Creative Approaches to Nutrition Education Jia Lu and Kia Lee Abstract The prevalence of overweight or obese fifth, seventh

and ninth graders is 42.7% in Fresno County, which is amongst the highest in California. Due to budget cuts in the public school system, physical activity and nutrition education is no longer an important component of the standard curriculum. Nutrition and Exercise Education Development (N.E.E.D.) was created to supplement the lack of nutrition education in the public school system. In 2011, N.E.E.D. was used to test Jacque Rancieres Ignorant Schoolmaster Theory when Anthropology students with little or no nutrition background taught nutrition education to school-aged children. Today, the program has been active for four years and received grant funding to expand our volunteer base and to conduct ethnographic research on the audience and the effectiveness of the program. Currently, we have gathered pre- and post- tests from 22 schools, ethnographic data, and effectiveness of our program. The findings will be presented to highlight effective methods of delivering nutrition education to ethnically diverse audience in low socioeconomic communities.

A Snapshot of the Obesity Epidemic in the United States The cause of obesity and malnutrition is multifactorial and is often associated with multiple risk factors such as poverty, nutrition knowledge deficit, self-monitoring difficulties, genetics and sedentary lifestyles. Childhood overweight and obesity is a serious health issue in the United States since children who are overweight and obese are five times likely to become overweight or obese adults compared to their normal-weight counterparts (CDC, 2012). The onset of obesity is often associated with comorbidities such as diabetes mellitus, cardiovascular

complications, cancer, kidney disease and neurodegenerative disorders, which leads to a decline in quality of life. In addition to the implications on health status, there is a great economic impact from obesity-related illnesses such as decreased in workforce productivity and medical costs. The medical costs for treating adults with obesity-related conditions totals $190.2 billion dollars, accounting for 21% of the annual spending on medical treatment in the United States; childhood obesity alone totals $14 billion dollars (Cawley, 2012). Studies were conducted to evaluate the cost of medical spending at an individual level revealed an astonishing increase in health cost of individuals compared to their normal-weight counterparts. Finkelstein (2009) et al discovered that medical spending per capita was $1,429, or 42% higher in obese individuals. A recent evaluation by Cawley and Meyerhoefer discovered in their study that individuals are spending $2,741 (150% increase) more than healthy-weight individuals (Cawley 2012). The trend of elevated health care costs are expected to rise as obese children become obese adults. Recent data from the Center for Disease Control (CDC) reported a decline in childhood obesity in low-income preschool children. The CDC study collected and analyzed data from 19 of the 43 states participating in the research; the statistics revealed that one in eight preschoolers are obese and the trend of childhood obesity has declined from 2008 to 2011 (CDC, 2012). Michelle Obamas Lets Move! campaign and public health social services organizations like Extended Food and Nutrition Education Program (EFNEP) helped increase nutrition literacy, promote behavior change and improve overall nutrition health status as provened in Texass EFNEP program (AgriLife Extension). Introduction to the Paradox of Obesity and Food Insecurity in Fresno County The national glimpse of the decline in the prevalence of obesity is optimistic as the campaign to promote healthy lifestyle continues. California is one of the 43 states that

participated in CDCs 2013 study and the state overall has shown a decrease in the rate of childhood obesity. However, Fresno County still has one of the highest rates of obesity in California. According to the 2009 California Health Interview Survey, 33.6% of adults are overweight and 30.2% are obese compared to the statewide averages of 33.6% and 22.7% respectively. The 2013 data from County Health Rankings and Roadmaps collected and presented by the University of Wisconsin studied health outcome and health factors of every county in California. The health outcome ranking was based on the prevalence of mortality and morbidity and the health factors ranking was a summary of behavioral, clinical, social, economical and environment factors. An individuals lifestyle such as tobacco and alcohol usage, diet and exercise habits and sexual activity are health factor within the behavioral category that determines the risk of disease. In 2010, 20% of Fresno adults are inactive, however most alarming statistic is that 71% of the population does not have adequate access to areas for exercise. The behavior-factor statistic coincides with the rate of obesity in Fresno County for adults. In regards to children, the rate of childhood obesity in Californias San Joaquin Valley exceed 30% with the highest prevalence of obesity concentrated in impoverished communities (KSEE 24, 2011); thus the economic factors alone has the greatest impact of 40% on an individuals health and quality of life (County Health Rankings, 2014). The economic factor is based on education and income level, employment, support from family and social relationships, community safety and environmental quality (County Health Rankings, 2014). Fresno County has higher than the national average for unemployment (15%), inadequate social support (40%), highest rate of poverty in California (28.6%) and violent crimes (County Health Rankings, 2014). The

