CIN: Computers, Informatics, Nursing
& Vol. 32, No. 5, 232–241 & Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
F E A T U R E A R T I C L E
Development and Application of a Web-Based Nutritional Management Program to Improve Dietary Behaviors for the Prevention of Metabolic Syndrome YOON CHOI, PhD MIN JUNE LEE, PhD HEE CHEOL KANG, MD MEE SOOK LEE, MS, RN SUN YOON, PhD
Metabolic syndrome (MetS) is characterized by a cluster of disorders such as impaired glucose metabolism, central obesity, dyslipidemia, and hypertension, all of which increase the risk of chronic diseases including cardiovascular disease and type 2 diabetes and pose a serious health concern.1,2 Recent studies have shown that individuals with MetS are twice as likely to develop cardiovascular disease3,4 and 3.5 to 5 times more likely to develop type 2 diabetes.5 According to the 2008 Korean National Health and Nutrition Examination Survey (KNHANES), the prevalence of MetS was 25.98% in men and 20.39% in women, when applying the Asia-Pacific abdominal obesity criteria of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III. The prevalence of MetS in men older than 30 years was higher at 31.9%.6 In addition, office work tends to aggravate the progress of lifestyle-related diseases due to work-related stress, frequent eating out, frequent alcohol intake, and lack of exercise. A previous study reported that lifestyle modification programs reduce risk factors for cardiovascular disease and effectively improve the dietary habits and lifestyles of office workers.7 232
The purpose of this study was to develop a Webbased nutritional management program for the prevention of metabolic syndrome and to evaluate how the program affects health-related behaviors and the health status of office workers with metabolic syndrome risk factors. For the pilot test of the Web-based nutritional management program, 29 employees (19 males, 10 females) with more than one metabolic syndrome risk factor participated in the Web-based nutritional management program for 16 weeks. Participants visited the Web site more than two times per week and completed customized assessments of health status, smoking habits, alcohol consumption, dietary habits, food intake, ideal body weight, energy requirements, and exercise. Subjects had a significant decrease in body weight, waist circumference, body mass index (P G .01 in males, P G .05 in females), and body fat (P G .01 in males). The frequency of dietary habits such as eating snacks, eating out, and dining with others decreased, whereas the frequency of intake of foods such as whole grains, seaweed, fruit, and low-fat milk increased after intervention. After 16 weeks, program satisfaction was evaluated using a Web evaluation questionnaire, and most of the participants were highly satisfied with Web site components such as the loading speed, configuration, privacy, design, functionality, and contents. KEY WORDS Dietary behaviors & Metabolic syndrome & Office workers & Program satisfaction & Web-based nutritional management program
Author Affiliations: Department of Food and Nutrition, Brain Korea 21 Project, College of Human Ecology, Yonsei University (Drs Choi, Lee, and Yoon); Department of Family Medicine, Shinchon Severance Hospital, Yonsei University College of Medicine (Dr Kang); CoreMed Co Ltd, Ubiquitous Healthcare Company (Mrs Lee), Seoul, Korea. This project was conducted through the generous financial support of the CoreMed Corporation in Korea and the Brain Korea 21 Project, College of Human Ecology, Yonsei University. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Sun Yoon, PhD, Department of Food and Nutrition, College of Human Ecology, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-749, Korea ([email protected]). DOI: 10.1097/CIN.0000000000000054
CIN: Computers, Informatics, Nursing & May 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LITERATURE REVIEW Recently, several studies have reported that MetS requires lifestyle modification in addition to medical treatment and that modification of diet and exercise can delay the development of MetS.8–13 The results of providing a multicomponent health promotion program including nutrition, exercise, and stress management showed that body weight, blood pressure, and levels of total cholesterol (TC) and triglycerides (TGs) are improved.14 A multiple behavior intervention specifically designed for MetS led to significant reductions in blood pressure, and waist circumference, and in the levels of fasting blood glucose (FBG) and TGs.15 In another study, among various lifestyle modification components including physical activity, weight control, dietary habits, and alcohol and smoking, management of dietary habits was found to be the most effective way to decrease the risk of MetS.16 Another study showed that FBG levels and abdominal obesity could be improved through a 12-week nutritional education program.17 In persons without diabetes, but with elevated fasting and postload glucose concentrations, changes in lifestyle through a low-calorie and low-fat diet and 150 minutes of exercise per week led to decreased blood glucose levels, indicating that lifestyle modifications focused on the improvement of dietary habits are important for MetS prevention.18 In a study examining the effect of a lifestyle modification program on MetS in male office workers, a 12-week customized health program that promoted proper nutrition, no smoking, moderate alcohol intake, and more frequent exercise resulted in reduced levels of TC, TGs, FBG, and systolic blood pressure (SBP).19 However, health programs that involve face-to-face interviews are time-intensive, expensive, and inconvenient because direct visits are necessary.20 Moreover, most primary care practitioners tend to offer prescription medications rather than provide proper and sufficient counseling and education for lifestyle modifications.21 This tendency results from the limited time available to educate patients and the lack of professional human resources available for counseling.22 Internet-based interventions, on the other hand, are convenient and economical, involve multimedia elements such as audio and video, and have no time constraints. In addition, these interventions can provide customized information depending on user needs, preferences, and educational goals.23–26 In fact, it has been reported that Internet-based nutritional counseling and educational programs help establish a user’s motivation to modify dietary habits and physical activities through interactive features, strategies, and opportunities to provide and receive support and encouragement from other users.27,28 In a previous study, 787 workers enrolled in a 16-week healthcare management program via e-mail showed improved dietary habits and increased physical activity.29 Moreover, another study demonstrated the effectiveness of an online customized
intervention program for improving nutritional status, reducing smoking, and increasing physical activity.30 However, many studies have focused primarily on weight control, which is insufficient to manage disorders such as MetS with complicated health risk factors.
GOAL OF THE STUDY In this study, a Web-based nutritional management program (WBNMP) was developed to improve dietary behaviors and prevent and manage MetS. When creating the online content, the goal was to provide the following: (1) a customized evaluation through regular assessments of lifestyle and nutritional status; (2) tailored information and educational resources for disease, nutrition, and exercise management; and (3) nutritional counseling with a clinical dietitian regardless of the time and place. In addition, an online intervention was conducted via the Web site prototype to evaluate the effect of MetS management on office workers and to optimize user utility through a user satisfaction survey. Finally, this study evaluated the WBNMP in the context of workplace applicability.
METHODS Development of a Web-Based Nutritional Management Program This study used a nutritional management program for the prevention and management of MetS that consisted of four sections: ‘‘health and lifestyle management,’’ ‘‘nutritional status assessment,’’ ‘‘nutritional counseling,’’ and ‘‘healthcare information.’’ A family medicine doctor, dietitians, a research nurse, a computer programmer, and a Web designer participated in the development of the program. (1) Health and Lifestyle Management
This section consisted of a file for the input of anthropometric and biochemical data such as height, weight, waist circumference, body mass index (BMI), body fat, blood pressure, FBG, TC, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and TGs, as well as a file for the input of lifestyle questionnaires such as dietary habits, alcohol consumption, smoking, and physical activity. The number of drinks per week and amount of alcohol per session were recorded as were the current smoking status, smoking history, and number of cigarettes per day. The type of exercise, number of exercise sessions per week, and exercise duration and intensity were also noted. Dietary habits were characterized by the frequency of eating late at night, eating snacks, eating out, and dining with others.31,32 Participants were also asked how frequently they ate 14 key
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foods: whole grains, fish, beans, vegetables, seaweed, fruit, low-fat milk, meat, Chinese food, fast food, fried food, Ramen, cakes/pies, and sweets. All of these foods are thought to be related to the development or prevention of MetS, based on the KNHANES food frequency questionnaire.31 Finally, a customized assessment of health status and dietary habits was created based on all of the aforementioned data, using the criteria described in the National Health Information Portal (http://health.mw.go.kr),32 Korea Centers for Disease Control and Prevention (http:// www.cdc.go.kr),33 and Korean Dietetic Association (http:// www.dietitian.or.kr).34 (2) Nutritional Status Assessment
The degree of obesity, ideal body weight, and daily required energy levels were calculated based on users’ current weight, height, and physical activity. For those who needed to control or reduce their weight, the Conventional Calorie-Restricted Meal Plan, 500 kcal less than the recommended energy level, was used for the daily required energy level.35,36 The online food diary allowed users to input the type and amount of food they had for breakfast, lunch, dinner, and snacks. The Computer Aided Nutritional Analysis Program (CanPro 3.0 Professional) from the Korean Nutrition Society (Seoul, Korea) was used as the basic database for nutrition information and food group classifications. Energy input, intake of 15 key nutrients, and assessments of each daily meal were automatically evaluated and expressed as ‘‘under,’’ ‘‘normal,’’ or ‘‘over’’ based on the 2010 Dietary Reference Intakes for Koreans.37 If nutritional status was ‘‘under’’ or ‘‘over,’’ examples of major foods containing the relevant nutrients were suggested along with recommendations for decreased or increased intake. Guidelines for the prevention of diseases related to the intake status of relevant nutrients were also included. Food diaries were saved so that a dietitian could review them regularly and evaluate a user’s diet history before sending an organized evaluation sheet to the user via e-mail once a month. (3) Nutritional Counseling
Online nutritional counseling with a dietitian was possible through an online forum and by e-mail. Inquiries for counseling received a response within 24 hours. Frequently asked questions organized into three categories—clinical, nutrition, and exercise—were answered in an FAQ section. A forum was created for program users to share information and freely converse. (4) Healthcare Information
Healthcare information was divided into disease information, nutrition information, and exercise information. ‘‘Disease information’’ consisted of material on the prevention and management of MetS, obesity, dyslipidemia, hypertension, diabetes, stroke, heart disease, and fatty liver disease. Pictures were also provided for ease of comprehension. 234
‘‘Nutrition information’’ included material on the functions of nutrients, the importance of balanced meals, the principles and goals of diet therapy for each disease, the implementation and cautions of diet therapy, and the anticipated effects of each therapy. Information about meal management was provided via flash files (animations) and images. Through a food exchange list, information was provided on carbohydrates, protein, fat, and calories in terms of exchange units, along with a visual estimate of serving sizes.38 In addition, a 7-day ‘‘menu by calorie (1400, 1600, 1800 kcal),’’ the glycemic index, guidelines for eating out, and restricted and recommended foods were also included in the online content. Nutritional education materials for the management of MetS consisted of 10 topics as follows: (1) What is MetS? (2) abdominal obesity and MetS, (3) dietary principles for weight loss, (4) dyslipidemia and MetS, (5) dietary principles for dyslipidemia treatment, (6) hypertension management, (7) dietary principles for diabetes management, (8) health management by quitting smoking, (9) drinking and MetS, and (10) exercise strategies for the prevention of MetS, with reference to the Metabolic Syndrome Management Center of Seoul (http://www.5check.or.kr).39 ‘‘Exercise information’’ included material on exercise methods, types, intensity, and cautions depending on body shape and physical indices along with pictures. The importance of exercise for the prevention and management of diseases was explained.
