Nutrition Panel Tells All: Fueling the Future

According to an article on the Stanford Social Innovation Review, "No single organization has the ability to solve any major social problem at scale by itself. Collective impact is a powerful new approach to cross-sector collaboration that is achieving measurable effects on major social issues." New York City is exemplifying this idea of collective impact achieved through cross-sector collaboration to reverse the childhood obesity crisis in its own backyard.

The Centers for Disease and Prevention reports that in 2012, more than one-third of children and adolescents were overweight or obese. Millions of households struggle to put enough food on the table, and also lack the proper knowledge and skills to choose and prepare nutritious options.

In NYC - a diverse city with a population of more than eight million people - the approach needs to be comprehensive, inclusive, and focused. The NYC Department of Health & Mental Hygiene is leading the charge by focusing in on the drivers of diet-related health and obesity issues and how to address them, along with other key players and experts in the health field.

Common Threads - a national nonprofit organization whose mission is to fight childhood obesity by educating low-income children on the importance of nutrition and physical wellbeing, empowering them to be agents of change for healthier families, schools, and communities - brought together those key players to see what we could learn about how they, in partnership with Common Threads, are addressing the health crisis.

Linda Novick O'Keefe, Frances Largeman-Roth, Dr. Robert Graham, Stella Yi, Pamela Koch, Lorna Power

We spoke with: Lorna Power, New York City Department of Health & Mental Hygiene; Pamela Koch, Laurie M. Tisch Center for Food, Education & Policy; Stella Yi, NYU School of Medicine; Dr. Robert Graham, Office of Community and Public Health & North Shore-Long Island Jewish Health System and Founder of @farewellness; and Frances Largeman-Roth, RD, about the cross-sector collaboration approach that they are using to tackle childhood health.

These experts identified how we can work together and use systems and programs already in place to make sure our little ones, with their still-developing minds and bodies, are equipped with the nutrition and cooking skills they need to take control of their health - one meal or snack at a time.

This cross-sector collaboration in NYC can serve as a model for other cities to affect positive change in their own communities.

LORNA POWER, NYC Department of Health & Mental Hygiene
Building a task force to share information and working together towards a common goal can ensure success.

"Don't reinvent the wheel."

Lorna Power, the Assistant Manager of Nutrition Education Programs within the Bureau of Chronic Disease Prevention and Tobacco Control at the NYC Department of Health & Mental Hygiene, helps oversee nutrition education programming in childcare settings and farmer's markets.

Lorna described the NYC Department of Health & Mental Hygiene as a "resource hub" that acts as a connecter in the community. The longstanding relationships they have with various organizations and schools can help facilitate the sharing of information and resources to increase effectiveness for everyone.

In order for an organization to create change they must define what success means for them and determine how to best track progress. These ideas of common goals and shared measurements of success are key components of the organized collective impact models. Beyond that, she stressed the importance of collaborating with others for success in schools, and that a one-size-fits-all approach does not work. According to Lorna, success comes from sharing resources, making partnerships, and connecting already-existing processes amongst organizations with a common goal. Working together with teachers and administrators and focusing on the benefits of children is also important.

The NYC Department of Health & Mental Hygiene promotes and protects the health of all New Yorkers by working to close the health inequity gap and identifying the key drivers of diet-related health and obesity issues. The Bureau of Chronic Disease Prevention and Tobacco Control takes a broad approach to raising awareness of health issues facing the population. Strategies include warning labels at restaurants, media campaigns, targeted community approaches, nutrition education workshops, farmer's market programs, and programs designed to increase access to healthy food.

PAMELA KOCH, Laurie M. Tisch Center for Food, Education & Policy
A multifaceted approach is necessary to reach more kids with effective nutrition education. If evaluation is a part of it, with data showing that kids are not only healthier, but also learning better because of it, then nutrition education will become a top priority.

"I really believe that you need quality nutrition education, hands-on experiences, and exposure to health food in order to navigate through today's food environment successfully."

Pamela Koch's work at the Tisch Center focuses on curriculum development and evaluation. She researches the connections between a just, sustainable food system and healthy eating. The Tisch Center then translates that research into useful resources, such as curricula for school teachers and recommendations for policy makers.

