Know, Grow and Eat Your Vegetables: Increasing Access to Healthier Foods Among the Developmentally Disabled

State: NY Type: Model Practice Year: 2012

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Of the 155,000 individuals comprising Schenectady County Public Health Services (SCPHS) jurisdiction, approximately 3% of individuals ages 18-64 are diagnosed with a cognitive difficulty. These diagnoses include some form of intellectual or developmental disability (I/DD), including mental retardation, autism, cerebral palsy, epilepsy and other neurological disorders. Schenectady ARC (SARC), a longstanding provider of residential, vocational, clinical and adult day services in New York State’s Capital Region, assists 1,480 individuals, of which an estimated 9% (137) are diagnosed with cardiovascular disease, obesity and/or diabetes. Studies indicate that people with I/DDare 50% more likely to diagnosed with obesity, diabetes and other chronic diseases as heart disease and epilepsy. SARC recognized the need to increase consumer consumption of healthier foods and was intrigued by studies in which garden-based nutrition education programs increased awareness and consumption of fruits and vegetables.

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Schenectady County Public Health Services
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Know, Grow and Eat Your Vegetables: Increasing Access to Healthier Foods Among the Developmentally Disabled
Of the 155,000 individuals comprising Schenectady County Public Health Services (SCPHS) jurisdiction, approximately 3% of individuals ages 18-64 are diagnosed with a cognitive difficulty. These diagnoses include some form of intellectual or developmental disability (I/DD), including mental retardation, autism, cerebral palsy, epilepsy and other neurological disorders. Schenectady ARC (SARC), a longstanding provider of residential, vocational, clinical and adult day services in New York State’s Capital Region, assists 1,480 individuals, of which an estimated 9% (137) are diagnosed with cardiovascular disease, obesity and/or diabetes. Studies indicate that people with I/DDare 50% more likely to diagnosed with obesity, diabetes and other chronic diseases as heart disease and epilepsy. SARC recognized the need to increase consumer consumption of healthier foods and was intrigued by studies in which garden-based nutrition education programs increased awareness and consumption of fruits and vegetables. In response, SARC created a garden-based nutrition education program at its commercial-sized greenhouse in March of 2010. The agency’s horticulture coordinator initially met with 70 participants to assess their awareness of and preference for 15 vegetable types to be grown through the project. Thereafter, they worked alongside the coordinator each day for six months to plant and cultivate the seedlings. The plants were eventually transferred to four raised planting beds located adjacent to a concrete walkway, facilitating access by the project’s 75 wheelchair-bound participants. A $3,100 grant from the SCPHS’ Strategic Alliance for Health (SAH) was used as start-up funding to purchase materials necessary to construct and fill two of the raised planters as well as acquire seeds and heated propagation mats to expedite seedling growth. An additional $4,600 was contributed in-kind by SARC to construct the raised planting beds and assist participants in planting, growing and harvesting the vegetables. While the vegetables were being grown, nutritional educators from Cornell Cooperative Extension of Schenectady County (CCESC) conducted a six-week program at four SARC group homes and an adult day program. Funded entirely through the USDA, it taught participants and staff about healthy meal preparation practices and how to incorporate vegetables into daily meals and snacks. Thereafter, from late summer to early fall of 2010, participants harvested approximately 500 vegetables from the outdoor raised planters. They were then distributed to participating consumers, along with recipes, for consumption in the group home or family home setting. The following is a list of project milestones and corresponding outcomes, each of which were achieved due to the efforts of SARC’s horticulture education program and CCESC as well as funding through SCPHS:  Objective 1: Program participants will increase their awareness of and contact with vegetables. 70 participants planted and cultivated 15 different types of vegetable plants. 25 participants harvested over 500 vegetables from four raised planters. Post-surveys revealed improvement in recognizing 10 of the 15 vegetable types grown. Objective 2: Program participants will learn healthy meal preparation strategies. 28 SARC participants attended weekly CCESC healthy cooking classes Consumption of fruits and vegetables increased from 2.3 to 3.3 cups per day. 56% showed improvement in one or more nutrition practices. The frequency with which consumers think about healthy food choices improved by 19%, preparing foods without salt improved by 25% and the tendency to use nutrition food labels, by 21%. Objective 3: Program participants will have increased access to fresh produce through incorporating harvested produce into healthy meals. 25 individuals participated in harvesting approximately 500 vegetables At least 80 participants received fresh produce from the garden At least 10 meals were prepared using produce from the garden  Improvement in recognition was noted in 10 of the 15 (67%) vegetable types grown Several lessons were learned as a result of this program: It was necessary for CCESC nutritionists to modify their curriculum to accommodate the learning styles and pace of involved participants. Certain vegetables, such as spinach, were not amenable to summer weather conditions. SARC originally included pressure treated lumber as the material for constructing the raised planting bed. Given the toxicity of this type lumber and its potential impact on the vegetables grown, it was decided to utilize cedar lumber instead. This project served to strengthen SARC’s relationship with CCESC whose nutritionists gained increased awareness of the needs facing individuals with I/DD.
