Research Original Research| Volume 117, ISSUE 9, P1384-1395, September 2017

Evaluation of Online and In-Person Nutrition Education Related to Salt Knowledge and Behaviors among Special Supplemental Nutrition Program for Women, Infants, and Children Participants

Published:February 09, 2017DOI:



      The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) differs from other federal nutrition programs in that nutrition education is a required component. WIC programs traditionally provide in-person education, but recently some WIC sites have started offering online education. Education focused on reducing salt intake is an important topic for WIC participants because a high-sodium diet has been associated with high blood pressure, and low-income populations are at increased risk.


      Our aim was to examine the impacts of traditional in-person and online nutrition education on changes in knowledge, self-efficacy, and behaviors related to reducing salt intake in low-income women enrolled in WIC.


      Although a comparison of groups was not the primary focus, a randomized trial examining the impact of online and in-person nutrition education on participant knowledge, self-efficacy, and behaviors related to salt intake was conducted.


      Five hundred fourteen WIC participants from three Los Angeles, CA, WIC clinics received either in-person (n=257) or online (n=257) education. Questionnaires assessing salt-related knowledge, self-efficacy, and behaviors were administered at baseline and 2 to 4 months and 9 months later from November 2014 through October 2015.


      Positive changes in knowledge and self-efficacy were retained 2 to 4 months and 9 months later for both groups (P<0.05). Both groups reported significant changes in behaviors related to using less salt in cooking (P<0.0001) and eating fewer foods with salt added at the table or during cooking (P<0.001) at 2 to 4 months and 9 months.


      Both online and in-person education resulted in improvements during a 9-month period in knowledge, self-efficacy, and reported behaviors associated with reducing salt intake in a low-income population. Offering an online education option for WIC participants could broaden the reach of nutrition education and lead to long-term positive dietary changes.


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      1. US Department of Agriculture. Women, Infants and Children (WIC) Revitalizing Quality Nutrition Services (RQNS). Published 2013. Accessed August 19, 2015.

      2. US Department of Agriculture. Women, Infants, and Children (WIC) frequently asked questions. 2014; Accessed October 20, 2014.

        • Bensley R.J.
        • Anderson J.V.
        • Brusk J.J.
        • Mercer N.
        • Rivas J.
        Impact of internet vs traditional Special Supplemental Nutrition Program for Women, Infants, and Children nutrition education on fruit and vegetable intake.
        J Am Diet Assoc. 2011; 111: 749-755
        • Bensley R.J.
        • Hovis A.
        • Horton K.D.
        • et al.
        Accessibility and preferred use of online web applications among WIC participants with Internet access.
        J Nutr Educ Behav. 2014; 46: S87-S92
        • Au L.E.
        • Whaley S.
        • Rosen N.J.
        • Meza M.
        • Ritchie L.D.
        Online and in-person nutrition education improves breakfast knowledge, attitudes, and behaviors: A randomized trial of participants in the Special Supplemental Nutrition Program for Women, Infants, and Children.
        J Acad Nutr Diet. 2016; 116: 490-500
        • Au L.E.
        • Whaley S.
        • Gurzo K.
        • Meza M.
        • Ritchie L.D.
        If you build it they will come: Satisfaction of WIC participants with online and traditional in-person nutrition education.
        J Nutr Educ Behav. 2016; 48: 336-342.e1
      3. Pew. Who’s online: Internet user demographics. Published 2014. Accessed October 15, 2014.

        • Weinberger M.H.
        • Fineberg N.S.
        • Fineberg S.E.
        • Weinberger M.
        Salt sensitivity, pulse pressure, and death in normal and hypertensive humans.
        Hypertension. 2001; 37: 429-432
        • Aburto N.J.
        • Ziolkovska A.
        • Hooper L.
        • Elliott P.
        • Cappuccio F.P.
        • Meerpohl J.J.
        Effect of lower sodium intake on health: Systematic review and meta-analyses.
        BMJ. 2013; 346: f1326
        • Graudal N.A.
        • Hubeck-Graudal T.
        • Jurgens G.
        Effects of low-sodium diet vs high-sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride (Cochrane Review).
        Am J Hypertens. 2012; 25: 1-15
        • He F.J.
        • Li J.
        • Macgregor G.A.
        Effect of longer term modest salt reduction on blood pressure: Cochrane Systematic Review and meta-analysis of randomised trials.
        BMJ. 2013; 346: f1325
      4. Institute of Medicine. Sodium intake in populations: Assessment of evidence. Published 2013. Accessed August 19, 2015.

