Using food models to enhance sugar awareness among older adolescents: evaluation of a brief nutrition education intervention

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of a brief nutrition education intervention

by Maria Santalo

A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of

MASTER OF ARTS

in the School of Exercise Science, Physical and Health Education

ã Maria Santalo, 2019 University of Victoria

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Supervisory Committee

Using food models to enhance sugar awareness among older Adolescents: evaluation of a brief nutrition education intervention

by Maria Santalo

Supervisory Committee

Dr. Patti-Jean Naylor, School of Exercise Science, Physical and Health Education Supervisor

Dr. Sandra Gibbons, School of Exercise Science, Physical and Health Education Departmental Member

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Abstract

The health implications of poor dietary habits among adolescents are increasingly evident with the high prevalence of obesity and diet-related ill health in this population. Of particular concern is the high amount of sugar present in the adolescent diet. Nutrition education is an efficacious strategy to change sugary drink consumption particularly when including experiential strategies but sugar consumption within a more

comprehensive diet has not been addressed. Food models have been incorporated as a teaching aid that support experiential activities and there is some evidence that they can be effective. However, there is a lack of evidence on the use of these strategies with adolescents and specifically for reducing sugar consumption across the diet. This study aimed to assess the impact of a two 45-minute interactive nutrition session intervention using food models on adolescent's sugar literacy (knowledge and awareness of added sugar, confidence in label reading to assess sugar content in food, and intention to limit consumption of added sugar). An experimental design with randomization into

intervention and control condition and pre and post measures was used to test the efficacy of the intervention.

Two hundred and three students ages 14 to 19 from 6 schools on Vancouver Island, BC, Canada participated in the study. The intervention group received two 45-minute

interactive nutrition sessions using food models to learn about added sugar content in foods and beverages, recommendations for added sugar in the diet and food group servings in a healthy diet. A questionnaire to evaluate sugar literacy, including student

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knowledge, self-efficacy and intention to consume less added sugar, was completed at baseline and after the intervention.

Adolescents’ knowledge of added sugar in foods and beverages and of the number of servings of food groups in a healthy diet was limited at baseline but improved

significantly in the intervention condition [F(1, 201)=104.84, p<.001] compared to the controls. Intention to consume less added sugar increased significantly after the

intervention [F(1, 201)=4.93, p=.03] as did label reading confidence [F(1, 201)=14.94, p<.001]. It appears that a brief nutrition education intervention using food models as an experiential learning strategy was efficacious for changing student’s knowledge about sugar guidelines and sugar in food, label reading confidence and intention to change sugar consumption. Further studies are needed to analyze the impact of a sugar literacy intervention using food models on actual sugar consumption in adolescents.

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I would like to thank my supervisor Dr. Patti-Jean Naylor for believing in my project right from the start and for all her valuable time and support to make it happen. I also would like to thank Dr. Sandra Gibbons for her contributions and for encouraging the PE teachers to participate in my project. I want to thank Dr. John Walsh for

reminding me how fun stats can be and making me enjoy the stats in my project.

Thank you to my family for being so supportive. Thank you, Fernando, for always being my source of inspiration and Gary, for encouraging me to keep going and for being so patient giving up time together so I could finish this project.

Thank you, Canada and the people from Victoria for being so welcoming from day one and making me feel so at home and comfortable to work on my Masters. Of course, it would not have been the same without my dearest friend Ingrid Heckel’s helping hand.

This project could not have been completed without the support of the PE

teachers that believed in my project as well as the interest and active participation of each of the students involved in this study. Thank you.

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Dedication

To Fernando for being my source of inspiration. To Gary for sharing my here and now.

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Chapter 1: Introduction and Literature Review

Introduction

Excess weight in the population, represented by overweight and obesity, has been rising and has become a public health concern because it is a risk factor for chronic diseases like diabetes and cardiovascular disease (Hammond & Levine, 2010). One factor in excess weight gain and tooth decay is the high consumption of added sugars.

Although there is currently a lack of consensus on the maximum amount of sugar that could be present in a healthy diet, recommendations from the World Health

Organization (WHO) are widely used (Thow & Hawkes, 2014). The WHO suggests that less than 10% of the calories in the diet come from free sugar (World Health

Organization, 2015). Some populations are consuming more than this and adolescents typically consume the highest levels (Thow & Hawkes, 2014). In Canada for instance, adolescents are consuming 14.1 % of their calories from added sugar (Brisbois, Marsden, Anderson, & Sievenpiper, 2014). The added sugar they consume is typically from both sugar-sweetened beverages and solid foods (Reedy & Krebs-Smith, 2010; Brisbois et al., 2014). This is a concern because this is an age of eating habit formation as well as an age when diet quality deteriorates. The chance of adult overweight or obesity is higher for those that were overweight or obese as adolescents (Manger et al., 2012).

To combat this emerging issue it is essential to create awareness among adolescents about: (a) the health impact of excess added sugar in their diet, (b) the maximum amount of added sugar in a healthy diet and (c) the added sugar content in

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foods and beverages, in order to encourage diet behaviour changes in relation to sugar consumption (Thow & Hawkes, 2014).

This review of the literature provides the foundation for the current research by addressing the different types of sugars, exploring the effect of sugar on health and by detailing the findings of previous studies related to sugar education interventions and their use with adolescents.

