Around the Table: Promoting Healthy Eating through Culture and Food

Module 1 Emerging Knowledge

Overview

Module 1 summarizes the state of nutrition among children and youth in the United States. It discusses:

- The increase in overweight and obesity - Racial Disparities in diet and nutrition - Dietary Guidelines for Americans- The principles of a healthy diet- Serving sizes- Nutrition fact labels- Healthy eating initiatives- Nutrition counseling- Nutrition needs assessment- Nutrition services

Module 1 also provides:- Answers to questions related to nutrition and culture - Information on common nutrition concerns for children and youth from all

cultures during each developmental period - Information on how cultures contribute to dietary concerns - Guidance on how to address nutrition concerns in a culturally appropriate

manner.- Culturally sensitive interview questions related to eating behaviors, food

choices, weight and body image, and perceptions of physical activity.- Links to food resources

What the tables tell us

Since 1980, obesity has more than doubled among children ages 2 to 5 and nearly tripled among children 6 through 12. At the same time, the rate of obesity among adolescents ages 12 to 19 has increased from 5 to more than 18 percent.

National Center or Health Statistics, Centers for Disease Control and Prevention (CDC), National Health Examination Surveys II (ages 6-11), III (ages 12-17), and National Health and Nutrition Examination Surveys (NHANES) I-III and NHANES 1999-2000, 2001-2001, 2003-2004, 2005-2006, and 2007-2008.

Uneven Proportions

These numbers tell only part of the story, however, since the prevalence of obesity has disproportionately affected certain racial and ethnic populations. In 2007-2008, the prevalence was particularly high among 2- to 19-year old African-American females (22.7%) and among 2- to 19-year-old Hispanic males, including Mexican-American males (24.4%).

Overall, approximately 32 percent of children and adolescents ages 2 -19 are overweight or obese.

Ogden CL, Carroll MD. Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in US children and adolescents. 2007-2008. JAMA. 2010-303 (3):242-249.)

National Center for Health Statistics, Centers for Disease Control and Prevention (CDC), National Health and Nutrition Examination Survey (NHANES) III 1988-1994, NHANES 2007-2008.

National Center for Health Statistics, Centers for Disease Control and Prevention (CDC), National Health and Nutrition Examination Survey (NHANES) III 1988-1994 and NHANES 2007-2008.

Dietary Guidelines for Americans 2010. U.S. Department of Agriculture, U.S. Department of Health and Human Services. www.dietaryguidelines.gov

Overweight and Obesity: What’s the Difference?

A person’s body weight status -- whether underweight, healthy weight, overweight, or obese – is often estimated using the Body mass index (BMI). BMI is a measure of weight (in kilograms) relative to height (in meters).

The term overweight and obese describe ranges of weight that are greater than what is considered healthy for a given height, while underweight describes a weight that is lower than what is healthy for a given height.

The BMI of growing children and adolescents is typically plotted on growth charts for age and gender

Category Children and Adolescents (BMI for Age Percentile Range)Underweight Less than the 5th percentileHealthy weight 5th percentile to less than the 85th percentileOverweight 8th percentile to less than the 95th percentileObesity Equal to or greater than the 95th percentile

Diet-related Disease Across the Lifespan: An Unhealthy Course

The high prevalence of overweight and obesity is of concern because these can lead to an increased risk of health problems such as Type 2 diabetes, heart disease, and certain types of cancer. And these health risks are not limited to adults.

Weight-associated diseases and conditions that were once diagnosed primarily in adults are now observed in children and adolescents with excess body fat. For example, cardiovascular disease risk factors, such as high blood cholesterol and hypertension, and Type 2 diabetes are now increasing in children and adolescents.

The adverse effects tend to persist through the lifespan, as children and adolescents who are overweight or obese are at substantially increased risk of being overweight or obese as adults and are more likely to develop weight-related chronic diseases later in life.

_________________________________________________________________________________An obese teenager has over a 70% greater risk of becoming an obese adult. -- The Surgeon General’s Vision for a Healthy and Fit Nation 2010, U.S. Department of Health and Human Services _________________________________________________________________________________

Adequate nutrition and regular participation in physical activity are important factors in achieving and maintaining optimal bone mass, since 85-90 percent of adult bone mass is acquired by the age of 18 in girls and by the age of 20 in boys.

___________________________________________________________________________________One out of every two women and one in four men ages 50 years and older will have an osteoporosis-related fracture in their lifetime. – Dietary Guidelines for Americans 2010 _________________________________________________________________________________

Primary prevention of obesity, especially in childhood, is an important strategy for combating and reversing the obesity epidemic.

