thahin d/h/o intervention .docx file · web viewwithin the last few decades, thailand has...

Running Head: Diabetes in Thahin 1

Assessment of Individual Dietary Behavior and Diabetes Health Status among Adults in Thahin,

Thailand: A Correlational Study.

Public Health Field Practicum: Research Proposal

Khon Kaen University

Caroline de Bie, Desbelet Berhe, Diane Jang, Anisa Sanghrajka

Diabetes in Thahin 2

Executive Summary

Rapid globalization is occurring in almost every country, and Thailand is no exception.

As Thailand has experienced economic growth, it has also seen a shift in diet, from more

traditional dishes to more processed, high sugar and high fat foods. As a result, lifestyle related

diseases such as hypertension, obesity and diabetes have become increasingly more common. In

addition to the many people who are diagnosed as diabetic, there are thousands more who go

undiagnosed until symptoms are severe enough to seek care. Our research aims to measure the

susceptibility to diabetes among individuals in the Thahin community of Khon Kaen province.

By distributing questionnaires, we are seeking to find the correlation between dietary habits and

diabetes. With this information, we hope to design an appropriate intervention surrounding

nutrition and the prevention of type II DM. This may take the form of a nutrition seminar, a

cooking class or another educational program in the community.


Topic

Within the last few decades, Thailand has experienced rapid economic and social change.

With this change comes a change in dietary patterns, a nutrition transition from traditional foods

to a more Western diet. This has lead to a rapid increase in the prevalence of type II DM.

Almost 10% of Thai adults have been diagnosed with the disease (World Health Organization,

2012). Although this chronic disease is usually not very intrusive in everyday life, it can be very

dangerous and can cause diabetic comas, eye problems and circulation issues when left

unchecked. It also can increase an individual’s risk for heart disease, stroke and kidney failure

(WebMD).

In the Thahin community specifically, diabetes has been expressed as a great concern by

community members. During an interview conducted by CIEE students in the fall of 2013, a

village health volunteer responded that diabetes was one of the most important health concerns in

the community. Additionally, because there is a strong relationship with this community from

previous visits, Thahin is well-suited for research and interventions relating to diabetes.

Objectives

Prior to collecting data for the upcoming intervention in Thahin, it is essential to clearly

think through personal and group objectives. By administering a minimum of 30 questionnaires

to adults above the age of 18 throughout the community, we wish to assess the dietary behaviors

by measuring the frequency of specific food item intake. By measuring the prevalence and

susceptibility of diabetes in individuals, through data collected in the questionnaire, specific

interventions can be shaped for the near future. By assessing the community wants and needs, we

will be able to lay a solid foundation as to the approach of our intervention as well. Lastly,

building strong community relationships is extremely important, not only in the success of our


intervention, but also in the continuing of the strong relationship between CIEE, Khon Kaen

University’s Faculty of Public Health, and Thahin.

Research Question

The research question that will be explored is, “What is the correlation between dietary

behaviors and type II DM status among adults in Thahin?” We will measure dietary behaviors by

asking questions about food consumption, food purchasing, food preparation and dietary

restrictions. Because diet has been shown to be a risk factor for diabetes, we will distribute 30

questionnaires to show that individuals with high saturated fat, carbohydrates, and salt intake

have higher prevalence and susceptibility to type II DM among adults in Thahin.

Rationale for Study

CIEE Public Health students have had the opportunity of visiting Thahin numerous times

over the past several years, which has continued to give students insight into some of the health

issues that face the community. In an interview conducted with a village health volunteer in the

Fall 2013 semester, diabetes was identified as being one of the most pressing public health

issues. Looking more broadly, at Thailand and the northeast Isaan region, it is evident that this is

the case. By studying diabetes more in depth and gaining an understanding of its impact in

Thahin specifically, an effective intervention can be organized and conducted.

