Transforming Community Health Through Civic Engagement and Data
Second Annual Report
Submitted by Bryan Bayles, PhD, MPH Curator of Anthropology and Health YEAR TWO HIGHLIGHTS: • In Year 2, the H-E-B Body Adventure Powered by the University Health System received the following state and national recognition and accolades, achieving the Inaugural Texas Association of Museums Media Innovation and Excellence Award; special recognition from the San Antonio Mayor’s Fitness Council, the American Alliance of Museums, and the University of Texas Health Science Center’s Institute for the Integration of Medicine and Science. • The Witte Museum saw a quadrupling of the number of participants in Food is Fuel on nutrition for grades K-2, and a tripling of the number of students participating in The Machine Within: Muscle Mechanics on physical activity and the musculoskeletal system for grades 6-8. • 143,049 visitors signed in and received POWERpass cards in Year 2, making for a grand total of 311,818 POWERpass cards issued since opening the H-E-B Body Adventure. School-aged children ages 5 through 18 represent 69% of POWERpass users. • Asked about safe places for physical activity, 47.1% of Bexar County respondents ages 8 and up reported that there are “a lot” of fun, safe places to go outside and play near where they live. However, 17.2% of Bexar County youth ages 13 to 18, stated that there are “no fun, safe places” to play outside near where they live. This was slightly higher than Year 1 (15%). • 57.5% of Bexar County youth ages 13 to 18 spent 2 or more hours watching TV or playing video games on an average school day; one in four (24.7%) of these youth reported spending 4 or more hours screen time on an average school day. • Fruit and vegetable consumption was lowest, and sedentary screen time highest, in the age group of 13 to 18 year olds in Bexar County, making them an important target population for outreach and programs. • Fruit (chosen by 54% of respondents) continues to be the most popular item selected as a favorite healthy snack. Despite fruit’s popularity, however, 31% of Bexar County Youth ages 13-18 ate ‘no fruit’ prior to their H-E-B Body Adventure visit. • Vegetables were chosen as a favorite healthy snack by only 11% of respondents. 36% of Bexar County youth ages 13-18 ate ‘no vegetables’ the previous day. • Soda consumption was more or less equal in the age groups 8 to 12 and 13 to 18, at approximately 37% reporting drinking one or more sodas per day. Youth between the ages of 13 and 18, however, were more likely than their younger counterparts to drink 2 or more sodas per day (19.4% vs. 15%). Adult consumption tends to be slightly lower, with 33% of adults ages 19 and up reported drinking one or more sodas per day. • According to Year 1 and Year 2 data, approximately 46% of school-aged youth 8-18 in Bexar County were either Overweight or Obese (17.6% and 28.2% respectively).1 • Significant regional disparities are evident in the health data for Bexar County and deserve closer examination.
*Please note: Any public use or interpretation of data from the H-E-B Body Adventure Annual Reports must be accompanied by the following statement/disclaimer: This [explain activity] was prepared or accomplished by [insert author name(s)] in his/her personal capacity. The opinions expressed in this article (or presentation) do not reflect the view of either the San Antonio Metropolitan Health District or the Witte Museum. Community Partners in Health and Wellness As the People’s Museum, and with more than 100 community partners from San Antonio and regionally, Witte Museum leadership decided to put a stake in the ground and dedicate its entire science center to a pioneering, revolutionary model: the H-E-B Body Adventure Powered by University Health System. The Witte has long-standing and profound social equity through the diverse multigenerational demographics of its visitors. Since its grand opening on May 24, 2014, the H-E-B Body Adventure has now issued over 312,000 POWERpasses, with each visitor choosing a virtual “Buddy” and experiencing authentic interactive physical and mental health behavior change. The evaluations from students, teachers and families illustrate resounding success. The H-E-B Body Adventure transforms health behaviors, with a focus on Health IQ, Empowerment and sustained Wellness through POWERpass technology.
