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A Review on the Relationship between Obesity, Dietary Habits, and the Many Other Factors Contributing to this Deadly Epidemic Jenna Dennis, Caitie Thomas, Ryan Bright, Vivian Arula Spring 2016 Georgia Southern University 1

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Page 1: Eat Healthy Be Healthy Program

A Review on the Relationship between Obesity, Dietary Habits, and the Many Other Factors Contributing to this Deadly Epidemic

Jenna Dennis, Caitie Thomas, Ryan Bright, Vivian Arula

Spring 2016

Georgia Southern University

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Table of Contents

Planning Team Biographies 3

Planning Committee Members 5

Abstract 6

Introduction/Literature Review 7

Needs Assessment 13

Mission, Goals, and Objectives 17

Framework 18

Timeline 20

Logic Model 21

Intervention 22

Budget 25

Methods 29

Results 32

Discussion 35

References 39

Appendix 46

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Planning Team Biographies

Jenna Dennis

My name is Jenna Dennis and I am from Vidalia, Georgia. I am a senior at Georgia

Southern University about to graduate with my Bachelor’s Degree in Public Health Education

and Promotion. After graduation in May, I have obtained an internship through the International

Rescue Committee with their Resource Development Program.

Vivian Aralu

My name is Vivian Aralu and I am from Nigeria but have lived in Atlanta Georgia for six

years. I am a senior at Georgia Southern University and will be graduating in the fall will my

Bachelor’s Degree in Health Education and Promotion from the college of Public Health.

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Caitie Thomas

My name is Caitie Thomas and I am from Macon, Georgia. I am currently a senior at

Georgia Southern University and I will be graduating in the fall with my Bachelor’s Degree in

Public Health.

Ryan Bright

My name is Ryan Bright and I am from Riverdale, Georgia. I am a senior at Georgia

Southern University and will be graduating in the fall of 2016 with my Bachelor’s Degree in

Public Health and a minor in Nutrition.

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Planning Committee Members

This planning committee will consist of students of Georgia Southern University’s College of Public Health.  Members from this group hold a specific role towards the implementation of the program at the Hearts and Hands Clinic of Bulloch County. Each member will help contribute equally to assure the success of the program, each providing different insight on health dietary habits and ideas of how to avoid obesity, specifically within the realm of the Statesboro community.  The members include:

Urkovia Andrew, Hearts and Hands Clinic, Executive Director

Caitie Thomas, Program Planner, student at Georgia Southern University, (Health Education and Promotion)

Jenna Dennis, Program Planner, student at Georgia Southern University, (Health Education and Promotion)

Vivian Aralu, Program Planner, student at Georgia Southern University, (Health Education and Promotion)

Ryan Bright, Program Planner, student at Georgia Southern University, (Health Education and Promotion)

Ms. Urkovia Andrew is the Executive Director of The Hearts and Hands clinic of Bulloch County. Being the Executive Director for over a year at this facility, she understands our target population and will help guide the program to meet our overall mission, goals, and objectives. She will also assist in executing our marketing plan to help reach a majority of the patients that attend the Hearts and Hands Clinic. Ms. Andrews will also help monitor the program to ensure that the program is being carried out effectively. Caitie Thomas, Jenna Dennis, Vivian Aralu, and Ryan Bright will act as Program Planners and will actively implement the program to the program participants which will include, patients at the Hearts and Hands Clinic, and to members of the Statesboro/Bulloch County community who may also attend the program. The Program Planners will utilize Health Education Strategies such as print materials including flyers, to ensure that there is an equal opportunity for individuals to attend the program, as well as utilize PowerPoint lectures along with the two activities outlined in the Centers for Disease Control and Prevention Road to Health Toolkit, including “Community Kitchen” and “Portion Distortion”, to ensure program participants receive the information they need to incorporate healthy dietary practices into their daily life. Each member is significant and it is vital that they carry out their roles effectively to ensure the success of the program.

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A Dietary Habits Intervention Program for Middle Aged Adults: Eat Healthy, Be Healthy

Jenna Dennis, Ryan Bright, Caitie Thomas, Vivian Arula

Georgia Southern University

Abstract

Background: Adult obesity is becoming an increasing concern in the United States.

Obesity can be linked to other health conditions like heart disease, type 2 diabetes, stroke and

many more. The two main risk factors for adult obesity include dietary habits and lack of

physical activity. Objective: The purpose of this study was to evaluate the effectiveness and

feasibility of an intervention held at a low poverty dental organization aimed to educate middle-

aged adults on healthy dietary habits with emphasis on understanding how to read food labels

correctly and learning correct portion sizes. Methods: Through voluntary-based participation,

the participants attended the intervention at the Hearts and Hands Clinic (n=4). This intervention

was a one group pretest/posttest design. Program intervention consisted of two 20 minutes

portions: reading food labels and understanding portion sizes. Through a researcher developed

pretest and posttest, participants were tested to measure knowledge. Results: The intervention

displayed no statistical significance. The overall outcome of the study displayed an increase in

the mean score of the pretest and posttest from (5.250) to (10.500) with an overall increase of

5.25. Conclusion: This study overall confirmed early insinuations for increasing knowledge in

middle aged adults of healthy dietary habits through education.