Turning the Tables

In their efforts to reduce the number of children and adolescents who are affected by overweight and obesity, maternal and child health professionals have an array of expert guidelines, teaching opportunities, and culturally-sensitive tools from which to choose, including

Healthy-eating initiatives aimed at reducing obesity among high-risk populations

Updated guidelines released by the U.S. Department of Agriculture Advances in research and information technology

Dietary Guidelines for AmericansThe 7th edition of the Dietary Guidelines for Americans (U.S. Department of Agriculture, U.S. Department of Health and Human Services. www.dietaryguidelines.gov) focuses on consuming more healthy foods and balancing calories with physical activity.

The 2010 Dietary Guidelines for Americans include 23 key recommendations for the general population and six additional key recommendations for specific population groups, including women who are pregnant. The recommendations are intended as an integrated set of advice to achieve an overall healthy eating pattern.

The Dietary Guidelines for Americans, 2010 recommends that Americans:

Eat more Consumer less Fruits SodiumVegetables Saturated and trans fatsWhole grains Refined grainsSeafood Added sugars

(Guidelines press release at http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PressRelease.pdf).

Key Recommendations

Balancing Calories to Manage WeightPrevent and/or reduce overweight and obesity through improved eating and physical activity.

Control total calorie intake to manage body weight. For people who are overweight or obese, this will mean consuming fewer calories from foods and beverages.

Increase physical activity and reduce time spent in sedentary behaviors.

Maintain appropriate calorie balance during each stage of life—childhood, adolescence, adulthood, pregnancy and breastfeeding, and older age.

Foods and Food Components to ReduceReduce daily sodium intake to less than 2,300 milligrams (mg) and reduce intake to 1,500 mg if you are African American; 51 years of age or older; or have diabetes, hypertension, or chronic kidney disease.

Consume less than 10 percent of calories from saturated fatty acids by replacing them with mono-unsaturated and polyunsaturated fatty acids.

Consume less than 300 mg per day of dietary cholesterol.

Keep trans fatty acid consumption as low as possible by limiting foods that contain synthetic sources of trans fats such as partially hydrogenated oils and by limiting other solid fats.

Reduce the intake of calories from solids fats and added sugars.

Limit the consumption of foods that contain refined grains, especially refined grain foods that contain solid fats, added sugars, and sodium.

If alcohol is consumed, it should be consumed in moderation—up to one drink per day for women and two drinks per day for men—and only by adults of legal drinking age.

Foods and Nutrients to Increase

Increase vegetable and fruit intake.

Eat a variety of vegetables, especial dark-green and red and orange vegetables and beans and peas.

Consume at least half of all grains as whole grains. Increase whole grain intake by replacing fine grains with whole grains.

Increase intake of fat-free or low-fat milk and milk products such as yogurt, cheese, or fortified soy beverages.

Dietary Guidelines for Americans 2010. U.S. Department of Agriculture, U.S. Department of Health and Human Services. www.dietaryguidelines.gov

Key Recommendations

Balancing Calories to Manage WeightPrevent and/or reduce overweight and obesity through improved eating and physical activity.

Control total calorie intake to manage body weight. For people who are overweight or obese, this will mean consuming fewer calories from foods and beverages.

Increase physical activity and reduce time spent in sedentary behaviors.

Maintain appropriate calorie balance during each stage of life—childhood, adolescence, adulthood, pregnancy and breastfeeding, and older age.

Foods and Food Components to ReduceReduce daily sodium intake to less than 2,300 milligrams (mg) and reduce intake to 1,500 mg if you are African American; 51 years of age or older; or have diabetes, hypertension, or chronic kidney disease.

Consume less than 10 percent of calories from saturated fatty acids by replacing them with mono-unsaturated and polyunsaturated fatty acids.

Consume less than 300 mg per day of dietary cholesterol.

Keep trans fatty acid consumption as low as possible by limiting foods that contain synthetic sources of trans fats such as partially hydrogenated oils and by limiting other solid fats.

Reduce the intake of calories from solids fats and added sugars.

Limit the consumption of foods that contain refined grains, especially refined grain foods that contain solid fats, added sugars, and sodium.

If alcohol is consumed, it should be consumed in moderation—up to one drink per day for women and two drinks per day for men—and only by adults of legal drinking age.

Foods and Nutrients to Increase

Increase vegetable and fruit intake.

Eat a variety of vegetables, especial dark-green and red and orange vegetables and beans and peas.

Consume at least half of all grains as whole grains. Increase whole grain intake by replacing fine grains with whole grains.

Increase intake of fat-free or low-fat milk and milk products such as yogurt, cheese, or fortified soy beverages.

