Community-Based Nutrition Intervention within the Healthcare Setting

Midwood, Brooklyn
Marie Salvador, Christine Chieffo, Feng Zhao, Rena Weinhouse
December 18, 2017

Abstract

The development of obesity-related diseases bears an enormous impact on our health status. There has

been an upward trend in obesity rates in the U.S; this is especially relevant given that 28% of Midwood

residents are obese. While various weight loss strategies have been implemented, some of these

interventions do not sufficiently address social and environmental barriers. By shifting our focus towards

the socio-ecological framework and coordinating community-based nutrition programs within a

healthcare setting, allow us to approach diet-related diseases in a different manner. Shop Smart, Eat Right

(SSER) is a 2-year program with a proposed budget of $250,000. The program goal is to reduce the

prevalence of obesity in Midwood community adults; this goal will hopefully be obtained through the

development of a 12-month intervention that includes: nutrition education classes, interactive cooking

demonstrations, and supermarket tours. Prior to the start of the program, each participant will complete a

behavioral survey and various anthropometric measurements will be collected and compared to the end of

the program data to assess for changes. Results and feedback will be used to evaluate the program, assess

for areas of improvement, and ideally be used to implement changes throughout the community.

Community Description and Statement of Need

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 Midwood, with a population of approximately 163,620 residents, is nestled in the south-central

part of the borough of Brooklyn. This diverse multi-cultural neighborhood hosts residents of all different

ethnicities: 38% Caucasian, 31% non-Hispanic Black, 10% Asian, 18% Hispanic, and 3% other, as well

as 45% foreign-born immigrants.1 21.2% of Midwood residents are living in poverty; poverty rates in this

neighborhood are 1.4 times greater than New York City and 1.5 times greater than the national average. 2

While a variety of food retailers exist in the neighborhood, many are considered fast food outlets. 28% of

Midwood residents drink at least 1-12oz sugary beverage daily and only 84% are eating at least 1 serving

of fruits or vegetables daily. Recreation areas were limited, and there were no green cart vendors or

nearby farmers’ markets.

In the U.S., two thirds of adults and one third of children are either overweight or obese. 3 In

Midwood, 28% of adults are obese, 11% are afflicted with diabetes and heart disease continues to be the

leading cause of death.2 If the obesity trend continues, it will account for $860 billion, or more than 16%

of healthcare spending by the year 2030.3 The high costs associated with treating obesity-related diseases

is a critical public health issue. Just a modest 5-10% reduction of body weight has been reported to

clinically reduce obesity-related risk factors. 4 Establishing strategies to address the prevalence of obesity

and diet-related diseases is crucial to improving the wellbeing of Midwood adult residents.

Various community nutrition interventions have been implemented within the healthcare setting,

including farmers’ markets, cooking demonstrations, shopping tours, and group education sessions. Not

only do hospitals coordinate farmers’ markets outside their grounds to increase patients’ access to fresh

fruits and vegetables, they also distribute farmers’ market coupons as incentives to increase their purchase

and consumption of these foods.6 Cooking demonstrations introduce patients to different foods and

healthy alternative cooking methods.7,8 Group nutrition education sessions teach patients how to make

optimal food choices, further complementing other interventions. 6-8

Social and environmental barriers to weight loss are not always adequately addressed by current

interventions. An alternative approach to combating the rising obesity trend is the socio-ecological model

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(SEM); it places emphasis on the role of the environment at multiple levels; individual, interpersonal,

organizational, community, and policy and its influences on individuals’ eating behaviors and health

outcomes.8 The individual level recognizes readiness to change, knowledge growth, and reshaping

attitudes toward a targeted behavior. On the interpersonal level, behavior change is influenced by social

networks such as families, friends, peers, and health care providers. As addressed in the article by

