TECHNOLOGY-BASED INTERVENTIONS TO IMPROVE THE NUTRITION AND HEALTH OF INTELLECTUALLY/DEVELOPMENTALLY DISABLED PERSONS

• Sponsoring Institution: National Institute of Food and Agriculture
• Project Status: COMPLETE
• Funding Source: SMALL BUSINESS GRANT
• Reporting Frequency: Annual
• Accession No.: 0223620
• Grant No.: 2010-33610-21863
• Proposal No.: 2010-02296
• Project Start Date: Sep 1, 2010
• Project End Date: Mar 31, 2013
• Grant Year: 2010
• Program Code: [8.5]- Food Science & Nutrition

Recipient Organization
MAINSTAY, INC.
(N/A)
WINNETKA,IL 60093

Performing Department
(N/A)

Non Technical Summary
People with intellectual and developmental disabilities (IDD) experience poor nutrition, obesity, and other serious health problems at significantly higher rates than those in the general public. The incidence of obesity among people with IDD is 50%, almost double the rate exhibited by mainstream Americans. Similar discontinuities exist with diseases such as diabetes and hypertension within this population. There are genetic, metabolic, and pharmacological reasons for these elevated rates and previous attempts to improve the health of people with IDD, employing exercise routines and education, have been neither efficacious nor sustainable. Recent programmatic interventions focusing on diet and the nutritional intake of people with IDD have been much more successful in improving their quality of life and dietary patterns, as well as reducing the rate of serious secondary medical conditions. A Phase I study at a social service agency that residentially supports people with IDD, found that caregivers in group homes experienced significant increases in their knowledge, attitudes and behaviors towards nutrition and healthy eating. And through using these web-based interventions and the documentation from the Mainstay nutrition program, the people with IDD supported by the caregivers have experienced material improvements in Healthy Eating Indexes, Body Mass Indices, health status indicators, as well as more cost-effective, diverse meals and menus. The Phase II randomized trial will occur over a larger sample size that is more geographically dispersed. It will test the differing impact of a range of revised interventions on the knowledge, attitudes and behaviors of the staff that support people with IDD, along with measuring the nutrition, health and operating parameters mentioned above among the individuals with IDD. In this way, we will determine the tradeoff among efficacy, cost and implementation outcomes for various intervention alternatives. The results of the larger trial will have significance to the quality of life and quality of health for the five million people with IDD in the nation. In addition the outcomes will influence policy for the organizations as well as the state and federal government entities providing services and funding to this population.

Animal Health Component

100%

Research Effort Categories

Basic

(N/A)

Applied

100%

Developmental

(N/A)

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
703	6010	2020	100%

Knowledge Area
703 - Nutrition Education and Behavior;

Subject Of Investigation
6010 - Individuals;

Field Of Science
2020 - Engineering;

Keywords

disabled

intellectually disabled

developmentally disabled

nutrition

health

obesity

diabetes

weight

computer

on line

group home

bmi

Goals / Objectives
The Mainstay Phase I trial produced statistically significant, meaningful results across a range of outcomes - knowledge, attitudinal and behavioral, particularly the menus designed, food ingredients procured, and meals prepared and consumed by people with intellectual or developmental disabilities (IDD). To expand the availability of these supports to more customers, and in order to understand the uptake and efficacy of multiple variations of our current or proposed interventions, we will conduct research over a statistically representative number of group homes in multiple states. Four objectives will be achieved during the Phase II, multi-outcomes research. 1), the scope of the original online intervention package will be revised and expanded. Additional curricula content will be created. The ease of use of the Pinpoint Menu Guide (PMG) software will be enhanced by simplifying the interface and developing an online tutorial. System documentation to supplement staff and people with IDD developing nutritious, cost-effective, flavorful meals and menus will increase. Ongoing staff interaction will be provided via email with the Mainstay chef on food shopping, menu-planning and cooking topics for the Online Services version of this project. 2), the web-based instructional materials and the online recipe planning software will be enhanced to enable delivery via DVD and facsimile, to enable their use within group homes that do not have current access to computers. a), the revised text, image, video, and menu-development materials will be ported to DVD format for use in a second set of group homes that do not have computers but where the DVD plus Facsimile technologies are available; b), the printed recipe content, the pictorial recipes, and the Pinpoint Menu Guide will be converted for delivery to a third set of houses that do not have computers or DVD players but do have onsite fax machines in the Facsimile Only condition. 3) Group homes from a large provider of services to IDD persons living in community-based settings around the United States, will be assigned to the three Intervention conditions (Internet Services, DVD plus Facsimile, and Facsimile Only) and to the non-treated Control Group. The individual houses in each condition in this non-equivalent control group study design will be matched on characteristics of the staff (such as educational level, years of experience working in group homes) and on resident characteristics (e.g., age, gender, Functional Quotient level) during at the start-up of this project. 4), a range of process and outcome variables will be collected from house staff, group home residents, and program administrators at baseline, during the course of the study, and at the end of the study period. Our research team and statistical staff will examine the impact of the interventions on the above outcomes and we will conduct between-group analyses of nutritional intake patterns, health and program costs for the four sets of group homes. This qualitative information will help interpret the quantitative research findings and to improve the effectiveness and the efficiency of later Mainstay service offerings.

