Project Eat Well

Sadia Azziem, Kristen Beasley, Samira Isaac, Sara Maiale, & Trevaill Ross

Mission Statement

A continual effort to improve the present and future health behaviors of middle schools students and their

families through education and empowerment.

Overview

Obesity has been a prevalent public health epidemic for several years, only increasing in

commonality and costs during recent years. Contrary to the once strongly held assumption that race

determines obesity, a study conducted by the University of Michigan Health System (2016) revealed the

positive correlation between low-income and obesity. When analyzing the data, African-American and

Hispanic children have a higher rate of obesity than other races. However, the previously observed

relationship between race and obesity was deemed inaccurate when family income was factored in. Ann

Arbor and Ypsilanti, although an approximate eight miles apart, are known to be extremely disparate.

Ann Arbor’s economy is fueled primarily by University of Michigan in addition to technology and

engineering firms, thus explaining the affluent culture amongst its residents. In comparison to Ann Arbor,

Ypsilanti is far more “blue collar”. Based on the demographics and economy, a significant amount of

Ypsilanti families are low-income and experience health disparities, including obesity.

Rationale

Global Perspective

Globally, obesity is an issue which affects individuals from all walks of life. Although the United

States is not the most obese country in the world, the overweight and obesity trends in North America are

alarming. In 2010, health complications linked to obesity, such as cardiovascular disease and diabetes,

were responsible for 3.4 million deaths globally (Mokdad, Murray, & Ng, n.d.). Between the U.S. and

Canada, two comparative countries in North America, the U.S. holds a higher percentage of overweight or

obese adults. Obesity is a financially demanding and growing problem, as an estimated annual amount of

$147 billion (CDC, 2017). Unfortunately, the sad reality of obesity is this: childhood obesity contributes

to a significant population of obese adults. Unless childhood obesity is addressed effectively, the rate of

obesity in the United States will continue to increase along with the medical costs and subsequent health

complications.

Identifying the Focus

Childhood obesity is a serious issue in the United States which stems from a variety of inherited

and learned behavior. According to the Centers for Disease Control and Prevention (CDC) as of 2017,

one in five children between the ages of 6-19 has obesity. Additionally, a 70% chance that an overweight

adolescent will become an overweight or obese adult exists (University of Michigan, 2016). While there

are several contributing factors, childhood obesity is most commonly influenced by: genetics,

environmental factors, social and individual psychology, eating and physical activity behaviors, and

metabolism. Obesity can lead to chronic and potentially life-threatening health complications, such as

diabetes and heart disease. Not only does obesity increase the risk of internal health, obese children often

struggle socially. Exclusion and teasing are dangerous triggers for obese children and subsequently might

cause a depression, a decrease in self-esteem, and negative body image.

Proposing a Solution

In order to combat childhood obesity, implementation of a program designed to educate and

improve health behaviors of this demographic is necessary. Upon entering middle school, students are

faced with a newfound sense of freedom pertaining to diet and physical activity. Inability to make healthy

and balanced choices will inevitably lead to an increase in the rate of obesity. Students tend to form habits

surrounding food and exercise around this age and it is crucial that they are provided with education and

materials in order to make the healthiest decisions possible within their respective environments.

Environmental factors, specifically available resources and socioeconomic background, largely influence

a child’s susceptibility to obesity. This program will therefore take into account the financial and

environmental limitations and resources available in order to successfully introduce healthier behaviors

which students will practice.

The Program’s Success

Keeping in mind the barriers our demographic of students and their families face, the program is

designed to promote optimal health and wellness specifically in this environment. Expanding beyond the

“eat better, move more” model of lifestyle change, the program will address all aspects of wellness and

take into consideration the several social determinants influencing the health of students. Based on an

comprehensive study conducted by the Agency for Healthcare Research and Quality in 2013, childhood

obesity prevention programs which include community and home components tend to have a higher

success rate than those which do not.

Methods of Data Collection

The program is created specifically for Scarlett Middle School, an Ann Arbor Public School

located in Ypsilanti, and takes into consideration the low-income and medically underserved population.