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A REVIEW ON THE RELATIONSHIP BETWEEN OBESITY, DIETARY HABITS, AND THE MANY OTHER FACTORS CONTRIBUTING TO THIS DEADLY EPIDEMIC

Obesity is a major public health problem in the United States affecting a very large

portion of the population. Obesity is the result of an imbalance between how much energy one

intakes and how much energy one puts out which leads to the buildup of excess fat (Skolnik &

Ryan, 2014). In order to determine if individuals are overweight or obese a tool recognized as

(BMI) or Body Mass Index, is used to estimate and determine the amount of fat in the bodies of

adults and children (Overweight and Obesity Statistics). Obesity is based on the BMI greater

than 30.0 kg/m2 of an adult’s total body fat (Skolnik & Ryan, 2014). More than one third of the

population in the United States is obese. Obesity itself is brought on by many different factors

and from that can cause other types of diseases such as diabetes, heart disease, some cancers, and

high blood pressure. Not only can obesity cause minor problems to a person’s well-being, but it

can cause severe and deadly complications. Many people are not properly educated in the

different factors that affect your chances of getting to the state of obesity. The epidemic of

obesity draws major concern due to the risk factors associated with this condition as well as other

health issues and chronic illnesses including heart disease, stroke, diabetes, and some types of

cancers, which are all diseases associated with individuals that are overweight and obese, and are

recognized for being some of the leading causes of death in the United States

(permanent.access.gpo.gov).

A report from the Harvard School of Public Health indicated that as at 1990, about 15%

of the United States population were obese. As of 2010, the number has risen to 25% (The

Nutrition Source, 2015). According to the Journal of Intellectual Disability Research over the

past several years the obesity rate has increased from 15% to 35% over the past 20 years (Hsieh,

Rimmer, & Heller, 2014). The Centers for Disease Control and Prevention Vital Signs monthly

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report recognizes obesity as common, serious, and costly (VitalSigns). In the United Stated

States more than 12 million adults are obese and persons who are obese have medical costs that

are $1,429 higher than those of normal weight, and no state in America is recognized for having

an obesity rate less than 15%, which is the national goal (VitalSigns). The United States has

spent about $147 billion just in 2008 as medical cost of obesity (CDC, 2015).

Obesity is not exclusively eating excessive amounts of food, there are many other factors

that play a part in an adult resulting in obesity. Food insecurity is defined as limited access to the

correct, healthy amount of food. (Nguyen, Shuval, Bertmann & Yaroch, 2015) With food

insecurity, comes an increased amount of stress levels and decreased amount of one's overall

wellbeing (Nguyen, Shuval, Bertmann & Yaroch, 2015). Food insecurity is a major stressor on

adults which can cause them to have many other health problems.

The greatest age population that obesity affects is middle aged adults. Middle aged adults

suffer from tremendous amounts of stress which can lead to a lack of physical activity and a

decreased amount in the adequate amount of food they are supposed to intake. Many adults do

not have enough time during the day to plan out their meals. As middle aged adults move into

the next stages of their life, it is a critical time period for the progression of the risk of obesity

(Xiang & An, 2014). Midlife is the most common period in which obesity peaks in an

individual's lifetime. Middle adulthood is also a time in which one's immunity begins to decline

which leads to excess weight gain, poor exercise, and poor dietary habits (Xiang & An, 2014).

Individuals in their middle ages need to be more aware of the risks that obesity can lead to.

Middle age adults need to be knowledgeable about outcomes because of their vulnerability.

There are many variables that factor into a person’s dietary habit causing their unhealthy

lifestyle. A person’s option of food is generally based on their location. Some Americans have

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less access to stores and markets that provide healthy and affordable foods such as fruits and

vegetables, especially in rural, minority and lower income neighborhoods where the foods being

easiest to access are foods high in sugar, fat, and salt; also restaurants, snack shops and vending

machines provide food that is often higher in calories and fat than food made at home

(VitalSigns). Those who live in rural areas are more likely to be obese because of how accessible

fast food restaurants are in the area. Rural areas face two distinct, but nevertheless related

phenomenon: high obesity rates coupled with obesity disparities between racial and ethnic

groups. As stated in research by Richard Dunn, understanding how to reduce obesity, and thus

the cost of obesity-related morbidity, is a topic of great interest for policy makers. The quick

increase of the obesity rate in the United States corresponds with the outburst in the number of

fast-food establishments. Also, Dunn made it known that “the cost and availability of fast-food

are both actionable policy levers; lawmakers can restrict access through zoning decisions,

impose taxes on the sale of fast-food items, require nutritional information be made available to

consumers, and prohibit the use of particular ingredients” (Dunn, 2012). This would increase

awareness in areas that are restricted to fast-food institutions and help create a healthier lifestyle.

Many changes can be attributed to a healthier lifestyle to avoid excessive weight gain and

possible health concerns. Alteration in dietary habits can be adjusted with knowledge of what to

eat, how much too considerably eat and what not to. Possible price taxes on high-calorie foods,

placements of more local grocery stores and farmers markets, and education on dietary habits

can lead to healthy weight reduction plummeting the risks of major health issues.

