EVALUATION OF A HEART-HEALTHY DIET PROGRAM 1

Formative Evaluation of a Heart-Healthy Diet Program for Social Service Employees

Arsinoe Del Real, Amy Martin, Louis Rojas, Sarah Schwantner

Department of Family and Consumer Sciences, Bradley University

FCS 311: Evaluation and Research Methods

Dr. Teresa Drake

May 12, 2020

Abstract
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According to the American Heart Association (AHA, 2019), cardiovascular disease is the

leading cause of death worldwide. Approximately half of all deaths due to this disease could be

prevented if lifestyle behaviors were modified (Stanner & Coe, 2019). Diet is one of the factors

that contributes to the development of cardiovascular disease, and consuming more fiber helps

decrease one’s risk (Stanner & Coe, 2019; Wallström, et al., 2012). The purpose of this study

was to evaluate a cardiovascular disease prevention program focused on preparing heart-healthy

meals. The stages of change, decisional balance, and self-efficacy constructs of the

Transtheoretical Model were utilized to develop this program. An informational presentation and

group discussions would help participants understand the benefits and barriers of preparing

heart-healthy meals. This would also help participants progress from the contemplation to the

preparation stage. A food demonstration would allow participants to practice preparing heart-

healthy meals. This would help participants conquer barriers and build self-efficacy related to

this skill. A formative evaluation was conducted. The justification evaluation displayed a need

for cardiovascular disease prevention in Peoria. A consumer-orientation survey highlighted the

priority population’s interest in cardiovascular disease prevention and diet. The findings of the

evidence evaluation illustrated that interactive nutrition education is effective. Pre-testing

feedback helped the leaders make several revisions to their program. The information in the

presentation was condensed. More discussion questions were added to increase participant

engagement. Additional heart-healthy recipe ideas were included on the post-program handout

and in the presentation.

Introduction
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According to the American Heart Association (AHA, 2019), cardiovascular disease is

currently the leading cause of death worldwide. From 2013-2016, the prevalence of

cardiovascular disease in adults over 20 years of age was 48% (AHA, 2019). By 2030, 23.6

million people will die globally every year due to this condition (AHA, 2019). Cardiovascular

disease is also the leading cause of death in the United States, as 840,768 Americans were killed

by this condition in 2016 (American College of Cardiology, 2019). Additionally, cardiovascular

disease places an extreme financial burden on the American economy, as this condition costs the

United States around $200 billion every year (CDC, 2017). This amount includes health care,

medication, and lost productivity expenses (CDC, 2017). Similarly to the rest of the country and

the world, cardiovascular disease is the number one cause of death in Peoria (Peoria City/County

Health Department, 2018). In 2018, 21% of all deaths in Peoria were due to cardiovascular

disease (Illinois Department of Public Health, 2019). Although cardiovascular disease is a deadly

illness, approximately half of all deaths due to this disease could be prevented if lifestyle

behaviors were modified (Stanner & Coe, 2019).

Diet is one of the main factors that contributes to the development of cardiovascular

disease (Stanner & Coe, 2019). In one study, employees at a medical center were invited to

participate in a diet intervention with the aim of reducing cardiovascular disease risk factors

(Racette, et al., 2009). Half of these employees were given hard copy resources to guide them in

improving their diet and reducing their risk for cardiovascular disease (Racette, et al., 2009). The

other half were given access to in-person appointments with registered dietitians (Racette, et al.,

2009). Both groups of employees consumed more fruits and vegetables and less saturated fat

after the program (Racette, et al., 2009). However, those in the group that had access to dietitians

displayed greater improvements than those who simply received hard-copy resources (Racette, et
EVALUATION OF A HEART-HEALTHY DIET PROGRAM 4

al., 2009). This is likely due to the fact that those in the dietitian group were able to interact with

a health professional one-on-one. Therefore, they were able to ask individual questions about

their specific diets. On the other hand, those who were given hard copy resources were left to

navigate their diet-improvement journey on their own without the help of a specialist. Other

researchers using similar methodology have come to the same conclusions (Radler, Marcus,