Layout and Operating System of the Web-Based Nutritional Management Program The program Web site was developed jointly with CoreMed Co, Ltd (Osaka, Japan). The layout of each section of the program is shown in the Figure 1. The background color of the Web site was light yellow and white, and the text font size ranged from 12 to 16 points, primarily in dark green or black. All pages used the same format, because usability is enhanced when the format of each page is consistent. To design an interactive Web site, the screen-based controls (widgets) included links, push buttons, check boxes, dropdown lists, and entry fields created in the home page and subsequent pages. All Web site content was designed in print format so that information would print out as seen on the computer screen. The program requires an operating system of Windows 2003 or newer, and the language used to develop the program was ASP.Net(C#) (Microsoft, Redmond, WA) for the server and HTML/Java script (Mozilla Foundation, Mountain View, CA) for the client. Web server IIS 6.0 or newer, database MS-SQL Server 2005 or newer, CPU Intel Core 2 Quad, and RAM 4GB are required for the program to operate efficiently. All parts of the database, including personal information and outcomes, are protected with SSL encryption. Security and restriction of the program ensure that only
CIN: Computers, Informatics, Nursing & May 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
FIGURE 1. Illustration of the WBNMP. A, Homepage. B, Health and lifestyle management. C, Nutritional status assessment. D, Nutritional counseling. E. Healthcare information.
authenticated users with authorized permission are able to view the allowed content and to participate in the forums. The research staff, a dietitian, a nurse, and Web programmers/designers tested the WBNMP prototype for design, content, ease of use, and browser errors in the data flowsheets. Any errors discovered were discussed by both the Web site development team and the research team and resolved before the start of the online intervention.
ONLINE INTERVENTION USING THE WEB-BASED NUTRITIONAL MANAGEMENT PROGRAM A pilot test of the WBNMP was conducted to evaluate its effectiveness for preventing MetS from May 2010 to April 2011. The institutional review board of Yonsei University approved all study protocols. Participants included male and female office workers, aged 20 to 60 years, who had at least one risk factor for MetS and had access to a computer. Pregnant and lactating women and individuals with
a serious illness were excluded. The criteria for MetS were based on NCEP Adult Treatment Panel III40 (fasting plasma glucose Q100 mg/dL, blood pressure Q130/85 mm Hg, TGs Q150 mg/dL, HDL cholesterol G40 mg/dL [male] G50 mg/dL [female]), and waist circumference was based on the World Health Organization Asia-Pacific abdominal obesity criteria41 (male 990 cm, female 980 cm). Before starting the 16-week program, at a health service center (offline), participants provided written informed consent and met with the researcher in person to learn how to use the program and how to complete the online food diary (dietary records). As part of the MetS diagnosis, height, weight, and body fat (Inbody 230; Biospace, Seoul, Korea) were measured. Waist circumference was also measured 2.5 cm above the navel using a tape measure, and fasting blood samples were collected for baseline data. All individuals who decided to participate in the study received program instructions, ‘‘the Recent Calorie Book’’ (Samsung Publisher, 2010), and the results sheet of their body composition measurements. The starting point for the online intervention was considered to be when a participant generated his/her user ID
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and password and logged in to the program for the first time. Participants were encouraged to visit the Web site at least twice a week. During the first visit, participants completed online questionnaires about alcohol intake, smoking habits, physical activities, dietary habits, and frequency of food intake in the ‘‘Health and lifestyle management’’ section. Participants then automatically received an overall evaluation including guidelines on health status and dietary habits, along with assessments of their anthropometric measurements and blood analysis data that had been previously entered by the researcher. Participants were asked to enter dietary information in the online food diary in the ‘‘Nutritional status assessment’’ section at least three times a month (twice on weekdays and once on weekends), and meal evaluations were presented immediately after participants provided details about a given meal. A dietitian analyzed diet history based on the online food diaries and then arranged an assessment sheet that was e-mailed to participants monthly. The assessment contained an evaluation of nutrient intake status, menu selection, and dietary habits. Education materials for MetS management were e-mailed weekly for 10 weeks, and nutrition counseling was frequently provided by e-mail and through an online forum during the study period. After participation in the 16-week program, participants completed an online survey about alcohol intake, smoking habits, physical activities, dietary habits, and frequency of food intake. A program satisfaction survey, modified from the Web evaluation method of the American Customer Satisfaction Index (ACSI), was conducted through e-mail; it contained 14 questions related to Web site performance, privacy, design, necessity, reliability, and diversity.42,43 In addition, anthropometric measurements were taken, and blood samples were collected and analyzed at a health service center (offline). Five months after the intervention, a follow-up study was conducted through an online questionnaire about dietary behaviors and frequency of food intake to determine whether the effects of the nutritional management program had continued beyond the intervention.
mean adequacy ratio (MAR) were used to evaluate the quality of nutrient intakes.44 The ratio of daily individual intakes to the standard recommended amounts for a subject’s gender and age category was used to calculate NARs. The standard recommended amounts were based on the 2010 Dietary Reference Intakes for Koreans. The NARs for 10 nutrients including protein, vitamin A, vitamin B1, vitamin B2, niacin, vitamin C, folic acid, calcium, iron, and zinc were estimated. The MAR was calculated as the sum of the NARs divided by the number of nutrients (n = 10).
Data Analysis
CHANGES IN BLOOD PRESSURE, BLOOD LIPIDS, AND BLOOD GLUCOSE LEVELS
STATISTICAL ANALYSIS All data were analyzed using SPSS version 18.0 (IBM, Armonk, NY) and are presented as the mean (SD). Changes in anthropometric measurements, blood analysis, and food intake data were analyzed using a paired t test, and program satisfaction was analyzed with an independent t test. In the follow-up study, changes in dietary behaviors and food intake frequencies were analyzed using a paired t test.
RESULTS Outcome of Online Intervention DESCRIPTION AND ANTHROPOMETRIC CHANGES OF PARTICIPANTS To assess the effects of the WBNMP, 29 office workers (19 males and 10 females) participated for 16 weeks. The average age was 44.2 (SD, 10.58) years for males and 32.1 (SD, 8.10) years in females. Participants were included if they took any of the following medications: oral hypoglycemic agents (n = 1 among males), antihypertensive agents (n = 5 among males, n = 3 among females), and lipid-lowering agents (n = 3 among males). None changed their course of medications during the intervention. According to criteria established by the Korean Society for the Study of Obesity, males in this study were obese, with an average BMI greater than 25 kg/m2. Females, on the other hand, had an average BMI of 23.5 kg/m2 and tended to be overweight rather than obese. In females, waist circumference was slightly higher than the reference value for obesity (G80 cm, NCEP ATP III criteria). After 16 weeks, body weight, waist circumference, BMI, and body fat decreased significantly in males (P G .01), and body weight, waist circumference, BMI, and body fat decreased in females, although not significantly (Table 1).