She attributed the increase in childhood obesity to today's challenging food environment and has research to back that up. According to Pamela, changes over the last decade have brought challenges related to access to healthy and affordable food, families preparing and eating food at home less frequently, and a lack of the knowledge and skills to make healthy choices.

Collaboration is another critical component and Pamela, along with the other panelists, said that programs should partner together and incorporate research and evaluations to show success; a necessary step in implementing widespread programming. One of her recent studies (1) in the Journal of the American Dietetic Association showed that targeted curriculum intervention focused on energy balance was successful in "improving many of the specifically targeted behaviors related to reducing obesity risk, indicating that combining inquiry-based science education and behavioral theory is a promising approach."

Encouraged by direct service providers like Common Threads, the Tisch Center has used data from the 2013-14 school year to identify where programs are working in schools and which schools have a need. She explained, "nutrition education needs to follow evidence-based deterministic behavior changes that get kids motivated to want to make changes."

STELLA YI, NYU School of Medicine
Multiple things need to be in place at the same time to ensure success: nutrition education, access to affordable and healthy food, understanding cultural norms, and neighborhood social cohesion and engagement. Continued research and evaluation can help organizations fine tune the multilevel approach and reaching children early can create change for entire families and communities.

"Children can be a cornerstone to incorporate change into the family structure and can create a hybrid of American culture, while also being an ambassador in translating the different cultures together."

Stella Yi, Assistant Professor in the NYU School of Medicine Department of Population Health, explained that the approach to childhood nutrition must first start with education and access to healthy foods, regardless of culture, but also factor in cost and quality of food. The approach needs to be multilevel and collaborative, so once education and access are in place it is important to consider cultural norms in order to determine what is appropriate. She shared details of this type of approach in an article (2) published in the May 2015 issue of the American Journal of Public Health and hypothesized that "complementary initiatives, implemented simultaneously, will create a citywide food environment that fuels changes in social norms and cultural preferences, increases consumer demand, and supports sustainable access to affordable produce."

The NYC School system is one of the most radically segregated in the country. Stella works closely with community members to culturally tailor the nutrition education materials they provide to each community. While the diversity makes it challenging because there are so many different cultures with unique obstacles and considerations, in some ways it also simplifies things because it allows focusing on a specific population.

The sheer size and population density of NYC can disrupt social cohesion within communities, so in addition to access and cultural norms, Stella recommended focusing on the social environment of communities. She explained that early studies have shown that neighborhoods with higher levels of social cohesion are more physically active and eat more fruits and vegetables.

"We are finding that if you feel a sense of belonging within a community, you can improve someone's engagement with that community," said Yi. Measures that improve community engagement, increase access to healthy food, and impart the knowledge and skills to prepare meals at home will interact to improve nutritional status in underserved neighborhoods.

Given NYC's prevalent racial and health disparities it is imperative for service providers to consider ways to expose children to nutrition education at an early age in order to improve the situation. Children can be the gateway to American culture for immigrant families who, contrary to popular belief, may not adopt Westernized habits as they settle into life in this country.

DR. ROBERT GRAHAM, Office of Community and Public Health & North Shore-Long Island Jewish Health System, and Founder of @farewellness
The current medical system model makes it challenging for doctors to provide patients with nutrition education. Individuals should keep it simple and eat foods that their grandparents would recognize.

"Our education system is focused on disease management, not health's the perfect storm for a sick country."

Dr. Graham, a practicing physician, grew up in Queens in a diverse population. Board Certified in Internal Medicine, and one of the only 100 physicians Board Certified in Integrative Medicine, Dr. Graham's work incorporates his roots into integrative and traditional medicine, emphasizing good cooking, farming, and the healing properties surrounding those elements.

He traced the problems with the populations' health back to the fact that we no longer pass food knowledge from generation to generation; he explained that there is "tremendous wisdom from our ancestors that has been lost in food, nutrition, and healthcare."

