Pacific Tracker 2 - expert system (PacTrac2-ES) behavioural assessment and intervention tool for the Pacific Kids DASH for Health (PacDASH) study

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Food Chemistry xxx (2012) xxx–xxx

Contents lists available at SciVerse ScienceDirect

Food Chemistry

journal homepage: www.elsevier .com/locate / foodchem

Review

Pacific Tracker 2 – Expert System (PacTrac2-ES) behavioural assessment andintervention tool for the Pacific Kids DASH for Health (PacDASH) study

Rachel Novotny a,b,⇑, Claudio Nigg a, Katalina McGlone a, Gloria Renda b, Noah Jung a, Masako Matsunaga a,Njeri Karanja b

a University of Hawaii at Manoa, 1955 East West Road, Agricultural Science 216, Honolulu, HI 96822, USAb Kaiser Permanente, Center for Health Research, 501 Alakawa St., Suite 201, Honolulu, HI 96817, USA

a r t i c l e i n f o a b s t r a c t

Article history:Available online xxxx

Keywords:PacificFoodDietPhysical activityDASHExpert System

0308-8146/$ - see front matter � 2012 Elsevier Ltd. Ahttp://dx.doi.org/10.1016/j.foodchem.2012.11.047

⇑ Corresponding author at: University of Hawaii atAgricultural Science 216, Honolulu, HI 96822, USA. T808 956 4024.

E-mail address: [email protected] (R. Novotny)

Please cite this article in press as: Novotny, R., ePacific Kids DASH for Health (PacDASH) study.

The Pacific Tracker (PacTrac) is a computer program designed to analyse food intakes of individuals fromthe Pacific Region. PacTrac’s original output included servings of daily intake of food groups according tothe United States Food Guide Pyramid, nutrient intake recommendations, and a comparison to othernational nutrition recommendations. PacTrac was made available for public use through the HawaiiFoods website (hawaiifoods.hawaii.edu). PacTrac2 is an updated and expanded version of PacTrac thatuses the United States MyPyramid/MyPlate food groups in household units of daily intake, rather thanservings. In addition, the PacTrac2 includes a physical activity analysis tool which quantifies minutesof physical activities and their intensities based on energy estimates from the compendium of physicalactivity and research on children. An Expert System (ES) – a computerised decision tree to guide behav-iour change – was developed using information on self-efficacy and stage of readiness to change, and thefruit and vegetable intake and physical activity information from PacTrac2. The ES produces reports forthe child, the parent/guardian, and the child’s physician with child-specific strategies, targeted behav-ioural information, and feedback tailored to the child. PacTrac2-ES was designed for the Pacific Kids DASHfor Health (PacDASH) intervention study, conducted in the Kaiser Permanente health care system inHawaii. The intervention is based on the child’s self-efficacy and stage of readiness to change intake offruits and vegetables and physical activity, with a goal of maintaining body weight to prevent obesity.The intervention is complemented with stage-based mailers addressing the environment for physicalactivity and fruit and vegetable intake and newsletters that address related behaviours (sedentary activ-ity and a DASH eating approach). This project is the first to expand the PacTrac to contain children’s foodsand physical activities from the Pacific Region and to use current US MyPyramid/MyPlate food and phys-ical activity analysis and guidance systems, and to develop and implement an Expert System for fruits,vegetables and physical activity of 5–8-year-old children. The PacTrac2-ES was used in the PacDASHstudy and will be used for other programs to promote healthy eating and physical activity of childrenin the Pacific Region.

� 2012 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 002. PacDASH intervention study design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

2.1. Study population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 002.2. PacDASH intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 002.3. Usual care/control group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 002.4. Other measures/assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 002.5. Process evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

3. Origin and evolution of the Pacific Tracker tool. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

ll rights reserved.