In males, SBP and TGs tended to be high, but FBG, TC, HDL-C, and LDL-C were relatively close to normal. In females, BP, FBG, and blood lipid patterns were normal. After 16 weeks, SBP (P G .01), diastolic blood pressure, TG, and TC (P G .05) in males had decreased significantly, and FBG and blood lipid patterns tended to improve. In females, most parameters were maintained at normal levels (Table 1).
DETERMINATION OF NUTRIENT INTAKE DATA
CHANGES IN DIETARY HABITS AND FREQUENCY OF FOOD INTAKES
Data on nutrient intakes were collected from the dietary records entered in the online food diary for 16 weeks (3 days per 4 weeks). Nutrient adequacy ratios (NARs) and
Changes in dietary habits and frequency of food intake are shown in Table 2. In males, dietary habits such as eating late at night, eating snacks, eating out, and dining
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CIN: Computers, Informatics, Nursing & May 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
T a b l e 1 Changes in Anthropometric and Blood Biochemical Data Male (n = 19) Variables Age, y Height, cm Weight, kg WC, cm BMI, kg/m2 Body fat (%) SBP, mm Hg DBP, mm Hg FBS, mg/dL TGs, mg/dL TC, mg/dL LDL-C, mg/dL HDL-C, mg/dL
a
Baseline 44.2 (10.58) 172.2 (5.51) 78.9 (8.25) 91.1 (6.80) 26.6 (2.53) 25.1 (5.58) 130.9 (7.81) 80.7 (6.31) 99.1 (17.99) 172.2 (75.93) 197.8 (31.13) 107.9 (30.31) 55.4 (15.83)
Female (n = 10) 16 wk
b
77.3 (8.44)c 88.8 (6.08)c 25.0 (2.63)c 23.6 (5.20)c 124.9 (8.01)c 77.0 (5.76)d 95.7 (10.57) 143.8 (56.77)d 188.2 (22.92)d 106.1 (23.30) 53.47 (16.96)
Baseline 32.1 (8.10) 158.7 (4.37) 59.4 (4.71) 81.6 (4.95) 23.5 (1.88) 32.8 (4.52) 110.1 (9.85) 68.0 (8.10) 82.1 (5.22) 90.4 (38.1) 174.5 (32.5) 97.2 (24.8) 60.7 (12.3)
16 wk
58.5 (4.79)d 79.6 (5.23)d 23.2 (1.65)d 32.4 (3.58) 108.6 (9.20) 67.8 (8.47) 84.5 (3.78) 76.8 (25.9) 178.4 (40.9) 98.2 (25.5) 60.4 (38.1)
Values are presented as mean (SD). Abbreviations: DBP, diastolic blood pressure; WC, waist circumference. a Before participating in the program. b Sixteenth week of the intervention. c P G .01 by paired t test. d P G .05.
with others decreased significantly after 16 weeks (P G .001). In females, eating snacks (P G .01), eating out (P G .001), and dining with others (P G .01) decreased significantly after 16 weeks compared with baseline. Males consumed whole grains, seaweed, fruit, and low-fat milk more frequently (P G .001), and they consumed meat, fast food, and simple sugars less frequently (P G .01) compared with baseline. Females consumed whole grains, fish, beans, seaweed, and fruit more frequently, and they consumed Chinese food, fast food, fried foods, and simple sugars less frequently (P G .05 to P G .001). The follow-up study conducted to determine whether changes in dietary habits and food intake continued 5 months after the nutritional management program showed that both males and females generally maintained their new dietary habits and food intake. However, males were eating sweets more frequently compared with the end of the 16-week study (P G .05), and females were eating more simple sugars and saturated fats compared with the end of the 16-week study (P G .05). Snack intake also increased, although not significantly, in both males and females. CHANGES IN NUTRIENT ADEQUACY RATIOS AND MEAN ADEQUACY RATIO In this study, it was important to increase the quality of meals because participants carried out a calorie restriction diet to manage overweight and central obesity. The findings of the study indicated that the MARs were mostly improved in both males and females during the intervention except for vitamin C and folic acid. The MAR scores, used as a measure of the adequacy of an overall diet,
increased significantly in both males and females after 12 weeks (Table 3). CHANGES IN ALCOHOL CONSUMPTION, SMOKING, AND PHYSICAL ACTIVITY At the beginning of this study, 75.9% of the males drank, 37.9% did not exercise, and 17.2% smoked. None of the 10 females in this study smoked, 60% drank, and 30% did not exercise. After 16 weeks, there were no significant changes in alcohol consumption, smoking, or physical activity (data not shown).
Program Satisfaction The results of the program satisfaction survey are shown in Table 4. Participants expressed overall satisfaction with the program. More specifically, they were satisfied with loading speed, ease of use, clarity of site organization, security of personal information, site layout, and usefulness of the information. The information provided was considered to have very high reliability, and the content was considered to be diverse. The participants indicated that an online nutritional management program was very necessary for the prevention and management of MetS and that they were interested in introducing the program to their coworkers, family, and friends.
DISCUSSION The WBNMP is a program that was developed to assess an individual’s dietary habits and lifestyle through various
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T a b l e 2 Changes in Dietary Habits and Frequency of Food Intake Male (n = 19) Variables
Baseline
Eating late at night Eating snacks Eating out Dining with others Whole grains Fish Beans Vegetables (excluding kimchi) Seaweed Meat Chinese food Fast food Delivery food Ramen Fried food Cakes, pies, pastries Sweets Fruit Low-fat milk
3.1 9.6 25.7 3.5 16.4 7.3 11.0 15.4 8.6 8.9 3.8 3.9 2.3 3.0 2.3 1.6 4.4 15.3 16.4
a
(3.16) (9.75) (21.1) (2.79) (13.7) (4.71) (4.36) (8.70) (6.95) (6.53) (3.85) (5.65) (3.17) (2.52) (3.28) (2.55) (3.18) (8.92) (18.0)
16 wk
Female (n = 10)
b
Follow-up
0.8 (1.52)d 8.4 (9.80)d 22.5 (17.5)d 3.3 (2.74)d 21.7 (15.6)d 9.8 (6.31) 12.1 (5.03) 19.0 (8.04) 8.7 (8.8)d 7.4 (4.9)f 2.0 (2.51) 1.9 (2.69)d 1.2 (2.54) 2.1 (1.80) 0.63 (0.76) 1.2 (1.53)f 2.5 (1.74)h 16.4 (18.0)d 26.4 (14.8)d
c
2.0 (2.54) 8.8 (9.58)e 14.8 (19.0) 3.3 (4.70) 22.1 (17.7)g 7.0 (5.53)i 11.6 (2.86) 16.9 (8.26) 8.0 (5.61) 5.5 (5.97)g,i 1.64 (1.11) 1.1 (1.40)g 1.6 (0.79) 2.7 (1.55) 1.3 (1.33) 1.3 (1.86) 4.4 (3.97)i 18.8 (17.5)e 27.8 (17.8)g
Baseline 2.5 13.9 21.0 0.75 13.0 2.7 11.0 11.7 5.6 7.1 2.3 3.9 1.3 2.4 1.1 2.6 5.6 11.5 9.0
a
(2.75) (9.91) (18.4) (0.79) (12.0) (1.69) (7.42) (7.04) (3.65) (5.59) (1.35) (3.76) (1.26) (1.63) (1.32) (3.17) (3.65) (7.90) (4.81)
16 wkb
Follow-upc
0.6 (2.02) 12.4 (8.20)f 22.4 (17.3)d 0.6 (0.77)f 18.2 (8.09)h 5.3 (4.06)h 13.0 (7.79)f 18.6 (9.79) 5.9 (3.39)d 6.5 (3.64) 2.0 (1.18)f 1.9 (1.34)d 0.4 (0.72) 1.7 (1.47) 0.3 (0.63)h 2.7 (4.25)f 5.7 (4.57) 18.0 (6.64)h 17.5 (8.96)
0.5 (0.86) 13.2 (1.96) 20.0 (8.66) 0.5 (0.86) 17.8 (10.1)e 4.3 (3.81) 13.3 (8.91)e 16.7 (1.75) 5.5 (3.78) 6.0 (5.78) 2.2 (1.05) 2.1 (3.35)g,i 0.4 (1.88) 2.5 (2.39) 0.9 (0.01) 2.7 (5.84)e 6.1 (9.11) 17.6 (5.67)e 15.7 (5.66)
Values are presented as mean (SD): times per month. a Before participating in the program. b Sixteenth week of the intervention. c Five months after the intervention. d P G .001 (baseline and 16 weeks). e P G .05 (baseline and follow-up) by paired t test. f P G .01 (baseline and 16 weeks). g P G .01 (baseline and follow-up) by paired t test. h P G .05 (baseline and 16 weeks). i P G .05 (16 weeks and follow-up).
