2009 Population Health Project: Food System Change Roadshow

This is a paper summarizing the work and research of the 2009 Stanford University Population Health Interns that worked on behalf of Collective Roots in the development of the Food System Change Roadshow.

May 27, 2009

Population Health Interns

Ian Corcoran-Schwartz, Deepa Galaiya, Nicolas Grundmann, David Kane (Collective Roots), Ashley Koegel, Long Nguyen, Mackenzie Wehner, Kipp Weiskopf, Gloria Yiu

Introduction and Background

Among the victims of America's obesity epidemic are school-aged children.  According to the Third National Health and Nutrition Examination Survey, over 15% of children aged 6-19 are overweight, and the prevalence of overweight Mexican-Americans and African Americans increased over 10% from 1988 to 1994.1  These groups comprise a large portion of a local target population of East Palo Alto, in which ~54% of the inhabitants are Hispanic, with 20% African American (census). 

A major contributor to the obesity problem is the lack of accessibility to healthy food options for children, especially in the school environment.  Many US schools provide cafeteria options that could at best be described as "junk food" with few fruit and vegetable offerings.2  It has been shown that an increase in consumption of fruits and vegetables improve weight related health parameters such as blood pressure and blood lipid profiles.3  Thus, reducing the overweight crisis among children should center around their fruit and vegetable intake.  In addition, habits of eating fruits and vegetables are formed in childhood, and preference for these foods is correlated with their availability.  Those with greater access to healthy foods will show a greater preference for them, presumably have healthier diets, and be less likely to become overweight.4-6  Children in the US currently do not eat enough healthy foods such as fruits and vegetables, however.  The majority of children do not meet the FDA's recommendation of five or more servings of fruits and vegetables per day, eating more accessible but less healthy options instead.7-9  This problem is likely even worse than the statistics show, as self-estimates of eating habits, portion size, and caloric intake are often incorrect.10  The correlation between poor eating habits and being overweight, as well as data showing vegetables and fruits improve health profiles, cannot be ignored.

The American Heart Association suggests both physical activity and dietary alterations be enacted in childhood to stem the increase in cardiovascular disease (CVD) in the US.11  Many programs have been enacted to improve the health of children in areas of activity and nutrition, with mixed results.  It has been shown that structured health related programs can have a significant impact on health, especially for children of lower income.12  In comparisons of parent-centered programs and child-centered programs, the two approaches have been shown to be equally efficacious in improving diet. Perhaps because of ease of intervention and perhaps in the hope to instill a lasting change in children's habits, child-centered programs operated in schools are more prevalent.13  Child-centered programs may be especially effective with families that have new Americans at home because the acculturation and dietary knowledge that the children gain can be taken home to families.14  Whole-school intervention approaches in schools have been well received and modestly successful in increasing student intake of fruits and vegetables.15-17  School cafeteria programs such as salad bar implementation have been shown to improve both exposure and consumption of vegetables, as well as lead to a reduction in both caloric and fat intake among the students.18  There is evidence to suggest that these programs are efficacious not only in improving diet, but also in improving health parameters such as BMI and blood pressure.19,20  It is especially important that these interventions occur during younger years, as dietary habits become less and less healthy as children move to higher grade levels.21  If implemented early, these programs may have long-term effects as well.  Repeated exposure to the taste of unfamiliar foods has been demonstrated to be a promising strategy for promoting children's like of previously rejected foods.22  The interventions do not seem to need to be extensive, as a period of 16 days of watching cartoons that feature characters who enjoy fruits and vegetables and receiving rewards for eating those foods has been shown to substantially increase children's consumption of fruits and vegetables.23  Not all research has shown a significant effect of intervention programs, however.  Several studies show that nutrition interventions have differential effects based on socioeconomic status and that in low socioeconomic groups, the impact was actually low to negligible.24,25  There is also evidence that the current programs lead to only short-term improvements, so it is obvious that more research and further development of interventions need to be continued.26 

We propose a means of increasing the intake of fruits and vegetables by children in order to help control obesity and improve the health outcomes of the US population.

We intend to implement an intervention program aimed at exposing children to fruits and vegetables, with the goal of improving their intake of these foods.  The program is a mobile ‘roadshow' that includes interactive activities centered on fruits and vegetables.  There is evidence showing the efficacy of such interventions, but there is still work to be done in this area of research, especially as it applies to individual communities like East Palo Alto.  Some schools have initiated a garden program, such as the East Palo Alto Charter School (associated with our partner, Collective Roots).  While programs such as these are believed to be able to improve the dietary habits of its participants, there is little published data to support this claim.27  As time goes on, we may see an increase in available evidence to convince other school districts of enacting similar programs with the same goals.  In addition, interventions must continually be re-evaluated, as food culture changes and new research on efficacy comes to light.  Our thought for the Food Systems Change Roadshow is that perhaps more hands-on activities are required as opposed to didactic, with a specific emphasis on nutrition.  A recent study shows that an intervention in both exercise and nutrition resulted in only an improvement in children's exercise, potentially owing to the fact that the children prefer the activity in which they can actively partake.28  It is our hope that our interactive and [hopefully] fun methods of exposing children to fruits and vegetables will be successful in forming long term habits of proper diet and good health.