In its first two years of operation, the H-E-B Body Adventure has fostered an astounding array of creative, enduring collaborative partnerships to change the culture of health in our city. These partners include the region’s largest and most visionary food retailer H-E-B, multiple recognized national leaders in hospital and clinical care systems (University Health System, the Children’s Hospital of San Antonio™), premiere health insurers (Blue Cross Blue Shield of Texas, Aetna) County and City entities (San Antonio Metropolitan Health District, the Mayor’s Fitness Council, County Commissioner’s Office, San Antonio Parks and Recreation) as well as additional cross-sector partners including leading Foundations (the Baptist Health Foundation of San Antonio, Saint Susie Charitable Foundation, the Semp Russ Foundation of the San Antonio Area Foundation, the Genevieve and Ward Orsinger Foundation, the Beulah M. and Felix J. Katz Memorial Trust, Dan and Gloria Oppenheimer Fund and Valley View Trust of the San Antonio Area Foundation), as well as additional partnership with the University of Texas Health Science Center at San Antonio, University of the Incarnate Word, YMCA of Greater San Antonio, the Culinary Institute of America, the San Antonio Botanical Garden, BioMed SA, the Synergy Studio, and the Pearl Farmer’s Market, and pioneering individuals such as Susan Moulton and Dr. Dacia and Lanham Napier and Witte Members.
These extraordinary partners have come together with the Witte Museum to create a trusted, safe and accessible civic space to promote lifelong learning and culturally relevant health promotion and enrichment for ALL bodies. The H-E-B Body Adventure creates a national model of community collaboration and public programming to revolutionize the fight against chronic disease through unprecedented interactive museum experiences, data collection and sharing. As San Antonio’s most enduring and most-visited museum, the Witte has a strong record of engaging multigenerational audiences with hands-on learning and scientifically accurate information. The H-E-B Body Adventure leverages this equity to address the urgent health and educational needs of the entire community.
Captain Calcium celebrates the Veg Out SA! Campaign and healthy eating with Witte Trustee and Blue Cross and Blue Shield of Texas (BCBSTX) Regional President Dr. Esteban López
1 The H-E-B Body Adventure SkyCycle® Goals for the Body Adventure The goals of the H-E-B Body Adventure are 1) to provide a safe haven for learning about how our bodies work (Health IQ), 2) to encourage visitors to set small, attainable goals (Empowerment) and 3) to offer a journey to sustained health (Wellness) for entire families. To accomplish these goals, the H-E-B Body Adventure introduces peer modeling, gaming technologies, physical activity and a regionally relatable cultural focus into a four-story, immersive indoor-outdoor experience. The three key themes of Health IQ, Empowerment and Wellness shape the content, creating teachable moments through exhibits, programs, daily demonstrations by trained professional actors (InterActors) and environments that invite hands-on experiential learning for all ages and bodies. Interactives and demonstrations are themed around locally recognizable landmarks and community resources, so that the H-E-B Body Adventure serves as a ‘hub’ of transformational experience that translates back to increased awareness and use of San Antonio’s growing network of parks, walking and cycling trails and other resources. Activities such as the Pick Up Your Pace Investigation Station activity allows visitors to see their stride length, speed and height and learn how long it will take for them to walk the entire 13-mile linear park from Mission Espada to the Witte Museum. Move It!, a game of action, Mt. Witte climbing tower, and the South Texas Trailblaze provide fun aerobic physical activity challenges. On the South Texas Trailblaze stationary bikes, visitors ride along the southern reach of the San Antonio River trails in real time while attempting to reach their target heart rate. Interactive computer games on the Blue Cross Blue Shield of Texas Wellness Floor like You Are What You Drink and Build a Balanced Meal prompt moments of nutritional discovery and real plastinated human specimens (two hearts and an entire gastrointestinal tract) immerse visitors in gross anatomy and principles of basic physiology. Wellness and relaxation components like Relax to Win and Relax Your Brain empower visitors to experience mental concentration and mindful awareness. Families learn about healthy eating in the Children’s Hospital of San Antonio™ full-scale, state of the art demonstration kitchen. The Children’s Hospital of San Antonio™ Toddler Discovery Garden playscape nearby offers a safe, comfortable space for young children and their families to experience physical activity in an environment that also promotes positive social norms of healthy eating and nutrition. 