T a b l e 3 Changes in Nutrient Adequacy Ratios and Mean Adequacy Ratio Male (n = 19) Baseline NARs Protein, g Vitamin A, HgREf Vitamin B1, mg Vitamin B2, mg Niacin, mg Vitamin C, mg Folic acids, Hg Calcium, mg Iron, mg Zinc, mg MAR
1.1 1.2 0.9 0.8 1.0 1.0 0.7 0.6 1.2 0.8 1.0
a
(0.3) (1.1) (0.3) (0.3) (0.3) (1.0) (0.4) (0.2) (0.5) (0.2) (0.4)
8 wk 1.1 1.0 0.8 0.7 0.8 0.8 0.5 0.6 1.0 0.8 0.9
(0.3) (0.5) (0.3) (0.3) (0.3) (0.7) (0.2) (0.3) (0.3) (0.2) (0.3)
12 wk 1.1 1.2 1.0 1.0 1.0 0.9 0.6 0.7 1.0 0.8 1.0
(0.4) (1.1) (0.4)f (0.4) (0.4)f (0.4) (0.3) (0.3) (0.3) (0.2) (0.3)
Female (n = 10) 16 wk 1.3 1.1 1.1 1.0 1.1 0.9 0.6 0.8 1.2 1.0 1.1
(0.4)b,c,d (0.6) (0.6)c (0.4)b,c (0.3) (0.3) (0.1) (0.4) (0.4) (0.4) (0.3)e
Baseline 1.1 1.3 0.8 0.7 0.7 0.7 0.5 0.7 0.7 0.7 0.8
a
(0.3) (1.8) (0.3) (0.3) (0.2) (0.6) (0.7) (0.5) (0.6) (0.1) (0.4)
8 wk 1.1 1.5 0.9 0.8 0.7 0.7 0.6 0.6 0.7 0.7 0.8
(0.3) (1.9) (0.3) (0.2) (0.3) (0.6) (0.6) (0.4) (0.5) (0.2) (0.4)
12 wk 1.4 0.8 1.0 0.7 0.9 0.7 0.5 0.5 0.7 0.9 0.9
(0.3) (0.4) (0.5) (0.2) (0.2) (0.6) (0.1) (0.2) (0.3) (0.3) (0.3)
16 wk 1.7 1.2 1.0 1.1 1.1 0.6 0.7 1.0 1.1 1.2 1.1
(0.4)e (0.7) (0.2) (0.3)e (0.3)c (0.1) (0.2) (0.3)c,g (0.6) (0.3)c (0.2)e
Values are presented as mean (SD). a Before participating in the program. b P G .05 (baseline and 16 weeks). c P G .05 (8 and 16 weeks). d P G .05 (12 and 16 weeks) by paired t test. e P G .01 (baseline and 16 weeks). f Retinol equivalent (RE). g P G .01 (12 and 16 weeks) by paired t test.
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T a b l e 4 Investigation of Program Satisfaction With the ACSI Methoda Category Site performance Search Navigation Privacy Design Functionality Content Satisfaction Primary resource Recommendation Willing to pay
Items
Male (n = 19)
Speed of loading Ease of use Comprehensiveness of search results Clarity of site organization Security of personal information Clean layout Usefulness of the health information provided Necessity of online nutritional management program Reliability of the information provided Diversity of the information provided Overall satisfaction Primary resource for health information Recommend to others Willing to pay for nutritional management program
4.1 3.8 3.8 3.8 3.8 3.7 3.8 4.3 4.3 4.0 4.1 3.6 4.1 2.3
(0.73) (0.50) (0.60) (0.50) (0.80) (0.63) (0.76) (0.67) (0.47) (0.88) (0.60) (0.88) (0.68) (0.59)
Femaleb (n = 10) 3.9 3.7 3.5 3.9 3.9 3.5 4.0 4.2 4.2 4.3 4.3 4.2 4.6 3.0
(0.73) (0.48) (0.52) (0.31) (0.73) (0.52) (0.66) (0.63) (0.42) (0.67) (0.48) (0.78) (0.51) (0.94)
Values are presented as mean (SD). Five-point Likert scale (high score denotes strong agreement). a These standardized questions were modified for this study from the ACSI survey methodology. b A t test revealed no significant differences between males and females.
online content, to provide customized professional dietary and lifestyle management services depending on an individual’s MetS risk factors, and to reinforce nutritional management. In this pre-post intervention, the WBNMP was applied to workers with MetS risk factors for 16 weeks and resulted in decreased body weight, waist circumference, BMI, and body fat in both males and females. It also led to improvement in blood profiles such as blood pressure, TGs, and TC. Dietary behaviors, frequency of food intake, and nutrient adequacy were improved in both males and females after the intervention. The results of the follow-up study showed that participants maintained most dietary behaviors but that the intake of snacks and simple sugars tended to increase after the intervention. This result may be attributable to the fact that study participants were workers with MetS risk factors who may not believe they have serious health problems and who may lack a strong motivation for health management. Thus, once the nutritional management program ended, participants tended to return to their old lifestyle. Moon et al45 reported that nutrition counseling not only should include primary knowledge-transfer education where the client receives information on nutrition and health, but also must focus on long-term behavior modification rather than short-term changes. It seems clear that follow-up programs should be implemented in addition to WBNMPs, given that lifestyle changes take considerable time and effort. Many current Internet-based programs have difficulties with longterm application. Kodama et al46 explained that after a long period text messages or e-mail communications from Web-based educational programs become ‘‘boring’’ to users, who develop a kind of tolerance and are no longer stimulated by the messages. This can make it difficult for users to sustain motivation when making lifestyle modifications and can ultimately reduce the long-term effects of the program.
Nevertheless, compared with a face-to-face program, an Internet-based nutritional management program can efficiently and economically provide services to a large number of people. Furthermore, the WBNMP is available at any time and can be accessed from a personal computer at work or at home according to a user’s schedule. Through such a program, healthcare providers such as dietitians, nurses, and caregivers can readily offer essential, updated healthcare information and nutritional management advice to their patients, as well as help meet their communication needs after discharge from the hospital. In particular, for office workers who have easy access to the Internet, an online healthcare management program is effective in improving healthcare management, quality of work life, and productivity while reducing medical expenses. Program satisfaction ratings for the present study underscore the very high need for Internet-based nutritional management programs, considering that many participants appreciated its convenience and helpfulness in terms of health management and suggested that it might be an appropriate health management approach for busy office workers. The prevalence of MetS among office workers has increased recently, highlighting the importance of a health management program in the workplace. However, according to the program satisfaction ratings in the present study, the participants expressed low willingness to pay for a health management program. Therefore, this research suggests that it is desirable to implement the WBNMP for the welfare of workers.
CONCLUSIONS AND LIMITATIONS This study aimed to develop a WBNMP for the prevention and management of MetS and to evaluate the effects
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of the program through a pilot test. The results showed that body weight, waist circumference, BMI, and body fat decreased after participation in the program. In addition, blood profiles, dietary behaviors, frequencies of food intake, and the index of nutritional quality improved in both males and females after 16 weeks. However, this study highlighted some limitations of the WBNMP that need to be resolved. Above all, future WBNMPs should include not only nutrition but also clinical and exercise management programs. This program included some clinical elements such as anthropometric measurements and blood tests, but professional counseling on diseases or other clinical symptoms was not provided, because the main purpose of the study was nutritional management. Thus, a systematic program including clinical, nutrition, and exercise sections should be designed. In the follow-up study, the dietary habits of some participants regressed, suggesting that 16 weeks of management was insufficient. Therefore, nutritional management should be customized, continuous, and convenient. In particular, follow-up management should be ‘‘intensive’’ and ‘‘entertaining’’ to maintain the continuous interest of participants. Finally, the sample size was too small to assess the utilization of a nutritional management program in the workplace. Therefore, a much larger study is required to determine the effectiveness of a WBNMP in more diverse populations.
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35. Kim KW. Nutritional education resources for obesity. 2004 spring symposium. Korean J Obes. 2004;1:301–312. 36. Han JS, Heo JY. A Web-based Internet program for nutritional assessment and diet management of patient having hyperlipidemia. J Korean Soc Food Sci Nutr. 2003;32(2):287–294. 37. The Korean Nutrition Society. Dietary Reference Intakes for Korean; First Revision. Seoul, Korea: The Korean Nutrition Society; 2010. 38. The Korean Dietetic Association. Food Exchange for Meal Plan. Seoul, Korea: The Korean Dietetic Association; 2010. 39. Metabolic Syndrome Management. Center of Seoul Metropolitan Government [Internet]. Seoul, South Korea: Seoul Metropolitan Government; 2009. http://www.5check.or.kr/index.html. Cited December 2010. 40. National Cholesterol Education Program (NCEP) Expert Panel on Detection Evaluation and Treatment of High Blood Cholesterol in Adults(Adult Treatment Panel III). Third report of the National Cholesterol Education Program(NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106:3143–3421.