        • Strazzullo P.
        • D'Elia L.
        • Kandala N.B.
        • Cappuccio F.P.
        Salt intake, stroke, and cardiovascular disease: Meta-analysis of prospective studies.
        BMJ. 2009; 339: b4567
        • Takachi R.
        • Inoue M.
        • Shimazu T.
        • et al.
        Consumption of sodium and salted foods in relation to cancer and cardiovascular disease: The Japan Public Health Center-based Prospective Study.
        Am J Clin Nutr. 2010; 91: 456-464
        • Tomonari T.
        • Fukuda M.
        • Miura T.
        • et al.
        Is salt intake an independent risk factor of stroke mortality? Demographic analysis by regions in Japan.
        J Am Soc Hypertens. 2011; 5: 456-462
        • Gardener H.
        • Rundek T.
        • Wright C.B.
        • Elkind M.S.
        • Sacco R.L.
        Dietary sodium and risk of stroke in the Northern Manhattan study.
        Stroke. 2012; 43: 1200-1205
        • Ritchie L.D.
        • Whaley S.E.
        • Spector P.
        • Gomez J.
        • Crawford P.B.
        Favorable impact of nutrition education on California WIC families.
        J Nutr Educ Behav. 2010; 42: S2-S10
        • Seth J.G.
        • Evans A.E.
        • Harris K.K.
        • et al.
        Preschooler feeding practices and beliefs: Differences among Spanish- and English-speaking WIC clients.
        Fam Commun Health. 2007; 30: 257-270
        • Seth J.G.
        • Isbell M.G.
        • Atwood R.D.
        • Ray T.C.
        Addressing language barriers in client-centered health promotion: Lessons learned and promising practices from Texas WIC.
        Health Promot Pract. 2015; 16: 320-328
      5. US Department of Agriculture, US Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Published 2010. Accessed December 19, 2014.

      6. Academy of Nutrition and Dietetics. The facts on sodium and high blood pressure. Published in 2015. Accessed March 11, 2015.

      7. American Heart Association. Sodium and salt. Published 2015. Accessed January 10, 2014.

        • Gilboy M.B.
        • Heinerichs S.
        • Pazzaglia G.
        Enhancing student engagement using the flipped classroom.
        J Nutr Educ Behav. 2015; 47: 109-114
        • Gerstein D.E.
        • Martin A.C.
        • Crocker N.
        • Reed H.
        • Elfant M.
        • Crawford P.
        Using learner-centered education to improve fruit and vegetable intake in California WIC participants.
        J Nutr Educ Behav. 2010; 42: 216-224
        • Bandura A.
        Guide for constructing self-efficacy scales.
        in: Pajares F. Urdan T. Self-efficacy Beliefs of Adolescents. Greenwich Information Age Publishing, Greenwich, CT2006: 307-337
        • Walker D.
        Investigation of a Dietary Behavior Questionnaire as a Predictor of Dietary Sodium Intake.
        Intercollegiate Center for Nursing Education, Washington State University, Pullman, WA1996
        • Arcand J.
        • Abdulaziz K.
        • Bennett C.
        • L’Abbé M.R.
        • Manuel D.G.
        Developing a web-based dietary sodium screening tool for personalized assessment and feedback.
        Appl Physiol Nutr Metab. 2014; 39: 413-414
      8. SAS [computer program]. Version 9.4. Cary, NC: SAS Institute Inc; 2013.

      9. The effects of nonpharmacologic interventions on blood pressure of persons with high normal levels. Results of the Trials of Hypertension Prevention, Phase I.
        JAMA. 1992; 267: 1213-1220
        • Whelton P.K.
        • Appel L.J.
        • Espeland M.A.
        • et al.
        Sodium reduction and weight loss in the treatment of hypertension in older persons: A randomized controlled trial of nonpharmacologic interventions in the elderly (TONE).
        JAMA. 1998; 279: 839-846
        • Anderson C.A.
        • Cobb L.K.
        • Miller E.R.
        • et al.
        Effects of a behavioral intervention that emphasizes spices and herbs on adherence to recommended sodium intake: Results of the SPICE randomized clinical trial.
        Am J Clin Nutr. 2015; 102: 671-679
        • Cook N.R.
        • Cutler J.A.
        • Obarzanek E.
        • et al.
        Long term effects of dietary sodium reduction on cardiovascular disease outcomes: Observational follow-up of the trials of hypertension prevention (TOHP).
        BMJ. 2007; 334: 885-888
        • Wantland J.D.
        • Portillo J.C.
        • Holzemer L.W.
        • Slaughter R.
        • McGhee M.E.
        The effectiveness of web-based vs non-web-based interventions: A meta-analysis of behavioral change outcomes.
        J Med Internet Res. 2004; 6: e40
        • Hebert J.R.
        • Ebbeling C.B.
        • Matthews C.E.
        • et al.
        Systematic errors in middle-aged women's estimates of energy intake: Comparing three self-report measures to total energy expenditure from doubly labeled water.
        Ann Epidemiol. 2002; 12: 577-586
        • Hebert J.R.
        • Ma Y.
        • Clemow L.
        • et al.
        Gender differences in social desirability and social approval bias in dietary self-report.
        Am J Epidemiol. 1997; 146: 1046-1055


      L. E. Au is an assistant researcher, Nutrition Policy Institute, Division of Agriculture and Natural Resources, University of California, Berkeley.


      K. Gurzo is a data analyst, Nutrition Policy Institute, Division of Agriculture and Natural Resources, University of California, Berkeley.


      L. D. Ritchie is director and cooperative extension specialist, Nutrition Policy Institute, Division of Agriculture and Natural Resources, University of California, Berkeley.


      S. E. Whaley is director of research and evaluation, Public Health Foundation Enterprises WIC, Irwindale, CA.


      M. Meza is executive assistant for special projects, Public Health Foundation Enterprises WIC, Irwindale, CA.


      N. J. Rosen is a senior associate, Informing Change, Berkeley, CA.