Web viewOne of the questions in the questionnaire asked whether they had diabetes or not, ... Dairy...

Running Head: Nutritional Program in Thahin 1

Nutritional Program for Adults in Thahin, Thailand: Obesity Prevention

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

Khon Kaen University

Abstract

Nutritional Program in Thahin 2

As the world has continued to industrialize, lifestyle related diseases like diabetes,

hypertension and obesity have become increasingly more common. Nearly half of the Thai

population is considered overweight or obese (Jitnarin et al., 2010). There has been extensive

research in this area of study, but it is quite difficult to find any direct correlations between

dietary intake, specifically portion size (Jitnarin et al., 2010). The pre-intervention research that

focused on this topic in relation to diabetes was inconclusive, but a weak correlation between

diet and BMI was found. Using this information supported by secondary research, we designed a

community-specific intervention for adults in the Thahin community. The program included

activities about portion size and healthy food preparation options. Participants said in evaluations

that they found the intervention helpful and that they felt equipped with the knowledge to make

informed decisions about nutrition. Although this program was limited due to budget constraints

and external factors that could not be controlled, the Thahin community expressed interest in

hosting another nutritional program and are excited to continue working with other students from

CIEE.

Keywords: obesity, nutrition, portion size, Thailand, intervention

Introduction


Diabetes, hypertension, and obesity are public health issues that are impacting

populations and individuals worldwide. In a report completed in 2013 by the World Health

Organization, 1.6 billion adults were classified as being overweight and more than 400 million

people were obese. Shockingly, children are also included in these statistics, with 20 million

children under the age of five being overweight (WHO, 2013). Looking specifically at Thailand

and the Isaan region, it is clear that these health issues impact these individuals as well.

According to the World Health Organization’s Regional Office for Southeast Asia, overweight

and obesity is defined as “abnormal or excessive fat accumulation that presents a risk to health”

(WHO, 2011). Obesity has become a widespread issue, as Thailand is among the top five nations

in Southeast Asia to have the highest numbers of obese individuals. The Ministry of Public

Health predicted that Thailand would have 21 million obese people by 2015 (Jitnarin et al.,

2007). A previous study, from the National Thai Food Consumption Survey, reported that

overweight and obesity are considered as serious health problems in Thailand as well (Jitnarin et

al., 2010).

Our team of researchers conducted research throughout the fall 2013 semester to identify

some of the health issues impacting the adult population of Thahin. Thahin, a semi-rural

community located 30 minutes outside of Khon Kaen and comprised of 99 households, is a

community which CIEE has built strong relationships over several years. The pre-intervention

research conducted in November 2013 was aimed at understanding how individual dietary

behaviors, BMI, and family history impacted an individual’s risk score for being susceptible to

diabetes in particular. After analyzing our data, we found that a very weak correlation existed

between between individual health practices and susceptibility to diabetes, therefore our group

redesigned our intervention to be nutrition-based, aiming at targeting overall health and obesity.


Eating habits, physical activity, socioeconomic status, education level, geographical location,

and several other factors play into the health of individuals. By conducting and analyzing

research, in combination with conducting secondary research, we were able to better understand

the health status within Thahin and to create a nutritional program in the community, targeting

adults ages 18 and older. This was done in hopes of educating the community on healthy eating

habits which will help to decrease individuals’ risk of entering obese and overweight statuses.

This paper will outline our primary and secondary research, our intervention methodology, data

results and analysis, and future recommendations and considerations for future studies.

Literature Review

Looking at the prevalence of obesity in Thailand and worldwide, as well as closely

related health issues including type II DM and hypertension, it is important to recognize the

impact that these health issues have in the Thahin community. By using primary and secondary

research conducted by our team, we were able to achieve our goals of assessing the dietary

behaviors of adults in Thahin and to related health issues, and to then lay a solid foundation for

our intervention project, while building and maintaining strong community relationships. We

conducted a pre-intervention research on November 23rd and our intervention was on December

3rd. Prior to starting our process, as well as throughout our process, we deemed it essential to

evaluate past research efforts specific to Thailand as well as worldwide.

Worldwide Impact

Globally, overweight and obese individuals are people who have an “energy imbalance

due to eating too many calories and not doing enough physical activity to use up the calories”

(WHO, 2011). Obesity has become epidemic in developing nations all over the world, with

more than 1 billion overweight adults, 300 million of them clinically obese. Obesity affects


people of all age groups, posing a major risk for chronic diseases including type II diabetes,

cardiovascular disease, hypertension, stroke, and other forms of cancer (Langendijk, Wellings,

van Wyk, Thompson, McComb, & Chusilp, 2003). With an increased consumption of nutrient-

poor foods with high levels of sugar and saturated fats and reduced physical activity, the number

of obese individuals is continually growing in both developing countries and the developed

world. On WHO’s Global Strategy on Diet, Physical Activity, and Health, the driving forces of

the rising obesity epidemic are due to the societal and worldwide nutrition transition, as well as

economic growth, modernization, urbanization, and the globalization of food markets (Puska,

Nishida, & Porter, 2003). Although there are major shifts towards urbanization and increases in

automated transportation and technology, there is less movement towards physical activity

(Puska, Nishida, & Porter, 2003).