Literature Review

Types of sugars. Sugar is present in food and beverages in different ways. It can be naturally present like the sugar in milk or milk products, the sugar in fruit, or in natural fruit juice. Sugar can also be added to food and beverages as in sugar-sweetened beverages (SSB) or pastries (Thow & Hawkes, 2014). Total sugar is the total amount of sugars a particular food or beverage contains, naturally or added. Added sugar is all the sugar that as the word says, has been “added” to foods through processing or by

individuals. Free sugar is a term used by the WHO for "all monosaccharides and disaccharides added to foods by the manufacturer, cook, or consumer, plus sugars naturally present in honey, syrups, and fruit juices" (World Health Organization, 2015). The main difference between the term “free” and “added” sugar is that the first one includes the sugar in fruit juices.

The body handles naturally occurring and added sugar in the same way, but foods high in added sugar tend to have lower nutrient densities, and thus, provide little

nutritional value (U.S. Department of Health and Human Services, 2015). “By contrast, foods with naturally occurring sugars tend to be higher in nutrients” (Langlois &

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quality of diet and excessive calorie intake, which in turn has been associated with increased body weight (Drewnowski & Rehm, 2014; Hu, 2013).

Overweight and obesity. The population of overweight and obese individuals has been growing worldwide. According to the WHO (2018), obesity nearly tripled since 1975 and overweight and obesity has risen dramatically among children and adolescents aged 5-19 from 4% in 1975 to just over 18% in 2016 (World Health Organization, 2018). According to Manger (2012), thirty percent of 50-year-old obese people were overweight when they were 13, so being overweight as an adolescent is a strong risk factor for adult obesity.

In Canada, between 1978 and 2004 overweight and obesity in adolescents

followed the same path as in the rest of the world. Among 12- to 17-year-olds overweight rate nearly doubled from 11% to 20% and obesity rate tripled from 3% to 9% in 25 years (Shields, n.d., Chart 1). Over the following 10 years, 2004-2013, overweight remained the same (20.3 vs. 20.1%), and obesity increased around one third (12.3 vs. 16.6%) for 12- to 17-years olds (Rao, Kropac, Do, Roberts, & Jayaraman, 2016). In 2018, 30% of children age 5 to 17 were overweight or obese (Government of Canada, 2018).

Health costs derived from overweight and obesity have risen drastically because overweight and obesity are risk factors for chronic diseases like diabetes, cardiovascular diseases and some types of cancer (World Health Organization, 2015). Medical spending for the obese may be as much as 100% higher than for healthy weight adults (Hammond & Levine, 2010). In Canada, one third of direct health care costs are spend in chronic diseases (Public Health Agency of Canada, 2016)

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The primary factor contributing to overweight and obesity for the past three decades has been an imbalance between calories consumed and calories expended which is a result of increased consumption of calorie-dense food high in saturated fats, and sugar, in combination with a sedentary lifestyle (Manger et al., 2012). According to the Canadian Community Health Survey, twenty-nine percent of overweight or obese adolescent boys and 27% of overweight or obese adolescent girls are sedentary (Shields, n.d., Table 2). To combat the problem of overweight and obesity, the WHO recommends:

• Being physically active

• Increasing the consumption of fruit and vegetables, as well as legumes, grains, and nuts and

• Limiting energy intake from total fats and sugars (World Health Organization, 2018)

Sugar in the diet. There are currently no dietary recommendations for total sugar intake. There are dietary recommendations for added sugars and for free sugars although there is a lack of consensus on what guideline is appropriate. Canada’s Food Guide at the time this study was conducted, recommended limiting foods and beverages high in sugar (Government of Canada, 2018) but did not include a recommendation on free sugars. The WHO suggests that no more than 10 percent of calories consumed be from free sugar and in fact is aiming to reduce the recommendation for free sugar to no more than 5% of daily calories. Ten percent of the calories in a typical diet of 2000 calories would mean 200 calories from sugar. Two hundred calories from sugar are the equivalent of 50 grams of sugar and that, in turn, is the equivalent of 11.9 teaspoons of sugar when considering that

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a teaspoon of sugar contains 4.2 grams of sugar (U.S. Department of Agriculture, 2018). As a quick reference; a 16 fl. oz sugar-sweetened soda have approximately 12 teaspoons of sugar (U.S. Department of Agriculture, 2018). A variety of guidelines from

organizations and jurisdictions around the world are displayed in Table 1. It is evident that although the specific guideline varies in amount and type of sugar (free versus added), all suggest limitations on sugar consumption.

Table 1

Examples of Sugar Consumption Guidelines

Despite the WHO recommendations and the dietary guidelines regarding sugar consumption, Newens & Walton (2016) in their review of world sugar consumption stated that added sugar consumption was well above 10% of total daily calories for school age children in many countries. Newens & Walton reported that most countries did not have information about sugar consumption and the ones that had information had

Organization / Jurisdiction Sugar recommendation

World Health Organization < 10% of calories in the diet should come from free sugar The Institute of Medicine (US)

< 25% of calories in the diet should come from added sugar. Higher than that too many nutrients in the diet can be displaced.