Project Methods
A quasi experimental, non-equivalent control group, pre-test - post-test, stepped intensity design will be used to assess the impact of the Internet Services, DVD plus Facsimile, and the Facsimile Only program interventions vis-a-vis the non-treated Control condition. Four sets of group homes will be included in the study, with thirty-five houses and approximately 175 residents assigned to each condition. Within the three sets of intervention houses, content and interactivity will be limited by the computers, DVD and facsimile equipment in the house. Staff in Control group homes will not receive any nutrition education, health information, menu-planning, or food preparation instruction during the project period. Given that computers and broadband communications are available in many but not all of the group home sites, randomization of group homes to conditions will not be feasible. This is the reason that we have elected to use a non-equivalent control group design. In selecting locations for the study we will identify group homes with approximately equal numbers of staff with equivalent levels of educational attainment and experience working with I/DD persons. We will also screen on the number of residents, and on their demographic characteristics, functional quotients (similar to an IQ but including skills and behavior) and health status in selecting sites for the study. The control group will be selected at random from the screened population of group homes and used by itself, rather than in conjunction with the intervention groups, in estimates of study parameters. Program impact will be assessed on a pre-post and continuing basis at the staff level, the resident level, and the group home/organizational level. The primary outcome measures for staff will include changes in their knowledge of nutrition and health information, and self-efficacy ratings for menu-planning, food-shopping and meal-preparation activities. The impact of the program on resident health status will be evaluated using both objective and subjective indicators. In addition to the staff collected measures of resident height, weight, percent body fat, Waist-Hip Ratio, and BMI, the PCS and MCS dimensions from the SF-8 survey will be used to assess the health related quality of life of the subjects in the four conditions. Organizational impact data, such as operational efficiency, will be gathered. Mainstay research staff will work with dieticians and biostatistics staff from the Feinberg School of Medicine at Northwestern in programming the study database, managing data collection and conducting the analyses of study data. We will work with a health economics consultant in conducting cost-effectiveness analyses. Specifically, we will measure the input costs of each intervention (viz., time and material costs associated with developing the program materials and food costs) so we can ascertain cost differences between each condition and compared with the Control condition. We will also assess the incremental cost-effectiveness of the interventions relative to each other and to the Control condition using the change in BMI as the measure of effectiveness.

Progress 09/01/10 to 03/31/13

Outputs
OUTPUTS: Activities: During the project period, we have applied the new analytics techniques first utilized in the Phase II project, for additional Mainstay customers. We have conducted health research among people with ID (Intellectual or Developmental Disabilities) to ensure that underweight people supported are not losing additional weight. We conducted categorization analysis to determine the pre-post BMI trending of people who were (according to CDC definitions) Obese, Overweight, Normal and Underweight at the beginning of the project. We correlated the increased health of consumers with ID, with the increased health of the caregivers (DSPs) after a Mainstay implementation is started. We are correlating the increased health of DSPs with improved employee productivity (fewer sick days, etc.) and other business parameters important to social service employers. And we analyzed reduced food costs for social service group homes - expected costs vs. actual costs. Events: Utilizing insights and statistics generated from this program, Mainstay presented at the two most recent annual conferences of the national association of social service agencies, representing the 400 leading social service agencies serving people with ID throughout the United States. We presented at the annual conference of 300 key social service agencies serving people with ID in the state of New York. We presented at the annual conference of 150 social service agencies serving people with ID in the state of Texas. We presented at the annual conference of 200 leading social service agencies serving people with ID in the south central United States. We presented at Special Olympics - Indiana conference on improving health of people with ID. And we have made over 100 presentations to leading social service agencies who are interested in improving the health of people with ID they support. For the past year, on a quarterly basis, we have sent email newsletters to the Executive Directors, Program Managers and Directors of Residential Services of the leading social service providers of supports to people with ID throughout the US. Topics already discussed, or white papers written and ready to disseminate include: a), quality of life improvements for people with ID who experienced better nutrition and health; b), how to improve nutrition and health in group homes, despite 50% annual DSP turnover; and c) how social service agencies can leverage better consumer health for more community resources. Products: With this project and follow-up feature roll outs, we have introduced: a), applied curricula and education materials, formatted for train-the-trainer purposes as well as for consumers with ID - more than 30 topics addressed, with an additional 20 which will be available soon; b), 15 - 20 videos developed expressly for people with ID, with several archived and available through YouTube; c), the creation of at least 200 recipes - emphasizing cost-effective, nutritious, flavorful, easy-to-prepare foods that invite residents' participation; and d), new software functionality, innovative to this market and critical to the improved health of people with ID. PARTICIPANTS: Northwestern University Feinberg School of Medicine mental health professors and doctoral students, supplying statistical, dietary overview and disabilities expertise and consulting. Multiple state and national advocacy groups supporting people with intellectual disabilities. Federal and state Medicaid and regulatory officials. Independent third party accreditation officials. Astek - IT developers. 15 United States Senators. Management and staff from multiple agencies residentially supporting people with ID. Our primary ID residential provider, with the assistance of twenty other providers of residential ID services TARGET AUDIENCES: 5000 organizations, ranging from very large to very small, that residentially support people with intellectual disabilities. Federal and state officials that regulate, inspect and pay for residential services for people with ID. Independent organizations that advocate for or accredit social service agencies providing residential supports for people with ID. PROJECT MODIFICATIONS: Nothing significant to report during this reporting period.

