Abstract
Objective:
To review the possibilities of using the Internet and especially the World Wide Web (WWW) in nutrition education.
Results:
A healthy existence is partly dependent on dietary behaviours. One way to promote health-promoting dietary habits is nutrition education. In the last decades several potentially important new channels for health communication and nutrition education have emerged, with the Internet and its WWW as the most striking example. The introduction and growth of the WWW has enabled swift and inexpensive distribution of nutrition education expertise and materials. Furthermore, the WWW has also been used for tailoring nutrition education to the personal characteristics of the user. Only few studies have investigated the effects of generic web-based nutrition education, while web-based computer-tailored nutrition education has been studied in randomised controlled trials, with promising but mixed results. Two important challenges for web-based nutrition education interventions are to realise sufficient exposure and to ensure sufficient source reliability and credibility.
Conclusions:
Next to the great opportunities, there are many challenges for web-based nutrition education. Some evidence for effects of web-based computer-tailored nutrition education has been reported, but more research is needed to obtain evidence for the effectiveness in real-life situations.
Sponsorship:
The contribution of WK was made possible by a grant from ZonMw, The Netherlands Organisation for Health Research and Development; the contribution of AO was made possible by a grant from the Netherlands Heart Foundation.
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Contributors: JB coordinated the writing of the paper and wrote the first draft. AO, WK and HR all provided comments on this first draft. AO wrote the paragraph on the effectiveness of web-based nutrition education. WK especially contributed to the paragraphs on tailored nutrition education. HR contributed especially to the paragraph on on-line research.
Discussion after Brug
Becker: Thinking about my role as a GP with my patients, I completely agree how ineffective we are, we try to give people information, but we know that they forget most of what we tell them even before they leave. It is a very inefficient way of doing the things that you can do very efficiently. However, at the same time your previous slide of all the gaps and the things that you want to be able to do, getting people to the website, building social support and making it an ongoing process, giving people skills, these are things that GPs can approach. There is a system; when someone calls your office they are directly appointed to your website with a task to do some of that work. Then somehow you get some feedback from what they have done so that during the visit I no longer have to rely on my instincts about their stage of change, I already assessed it. I have some information and we have a plan that we can work on. Has anybody looked at that type of plan?
Brug: I think that is a really good point, that we can try to combine the authority of the GP with the expertise that has been documented in a computer program. And indeed some of the first studies did computer tailoring with GP-offices. So people who visited the GP got the screening questionnaire, and they also got feedback that was signed by the GP; although he did not really write the feedback letter it was still under his authority. One of the things that we are now developing is computer-tailored intervention for parents of really young children who visit the baby clinic, and we encourage the parents to complete the computer tailoring; the feedback goes to their doctor, to the clinic and to themselves, and this is used as a preparation for interpersonal communication.
Helman: If we look at it in terms of input and output I think you are on the right track in terms of input. We find that the most popular thing people are looking for on the Internet is dietary analysis. People love to put in data about what they eat…. What I find a little bit striking is how primitive our outputs are….
Brug: Yes, although we have to be really careful with the output side. I was at a workshop in Boston a couple of weeks ago, that was on dialogue systems, in which they used talking animations that gave the feedback, and their research showed that the more their animation tried to look like a human the more irritating it became. There have been some good studies on what people prefer for the feedback. It was the paper and pen feedback that was preferred; the more the feedback looked like a personalized letter, with ‘Dear Hans’ above it, and signed by some kind of expert, the more the people liked it. It had more authority, the credibility was higher. One of the people in Boston told me that they did some research on what people preferred their websites to look like; they came up with a website looking very similar to the Google site, so very simple, no pop-up screens, not too many animations, but just text they can easily read. So we have to think about the output, but the more complicated and nice it looks does not mean that it is more effective.
Helman: If you assume that the output is information, it could vary. It could be a reminder, a graph and so on.
Brug: Certainly. And what you suggested, a combination with text messaging or e-mails, that is going on at the moment too, also with hand held computers and the wireless applications that we nowadays have. Part of the problem is that technology goes much faster than research. So we study things that are old, and in the meantime a lot of new applications have popped up.
Pavlekovic: My question is: I imagine myself as a layperson sitting at the computer and trying to find a reliable website. But there is a huge number of commercial ones. How can I find, in this jungle, professionally and ethically right websites. I always need some kind of advise.
Brug: How do you find the right website? In the Google search the first ten hits were one from the American Dietetic Association and eight from a university; while the tenth was from a consumer organisation. So if you do a Google search you will find more credible and reliable sources. That might help. And I think we should combine it with community-based approaches or with family-doctor-based approaches; they can refer people to go to that website. Also, the printout should be brought to the consultation so that we can discuss it together. The combination of the expertise you can put in a computer program, being the pooled expertise of many experts, much more than one GP can have, with the interaction of the GP, might be a really fruitful approach.
Helman: Can I put in a plea for Tufts Nutrition Navigator? Very reliable, very independent assessment of lay nutrition information available on the internet.
Brug: And if you do it in Dutch, and you search for ‘voeding’ and ‘gezondheid’, the Dutch words for nutrition and health, you do not get the Netherlands Bureau for Nutrition Education in the first 15 or 20 hits. They have to work on that to get there.
Reeves: GPs get money in the UK for bringing people to screening, but not a word about possible harms.
Brug: Here in The Netherlands we have a good example, about 5–10 y of focus on total fat. We needed to bring the total fat consumption down. And I must admit that I was involved in that campaign, doing at least an evaluation of the campaign. Nowadays there are data showing that the industry took it up rather nicely and took out a lot of the fat and put in other calories, and maybe saturated fat did not go down enough while unsaturated fat did; we were afraid to tell the complicated message so we talked about total fat. And now it is not really sure that the message was right. What about fruits and vegetables? Should we still promote them?
Lodge: It seems to me that this model is a build-up of useful things that we can do with the Internet, the internet being a source of health information for the public, and evidence-based health research information for the practitioners. Then the practitioners can recommend their patients to go to this website. ‘I will only talk to you for seven minutes, but go to this website, it has good information’. There is also the necessity to encourage a more informed patient base. The relationship between patient and doctors has changed, and will change further. Also because of the Internet. We have to use the Internet to reestablish a new dynamic between the patient and the practitioner. The patient should also do some homework before he comes in; then the numbers are already there. When we take on a new patient we ask their name, address, date of birth, history, telephone number, but what we should also ask them is, do you have e-mail and do you have Internet access?
Brug: I agree very much; just like we discussed yesterday, we should register their BMI as a standard procedure.
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Brug, J., Oenema, A., Kroeze, W. et al. The internet and nutrition education: challenges and opportunities. Eur J Clin Nutr 59 (Suppl 1), S130–S139 (2005). https://doi.org/10.1038/sj.ejcn.1602186
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DOI: https://doi.org/10.1038/sj.ejcn.1602186
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