Literature Review

Background

Diabetes, or also known as diabetes mellitus, describes a group of metabolic diseases in

which an individual has high blood sugar due to the inability to process insulin effectively.

Approximately 90% of diabetes cases worldwide are classified as type II DM. Individuals with

type II DM produce insulin, however there is not enough being produced, or it is not effective.


Insulin is defined as a protein hormone synthesized in and secreted by the pancreas to regulate

blood glucose levels. Most commonly in type II DM, cells become insulin resistant which causes

blood glucose levels to uncontrollably increase. Carefully monitoring daily glucose levels,

nutrition, and exercise are crucial in keeping diabetes symptoms under control.

Risk Factors

In the Progress of Diabetes Control in Thailand, the World Health Organization reported

that 1 in 13 Thai’s are diagnosed with diabetes mellitus. A previous literature review on diabetes

management in Thailand, specifically focusing on the burden, costs, and outcomes, provided that

non-communicable disease in Thailand were estimated to account for 71% of all deaths:

cardiovascular diseases representing 27%, cancers 12%, and diabetes 6%. According to the

National Health Examination Survey 2009, the prevalence of diabetes was higher in urban areas

than rural areas. An important problem of diabetes in Thailand is the under-diagnosis therefore

delaying the treatment and care for the patient. Consequently, those with diabetes living in rural

parts of Thailand may face more health implications due to a late diagnosis.

The lack of exercise, smoking, drinking alcohol, unsuitable food consumption, and stress,

including in association with environmental problems, all contribute to the prevalence of

hypertension and diabetes mellitus in Thailand (Nakagasien). These risk factors are more

commonly associated with undiagnosed diabetes, and are a determinant of cardiovascular

disease. In an ethnographic study in Thailand, Dr. Nakagasien reported that the greatest number

of people with diabetes live in the Northeast region, and known as the Isaan region. Dr.

Nakagasien stated that “understanding the process of diabetes mellitus knowledge management

of people in the community is essential” to support the process of knowledge management.


Naemiratch and Manderson (2006), explored a previous ethnographic study conducted in

Bangkok, Thailand to uncover the perceptions of diabetes and its control, later finding the

importance of diabetes impacting everyday life. It is not until diabetes becomes visible and

intrusive, when patients start to worry and exercise control. For example, extreme rises in blood

sugar levels in an indicator that the patient should see the doctor more often in order to stabilize

their condition (Naemiratch and Manderson, 2006).

In the International collaborative study of Cardiovascular Disease in Asia, researchers

aimed to compare the prevalence and management of diabetes and the association of diabetes

with cardiovascular risk factors. After collecting data through a structured interview, a brief

examination, and a blood sample from 5,105 Thai adults age 35 and older (Aekplakorn, et al.) .

As a result, researchers concluded that the national prevalence of diabetes of Thai adults was

9.6% (2.4 million people), including 4.8%of though previously diagnosed and 4.8% of those

newly diagnosed. The issue of diabetes in Thailand is not the treatment accessible to the patients,

but rather the fact that only half of all cases are undiagnosed (Aekplakorn, et al). Since diagnosed

diabetes is treatable with low-cost, preventive therapies, research suggest that initiative focusing

on diagnosis rates would most likely produce health benefits in Thailand.

Diabetes is a growing global health issue. In 2025, it is projected that the number of

individuals with diabetes will rise to 300 million, with the greatest increases in developing

nations, including Thailand (Aekplakorn, et al.). In order to control the prevalence of diabetes

mellitus in Thailand, there is a need for health education on nutrition, an increase of screening in

high risk populations, identifying factors that affect poor treatment outcomes, and providing an

effective framework to track the progress. Furthermore, by executing an intervention in the

Thahin community in the Khon Kaen province, we plan on leaving middle-aged adults with


basic knowledge about the health risks of diabetes and nutrition, and changes they could

implement in their diet in order to reduce the onset of severe diabetes related symptoms.