As a result of with obesity, many adults experience negative mental health effects that

can lead to certain mental disorders. It has been linked in a study that fat mass and obesity is

associated with a certain gene that relates obesity to impaired cognitions (Xiang & An, 2014).

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With all the different effects that obesity has on the body such as stress, and the factors brought

on by it, also not to mention the different chronic diseases, it clearly begins to affect the way

adults think about themselves. Obesity and depression have been proven to be linked to one

another and differ by sex, race and ethnicity (Xiang & An, 2014) Functional impairment can put

a strain on an individual's daily regular activities and reduce one’s overall quality of life. As a

result of these impairments, obesity can increase the morbidity and mortality rate (An & Shi,

2015).

The relationship between the occurrence of obesity and an individual being diabetic has

been studied extensively with an emphasis on the effects of physical activity. The interaction

between physical activity and obesity and how they influence the onset of type 2 diabetes was

studied by Qin et al in 2010. From this study, they observed that obesity was a stronger

independent risk factor than physical activity for type 2 diabetes (Qin et al., 2010). Environment

plays a role in obesity for middle aged adult; snacking or unhealthy eating, physical activity,

access to gyms, time and many more. Adults who spend an excessive amount of time in the

workplace are more likely to indulge in snacking as a result of stress induced overeating habit,

skipping meals, occupational sitting time and less time for physical activity (Park et al., 2014).

It is unarguable to state that the occurrence of diabetes related to obesity can be reduced

in the United States if the sufferers of these health conditions participate or increase their

participation in physical activities. For substantial health benefits, adults should do at least 150

minutes a week of moderate-intensity, or 75 minutes a week of vigorous-intensity aerobic

physical activity, or an equivalent combination of moderate and vigorous intensity aerobic

activity.

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Another major factor about the obesity epidemic is its prevalence in minority

populations. A review conducted by the Department of Biostatistics and Epidemiology at the

University of Pennsylvania Perelman School of Medicine, stated, the growing interest in obesity

in minority populations reflects an awareness of the high prevalence of obesity among black,

Hispanic, Asian and Pacific Islander and Native Americans as well as a generally increased

interest in minority health (Kumanyika, 2012). What is also identified is the fact that some

aspects of obesity among minorities differ from those in white populations, which suggests that

new insights may be gained from studying obesity in diverse populations. In the United States

minority populations are identified into four major subgroups including: African Americans,

Hispanic Americans, Asian-Pacific Islander Americans, and American Indians and Alaskan

Natives (US Department of Health and Human Services). In the United States, minority or “non-

white” status predicts certain negative health outcomes with a conspicuous degree of certainty

(Kumanyika, 2012). Describing health disparities according to minority group categories has

been very useful in epidemiological research. However, scholarly considerations of racial and

ethnic differences must acknowledge the uncertainties inherent in minority group classifications

and guard against the numerous pitfalls associated with their use (Kumanyika, 2012). The

dependency on these racial and ethnic classifications has become increasingly problematic for

health researchers, particularly as the diversity among minority populations increases

(Kumanyika, 2012).

There are many variables that factor into a person’s dietary habit causing their unhealthy

lifestyle. A person’s options of food is generally based on their location. Other factors that

contribute to an adults dietary habits have been identified by six key determinants: biological,

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economic, physical, social, psychological, attitude, beliefs, and knowledge about food (Yasmeen,

Jamshaid, Khan, Salmon, & Ullah, 2015).

With the prevalence of obesity rising in the United States, there is a more generated

extensive investigation into the many different consequences of obesity and the many diseases

associated with it (Skolnik & Ryan, 2014). Over the past several years, the prevalence of adult

obesity has more than doubled with the morbid obesity rate quadrupling (An & Shi, 2015).

Currently, the most readily available treatments for weight loss are are reducing food intake

while controlling appetite to produce better results for a reduced weight (Skolnik & Ryan, 2014).

Population-based strategies that improve an adult's social and physical environmental situations

for healthful eating and physical activity are available in forms such as clinical preventative

strategies and treatment programs for those who are already obese. (Flegal, Carroll, Ogden, &

Curtin, 2010). More preventative interventions about the link between the built environment and

the food environment may lead to health benefits for the adult population. (Flegal, Carroll,

Ogden, & Curtin, 2010). Intensifying efforts need to be made to provide health education on

obesity in order to lead to improved health and a decrease in the prevalence of obesity among

adults (Flegal, Carroll, Ogden, & Curtin, 2010). More programs need to be done to find better

and effective ways of curbing the incidence of obesity among middle aged adult in the United

States.

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Needs Assessment

Health StatusObesity in the United States is a public health concern and a social problem because the rise in

the obesity prevalence rate has been stunning over the past three decade (Morales, 2013). The

health risks associated with obesity make reducing the high prevalence of obesity a public health

priority. Previous publications have shown both racial and ethnic disparities in obesity

prevalence and no change in the prevalence of obesity among adults since 2003–2004. Compared

to 2008, more than one-third (age-adjusted 34.9%, crude 35.1%) of U.S. adults were obese in

2011–2012. Overall, the prevalence of obesity among middle-aged adults aged 40–59 was higher

than among younger adults aged 20–39 or older adults aged 60 and over. Middle age adult men

had 39.4% prevalence of obesity while middle age adult women had 39.5% prevalence of

obesity. More than 78 million adults were obese in 2011–2012. The majority of these obese

adults (more than 50 million) were non-Hispanic white. (CDC, 2013).