The American Heart Association (US)

< 6 teaspoons of added sugar a day for woman and < 9 teaspoons for men

Diabetes Canada < 10% of calories in the diet should come from free sugar Mexico's Dietary Guidelines

Foods rich in refined sugars should be consumed in moderation and sugar should be limited as much as possible

Eating Well with Canada's Food Guide 2007 Limit food and beverages high in sugar

2019 Canada's Food Guide Limit free sugar to less than 10% of total energy intake Europe Dietary Patterns Most countries suggest moderation in sugar intake 2015-2020 Dietary Guidelines for Americans < 10% of calories in the diet should come from added sugar Note: Data for sugar recommendation for World Health Organization (WHO) from WHO Guideline sugar intake for adults and children (2015), for Institute of Medicine from Rippe et al., (2017), for American Heart Association from Johnson et al., (2009), for Diabetes Canada from Diabetes Canada (2019), for Mexico's Dietary Guidelines from Diario Oficial de la Federacion (2013), for Eating Well with Canada's Food Guide 2007 and 2019 Canada's Food Guideline from Government of Canada, for Europe from Montagnese et al., (2015) and for the Dietary Guidelines for Americans from the 2015-2020 Dietary Guidelines for Americans.

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mostly addressed total sugar. No country reported free sugars and only a few had information about added sugar.

The 2004 and 2015 Canadian Community Health Surveys reported sugar consumption as total sugar, however, using the 2004 Canadian Community Health Survey, Brisbois et al. (2014) estimated the added sugar consumption of Canadians by categorizing sugar content of food groups based on the source of the majority of sugars they contained (either added or naturally occurring). For instance, they assumed that all sugars in fruits, vegetables, milk, and 100% fruit juice were naturally occurring, whereas all sugars in confectionary, sugars, fruit drinks, and cereals/grains were added. Brisbois calculated that among Canadians aged 9 to 18 years an average of 14.1% of daily calories came from added sugar and that they were the population with the highest added sugar consumption. Adolescents mostly consumed added sugar through beverages like soft drinks and fruit drinks, but it was also consumed in solid foods like confectionary and cereals or grains (see Table 2). Brisbois reported for this age group that 2.3% of their daily calories came from fruit juice. So, free sugar consumed by Canadian adolescents in 2004, accounted for around 16.4% of daily calorie consumption (% of calories from added sugar + % of calories from fruit juice).

Table 2

Top Sources of Estimated Added Sugar Intake by Canadians ages 9 to 18 in percent of Total Calories in the Diet

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Note. Adapted from “Estimated Intakes and Sources of Total and Added Sugars in the Canadian Diet” by T. D. Brisbois, S. L. Marsden, G. H. Anderson, J. L. Sievenpiper, 2014, Nutrient, 6, p. 1899-1912

Adolescent eating behavior and diet quality. The dietary intake of adolescents in industrialized countries is regarded as poor, with low consumption of vegetables, fruits, dairy and grains, and high consumption of sugar (Ronto, Ball, Pendergast, & Harris, 2017). In 2016 only twenty-eight percent of Canadian males and thirty-one percent of females ages, 12 to 17 reported that they had consumed fruits and vegetables five or more times per day (Statistics Canada, 2017). Albani, Butler, Traill, and

Kennedy (2017) found that adolescents consumed even less fruit (1 portion less) than the amount they consumed at age two.

Unfortunately, childhood and adolescence are critical formative periods for the development of eating patterns that track to adulthood with the potential to influence long-term health (Peralta, Dudley, & Cotton, 2016). Unhealthy sugar consumption patterns developed during childhood and adolescence are essential public health intervention targets. Research suggests that nutrition knowledge is a necessary

component in the process of changing eating habits (Wardle, Parmenter, & Waller, 2000).

Category Estimated added sugar (% of daily

energy)

Sugars (white and brown) 1.6

Other sugars (syrups, molasses, honey, etc.) 1.4

Cereals, grains and pasta 1.1

Other food categories 2.1

Total 14.1

Soft drinks—regular 3.5

Confectionary 2.6

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Nutrition knowledge, food literacy and sugar literacy. Nutrition knowledge refers to an individual’s understanding of nutrition, including the intellectual ability to remember and recall food and nutrition-related terminology, specific pieces of

information and facts (Krause, Sommerhalder, Beer-Borst, & Abel, 2016). It is important to note that there has been a recent transition in the literature where some authors are now using the term nutrition literacy and refer to both having the nutrition knowledge and the skills to transform that knowledge into healthy eating behavior, while others are calling it food literacy (Krause et al., 2016). Within the broader concept of food literacy, the term sugar literacy is used in this paper to describe the nutrition knowledge and awareness related to the amount of sugar that should be eaten, the amount of sugar in foods and beverages and, the health consequences of overeating sugar. It also includes the ability to understand and judge sugar information in packaged foods and the ability to select food and beverages with lower amounts of added sugar. By increasing sugar literacy, it would be expected that overall food literacy increases since it addresses one aspect of the knowledge, awareness, and skills needed for healthy and responsible eating behaviors.

The following study and systematic review provide evidence of the relationship between nutrition knowledge and eating behaviour. Pirouznia (2001) studied the

relationship between nutrition knowledge and eating behavior amongst 532 adolescents between the ages of 11 and 13 in the U.S. He found higher nutrition knowledge in girls than in boys, and also that nutrition knowledge for boys and girls in Grades 7 and 8 correlated to better eating behaviors. A more recent systematic review by Vaitkeviciute et al. (2014) included nine studies that investigated the relationship between knowledge and eating behaviour and found that adolescents’ food knowledge positively impacted dietary

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intake in six of the nine studies. Adolescents with greater nutrition and food knowledge and skills such as food preparation behaviors had healthier dietary behaviors

(Vaitkeviciute, Ball, & Harris, 2015).