Purpose and Goal:  

The overall goal of the "Food System Change Road Show" is to develop and implement engaging and informative interactive activities that promote healthy lifestyle and dietary changes in the context of school and community environments, and to decrease the prevalence of chronic illnesses associated with poor nutrition and childhood obesity with the overall goal of addressing health disparities in East Palo Alto and Belle Haven.

The final deliverable product to community partner Collective Roots is an original "Food System Change Road Show" operations manual that details road show instructions and subjective feedback regarding incorporated activities and their appropriateness in various settings.  

Community Partner Information:

According to the Collective Roots mission statement, the organization "aims to educate and engage youth and communities in food system change through sustainable programs that impact health, education, and the environment."

Collective Roots achieves its mission through the integration and implementation of four problem-focused program areas: garden-based learning, youth development, food systems change, and environmental action. They collaborate with other organizations in the area to provide their services free of charge to the people of East Palo Alto and rely on extensive community  partnerships to enable all aspects of their work, as well as countless volunteers.

One of these past collaborators includes the Stanford University School of Medicine's Population Health Initiative from 2007-2008. A group of first-year medical students donated their time to accomplish several goals: 1) the creation of a food system map that linked web visitors to online community forums and other online advocacy tools including petitions, community food system newsletters, food system action alerts, and e-letters to elected officials, and 2) an advocacy campaign to establish a community-based, Collective Roots-sponsored and certified Farmers' Market in East Palo Alto. More information can be found on the web (http://www.collectiveroots.org/whats_growing/collaborative_projects/stanford).

Materials and Methods

Grow-Your-Own-Food

Materials:

Ziploc Bags

Paper Towels

Seeds (tomato, corn, watermelon, lima bean, sunflower)

Water

This activity is ideal for a group of 6-8 children. First, the children should dampen a paper towel sheet and folded it in half. The next step is to allow the children to choose 3 seeds. The seeds are then placed in between the folds of the paper towel, about mid-way down, to allow the seed ample room to send roots down and sprout upward. The paper towel is then placed in the ziploc and the bag is left open. Send the children off with instructions to hang the bag vertically in a well lit window and water only when the paper towel becomes dry. The child should transplant the seeds when the sprout emerges from the top of the paper towel. Before the children begin the activity is the opportune time to emphasize the importance of healthy eating: achieving a diet with a high proportion of fruits, vegetables and nuts, the benefits of growing your own food free of pesticides, processing, and added preservatives, and the potential cost benefits of a garden. The activity duration time was about 15 minutes and the average cost per individual was $0.42.

Fishing for Fruits

This game can take on a variety of manifestations, allowing Road Show moderators to adapt the rules for a wide range of ages, although it is ideal for students up to the age of 8 or 9. Two students may play simultaneously, if desired. The primary goal of the game is to promote the idea of eating a wide selection and variety of fruits. The original version of this game is described here:

• First, nine contiguous boxes are drawn on the ground in a 3 x 3 matrix with blue tape. One could use sidewalk chalk or physical boxes. Inside each box, colorful cardboard or card stock cutouts of various fruits are placed. In our case, we had one box designated for pineapples, one for blueberries, two for bananas, one as a "choose-your-own-fruit," and so on.
• Then, about four feet away from the boxes, a line is drawn. Participants cannot cross this line.
• Participants then use a toy fishing rod, made from a dowel and yarn with a weight at one end, to "fish" for individual fruits. They get three tries. The goal is to choose three different fruits. If a participant fishes for the same fruit twice, that participant loses that turn. Alternatively, participants can throw three bean bags into the boxes to choose their fruit.
• As an addendum to this game, and to provide greater incentive, participants brought their paper cutouts of the three fruits to the Bicycle Blender station (see below), where they could make fruit smoothies using the real versions of the fruits they had won.
• Cost: 6 dowels, yarn, magnets, bean bags and colored card stock cost about $24 at a local craft store.