According to Georgia Department of Community Health, Obesity is also one of the

health issues in the state of Georgia. The prevalence of obesity has increased rapidly in Georgia.

The rise in obesity has had a severe health and economic impact on Georgia with a huge cost of

$2.4 billion every year. Reports states that 28% (1.9 million) of civilian adult, non-

institutionalized Georgians are obese. The percentage of the obese adults in Georgia does not

meet the Healthy People 2010 national goal (15%) regardless of age, sex, race, ethnicity, income

or education. Only 1 in 2 (48%) adults in Georgia are regularly active. Only 1 in 4 (25%) adults

in Georgia consume 5 or more servings of fruits and vegetables daily. Across all racial groups,

men (51%) are more regularly active than women (45%). All these factors are some of the things

that have an impact in the increased rate of obesity in Georgia.

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According to Georgia Department of Community Health, in overall, 29% of adult Georgians

were obese in 2007. However, the prevalence of obesity varies across the counties, ranging from

23.3% to 35.6%. Bulloch county rating for obesity is 29.2% and 24.2 to 34.9 confidence interval.

Community Description

Bulloch County of Southeast Georgia is up-coming and prospering to become a larger

community. The estimated population is roughly 72,087 according to the census of 2010 and is

made up of four cities; Statesboro, Register, Portal, and Brooklet. The different races that make

up Bulloch county are as given: White 67.0%, African American 29.1%, Hispanic 3.7%, Asians

1.7%, and other 0.5% as of July 1, 2014 (Quick Facts 2015). People who are 18 years of age and

under make up 20.4% of Bulloch County and those who that are 65 years old and accommodate

for 10.4% of the area. The median household income as of 2013 is $35,840 and 30.6% are living

under the poverty level. The local university of Bulloch County is Georgia Southern University,

with 20,517 students a of the 2014-2015 academic year, adding on to the total population and is

continuing to grow (Georgia Southern, 2015).

Preliminary Qualitative Data

On September 25, 2015, a formal meeting, and interview, with the Executive Director of

The Hearts & Hands Clinic, Ms. Urkovia Andrews, was conducted. When discussing and

assessing the needs of the population to formulate an effective program that will tailor the needs

of the Clinic, it was important to have an accurate depiction of the population of patients that

receive services from the Hearts & Hands clinic. Ms. Andrews stated, that we would be “dealing

with obese and diabetic patients that could benefit from programs incorporating healthy eating

habits and physical activity” (Andrews, U. 2015, September 25). What was also important was to

understand the dynamic and background of these individuals to have a degree of cultural

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competence and sensitivity when dealing with this population and Ms. Andrews stated that, “all

of our patients are 200% below the poverty line and this clinic is their only access to receiving

health services” (Andrews, U. 2015, September 25). The proposed program to Ms. Andrews was

adopted from the Centers for Disease Control and Prevention Road to Health Toolkit and

Activities Guide, known as Activity 4: Community Kitchen. This program activity was

formulated to teach the healthier side of cooking, how to read labels, and how to make dishes

lighter without giving up flavor as well as teach participants how to recognize healthier food

choices (ndep.nih.gov). This program is complementary to the services already provided by the

Clinic as it promotes health education and assist in accomplishing the purpose of the Clinic

which is to “serve the community by providing support for individuals as they seek ways to

better themselves”(The Hearts & Hands Clinic).

Community Link

According to Georgia Demographics, Bulloch County is recognized as the 32nd most

populated county in the state of Georgia out of 159 registered counties (Bulloch County

Demographics). What has to be recognized, since Bulloch County is one of the largest counties

in the state, is the fact that health disparities do exist. This is why programs that help and give

assistance to these individuals living in poverty is vital for this community. The Georgia

Volunteer Health Program, or (GVHCP), of the Department of Public Health, is recognized for

providing protection to licensed health care professionals who volunteer to treat uninsured

individuals at or below 200 percent of the federal poverty level (GVHCP). The Georgia

Volunteer Health Care Program is also recognized for partnering with free clinics and service

providers across the state of Georgia in order to ensure that health care services are made

available and are more accessible to low-income Georgia resident (Hearts and Hands Clinic).

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One of these free clinics can be found in Bulloch County, and is known as The Hearts & Hands

Clinic, which is Statesboro’s only free health care clinic for the medically uninsured (The Hearts

& Hands Clinic). The Hearts & Hands Clinic offers services for its patients at no cost, these

services include medical, dental, and vision care (Agency Information). The increase in

volunteer medical staff has resulted in about 80 healthcare providers volunteering their time in

support of the clinic, and the increase in array of services is due to a now full time executive

director administering this facility (Agency Information). The clinic also continuously offers

and conducts free educational programs to the public, as well as the patients at the Hearts &

Hands Clinic, topics covering issues related to diabetes, heart healthy living, and managing

chronic illness (Agency Information).