Nutrition education interventions framework. With an established relationship between nutrition knowledge and dietary behaviours demonstrated in the literature, improving dietary behaviors using effective nutrition knowledge and food literacy interventions appears to be one viable option for reducing chronic disease morbidity and mortality. Theory or conceptual models are often critical to intervention development and in fact have been shown to be an important component of efficacious programs

(Hoelscher, Evans, Parcel, & Kelder, 2002). However, Brooks and Begley (2014) analyzed food literacy programs for adolescents published between 2000 and 2012 and found that the majority of the programs (16 out of 23) did not use a theoretical basis for the development of their program. From the ones that did, four used Social Cognitive Theory and the other three used models like the experiential learning framework. This is not uncommon, and Michie et al. (2013) set out to support behavioral intervention efforts by systematically identifying and categorizing strategies used in the literature. They found 93 different behaviour change techniques and categorized them. Their more recent work involved designing a model to represent these strategies (Michie, Stralen, & West, 2011).

Atkins and Michie (2013) suggested designing interventions to change eating behaviors according to Michie’s (2011) behavior model. Michie’s behavioral model consists of three components that interact to generate behaviors. The components are capability, motivation, and opportunity (the model is often referred to as COM-B).

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Capability is the capacity of the individual to engage in the activity of concern. It can be either or both the physical or psychological capacity. For instance, a psychological capability would be the capacity to engage in the necessary thought processes like comprehension and reasoning to adopt an activity. Opportunity is all the factors outside the individual that make the behavior possible. The opportunity can, therefore, be physical meaning the environment (e.g., affordable healthy food), or social being the culture that dictates the way we think about things (e.g., wide acceptance of fast food). Motivation is those brain processes that energize and direct behaviors. Motivation can be reflective, involving evaluation and planning (analytical decision making), or automatic, including emotions and impulses that arise from associative learning. According to Michie et al. (2011), an intervention can include one or more behavior change techniques that can influence any of the components of the behavioral model she proposes.

Michie et al. (2011) classified interventions to change behavior into 9 categories. Each type of intervention influences one or more components of the behavior system (see Table 3). Education interventions increase knowledge and understanding and affect psychological capabilities and reflective motivations whereas training interventions impart skills and can affect physical and psychological capabilities.

Table 3

Definition of Interventions and Links to the Components of the ‘COM-B' Model of Behavior

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Note. Adapted from “The behaviour change wheel: A new method for characterising and designing behaviour change interventions” by Michie, M. van Stralen, R. West, S. 2011, Implementation Science, 6:42, p.7-8.

Adolescent food literacy programs. Brooks and Begley (2014) review of literature surrounding adolescent food literacy revealed that most nutrition education programs targeted early adolescence and focused on improving practical cooking skills as a component of food literacy. The majority of the programs were limited in innovation meaning they lacked unique elements (themes or activities). Most of them used didactic methods usually associated with a school setting. Only 17% of programs were targeted to older adolescents (=/> 16 years old) which is problematic given the known decline in their diet quality and consequently their need for food literacy programs.

Based on their review Brooks and Begley (2014) suggested effective food literacy programs include a minimum of 4 sessions, opportunities for experiential or “hands-on” learning and were implemented in schools, community centers or sporting clubs. A school, according to Peralta et al. (2016), represents an ideal setting to facilitate dietary

Intervention Definition Links to components of the ‘COM-B’ model of behaviour Education Increasing knowledge or understanding Psychological capability, reflective motivation

Persuasion

Using communication to induce positive or negative

feelings or stimulate action Reflective and automatic motivation Incentivisation Creating expectation of reward Reflective and automatic motivation Coercion Creating expectation of punishment or cost Reflective and automatic motivation Training Imparting skills Physical and psychologiucal capabilities

Restriction

Using rules to reduce the opportunity to engage in the target behaviour (or to increase the target behaviour by reducing the opportunity to engage in competing

behaviours) Physical and social opportunity

Environmental Restructuring Changing the physical or social context auromatica motivation and physical and social opportunity Modelling Providing an example for people to aspire to or imitate Automatic motivation

Enablement

Increasing means/reducing barriers to increase capability or opportunity1

Physical and psychologiucal capabilities, automatic motivation and physical and social opportunity

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behavior change since youth attend regularly. Therefore, the school presents an opportunity to provide health-related information to increase health literacy levels. In their school food literacy survey, Ronto et al. (2016) stated that schools that promoted health, enhanced lifelong learning skills, competencies, behaviors and specific cognate knowledge, skills, and self-attributes in the students. To increase adolescent food literacy, many schools can incorporate basic food and nutrition education in the curricula to promote the attainment of personal skills such as food selection and preparation (Price, Cohen, Pribis, & Cerami, 2017).

In British Columbia, Canada, the Ministry of Education has changed the

curriculum for physical education in schools to include a wide range of personal health outcomes (British Columbia Ministry of Education, 2018). Starting in 2018-2019 school year, the Physical and Health Education (PHE) curriculum for secondary students includes teaching them the role of nutrition in health and performance in order to help students develop the ability to choose to eat healthy foods (British Columbia Ministry of Education, 2018, PHE 11& 12). PHE curriculum encourages flexibility in finding different ways to bring this learning to students like exploring partnership with teachers, parents, health authorities or others that might help support the learning experience in nutrition and other health topics included in the new curriculum. Including sugar literacy education sessions as part of PHE could be a way to help adolescents make healthy food choices.