41. WHO/IASO/IOTF. The Asia-Pacific Perspective: Redefining Obesity and Its Treatment. Health Communications Australia: Melbourne, Australia; 2000. 42. Hsu SH. Developing an index for on-line customer satisfaction: adaptation of American Customer Satisfaction Index. Expert Syst Appl. 2008;34(4):3033–3042. 43. Wood FB, Siegel ER, Feldman S, et al. Web evaluation at the US National Institutes of Health: use of the American Customer Satisfaction Index On-line Customer Survey. J Med Internet Res. 2008; 10(1):e4. 44. Guthrie HA, Scheer JC. Validity of a dietary score for assessing nutrient adequacy. J Am Diet Assoc. 1981;78(3):240–245. 45. Moon SJ, Sohn CY, Kim JH, et al. Measurement of nutrition counseling effects for diabetes mellitus patients. Korean J Nutr. 1994; 27(10):1070–1077. 46. Kodama S, Saito K, Tanaka S, et al. Effect of Web-based lifestyle modification on weight control: a meta-analysis. Int J Obes. 2012; 36:675–685.
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& Vol. 32, No. 5, 232–241 & Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
F E A T U R E A R T I C L E
Development and Application of a Web-Based Nutritional Management Program to Improve Dietary Behaviors for the Prevention of Metabolic Syndrome YOON CHOI, PhD MIN JUNE LEE, PhD HEE CHEOL KANG, MD MEE SOOK LEE, MS, RN SUN YOON, PhD
Metabolic syndrome (MetS) is characterized by a cluster of disorders such as impaired glucose metabolism, central obesity, dyslipidemia, and hypertension, all of which increase the risk of chronic diseases including cardiovascular disease and type 2 diabetes and pose a serious health concern.1,2 Recent studies have shown that individuals with MetS are twice as likely to develop cardiovascular disease3,4 and 3.5 to 5 times more likely to develop type 2 diabetes.5 According to the 2008 Korean National Health and Nutrition Examination Survey (KNHANES), the prevalence of MetS was 25.98% in men and 20.39% in women, when applying the Asia-Pacific abdominal obesity criteria of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III. The prevalence of MetS in men older than 30 years was higher at 31.9%.6 In addition, office work tends to aggravate the progress of lifestyle-related diseases due to work-related stress, frequent eating out, frequent alcohol intake, and lack of exercise. A previous study reported that lifestyle modification programs reduce risk factors for cardiovascular disease and effectively improve the dietary habits and lifestyles of office workers.7 232
The purpose of this study was to develop a Webbased nutritional management program for the prevention of metabolic syndrome and to evaluate how the program affects health-related behaviors and the health status of office workers with metabolic syndrome risk factors. For the pilot test of the Web-based nutritional management program, 29 employees (19 males, 10 females) with more than one metabolic syndrome risk factor participated in the Web-based nutritional management program for 16 weeks. Participants visited the Web site more than two times per week and completed customized assessments of health status, smoking habits, alcohol consumption, dietary habits, food intake, ideal body weight, energy requirements, and exercise. Subjects had a significant decrease in body weight, waist circumference, body mass index (P G .01 in males, P G .05 in females), and body fat (P G .01 in males). The frequency of dietary habits such as eating snacks, eating out, and dining with others decreased, whereas the frequency of intake of foods such as whole grains, seaweed, fruit, and low-fat milk increased after intervention. After 16 weeks, program satisfaction was evaluated using a Web evaluation questionnaire, and most of the participants were highly satisfied with Web site components such as the loading speed, configuration, privacy, design, functionality, and contents. KEY WORDS Dietary behaviors & Metabolic syndrome & Office workers & Program satisfaction & Web-based nutritional management program
Author Affiliations: Department of Food and Nutrition, Brain Korea 21 Project, College of Human Ecology, Yonsei University (Drs Choi, Lee, and Yoon); Department of Family Medicine, Shinchon Severance Hospital, Yonsei University College of Medicine (Dr Kang); CoreMed Co Ltd, Ubiquitous Healthcare Company (Mrs Lee), Seoul, Korea. This project was conducted through the generous financial support of the CoreMed Corporation in Korea and the Brain Korea 21 Project, College of Human Ecology, Yonsei University. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Sun Yoon, PhD, Department of Food and Nutrition, College of Human Ecology, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-749, Korea ([email protected]). DOI: 10.1097/CIN.0000000000000054
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LITERATURE REVIEW Recently, several studies have reported that MetS requires lifestyle modification in addition to medical treatment and that modification of diet and exercise can delay the development of MetS.8–13 The results of providing a multicomponent health promotion program including nutrition, exercise, and stress management showed that body weight, blood pressure, and levels of total cholesterol (TC) and triglycerides (TGs) are improved.14 A multiple behavior intervention specifically designed for MetS led to significant reductions in blood pressure, and waist circumference, and in the levels of fasting blood glucose (FBG) and TGs.15 In another study, among various lifestyle modification components including physical activity, weight control, dietary habits, and alcohol and smoking, management of dietary habits was found to be the most effective way to decrease the risk of MetS.16 Another study showed that FBG levels and abdominal obesity could be improved through a 12-week nutritional education program.17 In persons without diabetes, but with elevated fasting and postload glucose concentrations, changes in lifestyle through a low-calorie and low-fat diet and 150 minutes of exercise per week led to decreased blood glucose levels, indicating that lifestyle modifications focused on the improvement of dietary habits are important for MetS prevention.18 In a study examining the effect of a lifestyle modification program on MetS in male office workers, a 12-week customized health program that promoted proper nutrition, no smoking, moderate alcohol intake, and more frequent exercise resulted in reduced levels of TC, TGs, FBG, and systolic blood pressure (SBP).19 However, health programs that involve face-to-face interviews are time-intensive, expensive, and inconvenient because direct visits are necessary.20 Moreover, most primary care practitioners tend to offer prescription medications rather than provide proper and sufficient counseling and education for lifestyle modifications.21 This tendency results from the limited time available to educate patients and the lack of professional human resources available for counseling.22 Internet-based interventions, on the other hand, are convenient and economical, involve multimedia elements such as audio and video, and have no time constraints. In addition, these interventions can provide customized information depending on user needs, preferences, and educational goals.23–26 In fact, it has been reported that Internet-based nutritional counseling and educational programs help establish a user’s motivation to modify dietary habits and physical activities through interactive features, strategies, and opportunities to provide and receive support and encouragement from other users.27,28 In a previous study, 787 workers enrolled in a 16-week healthcare management program via e-mail showed improved dietary habits and increased physical activity.29 Moreover, another study demonstrated the effectiveness of an online customized
intervention program for improving nutritional status, reducing smoking, and increasing physical activity.30 However, many studies have focused primarily on weight control, which is insufficient to manage disorders such as MetS with complicated health risk factors.
GOAL OF THE STUDY In this study, a Web-based nutritional management program (WBNMP) was developed to improve dietary behaviors and prevent and manage MetS. When creating the online content, the goal was to provide the following: (1) a customized evaluation through regular assessments of lifestyle and nutritional status; (2) tailored information and educational resources for disease, nutrition, and exercise management; and (3) nutritional counseling with a clinical dietitian regardless of the time and place. In addition, an online intervention was conducted via the Web site prototype to evaluate the effect of MetS management on office workers and to optimize user utility through a user satisfaction survey. Finally, this study evaluated the WBNMP in the context of workplace applicability.
