Use of Technology for Dietary Assessment in Immigrant Populations

Abstract

To determine the impact of educational programs on immigrant groups in the United States, nutrition educators must have assessment and evaluation tools that use the language and vocabulary of the target population. Filipino Americans exhibit health disparities with regard to several conditions and are an important target for nutrition education. Currently, there are no existing rigorously tested tools in the Tagalog language which also have a low user burden and are designed to measure diet for assessment and evaluation of nutrition education programs. As these programs are generally evaluated using time-intensive dietary assessment tools not tailored specifically to Filipinos, they may not effectively characterize the diet of this population. Given the high adoption rates of mobile phones by populations outside of the United States, mobile apps may represent a best choice for developing tools to assist individuals recently migrating to the United States or speaking English as an additional language. Several tools of this nature have been developed for immigrant groups and hold promise in terms of acceptability. Examples of dietary assessment tools using technology developed for Spanish speakers in the United States are provided. These methods may also be appropriate for addressing the needs of immigrant groups such as Filipinos.

‘Filipino Americans also exhibit health disparities with regard to diabetes. Among Asians, Filipinos have the second-highest prevalence of diabetes.’

Introduction

Filipino Americans are the second-largest and second-fastest-growing Asian subgroup in the United States. ¹ National data collected from 2011 to 2014 indicated 40.3% of Asian adults were overweight or obese. ² Furthermore, a 2013 study of Asian American subgroups revealed Filipino Americans had the highest reported mean body mass index (BMI), at 26.8 kg/m². ³ Previous studies have shown Filipino Americans exhibit health disparities with regard to several conditions such as overweight/obesity and hypertension, with low-income Filipinos at particularly high risk of disease. ⁴ For example, in a large study of Filipinos in California, 54.2% were overweight/obese and 38.9% had hypertension. ⁵ Another large-scale study of Filipinos in California reported that 59.9% of men and 53.2% of women had hypertension. ⁶ Furthermore, in a cross-sectional study performed in a multiethnic population in rural Hawaii, Filipinos had the highest odds for prevalent metabolic syndrome despite having a lower BMI compared with other Asian American and Pacific Islander groups. ⁷

Filipino Americans also exhibit health disparities with regard to diabetes. ⁸ Among Asians, Filipinos have the second-highest prevalence of diabetes. ⁹ In a prospective cohort analysis of 1 704 363 ethnically diverse adults in Northern California, Pacific Islanders, South Asians, and Filipinos had the highest prevalence (18.3%, 15.9%, and 16.1%, respectively) and the highest incidence (19.9, 17.2, and 14.7 cases per 1000 person-years, respectively) of diabetes among all racial/ethnic groups, including minorities considered high risk (eg, African Americans, Latinos, and Native Americans). ¹⁰ Previous research has also revealed that even without being diagnosed with obesity, Filipino Americans are at risk for developing type 2 diabetes. ¹¹ Furthermore, the Filipina Women’s Health Study performed in San Diego, California, found that the rate of diabetes in female Filipina Americans was significantly higher than the rate in non-Hispanic white women. ¹¹

Poor dietary intake contributes to development of chronic disease in underserved groups. Dietary intake is suboptimal in Filipino Americans, with a study of 200 Filipinos in the Eastern United States indicating that only one person met the recommendation for fruit and vegetable intake, and 75% reported adding salt to food. ¹² In another large study of Filipinos in California, 90.3% did not consume enough fruits and vegetables. ⁵ It is imperative to address the health status of this demographic and to promote dietary habits that will lead to maintenance of a healthy weight and ultimately prevention of disease.

Healthful food choices are key in promoting health and preventing conditions such as hypertension and diabetes. To this end, the US Department of Agriculture (USDA) administers several programs for low-income populations, such as the Supplemental Nutrition Assistance Program Education (SNAP-Ed). This program provides evidence-based recommendations for healthful eating and has demonstrated positive effects on the diet of low-income groups. There have been significant positive effects in outcomes among recipients of the SNAP-Ed programs implemented, such as increased fruit and vegetable intakes. These programs have demonstrated positive effects on nutrition behaviors of limited-resource populations across the lifespan; a recent evaluation of a number of SNAP-Ed programs found significant effects in outcomes for programs implemented in different age groups. ¹³

Evaluation of nutrition education programs is essential in determining the effectiveness of these efforts. However, such results going forward may be compromised by use of evaluation tools that have not been validated among diverse groups, and do not adequately reflect the language, vocabulary, and reading level of emerging target populations. To better evaluate the dietary intake disparities and assess the impact of these programs on low-literacy Filipinos, nutrition educators must have culturally appropriate tools tailored to the target population in terms of language, reading level, and vocabulary. A 2011 report from the US Census Bureau revealed that since the year 2000, the number of Tagalog speakers in the United States has increased significantly; moreover, of the total population of 1.6 million Tagalog speakers in the United States, 32.8% spoke English less than “very well.” ¹⁴