Sugar literacy education programs. Nutrition education is a strategy that has been used with adolescents to address sugar literacy. Sugar sweetened beverages (SSB) have been the focus for these interventions because it is the category of food/beverage

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from which adolescents do obtain a large amount of sugar and SSB have been positively related to overweight and obesity in adolescence (Hu, 2013). In their systematic review, Lane et al. (2016) reported that 51% of studies on SSB education programs that focused on strategies to change behaviour by increasing awareness, knowledge and attitudes towards SSB reported positive effects. An example of an effective SSB education

program is the one named SIPsmartER, comprised of 6 weekly 45-minute lessons on SSB literacy and media literacy. This program has proven to decrease in SSB consumption at the immediate follow-up and at a three-month follow -up in adolescents (Lane et al., 2018).

Although the consumption of added sugar from SSB is high among adolescents, the highest amount of added sugar is still consumed across all other food groups together (Brisbois, Marsden, Anderson, & Sievenpiper, 2014). Therefore, interventions that consider not only sugar awareness in SSB but also in other foods are vital to change eating behaviors that would reduce total added sugar in the diet. After a thorough search of the literature, it appeared that there was a paucity of information about nutrition education for adolescents that focused more broadly on sugar literacy in both foods and beverages. However, a recent study addressed this issue in 10 to 12-year-old children (Griffin, Jackson, McNeill, Aucott, & MacDiarmid, 2015). Conducted in the United Kingdom, the research showed that these children had limited knowledge of sugar in foods and beverages and that an educational intervention improved this knowledge. The intervention consisted of two 45-minute educational sessions delivered on two different days. During the first day of the intervention, children learned about the difference between sugar naturally present in food and added sugar, the sugar content in food and

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beverages, and the importance of minimizing sugar intake for health. The second session reinforced health messages about sugar and described the importance of energy balance. Researchers used heaped teaspoons of sugar as a teaching aid to illustrate added sugar content in food and beverages. There appears to be a paucity of evidence of the efficacy of this approach. Of interest to intervention development however, is the use of food models as a teaching aid.

Teaching aids for healthy eating education. There are a number of free, or at low cost teaching aids available online through not-for-profit and government funded agencies. In Canada for example, the Sip Smart! BC teacher’s resource guide with activity sheets can be downloaded from the Childhood Obesity Foundation (COF) website. Sip Smart! BC teaches children in grades 4-6 about sugary drinks (Childhood Obesity Foundation, 2018) using life size beverage models and interactive classroom activities. The Dairy Foundation offers posters and other educational brochures that serve as teaching aids some of which are interactive tools e.g. tracking tools (British Colombia Dairy Association, 2019) and Health Canada provides education materials like posters, postcards or images of the Canada’s Food Guide that can be downloaded and are free to use for educational purposes (Health Canada, 2019). They also have some meal planning tools (e.g. Build a Healthy Plate) and videos available for use. These are not specifically targeted at teachers whereas the Dairy Foundation and COF materials are designed for the classroom.

Visual aids are tools that encourage effective teaching by making learning easier, more interesting, more real, more accurate and more active (experiential). According to Shabiralyani, Hasan, Hamad, and Iqbal (2015), the process of learning is more effective

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when our vision is involved: 83% of what is learned is learned from the sense of sight, 11%, from what we hear and, the remaining from the senses of smell, touch, and taste. It is easier to remember something that we hear and see than something that we only hear: 20% of what is heard is retained and 50% if it is heard and seen (Shabiralyani et al. 2015).

There are many nutrition visual aids available these days: pictures, models, charts, videos, slides, real objects, etc. Food models are one type of visual aids used in nutrition education. Two- or three-dimensional replicas of foods and beverages are available, and some are life-sized. Literature shows they have been used to assess the amount of food consumed (Luevano-Contreras, Durkin, Pauls, & Chapman-Novakofski, 2013; Nieman, Henson, & Sha, 2011; Sheehy, Kolahdooz, Mtshali, Khamis, & Sharma, 2014; Sheehy, Roache, & Sharma, 2013; Zemel et al., 2008), to examine and teach nutrition knowledge in early childhood (Holub & Musher-Eizenman, 2010; Manger et al., 2012; Matheson, Spranger, & Saxe, 2002; Reynolds, Hinton, Shewchuk, & Hickey, 1999) and for nutrition education with families (Park, Brown, Murimi, & Hoover, 2018).

Resources for teaching sugar consumption issues are also available. Test tubes containing the amount of sugars in foods and beverages (Nasco, n.d.) and

two-dimensional life-size teaspoons of sugar (NutriKit-USA, 2018) are two such options. No literature was found on studies using them, but some interventions have incorporated them (Gamble, 2012). It also appears that there is little evidence of the use of these type of teaching aids with adolescents.

Life-sized 3-D food models have some practical limitations compared to two-dimensional models such as storage and expense, which then limits the range of foods to

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work with given the number of foods available and experienced within and across cultures and settings. Two-dimensional life-sized resources may offer the same experiential learning and a more extensive variety because of lower cost and fewer demands on storage. They could also be adapted to different cultures which, has been suggested for appropriate educational materials to teach healthy eating in schools (Peralta et al., 2016). Two-dimensional food models could add an experiential or hands on

component to food literacy programs as suggested by Brooks and Begley (2014). They are easy to manipulate, they accurately illustrate daily diets because they are life-sized and they promote interaction between students.

Summary

Based on the literature it is known that adolescents, especially in developed countries are consuming higher amounts of free sugar than what is recommended by the WHO. This is one of the many factors in the deterioration of the diet in this stage of life. High consumption of free or added sugar typically reduces the quality of a diet. Literature shows that nutrition or food literacy interventions can influence diet behaviors.