Health Issues  The “Know, Grow and Eat Your Vegetables” program was conceived and designed to address the overriding public health issue of chronic disease, particularly heart disease, obesity and diabetes, among the general United States population. In 2005, according to the U.S. Centers on Disease Control and Prevention (CDC), almost one out of every two adults were diagnosed with at least one chronic illness, attributing to seven out of every 10 deaths among Americans. They further report that one out of every three adults is considered obese, with diabetes being the leading cause of kidney failure, lower-extremity amputations, and blindness. Such alarming statistics also apply to those diagnosed with an intellectual or developmental disability (I/DD). According to the American Dietetic Association, people with I/DD are at “increased risk for chronic disease such as heart disease, obesity, seizures, hearing and vision problems, low bone mineral density and poor conditioning and fitness.” More so, national research has revealed that individuals with I/DD, as compared to the general public, are at increased risk for heart disease and 50% more likely to be diagnosed with obesity or diabetes. These findings mirror the incidents of chronic disease existing among the 1,480 individuals served by SARC, just under 10% of which carry a diagnosis of cardiovascular disease, obesity and/or diabetes. This, despite the ongoing provision of nutritional interventions conducted by the agency’s certified dietitian. We were encouraged, therefore, by a research study conducted in 2010 (“Improving the Nutrition and Health of People with Developmental Disabilities via On-Line Program Dissemination”, 2010) indicating that “interventions focusing on diet and the nutritional intake of people with developmental disabilities have been much more successful in improving their quality of life and dietary patterns as well as reducing the rate of serious secondary medical conditions.” In addition, the Guide to Community Preventive Services (2010) found that improving access to and consumption of healthier foods could help lower the risks for developing chronic diseases and obesity. More so, additional literature revealed the positive benefits of using a nutrition education program for persons with developmental disabilities living in group homes. In 2008, Schenectady County Public Health Services, received funding from the New York State Department of Health to coordinate the Strategic Alliance for Health (SAH) in Schenectady County. The Strategic Alliance for Health is a national grant program funded through the CDC’s Healthy Communities Program which uses community-based coalitions to reduce the incidence of cardiovascular disease, diabetes and obesity through policy, system and environmental changes. Schenectady County Public Health Services and its Strategic Alliance for Health then proceeded to utilize CDC’s Community Health Assessment and Group Evaluation (CHANGE) assessment to: assess and document policy, systems and environmental strategies currently in place in the community, develop a community action plan to implement strategies that facilitate healthy lifestyles, and assist with prioritizing community needs and allocating available resources. The CHANGE assessments revealed that community-based organizations, schools and the community-at-large lacked access to fresh fruits and vegetables necessary for the amelioration of chronic disease, whereas junk food and sugar-sweetened beverages were often readily available. Based on this needs assessment, therefore, the SAH decided to implement policy, systems and environmental changes based on the following three strategies: Increase the availability and visibility of affordable, healthier food and beverage choices Restrict the availability of less healthy foods and beverages Increase access or make enhancements to outdoor recreational facilities This initiative was designed to immerse participants into the vegetable growing, preparation and harvesting process in order to increase consumption and ameliorate the proliferation of chronic disease. Toward this end, the program featured a four-stage process: Pre-Program Assessment – Approximately 70 agency consumers participated in an initial survey designed to gather baseline data regarding their familiarity with the types of vegetables to be grown through the