The Food Trust & The Partnership for a Healthier America May 11, 2014 Heather Pavlik Aramark Dietetic Internship
2 OVERVIEW In the next year, The Food Trust will partner with the City of Philadelphia Department of Public Healths Get Healthy Philly initiative, the Philadelphia Water Department, and other local partners to promote the national Drink Up campaign. The Drink Up Philly campaign will aim to increase the availability and marketing of water in Philadelphia corner stores, schools, farmers markets, and Night Market events. The objective of the campaign will be to reach more than half a million Philadelphia residents with the message that water is a healthy choice. This far-reaching campaign will work to increase consumption of water and educate children and families on the importance of drinking water every day. 1 A nutritional education table was set up at the Drink Up Philly launch event to educate participants at the event on the importance of drinking water daily. Every bodily system depends on water, which makes up about 60% of a persons body weight, according to the Mayo Clinic. 2 Water is a calorie-free option for youth and families to substitute for sugar-filled beverages and is largely inexpensive and available practically everywhere. Yet, despite recent trends showing a rise in water consumption and declines in the amount of soda people drink, the Drink Up campaign is still needed. Obesity rates are also rising in the United States. 3 Health advocates have blamed the corn syrups and other sugars in soda for obesity, but the Drink Up campaign will not force anti-sugary drink messages on consumers. Instead, the campaign will opt to have a positive tone associated with water from start to finish.
3 NUTRITION ASSESSMENT The Nutrition Care Process is a standardized model and systematic approach intended to guide Registered Dietitians and Dietetic Technicians, Registered in providing high quality nutrition care. 4
Food/Nutrition-Related History 1. FH-1.2.1.1: Fluid/Beverage Intake Oral Fluid Intake A study analyzing the drinking habits of 3,397 adults who participated in the National Cancer Institute's Food Attitudes and Behaviors Survey was published in 2013 by the CDC's journal, Preventing Chronic Disease. According to this study, 43% of American adults drink less than 4 cups of water a day. This includes 36% who drink 1 to 3 cups per day, and 7% who drink none. Additionally, about 25% of kids under the age of 19 drink no plain water at all on any given day, according to government statistics. Thankfully, 35% of Americans drink 4 to 7 cups a day, while 22% drink 8 or more. 3
2. FH-6.3.1: Safe Water Availability Availability of Potable Water, access to functioning well or treated public water supply The Philadelphia Water Department (PWD) uses proven treatment practices in innovative research to provide drinking water that consistently exceeds standards. Philadelphias drinking water sources are the Delaware and Schuylkill Rivers. PWD embraces a watershed protection approach that monitors and evaluates events and practices that may impact water quality in Philadelphia. Watershed businesses and residents also play a role in the health of Philadelphia waterways. Proper disposal of hazardous wastes, household chemicals, and 4 unused prescriptions are essential to protecting drinking water. 5
Client History 1. CH-1.1: Personal Data The degree of water intake by Americans varies greatly depending on the demographics and health habits of persons living in the United States. In the Food Attitudes and Behaviors study, the likelihood of drinking less than 4 cups of water daily was significantly higher among participants aged 55 years or older than among those aged 18 to 34. The likelihood of drinking less water was also greater among residents of the Northeast than among residents of the South and among participants who consumed 1 cup or less of fruits or vegetables per day than among those who consumed 4.5 cups or more. 6 Participants who exercised 150 minutes or more per week consumed more water than participants who did not exercise. There was also a noticeable distinction between participants who were neither trying to gain nor lose weight and those trying to lose weight; participants aiming for weight loss seemed to consume more water daily. 3
Understanding the associations between culture, demographics, and ethnicity and water consumption helps to identify populations that may benefit from water- promoting interventions.
NUTRITION DIAGNOSIS PES Statements 1. Inadequate Fluid Intake (NI-3.1) related to food- and nutrition-related knowledge deficit concerning appropriate fluid intake as evidenced by reports of estimated 5 intake of fluid less than requirements (43% of American adults drink less than 4 cups of water a day). 3
2. Food- and Nutrition-Related Knowledge Deficit (NB-1.1) related to lack of prior nutrition-related education as evidenced by observations of verbalizing inaccurate or incomplete information, indicating the need for nutrition education.
