COMMUNITY OUTREACH PROPOSAL!

FIT PROJECT

The FIT Project

Creating family connections through planning, preparing, cooking, and consuming nutritious foods
Proposal prepared by Madeline Kinzly, OHSU Dietetic Intern

Goal
Facilitate an overall health and lifestyle transformation of the eight FIT Project families through modeling and reinforcement of positive nutritional decision-making.

Objectives
1. Families will be able to create grocery lists and budgets in order to be more e!cient, condent, healthy shoppers. 2. Families will be able to compare and evaluate nutrition facts labels and determine the healthiest options at the best price by scoring a 80% or above on the Nutrition Facts Quiz. 3. Families will be able to independently make shopping lists, buy ingredients, and follow recipes from the cookbook in the future as evidenced by an improved score on the follow-up survey.

Background
The increased prevalence of obesity and risk factors for chronic disease has been rising in children, particularly those who are part of an ethnic minority. Research shows that parental obesity is a strong indicator for higher level of o"spring obesity4. Increased consumption of food away from home and a decreased number of family meals is directly correlated to an elevated number of calories from processed sugar, fat, and saturated fat. Family meals are an important tool in preventing childhood obesity and and increasing the consumption of nutritious foods; it also aids in increasing a sense of belonging and inclusion5. Most parents or caregivers feel overwhelmed by the number of options at the grocery store and have trouble distinguishing healthy options from unhealthy options and will opt for foods that are quick, inexpensive, calorically dense, and highly processed.
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Literature Review
A Prospective Multifactorial Intervention on Subpopulations of Predominately Hispanic Children at High Risk for Obesity1

Alexander A, Grant W, Pedrino K, Lyons PE. Obesity: 2013

The study focused primarily on children of Mexican-American decent, and of the 561 children studied, 17% were considered overweight and 27% were considered obese. The research was designed as a nutrition intervention for rst and second grade students to determine the e"ectiveness of incorporating 150 minutes of extra physical education classes, weekly cooking classes, a structured nutrition curriculum, and parental counseling. At the end of the 6 month intervention period there were no statistical BMI di"erences that occurred between intervention and control group, thus it was determined that nutrition education and exercise can prevent but not treat obesity. Consequently those with the highest BMI were least impacted by the intervention. This study takes place in the school environment, where students are most vulnerable to ridicule and bullying. Additionally, in this study the students food consumption is only monitored for one meal a day, meaning most caloric intake is not happening during the hours children are in school. By targeting families and family meals, a greater impact can be made on the healthy food habits to create a sustainable environment for nutrition and positive reinforcement. Family intervention in conjunction with nutrition and physical education information should improve the outcomes for elementary aged children. Is Frequency of Shared Family Meals Related to the Nutritional Health of Children and Adolescents?6

Hammons AJ, Fiese BH. Journal of the American Academy of Pediatrics: 2011

In this meta-analysis of 182,8236 children from 17 studies were used to examine shared family mealtimes in relation to nutritional health. The three major focuses of this study in relation to public health are: obesity, unhealthy eating, and disordered eating. This study examined the e"ects of sharing 3 or more family meals per week verses 1 or none. When families meal frequency was related to weight status, the ndings show that children and adolescents were 12% less likely to be overweight in families that had at least 3 shared family meals per week than those who ate fewer than 3 shared family meals per week. Children and adolescents in families that share at least 3 family meals per week have a 20% reduction in the odds of eating unhealthy foods.

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Unhealthy foods included soda, fast food, fried foods, and sweets/ candy. Unhealthy eating also included the absence of healthy foods such as skipping breakfast and not eating at least 2 fruits or vegetables a day. Similarly children and adolescents who ate at least 3 family meals per week had an increased odds of 24% of eating healthy foods and maintaing healthy dietary habits than those who shared few or no family meals together. Food Purchasing Selection Among Low-Income, Spanish-Speaking Latinos3

Corts DE, Millin-Ferro A, Schneider K, Vega RR, Caballero AE. American Journal of Preventive Medicine: 2013
There is an apparent relationship between poverty and obesity. Low- income individuals tend to buy low-cost food that is more calorie-dense and ling because energy-dense foods are more a"ordable. The study provided three to ve home-based nutrition education sessions and a supermarket tour over a 6-month period to 20 Spanish-speaking, low-income Latino families. Families decreased the total number of calories and calories per dollar purchased between baseline and post-education. The total calories of food purchased decreased from a median of 16,356 at baseline to 15,093 at post-education however; the total calories from beverages purchased did not decrease. Median grams of carbohydrates per dollar purchased decreased from 66 grams to 45 grams post education. The percentage of calories from protein increased from 14% to 18% post-education, and total calories from processed food decreased from 11,000 calories to 7,845 calories post-education. These are statistically signicant and re-enforce the nding that nutrition education in the form of grocery store tours and shopping practices generate positive results. Trends in the Association of Parental History of Obesity over 60 Years4

Fox CS, Pencia MJ, Heard-Costa NL, Shrader P, Jaquish C, ODonnell CJ. Obesity: 2013
Using three generations of participants from the Framingham Heart Study, this research shows that parental history of obesity is a strong risk factor for higher levels of o"spring body mass index. Specically the association of parental obesity has become stronger in more contemporary time period, but the genetic risk of becoming obese has not changed. Parental history of obesity is an important determinant of o"spring BMI due to both shared environment among family members, as well as shared genetic risk.