Impacts
Change in Knowledge: During this project, we noted: a), applied education tailored for people with ID is preferred by caregivers and Direct Support Professionals (DSPs); b), a highly tailored series of customized interventions can statistically significantly improve the nutrition of people with ID in group homes; c), calorie and especially fiber levels are critical nutritional parameters to increasing the nutrition and subsequent health of people with ID; d), improved nutrition can positively impact preventive health for those with ID measured across multiple parameters (BMI, Body Fat, and Waist-Hips-Ratios); e), lower food costs can occur simultaneously with improved resident nutrition and health; and f), content delivery methodology does not appear to correlate with the degree of consumer nutrition or health improvement. Change in Actions: As a result of the project, we observe that: a), plates (portioned one half for vegetables, one quarter for lean protein and one quarter for high fiber starches) are increasingly purchased in group homes, b), there is increased attendance at ID preventive health seminars and webinars; c), more social service agencies are tracking preventive wellness parameters of the people they residentially support, d), social service agencies are reporting increased fidelity of what the menus indicate will be consumed each day, and what is actually being eaten upon unannounced house visits; e) social service agencies are noting increased fidelity between what a shopping list indicates (type & amount of foods) what should be purchased at the grocery store, and what the grocery receipt indicates was actually purchased; f), government officials in charge of regulating ID services are now aware of the health improvements possible and many are considering making providers more accountable for improving the health of people with ID; g), independent accreditation organizations are considering increased review of the preventive health of people with ID in group homes; h), Medicaid, which is the payer of long-term supports and medical costs for people with ID, is considering instituting improved disease management outcomes/responsibilities for providers; and i), DSPs are utilizing Mainstay recipes and menus in their personal homes to improve the nutrition and health (with success). Changes in conditions: By utilizing a series of tailored customized interventions, social service agencies can reduce Underweight, Overweight and Obese levels among people with ID, and increase the percentage of residents with ID in the Normal BMI range. Multiple social service agencies report as a result of improved nutrition and health: a), fewer sick days are being utilized by DSPs and there are improvements in other employee productivity measures; b) people with ID with better health are more involved in their community and have deeper relationships with an expanding cadre of friends. One agency has proved to CMS officials that Medicaid has spent less money on its consumers as a result of the improved preventive health of the people it supports. And for the first time ever, some agencies are budgeting spending less money next year on food.

