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The Development of the Nutrition4Kids Website
Michelle S. Williams, MPH, CHES
Background
Cancer incidence and mortality rates in the United States have been declining over the last
several decades (Kohler, et al., 2011). This downward trend has been primarily attributed to
preventative behaviors, early detection, and treatment (Kohler, et al., 2011; McCullough, et al.,
2011). Many types of cancer have similar modifiable and non-modifiable risk factors than can
affect a person’s risk of developing cancer (Jensen, Wing, & Dellavalle, 2010; Johnson & de
Mejia, 2011; Rieck & Fiander, 2006). Public health experts suggest that the adoption of
preventative behaviors will be the key to maintaining the declines in the cancer incidence and
mortality in the future (Sullivan, Beckjord, Rutten, & Hesse, 2008). The health behaviors that
may reduce the risk of developing cancer include avoiding the use of tobacco, limiting alcohol
consumption, maintaining a healthy weight, and eating a healthy diet (Danaei, Vander Hoorn,
Lopez, Murray, & Ezzati, 2005).
The type of food that a person consumes has a significant influence on their risk for
developing cancer. The results of several studies indicate that a high intake of fruits, vegetables,
and whole grains, which have an abundance of vitamins, minerals, and other bioactive
compounds, may lower the risk of developing several types of chronic diseases including cancer
(Ames, 2010; Fung, et al., 2010). For example, whole grain foods such as oats, whole wheat
bread, and brown rice contain a high amount of fiber, phytochemicals, and antioxidants that have
been shown to reduce the risk of developing gastrointestinal cancers, such as colorectal cancer
(Dixon, et al., 2007; Jonnalagadda, et al., 2011). Fruits like strawberries, oranges, and
grapefruits have a large quantity of flavinoids and cartenoids that have been shown to have an
inverse relationship to the development of pancreatic cancer (Johnson & de Mejia, 2011).
Furthermore, Su et al. (2010) found that women who consumed adequate amounts of cruciferous
vegetables, such as broccoli and cauliflower, as teenagers had a reduced risk of developing breast
cancer later in life.
Results from the Health Information National Trends Survey show that many Americans are
aware that nutrition plays a role in cancer prevention (Sullivan, et al., 2008). Yet, most
Americans, especially youth, do not consume the amounts of fruits and vegetables recommended
in the Dietary Guidelines for Americans (at least two cups of fruit and 2 ½ cups of vegetables
every day) (Krebs-Smith, Reedy, & Bosire, 2010; United States Department of Agriculture,
2008). The 2009 Youth Behavior Risk Surveillance Survey revealed that more 77.7% of the
teenagers that completed the survey had not eaten fruits and vegetables five or more times in the
seven days preceding the survey (Eaton, et al., 2010 ). This suggests that many American youth
are not consuming adequate amounts of food containing the micronutrients that may help them
prevent the development of cancer as they age (Ames, 2010).
Conceptual Framework
The Internet is an ideal communication channel for the delivery of targeted health interventions,
especially health interventions targeting youth (Neuhauser & Kreps, 2008; Ritterband,
Thorndike, Cox, Kovatchev, & Gonder-Frederick, 2009). Studies have shown that targeted
health messages are often more effective than generic health messages (Kreuter, Lukwago,
Bucholtz, Clark, & Sanders-Thompson, 2003; Noar, Benac, & Harris, 2007). The
Nutrition4Kids website is a health education Internet intervention that contains health messages
targeting 10 – 14 years olds who may be seeking information online about cooking.
The components of the Nutrition4kids website are grounded in the constructs and
principles the Health Belief Model, the Information-Motivation and Behavioral Skills Model,
and health literacy (Fisher & Fisher, 1992; Neuhauser & Kreps, 2008; Rosenstock, 1966). I
hypothesize that if students are provided with information about cancer prevention, healthy
eating habits, and guidance on how to prepare healthy snacks and meals, they will be more likely
to adopt eating habits that may help to reduce their risk of developing cancer later in life.
Content
The overarching goal of the Nutrition4Kids website is to increase the student’s understanding of
dietary cancer prevention and increase their consumption of fruits, vegetables, whole grains and
legumes. The primary objectives of the Nutrition4Kids website are to:
1) Increase students’ knowledge of how poor dietary habits can affect their health;
2) Increase students’ knowledge of healthy dietary habits that can reduce their risk for
cancer;
3) Increase students’ ability to prepare healthy, well-balanced meals and snacks;
4) Increase students’ ability to discuss healthy eating with their family and friends;
5) Increase students’ knowledge of nutrients that have health benefits.