Griehs, & Touger-Decker, 2015; Francis & Taylor, 2009). One group of researchers provided

participants with in-person counseling sessions with a dietitian to help increase their diet quality

(Radler, et al., 2015). Following the counseling meetings, participants were given access to

twelve weeks of educational materials formulated by dietitians (Radler et al., 2015). Although

the content was the same, participants were able to select whether they accessed these resources

in-person or online (Radler et al., 2015). After the twelve weeks, all participants lost weight and

experienced decreases in blood pressure no matter which medium of education they chose

(Radler et al., 2015). However, those who experienced in-person education displayed greater

improvements than those who used the online materials (Radler et al., 2015). After analyzing this

research, it was decided that this program will use an interactive intervention style, because these

studies suggest the use of in-person diet interventions to be more effective than hard copy

resources.

Certain dietary changes could be made to decrease one’s risk for cardiovascular disease.

While increased consumption of sodium, cholesterol, and saturated fat are associated with

higher risks for the development of cardiovascular diseases, higher fiber intakes are associated

with lower risks for cardiovascular diseases (Wallström, et al., 2012). Fiber sources such as

cereals and fruits are the most appropriate for lowering the risk of cardiovascular disease

(Wallström, et al., 2012). This means that offering a cereal such as oatmeal with a fruit such as
EVALUATION OF A HEART-HEALTHY DIET PROGRAM 5

bananas, is an appropriate method in reducing the risk of cardiovascular disease in a nutritional

intervention program for cardiovascular disease (Wallström, et al., 2012).

Worksite wellness programs are promising interventions for cardiovascular disease

prevention, and would bring many benefits to the employer, employee, and organization as a

whole. For the employer, insurance payments would be less expensive if their employees were

healthier. A group of researchers discovered that those employers who were dedicated to a

nutrition intervention program were found to have a decrease in healthcare costs (Sacks et al.,

2009). Employers would also benefit because when employees are healthier, their attendance

increases, leading to more consistent work (CDC, 2015). This is because healthy employees

would not be absent from their job due to sickness and doctor appointments (CDC 2015). In

addition, the employer has much to gain in terms of productivity. Currently, cardiovascular

disease and strokes cost the United States $131 billion as a result of lost productivity on the job

(CDC, 2019). Employees would be more productive when they consume a healthier diet because

they would have more energy and would be able to do more work (CDC, 2015). Therefore, if

employees prepare heart-healthy meals and do not develop cardiovascular disease, this would

save employers money and improve the overall productivity of the organization. Lastly, the

employee would also benefit from this intervention in their personal life. Without the burden of

sickness, they would feel happier and healthier (Norstedt, 2019). After analyzing all the possible

benefits of this nutrition intervention, it is evident that this program would be valuable for

everyone involved in the workplace. The purpose of this study was to evaluate a cardiovascular

disease prevention program focused on preparing heart-healthy meals for employees at a social

service organization.

Methods
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The Transtheoretical Model was used to develop this 30-minute program. Three

constructs guided the planning of the program. First, the stages of change construct is centered

around the idea that behavior changes occur across five stages (McKenzie, Neiger, & Thackeray,

2017). To move the participants from the contemplation stage to the preparation stage, a

PowerPoint presentation was created. Contemplation is when an individual plans on changing

within six months, and preparation is when an individual has begun to take action and plans to

change within thirty days (McKenzie, et al., 2017). This PowerPoint presentation taught

participants what to include in their diet to help lower cardiovascular disease risk such as fiber,

unsaturated fats, and produce. Knowing this information could have helped participants move

from contemplation to preparation, because this PowerPoint gave the participants the knowledge

needed to prepare to make heart healthy meals. This presentation provided a starting point for the

consumption of a heart-healthy diet. The reasoning behind this presentation was that if

participants received the knowledge necessary to prepare heart-healthy meals during the

program, they would be inspired to plan out more heart-healthy meals to integrate into their

lifestyle. It was expected that the participants would likely not have a plan or a starting point for

this behavior change, so the aim of the presentation was to provide this starting point.