Although there have been past research focusing on diabetes management and control

and teaching programs, there is still a failed attempt at uncovering the behaviors and trends

associated with people who have the condition but are not proactive in treatment. There are

thousands of Thais living in rural and isolated parts of Thailand who may not even know they

have diabetes until their condition has worsened enough to then see a doctor. Therefore, by

observing the Thai food chain and understanding the role of nutrition in diabetes mellitus, the

population can be provided with effective knowledge on how adapt to a healthier lifestyle.

Symptoms

Diabetes if not kept under control can lead to the development of more severe symptoms.

Some of these symptoms include increased hunger and thirst, frequent urination, unexplained

weight loss, fatigue, blurred vision, numbness or tingling of the hands or feet, slow healing sores

and cuts, dry and itchy skin, and frequent yeast infections. These symptoms can decrease one’s

quality of life and it is therefore important to control glucose levels before symptoms continue to

get worse. Other more overarching health concerns that are closely related to diabetes include:

mental health issues, hearing loss, hypertension, neuropathy, peripheral arterial disease, coma,

and stroke for example.

Dietary Intake

Individual diabetics need to keep in mind their dietary intake, as they as individuals must

keep their glucose levels in check. The American Diabetes Association outlined food suggestions

for type II diabetics suggesting that individuals should enrich their diet with calcium, potassium,

fiber, magnesium, and vitamins A, C, and E in correct portion sizes. Some of the “super-foods”


that are highly recommended include beans, dark leafy vegetables, citrus fruit, sweet potatoes,

berries, fish high in Omega-3 and fatty acids, whole grains, and fat-free milk and yogurt.

High sugar and alcohol intake can negatively impact the glucose control of a diabetic

patient. In order to make this process easier, there are several diet trackers and programs which

help to facilitate patient progress (American Diabetes Association, 2013).

Goals outlined in Diabetes Care discuss the short and long-term goals that should be

followed in order to reduce the impacts of diabetes. The goals are listed below:

1. To attain and maintain optimal metabolic outcomes specifically blood glucose levels,

lipoprotein profile, and blood pressure

2. To prevent and treat the chronic complications of diabetes by modifying personal lifestyle as

appropriate for the prevention and treatment of other diseases

3. To improve overall health through healthy food choices

4. To take into consideration personal and cultural barriers, including recognizing wish to change

and adapt (Diabetes Journal, 2013).

Using the above information, it is clear that individual food intake combined with other

factors, greatly impact diabetes in general. We plan on designing an intervention on the nutrition

within the Thahin community.

Cultural Eating Behaviors in Thailand

As previously mentioned, diet is a key factor in the development of type II DM. The

modern diet of northeastern Thailand in particular is highly likely to lead to this condition.

According to research done by Vongsulvat Kosulwat, the typical Isaan diet consists of dishes

such as sticky rice, grilled and fried meats, papaya salad, soups and ready-to-eat snacks. In more

urban areas like Bangkok, Thai staples are being replaced with pre-made, processed foods.


Across the country, the consumption of carbohydrates and fats has been steadily increasing since

the 1990s (2002). Additionally, the diversity of the Thai diet has greatly increased: there are

many more fruits, vegetables and animal products available at the markets (Dixon et. al., 2006).

The high consumption of sugars and fats across the entire country clearly correlate to the steady

increase in prevalence of diabetes.

Aside from the food itself, food purchasing and consumption practices greatly affect

one's health. The total amount of money spent on food in Isaan is a fair amount higher than the

amount of money spent in urban areas. The typical Isaan household spent approximately 37% of

their total budget on food in 1999, while urban families spent only 29% of their budget on food.