NUTRITION INTERVENTION Based on the nutrition diagnoses, an educational intervention in the form of a nutrition session at a campaign kick-off event was developed and provided. The session provided learners with nutrition information on drinking water, different types of water, and hydration status. 1. E-1.4: Nutrition Education Content, relationship to health and disease 2. E-2.2: Nutrition Education Application, skill development Healthy People 2020 Healthy People 2020 is a science-based program that sets an achievable, 10- year national objectives for the health of the American people aimed at encouraging individuals to make better, more informed health decisions, measure the impact of health-based prevention activities and encourage collaboration across communities and sectors. ! Goal: Increase the quality, availability, and effectiveness of educational and community-based programs designed to prevent disease and injury, improve health, and enhance quality of life. ! Objective: ECBP-3.5: Increase the proportion of elementary, middle, and senior 6 high schools that have health education goals or objectives which address practicing health-enhancing behaviors and reducing health risks (skills). The intervention delivered contributed to addressing the nutrition problem, knowledge deficit related to the required amount of water recommended daily, and the larger goal and objective in Healthy People 2020 related to improving educational and community-based programs. In 2006, 98.9% of elementary, middle, and senior high schools had health education goals or objectives that addressed practicing health- enhancing behaviors and reducing health risks (skills) articulated in the National Health Education Standards. The target for this objective is that 100% of schools address practicing health-enhancing behaviors and reducing health risks in their standards. The Healthy People 2020 objective to increase the proportion of elementary, middle, and senior high schools that have health education goals or objectives which address practicing health-enhancing behaviors and reducing health risks is written in SMART criteria and assists in the measurement of success of the educational intervention. The condition, population and target are very specific. An increase from 98.9% of schools to a target of 100% of schools is measureable. The target is achievable and realistic compared to the current percentage of schools with health education, especially over the time-frame of 14 years, 2006 2020. An emerging trend in dietetics that is addressed by this intervention is the groundbreaking innovativeness of a campaign that urges Americans to drink more water. This campaign piggybacks First Lady Michelle Obamas Lets Move effort to build a healthier youth and healthier families. Supporting organizations made the following commitments as part of the local campaign in Philadelphia 7 : 7 ! The Food Trust (TFT): To increase marketing and consumption of water in Philadelphia, The Food Trust pledged to promote water in more than 600 neighborhood corner stores, schools, farmers markets, and Night Market Philadelphia events, reaching more than half a million residents with the message that water is a healthy choice that we can all make every day. ! The Philadelphia 76ers: To help increase the consumption of water and raise awareness of its importance in Philadelphia. The 76ers pledged to provide suitable drinking water to children participating in all of the community programs conducted in the region over the summer. ! The Philadelphia Department of Public Health (PDPH): To increase marketing and consumption of water in Philadelphia, PDPH pledged to increase access to tap water in schools and afterschool settings and promote healthier beverage choices through healthy vending policies. ! The Philadelphia Water Department (PWD): To increase marketing and consumption of water in Philadelphia, PWD pledged to continue to provide high quality, cost-effective drinking water to the residents and businesses of Philadelphia and to encourage the consumption of tap water through a variety of educational tools, such as social media, school outreach, distribution of promotional materials, and programming at the Fairmount Waterworks Interpretive Center.
8 EDUCATION INTERVENTION Lesson Plan The science and evidence about hydration's importance is well-established. 8
70% of our lean body mass is water. Water is in our bloodstream, our cells, and filling the spaces between our cells. A nutrition education table for the Drink Up Philly campaign kick-off was prepared the week prior to the event. The table included posters, interactive games, and informational handouts for an audience of all ages. The first section of the nutrition table consisted of a two-sided sandwich board with large posters displayed on either side. The first poster educated learners on the importance of hydrating with water daily. Proper hydration is key to good health; not enough water can affect many systems in the body. Fluid in our bodies helps to control body temperature. When one is dehydrated, the ability to sweat and cool down the body is reduced, which could raise risk for heat exhaustion or heat stroke in hot weather. Another common issue associated with dehydration is decreased blood volume, which can cause stress on the heart and hinder the ability to maintain blood pressure, leading one to faint. To ensure proper hydration, leaners were educated to pay close attention to the color of their urine. The goal is to excrete clear urine at least once a day. Dark yellow urine is sure sign of dehydration. Younger learners were advised to compare hydrated urine and dehydrated urine using a lemonade and apple juice model. The opposing side of the poster board presented a poster that enlightened participants on various ways to jazz up plain old water to make drinking water fun. See Appendix A. The next section of the nutrition table was nick-named the Carbonation Station. At this station, partakers were encouraged to participate in an interactive game that 9 tested their knowledge on the differences between various carbonated waters. Learners were then presented with how to carbonate their own water using a Soda Stream and no added flavors or sweeteners. The process of carbonation was discussed and carbon dioxide was defined. The final portion of the educational table was a trivia wheel game with water-related trivia questions. Learners were able to spin the wheel and answer a question about water. See Appendix A. Marketing A marketing strategy is the basic foundation of a marketing plan that involves strategic analysis of the internal and external factors. Internal environmental factors include the marketing mix, or the 4 Ps, performance analysis, and strategic constraints. External environmental factors include customer analysis, competitor analysis, and target