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To show how the prevalence of obesity has increased over the generations, the study found that in the o"spring of the second generation, 15.4% had one a"ected (obese) parent, whereas in the third generation, 26.9% had one a"ected parent. The mean BMI increased with the number of a"ected parents. In terms of genetic risk, this study documents that the genotype for known BMI risk factors in the Framingham Heart Study participants has remained stable over the last 60 years and there was no change in the magnitude of the relation between a BMI genetic risk score and BMI. Ultimately interventions that target the family environment and not just individuals may be a more e"ective way to prevent obesity. Using the Family to Combat Childhood and Adult Obesity5

Gruber KJ, Haldeman LA. Preventing Chronic Disease: 2009

Family is a major mechanism of inuence in a"ecting change both in other family members and in head of household. This study is a literature review to provide evidence that supports the value of family inuences on children's diet, and exercise behaviors. Intake patterns among children and older adolescents when eating dinner with their parents resulted in consumption of more fruits and vegetables, less fried foods and soda, and less saturated and trans fat; lower glycemic loads; and more ber and more micronutrients from food5. This study shows that family members tend to share characteristics related to eating habits, exercise routines, food and activity preferences, blood pressure levels, body weight, body composition and adiposity, and physical activity. It is important to note that food habits are deeply rooted in a familys culture, which represents both their ethnic and community identity. Families must contend with outside inuences that a"ect the availability of preferred foods and as families become more acculturated, traditional foods are consumed less often. Hispanic families are particularly strongly family-centric, making the inuence of family both a facilitator and a barrier for participation in physical activity, and healthy eating decisions. To address this, family-based interventions must be developed within the cultural context of the target audience to have the most e"ective dietary and physical activity behavior change.

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Signicance
The FIT Project Mission is to teach the entire family healthy lifestyle, food and tness choices, which are adapted to a variety of cultures, neighborhoods and socioeconomic strata.8 A team of dietitians, physical therapists, social workers, physicians, and other coaches work collaboratively to give families tailored nutrition education and tness plans based on their health needs and nutritional goals. #Purchasing, menu planning, and cooking are vitally important skills to ensure the health and success of the FIT families. # Positive eating behavior changes last longer if interventions are aimed at families rather than individuals attitudes and habits.5 Including a grocery store tour into the nutrition education portion of the FIT Project will aid the success of the families in a variety of ways. It will challenge the most common argument that families buy high fat, high sugar, calorically-dense foods because they are less expensive than non-processed, nutrient-dense, whole foods. By providing the primary shopper with a working knowledge of how to generate a grocery list on a budget they will be more adequately prepared to be smart, condent shoppers. Additionally shoppers will learn how to e"ectively decipher nutrition facts labels, giving the shopper a better understanding of which ingredients in foods should be consumed in moderation, those which are important for maintaining and boosting health through all stages of life. Providing the families with a cookbook tailored specically to the FIT Project will alleviate some of the pressures for determining whether they are providing healthy meals for their families. By entering the homes of the families to teach a cooking lesson it will improve the self-e!cacy of the participants by allowing them to see how cooking can be a fun and exciting way to involve the whole family in meal preparation. Finally an emphasis will be placed on having a family meal time and the social, emotional and nutritional impact it has on developing children.

Target Audience
All eight families enrolled in the FIT Project will be included in implementation. Of the eight families, six speak Spanish as their primary language and are Hispanic. The remaining two families are white and english speaking. The program is open to anyone enrolled at James John Elementary school and opts to

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join the program. There is no specic criteria for the families to join although they must express readiness and enthusiasm for change. Families must attend a mandatory entrance meeting and must have a mandatory physical examination to take part in the project. They are committing to six months in the program and are eligible to continue for consecutive years if they choose. Not all members of the family are required to participate although it is strongly encouraged.