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t al. Pacific Tracker 2 – Expert System (PacTrac2-ES) behavioural assessment and intervention tool for theFood Chemistry (2012), http://dx.doi.org/10.1016/j.foodchem.2012.11.047

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PleasePacific

3.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 003.2. IHEI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 003.3. PacTrac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 003.4. MyPyramid Tracker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 003.5. PacTrac2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 003.6. Summary of PacTrac2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

4. Development of the ‘‘Expert System’’ for the PacDASH study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

4.1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 004.2. Expert System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 004.3. Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 004.4. ES use in PacDASH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 004.5. Self-efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 004.6. Stages of readiness to change physical activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 004.7. Stages of readiness to change fruit and vegetable consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

1. Introduction

The ethnic groups of the Pacific Region are predominantlyNative Hawaiian, Native Alaskan, Pacific Islander and Asian. NativeHawaiians, Native Alaskans and Pacific Islanders are among theworld’s most obese populations while Asians, although of rela-tively low body mass index (BMI), carry much of their body fatin the upper body and exhibit greater health risk at the sameBMI. Childhood offers an opportunity to develop and supporthealth-promoting behaviours to prevent obesity and relatedhealth problems. The Pacific Kids DASH for Health study devel-oped the PacDASH intervention with the goal of preventing weightgain and improving blood pressure in children of the PacificRegion.

Linking food, physical activity (PA) and health systems is criticalto prevent obesity. The PacDASH intervention includes food andphysical activity recommendations that provide personally rele-vant messages, for increased likelihood that the message will beread, processed, and used appropriately (Marcus et al., 2000). Thenature of foods and play areas available in the physical environ-ment stand out as significant influences on healthy behaviouramong children and youth (Martens, van Assema, & Brug, 2005;Taylor, Evans, & McKenna, 2005). Designing comprehensiveinterventions that systematically integrate the most consistentand modifiable individual behaviours with social and environmen-tal correlates of children’s overweight-related behaviours shouldbe most effective in changing those behaviours (Baranowski,Anderson, & Carmack, 1998; Sallis, Prochaska, & Taylor, 2000).

PacDASH was designed to support the child and parent, throughtargeted behavioural (food and PA) prescriptions delivered by thephysician, along with direct involvement with food and PA, withapplication of the messages to other social environments of thechild. The message was delivered to the child and parent by nutri-tion staff and by the child’s physician at a well-child visit at acommunity-based health centre, complemented with a toolbox ofrelated activities. The intervention approach supports child foodbehaviours and social and environmental cues, which are impor-tant to making healthy food and PA choices. Linking physiciansand health with food is designed to support increased intake ofnutrient-rich, less energy dense foods among children of under-studied ethnic groups who are at high risk for obesity.

This paper presents the key intervention tools that were devel-oped for the PacDASH intervention study, a new version of thePacific Tracker diet assessment and education tool (PacTrac2)(Martin et al., 2008; Murphy, Blitz, & Novotny, 2006), and an Ex-pert System (ES) of behaviourally tailored messages and output.The project extends and applies the nationally recommended

cite this article in press as: Novotny, R., et al. Pacific Tracker 2 – Expert SKids DASH for Health (PacDASH) study. Food Chemistry (2012), http://d

DASH eating pattern (Vogt et al., 1999), developed for White,African American and Hispanic adults, to children and to the grow-ing population of Asians and Pacific Islanders.

2. PacDASH intervention study design

2.1. Study population

PacDASH is a 15-month randomised, controlled interventionstudy to evaluate the impact of the PacDASH intervention on pre-venting weight gain and improving blood pressure in children atrisk for overweight and obesity in the Pacific Region (NovotnyR PI, USDA Grant award 2008-55215-18821, 2/15/2008–2/14/2012). The PacDASH sample consists of 85 children, 5–8 yearsold, with a body mass index for age and sex from the 50th to99th percentile. The children had a primary care provider at theKaiser Permanente Health Maintenance Organization on Oahu, HI.Children with various diseases that could affect participation wereexcluded. A parent or legal guardian gave consent for their child’sparticipation. In addition, children aged 7 or 8 years old were askedto assent to participate in the study.