project. They were asked to name the vegetable, indicate whether they had ever consumed and/or enjoyed it and, if given the chance, would eat it more often. Plant Cultivation – SARC’s 3,000-square foot commercial greenhouse was the setting at which participants met with the agency’s horticulture coordinator to select and become familiar with the various vegetables to be grown and receive hands-on assistance and instruction in planting and maintaining the vegetable seedlings. Later in the growing season, the mature seedlings were transferred outdoors to four raised planting beds, two of which were made possible using SAH funds. The planters, located alongside a 100’ concrete sidewalk, made it possible for the program’s 75 wheelchair bound consumers to actively participate in the program.  Healthy Meal Preparation Training – Concurrent with the growing process, nutritional Educators from CCESC provided healthy meal preparation instruction to 25 participants and staff from SARC’s residential and day service programs. This USDA-funded six to ten week course utilized the nationally recognized “Eating Right is Basic” curriculum designed to help limited literacy adults learn basic nutrition, food resource management, food safety, and food preparation. Each series of classes occurred one hour a week at four separate SARC group homes in Schenectady County. Plant Harvesting – Approximately25 consumers harvested over 500 vegetables which, once rinsed and wiped, were collated into plastic baggies along with a pertinent recipe. They were then distributed to individual participating consumers as well as to agency group homes and day programs. Innovation A literature review was the mechanism used to verify the singular nature of our practice in the field of public health. Although replete with information supporting the drastic need for improved nutritional interventions for individuals with I/DD, existing literature was without a garden-based program to increase consumption of vegetables amongst that population. Reported, instead, were the “nutritional deficits, inadequate diets, and poor nutritional status among adults with intellectual or developmental disabilities living in the community” as well as the U.S. Surgeon General’s 2002 declaration that “improved nutrition for adults with intellectual or developmental disabilities was to be a national priority”. (Humphries et al, 2008) Nutritional interventions pertaining specifically to those with I/DD included (a) adapted nutrition education and support materials for group home managers and staff (Humphries et al, 2008), (b) peer mentoring combined with interactive health education, supervised physical activity, behavioral modification, and clinical support (Bazzano et al, 2009), and (c) on-line delivery of nutrition-related curricula and pictorial recipes (Vail, 2010). Additional research, geared specifically toward children without disabilities, emphasized the efficacy of garden-based nutrition education and “seed-to-table” programs in enhancing fruit and vegetable intake. In those studies, children participated in an array of regularly scheduled activities such as vegetable taste-testing, hands-on gardening and recipe preparation which, in turn, “increased the number of fruits and vegetables ever eaten, vegetable preferences and fruit and vegetable asking behavior at home.” (Heim et al, 2009). The research discussed in Question 4a enunciates the alarming nutritional circumstances currently facing individuals with I/DD and suggests several interventions for its potential remediation. As well, other garden-based nutritional projects, conducted with children rather than those with I/DD, have proven effective in increasing awareness and consumption of vegetables. SARC’s “Know, Grow and Eat Your Vegetables” is the only known program of its kind in the United States to generalize the garden-based nutritional education approach to individuals with I/DD toward the amelioration of chronic diseases. In fact, we are proud to report that the CDC selected this novel project for publication of an implementation guide that will soon be available on its website. It has also been incorporated into a NACCHO-CDC video media project, soon to be released, entitled “Tell Your Story! Highlighting Local Health Department Success Stories about Preventing and Addressing Birth Defects, Disabilities, and Blood Disorders”.  