Implementation Details
Dates of Implementation October 1-13, 2013 October 15, 2013 October 20- November 10, 2013 November 14, 2013 December 9, 2013 December 15- 17, 2013 December 17-20, 2013 Detail of Activity Gather signicant research articles to formulate meaningful proposal Meet with FIT Project directors to discuss possible project ideas and areas of need within the program Prepare community outreach proposal Submit outreach proposal Administer Entrance Evaluation Assess current nutrition knowledge and habits of the FIT familiesIdentify gaps and areas for improvement using entrance interviews Create lesson plan for grocery store tour Formulate budget sheet for families to use while shopping January 6, 2014 January 18, 2014 Generate and nalize cookbook for copying/ printing Set up times for families to participate in grocery store tours Set up times for families to participate in home cooking demonstration January 24-26, 2014 February 1-2, 2014 Conduct grocery store tours/ purchase food necessary to make recipe from cookbook Kitchen tour and food safety overview Conduct recipe preparation/ cooking class to families March 1, 2014 Administer post-implementation survey

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Figure 1: Project ow chart

Activities
This project is designed to provide an understanding for the e"ective ow of foods in and out of the kitchen, including how this process can be made safer, simpler, and more e!cient. (See Figure 1) FIT Program Components: Entrance Survey will be used to determine baseline nutrition knowledge and purchasing needs Design cookbook that includes healthy and nutritious options for families and additional information tailored to the FIT population (see appendix A for example) With primary meal planner collaboratively develop family budget using template Develop lesson plan for grocery store tour that includes: Eat this, Not that! Grocery store scavenger hunt Healthier options for staple items Develop engaging kitchen tour lessons that include healthy preparation methods Help families understand the importance of family meal time

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Facilities and Personnel

Grocery Stores The following are two possible sites for grocery store tours, they are ideal locations because they are close to James John Elementary school and will likely be the stores the families regularly shop. Safeway 8330 North Ivanhoe St. Portland, OR 97203 (503) 205-1600 Grocery Outlet 7741 North Lombard St. Portland, OR 97203 (503) 688-5565 FIT Team Project President: Marni Renison Project Treasurer: Robyn McGillis FIT Dietitian: Dominique Lopez- Stickney FIT Translator: Sandra Riviera This project is being supervised, overseen, and encouraged by Marni and Robyn. Robyn will oversee the progress and implementation of the project and Marni will be involved with budget and coordination of families. Dominique will be providing support for grocery store tours- planning, key points, facilitation. Sandra will be assisting in translation for handouts, recipes, evaluations, tours, and cooking demonstrations.

Budget
Food Costs $100 is the preliminary budget for the cost of food to be used in cooking class. Ideally foods will be purchased at the time of the grocery store tour to use for the home meal preparation. The grocery store tour and cooking class have been planned a week apart so food and concepts remain fresh. Cookbook Cookbook will contain between 15-20 di"erent recipes that will include nutrition facts and other important health information. Budget for the cookbook will depend on a variety of di"erent factorsnumber of cookbooks, binding, black and white or color, paper quality, number of pages etc. A preliminary budget of $10 per booklet has been set. Total Cost of Implementation: Approximately $200

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Theories
Health Belief Model7 Change is determined by the individuals belief that he or she is susceptible to an illness or disease, that it would be serious to contract the illness or leave it untreated, that changing eating habits and practices will be benecial in reducing the disease risk, and that barriers to taking action can be overcome. By participating in the FIT Program families have self-identied and want to make a change towards health and wellness. They understand the health implications and that they are currently overweight or obese, at risk of becoming overweight or obese and/ or at elevated risk for developing a chronic condition. Most importantly the parents understand that their behaviors and health outcomes will directly impact the outcomes of their children. All participants must be willing and committed to making changes and overcoming barriers. Social Cognitive Theory7 People learn through observing others behavior, attitudes, and outcomes of these behaviors. The theory focuses on attention, retention, reproduction, and motivation to inuence their own personal behaviors. The outcome expectation of this project is to increase the number of family meals made at home and increase child participation in the food preparation process. Primarily the project will focus on increasing childrens self-e!cacy by providing parents or caretakers with tools to create environments for healthier lifestyles. Children are products of their environments and behaviors expressed by parents are likely mirrored by a child. Parents are encouraged to be positive role models and will be the most inuencing factor in reducing their childs risk of obesity and other chronic diseases.

Evaluation Criteria
Entrance Evaluation (see Appendix B) The entrance evaluation will be used to assess the current knowledge and practices of the families. Based on the information collected lesson plans will be formatted to address key challenges the families have identied within their planning, shopping, and cooking cycle. This also provides an opportunity for participants to identify their favorite meal item. I will use this information to generate a healthier option to put into the cookbook.
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Nutrition Facts Label Quiz (see Appendix C) Upon completion of the grocery store tour all members of families are encouraged to take the Nutrition Label Quiz, the primary family shopper will have a their quiz graded. In order to meet the objective they must answer 16 of the 20 questions correctly (80%). Follow-Up Survey The follow- up survey will be formatted the same as the entrance evaluation and will address the same questions. In order for the above objective to be met participants must have an improved score on 50% of the questions. Some additional questions will be added to address self-condence and e"ectiveness of the grocery tour, cookbook, and cooking demonstration.