disproportionate destitution in certain neighborhoods often leaves families without a safe area to play, thus increasing the prevalence of food insecurity and inactivity (Kurtis 2011, County Health Rankings, 2014). Given the San Joaquin Valleys reputation of a rich agricultural region with an annual revenue of $35 billion, a paradox of 21% prevalence of food insecurity is perplexing (EPA 2011, County Health Rankings, 2014). 15.6% of the total population have low access to grocery stores to purchase healthy foods (USDA, 2012). Like all markets, the agricultural industry thrives on the pull of supply and demand. Most local farmers will choose to sell their products to more lucrative markets with higher pay for their crops. Due to the saturation of farmers in the San Joaquin Valley, the local shops are less profitable compared to distant markets. Low-income individuals who do not work in the agricultural industry are less likely to eat adequate amounts of fruits, vegetables and will be more likely to experience food insecurity. The segregation of the rich and poor in Fresno is highly polarized. The affluent community is in the northern and eastern side whereas the poorer neighborhoods are typically located in the southern and western areas. In impoverished areas found in Fresno County, the access to adequate medical care and the quality of the care provided are taken into consideration. Citizens in Fresno do not seek or have adequate medical treatment for several reasons: 30% uninsured adults, 8% uninsured children, 20% of the population are deterred from seeing a physician due to cost and the ratio of non-primary care providers are 1,927:1 (County Health Rankings, 2014). Lastly, physical environment such as environmental quality has 10% impact on an individuals health factors. The data from the County Health Ranking placed Fresno County at 46 in health outcomes and 54 on health factors out of 57 counties. Since 2010 the trend of children living in poverty has not declined, but rather steadily increased (County Health Rankings, 2014).

The Founding of Nutrition and Exercise Education Development Due to the absence of nutrition education during school hours, public health programs developed by the California Obesity Prevention Program, and the California Endowment have taken steps to educate and provide access to resources. Moreover, University of California Cooperative Extensions Extended Food and Nutrition Education Program (EFNEP) and CalFresh offer a six to eight week classes to families and youths in the community. The nutrition programs are made available to students from K-12 upon the principals approve of the partnership and instructors acceptance to the EFNEP/CalFresh nutrition educators invitation to teach. In 2010, as undergraduates at California State University, Fresno (C.S.U. Fresno), we saw the need for nutrition intervention and education. As part of a project for the Community Nutrition course, we developed a nutrition education curriculum incorporating physical activity called Nutrition and Exercise Education Development (N.E.E.D.). Since then, we have volunteered with Every Neighborhood Partnership (E.N.P.), a local community benefit organization, and utilized the audience at E.N.P.s Saturday Sports. Saturday Sports is a collaboration of Fresno Unified School District, school staff, and volunteers from local churches, universities, and community members. Saturday Sports provide an outlet for the children to engage with positive role models, stay active, and occupy their Saturday mornings with guided activities. Following graduation, we continued to circulate the nutrition program and used N.E.E.D. as a service-learning opportunity for other undergraduates in at C.S.U. Fresno. Methodology: David Kolbs Experiential Learning Experiential learning is acquiring knowledge by engaging all senses through experience. Kolbs theory is based on the work of several philosophers. John Deweys theory is the

foundation of Kolbs theory, which states that experience is an important and continuous component in learning and adult development; therefore experience, inquiry and reflection are important elements of experiential learning (Chan, 2012). Deweys theory correlates with Jean Piagets cognitive development of experiential learning and Kurt Lewins four component of action research (Chan, 2012). Piagets cognitive development theory to explains that gaining knowledge is a lifelong process and acquired through discovery, engagement and adjusting to the experience (Chan, 2012). Lewins theory states that behavior is based on the entirety of an individuals experience; the process of reflecting, planning, action and observations contributes to a concrete learning experience (Smith, 2001, Chan, 2012). In comparison to the traditional classroom-based learning, experiential learning has long-term impression on students through participating in real-life activities and enriches students learning through projects such as engaging in laboratory experiments, field studies, and community engagement and service learning (Chan, 2012). Service Learning Component N.E.E.D. has been an avenue for California State University, Fresno (C.S.U.F.) student to become engaged in the addressing the needs of the community. C.S.U.F. Anthropology students were the first to get involved with the program through a service-learning project in Anthropology 101: Concepts and Application of Anthropology in 2011, when N.E.E.D. was in the second year of operation. The project was lead by Jia Lu, a co-founder of N.E.E.D. and supervised by James Mullooly, Ph.D., to teach the cohort of anthropology students to create a new N.E.E.D. curriculum and how to deliver nutrition education to an audience of K-12 students. Utilizing Jacques Rancires The ignorant schoolmaster: Five lessons in intellectual emancipation (1991) describes the life of Joseph Jacotot (1770-1840), a philosopher of education