In addition, the distribution of body mass index (BMI) is shifting upwards in many

populations around the world. As defined by the World Health Organization, BMI is the weight

in kilograms divided by the square of the height in meters (kg/m2) (WHO 2011). Recent studies

have shown that people who were undernourished in their early life and then become obese in

their adulthood may develop conditions such as high blood pressure, heart disease, and diabetes

in a more severe form and at an earlier age than those who were never undernourished (Puska,

Nishida, & Porter, 2011). Overall, obesity and being overweight pose extreme dangers for one’s

health as it is notably a major risk factor for chronic diseases, including diabetes.

Health in Thailand and Isaan

In Southeast Asia, 300,000 people die each year of being overweight and obese (WHO

2011). In Thailand, approximately 35% men and 49% women were considered overweight or

obese in accordance to the Asian standard based on individual body mass index. According to


Thai standards, men with BMI of >27, and women who are >25 are classified as obese

(Pongchaiyakul et. al., 2006). The Thai standards of classification for high blood pressure are in

conjunction with worldwide blood pressure readings at 140/90 mm Hg categorized as

hypertension (Aekplakorn, Bunnag, Woodward, Sritara, Cheepudomwit, Yamwong, &

Rajatanavin, 2006).

Obesity has become a widespread issue, as Thailand is among the top five nations in

Southeast Asia to have the highest numbers of obese individuals. By 2015, the Ministry of Public

Health predicted that Thailand would have 21 million obese people (WHO, 2011). A previous

study, from the National Thai Food Consumption Survey, reported that being overweight or

obese are considered serious health problems in Thailand (Jitnarin et. al., 2010). Researchers

from the Institute of Nutrition at Mahidol University have drawn a connection from the current

prevalence of obese individuals to the nutrition and health transition in Thailand. By exploring

the nutrition transition, results from nationwide surveys indicated that food consumption pattern

has changed, noticeably (Kosulwat, 2002). This nutrition transition marks the shift from Thai

staples and side dishes to diets containing high proportions of fats and sugars. Consequently, the

prevalence of overweight and obese children and adults has increased dramatically, most

pronounced in those living in urban areas than rural communities. Not only is this shift affecting

communities personally, but it is also creating a larger disease burden on the Thai population

(Kosulwat, 2002).

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

from more traditional dishes to more processed, high sugar and fat foods (Jitnarin et. al., 2010).

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

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


In more urban cities such as Bangkok, Thai staple dishes are being replaced with pre-made,

processed foods. Across the country, the consumption of carbohydrates and fats has been

steadily increasing since the 1990s (2002). As a result, there has been a rapid increase of

overweight and obese individuals, which has not only had detrimental effects of their health, but

it may also lead to other chronic diseases (Puska, Nishida, & Porter, 2003).

Current Policies

Since the pandemic of obesity and overweight is relatively new in Thailand, few

interventions and policies exist (Pawloski, Ruchiwit, & Markham, 2011). Nevertheless, the Thai

government launched few nutritional interventions to improve the problem of obesity. For top-

down, government nutritional programs included educations, promotion of community food

production, training, and consumer protection. For example, the government-issued Food Based

Dietary Guidelines which lists recommended diets for each age group, encouraging people to

consume more proteins, vitamins, vegetables, and fruits. The nutrition labeling became a

mandatory for any packaged or processed food, so the consumers are informed of their

nutritional choices. Lastly, the government fortified salt, instant noodles, and milk with

necessary vitamins in order to reduce nutritional deficiencies. For the bottom-up process,

community involvements were greatly encouraged. Village health volunteers became responsible

for around 10 households in their villages, monitoring diabetic patients and distributing vitamin

supplements to the community members when needed (Tontisirin & Bhattacharjee, 2001).

Despite these efforts, there is still a significant need for an effective nutritional program for

raising awareness for dietary habits and their impact on chronic diseases such as obesity,

hypertension, and diabetes (Tee, Dop, & Winichagoon, 2004). In fact, long-term nutrition


educations are proven to effectively improve people’s dietary habits (Taechangam Pinitchun &

Pachotikarn, 2003).

CIEE Research

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

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

issues that face the community. By speaking with the stakeholders of the community and

analyzing our data collected on November 23rd, we found that a nutrition-based intervention in

the Thahin community would be an effective and sustainable way of benefiting and working with

the community. In terms of primary research, our team aimed to assess the dietary behaviors and

prevalence of health status relating specifically to type II DM in adults in Thahin. After

completing our research and analyzing our data, and recognizing that a weak correlation existed

between individual dietary behaviors and the calculated susceptibility score, we chose to

redesign our intervention approach.

In a past CIEE study conducted in Thahin in November 2013, students were able to find

that the overall socioeconomic status for individuals in Thahin ranged from 3,000-65,000 baht

monthly household income, with the average monthly household income being 17,900 baht ±

2,590 (CIEE, 2013). Socioeconomic status is a large indicator of individual health-related

behaviors, and similarly can have an impact on occupational status, education level, as well as

weight status. In a study published in January 2010, it was found that individuals with lower SES

were found to be at greater risk for obesity and becoming overweight (Jitnarin et al., 2010).

Additionally, high education levels were shown to have decreased risk for developing health

problems as a result of being educated on different health-related topics (Jitnarin et al., 2010). In

past CIEE research, it was found that 53.3% of people who were surveyed had only completed a


primary level education (CIEE, 2013). Additionally, from our pre-intervention research only

2/33 participants had been exposed to a nutritional program in the past was motivation to have a

nutrition-based intervention plan. We found that eating habits, physical activity, socioeconomic

status, education level, geographical location, and several other factors play into the health of

individuals (CIEE, 2013).