2 A Year of National and State Recognition and Accolades The Second Year of the H-E-B Body Adventure brought tremendous recognition and momentum that continues to place the Witte in the promised Top Tier category among museums worldwide, proving the Witte is indeed a catalyst for creating San Antonio as a city on the rise. Witte museum leadership is thrilled to announce that the H-E-B Body Adventure has been recognized as the winner of an Inaugural Texas Association of Museums Media Innovation and Excellence Award. This award compliments the Museum’s exclusive invitation from the American Alliance of Museums (AAM) to present the success of the H-E-B Body Adventure on a national stage in Washington, DC at the 2016 Annual Meeting and MuseumExpo. Representing Witte Trustee and H-E-B Vice President Kate Rogers, H-E-B Health Promotions Manager Monica Garza traveled along with Witte President and CEO Marise McDermott, Witte Curator Dr. Bryan Bayles and San Antonio Metropolitan Health District Assistant Director Dr. Anil Mangla to reveal the innovation and community-wide impact of the H-E-B Body Adventure in a lively discussion entitled “Do the Impossible: Transforming with Civic Engagement and Data.” The team shared the story about how the Witte is now generating unprecedented metrics for physical activity, nutrition and health behavior on a scale never before available to help guide community- wide strategic planning. Through sweeping collaborative partnerships the Witte has created a bold national model to ignite health behavior changes across the country. The overwhelmingly positive response was accompanied by numerous follow-up inquiries and a clear indication that the metrics and partnerships the Witte is pioneering between City, Foundations, private industry and members are not being produced anywhere else in the entire nation. The H-E-B Body Adventure also accepted a special ‘Thank You’ recognition in December from the City of San Antonio Mayor’s Fitness Council for its commitment to health and wellness and our sustained partnership with City Leadership. Dr. Bayles has been promoted to serve as a member of the Executive Committee of the Mayor’s Fitness Council, in addition to serving on the Healthcare Subcommittee and Active Living Council. Since opening its doors, the Witte Museum’s H-E-B Body Adventure has been the host for regular trainings and visits by the Mayor’s Fitness Council’s flagship Student Ambassador Program, which brings together school mentors and students and nurtures them through training and program development to become role models, leaders, idea creators and change makers that empower their schools, friends, and families to lead healthier lives. As a direct result of the success of the H-E-B Body Adventure this past year, Curator Dr. Bayles also now represents the Witte Museum on several Advisory Boards and committees, including the H-E-B Statewide Health and Wellness Promotion Committee, the University of Texas Health Science Center Institute for the Integration of Medicine and Science Community Engagement Board, the San Antonio Health Literacy Initiative, the Bexar County Healthy Beverage Coalition, and the University of Texas at San Antonio (UTSA) San Antonio Chronic Disease Collaborative, which seeks to further leverage community-wide partnerships to sustain crucial research in health equity and largely preventable chronic disease. The Witte’s Museum also shared its powerful localized data on fruit, vegetable, soda consumption and obesity in an opening presentation entitled “Framing the Challenge” at the Physicians Culinary Medicine Conference sponsored by the Goldsbury Foundation and the Witte’s close partner The Children’s Hospital of San AntonioTM. Data and interactive learning models were also shared at multiple seminal community–wide forums: The 2015 Health and the Built Environment: Leveraging a More Livable San Antonio Conference hosted by the San Antonio Metropolitan Health District, the San Antonio Military Health System (SAMHS) & Universities Research Forum at UTSA and the University of Texas Health Science Centers’ Voelcker Biosciences Teacher Academy 5th Annual Spring Conference. 