During the initial phase of creating the program, secondary sources of data will be imperative. These

sources include data previously collected by Washtenaw County Health Department which further detail

the demographic of our student population. In order to collect primary data for the program, the best

course of action would be to construct and distribute a survey amongst the students. The survey will be

constructed in accordance with a likert scale and consist of a variety of questions regarding nutrition,

physical activity, and environment (home, school, and social). Ultimately, the survey will allow us to

identify patterns in students’ health behaviors and the areas of the program which should be emphasized

based on this.

Ensuring Program Continuity

Our time and efforts will be directed towards teachers and principals because after our program

they will need to stay consistent with the students to help create change. We will come back mid-semester

to check on the students and ensure the faculty information s still encouraging proper nutrition and

physical activity. We will provide the faculty with information and material throughout the year to remind

the students of what they had learned in the beginning of the year. This way we will also known if the

information is being relaid to the students continuously and if any particular student is in need of more

assistance.

References

Centers for Disease Control and Prevention. (2017, January 25). Childhood obesity facts. Retrieved from

https://www.cdc.gov/healthyschools

Mokdad, Murray, & Ng. (n.d.). The vast majority of American adults are overweight or obese and weight

is a growing problem among US children. Institute for Health Metrics and Evaluation. Retrieved from

http://www.healthdata.org

Agency for Healthcare Research and Quality. (2013, June 10). Childhood obesity prevention programs:

comparative effectiveness review and meta-analysis. U.S. Department of Health and Human Services . Retrieved from https://effectivehealthcare.ahrq.gov

University of Michigan. (2016, January 7). Low income communities more likely to face childhood

obesity. Michigan Medicine. Retrieved from http://www.uofmhealth.org/news/archive

Needs Assessment

What We Need to Know In order to gather the appropriate information for our target population, we would need to conduct

a needs assessment which would comprise of both a social and social-environmental assessment. We will be collecting this data on the students, the parents, and the environment the students are in (school and home life). It will be essential for our program to know everything there is to know about the student. In order to conduct the social assessments, we will create small yet fun activities that focus on what their

favorite flavors are, what they like to eat, when they like to eat, where they like to eat and all of their interests. The most effective way to create change is to address and include their interests and make the change appear easier in comparison to whatever it is they are currently doing now. So in order to improve the nutrition of these middle school students, we need to focus on fun and effective methods to encourage positive behavior changes.

In terms of collecting data about the parents, we will need help from the students, faculty and administration at the school and if needed the physical parents. The information that we could gather from the students would be through creative avenues like art projects, word searches, kid surveys, group activities, among other fun and creative tools. These activities would notify us about the family dynamics and in particular, how close the children are to their parents . We would need to develop data collection tools which would address the following questions. Do the children come from 2 parent households? Are the parents able to spend a lot of time with their children? Is cooking a priority in the household? If the parents are working most of the time and are obligated to go out to eat more than they prepare a meal at home, this information is very valuable to us! The most beneficial information would be what dietary regimens do the parents follow? For instance, do they eat fresh fruits or vegetables and how often? Students in middle school really don’t have much option but to eat at home whatever their parents provide for them. If the work needs to be done side by side with the parents, we need to make sure that we are connecting and engaging both of our populations on the positive changes we are trying to make in their lives.

Finally, we will want to know as much information as possible about the school and the environments that the students are exposed to on a daily basis. We would first need the administration, teachers and lunch aids full cooperation. We would need to conduct a social-environmental assessment on our students based on information provided by the faculty and administration at the school. This would include information about the student’s demographics and SES, like for instance what neighborhoods do most of the students come from? Do most of the children ride the bus or receive a ride to school? We would need to know what type of race and ethnicities we are up against, since culture has a major influence on the children and their family’s diets. What foods are provided during school lunch? How many children eat free lunch vs. students who bring a lunch to school? We would conduct meetings that are centered on the observations of the lunch aides during the student’s lunch period. For instance, what particular foods do the students seem to finish and what ends up in the garbage at the end of the lunch period? Do they notice a trend with a particular group of students? Who do they observe most of the students gravitating towards and what are those student’s dietary practices?