While there have been significant improvements documented in SNAP-Ed programs in the major ethnic groups in the United States, these same results may be compromised when evaluating the emerging ethic group of Filipinos. A review of the literature reveals a lack of validated Tagalog-language tools for health promotion and disease prevention related to nutrition and dietary intake. In reviewing the literature with regard to dietary assessment tools developed for Filipinos in the United States, only one Tagalog-language tool was found.^15,16 The tool, a food behavior checklist, was based on a previously validated English-language assessment developed for a limited-resource population.^17,18 Validity and reliability of the Tagalog version were evaluated in low-income Filipinos in Hawaii. Additional studies are needed to further examine the psychometric properties of the tool, and Filipinos in other parts of the United States should be included in this work.^15,16 Furthermore, while this tool is intended to be administered on paper, other methods of assessing diet should also be considered, including those that involve use of technology.

Estimates of the world’s population using the internet is 43%, and there are more mobile phone subscriptions than people in the world. ¹⁹ Given the high adoption rates of mobile technology by populations outside of the United States, mobile applications and other technology may be the best choice for developing tools to assist individuals recently migrating to the United States or those speaking English as an additional language. While this example highlighted Filipino Americans, the concerns raised may apply to individuals emigrating from other countries. For example, while there have been many studies focused on improving the diet of Spanish speakers in the United States, there have been limited studies focused on validating dietary assessment tools for this group.

Technology-based nutrition education has been well received by Spanish-speaking individuals in the United States. ²⁰ Such programs have been shown to increase knowledge and improve weight loss. ²¹ Interventions that are culturally tailored have been shown to be more beneficial and well-received.^20-22 One study aimed to assess the acceptability of a mobile application to facilitate healthy behaviors in English and Spanish speakers. In this study, English-speaking participants were “more likely to use an app if it was entertaining and customizable,” while Spanish speakers “put a high priority on app functionality.” ²³

Despite the increasing use of technology for nutrition education, dietary assessment methods using technology for immigrant populations are still lacking. There are few assessments in the Spanish language created for immigrants to the United States, and even fewer have been validated.

One study performed in a population of low-income English and Spanish speakers in Colorado involved the validation of an interactive, computer-based, multimedia tool offered in English and Spanish through comparison with a dietary recall administered by a nutrition professional in the same language. There were no significant differences between the technology-based recall and the recall performed by the interviewer except with regard to vitamin C intake. A major limitation of this study is that the English and Spanish versions were not compared. Out of 80 participants, 72 completed valid opinion surveys. Of those, 58% preferred the interactive, computerized recall over the interview or pencil-and-paper method. ²⁴

Another study involved the development and piloting of a multimedia dietary assessment tool in a Spanish-speaking population. A team of researchers aimed to create a method by which to better collect children’s dietary records via their immigrant mothers. A 5-page paper survey was adapted for administration through audio-assisted tablet computers. Individuals were prompted to answer each question, which addressed the issue of missing data that occurred with the use of paper forms. Researchers observed that participants were enthusiastic about the use of the audio-assisted tablet computers. ²⁵

In a third study, researchers investigated the use of an automated, web-based dietary recall in a group of multiethnic, older (56-80 years old) adults. The Automated Self-Administered 24-hour dietary recall was developed in English and Spanish by the National Cancer Institute based on the USDA’s Automated Multiple Pass Method. In this study, some of the Latino participants preferred to complete the assessment in Spanish. However, the researchers found that over half of the individuals did not have access to a computer/internet. Of the individuals who did have access (n = 100), only 37% completed the assessment. Older, minority participants were less likely to have access to the assessment or to be willing to complete the assessment. This suggests that technology-based assessments may not be as useful for older individuals of minority populations. ²⁶

A major limitation of technology-based dietary assessment tools developed for the Spanish-speaking population in the United States is the lack of evaluation of validity, though there have been a few studies examining validity of such tools. For example, one study validated a technology-assisted risk assessment, which included a dietary component, against 4 measures of early childhood caries activity. Spanish-speaking caregivers completed an iPad-based survey on children’s diet and other behavioral risks for caries. Researchers concluded the tool may have clinical utility as the diet risk scores were significantly positively associated with standard measures of caries risk. ²⁷ More research is needed to assess the validity of technology-based dietary assessment tools designed for immigrant populations.

Developing rigorously tested, technology-based tools that may be used to assist the evaluation continuum of the USDA’s nutrition education programs and culturally tailored health interventions will lead to enhancement of programs and improvement of health outcomes. Research on dietary assessment tools utilizing technology for immigrant groups will serve a rapidly growing segment of the population in the United States and contributes to efforts to combat chronic disease in underserved populations, thus increasing health equity. As research is needed on how programs may be implemented to shape equitable and healthy communities, development of tools for better tailoring intervention approaches/messages and program evaluation are key steps required.