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Mission Statement

The mission statement for this program is to provide information on healthy dietary

habits to the adults of the Hearts and Hands Clinic to promote healthy eating habits.

Goals

1. To increase education on healthy dietary habits for adults at the Hearts and Hands Clinic

2. Provide strategies to increase knowledge on healthy portion sizes for a healthy diet

among adults at the Hearts and Hands Clinic

Objectives

1. By the end of our program, more than 80% of the participants at the Hearts and Hands

Clinic will be able to read food labels with an 80% accuracy.

2. By the end of our program, more than 50% of the participants at the Hearts and Hands

Clinic will be able identify accurate portion sizes within food groups with an 80%

accuracy.

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Framework

Other important concepts incorporated in the Social Cognitive Theory include behavioral

capability and self-efficacy. Behavioral capability is defined as the knowledge and skill to

perform a given behavior; or promoted mastery learning through skills training (Social Cognitive

Theory). Through the implementation of our program we intend to increase the behavioral

capability of our participants by using two of the activities outlined in the Centers for Disease

Control and Prevention Road to Health Toolkit, including “Community Kitchen” and “Portion

Distortion”. The participants will be able to display their level of understanding through these

activities which will promote self-efficacy and an overall change in behavior. Self-efficacy is

defined as an individual’s confidence in performing a particular behavior; or to approach

behavior change in small steps to ensure success (Social Cognitive Theory). Having the

participants gain a sense of self-efficacy will be vital to their overall change in their behavior.

Using the constructs collectively that are outlined in the Social Cognitive Theory will positively

affect behavioral change in our participants at the Hearts and Hands Clinic.

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(“Bandura’s Triadic Reciprocal Determinism model”, 1989)

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Timeline

February 3, 2016

Meeting with Community Partner

Discussion of Program

March 7, 2016

Program Implementation

Pretest Given

March 7, 2016

Program End date

Posttest Given

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Logic Model

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Inputs

Money for incentives

Time

Road to Health Toolkit

ActivitiesCommunity

Kitchen

Food Detective 1

Outputs

Program Implmentation

with Participants

Powerpoint Presentation

with Activities

Outcomes

1. Increase in being able to

read food labels2. Increase in

understanding accurate

portion sizes

ImpactIncreased

education on Dietary Habits

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Intervention Strategies

The intervention that will be implemented for this program will involve both Health Communication and Health Education strategies. The outlined steps will be used to promote healthy dietary habits for the adults at the Hearts and Hands Clinic. The primary audience will include the adults at the Hearts and Hands Clinic and the secondary audience will be the adults of the community of Bulloch County. Presenters will develop a program to provide middle age adults with knowledge and specific tools that will promote healthy dietary habits.

Health Communication Strategies- the health communication strategy will be successful to inform our

participants how to improve their dietary habits - the health communication tools that our implementators will use include:

- Food Detective I : to compare portion sizes and how they’ve changed and the negative impact of them

- Community Kitchen : to teach participants how to read food labels and how to recognize healthier food choices

- Printouts and Pens : for participants to interact and answer questions from the activities and to complete pre and post tests

- This seminar will be successful in promoting healthy dietary eating habits. It will also help our participants properly read food labels and make healthier eating choices and improve their eating habits and portion sizes. It will communicate to participant’s information about how portion sizes have changed over the years by using the Portion Distortion activity. By using the Community Kitchen Activity, we will be able to communicate to participants the proper way to read food labels and how to recognize the differences between healthy and unhealthy food choices.

- These elements will focus on an intrapersonal approach because it is in the individual's best interest to understand how to properly read food labels and correctly make portion sizes that are healthiest for them. Individuals will have to want to change themselves for the better.

In order to grab the attention of our target audience of middle age adults, we will be using flyers and posters that will be posted around the downtown area of Bulloch County. They will also be left in the lobby of the Hearts and Hands Clinic. We will list in these promotional tools facts on how dietary habits can have a direct correlation with obesity. We will offer snacks, drinks, and hand out prizes such as lotions, travel size toiletries, and other simple things for everyday use, as an incentive to increase our program participation.

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Health Education Strategies- the health education tools that we will be using are:

- Flyers : to get people to attend our seminar in our to gain knowledge on how to improve everyday eating habits

- PowerPoint Lecture : to grab the attention of participants while presenting our Portion Distortion activity, which will compare foods and help explain the adequate portions needed.

The different materials used for this program will be used to draw attention from the audience to get them involved in the activities and eager to learn about healthier dietary habits. The main goal is to educate and inform individuals on the importance and the positive impacts of a healthy diet.

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Lesson Plan for Hearts and Hands ClinicHearts and Hands Clinic

Statesboro, Georgia

Spring 2016

Materials:Printed handouts, PowerPoint, pens, arranged chairs, music, snacksTime: Type Action

8 mins

3mins

15 mins

15 mins

15 mins

3 mins

10 mins

Introductions and Description

Pretest

Lecture

Activity #1

Activity #2

Post-Test

Discussion

Introduce ourselves to the audience and allow them to introduce themselves to the group, go over what our program is about, how it will affect them and the importance of it. Go over the objectives.