Also, the money spent on food from markets and convenience stores, which can be very high in

sugar and fat, has greatly increased over all of Thailand. In the northeast, the total proportion

almost doubled from 12.2% of food expenditures in 1990 to 21.7% in 1999. In urban areas, this

number is much higher, at about 50% of total food expenses. When food is prepared in the home,

it is most commonly either stewed, grilled or fried. Traditionally, dishes are served all at once

and shared amongst everyone (Kosulwat, 2002). Such practices have significantly impacted the

prevalence of diabetes mellitus in Thailand overall, but northeastern Thailand in particular has

seen the most rapid growth in this disease. Previous research has indicated that this is a serious

problem, and the reasons for higher growth in the Isaan region must be explored further.

Rationale for Questionnaire

For numerous previous research projects, researchers utilized Simplified Food Frequency

Questionnaire to assess participants’ individual dietary behaviors. Simplified Food Frequency

Questionnaire is consisted of a list of questions that ask about participants’ consumption

frequencies of foods and beverages. Then the nutrient intake can be estimated by multiplying the


frequency of each food by the amount of nutrients. We decided to base our questionnaires on the

Simplified Food Frequency Questionnaire because it is very easy to administer, represents the

usual intake of the participants, and has high validity despite the fact that Simplified Food

Frequency Questionnaire is relatively short and does not take into portion sizes. When Simplified

Food Frequency Questionnaire was compared with 7-day Estimated Diet Records, the

researchers found out that Simplified Food Frequency Questionnaire yields similar responses and

conclusions as 7-day Estimated Diet Records. The results were valid across most food groups

across different gender and age groups. The results for grains and sauces were only slightly

different (De Keyzer et al., 2013). There was also another study that assessed the validity of

Simplified Food Frequency Questionnaire conducted on Taiwanese elderly. They then compared

the responses with the 24-hour Dietary Recall and Biomarkers. Their results showed that the

responses from both dietary assessment tools are very similar, thus making the Simplified Food

Frequency Questionnaire valid. Also, the validity was high for dairy, fish, and fruit intakes for

both genders (Huang, Lee, & Wahlqvist. 2011). Therefore, we incorporated question types from

the Simplified Food Frequency into our questionnaires to increase the validity of our assessment

of individuals’ dietary behaviors.


Conceptual Framework

Figure 1. Conceptual Framework of Research in Thahin

The above diagram breaks down the conceptual framework that we have developed in the

design of our research. To start, our variables include individual dietary practices including the

intake of fats, carbohydrates, sugar, and salt, as well as measuring dependent variables including

prevalence and susceptibility by looking at family history, medical records, BMI, and blood

pressure. The objective of this research is to be able to measure the susceptibility of diabetes in

Thahin after collecting thirty surveys. The research question that will be focused on is, What is

the correlation between dietary behaviors and type II DM status among adults in Thailand. From

this research question, we expect to find that adults who consume high amounts of fats,

carbohydrates, sugars, and salt, will have a higher susceptibility of getting diabetes. The


reasoning behind focusing our research in this way is because the problem in Thahin, which we

are identifying is that poor nutritional behaviors can negatively impact an individual’s health,

specifically those who are susceptible to diabetes.

Methods

In this research study, data collectors will conduct questionnaires through interviews. We

will be targeting our questionnaires at the adult population in the Thahin community. Prior to the

interviews, we plan to introduce ourselves and the reasoning for our research. Interviews will be

conducted in the presence of a translator in order eliminate any language barriers. The translators

in this study will receive the survey ahead of time to be translated in Thai. The research that will

be conducted in the Thahin community includes both qualitative and qualitative methodologies

in our data collection. In accordance to the characteristics of quantitative and qualitative

methodologies presented in the Public Health Field Practicum Reading Packet, CIEE 2013, our

purpose is to measure actions, tendencies, and levels of knowledge carried out by our objectives

and variables (International Planned Parenthood Foundation, 2002).

Although the survey, found in the appendix A, is majority quantitative consisting of

close-ended questions carried out by predefined variables before data collection, we will also

utilize a qualitative approach in obtaining information on family history and medical records.

Implementing qualitative and quantitative strategies in the data collection will strengthen the

evaluation design and data analysis.