Next, decisional balance involves weighing the advantages of making a behavior change

against the costs of this change (McKenzie, et al., 2017). Leaders planned to address this

construct by first stating the pros of preparing a heart-healthy diet. Then, they planned to

acknowledge the cons of this behavior by facilitating a group discussion. Lack of time was one

of the cons that the leaders expected to be mentioned during the discussion. In order to

counterbalance this disadvantage of the behavior, a food demonstration was planned. During this

demonstration, the program leaders intended to show the participants how to make a simple
EVALUATION OF A HEART-HEALTHY DIET PROGRAM 7

heart-healthy recipe. By demonstrating a simple recipe, the program leaders aimed to convince

participants that preparing heart-healthy meals is quicker and easier than they think. Thus, by the

conclusion of the program, the program leaders hoped that the decisional balance of the

participants would remain where the pros of the behavior outweigh the cons.

Lastly, self-efficacy represents an individual’s sense of confidence in performing a task

(McKenzie, et al., 2017). Self-efficacy was addressed through the planned food demonstration as

an interactive exercise. It was intended to have the participants watch the leaders prepare the

recipe first. After gaining self-efficacy through observational learning, the participants would be

able to individually practice the recipe used in the demonstration. This program was intentionally

planned so that by the time the participants leave the program, they would feel capable of

performing the behavior on their own. This program was specifically designed for employees of

a social service organization in Peoria, Illinois. The program leaders anticipated that

approximately 20 employees would attend this program.

Impact Objectives

● Increase at least 80% of the participant’s confidence regarding the preparation of heart-

healthy meals.

● 80% of all participants are able to list two benefits of preparing heart-healthy meals.

● Move 80% of all participants from the contemplation stage to the preparation stage.

For the formative evaluation of this program, justification, evidence, consumer-

orientation, and adjustment evaluations were completed. The justification evaluation was

performed by examining the cardiovascular disease prevalence in Peoria, IL. To complete this

evaluation, leaders examined statistics regarding the prevalence of cardiovascular disease in

Peoria. The evidence evaluation was conducted by completing a literature review. The leaders
EVALUATION OF A HEART-HEALTHY DIET PROGRAM 8

examined the methodology of similar nutrition education interventions to develop the present

program. A consumer-orientation evaluation was performed by selecting a topic for the program

that was of interest to the priority population. The leaders analyzed the results of a survey

completed by the priority population to determine the program focus. An adjustment evaluation

was conducted using feedback collected during a pre-test. To continue, pre- and post-test surveys

were developed to be used for summative evaluation (Appendix E & F). The surveys are

designed to assess the participant’s knowledge about cardiovascular disease by asking them to

list two benefits of preparing heart-healthy meals. These surveys also assessed the participant’s

confidence in preparing heart-healthy meals, and they placed the participants in one of the stages

of change. Additionally, the pre-survey asked participants to answer questions regarding

demographics such as age, gender, and race to allow the program leaders to examine differences

among people of different backgrounds. Lastly, the pre-survey asked participants about whether

they are at risk for cardiovascular disease. Questions about demographics and cardiovascular

disease risk were only included in the pre-survey to avoid redundancy.

Results

The leaders utilized the results from the formative evaluation to improve the program.

First, the justification evaluation examined the prevalence of cardiovascular disease in Peoria.

According to the Peoria City/County Health Department (2018), cardiovascular disease is the

number one cause of death in Peoria, displaying a clear need for cardiovascular disease

prevention in Peoria. Next, results of the consumer-orientation evaluation showed that healthy

eating and cardiovascular disease were of interest to the priority population. In the survey

completed by the priority population, 64% and 30% of the respondents were interested in healthy

eating and reducing heart disease risk respectively (Drake, 2018). Then, the results of the
EVALUATION OF A HEART-HEALTHY DIET PROGRAM 9

evidence evaluation displayed that interactive nutrition education is more effective than hard-

copy resources. In one study, the fruit, vegetable, and fat intakes of participants improved more

when they attended sessions with a dietitian than when they simply received hard copy resources

(Racette, et al., 2009). Thus, the program was rooted in evidence from previous programs.