Will measure pre-existing knowledge on the topic.

Provide information on healthy dietary habits as discussed in our literature review and discuss the consequences and benefits

Portion Distortion: go through different types of food and share the difference in calories, fat, and sugar of each pair.Sharehow food portions have changed over time.

Community Kitchen: To teach the healthier side of cooking, how to read labels, and how to make dishes lighter without giving up flavor.

Will measure the knowledge after information is provided.

Review what the audience has learned from the both the lecture and activities regarding the importance of understanding healthy dietary habit. Participants will be asked if they have any questions or if they need clarity over what was presented.

Assignment/Extra time activity: To go home and read at least 1-3 different food labels of anything they have in their food cabinets. Notes: *Discussion- Audience members will be able to name one thing that they learned from the Intervention Program.

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Budget

Place

Hearts and Hands Clinic of Statesboro, Georgia $0

Equipment

Cups 5 @ $2.50/pack $12.50

Juice 5 @2.00 $10.00

Fruit Tray 2 @ $15.00 $30.00

Vegetable Baked snacks 10 @ $1.50 $15.00

Poster/Flyers 50 @0.50 $25.00

Pens 3 pack of 8 @3.99 $11.97

Chairs 15 $0

Projector 1 $0

Computer 1 $0

Printouts of Activities 30 $0

People

Community Partner (Urkovia Andrews) In Kind $0

TOTAL $104.47

Deductions $0

No Deductions $0

GRAND TOTAL $104.47

Budget Justification

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Place

Hearts and Hands Clinic of Statesboro, Georgia

The Hearts and Hands Clinic is a free health care clinic for the medically uninsured and

individuals living 200% at or below the federal poverty line. The program will be held at this

facility and will be open to all citizens of Bulloch County, there will be no cost associated for

attending.

Equipment

Cups

We will be providing refreshments for all of the participants who choose to come to our

program. We will utilize the cups for the juice provided during our program.

Juice

We are offering juice as a beverage option for participants that enter the program. This

offering will act as an incentive for participants to enjoy while listening to the the information

being provided to them.

Fruit Tray

The fruit trays we are providing for our participants will be an incentive for them. It also

enforces the purpose of our program, which is to provide them with healthier and more nutrient

dense food options, part of the purpose of our program.

Vegetable Baked Snacks

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These will be utilized during the Road to Health Toolkit Activity Community Kitchen.

Individuals will utilize this snack in order to properly read a food label and recognize healthier

options in regards to food intake.

Poster/Flyers

Posters and flyers are needed to promote and advertise the program. Posters and flyers

will be placed in the lobby of the Hearts and Hands Clinic as well as distributed throughout

downtown Statesboro, Georgia. These advertisements will be produced by the Georgia Southern

University Eagle Print Shop.

Pens

Pens are needed for completing the pre and post-tests. The activities may also require the

participants to use this utensil. They can also simply write their names on their cups if they so

choose.

Chairs

The chairs are provided by the Hearts and Hands Clinic and placed in the lobby where the

program will be implemented for the participants to sit in.

Projector

The projector is needed in order to educate the participants using the slideshow that we

have created. Also, enlarged copies of the printouts we have for provided them will also be

displayed to participants in order for them to actively learn from our program.

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Computer

A single computer is needed in conjunction with the projector in order to show our

presentation of our slideshow and materials that we will use throughout the program. We need a

computer in order to have our information on hand in case anything goes wrong with the

projector.

Printouts of Activities, Pretests and Posttests

In order to engage with our participants we need to have the activities from the Road to

Health Toolkit. We will also need the pretests and posttest in order for us to measure the quality

of our program and to measure how accurate our program was and to discover if it was

successful.

People

Community Partner Mrs. Urkovia Andrews

Mrs. Andrews is our community partner and the Executive Director of the Hearts and

Hands Clinic. She is our main contact in regards to scheduling the days and times of our

program, and when implementing our program at the Hearts and Hands Clinic. She will assist in

helping us setup appropriate times that work well with her schedule and will help facilitate us

contacting patients that use the services at the Hearts and Hands Clinic.

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Methods

Participants:

Following the Institutional Review Board approval, an estimated sample group of 10-20

local citizens of Statesboro, Georgia will be obtained for this intervention. The research design

for the “Eat Healthy, Be Healthy” study is an experimental study consisting of groups being

tested with a pretest and posttest. Participants of the study are obtained via flyers placed in the

lobby of the Hearts and Hands Clinic of Statesboro, as well as around the downtown area. The

demographics of the participants range from a variety of backgrounds and ages approximately

from 30-50 years of age.

Intervention:

The Eat Healthy, Be Healthy program about proper dietary habits consists of two

PowerPoint lectures and two activities from the Road to Health Toolkit. The first part of the

lecture include information on how to properly interpret food labels such as what amount of each

ingredient is considered to be excessive or lacking. The PowerPoint for this section will involve

actual food labels from people's everyday diet. After this section of the PowerPoint will be

demonstrating the Road to Health Toolkit Activity labeled “Community Kitchen” where as a

group we will do a hands on activity with the actual food labels and help the people one on one

on how to read them.