Dr. Graham, who estimates that 20% of his patients are diabetic, believes that the medical professionals need to adapt and offer more health and wellness information and programs. The conversation needs to be about how the medical education system can introduce that knowledge; he feels his patients are ready for a change. While some large medical schools are introducing nutrition into the curriculum, there are currently no set requirements for nutrition education in graduate medical education. As the system is set up currently, most physicians receive a few hours of nutrition education and no culinary education.

Dr. Graham identified a problem that has been called out by others in the past. "The latest word on this gap in medical education came from a study published in 2010 showing that only about one quarter of more than 100 medical schools surveyed provided the 25 hours of nutrition instruction recommended by the National Academy of Sciences in 1985 - more than 25 years ago," said Dr. Andrew Weil.

Research has shown that overweight patients are more likely to be aware of their obesity and to have attempted weight loss if their physician has discussed it with them. Dr. Graham chooses to focus on the positive instead of telling patients what not to eat. He sticks to a couple of simple guidelines: Limit foods that come in a box, practice mindful eating by listening to your body's cues to stop eating when you are 80% full and start cooking!

Make the good-for-you-food fun! Children will be intrinsically motivated to make healthy choices on their own.

"We have to make the non-junkie food items just as fun, interactive, and cool as the junky stuff, which is challenging."

Registered Dietitian Nutritionist and best selling author Frances Largeman-Roth has helped thousands of women and families in America feel healthy and lose weight with her nutrition advice and healthy recipes.

While there might be regulations on the advertising that can be shown on television, there is a whole new frontier out there now. YouTube videos, the Internet, games, and apps - our kids are surrounded by food advertisements and marketing campaigns. Nearly 40% of all food and beverage ads children and teens see on television are for snacks. Mobile apps and social media are also seeing more and more of these ads and much of that marketing is confusing. Just because a company has reduced the amount of sugar and added whole grains in a food product, it does not mean it is a healthy product.

Children are attracted to a certain type of packaging and characters, and food companies use that in their favor. Frances pointed out that the same type of packaging can be used in healthy foods and it will have the same attraction. There are some examples of companies doing just that. Frances cited Chobani and Annie's as examples of companies that are using innovative and fun packaging for their products, which means parents who prioritize their kids making healthier choices can feel good about that. Sprout Network 's television show, Lazy Town, is another example of healthy information being delivered in a way that is appealing to children.

Frances works to make healthy food fun in her own life. She takes note of things that cooking shows, major brands, magazines, and others are doing and applies it positively on her own. She prepares smoothies for her three kids and adds hot pink dragon fruit to the ingredients; color is a great way to get kids excited about eating healthier foods. People eat with their eyes and food should look tasty and exciting, especially when trying to get kids to try new things. She also focuses on the positive instead of the negative - rather than a list of things not to eat she encourages adding more fruits, vegetables, and whole grains. Being prepared with healthy options ready for snacking is another way to avoid unhealthy, convenient foods.

Every panelist provided thoughts and suggestions that will contribute to creating a culture of health for kiddos in their communities, schools, and homes. A common element that everyone stressed is the idea of collaboration. Other cities can learn from the collective impact being created through cross-sector collaboration in New York City. If organizations, schools, medical professionals, and companies join forces and share resources and information then the fight against childhood obesity can advance by leaps and bounds.

Another article on the Stanford Social Innovation Review laid it out perfectly, "Large-scale social change requires broad cross-sector coordination." It goes on to explain that the focus must shift from isolated efforts and intervention to the collective efforts than can be made when people and organizations work together.

(1) J Am Diet Assoc. 2010 Dec;110(12):1830-9. doi: 10.1016/j.jada.2010.09.015.
Adolescents demonstrate improvement in obesity risk behaviors after completion of choice, control & change, a curriculum addressing personal agency and autonomous motivation. Contento IR1, Koch PA, Lee H, Calabrese-Barton A.

(2) Am J Public Health. 2015 May;105(5):e29-37. doi: 10.2105/AJPH.2015.302587. Epub 2015 Mar 19. Increasing access to fruits and vegetables: perspectives from the New York City experience. Sacks R1, Yi SS, Nonas C.