Drieling, clinical providers have limited training in obesity counseling and community-based

organizations are limited in their abilities to respond to obesity-related comorbidities; implications are

that coordinated efforts between the two may be more effective than either approach alone. 4 The

organizational level, which includes hospitals and workplaces, influence individual behavior through

organizational regulation and policies. Researchers found that many nutrition based programs in

healthcare settings focus on the conventional approach for distributing nutrition information instead of

providing behavior-changing skills to support change in diet. 9 Consequently, there is a need to create

more hands-on activities such as farmers’ markets, shopping tours, and interactive cooking programs

within the healthcare setting. For example, participants were extremely satisfied with their improved

knowledge and skills for making healthy food choices, which were gained during a collaborated food

shopping tour between a hospital and its adjacent supermarket. 10 It was also reported that offering more

nutrition services, such as cooking demonstrations and shopping tours, would improve their knowledge

and skills.11 On the policy level, community nutrition interventions are influenced by federal, state, and

local agencies; policy change is essential to promote and maintain healthy environments. One study noted

that the cardiac rehabilitation program that employed a dietitian offered more nutrition services compared

to sites without dietitians.11 Policy changes, such as increasing funding to hire more dietitians and

improving health insurance coverage for nutrition intervention services, are essential. 12 Partnering

community-based strategy with a healthcare setting allows us to target multiple environment in effort to

reduce the health consequences of obesity.

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 This concept paper is prepared to implement a community-based nutrition intervention program,

Shop Smart, Eat Right (SSER) at the New York Community (NYC) Hospital on Kings Highway. In our

designed activities, the SEM will be applied to the program through collaboration between a local

supermarket and the NYC Hospital.

Program goals and intended outcomes:

Our goal is to reduce the prevalence of obesity in Midwood community residents participating in

the program. Program objectives will be achieved by combining individual, interpersonal, organizational,

and community efforts by using the health-care setting in combination with community interventions. The

nutrition intervention program is intended to enhance participants’ knowledge and skills and improve

their dietary behavior. By integrating the healthcare and community-settings, we aim to promote weight

loss, improve obesity-related anthropometric markers, reduce obesity-related health outcomes, and

improve quality of life amongst the diverse adult Midwood community residents.

Short-term outcomes

By the end of the program, 80% of participants will:

● have increased awareness of obesity-related chronic diseases

● be able to identify benefits of eating healthy
● have learned how to shop smart i.e. price, nutrition contents
● be able to list healthy cooking methods
Intermediate

By the end of the program, 75% of participants will:

● increase fruits/vegetables consumption to at least 60% of the recommended

intake of 5 servings per day
● replace frying with healthy cooking alternatives
● substitute a higher fat ingredient with a lower one
● replace refined carbohydrates with fiber rich foods
● decrease sugar sweetened beverage consumption to ≤1 drink per day
Long-term

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 By the end of the program, at least 70% of participants will:

● decrease body weight by ≥5%

● reduce waist circumference by ≥4 cm
● increase health perception by 30%

Description of Program Activities

The entirety of the SSER program will run for 2 years. The first 4 months will be used for program

preparation, including staff recruitment and training, equipment/food purchasing, creation/design of

nutrition handouts/curriculum, and participant recruitment. Recruitment will take place at the local NYC

hospital via flyers, which will be also be posted around the neighborhood. In addition, volunteers and

research assistants working on this project will hand out the flyers in order to actively recruit participants.

Criteria for participation include: BMI ≥25, and a waist circumference of ≥102 cm for men and ≥88cm

for women. Various anthropometric measurements will be obtained prior to the start of the intervention:

height, weight, body mass index (BMI), and waist circumference.There will be a total of 100 adults

participating in the program, comprised of both males and females. In order for every person to get

maximum benefit from the program, the participants will be randomly split into 4 even groups (25 people

per group). Each group will meet once a month for 12 months for various activities and will receive $10

worth of coupons at the end of each session. Coupons will be redeemable for fruit and vegetable

purchases at the local Key Food supermarket. In month 1 and month 12, each group will be taken on a 60-

minute supermarket tour led by the RD. For months 2 through 11, there will be ten 75-minute sessions

consisting of a 30 minute nutrition education class followed by a 45 minute of interactive cooking class.

Attendance will be taken at each meeting to measure participation. See table below for activity details.