METHODS Development of a Web-Based Nutritional Management Program This study used a nutritional management program for the prevention and management of MetS that consisted of four sections: ‘‘health and lifestyle management,’’ ‘‘nutritional status assessment,’’ ‘‘nutritional counseling,’’ and ‘‘healthcare information.’’ A family medicine doctor, dietitians, a research nurse, a computer programmer, and a Web designer participated in the development of the program. (1) Health and Lifestyle Management
This section consisted of a file for the input of anthropometric and biochemical data such as height, weight, waist circumference, body mass index (BMI), body fat, blood pressure, FBG, TC, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and TGs, as well as a file for the input of lifestyle questionnaires such as dietary habits, alcohol consumption, smoking, and physical activity. The number of drinks per week and amount of alcohol per session were recorded as were the current smoking status, smoking history, and number of cigarettes per day. The type of exercise, number of exercise sessions per week, and exercise duration and intensity were also noted. Dietary habits were characterized by the frequency of eating late at night, eating snacks, eating out, and dining with others.31,32 Participants were also asked how frequently they ate 14 key
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foods: whole grains, fish, beans, vegetables, seaweed, fruit, low-fat milk, meat, Chinese food, fast food, fried food, Ramen, cakes/pies, and sweets. All of these foods are thought to be related to the development or prevention of MetS, based on the KNHANES food frequency questionnaire.31 Finally, a customized assessment of health status and dietary habits was created based on all of the aforementioned data, using the criteria described in the National Health Information Portal (http://health.mw.go.kr),32 Korea Centers for Disease Control and Prevention (http:// www.cdc.go.kr),33 and Korean Dietetic Association (http:// www.dietitian.or.kr).34 (2) Nutritional Status Assessment
The degree of obesity, ideal body weight, and daily required energy levels were calculated based on users’ current weight, height, and physical activity. For those who needed to control or reduce their weight, the Conventional Calorie-Restricted Meal Plan, 500 kcal less than the recommended energy level, was used for the daily required energy level.35,36 The online food diary allowed users to input the type and amount of food they had for breakfast, lunch, dinner, and snacks. The Computer Aided Nutritional Analysis Program (CanPro 3.0 Professional) from the Korean Nutrition Society (Seoul, Korea) was used as the basic database for nutrition information and food group classifications. Energy input, intake of 15 key nutrients, and assessments of each daily meal were automatically evaluated and expressed as ‘‘under,’’ ‘‘normal,’’ or ‘‘over’’ based on the 2010 Dietary Reference Intakes for Koreans.37 If nutritional status was ‘‘under’’ or ‘‘over,’’ examples of major foods containing the relevant nutrients were suggested along with recommendations for decreased or increased intake. Guidelines for the prevention of diseases related to the intake status of relevant nutrients were also included. Food diaries were saved so that a dietitian could review them regularly and evaluate a user’s diet history before sending an organized evaluation sheet to the user via e-mail once a month. (3) Nutritional Counseling
Online nutritional counseling with a dietitian was possible through an online forum and by e-mail. Inquiries for counseling received a response within 24 hours. Frequently asked questions organized into three categories—clinical, nutrition, and exercise—were answered in an FAQ section. A forum was created for program users to share information and freely converse. (4) Healthcare Information
Healthcare information was divided into disease information, nutrition information, and exercise information. ‘‘Disease information’’ consisted of material on the prevention and management of MetS, obesity, dyslipidemia, hypertension, diabetes, stroke, heart disease, and fatty liver disease. Pictures were also provided for ease of comprehension. 234
‘‘Nutrition information’’ included material on the functions of nutrients, the importance of balanced meals, the principles and goals of diet therapy for each disease, the implementation and cautions of diet therapy, and the anticipated effects of each therapy. Information about meal management was provided via flash files (animations) and images. Through a food exchange list, information was provided on carbohydrates, protein, fat, and calories in terms of exchange units, along with a visual estimate of serving sizes.38 In addition, a 7-day ‘‘menu by calorie (1400, 1600, 1800 kcal),’’ the glycemic index, guidelines for eating out, and restricted and recommended foods were also included in the online content. Nutritional education materials for the management of MetS consisted of 10 topics as follows: (1) What is MetS? (2) abdominal obesity and MetS, (3) dietary principles for weight loss, (4) dyslipidemia and MetS, (5) dietary principles for dyslipidemia treatment, (6) hypertension management, (7) dietary principles for diabetes management, (8) health management by quitting smoking, (9) drinking and MetS, and (10) exercise strategies for the prevention of MetS, with reference to the Metabolic Syndrome Management Center of Seoul (http://www.5check.or.kr).39 ‘‘Exercise information’’ included material on exercise methods, types, intensity, and cautions depending on body shape and physical indices along with pictures. The importance of exercise for the prevention and management of diseases was explained.
Layout and Operating System of the Web-Based Nutritional Management Program The program Web site was developed jointly with CoreMed Co, Ltd (Osaka, Japan). The layout of each section of the program is shown in the Figure 1. The background color of the Web site was light yellow and white, and the text font size ranged from 12 to 16 points, primarily in dark green or black. All pages used the same format, because usability is enhanced when the format of each page is consistent. To design an interactive Web site, the screen-based controls (widgets) included links, push buttons, check boxes, dropdown lists, and entry fields created in the home page and subsequent pages. All Web site content was designed in print format so that information would print out as seen on the computer screen. The program requires an operating system of Windows 2003 or newer, and the language used to develop the program was ASP.Net(C#) (Microsoft, Redmond, WA) for the server and HTML/Java script (Mozilla Foundation, Mountain View, CA) for the client. Web server IIS 6.0 or newer, database MS-SQL Server 2005 or newer, CPU Intel Core 2 Quad, and RAM 4GB are required for the program to operate efficiently. All parts of the database, including personal information and outcomes, are protected with SSL encryption. Security and restriction of the program ensure that only
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FIGURE 1. Illustration of the WBNMP. A, Homepage. B, Health and lifestyle management. C, Nutritional status assessment. D, Nutritional counseling. E. Healthcare information.
authenticated users with authorized permission are able to view the allowed content and to participate in the forums. The research staff, a dietitian, a nurse, and Web programmers/designers tested the WBNMP prototype for design, content, ease of use, and browser errors in the data flowsheets. Any errors discovered were discussed by both the Web site development team and the research team and resolved before the start of the online intervention.
ONLINE INTERVENTION USING THE WEB-BASED NUTRITIONAL MANAGEMENT PROGRAM A pilot test of the WBNMP was conducted to evaluate its effectiveness for preventing MetS from May 2010 to April 2011. The institutional review board of Yonsei University approved all study protocols. Participants included male and female office workers, aged 20 to 60 years, who had at least one risk factor for MetS and had access to a computer. Pregnant and lactating women and individuals with
a serious illness were excluded. The criteria for MetS were based on NCEP Adult Treatment Panel III40 (fasting plasma glucose Q100 mg/dL, blood pressure Q130/85 mm Hg, TGs Q150 mg/dL, HDL cholesterol G40 mg/dL [male] G50 mg/dL [female]), and waist circumference was based on the World Health Organization Asia-Pacific abdominal obesity criteria41 (male 990 cm, female 980 cm). Before starting the 16-week program, at a health service center (offline), participants provided written informed consent and met with the researcher in person to learn how to use the program and how to complete the online food diary (dietary records). As part of the MetS diagnosis, height, weight, and body fat (Inbody 230; Biospace, Seoul, Korea) were measured. Waist circumference was also measured 2.5 cm above the navel using a tape measure, and fasting blood samples were collected for baseline data. All individuals who decided to participate in the study received program instructions, ‘‘the Recent Calorie Book’’ (Samsung Publisher, 2010), and the results sheet of their body composition measurements. The starting point for the online intervention was considered to be when a participant generated his/her user ID
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and password and logged in to the program for the first time. Participants were encouraged to visit the Web site at least twice a week. During the first visit, participants completed online questionnaires about alcohol intake, smoking habits, physical activities, dietary habits, and frequency of food intake in the ‘‘Health and lifestyle management’’ section. Participants then automatically received an overall evaluation including guidelines on health status and dietary habits, along with assessments of their anthropometric measurements and blood analysis data that had been previously entered by the researcher. Participants were asked to enter dietary information in the online food diary in the ‘‘Nutritional status assessment’’ section at least three times a month (twice on weekdays and once on weekends), and meal evaluations were presented immediately after participants provided details about a given meal. A dietitian analyzed diet history based on the online food diaries and then arranged an assessment sheet that was e-mailed to participants monthly. The assessment contained an evaluation of nutrient intake status, menu selection, and dietary habits. Education materials for MetS management were e-mailed weekly for 10 weeks, and nutrition counseling was frequently provided by e-mail and through an online forum during the study period. After participation in the 16-week program, participants completed an online survey about alcohol intake, smoking habits, physical activities, dietary habits, and frequency of food intake. A program satisfaction survey, modified from the Web evaluation method of the American Customer Satisfaction Index (ACSI), was conducted through e-mail; it contained 14 questions related to Web site performance, privacy, design, necessity, reliability, and diversity.42,43 In addition, anthropometric measurements were taken, and blood samples were collected and analyzed at a health service center (offline). Five months after the intervention, a follow-up study was conducted through an online questionnaire about dietary behaviors and frequency of food intake to determine whether the effects of the nutritional management program had continued beyond the intervention.
mean adequacy ratio (MAR) were used to evaluate the quality of nutrient intakes.44 The ratio of daily individual intakes to the standard recommended amounts for a subject’s gender and age category was used to calculate NARs. The standard recommended amounts were based on the 2010 Dietary Reference Intakes for Koreans. The NARs for 10 nutrients including protein, vitamin A, vitamin B1, vitamin B2, niacin, vitamin C, folic acid, calcium, iron, and zinc were estimated. The MAR was calculated as the sum of the NARs divided by the number of nutrients (n = 10).
Data Analysis
CHANGES IN BLOOD PRESSURE, BLOOD LIPIDS, AND BLOOD GLUCOSE LEVELS
STATISTICAL ANALYSIS All data were analyzed using SPSS version 18.0 (IBM, Armonk, NY) and are presented as the mean (SD). Changes in anthropometric measurements, blood analysis, and food intake data were analyzed using a paired t test, and program satisfaction was analyzed with an independent t test. In the follow-up study, changes in dietary behaviors and food intake frequencies were analyzed using a paired t test.
