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A model for teaching healthy nutrition to clients of rehabilitation services.

A Model for Teaching Healthy Nutrition to Clients of Rehabilitation Services

A healthy and proper diet has an impact upon disease, physical health, emotional well-being, and provides numerous other benefits (Brandon, 1985; Clark & Blackburn, 1983; Pearson & Long, 1982; Smith, 1985; Vass, 1983; Williams, 1985). Thus it is important for persons to become nutritionally aware. Surprisingly, there have been few research studies which address the teaching of nutrition in rehabilitation settings, and concurrently provides an evaluation of the material taught/learned.

A review of the literature showed that most of the research regarding the teaching of nutritional awareness and dietary information has been directed at children. For example, Warden, Duncan and Sommars (1982) studied children who had some degree of mental retardation over a five-year period. They found that by eliminating refined carbohydrate foods, and in its place establishing fresh foods, both behavior and learning patterns of the children improved. This study also supported the theory that certain behavioral disturbances of children, such as hyperactivity, is related to various foods (Feingold, 1973). Conners and Blouin (1982/1983) studied the behavioral effects of breakfast and simple sugars in normal and psychiatrically impaired children. They found that a healthy breackfast, one that is well-balanced among the five major food groups, enhanced the capacity of the children to do academic work and benefited the children emotionally. A study done by Pollitt, Lewis, Garza and Shulman (1982/1983) demonstrated that the skipping of breakfast by children had an adverse effect on the child's late morning problem-solving performance and that a relationship exists between a healthy nutritional status and a child's capacity to learn. Lindholm, Touliatos, & Wenberg (1984), taught a nutritional education program to ten to thirteen year-olds and found that while nutritional knowledge improved, dietary quality and selection of healthy foods did not improve.

There was one study which involved a 34-year-old female who had a WAIS IQ score of 57. She was taught to plan and prepare nutritious meals for her daughter and herself as well as devise a grocery list and select correct items at a supermarket. A three- and five-month follow-up showed that skills and positive changes were maintained (Sarber, Halasz, Messmer, & Lutzker, 1983).

The purpose of the current study attempted to establish a model for teaching healthy nutrition to rehabilitation clients, while concomitantly encouraging clients to develop an interest in, and learn, proper nutrition. The program was developed at a sheltered workshop where clients with a variety of medical concerns voluntarily participated in this study.

Healthy eating habits, proper nutrition selection and preparation, were taught by the remedial education teacher, a certified Special Education teacher who had no prior formal nutritional training. The guidelines described in the Recommended Dietary Allowances (RDA's) (National Research Council, 1980), were utilized, along with recommendations regarding the buying and fixing of food, published by the National Dairy Council and Iowa State University (1985, 1986), as the foundation for the lessons. The material was taught over an eight-week period. The design of the study was a pretest/posttest design with subsequent six-week and three-month follow-up evaluations.



Twelve clients, seven males and five females, participated in the study. Their ages ranged from 23-59 years old, with a mean of 40 years old. Participant-clients were diagnosed as having a variety of multiple disabilities. Nine clients had some degree of mental retardation; four had a psychiatric diagnosis; four had other medically-related problems such as epilepsy, hypertension and alcoholism. Of the seven men, two were underweight; five were overweight by more than 20 percent of normal weight range for their age, height, and body build, placing them at risk for health (Williams, 1985). All the women were overweight by a least 20 percent of normal weight. Five clients (42 percent) smoked cigarettes; two clients (17 percent) reported they took vitamins daily. Five clients (42 percent) reported they exercise regularly. (There is an exercise program available at the workshop for interested clients.)

All participants had been identified as being appropriate candidates for independent living. This latter consideration strengthened the need to teach this group the basics of healthy nutrition as they may eventually be responsible for selecting, purchasing and preparing their own meals.


To select candidates for the study, rehabilitation counselors at the sheltered workshop were asked to identify clients whom they believed would be interested, and could benefit from, participating in a nutrition education class. Twelve individuals were recommended.