market analysis. A crucial element of a marketing strategy is to keep marketing and promotion in line with the missions and objectives of all subsidiaries involved; The Food Trust, The Partnership for a Healthier America, the Philadelphia Department of Public Health, and the Philadelphia Water Department included. Internal factors play a major role in the way an operation markets and promotes its product, or cause in this case. The marketing mix, also known as the 4 Ps, is one of these internal environmental factors that includes product, place, price, and promotion. The Drink Up Philly Campaign Kick-Off (product) was a free event (price) held at the Fairmount Water Works in Philadelphia, PA on Thursday, May 8, 2014 from 10:00 am to 1:00 (place). The event was endorsed (promotion) by the use of news releases, announcements on the websites of the various organizations involved in the planning of the event, invitations sent out to local businesses and schools, flyers, and floor mat 10 posters placed in offices, supermarkets, and corner stores. Corner store operators, food truck vendors, youth leaders, and community groups helped to promote the campaign kick-off by word of mouth and will continue to promote the campaigns commitments in the future. An Instagram account (@drinkupphl) and a Twitter account (@drinkupphl) were created to support the campaign and provide live updates throughout the kick-off event via pictures, tweets, and videos. See Appendix B for examples of promotional materials. The Drink Up campaign will include a water drop logo that will be featured on select water bottles and drinking fountains. Public service announcements will also run on television networks, and several celebrities, including Eva Longoria, have joined the campaign and will encourage water drinking through social media. 1. Product: Drink Up Philly Campaign 2. Place: Fairmount Water Works in Philadelphia, PA 3. Price: Free 4. Promotion: News releases, Twitter, Instagram, website announcements by various organizations involved, flyers, word of mouth, TV, water bottles, drinking fountains, celebrities, PSAs Resources All educational materials, equipment, supplies, and paper products required for the implementation of the nutrition intervention were calculated into The Food Trusts budget for the Drink Up Philly launch event. Promotional materials for the campaign launch event were provided by the national campaign and the Partnership for a Healthier America. 1
11 NUTRITION MONITORING AND EVALUATION Evaluation of the effectiveness of the educational intervention was achieved by use of a verbal pre- and post- test. Learners were invited to participate in a verbal pre- test in the form of various water-related activities, including a SpinQuest trivia game, a guessing game about carbonated waters, and a demonstration on the process of carbonating water. After completing the activities, the instructor and the learners performed a verbal post-test in which the correct answers to the trivia questions were discussed, the differences between the types of carbonated waters were explained, an understanding of hydration status was addressed, and learners return demonstrated the process of carbonation with the Soda Stream. The Drink Up Philly kick-off event had about 150 attendants that included a wide array of people, from CEOs of major corporations to fifth grade students to. Almost 75% of the attendants took the time to stop by the nutrition education table to participate in the water activities provided. All participants were engaged in the educational session and asked relevant questions. In terms of the verbal pre- and post-test, almost no one was able to determine the difference between tonic water, seltzer water, and club soda. Participants were educated on the differences between these carbonated waters and were able to return demonstrate comprehension of the concept. Most, about 70% of learners, were able to correctly answer water-related trivia questions prior to education on the information. Questions and answers were reviewed with the participants at the end of the educational session. Hydration status, urine color, the human water cycle, and numerous ways to jazz up plain water were discussed with the learners. Leaners were invited to share thoughts, comments, and observations about the material. 12 Suggestions for future plans in executing this nutrition intervention include having the event indoors. The Drink Up launch event was held at the Fairmount Waterworks, an outdoor venue right on the Schuylkill River in Philadelphia, PA. The posters, games, and interactive activities set up at the nutrition table were quite difficult to keep in place with wind and rain as a contributing factor. Another suggestion for the event would be to make the nutrition education table a more formal session in which learners could be given written pre- and post-test to truly determine the effectiveness of the intervention. Overall, the kick-off event was extremely successful. Attendants were able to meander through the Waterworks to various tables and educational booths. A street dancing and hip-hop group and the Philadelphia 76ers performed for attendants. Leaders of local supporting organizations were able to speak to attendants and a water toast was made to kick-off the Drink Up Philly campaign. Supporters and attendants were delivered the important message that you are what you drink, and when you drink water, you drink up!
Figure 1. Campaign Promotion The Food Trust Website
Figure 2. News Release The Partnership for a Healthier America Website
21 Figure 3. Drink Up Philly Instagram Account
Figure 4. Drink Up Philly Twitter Account
22 REFERENCES
1. America PfaH. Drink Up. 2014; http://youarewhatyoudrink.org/. Accessed May 5, 2014. 2. Clinic M. Water: How much should you drink every day? 2014; http://www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in- depth/water/art-20044256. Accessed May 4, 2014. 3. Goodman AB, Blanck HM, Sherry B, Park S, Nebeling L, Yaroch AL. Behaviors and attitudes associated with low drinking water intake among US adults, Food Attitudes and Behaviors Survey, 2007. Prev Chronic Dis. 2013;10:E51. 4. Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process. Chicago, IL; 2013. 5. Department PW. Drinking Water Quality. 2014; http://www.phillywatersheds.org/drinkingwaterquality. Accessed May 9, 2014. 6. Tate DF, Turner-McGrievy G, Lyons E, et al. Replacing caloric beverages with water or diet beverages for weight loss in adults: main results of the Choose Healthy Options Consciously Everyday (CHOICE) randomized clinical trial. Am J Clin Nutr. Mar 2012;95(3):555-563. 7. America TPfaH. Drink Up Comes to Philadelphia. 2014; http://ahealthieramerica.org/media/news-releases/. Accessed May 8, 2014. 8. Popkin BM, D'Anci KE, Rosenberg IH. Water, hydration, and health. Nutr Rev. Aug 2010;68(8):439-458.