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Design and evaluation of peer - led community based food clubs: a means to improve the diet of older people from deprived social backgrounds
Project Code: N09015
University of Newcastle
Moynihan, P ; Seal, C; Zohoori, V; Hyland, R; Wood, C
The National Diet and Nutrition Survey showed that the diet of older adults (those aged 65+) in the UK is too high in saturated fat, non-milk extrinsic (NME) sugars and too low in fruits and vegetables, non-starch polysaccharide (NSP) and vitamin D. A Health Education Authority (HEA) Systematic Review of the effectiveness of interventions to promote healthy eating in elderly people, identified a need for controlled dietary intervention studies in this age group. Older adults may lack motivation to cook for themselves or may cook using traditional and often less healthy methods for example roasting and baking using saturated fats and overcooking vegetables. Encouraging food preparation using more contemporary healthier methods and recipes suitable for one or two may help address this. Using peers to deliver health education to older adults has been used successfully in some areas of health promotion in older adults (e.g. falls prevention) but its use to promote healthier eating has not been evaluated.
The aims of this project were to: (1) design a dietary intervention in the form of a practical food preparation club ‘Food Club’ that could be delivered by ‘peer leaders’ to older adults living in sheltered housing accommodation; (2) recruit and train peer leaders to deliver the Food Clubs and; (3) test the effect of this Food Club on dietary knowledge, attitude and practice.
Formative research was conducted to inform on the intervention design. This involved focus groups and semi-structured in depth interviews with older adults (e.g. from lunch clubs), the health development officer at Age Concern, local dietitians and community nutrition assistants. Information on food preparation and dietary issues in later life and the concept of a ‘Food Club’ was obtained. A methodological literature review, based on the original strategy used in the HEA review was conducted in order to obtain published information on healthy eating initiatives in older adults and to find examples of good practice. Information from the qualitative investigations and the literature review was used to design a 20 week Food Club. This included a Recipe File of easy to prepare dishes that were low in saturated fats and NME sugars, high in fruits, vegetables, NSP and vitamin D, and a 20 week session plan with nutrition notes to support the recipes in each session, for use by the peer leaders.
Twenty two people aged 60 years and over (18 women and 4 men) were recruited and trained to become peer leaders. Using a modified version of a training pack used to train Community Nutrition Assistants, the peer leaders followed a 13 week theoretical course based on basic nutrition and group work skills. The course led to the award of an Open College Network (OCN) Certificate in Nutrition Skills. Twenty one peer leaders (18 women and 3 men) successfully saw the project to completion.
The project design was a cluster randomised trial that aimed to recruit 9 older adults in each of 32 Sheltered Housing Schemes (in total 288 older adults) located in socially deprived areas of north east England. Following successful recruitment of 32 sheltered housing schemes, schemes were randomly allocated to intervention or control clusters. Evaluative measures were taken at baseline (T0), immediately following the intervention (T1) and one year following the intervention (T2). The main outcome measure was a change in the percent energy from dietary fat. Other outcome measures included:
- Diet (e.g. intake of total and saturated fat, carbohydrates including total sugars, NME sugars, NSP, iron, calcium, vitamin C, vitamin D, folate and fruits and vegetables);
- Change in the mean daily amount of foods belonging to the food groups of the Balance of Good Health (Food Standards Agency, 2001):
- Serum antioxidant capacity and concentrations of beta carotene, retinol and alpha tocopherol (as a marker of intake of fruits and vegetables);
- Body weight, body mass index, and demiquet and mindex indicies for males and females respectively;
- Bowel movements (as an index of the adequacy NSP intake);
- Knowledge of nutrition and food safety;
- Attitudes towards eating more healthily and perceived barriers to healthy eating, including Stage of Change with respect to eating more healthily.
In addition a Sociologist conducted in depth semi-structured interviews with the peer leaders, before, during and after the intervention to obtain qualitative data on the peer training process. In depth interviews were also conducted on a sub-sample of the Food Club participants in order to get their views on the success of the Food Clubs and any changes in diet or food related issues as a result of taking part in the study. Finally it was planned to calculate the cost of training and running a Food Club and to conduct a cost-benefit analysis. However, as the intervention resulted in no significant benefits to health outcomes, it was not possible to conduct a cost benefit analysis.
Key results obtained
Of the 22 peer leaders recruited, 21(18 females and 3 males) completed the study and obtained an OCN certificate in Nutrition Skills.