The culture and climate of the school (the practices, beliefs, and the influence that the teachers have on the students) is very important. We would need to conduct an assessment on the school environment. An important question that we would need to find out is: Does the school already offer information on nutrition/health? If there are health classes, we would like to know how they are run. What are the teacher’s promotions and views on health? We would need to gather a group of people from our organization to conduct a sit-in and do some shadowing within these health classes. We need to make sure that what they are teaching coincides with our programs goals and objectives throughout the school year. Keep the students focused and engaged, while creating enjoyable experiences that they will remember for a lifetime is what the program is all about.

We will stick to the following three categories, which are students, parents, and school environment as our primary focus. Based on all of our data collected, we would make sure that our

organization is familiar with the culture we are dealing with. We will be sure to be sensitive to any necessary factors that may arise, such as religious practices that affect diet, etc...that may interfere with what our organization had in mind. Once we analyze all of our data, we will create a program that will be the most beneficial to the students and their families. Our goal is to be a successful program which prevents poor dietary choices both inside the school and inside the students’ homes!

Identifying Methods Prior to creating our data collection methods, we plan to utilize secondary data found on the Washtenaw County Public Health Department’s website in order to gain an accurate understanding of our targeted

population’s average income. Essentially, the nutrition and lifestyle of these students is contingent on the income of their parents. Taking the socioeconomic status of this demographic into consideration will

allow us to tailor the surveys for both students and parents based on the perceived barriers which are very much apart of daily living. Additionally, secondary data will serve as the building blocks in creating a survey which is unique to our target population and ensures that we, as health educators, are creating a

program which is relevant and realistic based on the data which has already been collected. Data collection requires the cooperation of parents and students, which emphasizes the

importance in creating surveys for parents and students based on what their lifestyles are, rather than our perception. Having a broad understanding about the population based on secondary data prior to conducting our research will serve as an asset: tailoring the parent survey and student survey to be relatable will increase our chance of receiving useable data - something which further increases our chance of implementing healthier behaviors. More importantly, students and parents will likely become empowered through a program which has been designed with their lifestyle and social determinants in mind. Ultimately, the success of our program heavily relies on our ability to assess the needs within this population and create data collection materials accordingly. Materials Parent Survey: The parent survey has been designed with in order to gain an understanding of parents’ behaviors and decisions in buying, cooking, and consuming food. This survey will be distributed in the primary phase of the program as one of the first steps, which will then allow the team of health educators to tailor parent materials based on patterns of health behavior observed from the data collection. Student Survey: The purpose of the general survey to gain an understanding of the students’ behaviors, pertaining especially to nutrition and physical activity. These behaviors are heavily influenced by external factors, such as resources and social influence. Attached below is a draft of a questionnaire serving this purpose. Do you cook at home? Y or N

Do you include your child’s input in what you buy from the grocery store ? Y or N Do you include your child's input in what you cook? Y or N

Does your child know how to make their own meals? N Y

Do you provide healthy alternatives for your child to eat? Y N

Do you incorporate vegetables into your child's diet?

Does your child eat breakfast daily? N Y

Does your child eat three meals a day? N Y

Does your child eat more than two snacks a day? Y N

Does your child eat Fast Food on a regular basis? Y N

Does your family eat meals together on a regular basis? N Y

Does your child eat after dinner and before bedtime? Y N

Does your child have a TV in his/her room? Y N

Does your child get physical exercise on a daily basis? N Y

Does your child have more than 2 hours of screen time on a daily basis? Y N

(TV, computer, texting, etc.)