Activities Personnel/Supplies Activity Description

Nutrition - RD to facilitate group discussions - Group nutrition education lectures/discussions
- Educational materials (curriculum,
Education within the healthcare setting
education flyers/handouts) - The nutrition education sessions will cover a

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 variety of health/nutrition related topics
- RD to lead cooking demonstrations - Interactive cooking
- Volunteers to prep food & ingredients - Preparing healthy meals and/or snacks
Cooking Demos
- Food supplies - Food and ingredient prep (cutting/defatting etc.
- Cooking equipment & utensils - Cooking methods (healthy vs. unhealthy methods)
- RD to lead tours - Trip to the supermarket for shopping guidance
- Volunteers - How to navigate throughout a supermarket
Supermarket Visits - Educational materials (handouts, - How to shop on a budget; coupon clipping/sales
- How to read a food label
worksheets)

Timeline

2 months
6 months post survey/data
4 months program 12 months
program analysis and
preparation intervention
evaluation program
improvement

Four months will be used for preparation of the program (hiring and training personnel, preparing

educational material, setting up the location, recruitment of participants, and purchasing material). The

twelve months participant intervention will begin thereafter, as described above. Program evaluation will

be done at the end of the 12 month intervention program and again six months post-program via follow-

up surveys and assessment of various anthropometric changes.

Process/Outcome Evaluation

For evaluation purposes, each participant will fill out a pre-program survey, and research staff will

measure pre-program weight and waist circumference to be used as a baseline. Participants will complete

three surveys during the course of the program; initial pre-program survey, at the end of the 12 month

intervention, and 6 months post-program. Surveys will inquire about participants’ knowledge, skills,

behavior, and health perception. Research staff will remeasure weight and waist circumference upon

completion of the intervention at month 12 and 6 months post-intervention to determine intermediate and

long-term effects of the program. Information, feedback, and data from the evaluation surveys will be

used to improve the program.

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 Objectives Evaluation Measures

Initial survey completed by participants, compared with survey at

Short-Term Goals (knowledge and skills)
Intermediate Goals (behavior change)
Long-Term Goals (change in morbidity and
health perception)
month 12 at the end of the intervention.
Initial survey completed by participants, compared with survey at
month 12 at the end of the intervention & 6 months post-program
survey.
Initial anthropometric measurements of body weight and waist
circumference by research staff, compared with measurements at
month 12 at the end of the intervention and 6 months post-program
measurements. Initial survey completed by participants, compared
with survey at month 12 at the end of the intervention & 6 months
post-program survey.

Budget Narrative

We are requesting $250,000 to fund the SSER program at the NYC hospital, from January 1,

2018 to January 1, 2020. Personnel, fringe benefits, and non-personnel costs are listed below (also see

Table 1).

A total of six part-time employees will be hired for a two-year contract. A project director will

work for 50% of the project time for a total of $50,000 over two years. Responsibilities will include

overseeing development of the program, recruiting and managing staff, establishing partnerships between

the community hospital and its adjacent supermarkets, and overseeing program curriculum, activities, and

evaluation results. A project manager will work for 50% of the project time for a total of $40,000.

Responsibilities will include developing the program, creating curriculum and learning materials, and

training and managing staff and volunteers. Two registered dietitians will be hired for 40% of the project

time each for a grand total of $60,000. Their responsibilities will include implementing nutrition

education sessions and collaborating with a program coordinator. A community research and evaluation

specialist will work for 30% of the project time for a total of $30,000. Responsibilities will include

assisting the director and manager to develop and implement the program, collecting data, evaluating

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outcomes, and developing and presenting publications and study findings. A program coordinator will

work for 30% of the project time for a total of $20,000. Responsibilities include coordinating volunteer

schedules and providing volunteer training, building sustainable relationships with community

supermarket partners, and ensuring inventory of supplies. Also, two to four unpaid volunteers will be

recruited to assist staff.

Total fringe benefits are $26,600. It is 20% for 1 project director at 0.2 x $50,000 for a total of

$10,000; 15% for 1 project manager at 0.15 x $40,000 for a total of $6,000; 10% for 2 registered

dietitians and 1 community research and evaluation specialist at 0.1 x $90,000 for a total of $9,000; and

8% for 1 program coordinator at 0.08 x $ 20,000 for a total of $1,600.

Total non-personnel expenses are $23,400. They are $2,500 for cooking equipment, $2,000 for

food, $12,000 for farmer’s market coupons ($10/person x 100 people x 12 months), $1,000 for materials

and supplies, $800 for staff training and development, $500 for recruitment and outreach, $2,000 for rent

and utilities, $1,000 for evaluation and publication, and $1,600 all other direct costs.