As dietary behavior plays a significant role in the health of populations and individuals,

relating to diabetes, hypertension, and obesity, we designed a nutrition based intervention for the

Thahin community, in order to educate and work with the population to improve overall health

and well-being.

Methods

Sample Population

Our sample population during our research and data collection was adults ages 18 and up.

Since our questions geared towards cooking, preparing meals, medical history, family history,

and BMI, we figured the responses we received would be reliable and adequate to further

analyze the data. We did not, however, exclude an adult based off of their pre-diabetic or post-

diabetic history. One of the questions in the questionnaire asked whether they had diabetes or

not, and if someone in there family has diabetes or hypertension (refer to Appendix A). Overall,

our pre-intervention sample size consisted of 33 participants, which is not representative of the

rest of the Thahin community, but it allowed us to receive a variety of persons by not exclusively

interviewing only those community members living with type II DM. Although our research

during our data collection represented an adult sample population in Thahin, we decided to

include all age groups in our program. Due to the fact that nutrition based information is valuable

and relevant to everyone no matter what age, we accepted all ages.


Measurements (Pre-Intervention)

The purpose of the pre-intervention study was to assess the susceptibility and prevalence

of type II diabetes mellitus (DM) and dietary behaviors of adults in Thahin village. To assess the

two variables, we utilized quantitative tool by closed-ended survey questions. The susceptibility

and prevalence of type II DM was defined as type II DM risk score. To assess the risk score, we

looked at five risk factors for type II DM: age, gender, BMI, hypertension, and family history

(Aekplakorn et al., 2006). Participants’ age, gender, and family history of diabetes or

hypertension were collected through the survey questions. We measured each participant’s

height and weight for BMI and blood pressure for diagnosing hypertension. Participants who had

blood pressure over 140/90 mm Hg were classified as having hypertension (Aekplakorn et al.,

2006). Then each participant was given a type II DM risk score based on the Thai-specific risk

score chart (Appendix B). The questionnaire also asked about physical activity but since it is not

a risk score, it was not accounted in the scoring system.

The dietary behavior of adults in Thahin was defined as their dietary score. First, we

assessed how much ingredients such as oil, salt, MSG, soy/fish sauce, and sugar the participants

usually use in cooking. For salt, MSG, and sugar, participants were asked to scoop out

appropriate amount of sand with a tablespoon to represent the amount they usually use in

cooking. For oil and soy/fish sauce, they poured appropriate amount of water into a cup. For the

consumption frequency of different types of dish, we simply asked the participants to recall how

often they eat certain food by checking options from never, once, 2-3 times, 4-5 times, 6-7 times

per week.

After gathering dietary information about how much ingredients they use for cooking and

how often they consume differently-prepared dishes and we assigned a dietary score for each


participant based on the scoring system from 0 to 4. Score 4 means the healthiest behavior and 0

means the least healthy behavior. A person who responded that he/she consumes fruits every day

receives score 4 for the section while another who responded to consume fruits once a week

receives score 0. Same scoring system was applied to all food groups and the maximum dietary

score one can get was 88.

Intervention

Our nutrition education program intervention took place on Tuesday, December 3rd at

4:45pm. We had 23 participants attend the program, including three Village Health Volunteers

and a couple of teenagers. In our pre-intervention research, we excluded anyone that did not fit

into the adult age group (ages 18 and over), however, we were cognizant of the educational

information that could be useful and relevant to community members of all ages. Although not

all of the participants who completed our survey were present at the program, there were familiar

faces suggesting some members came back to attend our program and asked to see their BMI

results.

Prior to this intervention; our groups arrived in Thahin 3 hours before to set-up and start

the food preparation. We began the intervention by introducing ourselves as American students

studying public health at Khon Kaen University. By stating the purpose of our research and

intervention, we then made it clear that the majority of the Thahin community members that

were surveyed in our research perceived diabetes as a major health concern and we were there to

help improve the overall health of the community. After a brief introduction, we began the

lecture portion of our nutrition program. We gave an overview of nutrition-related topics, such as

BMI and risk factors for obesity, including definitions and significance to overall well-being. We

informed the community on their health status in comparison to Thailand’s national averages in


order to further stress the importance of of this health issue. Our goal was to make sure the

community members are well equipped with healthy eating habits and general knowledge of

nutrition. Throughout the program, we asked if anyone had any questions to make sure everyone

was on the same page.

Following the short lecture, we led an interactive session that included activities relating

to serving size and food preparation. In this first activity, we handed out blank pictures of plates

and asked them to draw a typical meal that they would eat at home. Then we taught them about

serving sizes using the Thai nutrition flag and how that translated into an average meal. We then

had them draw how much of each food group they should consume on a daily basis compared to

the recommended amount. After comparing the two plates, before and after showing the nutrition

flag and learning about portion size, we noticed the latter had correct amounts of food in

accordance to the serving sizes. In order to reinforce the importance of portion size, we handed

t-shirts saying, “A han dee, suk a pap dee” which translates into “Good Food, Good Health” Our

second activity outlined some healthier ways that they can prepare traditional Isaan dishes. Each

person received 4 small paper cups filled with foods for them to sample. Each pair of cups was

filled with the same food, just prepared in different ways. We had the participants taste each

variation and guess what the difference was. The first dish was kie giow (deep-fried egg) and the

second dish was som tam (green papaya salad). We prepared these dishes with the traditional

ingredients regularly used, however, we limited the following ingredients: MSG, fish sauce,

fermented fish sauce, salt, sugar, and oil in the second preparation. The purpose of this activity

was to help illustrate the different, healthy and equally delicious ways to cook common dishes.