Primary Stakeholders Schenectady County Public Health Services Strategic Alliance for Health Cornell Cooperative Extension of Schenectady County Schenectady County Chapter NYSARC Inc. Schenectady ARC Capital District Tobacco Free Coalition Role of Stakeholders/Partners Schenectady ARC, as a member of the Strategic Alliance for Health, took full advantage of the collaborative opportunities available through coalition partners in the planning and implementation of its garden-based nutrition education program. As mentioned earlier, the SAH, through the release of its the sub-award grant application, provided the financial impetus for developing the “Know, Grow and Eat Your Vegetables” project. Thereafter, SARC formed an internal planning group to develop the preliminary proposal and immediately sought assistance from another coalition member, Cornell Cooperative Extension of Schenectady County, to fulfill the project’s need for healthy meal preparation classes. Representatives from SARC, CCESC and the SAH met regularly to draft and refine the program’s four-stage framework that was described in Question 3. The following is a brief reiteration of each stage and role played by each partner: Pre-Program Assessment – SARC’s horticulture coordinator administered an initial survey to participating consumers to ascertain awareness of and preference for vegetables to be grown. Plant Cultivation – With a newly restored greenhouse as a base operations, SARC’s horticulture coordinator provided instruction and assistance to participants in planting and maintaining the vegetable seedlings and transferring the mature plants to four raised handicapped accessible planting beds. Healthy Meal Preparation Training – Nutritional educators from CCESC administered their “Eating Right is Basic” six to ten week healthy meal preparation course to 25 participants at four group homes and a day service program. Plant Harvesting – The SARC horticulture coordinator provided oversight and assistance to approximately 25 consumers in harvesting and rinsing the mature vegetables and then helped with collating them for distribution to participating consumers, agency group homes and day programs. LHD Role Schenectady Public Health Services and its Strategic Alliance for Health (SAH) served as the mechanism for provided the funding, structure and technical assistance necessary for implementation of the “Know, Grow and Eat Your Vegetables” project. The SAH is a CDC-funded community-based coalition of Schenectady County non-profit organizations that implement policy, systems and environmental changes designed to (a) increase the availability and visibility of affordable, healthier food and beverage choices, (b) restrict the availability of less healthy foods and beverages, and (c) increase access or make enhancements to outdoor recreational facilities. The SAH developed these strategies based entirely on implementation of the CDC’s Community Health Assessment and Group Evaluation (CHANGE) community needs assessment which concurrently identified key stakeholders from the community-at-large, community-based organizations (including Schenectady ARC) and school sectors that would help to implement them. The SAH monitored and provided ongoing consultative support, along with other coalition members (including CCESC) for implementation of the program. Schenectady County Public Health Services is only one of 14 communities in the United States to operate a CDC-funded Strategic Alliance for Health. By its very nature, it consists of a broad array of Schenectady County nonprofit organizations, health care facilities, worksites and schools that can implement and/or provide support for the SAH strategies of (a) increasing the availability and visibility of affordable, healthier food and beverage choices, (b) restricting the availability of less healthy foods and beverages, and (c) increasing access or making enhancements to outdoor recreational facilities. The SAH Coalition meets monthly to review the progress of funded projects, discuss legislation and mandates which support or dissuade the implementation of these strategies, and conduct trainings which support coalition members in the pursuit of program objectives and community wellness. The SAH coalition served as the impetus for several partnerships that were essential to achieving the project’s main goals. A primary member of the coalition, Cornell Cooperative Extension of Schenectady County, offered its USDA-funded “Eating Right is Basic” curriculum as the project’s on-site nutrition education and healthy meal preparation classes. This led to an ensuing SAH-funded collaborative program in which CCESC provided master gardener consultative services in the creation of a 2,000 square foot vegetable garden at SARC’s Minard House group home in Pattersonville, New York. The SAH Coalition was also instrumental in connecting SARC with yet another member, the Capital District Tobacco-Free Coalition, which provided “tobacco-free zone” signs for posting at each of its commercial buildings. Lessons Learned A number of valuable lessons were learned following year-one implementation of this project, as follows: In its original application to the Strategic Alliance for Health, SARC included pressure treated lumber as the material for constructing the raised planting bed. Upon discussion regarding the toxicity of this type lumber and its potential impact on the vegetables grown, it was mutually decided to utilize cedar lumber instead.  