Variations to the game include:

• Adding a magnet to the end of the fishing pole and magnets to each of the cutouts, so that the "fishing" is a more real, mechanical task for older participants. In this case, the nine boxes need not be used, and all the cutouts can be mixed to add to the difficulty of selecting a variety of fruits
• Drawing the line closer to the boxes for younger participants.
• Use the same concept to generate a "tree" with fruits stuck onto it. Participants can then aim for fruits on the tree using bean bags rather than "fishing" for them.
• Older children may respond well to quiz questions that can help them "regain" lost turns.

Bicycle Blender
Collective Roots owns a Bicycle Blender, which has a stand and can be pedaled in-place to make fruit smoothies with the blender attached to the back wheel.  This aspect of the Roadshow can be implemented alone or in conjunction with Fishing for Fruits.  It appeals to children of all ages and can be operated by either participants or Roadshow volunteers.  Materials include ingredients for smoothies, a large spoon for blender troubleshooting, and small cups.  Ideal ingredients include fresh fruits (oranges, bananas), yogurt, canned fruits (pears, peaches, pineapple in water rather than syrup), and frozen fruits (blueberries, strawberries).  As much fresh fruit as possible should be used, but fruits that are not in season can still be used in canned form.  Actually, canned fruits tend to blend better than fresh, which makes them especially good for the sometimes low-powered Bicycle Blender.  A mix of fresh and canned fruits makes for the best smoothies, in combination with the essential frozen fruit and yogurt ingredients.  Cups should be small: just large enough to fit 4 oz smoothies, which is the appropriate portion size.  During the blending volunteers get to connect with participants about nutrition and portion size, as well as encourage physical activity such as bicycling.  Fliers detailing the hours of physical exercise required to expend the number of calories in the smoothies or giving information about seasonal fruit in the area are an especially good idea at this station, which is all about having fun with fruit and exercise.

Salad-Making Relay Race

The Extreme Green Team Challenge was designed to engage children through competition and exercise in order to promote healthy eating habits.  The challenge takes the form of a salad-making relay race.  The following produce items are purchased beforehand for use in the race: fresh green leaf lettuce, tomatoes, cucumbers, baby carrots, broccoli, green bell peppers, sweet red onions, canned black olives, canned kidney beans, and salad dressing (fat-free Ranch and fat-free Italian).  All vegetables are washed and coarsely chopped prior to use in the activity.  The relay race is set up in a field with tables on opposing sides, separated by a distance of 20 yards.  On one table, small paper bowls containing the vegetables (except for the lettuce) are placed in a line.  The opposing table contains a chopping station and a large bowl  for each team.  Each chopping station consists of a Ronco Chop-O-Matic Food Chopper and a large paper plate beneath it.  The large bowls contain the lettuce and are used for combining the ingredients of the salad.  Participants are divided into two teams of five to eight individuals.  Teams are asked to choose a team name based on a consensus of their favorite vegetable (e.g. "Team Carrots" or "Team Broccoli").  Teams line up in single-file next to the bowls of vegetables at the first table.  Participants are instructed to choose one bowl of vegetables each.  A member of the roadshow group is present at each chopper station to aid in the safe use of the device.  A third roadshow member is designated as the referee.  To begin the race, the referee gives a countdown, and upon yelling "go!" the first participant of each team runs with his or her bowl of vegetables to the opposite table.  Upon reaching the opposite side, the participants place their vegetables on the chopper stations and finely chop them, and then add the vegetables to the salad bowl.  After completing this task, each participant runs back to the starting side and tags the next member of his or her team, who then runs to the opposite side carrying the next bowl of vegetables.  The process repeats until all team members have run a leg in the relay and all bowls of vegetables have been chopped and added to the salad.  The winning team is the team that adds all of their vegetables to the salad first and runs back to the starting side.  After the race is complete, the salad is distributed to all participants in small disposable bowls, and participants are offered their choice of salad dressing.  The race can be run at a cost of approximately $1.00 per individual.

Child Survey

In order to better understand the desires and needs of the community target, we designed a brief survey that we administers to the children as they were participating in the various stations. Questions were asked orally, and responses recorded by the medical student volunteers. As we did not collect informed consent, we cannot use this data in any manuscript or publication. The purpose of the survey was therefore to internally tweak the Nutrition road show as we were developing the curriculum. A example survey is attached as appendix to this document. Questions broadly focused into two categories:
1) the current state of the children's nutrition, including recent meals and food choices
2) the student's response to the Nutrition Roadshow, and possible improvements/suggestions.
These questions were designed to give us the organizers a better understanding of out target community, and to gauge their responses to our activities and event.