Although many had different taste opinions about the foods and how they were prepared, most of


the participants said they would adapt these healthier food preparations in our discussion held

after this activity.

At the end of our program, we thanked our participants for their time and handed out

brochures (Appendix C) summarizing the key topics we covered in our intervention, a portion

size chart with the food flag that could be hung up on their refrigerators, and a food flag poster

for the community to display in an accessible and common area. We also handed out an

evaluation form (Appendix D) to receive feedback on this intervention program.

Budget

Materials Quantity Cost [Baht] Expenditure [Baht]

Nutrition Flag Poster 1 poster 400 400

Colored Pencils 2 packs 100 84

Small Cups 100 cups 80 80

Brochures and paper 100 copies 400 600

Water 3 packs 180 180

Food To feed 30 700 374

Transportation Round-trip 1000 700

Translation 1 translator 1000 1000

T-shirts 30 shirts 5000 4800

Fruit To feed 30 180 330

Gifts 2 gifts 300 278


Tissues 1 roll N/A 10

Glue 1 stick N/A 64

Clear cups 6 cups N/A 36

Forks 1 pack N/A 12

Total 9600 Baht 8948 Baht

652 Baht left

The above chart is a breakdown of our group’s budget. We were allotted 9,600 Baht to complete

our intervention and to buy the appropriate materials necessary. Some of our initial cost

estimates were too high, allowing for us to remain under budget, with an amount of 652 Baht left

over. We had also initially accounted for having to buy stickers, however this part of the

intervention was cut, therefore as was the cost. Some costs, which we had not specifically taken

into account when submitting our proposal was the need for: tissues, glue, clear cups, and small

forks. Although we remained under budget, some costs were cut from our initial plan in

additional to not considering resources of higher value. This will be further explained in the

strengths and limitations section.

Timeline

Research and Project Timeline (18 November - 9 December)


Date Tasks Completed

18 - 19 November Designed research tool (survey)Wrote research proposal

20 November Research proposal presentation run throughPresentation and proposal submission

22 November Had materials translated and printed

23 - 24 November Conducted 33 surveys

25 - 27 November Analyzed data collectedWorked on intervention proposal

26 November Consultation with Ajaan Jen and P’facs

28 November Intervention presentation run-through Presentation and proposal submission

29 November - 3 December

Finalized materialsPracticed intervention

3 December Intervention day

4 December Delegation of roles

6 December Met with Ajaan Toon about Final Paper Expectations

4 - 12 December Group work on final project reportRun-through of presentation

9 December Final presentations

The timeline above shows our general schedule throughout our research and intervention

process. Due to the limited amount of time we had in this course, our group found it very helpful

to get things completed as early and efficiently as possible.

Intervention Day Timeline (3rd December)


Time Activity

1:00 - 1:30 Traveled from CIEE to Thahin in van

1:30 - 2:00 Shopped for ingredients at market

2:00 - 2:30 Set up chairs, arranged room

2:30 - 4:30 Prepared food (papaya salad and fried egg)

4:15 - 4:45 Participants arrived

4:45 - 4:55 Introductions, brief overview, shared findings

4:55 - 5:15 Portion size activity

5:15 - 5:25 Handed out shirts, break

5:25 - 5:50 Taste testing activity, discussion

5:50 - 6:00 Thank you, evaluations

6:00 - 6:30 Cleaned up, gave gifts to VHVs

The above chart is a detailed timeline of the day of our event.

Outcome Measures (Post-Intervention)

The purpose of post-intervention evaluation was to assess the change in knowledge of the

participants regarding diabetes, obesity, and nutrition. Before the Thai Nutrition Flag lecture, the

participants were asked to draw a plate with proportionate amount of each food group such as

rice, meat, vegetables, fruits, and dairies. Then the participants drew a new plate with the same

food groups after the lecture in which they learned about recommended portion size for healthy

diet through the Thai Nutrition Flag. By comparing pre and post-lecture plates, we expected to

see an improvement in knowledge about serving sizes. Also, the evaluation survey which

consisted of four yes or no questions and one comments section was distributed at the end of the

program to be completed by the participants. The questions included: 1. Did you find this

program helpful? 2. Do you feel like you’ve learned enough to make healthy food choices? 3.


Would you be interested in participating in another nutrition program? 4. Would you be

interested in participating in an exercise program? The yes or no questions were asked to assess

how many people thought the program was effective enough to help them improve their dietary

knowledge and behavior. The comment section was included at the end of the survey in order to

gather any qualitative data on the participants’ opinions or feedbacks. The questions evaluate the

effectiveness of the program and the participants’ willingness to participate in more diabetes or

obesity-related programs in the future.

Data Analysis

Pre-Intervention. The purpose of the pre-intervention study was to assess the

susceptibility/prevalence of type II DM and individual dietary behaviors among adults in Thahin.

