From The Field O C T O B E R 2 0 , 2 0 1 5 Recipe for In-Clinic Nutrition Education BRENDA SEARS Program Officer-Healthy Living, The Colorado Health Foundation E ach year, food and beverage companies spend billions food label accurately were able to show an increase in to market their products to children in every environ- knowledge but had little to no effect on behavior or health ment where they live, learn, and play. In addition to outcomes. commercials and print ads, food and beverage companies ® Lesson Two: Values and beliefs are essential. The market their products to children through product placement foundation saw better outcomes when programs included in movies, television shows, and video games. They also use time for participants to examine their personal perspectives spokes-characters and celebrities to encourage consumption of about food. Children and their parents value food that is products and offer free music downloads, cell phone ringtones, tasty, affordable, convenient, filling, or comforting. If they toys, and online games on their websites and in emails and text believe they can get these things from healthy foods, they messages. These tactics affect not only which foods children are more likely to consume them. The most effective ask their parents to purchase, but also which foods they are nutrition programs help participants identify their values willing to eat. Unfortunately, the overwhelming majority of and beliefs related to food, understand how their values and the food and beverage products marketed to children are high beliefs impact their food choices, and identify healthy foods in calories, added sugar, saturated fat, and sodium. that are aligned with their values. NUTRITION EDUCATION PROGRAMS CAN ® Lesson Three: Address social pressures and influences. ENCOURAGE HEALTHY FOOD Several studies show that people are happier if they are CONSUMPTION making similar choices to those sitting around them. It can be lonely, frustrating, and depressing for people to watch When The Colorado Health Foundation began funding in the their friends and family eat sugary cereal, salty snacks, and healthy living space in 2007, we saw nutrition education as an supersized portions while they are limiting their own avenue to encourage the consumption of healthy foods. Some consumption. In addition, well-meaning friends can ask nutrition education classes were successful in changing dietary the wrong questions or give bad advice. The foundation habits and improving health outcomes while others appeared realized that participants in the best programs developed to have no effect on participants. Recently we reviewed our skills related to talking to friends and family about their investments and identified sev- eral lessons that have improved our funding strategies and that Tactics used by food and beverage companies—ads, product placement in movies may help inform the field. and television shows, free music downloads, and toys—not only affect which foods children ask their parents to purchase, but also which foods they are willing to eat. CHARACTERISTICS OF EFFECTIVE NUTRITION EDUCATION PROGRAMS new dietary lifestyle and soliciting support. Effective programs also linked participants to influential people ® Lesson One: Facts are not enough. Food and beverage (such as peers or parents) who affirm and reinforce healthy companies are skilled at persuading consumers that choices. unhealthy food is healthy with words and phrases like “all-natural” and “low-fat.” It is important to provide ® Lesson Four: Incorporate relevant cultural resources. basic and accurate information about food to program The best programs integrated culturally relevant songs, participants; however, providing dietary guidelines and games, and traditions to promote learning. For example, recommendations alone does not change behavior. The one program used the colors of the Mexican flag to teach foundation found that programs that only teach partici- children and their families about healthy foods, and pants how to select foods with less fat or how to read a highlighted fruits and vegetables from Mexico. ENGAGING PRIMARY CARE ® Lesson Two: The program needs to be consistent with the clinic’s values and culture. To implement a nutrition Most of the nutrition education classes funded by the education program in a clinic, patient education must be a foundation took place in community settings. At the same key value. The providers need to believe that dietary changes time, the foundation was growing increasingly interested in can be just as effective as prescriptions. The clinic needs what we called the sweet spot—the areas in health care and to welcome and support innovation and creativity. In healthy living that overlapped. The primary care practice is an addition, staff must embrace a spirit of teamwork and be ideal site to identify unhealthy behaviors, educate children flexible about their roles. and their parents about the risks of unhealthy nutritional habits, and establish and imple- ment therapeutic interventions. Several health professional Nutrition education programs are an effective strategy for encouraging associations recommend that healthy dietary behaviors. The most effective programs address values and primary care providers include beliefs, social pressures and influences, and culture. nutrition interventions as part of routine medical care; however, many providers struggle with how best to intervene. ® Lesson Three: Support from leadership is key. Leadership In 2010 the foundation partnered with the Colorado should believe that the program is needed and will be Academy of Family Physicians and the University of worthwhile. The most successful clinics had high levels of Colorado’s Department of Family Medicine to develop a commitment from people in key decisionmaking positions. primary care, office-based program for children and their They made the nutrition education program an organiza- families that emphasized increasing fruit and vegetable intake tional priority and had the authority to allocate the time and and decreasing sugar-sweetened beverage consumption. The resources to make the program a success. Additionally, they program, named Fit Family Challenge, makes nutrition actively championed the program and its implementation. education a part of routine primary care. Ten sessions are delivered monthly by clinic case managers to a group of ® Lesson Four: Resources need to be available. Staff need to children and their accompanying parents and siblings. The be available to plan and implement the nutrition education program provides nutrition education classes to children and program. It is important that the clinic not have several families in a setting that is familiar and accessible and in a other initiatives going on at the same time that could place they visit regularly for other reasons. compete with the nutrition program. There should also be stability in staffing. Recent and high levels of turnover signal SETTING MATTERS: CHARACTERISTICS OF potential problems later with maintaining the program and SUCCESSFUL CLINICS the relationships with participants. The Fit Family Challenge was implemented in family CONCLUSION medicine and pediatric clinics all across the state. Overall, there were statistically significant increases in fruit and Nutrition education programs are an effective strategy for vegetable intake and physical activity, and statistically encouraging healthy dietary behaviors. The most effective significant decreases in body mass index among overweight programs address values and beliefs, social pressures and children in the program. While we expected changes in influences, and culture. In addition, offering classes in the behavior, we were surprised to see a change in body mass clinic setting presents health care providers as credible heroes index. However, the success varied from clinic to clinic. to counter persuasive messages that come from food and Implementing this type of program requires a shift in the way beverage company spokes-characters and celebrities. Having a physicians think and the way clinic staff do their work. Here professional association develop and promote the in-clinic are some of the characteristics of a clinic most associated nutrition education program is key for creating buy-in and with success: furthering success. ® Lesson One: The program should align with the vision, mission, and strategic plan of the clinic. A clinic with a goal of being a provider of innovative and complex care will prioritize different activities than a clinic with a goal of disease prevention. The nutrition education program needs to align with the organization’s mission and vision. It is Views from the Field is offered by GIH as a forum also important that the program supports the organiza- for health grantmakers to share insights and experiences. If you are tion’s approach to achieving its goals and objectives. interested in participating, please contact Osula Rushing at 202.452.8331 or orushing@gih.org.