After the first part of the PowerPoint and the activity that goes along with it, we will

being the second point of the PowerPoint lecture. This part of the lecture will involve

information on how to correctly measure out food portions and how much a male and female

need of each food group. The lecture will include easy tips on how to hands on measure food

without proper measuring materials and how to help them remember the correct portions.

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Following this part of the lecture we will being our second activity titled “Food Detective 1.” For

this activity we will have actual food from each food group and help the participants of our

program accurately measure out the correct portions needed daily for their gender and for each

food group. This part will help them have hands on experience and practice so they can take

home what they learned.

At the beginning of our lecture after the introductions we will provide them with a pretest

to test their knowledge, and we will provide a posttest at the very end of our program to be able

to measure how much they learned. The Food Detective activity also has a take home handout

for the participants for them to refer back to for adequate portion sizes.

Measurement:

The program is designed to measure knowledge on portion sizes and food label reading.

Measurement will be determined through a researcher designed multiple choice pretest and

posttest. Half of the questions will be used to measure knowledge on portion sizes while the

other half will be used to measure knowledge on reading food labels correctly. The section on

the tests pertaining to portion sizes contains questions on the amount of food needed daily for

men and women. The other section on the test pertaining to food labels will contain questions on

how to calculate and read a food label correctly. Participants who will be given the tests will be

told that it is completely voluntary and will include names in order to be able to measure the

change in knowledge in SPSS from the beginning of the program to the end.

Data Analysis:

Data analysis for the program Eat Healthy, Be Healthy, will be conducted using computer

processing. The IBM SPSS Statistics 23.0 software will be utilized. Using a Quasi-experimental

research design data will be collected from the pre and post-tests. It will be analyzed using

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detailed coding instructions in the IBM SPSS Statistics 23.0 software. Once the given data has

been processed it will give a description of the result of the program and a measurement of the

knowledge of the participants before and after the program.

Results

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“Eat Healthy, Be Healthy” had a total of 4 participants (n=4). Table 1 shows the increase in mean score from the pretest (5.250) to the posttest (10.500) with an increase of 5.25 overall. However, there was no significant difference between the two tests because the value reads above the designated p value.

Table 1. Report of overall means of knowledge of portion sizes and comprehension of reading food labels accurately as determined by T-test.

Variable n x̄ SD df F Significance Group Pretest 4 5.250 3.30 6.000 .833 .397 Posttest 4 10.500 4.43 5.546 _________________________________________________________________________________ *p≤0.05

The significance level is set at a p value that is less than or equal to 0.05. The table shows that there is a no significance for any of the demographics in this study.

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Table 2. Statistical significance of Portion Sizes and comprehension of reading foodlabels accurately as determined by ANOVA’s.

Demographics Degrees of Freedom

Mean Sq. F Significance

Age 3 1.375 0.039 0.988

Gender 1 6.125 0.261 0.628*

Race 1 6.125 0.261 0.628

Group 1 55.125 3.605 0.106

*p ≤ 0.05

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A descriptive analysis of participant’s responses was reported by frequencies and percentiles. There are some questions that are highlighted meaning that the majority of the participants answered the question incorrectly. Refer to Table 3.

Table 3. Descriptive analysis of participant’s responses as reported by frequencies and percentiles.

Correct Incorrect n(%) n(%)

1. How many ounces of protein should women have in their daily 2(50%) 2(50%)2. intake?3. How many ounces of protein should men have in their daily 1(25%)

1(75%)4. intake?5. How many cups of fruit should men consume daily? 3(75%)

1(25%)6. How many cups of fruit are recommended for women daily? 0(0%) 4(100%)7. How much dairy is recommended for men and women daily? 3(75%)

1(25%)8. ___ cups of vegetables are needed daily for women? 1(25%) 3(75%)9. ___ cups of vegetables are needed daily for men? 1(25%)

3(75%)10. How many ounces of grains (rice, oatmeal, bread) are 0(0%) 4(100%)11. needed daily for men?12. How many ounces of grains (rice, oatmeal, bread) are 1(25%)

3(75%)13. needed daily for women?14. How many calories are in this container? 0(0%)

4(100%)15. How much protein is in this container? 0(0%)

4(100%)16. How much cholesterol is in this container? 0(0%)

4(100%)17. How much sodium is in 1 serving 4(100%) 0(0%)18. How many servings are in this container? 3(75%) 1(25%)19. How many calories per fat are in 1 serving? 2(50%)

2(25%)Findings and Discussion

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In this study, we considered the correlation between middle aged adults below the

poverty level and dietary habits in regards to the escalating epidemic of obesity in the Statesboro,

Georgia. We explored the knowledge middle aged adults in Statesboro, Georgia currently had on

proper dietary habits with emphasis on reading food labels correctly and measuring portion sizes

correctly for their age group and gender. The two objectives for this study are as follows, (1) At

the end of our program, more than 50% of the participants at the Hearts and Hands Clinic were

able to understand accurate portion sizes within food groups with 80% accuracy, (2) At the end

of our program, more than 80% of the participants at the Hearts and Hands Clinic were able to

read food labels with 80% accuracy. There are very few studies on low poverty level adults

examining their knowledge and how it affects their everyday dietary habits and overall how it

reflects the society as a whole. There are articles out there regarding research on low poverty

level adults and their availability to resources in regards to their location, however there are few

in the field of public health that are looking at their knowledge and how it affects their everyday

life and overall understanding of proper dietary habits. This study fills a crucial gap that needs to

be met regarding the availability of educational programs that need to be made to middle aged

adults in low poverty areas. Key findings of the study were that (1) middle aged adults had a low

understanding of how to correctly read a food label, (2) middle aged adults showed a

substantially low understanding of which portion sizes were necessary for men and women for

each food group. These findings are further discussed below.