Dietary Guidelines for Americans 2010. U.S. Department of Agriculture, U.S. Department of Health and Human Services. www.dietaryguidelines.gov

Food Guides across Cultures and Countries

Although it is widely known that various countries and cultures have different food preferences, availabilities, and dietary patterns, most recommend that consumers select from a variety of food groups and that they monitor how much they eat in order to maintain optimal health.

Choose a variety of protein foods, which include seafood, lean meat and poultry, eggs, beans, peas, soy products, and unsalted nuts and seeds.

Increase the amount and variety of seafood consumed by choosing seafood in place of some meat and poultry.

Replace protein foods that are higher in solid fats with choices that are lower in solid fats and calories and/or are sources of oils.

Use oils to replace solid fats where possible.

Choose foods that provide more potassium, dietary fiber, calcium, and vitamin D, which are nutrients of concern in American diets. These foods include vegetables, fruits, whole grains, and milk and milk products.

Building Healthy Eating PatternsSelect an eating pattern that meets nutrient needs over time at an appropriate calorie level.

Account for all food and beverages consumed and assess how they fit within a total healthy eating program.

Follow food safety recommendations when preparing and eating foods to reduce the risk of food born illnesses.

Dietary Guidelines for Americans 2010. U.S. Department of Agriculture, U.S. Department of Health and Human Services. www.dietaryguidelines.gov

While the physical shape of food guides varies from country to country, the guidelines consistently urge individuals to consume lots of grains, fruits, and vegetables and to limit their intake of meat, milk, and dairy products.

China Sweden Mexico

A Sampling of food guides from around the globe

Painter, J., Rah, J-H, and Lee, Y-K. “Comparison of international food guide pictorial representations,” Journal of the American Dietetic Association. April 2002.

The guidelines represented in “My Plate” replace those of the earlier U.S. Food Guide Pyramid:

http://www.choosemyplate.gov/

Nutrition Labels andRecommended Serving Sizes

“Avoid oversized portions. Use a smaller plate, bowl, and glass. Portion out foods before you eat. When eating out, choose a smaller size option, share a dish, or take

home part of your meal.” -- from Ten Tips to a Great Plate http://www.choosemyplate.gov/downloads/TenTips/DGTipsheet1ChooseMyPlate.pdf

   The Serving Size

(#1 on sample label):The first place to start when you look at the Nutrition Facts label is the serving size and the number of servings in the package. Serving sizes are standardized to make it easier to compare similar foods; they are provided in familiar units, such as cups or pieces, followed by the metric amount, e.g., the number of grams.

 The size of the serving on the food package influences the number of calories and all the nutrient amounts listed on the top part of the label. Pay attention to the serving size, especially how many servings there are in the food package. Then ask yourself, "How many servings am I consuming"? (e.g., 1/2 serving, 1 serving, or more) In the sample label, one serving of macaroni and cheese equals one cup. If you ate the whole package, you would eat two cups. That doubles the calories and other nutrient numbers, including the %Daily Values as shown in the sample label.

Understanding and using the Nutrition facts label

Portion Sizes

* Kids are smaller than adults and should eat smaller portions. * Use smaller plates for kids. * Don't force kids to clean their plates if they are full. * Portions should be about the size of the back of a fist—a child’s fist for a child’s portion. * Start with a small portion. Children can have seconds if they are still hungry.

From Let’s Move, Healthy Families http://www.letsmove.gov/healthy-families

http://www.fda.gov/Food/LabelingNutrition/ConsumerInformation/ucm078889.htm

Cultural Diversity: Eating in America(From the series of family and consumer science fact sheets produced by the Ohio State University Extension, http://ohioline.osu.edu/hyg-fact/5000/index.html:

Mexican-American The traditional Mexican-American diet is rich in a variety of foods and dishes

that represent a blend of pre-Columbian, Indigenous Indian, Spanish, French, and more recently, American culture.

Popular fruits and vegetables are tomatoes, squash, sweet potato, avocado, mango, pineapple, and papaya.

The intake of carbonated soft drinks and pre-sweetened drinks is often high among Mexican-Americans.

The nutrients most likely to be inadequately represented in the diet of Mexican-Americans are calcium, iron, folacin, and vitamins A and C.

Pregnant Mexican-American women of marginal socio-economic standing are often deficient in dietary iron, vitamin A, and calcium, and should therefore be encouraged to consume low-fat cheese, lean red meat, and fresh fruits and vegetables.

Since tap water is often unsafe in Mexico and Central America, new immigrants may need to be reassured that tap water in the U.S. is safe.

Breastfeeding is widely practiced in Mexico, although most Mexican-Americans use infant formula.