RESULTS Outcome of Online Intervention DESCRIPTION AND ANTHROPOMETRIC CHANGES OF PARTICIPANTS To assess the effects of the WBNMP, 29 office workers (19 males and 10 females) participated for 16 weeks. The average age was 44.2 (SD, 10.58) years for males and 32.1 (SD, 8.10) years in females. Participants were included if they took any of the following medications: oral hypoglycemic agents (n = 1 among males), antihypertensive agents (n = 5 among males, n = 3 among females), and lipid-lowering agents (n = 3 among males). None changed their course of medications during the intervention. According to criteria established by the Korean Society for the Study of Obesity, males in this study were obese, with an average BMI greater than 25 kg/m2. Females, on the other hand, had an average BMI of 23.5 kg/m2 and tended to be overweight rather than obese. In females, waist circumference was slightly higher than the reference value for obesity (G80 cm, NCEP ATP III criteria). After 16 weeks, body weight, waist circumference, BMI, and body fat decreased significantly in males (P G .01), and body weight, waist circumference, BMI, and body fat decreased in females, although not significantly (Table 1).
In males, SBP and TGs tended to be high, but FBG, TC, HDL-C, and LDL-C were relatively close to normal. In females, BP, FBG, and blood lipid patterns were normal. After 16 weeks, SBP (P G .01), diastolic blood pressure, TG, and TC (P G .05) in males had decreased significantly, and FBG and blood lipid patterns tended to improve. In females, most parameters were maintained at normal levels (Table 1).
DETERMINATION OF NUTRIENT INTAKE DATA
CHANGES IN DIETARY HABITS AND FREQUENCY OF FOOD INTAKES
Data on nutrient intakes were collected from the dietary records entered in the online food diary for 16 weeks (3 days per 4 weeks). Nutrient adequacy ratios (NARs) and
Changes in dietary habits and frequency of food intake are shown in Table 2. In males, dietary habits such as eating late at night, eating snacks, eating out, and dining
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T a b l e 1 Changes in Anthropometric and Blood Biochemical Data Male (n = 19) Variables Age, y Height, cm Weight, kg WC, cm BMI, kg/m2 Body fat (%) SBP, mm Hg DBP, mm Hg FBS, mg/dL TGs, mg/dL TC, mg/dL LDL-C, mg/dL HDL-C, mg/dL
a
Baseline 44.2 (10.58) 172.2 (5.51) 78.9 (8.25) 91.1 (6.80) 26.6 (2.53) 25.1 (5.58) 130.9 (7.81) 80.7 (6.31) 99.1 (17.99) 172.2 (75.93) 197.8 (31.13) 107.9 (30.31) 55.4 (15.83)
Female (n = 10) 16 wk
b
77.3 (8.44)c 88.8 (6.08)c 25.0 (2.63)c 23.6 (5.20)c 124.9 (8.01)c 77.0 (5.76)d 95.7 (10.57) 143.8 (56.77)d 188.2 (22.92)d 106.1 (23.30) 53.47 (16.96)
Baseline 32.1 (8.10) 158.7 (4.37) 59.4 (4.71) 81.6 (4.95) 23.5 (1.88) 32.8 (4.52) 110.1 (9.85) 68.0 (8.10) 82.1 (5.22) 90.4 (38.1) 174.5 (32.5) 97.2 (24.8) 60.7 (12.3)
16 wk
58.5 (4.79)d 79.6 (5.23)d 23.2 (1.65)d 32.4 (3.58) 108.6 (9.20) 67.8 (8.47) 84.5 (3.78) 76.8 (25.9) 178.4 (40.9) 98.2 (25.5) 60.4 (38.1)
Values are presented as mean (SD). Abbreviations: DBP, diastolic blood pressure; WC, waist circumference. a Before participating in the program. b Sixteenth week of the intervention. c P G .01 by paired t test. d P G .05.
with others decreased significantly after 16 weeks (P G .001). In females, eating snacks (P G .01), eating out (P G .001), and dining with others (P G .01) decreased significantly after 16 weeks compared with baseline. Males consumed whole grains, seaweed, fruit, and low-fat milk more frequently (P G .001), and they consumed meat, fast food, and simple sugars less frequently (P G .01) compared with baseline. Females consumed whole grains, fish, beans, seaweed, and fruit more frequently, and they consumed Chinese food, fast food, fried foods, and simple sugars less frequently (P G .05 to P G .001). The follow-up study conducted to determine whether changes in dietary habits and food intake continued 5 months after the nutritional management program showed that both males and females generally maintained their new dietary habits and food intake. However, males were eating sweets more frequently compared with the end of the 16-week study (P G .05), and females were eating more simple sugars and saturated fats compared with the end of the 16-week study (P G .05). Snack intake also increased, although not significantly, in both males and females. CHANGES IN NUTRIENT ADEQUACY RATIOS AND MEAN ADEQUACY RATIO In this study, it was important to increase the quality of meals because participants carried out a calorie restriction diet to manage overweight and central obesity. The findings of the study indicated that the MARs were mostly improved in both males and females during the intervention except for vitamin C and folic acid. The MAR scores, used as a measure of the adequacy of an overall diet,
increased significantly in both males and females after 12 weeks (Table 3). CHANGES IN ALCOHOL CONSUMPTION, SMOKING, AND PHYSICAL ACTIVITY At the beginning of this study, 75.9% of the males drank, 37.9% did not exercise, and 17.2% smoked. None of the 10 females in this study smoked, 60% drank, and 30% did not exercise. After 16 weeks, there were no significant changes in alcohol consumption, smoking, or physical activity (data not shown).
Program Satisfaction The results of the program satisfaction survey are shown in Table 4. Participants expressed overall satisfaction with the program. More specifically, they were satisfied with loading speed, ease of use, clarity of site organization, security of personal information, site layout, and usefulness of the information. The information provided was considered to have very high reliability, and the content was considered to be diverse. The participants indicated that an online nutritional management program was very necessary for the prevention and management of MetS and that they were interested in introducing the program to their coworkers, family, and friends.
DISCUSSION The WBNMP is a program that was developed to assess an individual’s dietary habits and lifestyle through various
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T a b l e 2 Changes in Dietary Habits and Frequency of Food Intake Male (n = 19) Variables
Baseline
Eating late at night Eating snacks Eating out Dining with others Whole grains Fish Beans Vegetables (excluding kimchi) Seaweed Meat Chinese food Fast food Delivery food Ramen Fried food Cakes, pies, pastries Sweets Fruit Low-fat milk
3.1 9.6 25.7 3.5 16.4 7.3 11.0 15.4 8.6 8.9 3.8 3.9 2.3 3.0 2.3 1.6 4.4 15.3 16.4
a
(3.16) (9.75) (21.1) (2.79) (13.7) (4.71) (4.36) (8.70) (6.95) (6.53) (3.85) (5.65) (3.17) (2.52) (3.28) (2.55) (3.18) (8.92) (18.0)
16 wk
Female (n = 10)
b
Follow-up
0.8 (1.52)d 8.4 (9.80)d 22.5 (17.5)d 3.3 (2.74)d 21.7 (15.6)d 9.8 (6.31) 12.1 (5.03) 19.0 (8.04) 8.7 (8.8)d 7.4 (4.9)f 2.0 (2.51) 1.9 (2.69)d 1.2 (2.54) 2.1 (1.80) 0.63 (0.76) 1.2 (1.53)f 2.5 (1.74)h 16.4 (18.0)d 26.4 (14.8)d
c
2.0 (2.54) 8.8 (9.58)e 14.8 (19.0) 3.3 (4.70) 22.1 (17.7)g 7.0 (5.53)i 11.6 (2.86) 16.9 (8.26) 8.0 (5.61) 5.5 (5.97)g,i 1.64 (1.11) 1.1 (1.40)g 1.6 (0.79) 2.7 (1.55) 1.3 (1.33) 1.3 (1.86) 4.4 (3.97)i 18.8 (17.5)e 27.8 (17.8)g
Baseline 2.5 13.9 21.0 0.75 13.0 2.7 11.0 11.7 5.6 7.1 2.3 3.9 1.3 2.4 1.1 2.6 5.6 11.5 9.0
a
(2.75) (9.91) (18.4) (0.79) (12.0) (1.69) (7.42) (7.04) (3.65) (5.59) (1.35) (3.76) (1.26) (1.63) (1.32) (3.17) (3.65) (7.90) (4.81)
16 wkb
Follow-upc
0.6 (2.02) 12.4 (8.20)f 22.4 (17.3)d 0.6 (0.77)f 18.2 (8.09)h 5.3 (4.06)h 13.0 (7.79)f 18.6 (9.79) 5.9 (3.39)d 6.5 (3.64) 2.0 (1.18)f 1.9 (1.34)d 0.4 (0.72) 1.7 (1.47) 0.3 (0.63)h 2.7 (4.25)f 5.7 (4.57) 18.0 (6.64)h 17.5 (8.96)
0.5 (0.86) 13.2 (1.96) 20.0 (8.66) 0.5 (0.86) 17.8 (10.1)e 4.3 (3.81) 13.3 (8.91)e 16.7 (1.75) 5.5 (3.78) 6.0 (5.78) 2.2 (1.05) 2.1 (3.35)g,i 0.4 (1.88) 2.5 (2.39) 0.9 (0.01) 2.7 (5.84)e 6.1 (9.11) 17.6 (5.67)e 15.7 (5.66)
Values are presented as mean (SD): times per month. a Before participating in the program. b Sixteenth week of the intervention. c Five months after the intervention. d P G .001 (baseline and 16 weeks). e P G .05 (baseline and follow-up) by paired t test. f P G .01 (baseline and 16 weeks). g P G .01 (baseline and follow-up) by paired t test. h P G .05 (baseline and 16 weeks). i P G .05 (16 weeks and follow-up).