Results and Discussion

Grow-Your-Own-Food

The "Grow-Your-Own-Food" activity was well received by our first group of children at the East Palo Alto YMCA. We were initially concerned about maintaining attention throughout the extent of the activity, but with a group of 6-8 children at the East Palo Alto YMCA, this was easily accomplished. However, at the health fair, the activity was much more difficult to organize because the children and their families stopped for shorter periods of time at the booths and were involved in many of the other health fair activities. Much of the children's excitement and attentiveness seemed to be dependent on allowing the children to choose which seeds they wanted to use. Few of them wanted the tomatoes and nearly all of them wanted watermelon. Therefore, identifying healthy foods that are also well-received by the children seems to be a crucial variable that must be addressed in order to alter eating habits. In the future, one aspect of the activity that should be followed out is whether the children are able to transplant and continue to grow plants once they are at home. The activity unquestionably served to increase motivation to initiate gardening and increase vegetable intake, but whether this motivation endures over the following weeks and will actually lead to healthier eating habits should be addressed in the future.

Fishing for Fruits

The Fishing for Fruits game was popular when used with younger children. Older children (fourth grade and up) were somewhat too advanced for the game and its message. The Bicycle Blender was also somewhat distracting in that participants wanted to simply ride the bicycle rather than going through the long process of fishing for fruits. To mitigate this, it is critical that clear, physical stations be set up. It must seem like a natural step-by-step process to move from the Fishing for Fruits to the Bicycle Blender. This may be difficult to ensure in a booth setting at a fair or carnival, but can be much easier to control in a controlled classroom/presentation setting.

Also, as with all these games, the goals of the game must be explicitly stated so that participants understand the value of eating a variety of fruits and vegetables. Encouraging participants to fish for fruits they had not tried before was somewhat effective (including mango, starfruit, or some other exotic varieties may be a good idea in this case). With older children, quiz questions intermittently incorporated into the game may help maintain interest and reinforce knowledge gained.

Bicycle Blender

The Bicycle Blender was the most popular activity, though some of the participants did not have the pedal-power to blend smoothies very well.  The volunteers did some of the blending, especially when more fresh or frozen fruits were used, as they can be especially hard to blend.  One particular pitfall encountered in the trial runs was oversized smoothies.  4 oz portions for the participants are small, and it was easy to overestimate the ingredients necessary and end up with a very large smoothie that had to be drunk by volunteers before the next smoothie could be blended.  To make the activity educational, fliers or specific questions asked by volunteers are crucial, though unfortunately much of this information is overshadowed by the excitement over the bicycle blender itself.  Overall, the bicycle blender is a crowd pleaser and equally effective in small groups as well as large fair or carnival settings.  

Salad-Making Relay Race

The Extreme Green Team Challenge, the salad-making relay race, proved to be a successful way of educating children about the benefits of healthy eating.  In both the YMCA and health fair settings, the children involved were excited to participate and provided positive feedback regarding the event.  Additionally, the salad was eagerly consumed by the participants at both events, even though the children at the YMCA reported they did not generally enjoy salad.  We also found that certain vegetables were more palatable than others--many participants informed us that carrots and broccoli were their favorite vegetables, thus they were added to the salad during the second implementation of the relay race.  Some of the children expressed negative opinions of other vegetables, but this seemed to be largely due to individual preference.  Other participants reported that they were exposed to certain vegetables and foods for the first time when they ate the salad created in the relay race.  For example, multiple children had never tried olives before this activity.  This result is a benefit of the relay race, since exposing children to a wider variety of vegetables may increase the likelihood that they will consume more vegetables in their daily lives.  The relay race also provided an opportunity to discuss the benefits of eating vegetables with the children and to encourage them to incorporate both fruits and vegetables into their everyday diets.

Achievement of Learning Objectives

We successfully developed and implemented a "Food System Change Road Show" aimed at informing and encouraging healthy diets in children. In our road show we developed and troubleshooted various activities including: seed gardening practices to encourage self-grown food, choosing fruits for healthy soft drink alternative smoothies, blending said fruits in Collective Roots provided bicycle blender and exercising in a salad assembly relay.  This event was executed in two different settings: YMCA after school program with a set group of students and at a Health Fair catering to a larger and more varied audience. Our final deliverable was successfully compiled in a manual format enabling longevity of the road show for future implementers and volunteers.

It remains unclear if we were able to decrease the prevalence of chronic illnesses associated with poor nutrition and childhood obesity or address health disparities in East Palo Alto and Belle Haven. Future follow up studies are necessary to clarify these larger and downstream goals. Additionally, a wider range of children may be necessary to address poor nutrition, childhood obesity, and local health disparities. The majority of the children who participated in road show activities did not report grossly poor nutrition habits or obesity. There may be a selection bias where children enrolled in after school programs or attending health fairs already have positive encouragement for healthy lifestyle choices.