Efficacious SSB awareness education interventions have been implemented with

children. Little has been done around sugar literacy interventions addressing sugar in all foods and beverages in children, and it appears that there is currently no evidence of their use with adolescents. Life-sized food models seem to be a viable way to enhance

experiential learning within nutrition education that aims to improve food literacy. However, two-dimensional models may be more feasible due to practical considerations.

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Purpose

The purpose of this research is to examine the impact of a brief nutrition

education intervention (focused on sugar content) using two-dimensional food models on the sugar awareness of older adolescents.

Specifically, the research questions were;

Research Question 1: Does a two 45-minute nutrition session intervention using two-dimensional food models significantly increase the knowledge that adolescents have about:

• the amount of sugar they can consume as part of a healthy diet • the amount of added sugar in beverages and foods

• the number of servings of each food group that should be present in a healthy diet for their age according to Canada’s Food Guide when compared to a non-intervention group of adolescents?

Research Question 2: Does a two 45-minute nutrition session intervention using two-dimensional food models significantly increase:

• the intention of adolescents to reduce the amount of added sugar they consume and,

• the self-efficacy that adolescents have to consume food and beverages with less added sugar the following two weeks after the intervention when compared to a non-intervention group of adolescents?

Research Question 3: Does a two 45-minute nutrition session intervention using two-dimensional food models significantly increase the ability of adolescents to understand the amount of added sugar in food and beverages by reading food labels when compared to a non-intervention group of adolescents?

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Operational Definitions

Free sugar: According to the WHO (2015) “Free sugars include

monosaccharides, and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices, and fruit juice concentrates.” (World Health Organization, 2015, pp. 4)

Added sugar: Are defined as “caloric sweeteners that are added to foods as ingredients during food preparation, at the table, or during food processing. Sugars such as cane sugar, brown sugar, and confectioners’ sugar, syrups, honey, molasses, dextrose, fructose, maltose, and undiluted juice concentrated present in foods and beverages are examples of added sugars” (Bowman, 2017)

Total sugar: Are the sum of added sugar and naturally occurring sugars (as in

vegetables, fruits, 100% fruit juice and milk) in the diet (Langlois & Garriguet, 2011).

Sugar awareness: For the purpose of this study, sugar awareness is defined as the

understanding about the effect of added sugar in health and the knowledge of where and in what amount added sugar is present in food and beverages.

Sugar literacy: For the purposes of this study, sugar literacy was defined as sugar

awareness and skills necessary to assess sugar consumption and change sugar related dietary behaviors.

Self-efficacy: Self-efficacy was defined as an individual's belief in the ability to

achieve a desired goal (Bandura, 2012). Self-efficacy in the current study is focused explicitly on the belief in having the ability to eat/drink foods and beverages with less added sugar.

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A teaspoon of sugar: For the purpose of this study a ‘teaspoon of sugar’ is

considered the amount of sugar that a spoon with a volume of 5ml, holds. This amount of sugar was defined as 4.2 grams according to the US Department of Agriculture Food Data Base (U.S. Department of Agriculture, 2018)

Assumptions and Limitations

The study relied on the assumption that participants would truthfully complete the questionnaires. Another assumption was that an increase in sugar content awareness leads to a reduction in sugar consumption. This leads to a limitation of the study which was that there were no follow-up measures to assess changes in eating habits after the intervention. There was however, a measure of intention to reduce the amount of added sugar consumed.

The appropriateness of the instruments used for assessment are a further

limitation. Several measures were adapted to meet the unique study objectives. Having control and intervention groups in the same school may also have limited the

interpretation of the findings because of the possibility of contamination; information from the intervention group students to students in the control groups.

Delimitations

The findings of the study were delimited to secondary students between 15 and 19 years of age that were enrolled in Physical & Health Education in a participating school. Additionally, the nutrition education intervention focussed mainly on free sugars.

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References

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Atkins, L., & Michie, S. (2013). Changing eating behaviour: What can we learn from behavioural science? Nutrition Bulletin, 38(1), 30–35.

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Chapter 2: Manuscript Introduction

Sugar in the diet is present naturally or as an added ingredient that has been related to both tooth decay and excess weight gain (Newens & Walton, 2016).

Overweight and obesity in populations has been rising worldwide, and this is a significant public health concern as it is associated with health problems like diabetes and

cardiovascular disease (Hammond & Levine, 2010). Medical expenses for obese people are at least 100% higher than for people that are not overweight (Hammond & Levine, 2010), not to mention the burden of decreased quality of life, mental health and wellness on individuals (Buttitta, Iliescu, Rousseau, & Guerrien, 2014). Adolescent overweight and obesity rates in Canada have mirrored this pattern; where they both increased

substantially between 1978 and 2004 (Shields, n.d., Chart 1) and then from 2004 to 2013, overweight remained the same (20.3 vs. 20.1%), and obesity continued to increase to approximately 30% (12.3 vs. 16.6%) among 12- to 17-years olds (Rao, Kropac, Do, Roberts, & Jayaraman, 2016). Similarly, in 2018 30% of children age 5 to 17 were overweight or obese (Government of Canada, 2018).