Finally, the results of the adjustment evaluation helped the leaders make various revisions to

their program. The peers of the leaders suggested a simplification of the program’s content, an

increase in participant engagement, a decrease in the amount of information presented, and an

addition of more heart-healthy recipe ideas. The main feedback gained from the pre-test was to

shorten the length of the presentation, as eight individuals suggested this change.

Discussion

The results of the justification evaluation, in combination with the results of the consumer

orientation evaluation, led to the development of a cardiovascular disease prevention program

using healthy eating. This is because the priority population displayed both a need for

cardiovascular disease prevention, and a desire to learn about this topic. Next, once the existing

literature was analyzed for the evidence evaluation, it was decided that this program would use

an interactive intervention style. This is because these studies suggest the use of in-person diet

interventions to be more effective than hard copy resources. The leaders decided to include an

interactive overnight oats food demonstration in this program as a hands-on experience for the

participants. Additionally, after examining the feedback from the pre-test, several alterations

were made to the program. First, the terminology used in the presentation segment of the

program was simplified to make it more understandable to those without a nutrition background.

Specifically, complex terminology such as “poly and monounsaturated fats,” and “low-density

lipoprotein” was removed. Also, the information in the presentation was condensed, because the
EVALUATION OF A HEART-HEALTHY DIET PROGRAM 10

original presentation was too long. The leaders would revise the program to solely include the

key concepts of cardiovascular disease and heart-healthy diets. The original program provided

participants with an in-depth guide to cardiovascular disease and heart-healthy diets. The revised

program would consist of quick and straightforward tips to decrease salt and saturated fat intakes

while increasing fiber and healthy fat intakes. Next, the leaders would add more discussion

questions to their presentation to increase participant engagement. The original presentation only

included two discussion questions, but the revised program would include four discussion

questions. Lastly, more heart-healthy recipe ideas were added to both the presentation and post-

program handout. This would provide participants with other heart-healthy options in case they

did not enjoy the overnight oats recipe used during the program.

These proposed changes are supported by the results of a previous study by Meyer,

Coveney, and Ward (2014). The results of this study suggest that cardiovascular disease patients

struggle when large volumes of dietary information are presented to them by general

practitioners (Meyer, et al., 2014). When these patients receive excess dietary information, they

become overwhelmed (Meyer, et al., 2014). In turn, these patients tend to return to their old

eating habits (Meyer, et al., 2014). This is because these individuals are too overloaded with

information to effectively apply what they learned during their appointment with the practitioner

(Meyer, et al., 2014). The results of this study suggest that overall, the quality of information

provided to cardiovascular disease patients is more important than the volume (Meyer, et al.,

2014). Therefore, it would be best if the present program was shortened and simplified. This

would help prevent the participants from feeling overwhelmed and returning to previous eating

habits. By including less information in the program, the participants would be more likely to

comprehend the content and integrate what they learned into their lifestyle.
EVALUATION OF A HEART-HEALTHY DIET PROGRAM 11

The main limitation of the program is that it was not implemented. Therefore, it remains

unknown whether the present program is effective. Additionally, only a few evaluators provided

feedback on the program, and these individuals were not members of the priority population. The

evaluators were students focused on improving the quality of the program. Thus, these evaluators

may have provided different feedback than what would have been proposed by members of the

priority population.

In conclusion, the evaluation of this program could be used in the future to determine the

most effective methodology for nutrition education programs. Future research should examine

the success of interactive nutrition education programs that include a variety of activities. This

would help future program planners determine the most beneficial activities to include in

nutrition education interventions.

References

American College of Cardiology. (2019). AHA 2019 heart disease and stroke statistics.

Retrieved from https://www.acc.org/latest-in-cardiology/ten-points-to-

remember/2019/02/15/14/39/aha-2019-heart-disease-and-stroke-statistics.

American Heart Association. (2019). Heart disease and stroke statistics- 2019 at-a-

glance. Retrieved from https://professional.heart.org/idc/groups/ahamah-

public/@wcm/@sop/@smd/documents/downloadable/ucm_503396.pdf.

Centers for Disease Control and Prevention. (2017). Heart Disease Fact Sheet. Retrieved

from https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm.
EVALUATION OF A HEART-HEALTHY DIET PROGRAM 12

Centers for Disease Control and Prevention. (2015). Workplace health promotion. Retrieved

from https://www.cdc.gov/workplacehealthpromotion/model/control-

costs/benefits/productivity.html.