These individuals were personally contacted by the remedial education instructor, one of the principal researchers of the study. She described the nature and extent of the classes to each client. An information and consent form was secured from each participant so that access to medical records and other information could be reviewed prior to instruction. Records were subsequently discussed with the nurse to see if there were any contraindications to an individual participating in the study. It was the nurse's opinion that the twelve candidates did not have any medical concerns which would preclude them from participation. This is an especially important procedure as a particular medical condition and/or medication may impact upon the selection of proper foods for an adequate and nutritious diet. Steps which guarantee confidentiality and are within APA guidelines, where personal information will not be casually revealed to others, were described to each individual prior to the study and maintained throughout the study (American Psychological Association, 1981).

A base line was gathered through a pretest to determine client awareness of nutritional knowledge. The results of the pretest aided the teacher to organize the scope of the material and methodology for the material to be taught.

The Nutrition Achievement Test for kindergarten through sixth grade was chosen to evaluate the effectiveness of the learning of the nutritional information. This test was developed by the National Dairy Council and Iowa State University (1980) for this specific purpose. The test consists of 40 questions, designed in a pictorial format. Examples of some questions include:

* Select the food that has the most sugar from the following choices: watermelon, egg, hamburger, french fries, cookies, or apple.

* Select the food that is most healthy for lunch: sandwich, potato chips, cake, popcorn, coffee, or candy.

* Select the food that is best for your teeth: candy, raisins, potato chips, milk, cookies, or soda pop.

* Identify the number of cups of milk recommended (for adults) each day: one, two, three, four, five, or six.

* Sect the food that is in the same food group as a pancake: milk, bread, egg, sausage, grapefruit, or bacon.

The accuracy of test questions were verified by nutritional specialists and researchers and designated as important concepts by the 1969 White House Conference on Food, Nutrition and Health. Reliability was found to be .75, and was calculated by using the Spearman-Brown procedure.

This particular test was chosen because of the low reading level of participants and limited attention span, as well as the limited time needed to respond to test items (approximately 30 minutes). Participants were asked to place an X on what they perceived to be the correct or best answer, as the teacher read and described specific nutrition questions.

The 12 clients in the program were provided individualized instruction based on their reading, comprehension level, and style of learning, gleaned by a review of their file. Clients who had independent reading levels were provided materials and were able to advance at their own speed. Clients who did not have independent reading levels were provided additional individual and/or small group instruction so that the information could be learned. Classes met weekly for 30 minutes for eight weeks. Attendance was taken before each class. If an individual was absent for their allotted time slot, the teacher arranged a convenient time to make up the lesson.

Teaching Method

Nutritional information was presented in an open-ended format to facilitate discussion and participation in the lessons by the clients. General lead statements described why particular foods, and their amounts, were recommended for robust health. Proper preparation for each food, and the reason for this recommendation, was reinforced throughout broiling is healthier than frying foods, as the latter increases calories and the foods are harder to digest (Smith, 1983). There was an emphasis on encouraging clients to eat fresh fruits and vegetables whenever possible, explaining canned foods contain additional sugars and salt (Smith, 1983; Whitney & Cataldo, 1983; Whitney & Hamilton, 1984; Williams, 1985).

The Basic Five and Recommended Dietary Allowances (RDAs), for daily eating, provided an outline for classroom teaching and the learning of healthy nutritional habits (National Research Council, 1980). The five food groups were described using pictures and charts and is as follows:

* Milk and milk products, two servings

* Meat and meat alternatives, two servings

* Fruits and vegetables, four servings

* Bread and cereals, four servings

* Fats, oils, sugars and water (supplemental foods; no required amount).

Each week foods which constitute one food group from the Basic Five were displayed on a poster board. It was believed visual props would enhance learning, especially for some of the poorer readers.

The teacher asked each client to name each food displayed on the poster and why a particular food would be in this food group. A discussion of the role of various vitamins found in each food group was included (Smith, 1983). Clients were asked to name additional foods which could also be included in each of the food groups. Clients were taught to rate their own dietary quality by charting the number of servings they consumed daily for each food group.

All material which was previously taught was briefly reviewed at the beginning of each session. At the end of the five weeks, the emphasis shifted to food preparation, meal planning, and a review of previously learned information. There was some minimal discussion of caloric content of foods, but the emphasis of the teaching was conceptual, rather than quantative. Clients were provided with magazines and instructed to cut out pictures of foods which represented a balanced meal and to describe their choices to the teacher and to any other members which were present.