It is well accepted that a major cause of overweight and obesity in the last three decades has been the imbalance between the calories consumed and the calories

expended. This is a result of sedentary lifestyles and changes in the diet including

consumption of less fruits and vegetables and more energy dense foods and beverages in the diet (Manger et al., 2012). To address the overweight and obesity epidemic the World Health Organization (WHO) recommends encouraging physically active lifestyles,

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consumption of more fruits and vegetables and limiting intake from total fats and sugar (World Health Organization, 2018).

Although there is not yet consensus around the maximum amount of sugar that should be present in a healthy diet, recommendations from the WHO are widely used

(U.S. Department of Health and Human Services, 2015; Diario Oficial de la Federación,

2013). These state that less than 10% of the calories in the diet come from free sugar being free sugar the sugar added to food and beverages and sugars naturally present in honey, syrups, and fruit juices. In Canada, adolescents are consuming 14.1 % of their calories from added sugar (Brisbois et al., 2014). Added sugar is consumed by adolescents in sugar-sweetened beverages (SSB) but in solid foods as well (Reedy & Krebs-Smith, 2010). Adolescent sugar consumption is a concern since this is an age where eating habits are formed and diet quality deteriorates (Delisle & World Health Organization, 2005).

Strategies and interventions to change this public health trend are needed. Atkins and Michie (2013) proposed a model incorporating the evidence on efficacious behaviour change techniques and suggested that it was important to include one or more behavioral change techniques in interventions to influence any of the components (capability, motivation, opportunity) that can potentially change behavior. Education and training are two intervention techniques that can affect the capacity of an individual to engage in a specific activity (capability). These techniques have been used extensively and studies focussing on improving nutrition knowledge or food literacy through education

interventions have had demonstrated positive impact on eating habits (Vaitkeviciute et al., 2015). Food literacy is not only the knowledge and awareness but the skills/capacity

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to act (Krause, Sommerhalder, Beer-Borst, & Abel, 2016). Within broader food literacy definitions, it could be suggested that food literacy is comprised of a number of unique food specific literacies such as sugar literacy which encompasses not only the knowledge and awareness but the skills necessary to assess sugar consumption and change sugar related dietary behaviours.

Brooks and Begley (2014) reviewed literature focused on adolescent food literacy and found there was a lack of such interventions for older adolescents (high school students). Additionally, based on their review of the effective interventions, they suggested using innovative teaching aids, including opportunities for experiential or “hands-on” learning were necessary and suggested schools, community centers or sporting clubs as the possible delivery settings for food literacy intervention.

Schools represent an ideal setting to facilitate dietary behavior change since youth regularly attend for prolonged periods across a year and as they age (Peralta et al., 2016). Therefore, the school presents an opportunity to provide nutrition-related education interventions that incorporate evidence-based intervention techniques to increase health literacy levels.

In British Colombia, Canada, the Ministry of Education has changed the curriculum for physical education in schools (British Columbia Ministry of Education, 2018). Starting in 2018-2019 school year, the Physical and Health Education (PHE) curriculum for secondary students includes teaching them the role of nutrition in health and performance in order to help students develop the ability to choose to eat healthy foods (British Columbia Ministry of Education, 2018, PHE 11& 12). The Ministry of Education encourages flexibility in finding different ways to bring this learning to

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students like exploring partnership with teachers, parents, health authorities or others that might help support the learning experience in nutrition and other health topics included in the new curriculum. Including sugar literacy education sessions as part of physical education could be a way to help adolescents make healthy food choices.

Nutrition education with adolescents concerning sugar literacy has been mostly addressed to SSB consumption (Lane, Porter, Estabrooks, & Zoellner, 2016; Lane et al., 2018). Sugar sweetened beverages are the single category of food/beverage through which adolescents consume the most sugar; although the highest amount of added sugar they consume comes from across all other food groups together (Brisbois et al., 2014). Therefore, interventions that consider not only knowledge, awareness, and skills related to sugar in SSB but also in other foods are vital to potentially change eating behaviors that could reduce total added sugar in the diet. Although there appears to be no published literature related to broader sugar literacy interventions targeting adolescents, a recent study was found for 10 to 12-year-old children in the United Kingdom (Griffin et al., 2015). The researchers provided two 45-minute educational sessions across 2 days that also incorporated experiential activities using a teaching aid (heaped teaspoons of sugar to illustrate the amount of sugar in a variety of foods). At baseline, children had limited knowledge of sugar in foods and beverages. The educational intervention improved their knowledge significantly at follow-up (p<.001). This is not surprising as visual teaching aids have been shown to make learning more effective. Shabiralyani et al. (2015) suggest that 83% of what is learned is gained from the sense of sight, 11%, from what we hear and, the remaining from the senses of smell, touch, and taste.

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Life-sized food models are visual aids that have been used in nutrition education. The literature shows that two- or three-dimensional food models have been used to assess the amount of food consumed (Luevano-Contreras, Durkin, Pauls, &

Chapman-Novakofski, 2013; Nieman, Henson, & Sha, 2011; Sheehy, Kolahdooz, Mtshali, Khamis, & Sharma, 2014; Sheehy, Roache, & Sharma, 2013; Zemel et al., 2008), to examine and teach nutrition knowledge in early childhood (Holub & Musher-Eizenman, 2010; Manger et al., 2012; Matheson, Spranger, & Saxe, 2002; Reynolds, Hinton, Shewchuk, & Hickey, 1999) and for nutrition education with families (Park, Brown, Murimi, & Hoover, 2018). However, to date there appears to be little evidence about the use of life-sized food models for nutrition education with adolescents. Two-dimensional food models because of their advantage in cost, weight, and size could be a more feasible option than three-dimensional models to be used with adolescents, but their effectiveness needs to be tested.