The susceptibility was measured by the type II DM risk score while the individual dietary

behavior was measured by the dietary score. Then correlational statistics were conducted to see

if there was any correlation between the type II DM risk score and the dietary score. Also, same

statistics was used to see the correlation between the BMI and the dietary score. Our hypothesis

was that individuals with high type II DM risk score will have lower dietary score. In other

words, individuals who have unhealthy dietary behaviors are more likely to be highly susceptible

to type II DM than those who eat healthy. Our second hypothesis was that individuals who have

lower dietary score or unhealthy diet are more likely to have high BMI, meaning overweight or

obese. Moreover, prevalence of diabetes, obesity, and overweight among the participants was

also analyzed to see if there is a high rate of any of the health conditions in Thahin village.

Post-Intervention. The post-intervention data were all analyzed both quantitatively and

qualitatively. The participants’ improvement in their knowledge about serving size was analyzed

qualitatively by comparing the pre and post- lecture plate drawings. We observed the difference


in the serving size proportions before and after the lecture. For the evaluation survey, we

analyzed the responses quantitatively. The number of yes or no responses was counted for each

survey question to analyze the effectiveness of the nutritional program.

Ethics

After conducting our intervention, it was important to evaluate the ethical measures that

were executed during our process, pre and post-intervention.

Pre-intervention. During the research stage, or the pre-intervention phase of our

process, confidentiality was maintained as when conducting the interviewees, the interviewers

and the translator asked for the gender and age of the participants, rather than their house number

or name of those who attended. Also, in order to protect the privacy of our participants, we

wanted to keep our age group as the 18 and older population. Upon completion of our data

collection, we found that the information should be shared with the community, as we feel that

their health information is the right for them to know. We compiled the information collected

from the research day, and shared the information with participants, who attended our

intervention. The information was surrounding body mass indexes (BMI), which were collected

during our research collection day. Sharing this information was complementary to the

information being shared on the Thai standards of being overweight or obese.

Post-intervention. Another ethical concern, which should be taken into account if

conducting research in the future, is the cultural and social norms surrounding different topic

areas. For example, in our research involved measuring individual height and weight we had to

consider the sensitivity of that information. In some communities this may be seen as very

personal information. At some points during the interview process, as many other waiting

participants were in the same area as the interviewer and interviewee, an individual’s name may


have been said by a friend or neighbor. If this process were to be repeated, it would be advised to

conduct the interviews in a private space to avoid conversation that would possibly leak an

individual’s personal information either to the research team or vice versa.

Results

Pre-Intervention

The purpose of the pre-intervention questionnaire study was to assess the dietary

behavior and susceptibility/ prevalence of obesity, diabetes, and hypertension among adults in

Thahin. Out of 33 participants who completed the questionnaires, 11 were males and 22 were

females. The mean age of the participants was 45.4 ± 19.8 years old with the range from 18 to 82

years old. The average BMI for females participants were 26.1 ±3.4 kg/ while for males was 24.5

± 4.3 kg/. Based on the BMI cut-off for diagnosing overweight in Thai population, men with

BMI >25 kg/ and women with BMI >23 kg/are considered overweight. For obesity, the cut-off

is >27 kg/for men and >25 kg/ for women (Pongchaiyakul et al., 2006). According to the post-

intervention study, 36.4% of men and women participants were overweight. Also, 50% of

women and 18.2% of men were obese. To sum up, about 70% of female and 40% of male

participants were either overweight or obese (Table 1).

Also, 24% of the participants had hypertension, meaning that their blood pressures were

higher than 140/90 mm Hg. Another 24% were classified as pre-hypertension because their

blood pressures were higher than the normal blood pressure 120/80 mm Hg but lower than

140/90 mm Hg. The blood pressure standard is accepted in both Thailand and worldwide

(Aekplakorn et al., 2006). Surprisingly, only two women (6%) had diabetes, but 10 people

(30.3%) had at least one family member who has diabetes or hypertension (Table 1).


For the past exposure to nutritional program, only 2 participants out of 33 responded that they

have had a nutritional program in the past and those same participants indicated that they had a

dietary restriction relating to diabetes, obesity, or hypertension by not eating sweets or sticky rice

due to their high carbohydrate content. Lastly, 39.4% of the participants exercise every day,

18.2% exercise 3-6 times a week and 42.4% exercise 1-2 times a week or never (Table 1).

Table 1. Diabetic health status of Thahin adults (age over 18) based on risk factors

Total sample size (n) 33Gender (n)

malesfemales

1122

Age (years) 45.4 ± 19.8 (mean ± standard deviation)BMI (kg/m2¿

malesfemales

24.5 ± 4.326.1 ±3.4

Overweight (n)males > 25 kg/m2

females > 23 kg/m224

Obese (n)males > 27 kg/m2

females >25 kg/m2211

Hypertension (n) > 140/90 mm Hg 8Diabetes (n) 2Family history of diabetes/hypertension (n) 10Nutritional program (n) 2Dietary restriction (n) 2Exercise per week (n)

never1-2 times3-6 timeseveryday

59613

Overall, the dietary behaviors of the participants were quite healthy. 54.5% of the

participant consumed boiled/steamed vegetables 6-7 times or more per week and 45.5%

consumed fruits every day. Also 57.5 % responded that they never or rarely (once a week)


consume deep fried meat/fish and 39.3% never or rarely consumed vegetables. The 60.6% of the

participants also never drink soda or alcohol. However, the participants’ consumption of fried

egg and sticky rice was very high. About 30% of the participants eat fried egg 4-5 or 6-7 times

per week and 60.6% eat sticky rice every day. The mean dietary score of the participants were

55.5 out of 88 (Figure 1).