The teacher gave permission and encouraged clients to speak in a spontaneous manner for clarification of any material. Throughout the study clients were encouraged to generate and incorporate additional ways to reinforce the learning of the material being presented, such as personal stories on selecting/eating/preparing various foods and meals. It was found that this teaching model could be easily tailored to a client's individual ability level.

The complimentary relationship of diet, health, and physical exercise, was emphasized throughout the study. The teacher explained that the way the body uses foods and burns up calories is through physical activity. Clients were taught that exercise promotes well-being, and that doctors recommend exercising three times a week for twenty minutes.

To complete and complement the learning of nutritional information, nutritious snacks were offered to all clients at the last nutrition class. Snacks consisted of celery, carrot sticks, crackers, cheese, hard-boiled eggs, raisins and nuts. Clients were asked to identify which food group the particular food could be found, and why a particular food was considered to be a healthy choice. Each person received a certificate of achievement participating in the study.


A total of 12 clients completed this educational program which emphasized the learning of healthy and proper nutrition. The format for evaluating client gain and progress in this study was a pretest/posttest research design. The means and standard deviation of the pretest and posttest were calculated. A t-test for independent samples for correlational analysis was used to compare differences between pretest/posttest scores. The analysis of individual scores yielded a significant difference, t = 2.31; p. [is less than] .05, pre X = 16.583, SD = 6.388, post X = 13.583, SD = 7.716. This demonstrated fewer items were missed on the posttest when compared with number of items missed on the pretest. These results indicate the educational program had a positive impact on the participants developing nutritional knowledge.

After a six-week elapse, the teacher invited each client to evaluate the nutrition class. Each individual was asked what they liked and/or disliked about the class and if he or she would like to know more about nutrition. The structure was kept informal and on a conversational level to see if the client would take the initiative to discuss general healthy nutritional concepts. The comments made by the clients led the teacher to believe nutritional knowledge had been maintained, as all clients said they attempt to incorporate the five food groups into their daily eating pattern, and that they have spoken up at mealtimes if something was missing, or not prepared in a healthy way. All clients agreed they would be interested in continuing to learn more about foods and how the selection and preparation of certain foods may be healthier choices over the selection or preparation of other foods.

A three-month follow-up pencil and paper questionnaire was developed which asked the 12 clients (individually) to select a meal (either breakfast, lunch, dinner or snack) and report which foods would be appropriate and healthy choices, and to identify the food group that their choice could be found. Nine members (82%) chose a balanced meal. Clients were asked if their foods were healthy choices, and to substantiate their answers. All clients recognized sugared foods (e.g., donuts or danish pastries), were unhealthy choices when compared with other foods.

In addition to the questionnaire, the three-month follow-up gauge of the group's success was in the form of client self-report of foods eaten. The results of an open-ended question which asked "What did you eat for breakfast, lunch, dinner, and snacks on the previous day?" indicated an increased awareness by all clients of the various food groups, and of the balance with which foods should be selected for a healthy diet, and of the ways which foods should be prepared for optimal benefit of available nutrients. The researchers opted for informal feedback from the clients, rather than formal testing, for the three month follow-up. This methodology was believed to serve as a reinforcement that healthy nutrition should be a lifelong habit, and one which is voluntarily followed, even with the absence of nutrition education classes, and certainly not tied to participation in a study.

Limitations of the Study

One limitation to this study is the small sample size (N = 12) of clients who participated. In addition, client selection was based on availability of participants and recommendations made by the rehabilitation counselor who managed the caseload.

A future study may want to include a larger group of participants, plus a comparison of clients selected proportionally from caseloads throughout the workshop. A control and experiential group may also be a stronger way to identify similarities, differences, and gains in awareness.