Observations/Reflections

One of the pleasant surprises of this project was the enthusiasm on the part of the children with which we worked.  Instead of displaying [some of our predicted response of] rejection to the notion of "Vegetable Games," most of the kids seemed entertained, responsive, and happy to be involved.  The other notable issue, from a population health standpoint, was their already-vast knowledge of proper eating and vegetable consumption, even among those who could be described as non-compliant to the daily recommendation of 5 servings per day.  This suggests that in general, people know what is and what is not healthy practice, however they tend to need some prodding in the right direction to help maintain their health.  Our project was able to reinforce much of what the students already knew, but in a way that [we think] made them more apt to consider this information in their daily lives.

There was an internal debate amongst the group in which we struggled with the topics of implementation and efficiency - not just as health care professionals working in the community but as physician scientists interested in delivering a measurable, efficacious outcome.  Throughout the course of the project, there was total consensus that with the growing obesity problem, greater information dissemination is a requirement to attempt to stem the problem in childhood.  However, the urge to immediately involve small fractions of the community was opposed by those of us interested in determining whether or not the methods we were using would actually make a difference in not only the lives of those we directly influenced, but also in the average health status of the population.  This latter side's argument was essentially that without long term follow up and a larger sample size, it would be impossible to prove a significant improvement in population health with the incorporation of our project in the community, and therefore donors would be less apt to fund similar projects, instead choosing to fund legal public health efforts with a broader scope (i.e. anti-smoking litigation, or the banishment of trans-fats, etc.).  In short: "Why bother investing time and money in a protocol for small groups that is unproven in reaching its goals?"  After a spirited, yet respectful, discussion, the conclusion reached was that because in order to prove statistical significance in this setting, we would need a considerably larger sample size and more extensive implementation of our methods (ideally nationwide), which is not only out of the scope of our project, but also would be cost prohibitive.  At this stage in our medical careers it is more beneficial to make the attempt, basically, and work with small communities and ask for feedback, than it is to sit and wait for a larger study to surface with empirical evidence to support the pieces of our protocol.  Small projects beget larger projects, and with the funds available, getting a "foot in the door" with a particular community (in our case, youth in East Palo Alto, as well as the community partner Collective Roots) is important to begin the process of interaction, information gathering, and trust building, even if measurable outcomes are impossible until a later time (which may be possible if the partnership cultivated leads to larger and larger projects with more sponsors).  This is analogous to the physician-patient relationship.

Finally, we had the opportunity to field test our roadshow in two different settings: a small venue at a local YMCA with an allotted time to be with the kids, and a larger, fair setting in which we set up a booth and people could stop by.  Both had their pros and cons.  With the fair, we were able to reach a larger number of people, and thus, in theory, spread information about health maintenance to a larger number of community members.  The problem was that with each wave of people, it was basically a shotgun approach to presenting them with our games and suggestions before they moved on to the next attraction (though with the smaller kids, Gloria's rendition of a dancing carrot held their attention a little longer).  It was difficult to recruit enough kids at one time to participate in the relay race, and with children this young, with other sites to see at the fair, having them return at a scheduled time (for salad!) was unfeasible.

On the other hand, there's nothing wrong with starting small.  At the YMCA, though we only had six participants, we were able to move through each of our planned events in sequence, field questions, and in general be more interactive with each youngster.  In our opinion, though we reached fewer people, we were better able to respond to the needs (both trust/rapport and education) of each individual.  There is a greater likelihood that our message will be propagated with this group, if only because of the repetition and the opportunity for them to have questions answered personally.  It is akin to the population health trial and error we were taught in the first quarter: Give a man a goat, and the goat may die; However, teach a man and his community to herd goats, and the population incidence of diabetes and obesity will decline.  This is obviously a simplification, but the idea is that to have a message stick with members of the community, there needs to be two way communication and education, rather than simply forcing information down the members' throats.

Attribution: LN provided the Project Purpose and Goals section and the extended information regarding the community partner, Collective Roots. AK provided the methods and materials section and the results and discussion section corresponding to the "Grow-Your-Own-Foods" activity. DG made the materials, coordinated the game and wrote the Materials and Methods and Results and Discussion sections on the "Fishing for Fruits" activity.  MW provided the methods and materials section and the results and discussion section of  the "Bicycle Blender" activity. GY coordinated game for "Fishing for Fruits" and wrote Achievements and Learning Objectives.  KW coordinated the game and wrote the Materials and Methods and Results and Discussion sections on the "Salad-Making Relay Race" activity.  ICS operated the Salad Relay Race with KW, and wrote the Observations/Reflections.

References