As shown in Figure 1, our objective is to measure the susceptibility of diabetes in the

Thahin community by looking at specific variables. In this study, the independent variable is the

individual dietary practices and the dependent variable is the prevalence and susceptibility. By

asking how one prepares their food, ingredients they use, frequencies and the amount, the data


collectors will use this evidence to better understand how their diets affects their health status

and susceptibility to diabetes.

Participants

The participants will be Thai men and women ages 18 and over from the Thahin Village,

Khon Kaen, Thailand. There is no participant requirement other than age. The participants can

either have or not have type II DM. Data collectors aim to reach a total of 30 participants,

recruited by convenience sampling method. One translator and four data collectors will walk

around the village and survey anyone who meets the age requirement. The surveys will be

conducted on the basis of the participants’ permission and comfortability.

Measures

Prevalence and susceptibility of type II DM. Participants’ demographic information

such as sex, age, and type II diabetic health status will be measured with simple survey

questions. The participants’ height and weight will be measured to calculate their Body Mass

Index (BMI). Also, with the help of Village Health Volunteers, we will measure the blood

pressure of each participant after conducting the questionnaire. Lastly, the participants will be

asked about the family history of type II DM and how often they exercise in order to assess

susceptibility of type II DM.

Dietary assessment. The questions that assess individual dietary behaviors are based on

the Simplified Food Frequency Questionnaire by Dr.Willet and his team at the Harvard School

of Public Health (2003). For questionnaires, please refer to Appendix 1.Through the survey

questions, the participants’ food intake frequencies will be assessed by recalling how many

times they ate certain food described in the questionnaires in the past week. Then, the individual

dietary behavior will be defined by dietary score based on the assigned scores for the frequency


of each food consumed (Question #16, Appendix A). Data collectors will also use a visible

representation to better gauge the amount of ingredients used in their foods, as indicated by the

following answer options : a little bit, moderate amount, a lot or none (Question #15, Appendix

A). With the use of a tablespoon and a measuring cup, we can better understand the amount of

these foods into ones diets, which will be helpful in our data analysis. For example, less than a

tablespoon indicates “a little bit,” a tablespoon is a moderate amount, and more than a tablespoon

is “a lot.” All of the responses for both measures will be anonymous to ensure participants’

privacy.

Data Analysis

It is important to note that we are assuming participants to answer the questionnaires as

honestly and accurately as possible. After gathering all the responses from the questionnaires,

descriptive statistics will be used to report participants’ demographic information and type II

diabetic status. According to a study conducted in a health check-up clinic in Khon Kaen,

Thailand, men who have a Body Mass Index (BMI) of ¿27, and women who are > 25 will be

classified as obese (Pongchaiyakul, et al., n.d.). The individual dietary score will be measured

according to the scores that we assigned to each food group (Appendix B).

The salt, sugar, and fat intake will be calculated by combining the amount of intake for

each group based on the participants’ responses for question number 15 (R. MSG, salt, and soy/

fish sauce will be categorized into salt group, sugar and condensed milk into sugar group, and

vegetable oil and butter into the fat group. For the dietary score, A (none) will score 4, B (little)

will score 3, C (moderate) 2, and then D (a lot) with 1. All the scores will be added up to yield

final score for each participant to assess their dietary behavior.


Then we will conduct correlation statistics to see what correlations exist between the the

individual dietary scores and Type II Diabetic health status. All quantitative data will be

analyzed using SPSS and Microsoft Excel. The qualitative data will be used as supplemental

information that will better prepare data collectors with the necessary tools and knowledge for a

future intervention project.

Discussion

After our research in the Thahin community is complete, it is expected that the data will

show a positive correlation between high fat, carbohydrate, sugar and salt intake and

susceptibility of diabetes. Our survey will ask questions about a variety of factors that can lead to

diabetes, such as food consumption and preparation, exercise patterns, and family history. These

questions will give us sufficient insight into each individual’s susceptibility to diabetes. In order

to make sure that our results are useful, as a group we will try to keep things as consistent as

possible so that the data is externally and internally valid. We will also take full advantage of the

time and resources given to us. We will try to successfully target subjects who will respond in

such a way that will clearly illustrate a relationship between the dependent and independent

variables in question without selection bias.