This study attempted to educate workshop clients about the basics of healthy nutrition. It was found clients were typically unaware of healthy nutritional habits, but that this can be changed by teaching healthy nutritional concepts based on the Recommended Dietary Allowances (National Research Council, 1980). The material pulished by the National Dairy Council (1985), was found to be easily adapted to test an individual participant's knowledge level. Nutritional information was well received by all clients who participated in the study. The authors believe the information was not difficult to teach and believe it could be easily incorporated into any program where education and counseling are part of the program. The material can be presented one on one, or a group basis. The small group approach affords the advantage of providing opportunities for clients to share experiences and feedback with others who may have a similar background. Groups also include an element of peer pressure. This may be helpful to decrease smoking and address needed weight loss or gain. For example, when one client asked if he could smoke in the group, the others in the class spoke up agains this, reminding him smoking is not a healthy habit.

The clients who participated in the study and in the learning of healthy nutrition were noted by staff to exhibit a heightened interest in their appearance. This benefit alone supports the belief that the teaching of regular nutritional educational classes in sheltered workshops may be helpful to rehabilitation clients.

An added benefit to the teaching of healthy nutrition was that clients complained they typically are not asked what foods they prefer. Rather, they are expected to eat whatever foods are placed before them. The clients who participated in this study reported they now believe they are better able to self-direct teir choice of foods. Clients also noted they spend their money more wisely on wholesome snacks, such as fruits and that this type of snack typically costs less than high-calorie, high-sugar snacks.


Proper nutrition has been shown to enhance a person's well being, both psychologically and physically. Yet there has been little research conducted on the effects of teaching or training nutritional concepts to rehabilitation clients. Typically rehabilitation researchers and authors have been more focused on understanding the medical, psychological, and social conditions of a disabling condition. Therefore, this sequential training program which emphasized the teaching and learning of healthy eating habits by utilizing the Basic Five food groups may be considered a successful pilot study where the focus was on ability, rather than disability.

The material encouraged clients to become more self-directed by encouraging them to think about foods they select. They were encouraged to utilize decision-making skills, and consider the consequences for their choices. A projected benefit is that the teaching of proper nutrition may help contribute to clients taking greater responsibility for events they may control, thereby fostering independence, as well as health. Further studies could consist of taking clients to the grocery store and teaching the selection and preparation of healthy and proper foods in an experiential way so that the learning of a balanced diet could be reviewed and reinforced.

Rehabilitation counselors and others involved with rehabilitation should be encouraged to develop an increased awareness of nutrition so that this material could be included as part of the rehabilitation program at their setting. The benefits include universality of the topic for all individuals, a focus on a positive lifestyle, decision-making skills, and even includes education regarding finances, budgets, and limited resources.


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Clark, R.A. & Blackburn, G.L. (1983). The role of nutrition in disease prevention and health promotion. Comprehensive Therapy, 9(4), 12-22.

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Feingold, B. (1973). Introduction to clinical allergy. Springfield, IL: Charles C. Thomas.

Lindholm, B.W.; Touliatos, J. & Wenberg, M. (1984). Predicting changes in nutritional knowledge and dietary quality in ten to thirteen-year-olds following a nutritional educational program. Adolescence 19 (74), 367-375.

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Pearson, J.E. & Long, T.J. (1982). Counselor, nutrition, and mental health. Personnel and Guidance Journal, 60, 389-392.

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Sarber, R. E., Halasz, M.M., Messmer, M.C., Lutzker, J.R. (1983). Teaching menu planning and grocery shopping skills to a mentally retarded mother. Mental Retardation, 21 (3), 101-106.

Smith, L, (1983). Feed yourself right. New York: Dell.

Vass, M. (1983). Nutrition, environment and behavior: The missing link in counseling approaches. International Journal for Biosocial Research, 4(1), 19-24.

Warden, N., Duncan, M. & Sommar, E. (1982). Nutritional changes heighten children's achievement: A 5-year study. International Journal for Biosocial Research, 3 (2) 72-74.

Whitney, E.N. & Cataldo, C.B. (1983). Understanding normal and clinical nutrition. St. Paul, MN: West.

Whitney, E.N. & Hamilton, E.M. (1984). Understanding nutrition. St. Paul, NM: West.

Williams, S.R. (1985). Nutrition and diet therapy (5th ed.). St. Louis, MO: Mosby.
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Author:Schoonmaker, Donna M.
Publication:The Journal of Rehabilitation
Date:Jul 1, 1990
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