1. During the PAST 7 Days, how many times did your family cook at home?

❏ We do not cook at home

❏ 1-3 times during the past 7 days

❏ 4-6 times during the past 7 days

❏ We cook 7+ times at home

2. During the PAST 7 days , how often did your family eat at fast food restaurants?

❏ We never eat at fast food places

❏ 1-3 times during the past 7 days

❏ 4-6 times times during the past 7 days

❏ We eat 7+ times at fast food restaurants

3. During the PAST 7 Days, how many times did your child eat fruit?

❏ They did not eat fruit during the past 7 days

❏ 1-3 times during the past 7 days

❏ 4-6 times during the past 7 days

❏ 1-2 times per day during the past 7 days

❏ 3 or more times per day during the last 7 days

4. During the PAST 7 Days, how many times did your child eat leafy green vegetables?

❏ They did not eat leafy green vegetables during the past 7 days

❏ 1-3 times during the past 7 days

❏ 4-6 times during the past 7 days

❏ 1-2 times per day during the past 7 days

❏ 3 or more times per day during the last 7 days

5. During the PAST 7 Days, how many times did your child eat other vegetables? (Green vegetables do not count)

❏ They did not eat other vegetables during the past 7 days

❏ 1-3 times during the past 7 days

❏ 4-6 times during the past 7 days

❏ 1-2 times per day during the past 7 days

❏ 3 or more times per day during the last 7 days

6. During the PAST 7 Days, how many times did your child eat breakfast in the morning?

❏ I did not eat breakfast in the morning during the past 7 days ❏ 1 day ❏ 2 days ❏ 3-4 days ❏ 5 or more days

7. During the PAST 7 Days, how many times did your child drink a can, bottle, or glass of soda or pop? ( Coke, Pepsi, Sprite, Dr. Pepper, or other)

❏ They do not drink soda or pop during the past 7 days ❏ 1-3 times during the past 7 days

❏ 4-6 times during the past 7 days

❏ 1-2 times per day

❏ 3 or more times per day

8. Do you pay attention to your child making healthy food choices when you eat with them?

❏ I never pay attention to them making healthy food choices

❏ I sometimes pay attention

❏ I frequently pay attention

❏ I always pay attention

9. During the PAST 7 DAYS, how many days was your child physically active for AT LEAST 60 MINUTES per day? (physical activity that increases your heart rate and makes you breathe hard some of the time.)

❏ 0 days

❏ 1 day

❏ 2-3 days

❏ 4-5 days

❏ 6 or more days

10. On an AVERAGE SCHOOL DAY, how many hours do your child watch TV?

❏ They do not watch TV on an average school day

❏ Less than 1 hour per day

❏ 1 hour per day

❏ 2-3 hours per day

❏ 4 or more hours per day

11. On an AVERAGE SCHOOL DAY, how many hours does your child play video or computer games or use a computer/tablet for something that is not schoolwork? (Include activities such as Ninetendo, DS, Play Station, Xbox, Facebook, Twitter, computer games, and the internet.)

❏ They do not play video or computer games or use a computer/tablet for something that is not

schoolwork

❏ Less than 1 hour per day

❏ 1 hour per day

❏ 2-3 hours per day

❏ 4 or more hours per day

12. On the following lines please answer the following prompt:

A. Do you believe your job/career/work prevents you from cooking more at home? Goals & Objectives

Goals 1. Students will gain a basic understanding about nutrition and exercise in relation to themselves. 2. Students and parents will feel empowered to work towards optimal health within their own lives. 3. The program will be designed based on resources already available in the community. 4. The school will have a good grounding on positive nutrition and exercise that they will continue

to implement even after the program 5. Students will continue their new habits throughout the rest of their schooling and on to their adult

lives. 6. Students relationships with their parents will improve while working on maintaining healthy

lifestyles together. 7. Students perspectives on healthy lifestyles will be changed to positive thinking and attainable

Objectives 1. Program materials for students and parents will be designed based on a needs assessment, both of

which will be completed by the first week of November.

2. By the end of the program, students will be able to identify healthy foods and forms of physical activity which contribute to a healthy lifestyle.

3. By the end of this program students will be able to apply what is learned in school about nutrition and apply it at home and at school lunches when choosing their own snacks.

4. At the end of the 1st month of the program, students will be able to take home to their families healthier alternative food recipes to some of their favorite dishes that they can either prepare on their own or with their family.

5. At the end of the first month of the program we would like students and parents to have completed the initial or primary surveys allowing the team to know more about their family relation to food. 6. After collecting the primary surveys I would like for the teachers to give the children the secondary survey on a weekly basis allowing the team to track the data on how well the parents and students are doing when it comes to eating healthier every week. 7. Each month the students will get new material or hear a new lecture on how to improve their eating habits to keep the information in the front of their minds. 8. At the end of every semester we will return to do another workshop and look at the students results directly and help them where they need it. 9. We also need to get access to all food allowed at school so we can adjust and inform students on the best options that are available while they are in school.

Intervention Outline

1. Strategies: The program consists of several components which encourage and enable students to make healthy behavioral changes. These strategies include education, evidence-based activities, groups activities, and interactive materials. Utilizing multiple strategies within our program will inherently improve the stigma and culture surrounding healthy lifestyle habits amongst the students.