Figure 1.Consumption frequency of different food groups per week

boiled/steamed vegetablesstir-fried vegetables

deep-fried vegetablesboiled/steamed meat/fish

grilled meat/fishstir-fried meat/fish

deep-fried meat/fishfried egg

deep-fried eggboiled eggsticky rice

sodaalcohol

chocolate, candy, chips

0 5 10 15 20 25 30 35

6-7 times4-5 times2-3 timesoncenever

Number of Respondents

Lastly, when we conducted correlational statistics to find out what correlations exist

between individual dietary behavior and susceptibility/prevalence of diabetes, there was no

correlation between the dietary score and the risk score (r= -0.11). Yet, there was a weak

negative correlation between the dietary score and BMI (r= -0.23).

Post-Intervention

For the intervention, 25 people participated in the program. Out of 25, 2 were males and

23 were females. All the participants were adults over age 18 except two middle school girls who


also participated in the program. For the plate drawing activity, many participants drew rice and

meat with the same proportion. Also many were missing dairy. After the Nutrition Flag lecture,

however, many participants redrew their plate with appropriate amounts of rice, fruits,

vegetables, meat, and dairy. Generally, portion sizes for meat and rice decreased and fruits and

vegetables increased after the lecture. Participants also learned how much they should be eating

based on their ages and physical activity levels through visual demonstration. Many expressed

that the information was new and were very enthusiastic to learn.

After the tasting activity, many showed interest in cooking som tam (green papaya salad)

with less fermented fish and fried egg with less oil. Despite that one participant said food with

MSG taste better, many expressed that dish B which had no MSG did not taste too different from

the regular dish A. Lastly, from the evaluation form after the program, all the participants

responded that they found the program helpful and that they felt like they’ve learned enough to

make healthy food choices. Also, all of them expressed interest in another nutritional program or

an exercise program from CIEE.

Discussion

Throughout our research process, we have learned a great deal about the health status of

Thahin. Preliminary scouting observations done earlier this fall by CIEE suggested that an

intervention in Thahin would be well-received: the Village Health Volunteers are very active in

the community and many community members are interested in health (CIEE, 2013). After

conducting extensive primary and secondary research in this community, we decided that the

topic of diabetes and dietary intake needed to be explored further. Our pre-intervention research

suggested that it was obesity, rather than diabetes, that was a significant problem in the

community. Out of the 11 males we interviewed, 4 were either overweight or obese according to


Thai standards. Even more startling, 15 out of the 22 females interviewed were overweight or

obese. These numbers are significantly higher than the national averages of 44.9% for women

and 35% for men (Jitnarin et al., 2010). By comparing each participant's dietary score and

diabetes risk score, we found that there was no correlation between these two numbers. But when

we compared the dietary scores to BMI, we found a weak negative correlation. This relationship

coupled with the high prevalence of overweight or obese individuals in Thahin and lack of

nutrition education was sufficient evidence to formulate an intervention based on this health

outcome.

Continued analysis of our data brought us to the conclusion that the community had a

relatively healthy diet; the mean dietary score was 55.5 out of 88, which we assessed as fair. The

most common dishes consumed were boiled or steamed vegetables, boiled or steamed meat,

boiled eggs and sticky rice. This made the high prevalence of obesity even more surprising. But

our questionnaire only asked about frequency of food consumption and did not address portion

sizes. In addition, our food preparation questions yielded uninformative results. One person

could use a pinch of sugar while another could use almost two tablespoons and both people

would receive the same dietary score. Both of these gaps in our own research as well as existing

literature helped form our specific nutrition program and activities.

We had several expectations for the outcome of our program. Our main goal was to make

a positive impact in the obesity situation in Thahin. To do this, we wanted people to leave our

program feeling equipped with the knowledge to prepare traditional dishes in a less traditional,

but healthier way. Because only two people had participated in a nutrition program in the past,

we thought this was very important. We also wanted them to have a stronger understanding or

portion sizes based on Thai national recommendations. In this sense, our program was very


successful. We had a fairly high turnout and reached our participant goal. Our participants were

responsive when we asked them questions, and many were very enthusiastic when trying to

guess the difference between the two dishes that we prepared. Each of the participants filled out

an evaluation form at the end of our program and all of them responded that they found it helpful

and that they learned enough to make healthy food choices. In addition, some of the plates where

they drew portion sizes before and after learning about the food flag were collected. In general,

the amount of fruits, vegetables dairy that they drew on their plates increased and the size of the

meat and rice portions decreased. By comparing the plates before and after the education session,

it is clear that they had a better grasp of how much of each food group they should be eating on a

daily basis.

We did run into some problems during the intervention that we did not foresee.

Throughout the intervention, participants were fairly distracted. The outdoor location of our

program was quite loud with motorcycles driving past every few minutes or children playing in

the streets. Many participants were talking amongst themselves while we were talking because

they were waiting for the translator to tell them the information. Also, there may have been a bit

of confusion during the portion size activity. Based on observation, many people do not eat one

dish per meal; it is typically more communal and people eat from shared dishes. There were

many questions asked during this activity, and participants may have missed the pie chart aspect.