who developed the theory that a learners mind is not an empty vessel awaiting information dissemination. The individual is already equipped with the skill to problem solve through critical thinking, thus producing effective learning and retaining information. Based on Rancires theory, the anthropology students were observed one N.E.E.D. live at Powers Elementary to gauge the parameters they may operate in to execute the program. Through the project, the anthropology students had indirect guidance in order to help increase creativity and cleverly created games such as cereal box bowling. At the conclusion of the project, an anthropology student shared the experience: I believed I got a lot out of this Saturday, I learned a lot about myself and the kids that we are working with. One thing that I learned about myself is how to learn to be patient with your kids, and also how to approach them. I also noticed that I have to be aware of my surroundings, the environment M.A. Currently, the volunteers are C.S.U.F. dietetic student who are participating in the program to fulfill volunteer hours, gain experience or for enjoyment. Like the anthropology students, the dietetic students are involved in the planning, organizing and executing the nutrition education lessons at each school. The experience and skill are valuable to the dietetic students because the community experience is pertinent to their long-term career goals. Differentiated Instruction to Deliver Nutrition Education Contento (2011) stated that the effectiveness of nutrition education is determined by focusing on behaviors and practices of the audience members, determinants of behavior and the use of theory. Food practices are shaped by cultural, social and personal preference. Investigating in an individuals food culture and behavior often leads to discovering strategies to help a person modify or adopt habits that will improve their health status. For example, children

who are not adventurous eaters may have a phobia to new foods, however if they are encouraged to participate in making the meals they are likely to try new foods. In the current curriculum the participants are taught how to read and follow recipes. The recipes may contain foods the participants are not exposed, such as yogurt, but after making yogurt parfaits the children discovered they really enjoyed the new food. The N.E.E.D. audience requires a nutrition education technique that effectively challenges their negative attitudes or beliefs about healthy eating, allow for experiential and memorable (e.g. fun) learning. The best approach to teaching the audience is through differentiated instruction. Learning styles methodology is used to teach C.S.U.F. student volunteers, differentiated instruction is utilized to disseminate nutrition information to the K-12 audience. Differentiated instruction is recognizes that all students have various learning styles such as auditory, visual and kinesthetic learning. The instructor should accept the all students natural ability to learn and understand that students will have varying thresholds for learning (Chamberlin, 2010). Therefore, the curriculum in differentiated instruction is designed around the different styles to improve student-learning outcome. Due to the variance of age, gender, skill, athletic ability, ethnicity, and cultural background of the K-12 audience differentiated instruction is the best approach to respond to the diversity and deliver nutrition education. The nutrition education and physical activity component continuously engages the students with strengths in all learning styles. During the nutrition education the K-12 audience gathers in front of a large MyPlate poster. The C.S.U.F. volunteers distributes laminated photographs of various food from the five food groups and systemically discuss each food group and the importance of eating a meal with components from each section of the MyPlate. During each discussion, the volunteers ask the audience to raise

their picture if it is a photo of the food group in discussion. To conclude the nutrition education session of the curriculum, the K-12 audience is asked to play fliegen clapper a flyer swatter game. The audience is divided into two teams, and handed a fly swatter. The first participants approaches the MyPlate poster and waits for the instructor to call out various foods, using the fly swatter the child must hit corresponding food group to what instructor presents. If the instructor calls out apple the child who hits their fly swatter on the Fruit portion of the MyPlate wins the challenge. During the relay race, the children are divided into two teams. Throughout the years, it was revealed that children enjoy the thrill of competition, and thrive well when they are tasked to playfully battle with their peers. The relay race is a small obstacle course with cones, soccer balls, P.V.C. pipe hurdles, potato sacks, hula-hoops, jump ropes, and tunnels. The CSUF volunteers decide the layout of the obstacle course at every school rotation. However, the last obstacle in the course must be a bucket filled with food photos and the MyPlate poster. To complete the obstacle course, the participant must correctly place the food picture they have chosen from the bucket to into the appropriate group on the MyPlate. The curriculum is designed to reinforce the learning objectives and appeal to the different types of learning styles. Pre- and Post Test Results The funding from Kaiser allowed N.E.E.D. to thrive and grow; we purchased new equipment, teaching tools, and incentives were purchased to continue the efforts of teaching the diverse population of Fresno County about how to modify food choices in order to maintain healthier lifestyles. In Fall 2013, the program was modified to record and track the nutrition knowledge base of the participants of the program. Participants were tested on their categorization skills; how well they knew the various food groups and what belonged in each

