffee because it wasn’t as sweet as they were used to. We also did not consider

the difference in preparation between 3-1 coffee and instant coffee. This posed a challenge to us

during the intervention when community members tasted plain black coffee. Shocked by the

bitterness, many immediately expressed their dislike. To address the mistake, we explained the

different steps associated with preparing the coffee and provided samples for families to further

experiment at home.

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Additionally, we confirmed that access to healthy foods or affordability of it was not an

issue, but the issue lied in knowledge of nutrition and the methods in which food is typically

prepared. Stir-frying is a common form of cooking specific to Thai foods. This method is not the

healthiest way to cook, so we provided a solution to this issue with portion control as an option

in order to control the intake of foods high in unhealthy fats and excess oil.

Overall, the intervention brought in many interested community members, however, there

was an unequal gender distribution. Only one male community member was present, but he

unfortunately was not engaged in the information session. Therefore, it could be deduced that

there is a lack of interest in nutrition among men in the community. While we did not foresee the

issue of gender distribution as being a potential problem, it is important that future student

groups focus on the need to draw in more male community members. Ten male community

members were interviewed during the data collection process. The data indicates that men too

are affected by similar health problems that result from unhealthy diets and also consume the

common unhealthy foods typically consumed in the community. Perhaps male community

members perceive meal preparation and cooking as female responsibilities, and therefore, did not

understand the direct impact that food choice, meal preparation, and nutrition has on their health.

Therefore, these gendered norms may affect how men view health in relation to food and

nutrition.

Additionally, language barriers and cultural difference had an inevitable effect on our

research and intervention. Because we are foreign students, there is a possibility that many

community members attended the intervention for us, rather than for themselves. However, we

strongly feel that regardless of their intentions, community members actively engaged and

learned from the nutritional information session. Also, communication between the translator

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and the student group was difficult, as we were unsure if our words were communicated clearly.

There was some miscommunication that occurred during data collection between the translator

and the student group. At times, we realized that the translator did not provide us with the

complete answers given by the community members, and we sometimes had to encourage the

translator to relay the details of the conversations with community members. Therefore there

were certain gaps in the information provided to us and to the community members. Language

barriers were also a reoccurring issue during the intervention, as community members were

reliant on the translator to help walk them through the meal planning session. This was a

constraint because there was only one available translator assisting several community members.

Additionally, the cultural difference between American students and Thai community members

is also an inevitable constraint that restricted us to fully understand the cultural ties that may

withhold community members and their understanding of nutrition the way they saw it.

Despite the challenges faced during the research and intervention session, community

members expressed interest in our intervention. Additionally, they were actively engaged

throughout the intervention. During the evaluation, some community members expressed further

interest in learning about nutrition and asked questions that we could not answer due to or

limited knowledge on n nutrition. Other participants also expressed interest in more

informational sessions to address body mass index and food consumption. We recommend that

future groups invite a nutrition expert to help answer questions that come up to avoid the

spreading of inaccurate information. Overall, attendants of our intervention enjoyed themselves

and were engaged in what we had to teach them about. Hopefully our efforts further motivated

them to take their health into their own hands and improve their dietary habits.

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6. Conclusion

6.1 Summary of Findings

It was found that the Lao Nadi community members share many common dietary trends.

The top five foods and drinks consumed in the community are white rice, sticky rice, stir-fried

dishes, noodles/soups, and “3-in-1” instant coffee drink. Skipping breakfast was also common.

Additionally, diabetes, hypertension, and heart disease are the three most common NCDs that

affect adults within the community. An information based intervention session was created

based on the community research results. The intervention focused on the concepts of the

common NCDs, the top 5 consumed foods, portion control, alternative food options, the Thai

Nutritional Flag, and meal planning. The intervention was evaluated to be successful based upon

participation levels and audience comprehension.

6.2 Strengths and Limitations

There were several strengths and limitations to the research and intervention. A major

strength is that each member of the research group had developed a strong relationship with the

Lao Nadi community by returning several times over the course of the semester. As a result, the

community was highly receptive to being involved in the research and intervention process. The

intervention had a large number of participants in attendance considering that the intervention

took place on a weekday right before dinnertime. In addition to the strong relationship with the

community, a second strength contributing to the participation was the use of advertising. The

creation of a budget that aimed high was a strength because while many items ended up costing

less than anticipated, other basic items that had not been previously factored into the budget were

able to be purchased, such as tape and highlighters.