African American The popular term for African-American cooking is “soul food.” Many of these

foods are rich in nutrients, as found in collard greens and other leafy green and yellow vegetables, legumes, beans, rice, and potatoes.

Parts of the African American diet tend to be low in fiber, calcium, and potassium, and high in fat.

Common ways for African-Americans to prepare food include frying, barbecuing, and serving foods with gravy and sauces. Home-baked cakes and pieces are also common.

Many African Americans are Protestant and have no specific food restrictions. However, a large number of families are members of religious groups that may have some restrictions or dietary preferences. These may include Seventh-Day Adventists Muslims, Jehovah’s Witnesses, and others.

Middle Eastern Foods common in all Middle Eastern cuisine include dates, olives, wheat, rice,

legumes, and lamb. The wide use of olive oil in food preparation attributes to a diet high in

monounsaturated fatty acids and a culture commonly known for lower blood pressures.

Many Middle Easterners are Muslim in faith, and their religion prohibits their eating any form of pork.

Muslims cannot drink alcoholic beverages or food flavored with alcohol. Middle Easterners have a high incidence of lactose intolerance and therefore

fresh milk is not widely consumed. Fasting from sunrise to sunset is a Muslim religious obligation practiced

during Ramadan.

Asian Most Asians living in America follow a traditional Asian diet interspersed

with American foods such as breads and cereals. Many Asian Americans are lactose-intolerant. Dairy products are not consumed in sufficient quantity, except for ice cream.

Calcium is consumed through tofu and fish (bones eaten) Most Japanese women in the United States breastfeed their babies. Thai

women usually breastfeed their children up to age two. Many Korean parents bottle-feed their babies.

Nutrition Supervision Culturally-sensitive guidance from Bright Futures, 3rd edition

• Health professionals can encourage people to be more candid by asking open-ended, nonjudgmental questions.

• People from different cultures may view body weight differently. Keeping a child from being underweight may be very important to people from cultures where poverty or insufficient food supplies are common. Families may not recognize that their child is overweight. They may view excess weight as healthy and might be offended if a health professional refers to their child as overweight.

• Traditional Chinese people believe that health and disease are related to the balance between the yin and yang forces in the body. Diseases caused by yang forces are treated with yin foods to restore balance, and vice versa. In Puerto Rico, foods are classified as “hot” or “cold” (which does not reflect the temperature or spiciness of foods), and people believe that maintaining a balance between these two types of foods is important to health.

• Lactose intolerance is much more common in people of non-European ancestry. For those who cannot tolerate any milk or dairy products in their diet, health professionals can suggest other sources of calcium such as dark green, leafy vegetables; calcium-fortified organize juice, and tofu or corn tortillas processed with calcium.

• Include culturally sensitive interview questions on eating behaviors and food choices, food resources, weight and body image, and perceptions of physical activity.

Keys to Good Cross Cultural Communication

Respect personal spaceLearn and follow cultural rules about touchingEstablish rapportExpress interest in peopleListen carefullyRespect silenceNotice how people make eye contactPay attention to body languageReach the appropriate family memberStudy a person’s responseCommunicate effectively

Interview questions (from Bright Futures, 3rd edition )

Below are some general questions that health professionals might ask during health supervision, keeping in mind how language can be customized to reflect cultural awareness, promote cross cultural communication, and encourage healthy eating behavior among diverse populations

General questions

Prenatal (for pregnant women)Are there any health concerns you want to share so that I can help you take good care of your baby and your family?Tell me about your living situation. Do you have enough hat, hot water, and electricity? Do you have appliances that work?Do you have what you need to take care of your baby? Do you have enough money for food, clothing, diapers, a crib, childcare?How much weight have you gained so far during your pregnancy?Are you taking prenatal vitamins? Other vitamins or minerals?Are you taking any medications?Do you drink alcohol or special teas? Have you used any special or traditional health remedies since you have been pregnant?Are you restricting any foods in your diet because of food allergies, worry about weight gain, vegan or vegetarian diet, or any other reason?How do you plan to feed your baby? Bottle feeding or breastfeeding?Do you have any problems with your teeth? Does the water you drink contain fluoride?

InfantsHow do you think feeding is going for you and your baby? Do you have any questions?How often do you feed your baby?Does your baby receive anything else besides breast milk or infant formula?How does your baby let you know when he is hungry? How do you know when to stop feeding him?Do you ever worry about not having enough money to buy food?What is your source of cooking and drinking water? Do you use bottled or processed water?How do you feel about the way your baby is growing?

Early childhoodWhat concerns do you have about your child’s eating behaviors or growth?What concerns, if any, do you have about your child’s weight?What do you do if your child doesn’t like a particular food?