The purpose of this study was to explore the impact of two 45-minute nutrition lessons using 2-dimensional life-sized food models, on adolescent’s sugar literacy. Specifically, the study objectives were to determine the effect of the experiential lessons on the awareness about the sugar content in foods and beverages and the

recommendations for limits on sugar as part of a healthy diet as well as the impact on skills and intention to consume less added sugar.

Methods

Research design. The research design utilized in this study was a randomized comparison trial with baseline and follow-up measures (see Figure 1). Participants were randomized to either a regular Physical and Health Education class condition (usual

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practice) or, into an intervention condition that had two nutrition education sessions using food models during physical and health education (PHE) after baseline and before

follow-up.

Figure 1. Research Design Diagram and Timeline

Sampling. The sample size was calculated using G*Power software with power set at .9, significance at p<.05 and an effect size d=.8 (large effect). A minimum of forty-nine participants was needed in each condition to be able to detect a difference between groups.

Recruitment. Physical and Health Education (PHE) teachers from a group of high school teachers meeting as part of a different project entitled “Relatedness-supportive strategies for girls in Physical Education” were invited to participate. This group of teachers had been involved in a project focused on increasing participating of girls in PE for several years, and were all attending a meeting and workshop at the University of Victoria. A 5-minute recruitment presentation explained the project to the

Randomization Control group Nutrition Education Session 1 & 2 Intervention group Nutrition Education Session 1 & 2

April and May 2018

Ba se lin e M ea ss ure Fo llo w -u p m ea su re

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group and potential teacher participants were asked to contact the researcher if they were interested. The teachers were from several different school districts on Vancouver Island.

Eleven teachers from six schools in Saanich, Sidney, Saanichton, Victoria, Courtenay, and Cumberland indicated interest in participating in the project. An

information letter and a consent to participate form were sent to the Principal of the six schools where the teachers worked. Once University Human Research Ethics approval, Principal consent and School District Approval were received, a presentation about the study (objectives, participation dates, and evaluation guidelines) was made to the

participating teachers’ PHE classes, and an information package including consent forms was handed out to each student. The schedule for nutrition education sessions was coordinated directly with each teacher.

Sixteen classes with a total of 334 students received the two 45-minute nutrition education sessions. Classes were randomly assigned to either the control (n=8) or intervention (n=8) condition. Each school had at least one control and one intervention group with 2 schools having 2 control and 2 intervention groups. As shown in the consort study flow diagram (see Figure 2) 214 students consented, 110 were in the intervention condition and 104 in the control group. Only the information from the students that consented was analyzed. All control class students received the intervention after measurement was completed.

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Figure 2. Flow of Participants through the Study

Intervention: Nutrition education sessions. The primary purpose of these two 45-minute nutrition education sessions was to positively influence eating behaviors by enhancing sugar literacy among youth. The sessions included an educational component according to Michie’s behaviour change model – COM-B (Michie et al., 2011) to

increase knowledge and understanding around sugar content in food and beverages, daily amount of sugar in a healthy diet and Canada´s Food Guidelines to promote healthy eating and lower consumption of added sugar. The sessions also included an interactive component to help students develop the necessary skills to interpret nutrition fact labels in packaged products and design healthy eating patterns.

Each nutrition education session took place during PHE class time (45-65 minutes depending on the school schedule) and was held either in a room with large tables or, on the gym floor so students could have enough space to work with the food models.

Assessed for eligibility (n=334) Randomized (n=334)

Allocation

Allocated to intervention (n=180) Did not receive allocated intervention (n=154) Consented (n=110) Consented (n=104)

Did not consent ( n=70 ) Did not consent ( n=50 ) Follow up

Consented and did not complete intervention and follow-up measure

(n=13) Consented and did not complete follow-up measure (n=24) Consented, did complete follow-up but

did not participate in baseline measure

(8) Consented, did complete follow-up but did not participate in baseline measure (3) Analysis

Analyzed (n= 102) Analyzed (n= 101 ) From complete data (n=89 ) From complete data (n=77 ) From intention to Treat protocol (n=13) From intention to Treat protocol (n=24)

Received Nutrition Program after follow-up measure

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Participants were provided with 2 didactic lectures and then experiential activities. For the experiential activities, participants were teamed in groups of 3 or 4, and each team was given a kit with more than 150 life-sized food and beverage models, 100 models of sugar teaspoons and colored copies of seven nutrition fact labels of commercial foods and beverage packages. NutriKitUSA and Sip Smart BC life-sized two-dimensional food and beverage models with nutrition information including added sugar on the back were used (see example in Appendix A). The food models in the kit included servings of fruits, vegetables, grain products, milk products, protein-rich foods, and beverages. For understanding added sugar content in packaged foods and beverages, seven additional nutrition fact labels of sugar-containing foods and beverages were analyzed (see Appendix B).

The schedule and intervention curriculum content are described in detail following.

Day 1:

Lecture: A brief educational lecture was provided for the class covering the following content:

Ø Review of Canada´s Food Guide and number of Food Guide Servings recommended being consumed daily for the age of each participant Ø Limiting consumption of added sugar as part of a healthy lifestyle Ø Introduction to the use of two-dimensional food models

Using food models to enhance sugar awareness among older adolescents: evaluation of a brief nutrition education intervention

Supervisory Committee

Abstract

Table of Contents