Nine months of the study were intervention and 6 months weremaintenance (Fig. 1). All study participants (intervention and con-trol) were asked to attend five assessment visits at the researchcentre. In addition, all children attended a well-child visit within1 month after the baseline visit. The four assessment visits wereduring the intervention phase (baseline, month 4, month 7, andmonth 10). Five months later, at month 15, participants attendeda fifth and final visit. For those in the intervention group, the fifthvisit was during the maintenance phase. Before each visit, parentscompleted 2-day diet and physical activity records for their childon a weekday and a weekend day (Friday/Saturday). At the re-search centre, one of four trained and standardised interventionistsreviewed these 2-day records with the parent/legal guardian andthen probed for additional information as needed. The interven-tionist then entered these records directly into the PacTrac2 dietand PA data entry and analysis tool on the computer. The Friday re-cord was used to generate ES reports for the child, parent andphysician.

2.2. PacDASH intervention

At baseline (Visit 1), staff provided to the intervention and con-trol group participants and their parents a PacDASH Study Informa-tion Packet that contained:

ystem (PacTrac2-ES) behavioural assessment and intervention tool for thex.doi.org/10.1016/j.foodchem.2012.11.047

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Fig. 1. PacDASH intervention timeline.

Assessment data entered byPacDASH staff

PacTrac2 Behavioral Assessment of ChildPhysical ActivityDietary Intake

Expert System Assessment of ChildState of Readiness to Change &Self Efficacy for Physical Activity

Fruit and Vegetables

Decision Rules by Computer(Expert System)

Printed Reports created by Computer(Expert System)

PARENT INFORMATION

ON CHILDBehavior

StageSelf Efficacy

CHILDINFORMATION

ON CHILDBehavior

StageSelf Efficacy

PHYSICIANINFORMATION

ON CHILDStage-related

behavioral prescription

Fig. 2. PacDASH behavioural and Expert System assessment.

R. Novotny et al. / Food Chemistry xxx (2012) xxx–xxx 3

(1) PacDASH Grocery bag.(2) Welcome letter with the study overview and contact

information.

In addition, parents and children from the intervention groupreceived several support materials:

(1) Stage-based environment maps with interactive activitiespertinent to their stage of change (readiness to change)showing the nutrition and physical activity opportunitiesin their environment.

Please cite this article in press as: Novotny, R., et al. Pacific Tracker 2 – Expert SPacific Kids DASH for Health (PacDASH) study. Food Chemistry (2012), http://d

(2) Farmers’ market locations.(3) Food and physical activity (PA) handout for Dietary

Approaches to Stop Hypertension (DASH) eating principlesand regular physical activity.

(4) The ‘‘DASH of Aloha Healthy Cuisine and Lifestyle Book’’ thatfeatures local foods in recipes, including recipes that incor-porate DASH eating principles.

The DASH eating plan was developed by the US National Insti-tutes of Health to lower blood pressure without medication inadults. The DASH eating plan has been shown to reduce blood pres-sure and cholesterol levels, and to improve insulin sensitivity inadults and improve blood pressure in adolescents (Couch et al.,2008). It is a healthy eating plan that is rich in fruits, vegetables,and low fat or nonfat dairy. It also includes grains, especially wholegrains; lean meats, fish and poultry; nuts and beans. It is high fibreand low to moderate in fat. The DASH eating plan is recognised as amodel healthy eating plan that emphasises nutrient-dense foodchoices, which aligns very closely to the UDSA eating pattern andhas been described as embodying the US Dietary Guidelines (USDA,2010a, 2010b, chap. 5, 2010c). The DASH eating plan makes it eas-ier to lose weight. It was designed to be flexible enough to meet thelifestyle and food preferences of most people.