Drake, T. (2018). Health assessment of employees at a social service organization. Unpublished

raw data.

Francis, S.L. & Taylor, M.L. (2009). A social marketing theory-based diet-education

program for women ages 54 to 83 years improved dietary status. Journal of the American

Dietetic Association, 109(12), 2052-2056.

Illinois Department of Public Health. (2019). Statewide leading causes of death by

resident county, Illinois residents, 2018. Retrieved from http://dph.illinois.gov/data-

statistics/vital-statistics/death-statistics/more-statistics.

McKenzie, J.F., Neiger, B.L, & Thackeray, R. (2017). Planning, implementing & evaluating

health promotion programs: A primer, 7th ed. Pearson Education.

Meyer, S.B., Coveney, J., & Ward, P.R. (2014). A qualitative study of CVD management

and dietary changes: problems of 'too much' and 'contradictory' information. BMC

Family Practice, 15(1), 25-31.

Norstedt, M. (2019). Work and invisible disabilities: Practices, experiences and understandings

of (non)disclosure. Scandinavian Journal of Disability Research, 21(1), 14–24.

Peoria City/County Health Department. (2018). Peoria county mortality report. Retrieved

from http://pcchd.org/ArchiveCenter/ViewFile/Item/228.
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Racette, S.B., Deusinger, S.S., Inman, C.L., Burlis, T.L., Highstein, G.R., Buskirk, T.D.,

… Peterson, L.R. (2009). Worksite opportunities for wellness (WOW): Effects on

cardiovascular disease risk factors after 1 year. Prev Med, 49(0), 108-114.

Radler, D.R., Marcus, A.F., Griehs, R., & Touger-Decker, R. (2015). Improvements in

cardiometabolic risk factors among overweight and obese employees participating in a

university worksite wellness program. Health Promotion Practice, 16(6), 805-813.

Sacks, N., Cabral, H., Kazis, L. E., Jarrett, K. M., Vetter, D., Richmond, R., & Moore, T.

J. (2009). A web-based nutrition program reduces health care costs in employees with

cardiac risk factors: before and after cost analysis. Journal of Medical Internet Research,

11(4), e43.

Stanner, S. & Coe, S. (2019). Diet and heart disease – what have we learnt over the last

15 years? Nutrition Bulletin, 44(2), 104-106.

Wallström, P., Sonestedt, E., Hlebowicz, J., Ericson, U., Drake, I., Persson, M., Gullberg, B.

Hedblad, B., & Wirfält, E. (2012). Dietary Fiber and Saturated Fat Intake Associations

with Cardiovascular Disease Differ by Sex in the MalmöDiet and Cancer Cohort: A

Prospective Study. PLoS ONE, 7(2), 1–9. https://doi-

org.ezproxy.bradley.edu/10.1371/journal.pone.0031637
EVALUATION OF A HEART-HEALTHY DIET PROGRAM 14

Appendix

Table of Contents

Appendix A: Informed Consent Document…………………………………………………….pg. 16

Appendix B: Program Materials.……………………………………………………………….pg. 17

Appendix C: Program Flyer…………………………………………………………………….pg. 18

Appendix D: Program Handout.…………….………………………………………………....pg. 19

Appendix E: Pre-Program Survey.…………………………………………………………….pg. 20

Appendix F: Post-Program Survey……………………………………………………………pg. 23

EVALUATION OF A HEART-HEALTHY DIET PROGRAM 15

Appendix A: Informed Consent Document

INFORMED CONSENT FOR EXEMPT STUDIES WITH MINIMUM RISK

Study Title: Evaluation of a Heart-Healthy Diet Program for Social Service Employees

You are invited to participate in a research study. The purpose of this study is to evaluate the
effectiveness of heart healthy snack preparation on reducing cardiovascular disease risk. This
study consists of participation in a discussion, observing a presentation, participation in a food
demonstration and answering questions on a survey. The questions on the survey will gauge
participant’s level of knowledge regarding heart disease, and will also ask about barriers and
benefits to preparing heart healthy meals. Your participation in this study will take
approximately 30 minutes. The privacy of the participants will be protected by not linking them
to their survey responses. The investigators will not know which participant filled out each
survey, because the signed informed consent documents will be kept separate from the
anonymous surveys. Taking part in this study is voluntary. You may choose not to take part or
may leave the study at any time.