Increased Accuracy in Understanding Portion Sizes

At the end of our program, more than 50% of the participants at the Hearts and Hands

Clinic were able to understand accurate portion sizes within food groups with 80% accuracy. All

of our participants showed improvement between their pre and post-test when compared. This

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was not surprising because we used different types of learning styles (written, visuals, and hands

on) during our program. We provided different food from each food group and calculated the

portion sizes for each food group on their own. This result was similar to Parikh, Hamadeh, &

Kuk (2015), study on estimating serving sizes for healthier and unhealthier versions of what their

study suggested that serving sizes may be poorly understood, by overestimating serving sizes for

certain vegetables, fruits, and grains (Parikh, Hamadeh, & Kuk, 2015). Interestingly, during our

program for the pretest we observed some of our participants overestimating portion sizes for

fruit, vegetables, and grains. It is uncertain whether the larger estimated portion sizes of healthier

food are due to conscious action which is associated with the assumed healthful benefits (Parikh,

Hamadeh, & Kuk, 2015). Our result was also similar to that of Zlatevska, Dubelaar, & Holden

(2014), study on Sizing up the effect of portion size on consumption which showed that the

portion-size effect is substantial, although it was smaller than they expected if consumption were

guided by the portion size (Zlatevska, Dubelaar, & Holden, 2014). We had a substantial increase

between our pre and post-test, and according to the participants they felt more comfortable about

their portion sizes and food control. We provided information on healthy dietary habits as

discussed in our literature review and discussed the consequences and benefits of healthy dietary

habits. We provided visual example of different food group which according to the participants

made it easier to them to understand. More program on educating people about portion sizes and

the way it has changed overtime should be put out there and made available to the public.

Accurately calculating portion sizes is important in having a healthy dietary habit, which

in turn can reduce the rate of diseases such as, diabetes, obesity, cardiovascular disease. A lot of

people are unaware of the right way to calculate portion sizes or the right portion needed on a

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daily base for the different food. There are too little programs on educating the population on the

daily right portion sizes.

Increased Accuracy in Understanding Food Labels

At the end of our program, more than 80% of the participants at the Hearts and Hands

Clinic were able to understand food labels with an 80% accuracy.  As with the portion sizes, the

participants were able to show their understanding from the pre-test to the post-test given.  These

results were no surprise as well, as to the assumption that providing visual education and lecture

aided their understanding.

These results are a prime example from a study done about the effects of fast food

consumption for those who live in rural areas due to its cost-availability by Richard Dunn.

Because fast food is more readily available and cost effective for families, that is the majority

choice that is chosen for meals instead of going to a grocery store or food market to purchase

healthier items that may not be as “cheap”.  If health promotion specialists, or even the

government, could educate a rural population and implement a program providing health facts

and food labels, it could possibly change their perspective.  A quote from Dunn’s research, “The

cost and availability of fast-food are both actionable policy levers; lawmakers can restrict access

through zoning decisions, impose taxes on the sale of fast-food items, require nutritional

information be made available to consumers, and prohibit the use of particular ingredients”

(Dunn, 2012).  By providing nutritional information (food labels), people may be more cautious

about the ingredients they are essentially putting into their body and will think twice about food

only based on a low cost.

Educating people on how to accurately read a food label could help lower obesity

because from research gathered and from personal observations, many people (mostly middle

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age adults) consume more than required.  Education on what is measurably healthy could reduce

obesity that leads to other illnesses and diseases.

With the food labels, a hands-on lecture was given and a small bag of a healthy snack to

show and educate them on correctly reading and understanding a food label was provided to the

participants.  The good nutrients to look for and the ones to avoid were discussed as well as

looking at how many calories are in a serving size and how many servings come in a container.

Limitations and Weaknesses/Hypothesis

The results of the program helped to illustrate that the program was effective in educating

individuals on how to read food labels and recognize healthy portion sizes. The limitations

included the fact that there was a small sample size and that the program was conducted at only

one intervention site, The Hearts and Hands Clinic. There was also the limitation of having only

one opportunity to administer both the pretest and posttest. Despite the fact that the program was

only conducted at this specific site, it has to note that the objectives that were set were met and it

is also conclusive from the results that this program is suitable to be tested further at other

locations to confirm its validity and reliability.

Based upon the results of the program, it can be concluded that this program can be

implemented in further research. After implementing this intervention, a newfound

understanding was grasped in regards to helping program participants increase their knowledge

and understanding of portion sizes and food labels. It is understood that hands on instructions is

necessary in order to ensure comprehension.

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Appendix

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