Publications

• Pending 2013 & 2014

Progress 09/01/10 to 08/31/11

Outputs
OUTPUTS: We have made substantial progress toward our goal of improving the education, nutrition and health of people with intellectual disabilities (mental retardation, autism, etc.), and understanding the impact of differing content and information delivery modalities on the nutrition and health of people with intellectual disabilities (ID) in community-based group homes. Mainstay has completed all of the foundational elements of its work plan including: adding photographic (still and video) representation of recipes; increasing its curricula and E-Learning tools; and enhancing proprietary software to improve the ability of staff and caregivers to provide cost-effective nutritious meals. We prepared multiple test instruments, such as food diaries, staff demographic and Knowledge/Attitudes/Behavior (including Readiness to Change - referenced as KAB) questionnaires. We finalized the qualitative and quantitative health parameters we wished to track across people with ID. After receiving IRB approval, we approached our research partner (Mosaic) and discussed our project with field managers. We asked they indicate which group homes would be interested in project participation, along with information (staff tenure, functional level of residents in each house, the houses with customers who were likely to sign the IRB informed consent form, etc.) which would be important in the random assignment of houses into the four condition groups. With 150+ homes returning information indicating they would participate, our research consultants randomized the sites. After the categorization of the houses, we asked Mosaic staff distribute and have staff complete/enter the resident medical information survey, the demographic and KAB information, as well as having staff and customers with ID sign and return the informed consent forms. We asked the houses to relay any specialized dietary or food allergy restrictions. As our study divided the houses into four conditions (Internet, DVD + Fax, Fax Only and Control), we sourced and provided any necessary modality equipment (computer or faxes) a house did not have. We visited all of the Mosaic territorial offices/agencies, explaining our project and asked their assistance in securing the baseline information needed for the project. Based on the dietary needs for each house, our chef designed new recipes (renal, gluten-free casein-free) and recommended suggested menus, which we reviewed with Mosaic managers. We populated the data base for each house, noting the residents and any specialized dietary needs. We also invested significant time talking to and training Mosaic house personnel and managers on how to use our system. We also: input and sorted KAB information on over 250 Mosaic staff members into our database: input and analyzed over 1000 days of food diaries across 100+ houses; and reviewed, categorized and analyzed qualitative and quantitative health data from over 700 people with ID. When we were certain we had significant baseline information, and had sufficiently trained staff and managers from each agency, we started implementation. This occurred across all houses between late May 2011 and early July 2011. PARTICIPANTS: Partner organizations: Mosaic, Inc. Employees: Principal Investigator, President, Chef, Research Associate, Research Manager. Consultants: Web and Software Developer, Photographer, Curricula developer, Dietitian, Health Economist, Database analyst. TARGET AUDIENCES: Our target audience continues to be people with intellectual disabilties and the organizations that support these vital and vibrant individuals PROJECT MODIFICATIONS: Nothing significant to report during this reporting period.

Impacts
In reviewing the pre-implementation information returned, we believe the random assignment of group homes was effective. Information completed by staff such as demographic information, the KAB data, and the readiness to change answers, all indicated quite similar means and narrow ranges across the four conditions regarding tenure, nutrition knowledge and staff readiness to change. Food diaries exhibited similar nutrient means (re: calories, carbohydrates and dietary fiber) among the four groups. Health data for the people supported with ID, across multiple parameters, did not exhibit significant differences among the four conditions. Other observations are: a), Mosaic meals (with means of 1800-1900 calories and 18+ grams of dietary fiber) are more nutritious than that seen from other start-up clients; and b), as might be expected with good nutrition results, the pre-implementation percentage of Mosaic people supported who are obese or overweight is lower than the obesity percentages we observe from other commercial customers. The typical percentage of people with ID who live in group homes and who are obese/overweight, is 65%. Among Mosaic customers, this rate is 56%. At about the time most Mosaic homes started implementing the Mainstay materials, our key contact at Mosaic HQ left the organization. The absence of this senior manager slowed full program uptake until recently at many sites. In previous studies, we see preliminary findings of efficacious nutrition and health results of our program within 1 - 2 months after program start; given the above, we expect there will be an additional 1 - 2 month delay at Mosaic houses. We are only now beginning to see preliminary positive nutrition and health results. Initial outcomes indicate improvement in the nutritional quality of meals served, and customer health statistics are moving in the anticipated direction (implementation vs. control houses). Specifically: 1), Two key nutrition parameters (dietary fiber over 25 grams per day and calories of 1800 per day) are occurring more often in the implementation homes than a), occurred in these houses before program implementation, and b), either previously was observed or is presently occurring in the control houses. 2), Health improvement is occurring in homes that have implemented the Mainstay intervention. Early results show that in the implementation houses, the number of people who are moving towards a more favorable BMI category (those who are overweight/obese and losing weight, combined with those who are underweight and gaining weight), is double the number who are overweight/obese and gaining weight combined with those who are underweight and losing weight. We note this: a), contrasts to the control houses where a larger percentage of people are moving away from an ideal BMI: b), is not more prevalent with any particular delivery modality; and c) is dependent on the tenure of program implementation. We are also hearing anecdotal stories of multiple houses and territories indicating their food costs (in aggregate and on a per person per day basis) are now declining; this is happening simultaneously with the increase in nutrition.

Publications

• No publications reported this period