For a variety of reasons, the number of consumers originally projected to participate in the project did not transpire. SARC found that some participants either lacked interest in horticultural activities or were not particularly well suited to the project due to their disability.  It was necessary for Cornell Cooperative Extension Schenectady County nutritionists to modify their “Eating Right is Basic” curriculum and associated activities to accommodate the learning styles and capabilities of involved participants. Certain vegetables, such as spinach, were not amenable to the hot and dry weather conditions experienced during the summer. As such, a small percentage of the planned crop did not grow, yet was compensated by an otherwise bountiful quantity of other vegetables. Implementation Strategy What were the specific tasks taken to achieve each goal and objective of the practice? Objective 1: Program participants will increase their awareness of and contact with vegetables. Task 1: Administer the pre-program survey Task 2: Review the types of vegetables to be grown Task 3: Plant seedlings Task 4: Maintain seedlings Task 5: Construct two additional raised planting beds Task 6: Transfer seedlings into raised planting beds Task 7: Maintain and monitor plants Objective 2: Program participants will learn healthy meal preparation strategies. Task 1: Conduct a pre-course evaluation to determine familiarity with healthy cooking, eating and safety habits Task 2: Conduct meal preparation course at five SARC locations Task 3: Administer post-course evaluation to measure comprehension of course principles and strategies. Objective 3: Program participants will have increased access to fresh produce through incorporating harvested produce into healthy meals. Task 1: Harvest vegetables from raised planting beds Task 2: Distribute vegetables Task 3: Conduct evaluation Task 4: Incorporate vegetables into meals Objective 1: Task 1: Administer pre-program survey - March - April, 2010 Task 2: Review types of vegetables to be grown – March -April, 2010 Task 3: Plant seedlings - March - April, 2010 Task 4: Maintain seedlings - March - July, 2010 Task 5: Construct two raised planting beds –April -May 2010 Task 6: Transfer seedlings into raised planting beds – April -May 2010 Task 7: Maintain and monitor plants – May -June, 2010 Objective 2: Task 1: Conduct a pre-course evaluation to determine familiarity with healthy cooking, eating and safety habits – June 2010 Task 2: Conduct meal preparation course at five SARC locations – June to August 2010 Task 3: Administer post-course evaluation to measure comprehension of course principles and strategies – August -September, 2010 Objective 3: Task 1: Harvest vegetables from raised planting beds – August -September 2010 Task 2: Distribute vegetables - August -September 2010 Task 3: Conduct evaluation - August -September 2010 Task 4: Incorporate vegetables into meals – August-September  
Process & Outcome Objective 1: Program participants will increase their awareness of and contact with vegetables. Performance measure: Number of program participants involved in planting Number of pre and post-surveys completed Participant ability to identify the 15 vegetable types grown and active participation in plant cultivation and harvesting Data: A pre and post-project was administered verbally to 70 participants by SARC’s horticulture coordinator, asking that they identify 15 vegetable pictures, indicate whether they had eaten and enjoyed those vegetables previously, and if given the opportunity, would eat them more often. Evaluation results: Following completion of planting and cultivation activities and meal preparation classes, the horticulture coordinator verbally re-administered the original survey to 70 participants to assess the impact of program interventions on vegetable awareness. Results indicated that the objective was achieved, given that improved recognition was noted in 10 of the 15 (67%) vegetable types grown. Feedback: The evaluation results were provided to Schenectady County Public Health Services, its Strategic Alliance for Health and, ultimately, the CDC which they, in turn, will incorporate into the project’s on-line implementation guide. The agency learned that certain vegetables are not necessarily conducive to the summer growing season and that not all consumers shared an interest or ability in horticultural activities. Objective 2: Program participants will learn healthy meal preparation strategies. Performance measures: Number of consumers participating in the CCESC healthy meal preparation classes Number of program participants reporting an increase in the ability to prepare healthier foods Outcome of post-class evaluation Data: Data was collected by