2. Settings: Materials and education for students will take place within the middle school via health educators. However, the parent survey is conducted in the initial phase of the program in order to effective promote parent involvement and contribution to the behavioral change of students. By taking into consideration the impact which home life and social life (particularly at school) have on eating habits and physical activity, we hope to enable students based on both of these extremely influential environments.

3. Levels of Change a. Individual: On a personal level, this program provides opportunity and materials which

promote healthy behavioral changes in a way which is unique to the perception, circumstances, and obstacles within the lives of each student.

b. Interpersonal: Social support is imperative to the success of this program. The program has been designed in a way which encourages participation and hands-on learning from students, in hopes that this will build and strengthen relationships between other peers, teachers, and the health educators.

c. Environmental: Holding the program at school effectively changes the negative or “uncool” stigma which students might associate with eating healthy foods or exercising on a regular basis. Creating this sense of togetherness is encouraging for students and contributes to breaking the negative stigma.

d. Policy: This program changes the entire trajectory of nutritionally acceptable lunches which are served in Ann Arbor Public Schools, and hopefully serves as a building block in eventually offering healthier lunch options for students and eliminating those which have little to no nutritional value.

4. Utilizing Theory: Constructs within the Theory of Planned Behavior emphasize the influence of attitude and individual thoughts in behavioral change. For this reason, we found it promising to design program components based on subjective and social norms (determined by student surveys early in the program), perceived behavioral control, and attitudes. This theory creates alignment between the students’ perception of making healthy choices, their intention to practice healthy behaviors, and most importantly: behavioral change.

Budget

Category Item Total Cost

Wages 5 Person Project Staff $40,000

Materials Recipe Cards/ Reading Materials

$500

Health Education Materials Specialized Food Journals $1,000

Pocket Sized MyPlate Recommendation Cards

$50

Nutrition Education DVD’s $75

Health Equipment Blood Pressure Test Kits $50

Blood Glucose Test Kits $100

Environmental Costs Room Rental $35

Table and Chair Rental $50

AudioVisual Set Up $20

Incentives Gift Cards (Whole Foods/Fresh Thyme)

$500

WebPage Lease Per Month $25 (per month)

Miscellaneous/ Indirect Costs Electricity -----------

Discretionary Funds $5,000

Total $47,450

Timeline August 20, 2018: Initial meeting with faculty

● At this initial meeting, the staff of Project Eat Well will meet with the entire faculty of Scarlett middle school for a preliminary meeting. Faculty will be given information on the ins and outs of the program as well as the participation role that is necessary of them to ensure the success of their students and the success of the school as a whole. During this time, faculty will be given the materials that will be distributed to the students to look over and give feedback. By the end of this meeting we hope to have a fully committed faculty that understands this program so that they can help to guide their students and answer any additional questions that they might have. During this time as well, we plan on talking with teachers about healthier choices that we plan on implementing to the lunch menu and snack shop in the school and brainstorming any lunch ideas that would be both healthy and delicious enough to make the students want to eat them. The ChooseMyPlate recommendations will be given out at this time in a small size so that students can keep them with them to reference.

September 10, 2018: Initial meeting with students ● During this initial meeting we plan to introduce ourselves to the students in order to give them a

full understanding of who we are and why our program is important. We plan to start off with an introduction of ourselves and talking a little bit about nutrition. During this meeting, we will hand out the student surveys and allow students time to complete the surveys. After the surveys have been collected, we want to talk more about nutrition and why it is important for individual health and well being while also keeping in mind the beliefs of the students. We hope to present the material on healthy eating and healthy recipes in a fun and easy way so that students will perceive the information as useful and and cool. After our nutrition powerpoint, we plan to pass out recipe card booklets with 12 easy everyday recipes that can be created with ingredients available to students at their school as well. The recipes contain breakfast, lunch, dinner, and snacks. During this time we will also distribute the food and activity tracking journal and explain how to use it and what we hope they will gain from completing the journal. At this time parent surveys will also be distributed to students and are expected to be returned to the school as soon as possible. When we receive all this information, we will then be able to better tailor the program to fit the students needs.