The PacDASH-ES intervention consisted of providing individua-lised, targeted fruit and vegetable and physical activity behaviouralmessages for the child and parent at a study assessment visit(Fig. 2). After the child’s stage of change and self-efficacy were as-sessed through responses to questions that were analysed, on thespot, by the Expert System (ES) program, the ES generated tailoredand focused behavioural messages. Within 1 month after the base-line visit, the child went for a well-child visit (WCV) in which thephysician used the ES physician output report to support, encour-age, and reinforce the intervention messages. The ES physician out-put report provided brief fruit and vegetable and physical activityrecommendations in the form of a script that reinforced targetedchild behaviours. After the WCV, the physician signed the PacDASHphysician output report to acknowledge that they communicatedwith the child about this material.

Intervention participants also received stage-based activitymailings for activity-based learning and to support behaviour. Chil-dren in the intervention group were mailed interactive activitiesthat were pertinent to their stage (of readiness to change) that

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encouraged their engagement in activities that promoted goodnutrition and increased physical activity. These mailings were sentthree times during the 9-month intervention phase, in betweenstudy assessment visits. Three time point sets for mailing were cre-ated, consisting of different stages of change within each set. Chil-dren in the intervention group also received three educationalmailings that supported the targeted behaviours of the interven-tion. For example, information, tips, and recipes were providedon whole grains and low-fat dairy which are parts of the DASH eat-ing pattern. The mailings encouraged participants to be more ac-tive and engage in moderate to vigorous activity. Less sedentarytime was emphasised in conjunction with being more active, espe-cially in moderate to vigorous activity. The intervention group re-ceived six mailings in all.

2.3. Usual care/control group

Children in the usual care/control group also went for a WCVduring the same time frame. The physician saw the child as a stan-dard WCV and the physician was unaware that the child was in thestudy. The usual care/control group received three mailings duringthe study that featured general health practices, such as the impor-tance of hand washing, sun protection, and dental hygiene. Theydid not receive support behaviour mailings. At the end of the study,the usual care/control group received a packet of the PacDASHintervention materials.

2.4. Other measures/assessments

In addition to the PacTrac2-ES, which stored and analysed thediet and physical activity records and the stage of change andself-efficacy questions, a variety of other data were collected atthese visits: anthropometric measurements, dual energy X-rayabsorptiometry (DXA), blood pressure, and signs of puberty. Otherquestion sets covered socio-demographics of the child and the par-ents, and early life experience (prenatal and infant).

2.5. Process evaluation

A process evaluation was conducted twice during the interven-tion phase to assess use of materials, mailings, and reports at theWCV. Computerised process evaluation forms were completed atVisits 2 and 3 for the stage-based, support behaviour, usual caremailers, and PacTrac-ES reports. Staff reviewed questions pertain-ing to the materials specific to the participant group. A binder con-taining examples of the materials were shown to the participant/parent. For the intervention group mailers, staff was notified ofthe child’s particular stage assessed at the previous visit in orderto send stage-appropriate intervention material.

3. Origin and evolution of the Pacific Tracker tool

3.1. Overview

The Pacific Tracker (PacTrac) was first developed from the USDAInteractive Healthy Eating Index (IHEI) software provided to theHealthy Living in the Pacific Islands – Healthy Pacific Child Project,a USDA grant to the University of Hawaii (UH/CTAHR/HNFAS, Ra-chel Novotny PI). The IHEI tool was provided with documentationand an installation guide from Aquilent, the USDA contractor. TheIHEI tool was adapted for the Pacific Region using the University ofHawaii Cancer Center’s food composition database, which is basedon the USDA standard reference (Murphy et al., 2006) with addedfoods and recipes consumed in the U.S.-affiliated Pacific Region(Hawaii, Guam, Commonwealth of the Northern Mariana Islands,

Please cite this article in press as: Novotny, R., et al. Pacific Tracker 2 – Expert SPacific Kids DASH for Health (PacDASH) study. Food Chemistry (2012), http://d

American Samoa, Freely Associated States of Micronesia), whichwere gathered through the project, and from other sources. Theresulting PacTrac tool was posted on the UH Cancer Center websiteand on the UH College of Tropical Agriculture and HumanResources (CTAHR/FCS) Hawaii Foods website (hawaiifo-ods.hawaii.edu; Sylvia Yuen PI).