T a b l e 3 Changes in Nutrient Adequacy Ratios and Mean Adequacy Ratio Male (n = 19) Baseline NARs Protein, g Vitamin A, HgREf Vitamin B1, mg Vitamin B2, mg Niacin, mg Vitamin C, mg Folic acids, Hg Calcium, mg Iron, mg Zinc, mg MAR
1.1 1.2 0.9 0.8 1.0 1.0 0.7 0.6 1.2 0.8 1.0
a
(0.3) (1.1) (0.3) (0.3) (0.3) (1.0) (0.4) (0.2) (0.5) (0.2) (0.4)
8 wk 1.1 1.0 0.8 0.7 0.8 0.8 0.5 0.6 1.0 0.8 0.9
(0.3) (0.5) (0.3) (0.3) (0.3) (0.7) (0.2) (0.3) (0.3) (0.2) (0.3)
12 wk 1.1 1.2 1.0 1.0 1.0 0.9 0.6 0.7 1.0 0.8 1.0
(0.4) (1.1) (0.4)f (0.4) (0.4)f (0.4) (0.3) (0.3) (0.3) (0.2) (0.3)
Female (n = 10) 16 wk 1.3 1.1 1.1 1.0 1.1 0.9 0.6 0.8 1.2 1.0 1.1
(0.4)b,c,d (0.6) (0.6)c (0.4)b,c (0.3) (0.3) (0.1) (0.4) (0.4) (0.4) (0.3)e
Baseline 1.1 1.3 0.8 0.7 0.7 0.7 0.5 0.7 0.7 0.7 0.8
a
(0.3) (1.8) (0.3) (0.3) (0.2) (0.6) (0.7) (0.5) (0.6) (0.1) (0.4)
8 wk 1.1 1.5 0.9 0.8 0.7 0.7 0.6 0.6 0.7 0.7 0.8
(0.3) (1.9) (0.3) (0.2) (0.3) (0.6) (0.6) (0.4) (0.5) (0.2) (0.4)
12 wk 1.4 0.8 1.0 0.7 0.9 0.7 0.5 0.5 0.7 0.9 0.9
(0.3) (0.4) (0.5) (0.2) (0.2) (0.6) (0.1) (0.2) (0.3) (0.3) (0.3)
16 wk 1.7 1.2 1.0 1.1 1.1 0.6 0.7 1.0 1.1 1.2 1.1
(0.4)e (0.7) (0.2) (0.3)e (0.3)c (0.1) (0.2) (0.3)c,g (0.6) (0.3)c (0.2)e
Values are presented as mean (SD). a Before participating in the program. b P G .05 (baseline and 16 weeks). c P G .05 (8 and 16 weeks). d P G .05 (12 and 16 weeks) by paired t test. e P G .01 (baseline and 16 weeks). f Retinol equivalent (RE). g P G .01 (12 and 16 weeks) by paired t test.
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T a b l e 4 Investigation of Program Satisfaction With the ACSI Methoda Category Site performance Search Navigation Privacy Design Functionality Content Satisfaction Primary resource Recommendation Willing to pay
Items
Male (n = 19)
Speed of loading Ease of use Comprehensiveness of search results Clarity of site organization Security of personal information Clean layout Usefulness of the health information provided Necessity of online nutritional management program Reliability of the information provided Diversity of the information provided Overall satisfaction Primary resource for health information Recommend to others Willing to pay for nutritional management program
4.1 3.8 3.8 3.8 3.8 3.7 3.8 4.3 4.3 4.0 4.1 3.6 4.1 2.3
(0.73) (0.50) (0.60) (0.50) (0.80) (0.63) (0.76) (0.67) (0.47) (0.88) (0.60) (0.88) (0.68) (0.59)
Femaleb (n = 10) 3.9 3.7 3.5 3.9 3.9 3.5 4.0 4.2 4.2 4.3 4.3 4.2 4.6 3.0
(0.73) (0.48) (0.52) (0.31) (0.73) (0.52) (0.66) (0.63) (0.42) (0.67) (0.48) (0.78) (0.51) (0.94)
Values are presented as mean (SD). Five-point Likert scale (high score denotes strong agreement). a These standardized questions were modified for this study from the ACSI survey methodology. b A t test revealed no significant differences between males and females.
online content, to provide customized professional dietary and lifestyle management services depending on an individual’s MetS risk factors, and to reinforce nutritional management. In this pre-post intervention, the WBNMP was applied to workers with MetS risk factors for 16 weeks and resulted in decreased body weight, waist circumference, BMI, and body fat in both males and females. It also led to improvement in blood profiles such as blood pressure, TGs, and TC. Dietary behaviors, frequency of food intake, and nutrient adequacy were improved in both males and females after the intervention. The results of the follow-up study showed that participants maintained most dietary behaviors but that the intake of snacks and simple sugars tended to increase after the intervention. This result may be attributable to the fact that study participants were workers with MetS risk factors who may not believe they have serious health problems and who may lack a strong motivation for health management. Thus, once the nutritional management program ended, participants tended to return to their old lifestyle. Moon et al45 reported that nutrition counseling not only should include primary knowledge-transfer education where the client receives information on nutrition and health, but also must focus on long-term behavior modification rather than short-term changes. It seems clear that follow-up programs should be implemented in addition to WBNMPs, given that lifestyle changes take considerable time and effort. Many current Internet-based programs have difficulties with longterm application. Kodama et al46 explained that after a long period text messages or e-mail communications from Web-based educational programs become ‘‘boring’’ to users, who develop a kind of tolerance and are no longer stimulated by the messages. This can make it difficult for users to sustain motivation when making lifestyle modifications and can ultimately reduce the long-term effects of the program.
Nevertheless, compared with a face-to-face program, an Internet-based nutritional management program can efficiently and economically provide services to a large number of people. Furthermore, the WBNMP is available at any time and can be accessed from a personal computer at work or at home according to a user’s schedule. Through such a program, healthcare providers such as dietitians, nurses, and caregivers can readily offer essential, updated healthcare information and nutritional management advice to their patients, as well as help meet their communication needs after discharge from the hospital. In particular, for office workers who have easy access to the Internet, an online healthcare management program is effective in improving healthcare management, quality of work life, and productivity while reducing medical expenses. Program satisfaction ratings for the present study underscore the very high need for Internet-based nutritional management programs, considering that many participants appreciated its convenience and helpfulness in terms of health management and suggested that it might be an appropriate health management approach for busy office workers. The prevalence of MetS among office workers has increased recently, highlighting the importance of a health management program in the workplace. However, according to the program satisfaction ratings in the present study, the participants expressed low willingness to pay for a health management program. Therefore, this research suggests that it is desirable to implement the WBNMP for the welfare of workers.
CONCLUSIONS AND LIMITATIONS This study aimed to develop a WBNMP for the prevention and management of MetS and to evaluate the effects
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of the program through a pilot test. The results showed that body weight, waist circumference, BMI, and body fat decreased after participation in the program. In addition, blood profiles, dietary behaviors, frequencies of food intake, and the index of nutritional quality improved in both males and females after 16 weeks. However, this study highlighted some limitations of the WBNMP that need to be resolved. Above all, future WBNMPs should include not only nutrition but also clinical and exercise management programs. This program included some clinical elements such as anthropometric measurements and blood tests, but professional counseling on diseases or other clinical symptoms was not provided, because the main purpose of the study was nutritional management. Thus, a systematic program including clinical, nutrition, and exercise sections should be designed. In the follow-up study, the dietary habits of some participants regressed, suggesting that 16 weeks of management was insufficient. Therefore, nutritional management should be customized, continuous, and convenient. In particular, follow-up management should be ‘‘intensive’’ and ‘‘entertaining’’ to maintain the continuous interest of participants. Finally, the sample size was too small to assess the utilization of a nutritional management program in the workplace. Therefore, a much larger study is required to determine the effectiveness of a WBNMP in more diverse populations.
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