Do you enjoy sharing meals and snacks with your child?Do you have all the equipment you need to feed your child? (a highchair or booster seat? Dishes, eating utensils?)Do you have any concerns about the food served to your child when you are away from home?What is the source of drinking and cooking water for your child? Do you use bottled or processed water?Are you concerned about having enough money to buy food?

Physical activityHow much physical activity does your child get on a weekly basis?How much time does your child spend watching television or playing on the computer or videogames?Does your child watch television while eating?

Middle ChildhoodFor the child:Which meals do you usually eat each day?How many snacks do you have? What snacks do you eat?How often does your family eat meals together?What is your favorite food?Are there any foods you won’t eat? Which ones?What do you usually drink with your meals? With snacks?What fruits and vegetables, including any juices, did you eat or drink yesterday?For the parent:How often does your family eat meals together?Do you have any concerns about your child’s eating habits or behaviors (e.g. getting her to drink enough milk)?Do you think your child eats healthy foods? Why or why not?How often does your child eat breakfast?What does he usually eat for snacks?Where does your child eta snacks? At home? At school? At after-school care? At a friend’s house?What does your child usually drink (milk, juice, water, sports drinks? Soda?)For the child or parent:Who usually buys the food for your family? Who prepares it?Are there times when there is not enough food to eat or not enough money to buy food?

Physical activityFor the child:What do you do to be physically active? How often?How much time do you spend being active?How much time do you spend each day watching TV or playing computer of video games?What do you think you can do to be more active?

For the parent:What types of physical activity does your child engage in? How often?How much time does your child spend each day watching television of playing computer of video games?

Adolescence

Eating behaviors and food choices

For the adolescent:Which meals do you usually eat each day?How often do you snack? What snacks do you eat?How often does your family eat meals together?What do you eat in the morning? The afternoon? In the evening? Between meals?Are there any foods you won’t eat? Which ones?How often to you drink milk? Is it low-fat fat free, other other kind? What other types of milk products do you eat? What fruits and vegetables, including juices, did you eat or drink yesterday?How often do you drink soft drinks, energy drinks, or sports drinks?What changes would you like to make in the way you eat?For the parent:How often does your family eat meals together?Do you any concerns about your teenager’s eating behaviors?Do you think your teenager eats healthy foods? Why or why not?For the adolescent or parent:Who usually buys the food for your family? Who prepares it?Are there times when there is not enough food to eat or not enough money to buy food?

Weight and body imageFor the adolescent:How do you feel about the way you look?Do you think that you weight too little? Too much? Why?Are you trying to change your weight? How?For the parent:How do you feel about your teenager’s weight and height?

Physical activityFor the adolescent:What do you do to be physically active?How much time do you spend being active in a week?What physical activity would you like to do?How much time do you spend each day watching television and playing video or computer games?What do you think you can do to be more active?

For the parent:What type of physical activity does your teenager engage in? How often?How much time does your teenager spend watching T.V. or playing video games or on the computer?

Nutrition issues and concerns

InfancyParents must decide whether to feed their infant breast milk or infant formula. Health professionals can help identify barriers to breastfeeding and provide referrals to lactation consultants

Parents may need help in determining when to introduce solid foods in the infant’s diet. Health professional can provide information related to the infant’s nutrition needs and developmental abilities.

Parents will need to know when it is O.K. to introduce juice into their infants diet, and how much.

Parents will wonder how they know whether or not they’re feeding their baby too much, or not enough.

Parents might ask if they should give their baby sweets such as cookies or sweetened drinks, during the first year of life.

Early childhoodObesity has increased among children ages 2-1/2 to 5, and children who are obese often remain obese into adulthood. What can a parent do if their child is overweight?

Should my child eat low-fat foods?

My child is a picky eater? How can I get my child to try new foods?

How can I help my child get enough calcium?

Iron deficiency and iron-deficiency anemia are common in children, especially children from families with low incomes.

Middle ChildhoodDecrease in consumption of milk and milk productsIncrease in consumption of sweetened beverages, especially soft drinksLimited intake of fruits and vegetablesHigher consumption than recommended of foods high in fat, especially saturated and trans fats (chips, etc.