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References
1. Alexander A, Grant W, Pedrino K, Lyons PE. A Prospective Multifactorial Internvention on Subpopulations of Predominately Hispanic Children at High Risk for Obesity. Obesity 2013;00:1-5. 2. Centers for Disease Control and Prevention. Childhood Obesity Facts. Version current July 2013. Internet: http://www.cdc.gov/healthyyouth/obesity/facts.htm (accessed 11/7 2013). 3. Corts DE, Milln-Ferro A, Schneider K, Vega RR, Caballero AE. Food Purchasing Selection Among Low-Income, Spanish-Speaking Latinos. Am J Prev Med 2013;44:S267-S273. 4. Fox CS, Pencina MJ, Heard-Costa NL, Shrader P, Jaquish C, O'Donnell CJ. Trends in the Association of Parental History of Obesity over 60 Years. Obesity 2013;doi: 10.1002/oby.20564:Epub ahead of print. 5. Gruber KJ Haldeman LA. Using the Family to Combat Childhood and Adult Obesity. Prev Chronic Dis 2009;6(3):A106. http://www.cdc.gov/pcd/issues/2009/jul/080191.htm. Accessed Oct 20, 2013. 6. Hammons AJ, Fiese BH. Is Frequency of Shared Meals Related to the Nutritional Health of Children and Adolescents? Pediatrics 2011;127(6):e5165-e1574 7. Holli BB, Maillet JO, Beto JA, Calabrese RJ. Principles and Theorries of Learning. In: Troy DB, Hauber MJ, Connolly E., ed. Communication and Education Skills for Dietetics Professionals. Baltimore, MD: Lippincott Williams & Wilkins, 2009:214-236. 8. Renison M MR. The FIT Project. Version current Sept 2013. Internet: http://thetproject.org (accessed 10/22 2013).

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Appendix A
Cookbook

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Appendix B
Entrance Evaluation
1. How often do you or a member of your family go to the grocery store? Two or more times per week Once a week Once or twice a month Less than once a month 2. Before going grocery shopping how often do you make a list? Every time Most of the time Rarely Never 3. Do you feel buying fruits and vegetables are more expensive than buying other types of foods? Yes No Unsure 4. How often do you throw fresh fruits and vegetables away because they spoil before you or your family are able to eat them? Two or more times per week Once a week A few times a month Once a month or less If yes, how often does this occur? Two or more times per weeks Once a week A few times a month Once a month or less 5. How often do you look at the nutrition facts labels before putting the item in your cart? I look at every item I look at about half my items I only look at my items if Im interested in a specic ingredient I never look at the labels

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6. When you look at food labels, what do you you look for? (circle all that apply) Number of calories Sugar content Ingredients Fat content Other Serving size Vitamin and mineral content None

7. What is the deciding factor for what you put in your cart?

It is healthy

I like it My kids will eat it Other (please specify) ___________

It looks good It is low-priced

8. How often do you have family meal time? Every night A few times a week A few times a month Once a month, or less 9. How often do you make extra food at dinner time to store for lunch to dinner the following day? Every night A few times a week A few times a month Once a month, or less 10. How often do you eat dinner away from home? Every night A few times a week A few times a month Once a month, or less 11. Please identify some obstacles you have when planning and preparing meals for your family. (circle all that apply) I dont like to cook I dont feel like I have time to cook I dont know how to cook I dont have the proper tools or equipment to cook I dont know how to prepare an e"ective shopping list for the grocery store My family will not eat what I cook I get overwhelmed in the grocery store by all of the options Other (please specify): ___________

Please tell me what is your favorite meal to prepare for you family?

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Appendix C
Nutrition Labeling Quiz
1. How many calories are in one serving of whole milk?

a. 70 b. 125 c. 150 d. 240

2. Is whole milk a good source of vitamin D?

a. Yes b. No

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3. Skim milk a high- cholesterol food.

a. Yes b. No

4. What percent of your recommended daily value of dietary ber will you get in one serving of pizza?

a. 50% b. 42% c. 24% d. 17%

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5. What percent of your recommended daily value of Saturated Fat will you get in one serving of pizza?

a. 10% b. 27% c. 42% d. 50%

6. Pizza is a low- sodium food.

a. Yes b. No

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7. How many strawberries are in one servings?

a. 2 b. 8 c. 10 d. 25

8. What percent of your recommended daily value of Vitamin C will you get in one serving of strawberries?

a. 2% b. 20% c. 50% d. 160%

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9. Strawberries are a fat-free food.

a. Yes b. No

10. Which ingredient is there the most of in this spaghetti sauce?

a. Imported Italian Tomatoes b. Citric Acid c. Tomato Puree d. Fresh Onions

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