Through a second USDA grant, Pacific Kids DASH for Health(PacDASH, Novotny PI), USDA’s updated MyPyramid Tracker soft-ware was obtained by a Cooperative Agreement between the UHCancer Center (Murphy S, Co-I) and USDA. That software was usedto create a second version of the Pacific Tracker (PacTrac2), for useby PacDASH project. The software, however, was not provided withdocumentation or an installation guide from the USDA contractor,American Systems. The software was required programming andadaptation for use, which was done at UH in a partnership betweenthe UH/CTAHR/HNFAS and the Cancer Center. The same MyPyr-amid software was used by the Hawaii Foods website programmer(UH/CTAHR/FCS), who adapted the program with graphical displayfor use on the Hawaii Foods website. The Cancer Center’s foodcomposition database was also again included, which continuedto expand its contents of Pacific foods and recipes with ongoingstudies done in the region.

Novotny recently obtained a third USDA grant, Children’sHealthy Living Program for Remote Underserved Minority Popula-tions in the Pacific Region (CHL), a collaborative program amongU.S. affiliated jurisdictions in the Pacific Region. CHL is furtherdeveloping PacTrac2 into PacTrac3 for two distinct functions. Onefunction is for research use, involving saving data. A second func-tion is for outreach/public use, on a website. A memorandum ofagreement has been developed among the parties that will usethe PacTrac products.

3.2. IHEI

The Interactive Healthy Eating Index (IHEI) was an online die-tary assessment tool developed by the USDA’s Center for NutritionPolicy and Promotion using data from USDA’s Continuing Survey ofFood Intake by Individuals (CSFII), 1994–1996 and 1998, for foodand nutrient data. These data are available at: http://www.barc.us-da.gov/bhnrc/foodsurvey/Cd98.html. USDA’s Nutrient Database forStandard Reference, Release 14 was used for nutrient data for foodsnot found in the CSFII. These data are available at: http://www.nal.usda.gov/fnic/foodcomp/Data/SR14/sr14.html.

After creating a user ID, a user entered their age, gender, weightand height, and then, information about their dietary intake for1 day. The software generated the nutrient content of the diet en-try, a comparison of how the diet adheres to the USDA Food GuidePyramid (FGP) and to other federal dietary guidelines, such as theper cent of calories from total fat and saturated fat, amount of die-tary cholesterol, sodium intake, including the HEI score which wascreated by the USDA’s Center for Nutrition Policy and Promotion in1995 (http://www.cnpp.usda.gov/HealthyEatingIndex.htm).

3.3. PacTrac

The Pacific Tracker (PacTrac) was a modification of the IHEI. Thegoal was to modify PacTrac for collection, analysis and aggregationof food intake data in the Pacific Islands. Food composition datafrom Pacific Island populations that were collected by our groupwere added. By 2006, in its fourth version (Martin et al., 2008),the PacTrac database contained a total of 2903 food codes. Further-more, the IHEI was modified with the addition of a function to saveentered dietary data, to allow access to these data at a later time,which was needed for research. PacTrac provided output of dailyenergy and nutrient intake for 24 nutrients. PacTrac provided theoutput of food groups consumed in daily servings for each of the

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30 Food Guide Pyramid (FGP) food groups (U.S. Department ofAgriculture, Center for Nutrition Policy and Promotion, 1996).PacTrac also generated Healthy Eating Index (HEI) scores, whichranged from 0 to 10, for each of 10 components: grains, vegetables,fruits, dairy, meat, total fat, saturated fat, cholesterol, sodium, andvariety (Basiotis, Carlson, Gerrior, & Lino, 2002). Both PacTrac andthe IHEI have been evaluated for usability and acceptability for die-tary assessment by consumers (Hiza & Gerrior, 2002; Martin et al.2008). PacTrac was evaluated for data entry capacity for researchstudies (Murphy et al., 2009).