Rise in overweight and obesityIncrease in body image concerns

AdolescenceDecrease in consumption of milk and milk productsIncrease in consumption of sweetened beverages, especially soft drinks and sports drinksInsufficient intake of fruit and vegetablesHigher consumption than recommended of foods high in fat, especially saturated and trans fats, cholesterol, and sodium.Rise in overweight and obesityLow levels of physical activity.Increase in eating disorders, body images concerns, dieting, etc.Prevalence of idea-deficiency anemia (in females)Prevalence of hyperlipidemiaFood insecurity among adolescents from families with low incomes

A Strategies in Action(from Celebrating Diversity)

[My idea here is to hot link the topics in green to the Strategies in Action from Celebrating Diversity]

• Talking to pregnant adolescents about nutrition• Introducing children to new foods in multicultural classroom settings• Enlisting community support to help reduce childhood obesity• Communicating food and nutrition information to migrant workers• Teaching recent immigrants about healthy nutrition through language programs• Introducing healthier ways to prepare traditional foods• Teaching parents how to prevent food-born illnesses

Talking to pregnant adolescents about nutrition[Food as Common Ground, page. 11, Celebrating Diversity]

Situation: A 50-year-old nutritionist was asked to speak to a group ofpregnant adolescents, most of whom were from an ethnic backgrounddifferent from her own. Having worked with pregnant women for anumber of years, she felt comfortable with the assignment and the topicof nutrition during pregnancy. Thinking that these young women would behighly motivated to eat well because of the new life inside them, she wassurprised to find them uncommunicative. No one would even look at her.She realized that the adolescents did not want to be there.

Strategy: The nutritionist decided to confront the situation. She thoughtthat if she got the young women to start talking about food, she might beable to draw them out.

Action: The nutritionist told the adolescents that she understood thatthey didn’t want to be there. Then she asked a simple question: “Whatfood do you really like? Just tell me. Name one food.” One girl finallyasked the nutritionist if she would put these favorite foods in their dietplans. The nutritionist said she would try.

Result: The young women in the group knew that the nutritionist was ontheir side. Everyone started talking about food—the lines of communication had been opened.

Note: The nutritionist began by asking questions about favorite foods, but

one girl’s response indicated that she expected the nutritionist to give hera diet plan. Use communication about food to encourage involvement,active participation, and joint planning

Introducing children to new foods in multicultural classroom settings[Introducing New Foods, p. 29, Celebrating Diversity)

Situation: A fourth-grade teacher of a multicultural class realized that hisstudents could learn a lot from each other. Many of the students broughttraditional cultural foods for lunch, and he noticed several of them lookinginquisitively at other students’ lunches.

Strategy: The teacher decided to take advantage of the diversity withinhis classroom to introduce his students to new foods. He felt that if thestudents were exposed to new foods, they would be more likely tochoose them in the future.

Action: He began by telling his class that they were going to have a feast.Using an idea from the old story about “stone soup,” in which peasantsfrom a village all contribute ingredients needed to make the soup, heasked the children to bring in food to share with each other. He offeredto bring stuffed cabbage, a favorite recipe of his Greek grandfather. But, hesaid, it would not be a feast if they had only one dish. He said, “If only wehad some rice and a vegetable, then it would be a feast.” He asked thechildren to check with their parents about bringing a favorite family foodand suggested other alternatives (e.g., helping to make festive decorations) for children who were unable to bring in food.

Result: The children enjoyed trying new foods and sharing stories aboutsome of their families’ favorite dishes.

Note: Teachers should be sensitive to the fact that some children wouldnot be able to bring in food to share with a class because of economicor other family reasons. These children should be included in this type ofactivity in some other way

Enlisting community support to help reduce obesity[Setting the stage, p. 47, Celebrating Diversity)

Situation: In the Harlem community, there was concern about the highprevalence of cardiovascular disease, hypertension, and obesity.

Strategy: To provide a comfortable and familiar setting for nutrition and

health education for the entire family, enlist assistance from churches inthe community.

Action: A health festival was planned, with the church setting the stage. Forseveral weeks, the minister gave sermons leading up to the festival, whichfocused on mental and physical health, the family unit, and achievement.

Result: The church implemented several health-related measures: (1)Smoking was prohibited in the church; (2) meals served at the churchwere planned to be low in fat and sodium; and (3) walking clubs andexercise classes were started.

Communicating food and nutrition information to migrant workers[At Work in the Community, p. 49, Celebrating Diversity]

Situation: A nutritionist at a local health department tried to have nutrition classes for migrant farm workers at the health department, but nobody came. The health department tried extending its hours so that the clients could be seen after they came in from the fields, but that didnot work either.

Strategy: Use a community-based approach. Let the client group determine the appropriate time and place for communicating food and nutrition information, and let them choose the content.

Action: Since the farm workers and their whole families gathered everySunday afternoon in the city park to picnic, the nutritionist set up information booths in the town square and took the message to the people, who were already in an environment where food was the focal point.

Result: The nutritionist found that the people were relaxed and interested in talking about the foods they were eating, many of which were tied to their culture.