The activity was intended to show, based on daily recommendations, how much of each food

group they should eat at each meal. This message may not have been received. The second

activity also had unexpected complications. The villagers did not enjoy the different preparations

of the two dishes, som tum and fried egg. When asked about the differences, many participants

said it was too spicy or too salty. Although several of them said they would consider preparing


their dishes in a healthier way, they did not like the dishes we made for them and as a result may

actually shy away from trying the alternative cooking methods that we suggested. Despite these

challenges, all of the participants said that they would be interested in attending another nutrition

program

Conclusion

Summary of Findings

Through extensive primary and secondary research, we have determined that obesity is a

serious health issue in Thailand and especially in the Thahin community. The prevalence of

overweight and obese individuals in Thahin is significantly higher than the national average, yet

food choices appear to be healthy. They have very active village health volunteers and overall

people seem to be interested in learning about nutrition. After our nutrition-based intervention

that included activities about portion control and food preparation, participants reported a high

satisfaction with the program, saying that they learned enough to make healthy choices about

nutrition and that they would be interested in another nutrition program in the future.

Strengths and Limitations

Our research and intervention process had a variety of strengths. Throughout the entire

process, we saw the needs of the community as our first priority. When we found no correlation

between dietary intake and diabetes risk, instead of simply continuing on with our original plan,

we shifted our focus to reflect the actual health situation of the community. We based our

intervention on the results of our primary research rather than what we initially envisioned. In

addition, very few people had ever been exposed to a nutrition education program before so they

were eager to participate in our intervention. This resulted in a fruitful and community-specific

event. Our evaluation system, including the pre- and post-lecture plates and the written


evaluations, allowed for us to see the effectiveness of our program. We were able to see that the

participants actually had learned something from our event and found it helpful. We also left the

community with t-shirts, brochures, a large poster with the food flag and handouts with serving

sizes so that they would be reminded of what was said during our program. We hope that these

reminders will increase the likelihood that the community will modify their dietary behaviors in

a healthy way.

Our intervention does have some limitations that are worth mentioning. First, the budget

for this project was quite small. Because of limited funding, many sacrifices had to be made that

may have affected the quality of the program. We did not consider higher cost resources, such as

hiring a health professional to accompany us on the day of our intervention, so our group had to

answer difficult questions based on our somewhat limited knowledge about Thailand-specific

nutrition information. When questions were asked, the translator answered using her own

background knowledge on the topic rather than consulting us. The use of a translator in general

can obscure the original message and result in misinformation. Another limitation was the group

of participants used in research and the intervention itself. The intervention was based on

research primarily done on older women that the village health volunteers either knew or lived

close to. These women may not be representative of the whole community. As previously

discussed, during the intervention itself the participants were quite distracted. They may not have

taken in all the information that we gave them. Our evaluation system was very subjective and

qualitative, so it is difficult to gauge the true effectiveness of our program.

Recommendations

Based on these experiences, we have several recommendations for future research and

interventions. A larger budget would be able to accommodate for a local health professional to


join the group. This person could answer specific questions, providing an expert opinion on

difficult or unknown topics as well as add credibility to any program. A larger budget could also

allow for follow-up visits to the community. Further research before the intervention using a

random sample would provide more unbiased, community-specific information on which a

program could be based. A follow-up visit would also be useful in assessing the effectiveness of

the education session through observation or a post-test questionnaire. Returning to the village at

least a few days after an intervention to ask what they learned and if they used any of the

suggested tips would be very valuable for an evaluation of the program.

Further considerations

There are still several gaps in the research that should be further explored. First, there

should be more investigation on the correlation between portion sizes and lifestyle-related

diseases. Although it is known that diet in general affects health, there needs to be more concrete

evidence that links serving size to these diseases. This could be done using various tools

including observational methods, surveys, interviews and case-control studies. More research

and intervention programs could also be done in the field of exercise. Many people in the

community reported frequent exercise, and everyone expressed interest in an exercise program in

the future. Research in this area could look at the intensity and frequency of exercise and its

relationship to overall health or a specific health outcome. It is recommended that students

continue to work in the Thahin community. People in this village are very excited to work with

CIEE and eager to learn more about how to improve the health status of their tight-knit

community.


References

Aekplakorn, W., Bunnag, P., Woodward, M., Sritara, P., Cheepudomwit, S., Yamwong, S., &


Rajatanavin, R. (2006). A risk score for predicting incident diabetes in the Thai

population.(Cardiovascular and Metabolic Risk)(Clinical report).Diabetes Care, (8).

1872.

CIEE. (2013). The Status of Mental Health in the Thahin Community.

Jitnarin, N., Haddock, C., Poston, W., Kosulwat, V., Rojroongwasinkul, N., & Boonpraderm, A.

(2010). Risk factors for overweight and obesity among Thai adults: Results of the

national Thai food consumption survey. Nutrients, 2(1), 60-74.

Jitnarin, N. N., Kosulwat, V. V., Rojroongwasinkul, N. N., Boonpraderm, A. A., Haddock, C. C.,

& Poston, W. W. (2007). Prevalence of Overweight and Obesity in Thai Populations:

Results of the National Thai Food Consumption Survey. Obesity, 15(9), 335-P.