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Strengths of the intervention itself include the structure and content. The information

presented was based off of the findings of the research and these findings were presented to the

community members so that they could understand the reasoning behind selecting the

information being taught to them. It was highly beneficial to incorporate a mixture of

information and interactive activities and discussion into the structure of the intervention because

it maintained participant interest and could address the differences in learning styles of the

audience.

While there were multiple strengths, this final project had limitations as well.

Other than the addition of a small amount of observational data collection, only one research tool

was utilized for conducting research within the Lao Nadi community. The use of semi-structured

interviews, while highly beneficial, may not have provided complete information on the topic.

The use of a focus group may have proved to be beneficial as well for gathering information

about nutritional knowledge and motivations of certain eating habits and patterns, however this

tool was not implemented due to poor attendance at previous focus groups in the Lao Nadi

community during research earlier in the semester. In relation to this, a small sample size limited

the conclusions that could be drawn from the data collected. While there was a decent number of

people in attendance for the intervention, the time allotted for it was a possible limitation. The

headman had indicated that weekends were the best time for the community and originally the

intervention was scheduled for a Sunday but it had to be changed to a Tuesday evening due to

scheduling logistics for all of the interventions. The lack of men in attendance could be related to

them not yet returning home from work.

The use of a translator is always a limitation because of the possibility of mistranslations

and some information being lost in translation. Additionally, it would have been beneficial to use

32


more than one translator during the meal planning activity because many participants required

assistance. The translator was the only person with the language capability to assist the

participants in need and she had to focus her attention on those who were illiterate, preventing

some other participants from receiving help and fully understanding the activity. Next, the

researchers were not experts on nutrition and therefore only had the knowledge to teach basic

concepts of nutrition. Some questions presented by the participants could not be answered.

The effectiveness of the intervention was limited due to the short amount of time allotted for the

project and because it is difficult to change long-term and culturally based habits, especially after

a single presentation of information. Finally, effectiveness of this intervention cannot be

evaluated in the long-term by the research group who ran the intervention. It is possible that

future CIEE students will conduct further research related to nutrition in Lao Nadi for a potential

intervention but there is not a way to follow-up with the specific participants of this particular

intervention.

6.3 Recommendations for Future Interventions

It is highly recommended that students perform interventions within communities that

they have built a strong rapport with. The community and the students will be able to best meet

each other’s needs if a strong relationship between the two parties is developed over the course

of the semester. A recommendation for future interventions would be to hire an expert on the

intervention topic to help with certain components of the intervention. For example, in this case,

a nutritionist would best able to address the specific needs of the community and answer specific

questions. Next, a structure that includes the use of interactive activities is beneficial because

active tools can be effective in teaching and engaging the participants. The Lao Nadi community

members enthusiastically participated and remained attentive during the rice serving portion

33


activity and meal planning activity, while appearing distracted during the lecture component.

Finally, remaining flexible to unforeseen circumstances and possible changes is a necessary

component of the intervention process. Planning research and a subsequent intervention involves

not only the considerations of the student group and CIEE, but also the outside parties. Changes

are inevitable and the research team will need to adapt. Even if change occurs, the intervention

can still be successful.

6.4 Future Considerations and Directions for Further Research

Future considerations and directions for further research can be based on aspects of this

intervention. More research could be conducted about actual levels of nutritional knowledge

since the research that has been conducted within the community was mainly focused on dietary

trends and habits. The attendance and participation of multiple children during the intervention

indicates that they could be a potential target group for future research since the research

conducted had previously been limited to those ages 30 and up. Interviewing individuals under

the age of 18 could possibly bring about ethical implications. Possible directions for research and

interventions involving a younger demographic could focus on investigating what is taught in

schools and the actual knowledge level of children. Men could be another population to further

target because the research results indicate that they have a need for nutrition education but were

absent in attendance from the intervention. Therefore, potential means for reaching out to them

could be explored. Lastly, it could be beneficial to interview a nutritionist at Khon Kaen

University to understand potential nutrition related issues that Thai people in the Isaan region

face and how they could be addressed.

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7. Acknowledgements

The Lao Nadi nutrition research team would like to extend a big thank you to the

individuals who made our research and intervention possible and successful. First, we would

like to thank Ajaans Toon and Nai for being incredibly prompt in their responses to all of our

group’s needs. Next, we would like to thank Ajaan Pattara for his helpful suggestions during the

research and intervention planning process. Third, Ajaan Jen and KJ provided extra academic

and moral support. Finally, we would like to thank the Lao Nadi headman for graciously

welcoming us into his home on multiple occasions and for helping us to advertise our

intervention over the community loudspeaker system.

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