Teaching recent immigrants about healthy nutrition using language programs[Using Foods to Teach English, p. 54, Celebrating Diversity)

Situation: Because California is home to many recent immigrants who donot speak English and who do not read or write in their primary language,the WIC nutrition educators were not able to communicate effectivelywith them. The number of languages spoken by bilingual WIC staff members was limited, and it was discovered that WIC participants were oftennot excited about the WIC classes on nutrition and health. The greatestperceived need among non-English-speaking WIC participants was learning English.

Strategy: To meet this need, the San Bernardino County WIC Programestablished a nutrition and English as a Second Language (ESL) program.Health and nutrition were the subject content, and ESL was the vehiclefor content delivery. Nutrition education was provided in the same wayas low-literacy adult education ESL, where recent immigrants are taughtsurvival skills such as going to the doctor and applying for a job. In theWIC/ESL pilot project, the theme of the curriculum was making goodchoices at the grocery store.

Action: The pilot WIC/ESL classes were designed to accommodate avariety of students who spoke different languages and whose levels ofEnglish comprehension were not the same. Only English was spoken inthese 25-minute classes. No translation was used. Cooperative learning was encouraged so that those who had a better understanding of English who could help those who had less.

The curriculum incorporated some of the most recent advances in ESLTeaching.

Result: The WIC participants received the nutrition education positivelybecause their perceived need to learn English was met. The curriculumwas designed so that learning was active and fun. Additionally, all participants were referred to low-cost community ESL classes in their neighborhood so that they could continue to learn English.

Introducing healthier ways to prepare traditional foods[Cooking Traditional Foods in New Ways, p. 60, Celebrating Diversity)

Situation: A nutritionist was pleased that many of her African Americanclients ate greens, a good source of vitamins, minerals, and fiber, but shewas concerned about the high-fat cooking method.

Strategy: The nutritionist decided to help her clients make a simplechange in their usual cooking method.

Action: She taught them to cook collard greens in the following way:Instead of cooking the greens with neckbone or fatback, cook the meatthe night before and let it stay in the pot in the refrigerator overnight.The next day, take the pot out and skim the fat off the top. Then heat theremaining liquid, add the greens, and cook until tender.

Result: The clients learned a new way to cook an old favorite and wereable to lower their fat intake at the same time. The nutritionist helped

them build on a positive cultural habit.

Teaching parents how to prevent food-born illnesses[Teaching food safety and sanitation, p. 65, Celebrating Diversity)

Situation: A Head Start nutritionist identified the need to teach parentsthe importance of sanitation and food safety.

Strategy: She decided to model safe food practices at a parent meetingset up for another purpose.

Action: She asked the parents to bring in food representing their culture.As they brought the food in, the nutritionist talked about not letting hotfoods cool before serving them and the importance of keeping coldfoods cold so that germs would not grow. Cold food was set in a largecontainer of crushed ice to keep it cold. Hot food was kept above 140° Fby heating it in the oven or on the range until right before serving. Thenutritionist showed parents how to make sure their children’s hands wereclean before they sat down to eat.

Result: The danger of food-borne illness was minimized, and the familieslearned the importance of food safety and sanitation.

A Menu of Resources[Might want to add these to the Toolkit]

Bright Futures Nutrition

Strategies for Health Professionals to Promote Healthy Eating Behaviors [Tool G, Bright Futures Nutrition, page. 251] http://brightfutures.aap.org/pdfs/BFNutrition3rdEdition_tools.pdf

Nutrition Counseling Stages of Change – a Model for Nutrition Counseling [Tool F, Bright Futures Nutrition, page. 249] http://brightfutures.aap.org/pdfs/BFNutrition3rdEdition_tools.pdf

Cultural Competency in Obesity. A curriculum by Eric E. Coris, Professor, Department of Family Medicine. Assistant Director, Physical Diagnosis. Accessed 10/10/2012 at http://health.usf.edu/publichealth/obesity/Cultural%20competency%20in%20the%20management%20of%20obesity.pdf

Cultural Diversity: Eating in AmericaA series of family and consumer science fact sheets produced by the Ohio State University Extension, http://ohioline.osu.edu/hyg-fact/5000/index.html:

Nutrition needs assessment Dietary Assessment and Dietary Assessment tools, U.S. National Agriculture Libraryhttp://fnic.nal.usda.gov/nal_display/index.php?info_center=4&tax_level=2&tax_subject=256&level3_id=0&level4_id=0&level5_id=0&topic_id=1325&&placement_default=0

Nutrition servicesNutrition assistance programshttp://www.fns.usda.gov/fns/

Model Programs: Healthy eating and obesity prevention initiatives

American Heart Association (AHA), Healthier Kidshttp://www.heart.org/HEARTORG/GettingHealthy/HealthierKids/Healthier-Kids_UCM_304156_SubHomePage.jspProvides information about programs that aim to improve nutrition and physical activity in children and adolescents in homes, schools, and communities. AHA Programs include Alliance for a Healthy Generation, Hoops for Heart, Jump Rope for Heart, and Teaching Gardens.