Nutrition Information
The information contained on the Nutrition4Kids website is based on one of the
recommendations from the second expert report, Food, Nutrition, Physical Activity and the
Prevention of Cancer: A Global Perspective, that was prepared by the World Cancer Research
Fund (WCRF) and the American Institute for Cancer Research (AICR) (World Cancer Research
Fund & American Institute for Cancer Research, 2007). The report lists 10 recommendations
regarding lifestyle habits and cancer prevention. The information included on the
Nutrition4Kids website was selected primarily because of the fourth recommendation, “eat more
of a variety of vegetables, fruits, whole grains and legumes such as beans’’ (WCRF & AICR,
2007).
The Nutrition4Kids website provides information about the types of foods that contain
micronutrients, antioxidants, phytochemicals and other health promoting botanicals that may
reduce the risk of DNA damage and subsequently the development of cancer (Fung, et al., 2010;
Jonnalagadda, et al., 2011). The information about foods that may prevent cancer in the
“Healthy Foods” section was adapted from information from AICR’s (2010) list of Foods That
Fight Cancer. The website highlights six categories of food that have been show to contain
bioactive compounds and micronutrients that may prevent cancer. The food categories featured
on the website are beans, berries, cruciferous vegetables, dark leafy green vegetables, garlic, and
grapes. There is a webpage for each category of food that provides information about the cancer
fighting properties of the food, examples of the specific types of food within the category, and a
recipe containing the food.
Behavioral Skills
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Studies have shown that if people are confident in their ability to make healthy meals and
snacks, they will be more likely to choose to prepare and eat healthy food rather than unhealthy
food (Wilson, 2007). Therefore, the Nutrition4Kids website contains a section that provides a
list of recipes containing the foods and nutrients that are discussed in the “Healthy Foods”
section. These recipes were included to serve as guides to help the students learn to prepare
healthy meals and snacks. These recipes may help to increase the students’ self-efficacy for
preparing healthy food.
Research on dietary eating patterns and adolescents has shown that (children’s eating
habits greatly depend on their parents). To ensure that the target audience is taught how to
overcome this barrier, a section has been added to teach students how to speak to their parents
about healthy eating, and the importance of including fruits, vegetables, and whole grain in their
diet.
Reinforcement
There are sidebars throughout the website that contain a variety of information such as
nutrition facts, tips for preparing meals on the go, and information about serving sizes. The
purpose of these sidebars is to serve as reminders and reinforce information that was provided in
various sections of the website. According to the Health Belief Model, these sidebars will serve
as cues to action. The sidebars also contain links to external sites with age appropriate
information, such as the Nemours’ TeenHealth, and the Centers for Disease Control and
Preventions’ Fruits and Veggies Matter. These external websites contain more detailed
information about the topic discussed in the sidebar.
The Nutrition4Kids website contains games in the “Fun Activities” section that are
designed to reinforce the key health messages that are provided throughout the website. The
“Cancer Prevention Clue Sleuth Quiz” challenges students to identify images of nutritious foods
based on a description of the food. The “Serving Size Match Up” game requires students to
match a type of food to the correct serving size. The “Cancer Prevention” game contains
questions about cancer prevention in different formats including true/false, matching, and fill in
the blank. By providing reinforcement in the form of interactive games, students may be able to
increase their knowledge about dietary cancer prevention.
Health Literacy
The information on the Nutrition4Kids website was modified to ensure that the target audience
would be able to comprehend it. The original text about cancer fighting foods from the AICR
website was tested using a readability index calculator which indicated that the Flesch-Kincaid
grade level of the text was 23. The modified text was tested and it received a Flesch-Kincaid
grade level of 15. Although a grade level of 15 is significantly higher the recommended grade
level of health information, some terms, such as folate and phytochemical, could not be altered.
Therefore, a glossary is available on the website to provide definitions for complex scientific
terms.
Graphic Design
The layout of the information on the website was based on recommendations from the
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National Library of Medicine’s (2008) and the Center for Disease Control and Prevention’s
(2009)guidelines for creating easy-to-read health information material. These guidelines were
created to help health education professionals ensure that members of the target audience can
comprehend the material they create. For example, the text and whitespace on the website was
balanced to ensure that the website was visually appealing. Information on the website was
separated into sections with bolded subtitles. Where it was appropriate, the text was bulleted to
reduce the number of long paragraphs. Photos of foods are included with each recipe. The
bright, rainbow color scheme and illustrations of preteens who are different genders and
races/ethnicities are also intended to apparel to the target audience.
Discussion
There are many nutrition interventions targeting adolescents on the Internet that focusing
on healthy eating, physical activity, and weight management. The Nutrition4Kids website is an
innovative method of informing middle school age adolescents about healthy eating habits,
dietary cancer prevention, and increasing their efficacy to change their nutrition behaviors. The
Health Belief Model and the Information-Motivation Behavioral Skills model are the conceptual
models that were used to develop the informational components of the website. Furthermore,
this website could potentially be used as an adjunct to school-based nutrition programs. A
usability test using students from the target population can be used to determine if the website is
an effective tool for increasing students’ knowledge of cancer prevention through healthy eating.
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