Recipient Organization
UNIV OF HAWAII
3190 MAILE WAY
HONOLULU,HI 96822
Performing Department
(N/A)
Non Technical Summary
In collaboration with Drs. Corby Martin and John Apolzan, the Project Director (PD), Dr. Chloe Lozano, led the development and conducted preliminary evaluation of the PortionSize Ed mobile app at the Pennington Biomedical Research Center (PBRC), in Louisiana. PortionSize Ed is a dietary assessment and nutrition education app that provides real-time feedback to the user on adherence to personalized dietary recommendations. In collaboration with key stakeholders at the University of Hawaii (UH), Hawaii Extension, PBRC, and industry, the goals of this two year integrated extension and research Postdoctoral Fellowshipare to tailor PortionSize Ed for youth in the Hawaii Expanded Food and Nutrition Education Program (EFNEP), develop a modified EFNEP curriculum that facilitates the use of PortionSize Ed, and to test the feasibility, acceptability, and preliminary efficacy of integrating PortionSize Ed with EFNEP for improving diet quality among youth in Hawaii. Dr. Rachel Novotny at UH is the Primary Mentor, and Dr. Martin at PBRC is a Collaborating Mentor. The AFRI Farm Priority Area of this Postdoctoral Fellowship is food safety, nutrition, and health and it addresses food and nutrition translation. This research will build on the PD's experience in developing mHealth apps and delivering randomized controlled trials. The project supports one of EFNEP's key priority areas, which is to "strengthen science-based learning methods and enhance teaching techniques with appropriate new technologies, social media, and social-ecological approaches". Through the activities of this project, the PD will meet the requirements to be an independent researcher at UH.
Animal Health Component
0%
Research Effort Categories
Basic
100%
Applied
0%
Developmental
0%
Goals / Objectives
This Postdoctoral Award will provide training and experience for the Project Director (PD), Dr. Chloe Lozano, to be an independent researcher at the University of Hawaii (UH) with research focused on mobile health (mHealth) and the prevention of childhood obesity. The PD is a dietitian with a Master's in Health Promotion and completeda Postdoctoral Research Fellowship at the Pennington Biomedical Research Center (PBRC) in the T-32 Training in Obesity Research program. During the PD's masters and doctoral training, she gained experience using a mobile food record to assess food waste of youth in a cross-sectional study in Hawaii, and for dietary intake of adults in a randomized controlled trial (RCT) in Hawaii. As part of her Postdoctoral Fellowship at PBRC, in collaboration with Drs. Corby Martin and John Apolzan, the PD led the development and conducted preliminary evaluation of the PortionSize Ed mobile app in Louisiana. PortionSize Ed, is a dietary assessment and nutrition education app that provides real-time feedback to the user on adherence to tailored US Department of Agriculture's (USDA) MyPlate food group recommendations. The development of PortionSize Ed was informed by the Theory of Planned Behavior (TPB).With support from key stakeholders, the objectives of this two year Integrated Extension and Research project are for the PD to 1) gain experience in developing an mHealth tool for improving diet quality among youth in the Hawaii Expanded Food and NutritionEducation Program (EFNEP), 2) Obtain skills in developing an EFNEP curriculum that includes mHealth, 3) Learn key policies and procedures of EFNEP evaluation, and 4) demonstrate competence in developing and managing an RCT pilot study aimed at testing the acceptability, feasibility and preliminary efficacy of coupling PortionSize Ed with EFNEP to improve diet quality among youth in Hawaii. This project supports one of EFNEP's key priority areas, which is to "strengthen science-based learning methods and enhance teaching techniques with appropriate new technologies, social media, and social-ecological approaches". This project builds on the PD's research experience. However, the PD's previous research primarily focused on adults, and she has not developed and delivered a RCT aimed at improving dietary behaviors among youth. Therefore, under the primary mentorship of Dr. Rachel Novotny, who is renowned for community-based childhood obesity research in the Pacific region, co-mentorship by Dr. Martin, a leading expert in mHealth research, and through activities proposed in this project, the PD will meet the requirements to be faculty at UH with research focused on mHealth and prevention of childhood obesity.