Healthy Eating, Active Communities (HEAC)http://www.healthyeatingactivecommunities.org/ Through local collaborations, HEAC (Healthy Eating, Active Communities) sites across the state of California improved access to healthy food and physical activity in low-income communities to reduce childhood obesity. The HEAC model was designed to prevent childhood obesity through collaborative action that changes the local environment to make healthy living possible.

Healthy Weight for Kids, the Academy of Nutrition and Dietetics Foundationhttp://www.eatright.org/Foundation/content.aspx?id=6993&terms=%22healthy+weight+for+kids%22This Initiative was launched in 2001 to support public education projects and programs that address the national health concern of obesity among our children.

Moving to the Futurehttp://movingtothefuture.orgPresents resources to develop successful community programs that promote healthy eating and physical activity. Includes instructions for conducting a community assessment, writing objectives, developing a plan, and evaluating programs; forms, surveys, and worksheets that can be adapted to a community program; and discussion forums. Also provides links to state and local plans that address nutrition, physical activity, and obesity prevention.

National Heart, Lung, and Blood Institute, We Can!(Ways to Enhance Children’s Activity and Nutrition)http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan

We Can! is a national movement designed to give parents, caregivers, and entire communities a way to help children 8 to 13 years old stay at a healthy weight. We Can! serves as a centralized resource to promote a healthy weight in youth through community outreach, partnership development, and media activities that can be adapted to meet the needs of diverse populations.

Recipes for Healthy Kids Challengehttp://www.recipesforkidschallenge.com/Sponsored by the U.S. Department of Agriculture and First Lady Michelle Obama’s Let’s Move! campaign, this contest was designed to encourage the creation of healthy school lunch menus. Teams — consisting of students, parents, chefs, school nutrition professionals, and interested community members — were invited to develop and prepare a recipe in one of three categories (Whole Grains, Dark Green and Orange vegetables, or Dry Beans and Peas), then serve it in the school cafeteria where it was rated by students. Each recipe entered in the competition was to be submitted to contest judges with a nutrient analysis and statement describing how the specified portion contributes to the recommended meal pattern for Child Nutrition Programs:

Let’s Movehttp://www.letsmove.govStarted by First Lady Michelle Obama, the program aims to combat childhood obesity using a comprehensive approach that will provide schools, families and communities simple tools to help kids be more active, eat better, and get healthy. Individual programs include:

Let’s Move Cities, Towns, and Counties. Designed to encourage mayors and elected officials to adopt a long-term, sustainable holistic approach to fighting childhood obesityChefs Move to Schools. Chefs adopt a school and work closely with teachers, parents, school nutritionists, and administrators to teach new techniques and recipes for healthy meals that meet the school’s dietary guidelines and budgets.Let’s Move! Faith and Communities. Designed to help faith-based and neighborhood organizations promote healthy living for children and communities.Let’s Move Outside. Promotes healthy outdoor activities in 50 national parks across the country by highlighting existing junior ranger programs that have a strong physical activity component.Let’s Move! Museums and Gardens. A national initiative to provide opportunities for millions of museums and garden visitors to learn about healthy food choices and physical activity through interactive exhibits, afterschool and summer programs, and healthy food service.Let’s Move! in Indian Country. Brings together federal agencies, communities, nonprofits, corporate partners, and tribes to end the epidemic of childhood obesity in Indian County within a generation by focusing on four food areas: early childhood, healthy schools, healthy communities, and physical activity. Let’s Move! Child Care. A voluntary initiative to encourage child care providers and parents to implement the Let’s Move Child Care Checklist that improves the quality of nutrition, physical activity, and screen time in child care settings.

Let’s Move! In the Clinic. http://www.letsmove.gov/health-care-providersSince health care professionals directly impact children’s health, each encounter is an opportunity to help children understand the importance of a good nutrition and physical activity – from their earliest moments of life through adulthood.

For Health Care Providers: Five Simple Steps to Success

Join Let’s Move! and take the pledge.Make BMI Screening a standard part of your careTalk to your patients about breastfeeding and first foodsPrescribe activity and healthy habitsBe a leader in your community.

(From Let’s Move, http://www.letsmove.gov/health-care-providers)