food group. One of the volunteers was a Child Development minor student who tasked herself with recreating the pre- and posttest and making it age appropriate for those younger children since they were mostly illiterate. The finished test was two versions of the pre- and post tests, but both evaluated the same knowledge. Children who were third grade and under, the pre- and post tests were designed using a color-matching format utilizing the MyPlate as a guide. The pre and post test presented scattered images of various of three foods per food group. Younger children are more likely to engage in the test if they are encourage to color, rather than answering questions. Hence, the children were asked to color the food with crayons that corresponded with the food group color on the MyPlate (e.g. red for fruits, green for vegetables). The pre and post test for fourth grade children and over were required the same categorization concept, with the exception that they write the first letter of the food group next to the image displayed. Overall, 22 elementary schools with Saturday Sports programs received the revised curriculum of the N.E.E.D. program, which taught basic food group categorization and incorporated simple health benefits of each food group. Of those schools, N.E.E.D. reached approximately 750 school-aged children. Of those children, a total of 403 received pre and post tests, but only 229 of those were matched to have tested both pre and post. Overall, there was an average increase of 10% growth in retained nutrition knowledge. Each school varied, with results ranging from 3% to 32% in average growth of retained nutrition knowledge. Of the students tested, 19 total students scored 100% on the pretest, whereas 43 total students scored 100% on the post test. The post test provided an open-ended question, allowing students to share what they would like to learn or what they did learn as a result of the program. Students wrote: I learned that vegetables are good for you - Michael 3rd grader at Anthony Elementary I learned that beans are protein - Valeria 4th grader at Winchell

That nutrition fuels our body and its important - David 8th grader at unknown school I learned what belongs on each of MyPlate - Brenda 5th grader at Olmos Elementary Protein is good for your body - Devin 5th grader at Olmos Elementary It helps you have a healthy body and keeps your bones strong - Richard 5th grader at Vinland I learned that grains and proteins are not the same thing - Arianna 3rd grader at Pyle I learned that the food can keep you healthy - Gustavo 3rd grader at Powers Elementary Healthy food helps you do fun stuff - Emrie 2nd grader at Powers Elementary Project Improvements An area that requires the most improvement is consistency with administering and collecting the tests from the participants. Often, the participants receive both solicited and unsolicited assistance from their peers, siblings, parents or Saturday Sport volunteers thus influencing the accuracy of the test results. Tests without names are thrown out and not counted in the data. In addition, the participants ability to engage in focusing in the test is largely dependent on Saturday Sports site leaders involvement in disciplining the children. Since N.E.E.D. serves as a service-learning project for the C.S.U.F. students, we encountered challenges with consistency of the volunteers. Students were faced with scheduling conflicts by having to balance school, work, family, and volunteerism. The number of volunteers varies every Saturday, regardless of the inconsistency with the volunteers, N.E.E.D. still managed to maintain a minimum of four volunteers in each group. Many of the students were required to complete a certain number of hours in order to satisfy course requirements. Even with that factor, the program will experiences volunteer inconsistency since the average number of required hours were only twenty for the entire semester.

Potential Growth: N.E.E.D. has expanded so much in comparison to its initial curriculum. This semester, we are expanding the program to include a food demonstration component. This addition serves as a connection to what was taught previously, allowing participants to apply knowledge into application. This portion of the curriculum demonstrates healthy snack options, portion control, and preparation and assembly of the food products. It also teaches the participants how to read and follow recipes. Recipes used are: fruit and yogurt parfait, mango salsa, pasta salsa, fruit kabob with yogurt dip, veggie tortilla roll-up, and lettuce wrap. Along with the new curriculum, N.E.E.D. will be collaborating with Community Food Bank, another community benefit organization, which has a full-kitchen mobile unit. This mobile kitchen will be used by the nutrition volunteers to demonstrate food preparation inside its kitchen, allowing for hot foods to be prepared for the participants. The collaboration offers C.S.U.F. student volunteers another service-learning opportunity, providing more experience with another community-benefited nutrition program. This is a great opportunity for both the nutrition volunteers and the student participants. N.E.E.D. is expected to expand to incorporate a well-rounded family nutrition education component. The goal is to provide education for the participants by providing a curriculum that includes nutrition education, food demonstration, and improve understanding of the relationship between lifestyle and disease. The program will be all encompassing, focusing on the idea of a healthy family unit. Conclusion: N.E.E.D. is a small-scaled nutrition education program, but is unique for its incorporation of physical activity. N.E.E.D. is an engaging form of nutrition education through differentiated

forms of delivery, making the curriculum applicable to all ages, cultures, and backgrounds by utilizing differentiated instruction. Despite the data from the results of the pre and post test increasing only 10% may the answers in the open ended and unsolicited feedback from the children revealed the participants enjoy and learn from the program. Overall, N.E.E.D. is successful in providing nutrition education, and service-learning opportunities for university students.

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