December 10, 2018: Second session with students ● During this session, we will go over what the students have been recording in their food and

exercise journals. We will continue to talk about nutrition but during this session we will delve more into the physical activity portion of the program. We will go over games that can be played at recess and practice some proper stretching techniques as well as how to incorporate small exercises into everyday life. We will also collect any additional parent surveys at this time. We also will talk with students about how they have been incorporating their new recipes into their everyday life and introduce them to 12 new recipes. Additionally, we will speak with students

about their new school lunches and take feedback on how to improve them. Lastly, we will collect food journals to look over. Food journals will be returned to students in one week so that they can continue to track their daily food and exercise.

March 4, 2019

● During this session, we will go over more nutrition tips with students. We will incorporate group activities into this session so students can talk with people around them about how they have been coming along with their journey to better eating. We will ask students who seem fired up about healthy eating to come to the stage and talk to them more about what they have been doing and their favorite new recipes. 9 additional recipes will be handed out this day and we will go over them with students at this time. During this time we will show students how to take their blood pressure and blood glucose (if interested) and we will talk about what each of those numbers mean as far as health and how diet and exercise are important at managing them both.

June 3, 2019 ● During this session we will talk about student progress and how they enjoyed this program. We

will collect all food and nutrition journals to analyze. We plan to have this session be largely discussion based. We will talk with students about their favorite new foods and games that they have played recently. During this time, we will have a raffle l for students to have the opportunity to win gift cards to places like Aldi and Fresh Thyme. We will talk more with students at this time about what lunches and snack items they really enjoyed and which ones they could do without. We plan to take this information into account and relay it to the administrators at the school so that they can better tailor the lunch program for the following school year. We will have one final powerpoint at this time about nutrition tips such as how to read food labels and how to stretch your dollar at the store on healthy snacks. We will also have at least two activities that are fun and require students to stand up out of their seats and get a little bit of physical activity in. At the end of the program all the students will get a certificate of completion and we will take group pictures.

● After this last meeting with students we will have a meeting with faculty where they will discuss the outcomes of this program and ways that we can make it stronger.

Logic Model

1. Situation - Lack of healthy eating and lifestyle habits and education amongst middle schoolers - Limited resources and options due to low socioeconomic status - Unhealthy behaviors condoned or learned by families and parents - Issues stemming from entire family lifestyle habits, rather than the students only

2. Inputs - Program materials - Money for the program and resources - Time - Building relationships with the health educators, staff, and students

3. Outputs

a. Activities - Promote healthier choices by educating the students and parents - Evidence-based approaches in order to ensure success of the program - Program will consist of four educational sessions (two per semester)

b. Participation - Middle school students, inclusive of grades 6-8 - Parents of the students - Evidence-based approaches include interactive materials, such as lifestyle

journals and food prep courses which utilize seasonal vegetables and healthy ingredients

- Each of the four sessions will build on the previous ones, taking into consideration the self-efficacy and attitudes of the students

4. Outcomes a. Short

- Increase the access to healthy food options - Increase social support which is provided to students, including peers and

families - Students and parents educated and empowered to make healthier choices

b. Medium - Increase in healthy eating - Increase in physical activity - Disparities of food deserts and physical activity facilities will decrease - Students and parents making healthier choices to actively prevent the onset of

disease c. Long Term

- Families of students will maintain healthy weights - Decrease in overall rates of childhood obesity - Equitable resources available to low-income populations in order to achieve

optimal health -

Evaluation Because Project Eat Well will be implemented over the course of one school year, potential

evaluation options include seeking feedback from students, parents, and staff members as the program concludes. For parents and students, conducting the same survey from the beginning of the program will accurately determine how much has been learned over the course of the sessions. Success of the Program

Taking into consideration the several challenges which families of low socioeconomic status are faced with, this program has been designed in a way which uses these obstacles to empower students and their parents in adopting healthier eating habits. Furthermore, Project Eat Well promotes a strong sense of community, in which students will feel knowledgeable and equipped to make healthy choices for themselves. Lifestyle habits, referring to eating and physical activity, are often formed beginning in the pre-teen years, and have the ability to change the trajectory of these students’ lives in the future.

Providing resources and education to students of low SES breaks the cycle and combats obesity during the most critical and influential phase: the beginning.