Project Methods
The current study is a 6-week cluster randomized design, with two study arms, 1) usual EFNEP for youth, (EFNEP), and 2) EFNEP integrated with the PortionSize Ed app (ENFEP-PSEd). The study will be delivered in one school on Kauai. The Extension Nutrition Educator on Kauai will deliver the EFNEP program to youth, which is the HI-FLY curriculum. Having a paraprofessional from the local community deliver EFNEP is a key part of the program. This study design will help ensure study results are transferable to the local community in Hawaii. Inclusion criteria include males or females, Grades 9 to 12 students attending the target school on Kauai, Hawaii, and there are no additional exclusion criteria. Parental consent and youth's assent will be required for study participation. The aim is to recruit at least 20 out of ~30 students from each classroom. However, this study can accommodate participation by the entire class. The two classrooms will be randomized to either EFNEP or EFNEP-PSEd. Participants will receive a $100 stipend at study completion. Study approval will be obtained through the Institutional Review Board at UH and will be registered with ClinicalTrials.gov.Since EFNEP is usually performed during regular class time, all children in the participating classrooms will receive the standard EFNEP program, and only participants enrolled in the study will undergo additional assessment measures. EFNEP usual care is the HI-FLY curriculum which includes 6 lessons of 1-2 hours each, over 6-weeks. Lesson topics include 1) food storage, safety, and sanitation practices, 2) enjoying more fruits and vegetables, 3) preparing and eating more meals at home, 4) choosing right-sized portions, 5) moving more every day and limiting screen time, and 6) re-thinking your drinks. For the EFNEP-PSEd group, participants will receive EFNEP usual care and be provided with a study smartphone for the 6-week study. Between each EFNEP session, participants will be asked to log their food intake in PortionSize Ed for ≥ one day, outside of school hours. PortionSize Ed data will be used during EFNEP to support goal setting. Participants will be directed to access the educational videos in PortionSize Ed, outside of school hours, to achieve learning outcomes.For all study participants, at baseline, trained study staff will administer a demographics questionnaire, the EFNEP Nutrition Education Survey, and collect weight and height measurements. The Nutrition Education Survey evaluates healthy eating behaviors, physical activity and reduced sedentary behavior, food safety behaviors, and beverages. If requested by the school, height and weight will be measured for all students in the classroom. Study staff will provide participants with a study smartphone and PortionSize Ed training. All participants will complete a one-day mobile food record, on a weekend day, using PortionSize Ed on the study smartphone provided. The Portion Summary tab and Videos tab in PortionSize Ed will be disabled and not visible to the participant when capturing their mobile food record, to reduce reactivity, and to capture usual dietary intake. The Portion Summary and Videos tabs will be re-activated during the intervention period to assist with healthy behavior change. Food images from the mobile food records will be analyzed using RFPM, to ensure minimal error in energy estimates, and each food item will be matched to FPEDs. HEI-2015 total scores an HEI-2015 component scores will be calculated from the FPED data. On completion of the study, baseline measures will be repeated. In addition, trained study staff will administer the Computer Systems Usability Questionnaire (CSUQ)and a User Satisfaction Survey (USS). The CSUQ has 19 questions, answered using a 7-point Likert scale, to rate overall satisfaction, usefulness, information quality and interface quality. The USS has nine quantitative questions, answered with a 6-point Likert scale, and rates satisfaction, ease of use, and adequacy of training. The USS also contains an open-ended question where participants can provide any additional comments. For the EFNEP-PSEd group, throughout the study, data will be collected on participants' usage of the PortionSize Ed app (e.g., number of meals logged, number of times the app was used).Continuous variables will be reported as mean ± SD or SEM, and categorical variables will be reported as counts and percentages. To assess feasibility, we will collect data on participation in the two study arms (EFNEP-PSEd and EFNEP), including the number of students who consent to participate and attrition rates over the 6-week study. To assess acceptability, we will summarize quantitative data and qualitative responses from the USS, and scores from the CSUQ. Any positive or negative experience from study participation will also be evaluated using qualitative responses from the USS, and by evaluating reasons for study dropout. Tracking food group intake is in line with DGA recommendations; therefore, we do not anticipate this intervention will negatively affect eating behaviors. We will also assess PortionSize Ed usage data. To assess preliminary efficacy, we will use intention-to-treat-analyses, where all individuals will be analyzed in a randomization group, regardless of compliance. A linear mixed model will be fit for each outcome. This model uses all available data to estimate the treatment effects over time using maximum likelihood estimation under a missing-at-random assumption. The model will include an indicator variable for intervention group (EFNEP vs. EFNEP-PSEd). The F test will be used to assess the intervention effect, defined as the contrast of change in EFNEP minus change in EFNEP-PSEd. Outcome variables include HEI-2015 score, HEI-2015 component scores, and healthy eating behavior score from the Nutrition Education Survey. Comparisons will be made between Week 6 vs. baseline for HEI-2015 scores, HEI-2015 component scores, and healthy eating behavior scores. Transformations will be made for non-normally distributed data. Diet data will be represented as group mean daily values. Per protocol analyses, for changes in diet quality will also be conducted only among those completing the intervention (i.e., had a Week 6 assessment). Statistical significance will be defined as p<0.05.Primary outcome measures: Feasibility: 1) at least 65% of students in each classroom enroll in the study, 2) No more than 15% study attrition. Acceptability: 1) USS scores and qualitative responses, 2) CSUQ scores, 3) PortionSize Ed usage data across the 6-week intervention, 4) reason for study drop out. Efficacy: 1) change in total HEI-2015 total score, HEI-2015 component scores, and healthy eating behavior scores between baseline and Week 6, 2) difference between change in total HEI-2015 total scores, HEI-2015 component scores, and healthy eating behavior scores between baseline and Week 6 for EFNEP vs. EFNEP-PSEd.