3.4. MyPyramid Tracker

After the release of the MyPyramid recommendations in 2005,USDA created new software to incorporate MyPyramid food groupsand NHANES 2000 dietary supplement module, and called the newtool MyPyramid Tracker (Britten, Marcoe, Yamini, & Davis, 2006).IHEI employed the unit of servings from the U.S. Food Guide Pyra-mid, while the U.S. MyPyramid food guidance system uses house-hold units (cups for milk, vegetables and fruits, and ounceequivalents for meats and grains). The Pyramid Servings Databasefor USDA Survey Food Codes was used to calculate Food Guide Pyr-amid servings. These data are available at: http://www.barc.usda.gov/bhnrc/cnrg/intro.html. The newer MyPlate food group systemuses the same food groups as the MyPyramid system, so outputcan be provided in the MyPlate format.

The MyPyramid Tracker also included a tool to evaluate dailyphysical activity based on the Institute of Medicine’s Thermal En-ergy Expenditure equation for adults with four physical activitylevels or an alternative option to evaluate physical activity accord-ing to the time spent in individual activities per day (1440 min to-tal). Both options were available for adults, but for children onlythe 1440 min/day option was available. The tool quantified min-utes of physical activities and their intensities based on energyestimates (Ainsworth et al., 2000).

3.5. PacTrac2

Between May 2008 and November 2009, the University ofHawaii’s Department of Human Nutrition, Food and Animal Sci-ences department (HNFAS) and UH Cancer Center further devel-oped the PacTrac2 on this same MyPyramid Tracker computerplatform. The new PacTrac2 used SQL Server 2005, dot net 2.0 com-puter software, and the operating system IE 7.0. As with PacTrac,the Cancer Center incorporated into their database Asian and Paci-fic Island foods and recipes collected and analysed from the PacificRegion by first adding them to the Cancer Center’s food composi-tion database (Murphy, 2002). Recipes and children’s foods fromcommon food items identified from 24-h recalls collected in PacificRegion and from the Secretariat of the Pacific Community FoodComposition Table were also added as with PacTrac. New forPacTrac2 were 70 recipes that were calculated by the Cancer Cen-ter from the DASH of Aloha Healthy Cuisine and Lifestyle Cookbook(Kapiolani Community College, 2007) and used in the PacDASHstudy.

The PacTrac2 physical activity analysis tool added data on phys-ical activities common to children (Ridley, Ainsworth, & Olds,2008), including those found in Hawaii in the Female AdolescentMaturation (FAM) study (Novotny PI, unpublished data) such assurfing and hula dancing. The MyPyramid Tracker, and now Pac-Trac2, could analyse physical activity, while PacTrac did not pro-vide physical activity analysis. The process to use PacTrac2’sphysical activity assessment is to (1) type in and search from anexisting physical activity database; (2) select the physical activityand duration for each; and (3) analyse physical activity status forthe day. The PacTrac2’s physical activity assessment results include

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activity intensity and energy expenditure for each activity and thesum of energy expenditure for all activities. The overall physicalactivity status derived from the entry is compared to U.S. recom-mendations. These results can be saved to track physical activityover time up to 1 year.

3.6. Summary of PacTrac2

PacTrac2 analyses diets and physical activity for children andadults in the Pacific Region according to the MyPyramid dietaryguidance for the United States. PacTrac2 upgrade features include(1) an upgrade to the MyPyramid/MyPlate food groups and units(e.g., cups vs. servings) and (2) physical activity data entry andanalysis, to which we added children’s physical activities. TheMyPyramid computerised graphic output was not available, norwere updated HEI calculations. Thus, the primary food differencebetween PacTrac software and both IHEI and MyPyramid Trackeris the incorporation of the Cancer Center’s food composition table,which includes foods and recipes of the Pacific Region gatheredthrough multiple efforts. Also, the MyPyramid Tracker, andPacTrac2, also included a tool to analyse physical activity, whilePacTrac did not.