References

1. U.S. Census Bureau (2016). American Community Survey 1-year estimates. Retrieved from Census

Reporter Profile page for NYC-Brooklyn Community District 14--Flatbush & Midwood PUMA, NY

https://censusreporter.org/profiles/79500US36004015-nycbrooklyn-community-district-14flatbush--

midwood-puma-ny/>

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2. King L, Hinterland K, Dragan KL, Driver CR, Harris TG, Gwynn RC, Linos N, Barbot O, Bassett MT.

Community Health Profiles 2015, Brooklyn Community District 14: Flatbush and Midwood; 2015;

38(59):1-16.

3. Huang, Terry T.-K., & Glass, Thomas A. (2008). Transforming Research Strategies For Understanding

and Preventing Obesity. JAMA, The Journal of the American Medical Association, 300(15), 1811-3.

4. Drieling, R., Ma, J., & Stafford, R. (2011). Evaluating Clinic and Community-Based Lifestyle

Interventions for Obesity Reduction in a Low-Income Latino Neighborhood: Vivamos Activos Fair Oaks

Program. BMC Public Health, 11, 98.

5. Weinstein, E., et al., Impact of a Focused Nutrition Educational Intervention Coupled With Improved

Access to Fresh Produce on Purchasing Behavior and Consumption of Fruits and Vegetables in

Overweight Patients With Diabetes Mellitus. The Diabetes Educator, 2014. 40(1): p. 100-106.

6.. Vachon, G.C., et al., Improving access to diabetes care in an inner-city, community-based outpatient

health center with a monthly open-access, multistation group visit program. Journal of the National

Medical Association, 2007. 99(12): p. 1327-1336.

7. Saxe-Custack, A. and L. Weatherspoon, A Patient-Centered Approach Using Community-Based

Paraprofessionals to Improve Self-Management of Type 2 Diabetes. American Journal of Health

Education, 2013. 44(4): p. 213-220.

8. Gregson J, Foerster S, Zotz K, et al. System, Environmental, and Policy Changes: using the Social-

Ecological Model as a Framework for Evaluating Nutrition Education and Social Marketing Programs

with Low-Income Audiences. Journal Of Nutrition Education [serial online]. January 2, 2001; 33:S4-15.

9. Paxton F, Ball M, Bunker S, Cooper C. Nutrition Education in Outpatient Cardiac Rehabilitation

Programs. Australian Journal Of Nutrition & Dietetics. June 1999;56(2):76-80.

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10. Reid V, Molamphy F, O'Sullivan N. Shopping Tours for Cardiac Patients. Coronary Health Care.

November 1999;3(4):189-191. Available from: CINAHL Complete, Ipswich, MA.

11. Cavallaro V, Dwyer J, Murphy J, et al. Influence of Dietitian Presence on Outpatient Cardiac

Rehabilitation Nutrition Services. Journal Of The American Dietetic Association. April 2004;104(4):611-

614.

12. Timlin M, Shores K, Reicks M. Behavior Change Outcomes in an Outpatient Cardiac Rehabilitation

Program. Journal Of The American Dietetic Association. May 2002;102(5):664-671.

Appendix

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Table 1

Project Budget for Shop Smart, Eat Right (SSER) Program in Midwood Community

January 1, 2018 – January 1, 2020

2 YEARS DIRECT COSTS

A. Salaries and Wages

1 Project Director (PT) $50,000

1 Project Manager (PT) $40,000

2 Registered Dietitians (PT) $60,000

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1 Community Research and Evaluation Specialist $30,000
(PT)

1 Program Coordinator (PT) $20,000

B. Fringe Benefits $ 26,600

C. Total Salaries, Wages, and Fringe Benefits $ 226,600

D. Cooking Equipment $2,500

E. Foods for Cooking Demonstrations $2,000

F. Supermarket Coupons $12,000

G. Materials and Supplies $1,000

H. Staff Training/Development $800

I. Recruitment/Outreach $500

J. Rent/Utilities (Teaching Kitchen) $2,000

K. Evaluation and Publication $1,000

L. All Other Direct Costs $1,600

Total Direct Costs $250,000

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