The only members of the research team permitted to access information about participants are
Dr. Teresa Drake, Amy Martin, Sarah Schwantner, Arsinoe Del Real, and Louis Rojas.

Questions about this study may be directed to the research advisor in charge of this study: Dr.
Drake, tdrake@fsmail.bradley.edu. If you have general questions about being a research
participant, you may contact the Committee on the Use of Human Subjects office at (309) 677-
3877.

You are voluntarily making a decision to participate in this study. Your submission of the survey
(participation) means that you have read and understand the information presented and have
decided to participate. Your submission (participation) also means that all of your questions have
been answered to your satisfaction. If you think of any additional questions, you should contact
the researcher(s).
EVALUATION OF A HEART-HEALTHY DIET PROGRAM 16

Appendix B: Program Materials

● Computer

● Projector

● PowerPoint Presentation

● Table

● Oatmeal

● Disposable container

● Cling wrap

● Plastic silverware

● Brown sugar

● Bananas

● Paper towel roll

EVALUATION OF A HEART-HEALTHY DIET PROGRAM 17

Appendix C: Program Flyer

Appendix D: Program Handout

EVALUATION OF A HEART-HEALTHY DIET PROGRAM 18

Appendix E: Pre-Program Survey

Pre-Program Survey
EVALUATION OF A HEART-HEALTHY DIET PROGRAM 19

1. How do you usually describe your gender?

a. Man

b. Woman

c. Other/prefer not to answer

2. How would you describe yourself? Circle all that apply.

a. American Indian or Native Alaskan

b. Asian or Asian American

c. Black or African American

d. Hispanic or Latino/a/x

e. Middle Eastern/North African or Arab Origin

f. Native Hawaiian or Other Pacific Islander Native

g. White or Caucasian

h. Other

3. What is your age in years?

a. 18-24

b. 25-34

c. 35-44

d. 45-54

e. 55-64

f. 65+

4. Do you have or are you at risk for heart disease?

a. Yes, I have heart disease

b. Yes, I am at risk for heart disease

EVALUATION OF A HEART-HEALTHY DIET PROGRAM 20

c. No, I am not at risk/have heart disease

d. Unsure of my risk

e. Prefer not to answer

5. How confident are you in your abilities to prepare heart healthy meals?

a. Very confident

b. Confident

c. Somewhat confident

d. Somewhat unsure

e. Unsure

f. Very unsure

6. Which best describes you?

a. I am not planning on preparing heart healthy meals within the next six months.

b. I am planning on preparing heart healthy meals within the next six months.

c. I am planning on preparing heart healthy meals within the next thirty days.

d. I have prepared heart healthy meals within the past thirty days.

e. I have been preparing heart healthy meals regularly for more than six months.

7. What are challenges that prevent you from cooking heart-healthy meals? Select all that

apply:

a. Time

b. Cost

c. Lack of nutrition knowledge

EVALUATION OF A HEART-HEALTHY DIET PROGRAM 21

d. Cooking skill level

e. Other, please specify: __________________________________

8. List two benefits of preparing heart-healthy meals.

Appendix F: Post-Program Survey

1. How confident are you in your abilities to prepare heart healthy meals?

a. Very confident

b. Confident

c. Somewhat confident

d. Somewhat unsure
EVALUATION OF A HEART-HEALTHY DIET PROGRAM 22

e. Unsure

f. Very unsure

2. Which best describes you?

a. I am not planning on preparing heart healthy meals within the next six months.

b. I am planning on preparing heart healthy meals within the next six months.

c. I am planning on preparing heart healthy meals within the next thirty days.

d. I have prepared heart healthy meals within the past thirty days.

e. I have been preparing heart healthy meals regularly for more than six months.

3. List two benefits of preparing heart-healthy meals.