4. Development of the ‘‘Expert System’’ for the PacDASH study

4.1. Overview

An Expert System (ES), a computerised behavioural guidancesystem, was also developed and linked to the PacTrac2 program(PacTrac2-ES). The PacTrac2-ES was developed for use in the Paci-fic Kids DASH for Health (PacDASH) intervention study (Novotny,PI) in the Kaiser Permanente Health System. The ES was designedto provide individualised, targeted diet and physical activity mes-sages as part of the PacDASH intervention. The ES is used to (1) as-sess stage of change and self-efficacy, (2) generate individuallytailored output reports for the child and parent at assessment vis-its, and for the physician to explain at an upcoming WCV, and (3)randomly assign participants to control and intervention groups.(A subroutine was used to enforce that no more than 60% of theparticipants could be randomly assigned to either group, in orderto ensure an adequate basis for comparison.)

4.2. Expert System

The Expert System is capable of considering responses to ques-tions of self-efficacy, stage of change, fruit and vegetable intake,and physical activity minutes, reasoning, and then identifies thestage of change and recommends a course of action for improvingthe participant’s diet and physical activity (PA). The ES assessedstages of change for fruit and vegetable consumption and PA withtwo to three questions each. ES determined self-efficacy with onequestion for PA and one for fruit and vegetable consumption,addressing the belief that the individual can do the target behav-iour. A discussion of stages of change and the actual questions toassess the stages of change follow.

4.3. Theory

The Trans theoretical Model has identified stages of change thatreflect an individual’s readiness to change a behaviour or their hav-ing already practiced the behaviour. An individual’s readiness andwillingness to adopt a healthy lifestyle vary throughout thesestages. The five stages of change are Precontemplation, Contempla-tion, Preparation, Action and Maintenance. It is counterproductiveto offer one blanket intervention for everyone, regardless of

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whether they want to change. Tailoring the intervention to matchthe stage produces optimal progress (Norcross, Krebs, & Prochaska,2011). In general, persuasive texts used in the earlier stages involvethinking and feeling. Action-related or behavioural texts are usedto a greater extent in the later stages. An individual’s move fromone stage of change to the next is an indicator of progress towardsbehaviour change.

4.4. ES use in PacDASH

Self-efficacy and the child’s stage of change were assessed fivetimes during the PacDASH study. Ten different combinations ofstage of change and self-efficacy paragraphs of recommendationswere possible based on the assessment at baseline. Twenty differ-ent combinations were possible at follow-up. After each visit’sassessment, at baseline, 2, 5 and 8 months, informational materialswere tailored for the child based on the results. ES reports weregenerated at each visit for the intervention group only. After thefirst assessment, a graphic output depicts the child’s physical activ-ity level and fruit and vegetable intake (FV), with messages appro-priate to their self-efficacy and stage of readiness to change. Thechild output report provided: (1) information about the child’sFV and PA level, (2) tailored messages and pictures relevant to tar-geted behaviours based on self-efficacy and stage of change. Theparent output report provided all of the above and in additionhas parent-specific feedback text that support targeted childbehaviours. The physician output report provided brief diet andPA recommendations in a script that reinforced targeted childbehaviours, which the physician discussed with the child and par-ent at the well-child visit. After assessments baseline, two andthree, support materials were given at the PacDASH assessmentvisit or by mail.

4.5. Self-efficacy

Self-efficacy is the belief that one can engage in the behaviourdescribed. The individual’s self-efficacy responses were then com-pared to population norms (normative) and were also compared tothe individual’s previous response (ipsative). Self-efficacy was as-sessed with one question for physical activity and one item for fruitand vegetable consumption providing guidance to address the be-lief that the individual can do the target behaviour. This item hasshown validity with its hypothesised relationship with stage ofchange for both physical activity and fruit and vegetable consump-tion (Nigg, unpublished data). The participant chose a responsefrom the 5-point self-efficacy scale from disagree a lot to agree alot on two items: (1) I believe I can be physically active everyday. (2) I believe I can eat five or more servings of fruits and veg-etables every day.

