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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
Nutritional Program in Thahin 3
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.
Nutritional Program in Thahin 4
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
Nutritional Program in Thahin 5
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
Nutritional Program in Thahin 6
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.
Nutritional Program in Thahin 7
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
Nutritional Program in Thahin 8
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
Nutritional Program in Thahin 9
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.
Nutritional Program in Thahin 10
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
Nutritional Program in Thahin 11
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
Nutritional Program in Thahin 12
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
Nutritional Program in Thahin 13
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
Nutritional Program in Thahin 14
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)
Nutritional Program in Thahin 15
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)
Nutritional Program in Thahin 16
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.
Nutritional Program in Thahin 17
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
Nutritional Program in Thahin 18
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
Nutritional Program in Thahin 19
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).
Nutritional Program in Thahin 20
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)
Nutritional Program in Thahin 21
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
Nutritional Program in Thahin 22
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
Nutritional Program in Thahin 23
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
Nutritional Program in Thahin 24
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
Nutritional Program in Thahin 25
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
Nutritional Program in Thahin 26
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
Nutritional Program in Thahin 27
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.
Nutritional Program in Thahin 28
References
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Nutritional Program in Thahin 29
Rajatanavin, R. (2006). A risk score for predicting incident diabetes in the Thai
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(2010). Risk factors for overweight and obesity among Thai adults: Results of the
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Organization Global Strategy on Diet, Physical Activity and Health.
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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
Nutritional Program in Thahin 31
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
Nutritional Program in Thahin 32
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
Nutritional Program in Thahin 33
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
Nutritional Program in Thahin 34
BMI (kg/m2)< 23≥ 23 but < 27.5≥ 27.5
035
HypertensionNoYes
02
Family history of diabetes/ hypertensionNoYes
04
Appendix C. Nutrition Brochure
Nutritional Program in Thahin 35
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!