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

5(1A), 183-189.

Kumcheen, P. (n.d.). Thailand Under Obesity Crisis. Siam University .

Langendijk, G., Wellings, S., van Wyk, M., Thompson, S. J., McComb, J., & Chusilp, K. (2003).

The prevalence of childhood obesity in primary school children in urban Khon Kaen,

Northeast Thailand. Asia Pacific Journal Of Clinical Nutrition, 12(1), 66-72.

Pawloski, L. R., Ruchiwit, M., & Markham, S. M. (2011). The Growing Burden of Obesity in

Thailand: A Review of Current Trends and Policies. Pediatric Nursing, 37(5), 256-261.

Pongchaiyakul, C., Nguyen, T., Kosulwat, V., Rojroongwasinkul, N., Charoenkiatkul, S.,

Pongchaiyakul, C., & Rajatanavin, R. (2006). Defining obesity by body mass index in

the Thai population: An epidemiologic study. Asia Pacific Journal Of Clinical Nutrition,

15(3), 293-299.

Puska, Dr. P., Nishida, Dr. C., & Porter, Dr. D. (2003). Obesity and Overweight. World Health


Organization Global Strategy on Diet, Physical Activity and Health.

Taechangam S, Pinitchun U, & Pachotikarn C (2003). Development of Nutrition Education Tool:

Healthy Eating Index in Thailand. Asia Pacific Journal of Clinical Nutrition, 17, 365-7

Tee, E., Dop, M., & Winichagoon, P. (2004). Proceedings of the Workshop on Food

Consumption Surveys in Developing Countries: Future challenges. Food And Nutrition

Bulletin, 25(4), 407-414.

Tontisirin, K. K., & Bhattacharjee, L. L. (2001). Nutrition actions in Thailand--a country

report. Nutrition Research (New York, N.Y.) Nutrition Research, 21(1/2), 425-433.

World Health Organization (2013). Obesity and Overweight Fact Sheet.

World Health Organization (2011). Overweight and Obesity Fact Sheet. The Department of

Sustainable Development and Healthy Environments.

Appendices

Appendix A. SurveyDiabetes in ThahinNovember 23, 2013

Good morning! Today, as American public health students studying at Khon Kaen University, we are trying to understand the impact of diabetes within the Thahin community. We greatly


appreciate your participation in this survey. All of your responses will be anonymous.Please feel free to direct any questions you may have to our team.

Demographic

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

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

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

4. Do you have diabetes? Yes No

If yes, please kindly answer the following questions:

4a. Which type of diabetes do you have? Type I Type II Gestational Unknown 4b. How long have you been diagnosed with diabetes (in years)? ___________ years4c. How often do you visit your doctor? _____________________

5. Do you have high blood pressure? Yes No

Family History

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

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

Exercise

8. How often do you get physical activity (voluntarily or/and occupationally) ? ퟀ a. Never ퟀ b. 1 - 2 a week ퟀ c. 3 - 6 times a week ퟀ d. Everyday ퟀ e. Other. Please specify _________________

Nutrition

9. Have you had any exposure to a nutritional program in the past? Yes NoIf yes, please specify when: __________________

10. Do you have any dietary restrictions? Yes No If yes, please specify ______________________

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


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

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

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

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

Ingredient A B C D

MSGNone < ½ Tablespoon ½ Tablespoon > ½ Tablespoon

SaltNone < 1 Tablespoon 1 Tablespoon > 1 Tablespoon

SugarNone < 2 Tablespoons 2 Tablespoons > 2 Tablespoons

Vegetable OilNone < ½ Cup ½ Cup > ½ Cup

Condensed MilkNone < ¼ Cup ¼ Cup > ¼ Cup

Soy/ Fish SauceNone < ½ Cup ½ Cup > ½ Cup

16. How often do you consume the following foods per week?

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

Dairy (cow milk, soy milk, yogurt)

Fruits

Boiled/steamed Vegetables

Stir-fried Vegetables

Deep-fried Vegetables

Boiled/steamed Meat/ Fish


Grilled Meat/Fish

Stir-fried Meat/Fish

Deep-fried Meat/Fish

Fried Egg

Deep-fried Egg

Boiled Egg

Rice/Noodles

Sticky rice

Soda

Alcohol

Chocolate, Candy, Chips

Appendix C. Diabetes risk score chart based on the risk factors (adapted from Dr. Aekplakorn)

Risk factor Diabetes risk scoreAge (years)

34-4445-49≥ 50

012

GenderWomenMen

02


BMI (kg/m2)< 23≥ 23 but < 27.5≥ 27.5

035

HypertensionNoYes

02

Family history of diabetes/ hypertensionNoYes

04

Appendix C. Nutrition Brochure


Appendix D. Post-Intervention Evaluation Form

1. Did you find this program helpful?Yes No

2. Do you feel like you’ve learned enough to make healthy food choices?Yes No

3. Would you be interested in participating in another nutrition program?Yes No

4. Would you be interested in participating in an exercise program?Yes No

5. Any other questions/comments?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Thank you!

Web viewOne of the questions in the questionnaire asked whether they had diabetes or not, ... Dairy...

Documents

Transcript of Web viewOne of the questions in the questionnaire asked whether they had diabetes or not, ... Dairy...