nutritional educators from CCESC who verbally administered evaluations following the completion of classes. A number of data fields were examined including consumption of fruits and vegetables, meal planning, defrosting foods, healthy food choices, sodium content, and use of “Nutrition Facts” labels. Evaluation results: The post-program evaluation revealed the following results, substantiating the achievement of this particular objective: Participant consumption of fruits and vegetables increased from 2.3 to 3.3 cups per day. Of the 28 consumers participating in classes: 56% showed improvement in one or more nutrition practices (i.e. planning meals, comparing prices, preparing foods without salt or reading nutrition labels) 32% showed improvement in two or more food resource management practices (i.e., planning meals, comparing prices, not running out of food, and using grocery lists) 43% showed improvement in one or more food safety practices (i.e., thawing and storing foods properly) 19% showed an increase in the frequency with which they think about healthy food choices 25% showed improvement in preparing foods without salt 21% showed improved use of “Nutrition Facts” labels to make food choices 25% demonstrated decreased consumption of regular soda and fried foods 46% reported improved vegetable availability and consumption of milk 43% reported improved use of low-fat or skim milk Feedback: The evaluation results were provided to SCPHS, its Strategic Alliance for Health and, ultimately, the CDC which they, in turn, will incorporate into the project’s on-line implementation guide. As reported earlier, the CCSEC found it necessary to modify its curriculum to accommodate the learning styles and pace of individuals served through this program. Objective 3: Program participants will have increased access to fresh produce through incorporating harvested produce into healthy meals. Performance measures: Number of vegetables harvested Number of program participants who received fresh produce from the garden Number of program participants completing post-program survey Number of program participants who increased their knowledge about vegetables Number of meals prepared incorporating fresh produce from the garden Data: The same survey mentioned in Objective 1 was re-administered by the horticulture coordinator to 68 participants following the completion of program services. It asked (a) that they identify 15 vegetable pictures, (b) that they indicate whether they had ever consumed and enjoyed those vegetables, and, (c) if given the opportunity, whether they would eat them more often. Evaluation results: 25 individuals participated in harvesting approximately 500 vegetables At least 80 participants received fresh produce from the garden At least 10 meals were prepared using produce from the garden 68 participants completed the post-program survey Improvement in recognition was noted in 10 of the 15 (67%) vegetable types grown Feedback: As reported with the previous objectives, evaluation results were provided to Schenectady County Public Health Services, its Strategic Alliance for Health and, ultimately, the CDC which they, in turn, will incorporate into the project’s on-line implementation guide.  
There is ample stakeholder commitment to ensure the continued operation of this program operations in future years. As mentioned earlier, both Cornell Cooperative Extension of Schenectady County and Schenectady ARC are highly active coalition members of the Schenectady Strategic Alliance for Health as well as reputable and fiscally viable nonprofit organizations. They have enjoyed a longstanding relationship spanning numerous collaborative projects and look forward to ongoing partnerships, including the new fruit and vegetable garden at SARC’s Minard group home in Pattersonville, New York where CCESC provides consultative master gardener services. In addition, both organizations have expressed a commitment to continue their ongoing partnership. The “Know, Grow and Eat Your Vegetables” program is financially sustainable due to the following factors: Healthy meal preparation classes conducted by Cornell Cooperative Extension of Schenectady County are funded separately through a grant from the U.S. Department of Agriculture/Food and Nutrition Service and are therefore free of charge to SARC participants and staff. Salary and fringe benefit expenses of SARC’s horticulture coordinator and maintenance staff, whose in-kind services were described earlier, are fully subsidized by SARC as are non-personnel expenses (i.e., utilities, supplies and related equipment) and all food items required for CCESC’s meal preparation classes. The grant made possible through the Strategic Alliance for Health covered a number of one-time expense including: the purchase of “Agritape” to facilitate the growth of vegetable seedlings materials needed to construct and fill the raised planting beds SARC assumes ongoing financial responsibility for the maintenance of the planting beds and replenishment of compost, topsoil and seeds as necessary.
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