With the information collected, we will design an intervention to suit the needs of the

community while keeping in mind our own limitations, both in terms of time and resources. If

we find no correlation, we will deliberate on the next steps, conduct further research in the

community and decide on another feasible intervention that reflects the true needs of the

community. If we do find a positive correlation, we will potentially create education programs

based on cooking and nutrition to involve the whole community and have maximum impact. If a

nutrition program is not an expressed desire, we may incorporate exercise into an intervention


plan, which has also been shown to positively impact the course of diabetes and prevention.

Because diabetes has been expressed as a health concern in the community, an intervention

targeted at this topic will most likely be very well-received.


References

Aekplakorn, W., Suriyawongpaisal, P., Stolk, R., Neal, B., Woodward, M., Chongsuvivatwong,

V., & Cheepudomwit, S. (2003). The prevalence and management of diabetes in Thai

adults: The International Collaborative Study of Cardiovascular Disease in Asia.

Diabetes Care, 26(10), 2758-2763.

American Diabetes Association. (2013). What Can I Eat. Retrieved from

http://www.diabetes.org/?loc=logo

De Keyzer, W., Dekkers, A., Van Vlaslaer, V., Ottevaere, C., Van Oyen, H., De Henauw, S., &

Huybrechts, I. (2013). Relative validity of a short qualitative food frequency

questionnaire for use in food consumption surveys. European Journal Of Public Health,

23(5),737-742.

Deerochanawong, C., & Ferrario, A. (2013). Diabetes management in Thailand: a

literature review of the burden, costs, and outcomes. Globalization & Health, 9(1), 1-18.

Dixon, J., Banwell, C., Kanponai, W., Friel, S., Seubsman, S., & MacLennan, R. (2007). Dietary

diversity in Khon Kaen, Thailand, 1988-2006. International Journal Of Epidemiology,

36(3), 518-521.

Huang, Y., Lee, M., Pan, W., & Wahlqvist, M. (2011). Validation of a Simplified Food

Frequency Questionnaire as Used in the Nutrition and Health Survey in Taiwan

(NAHSIT) for the Elderly. Asia Pacific Journal Of Clinical Nutrition, 20(1), 134.

International Planned Parenthood Foundation (2002). Guide for Designing Results-Oriented

Projects and Writing Successful Proposals. Public Health Field Practicum Reading

Result, CIEE.

Kosulwat, V. (2002). The nutrition and health transition in Thailand. Public Health


Nutrition, 5(1A), 183-189.

Naemiratch, B., & Manderson, L. (2006). Control and adherence: living with diabetes in

Bangkok, Thailand. Social Science & Medicine, (5), 1147.

Nakagasien, P. (n.d.) Diabetes Mellitus Knowledge Management in the Rural Community: An

Ethnographic Study in Thailand. International Seminar Population and Development.

Nutrition Principles and Recommendations in Diabetes. (2004).American Diabetes Association.

Diabetes Care, 27S36-S46.

Pongchaiyakul, C., Nguyen, T.V., Wanothayaroj, E., Krusun, N., Klungboonkrong, V. (2007).

Prevalence of Metabolic Syndrome and Its Relationship to Weight in the Thai

Population. Journal for the Medical Association of Thailand, 90 (3), 459-467.

Tee, E., Dop, M., & Winichagoon, P. (2004). Proceedings of the workshop on food-consumption

surveys in developing countries: future challenges. Food And Nutrition Bulletin, 25(4),

407-414.