3 Major General Stephen L. Jones, USA Commanding, presented the Witte Museum with a Certificate of Appreciation for outstanding support of the Army Medical Department Center and School’s Performance Triad Kickoff. The H-E-B Body Adventure was recognized for its direct support of the Army Surgeon General’s priority to transform Army Medicine from a healthcare system to a System for Health and its three pillars of a healthier lifestyle: Sleep, Activity and Nutrition. Known as “Military City, USA,” San Antonio has one of the nation’s largest active and retired military populations. The Witte Museum is proud to serve as a sustained resource for these families and looks forward to expanding these partnerships. The H-E-B Body Adventure was also highlighted at the successful It’s Time Texas Summit, a two-day event presented by the Mayor’s Fitness Council that unites Texas’ leaders and champions in the health space to discuss community health roadblocks and share transformational solutions, with a keynote by Former Texas Comptroller Susan Combs. Together with several additional lectures and interactive presentations in Year Two, the H-E-B Body Adventure’s unique model and metrics have been shared with hundreds of policy leaders, physicians, residents, nurses, allied health personnel, museum, educational and community health advocates throughout the nation and San Antonio. The Witte is proud to be an educational resource for Texas and ensures that all H-E-B Body Adventure curricula (daily live demonstrations, interactive carts, Family Days, week-long camps and more) are aligned to Texas Essential Knowledge and Skills (TEKS) requirements to supplement classroom learning. With the enduring support of its visionary partners, the Witte Museum education team, under the leadership of Sarita Rodriguez, Vice President of Public Programs, has developed multiple 45-minute Interactive Student Programs (ISPs) to meet students’ needs for health and wellness education and teachers’ requests for relatively short, impactful programs in the health sciences. The Witte would especially like to recognize the Harvey E. Najim Family Foundation for their generous support of field trip scholarships for students to visit the H-E-B Body Adventure and participate in health and wellness programs. With such support and the sustained partnerships created to date, the Witte Museum saw a quadrupling of the number of participants in Food is Fuel on nutrition for grades K-2, and a tripling of the number of participating in The Machine Within: Muscle Mechanics on physical activity and the musculoskeletal system for grades 6-8. This latter increase was particularly exciting, given that several findings from the Year 1 Baseline Data report indicated that the age group of 13 to 18 year olds was a very strategic group to target for improved Health IQ, Empowerment and Wellness. Put Your Heart Into It! on cardiovascular health for 3rd-5th grades and the ever-growing array of educational offerings and Body Adventure-themed Family Days made possible through the collaboration of our partners like H-E-B, University Health System, BlueCross BlueShield of Texas, continue to be in very high demand. On their evaluations, 98% of the teachers rated H-E-B Body Adventure programs at a 4 or 5 on a 5-point scale. In addition to the high ratings, teachers left insightful comments that help the Witte know what some of the strengths in the programs are from the teachers’ perspectives.
Meeting Community Needs: Teacher Feedback Did the Program meet your expectations? “ We appreciated that everything was so interactive and educational.” ”No. It was above my expectations—it “Vocabulary was the same as those covered in science class.” was great!” “Great student-presenter interaction; real-world examples.” (High School Life Sciences class 9th-12th grade) 4 In response to “Did the program correspond to the TEKS (Texas Essential Knowledge and Skills)?” teachers answered, “Yes, science and math TEKS; health TEKS; food groups TEKS.” When asked, “What was your favorite aspect of the program?” teachers responded with phrases like: “very hands-on;” “very kid friendly;” “Offers direct connections to their health;” “ties right into the 6th grade Science curriculum” and “I liked that students learned ways to keep their hearts healthy: very practical for their lives,” among many others. This feedback indicates the Witte is on track to achieving the goal of increasing students’ and teachers’ Health IQ, personal Empowerment, and lifelong Wellness. Furthermore, a large majority (64%) of the teachers had never taken a field trip before to the Witte, which demonstrates these programs are drawing an even broader and new audience of teachers and students to the Witte to learn about their bodies (Health IQ), how to make good choices for their bodies (Empowerment), and how to sustain Wellness over a lifetime. For two years, the H-E-B Body Adventure has also served as a site for the Annual Public Health Camp led by the University of Texas School of Public Health San Antonio Regional Campus in collaboration with the University of Texas Health Science Center Area Health Education Center (AHEC). This year’s camp grew to 39 high school juniors and seniors (up from 22 the previous year), representing 23 high schools, 7 Independent School Districts, 2 Charter Schools and one Catholic School from across the state. For the second year in a row, the Witte Museum’s H-E-B Body Adventure also served as a site for an extremely successful American Diabetes Association Camp Power Up, where children experienced guided full-body activities and health cooking demonstrations in the H-E-B Body Adventure. The