Of the 301 subjects initially recruited, 201 completed baseline dietary assessment. The mean age of the 97 subjects who received a Food Club was 76 years and ranged from 71 to 80 years, with approximately14% being men. The mean age of the 104 subjects in the control group was also 76 years, ranging from 71 to 84, with approximately 15% being men. Three Sheltered Housing Schemes withdrew from the study before the Food Clubs commenced, however, the 13 Sheltered Housing Schemes that started a Food Club saw it through to completion. The median number of subjects per cluster at completion (T2) was 4 and ranged from 1-6.
The effect of the intervention on diet
Information on diet was collected from 201 subjects at baseline. This showed that the diet of older adults living in sheltered accommodation in socially deprived areas was high in saturated fat (13.4% energy intake compared with the Dietary Reference Value (DRV) of <10% energy intake), low in NSP (11.1g compared with the DRV of 18g) and fruits and vegetables (280g/d compared to the recommended intake of 400g per day) and low in vitamin D (2.6mg/d compared with the Reference Nutrient Intake of 10mg/d). Encouragingly, the diet was not too high in NME sugars (9.2% compared with the DRV of <10% energy intake).
Information on diet was collected from 94 subjects (49 intervention, 45 control) immediately following the intervention and 72 subjects (36 intervention, 40 control) at one year following the intervention. Immediately following the intervention no changes in diet were observed. At one year following the Food Club the change in percent energy from carbohydrates was significantly greater (and positive) in the intervention group. There were non-significant trends towards an increase in the percent energy from and absolute intake of total sugars (but not NME sugars) in the intervention group. The mean change in fruit intake was 25g higher in the intervention group compared with the control group but this did not reach statistical significance. At one year following the intervention, vitamin D intake had fallen in the intervention group and had increased in the control group resulting in a significant difference between groups for change in vitamin D intake.
At baseline the mean BMI was 29.2 kg/m2 and 76% of subjects were overweight or obese and 0.5% of subjects were underweight. Following the intervention there were no significant changes in anthropometric measurements.
Plasma levels of retinol and beta-carotene were not affected by the dietary intervention, and were not different throughout the period of the study. Plasma a tocopherol concentration fell during the study in both groups and was significantly lower at one year following the Food Clubs compared with baseline, however, there were no between group differences for change in plasma alpha tocopherol. No explanation can be offered for the fall in plasma a tocopherol.
Nutrition and food safely knowledge
Information on nutrition knowledge was collected from 177 subjects at baseline, using a valid and reliable questionnaire. The food safety questions were based on those previously used in Food Standards Agency surveys (Food Standards Agency 2001). The results indicated that approximately 50% of questions were answered correctly. In particular knowledge of sources of NSP and lower fat options was poor. There was low awareness of the links between diet and chronic diseases such as cancer, stroke and dental caries.
At baseline, information was obtained from 163 subjects on knowledge of food safety and showed that for all but one question, less than 50% of subjects answered the questions correctly and less than 1/3 of respondents knew the correct meaning of the terms ‘use by’ and ‘best meaning that in practice they could potentially consume foods that were unsafe to eat. Following the intervention (at T1 or T2) there were no changes in the level of knowledge of nutrition or food safety practices.
Attitudes towards and barriers to healthier eating
Information on dietary attitudes and behaviour was collected using a questionnaire based on the Theory of Planned Behaviour, with additional items added to assess ‘habit’ and ‘self identity’. The baseline responses to the questions on dietary attitudes (collected from 160 subjects) showed a positive attitude towards healthier eating and a perceived need to eat more healthily. There was evidence of ‘optimistic bias’ confirmed by the baseline data on diet.
Immediately following the intervention 88 subjects (49 in the Food Club group and 39 in the control) group answered the questionnaire on dietary attitudes and behaviour. One year after the Food Clubs 64 subjects (32 in the Food Club group and 32 in the control group), answered the questionnaire again. One year following the intervention those who attended a Food Club had a more positive attitude towards the role of a healthy diet in controlling their weight. The most important finding was that preparing and cooking foods was perceived to be less of a barrier towards healthier eating for subjects who had attended a Food Club. However, the level of optimistic bias had increased in the intervention group.
An algorithm was used to classify subjects into the 5 categories of the Stages of Change. At baseline 25% of subjects in the intervention group and 38% of subjects in the control group were in pre-action stages. There were no between-group differences for change in Stage of Change at either baseline, T1 or T2.
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