4.6. Stages of readiness to change physical activity

Current physical activity (PA) stage was assessed using the rec-ommendations by Reed, Velicer, Prochaska, Rossi, and Marcus,(1997). PA was defined as at least 60 min for 5 or more days eachweek of activities such as brisk walking, jogging, gardening, hula/dance, or paddling. Stages are defined as: (1) Precontemplation –no intention to engage in regular PA; (2) Contemplation – intentionto engage in regular PA within the next 6 months; (3) Preparation –intention to start regular PA in the near future (within the next30 days); (4) Action – participation in regular PA for less than6 months; and (5) Maintenance – participation in regular PA for6 months or more. For children, the word ‘‘intend’’ has been chan-ged to ‘‘plan’’ based upon pilot studies. The stage of change instru-ment is short, valid, and reliable and is able to detect changes in PAand exercise behaviour (Schumann, Estabrooks, Nigg, & Hill, 2003;

Please cite this article in press as: Novotny, R., et al. Pacific Tracker 2 – Expert SPacific Kids DASH for Health (PacDASH) study. Food Chemistry (2012), http://d

Schumann, Nigg, & Rossi, 2002). After giving a definition of ‘‘regu-lar physical activity,’’ the interventionist asked the participant ifthey currently do regular physical activity. If yes, have they beendoing so for the past 6 months. If not, do they plan to do regularphysical activity in the next 6 months, and plan to within the next30 days?

4.7. Stages of readiness to change fruit and vegetable consumption

The stage of change measure determines a child’s readiness toconsume five or more servings of fruits and vegetables each day.After describing a serving of fruits and vegetables (FV), the inter-ventionist asked the participant, ‘‘How many servings of fruitsand vegetables do you usually eat each day?’’ Depending on theiranswers to the previous question about five or more servings ofFV, the interventionist follows up ‘‘yes’’ answers by asking if theyhave engaged in that behaviour for the past 6 months. ‘‘No’’ an-swers are followed up with the question if they plan to eat fiveor more servings of fruits and vegetables a day in the next6 months; and if ‘‘yes,’’ their plan to eat them in the next 30 days.

The ES then classified the participants either into the Precon-templation, Contemplation, Preparation, Action, or Maintenancestage (Clark et al., 2005). Those classified in (1) Precontemplationhad not met the criterion (five or more servings of fruits and veg-etables a day), and had no intention of doing so in the foreseeablefuture (6 months). Those in (2) Contemplation did not meet the cri-terion but had an intention to do so within the next 6 months.Those in (3) Preparation did not meet criterion but had an inten-tion to start in the next 30 days. (4) Action and (5) Maintenancestages indicated that the participant had been at criterion for lessthan 6 months, and for 6 or more months respectively (Greeneet al., 2004).

5. Conclusion

PacTrac2 will be further developed for research and public usethrough the Children’s Healthy Living Program in Remote Under-served Minority Populations of the Pacific Region Program (CHL,Novotny, PI, 2011–2016). Results of the PacDASH intervention willbe important to guide future applications of Expert Systems andComputerised Dietary Analysis programs in health care systems.As the US Dietary Guidelines call for action highlighted, targetedbehavioural guidance, especially for children, is key to preventionof obesity and related diseases, and for attaining health (USDA,2011).

Acknowledgements

The authors would like to acknowledge Maj Earle, Joel Julian,John Grove, Caryn Oshiro, Suzanne Murphy, Wayne Toma, SteveSpielman, Ron Takahashi, Vinutha Vijayadeva, and the clinical staffat Kaiser Permanente Hawaii and at the University of Hawaii, JohnA. Burns School of Medicine’s Clinical Research Center, PacDASHchildren and their parents.

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