Type II DM (n.d.) Diabetes Health Center. WedMD. Retrieved from

http://diabetes.webmd.com/guide/diabetes_symptoms_types

Willett, W. (2003). Nurses’ Health Study II, Harvard School of Public Health and Harvard

Medical School. Retrieved from http://www.channing.harvard.edu/nhs/

World Health Organization (2004). Age-standardized Disability-adjusted Life Years (DALYs):

Diabetes Mellitus by Country.


Appendices

Appendix A. Questionnaire Diabetes in ThahinNovember 23, 2013

Good morning! Today, as American public health students studying at Khon Kaen University, we are trying to understand the impact of diabetes within the Thahin community. We greatly appreciate your participation in this survey. All of your responses will be anonymous.Please feel free to direct any questions you may have to our team.

Demographic

1. How old are you (years)? _________ years old

2. How much do you weigh (kg)? __________ kg

3. How tall are you (cm)? _________ cm

4. Do you have diabetes? Yes No

If yes, please kindly answer the following questions:

4a. Which type of diabetes do you have? Type I Type II Gestational Unknown

4b. How long have you been diagnosed with diabetes (in years)? ___________ years

4c. How often do you visit your doctor? _____________________

5. Do you have high blood pressure? Yes No

Family History

6. Does anyone in your immediate family (parents, grandparents, siblings) have diabetes? Yes No

7. Does anyone in your immediate family have high blood pressure? Yes No(parents, grandparents, siblings) Exercise


8. How often do you get physical activity (voluntarily or/and occupationally) ?

ퟀ a. Never ퟀ b. 1 - 2 a week ퟀ c. 3 - 6 times a week ퟀ d. Everyday ퟀ e. Other. Please specify _________________

Nutrition

9. Have you had any exposure to a nutritional program in the past? Yes No

If yes, please specify when: __________________

10. Do you have any dietary restrictions? Yes No

If yes, please specify ______________________

11. Do you think diabetes is a big issue in this community? Yes No

12. Where do you get most of your food from? __________________________________

13. Every week, how many times do you buy food to eat? _________ times

14. Every week, how many times do you cook for yourself? ____________ times

15. How much of the following ingredients do you cook with on a regular basis?


Ingredient A B C D

MSG

Salt

Sugar

Vegetable Oil

Butter

Condensed Milk

Soy/ Fish Sauce

A: NoneB: A lit bitC: A moderate amountD: A lot

16. Last week, how often did you consume the following foods?


Food Never Once 2-3 times 4-5 times 6-7 times

Dairy (cow milk, soy milk, yogurt)

Fruits

Boiled/steamed Vegetables

Stir-fried Vegetables

Deep-fried Vegetables

Boiled/steamed Meat/ Fish

Grilled Meat/Fish

Stir-fried Meat/Fish

Deep-fried Meat/Fish

Fried Egg

Deep-fried Egg

Boiled Egg

Rice/Noodles

Sticky rice

Soda

Alcohol


Chocolate, Candy, Chips

Appendix B. Dietary Scores. 4 being the healthiest to 0 being the least healthy

Food Never Once 2-3 times

4-5 times

6-7 times

Dairy (cow milk, soy milk, yogurt)

0 1 2 3 4

Fruits 0 1 2 3 4

Boiled/steamed Vegetables 0 2 3 4 4

Stir-fried Vegetables 0 2 3 2 0

Deep-fried Vegetables 4 3 2 1 0

Boiled/steamed Meat/ Fish 0 1 2 3 4

Grilled Meat/Fish 0 1 2 3 3

Stir-fried Meat/Fish 0 1 2 1 0

Deep-fried Meat/Fish 4 3 2 1 0

Fried Egg 2 4 3 2 1

Deep-fried Egg 4 3 2 1 0

Boiled Egg 0 1 2 3 4

Rice/Noodles - - - - -


Sticky rice 4 3 2 1 0

Soda 4 3 2 1 0

Alcohol 4 3 2 1 0

Chocolate, Candy, Chips 4 3 2 1 0

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