American Diabetes Association’s Camp Power Up hosted 39 local youth ages 9 to 14, who have been identified to be at-risk of developing type 2 diabetes. Camp Power Up empowers youth campers in an educational and fun-filled environment and focuses on diabetes education, nutrition, physical activity and combatting obesity. Witte Museum leadership is particularly grateful to H-E-B partners who have been shoulder-to-shoulder over many years in the development of the H-E-B Body Adventure, which includes culinary, boot camp, financial, and marketing expertise and support. University Health System’s leadership offered generous support for the innovative POWERpass systems, even before they were developed, as did the San Antonio Metropolitan Health District. We are grateful to BlueCross BlueShield of Texas for underwriting the entire second floor of the Body Adventure, including the popular Anatomy Table (sponsored by Dr. Dacia and Lanham Napier in honor of her parents) and You are What You Drink. We thank the Children’s Hospital of San Antonio™ for supporting the entire floor housing the Demonstration Kitchen and Toddler Discovery Garden. The Charles Moulton Serenity Floor, at tree canopy level with dramatic views of the San Antonio River, is the place where meditation, Tai Chi and Yoga, among other health initiatives can be found early morning and in the evenings. We thank the Baptist Health Foundation of San Antonio for their support of the plastinated specimens that give visitors a first-hand look at the inner workings of the body. We also thank the Aetna Foundation and Witte members for their support of the Move It! Dance Floor and Mt. Witte and to the Saint Susie Charitable Foundation for their early support of the Body Adventure. Through such powerful partnerships, the Witte Museum H-E-B Body Adventure is nurturing healthy living. Marise McDermott President and CEO
5 The H-E-B Body Adventure Buddies and POWERpass Technology
The H-E-B Body Adventure Buddies At the heart of the H-E-B Body Adventure is a sophisticated system of networked exhibition components called the POWERpass, made possible through the visionary support of University Health System. The POWERpass technology is the key differentiator between the H-E-B Body Adventure and other health science museums. Decades of evidence-based research have demonstrated a supportive social matrix are critical in building self-efficacy for health behavior change.1 Therefore, the Witte Museum has made peer support an integral aspect of the POWERpass experience: visitors sign-in, select one of twelve ‘Buddies’ and receive a POWERpass card that allows their chosen Buddy to guide them virtually throughout their adventure. Buddies are real San Antonio residents of diverse ages, backgrounds and body types who were chosen as inspiring role models and participated in extensive training on health behavior skill- building and goal-setting in the areas of physical activity, healthy eating and relaxation. Throughout their training, Buddies were interviewed and filmed so that they relate to museum visitors through inspirational, supportive and empowering multimedia presentations linked to the interactive exhibition components. The POWERpass card provides visitors with a seamless personalized experience that culminates with a take-home POWERprofile card to remember their visit and compare with future visits. Overall the most popular Buddies selected continue to be Evan (12 yr old Anglo male), Lexie (9 yr old Hispanic/Latino female), Carrie (19 yr old Asian female) and Matthew (12 yr old African American/White male), consistent with the first year. The broad ethnic demographic of the most popular Buddies chosen is notable, as we believe it also reflects the broad “mixed” ethnic heritage and representativeness of the Witte visitors. Interestingly, data confirms that male visitors continue showed a definite preference for male Buddies, and female visitors showed a definite preference for female Buddies. In Table 1 below, the most popular four of the 12 Buddies are shown below by gender of visitor. This indicates that one goal of giving visitors an opportunity to choose someone they identify with appears to be working very well.
6 Male Visitors (n=65,675) Female Visitors (n=77,374)
H-E-B Body Adventure Buddy Number (%) H-E-B Body Adventure Buddy Number (%)
Evan (12 yrs old) 25,304 (38.5%) Lexie (9 yrs old) 22,310 (28.8%)
Matthew 13,701 (20.9%) Carrie 16,371 (21.2%)
Hudson 13,701 (20.9%) Elisa 16,371 (21.2%)
Paul 5,257 (8.0%) Cheyenne 6,211 (8.0%)
Table 1: Most Popular H-E-B Body Adventure Buddy Selections by Gender; All Ages, 5/25/15-5/25/16
On-the-floor evaluation monitoring by Witte staff has also confirmed that, while individual stations are personalized though the experience of a personally selected Buddy, individuals often participate in the POWERpass activities together with others. For example, a mother, father or peer often stands next to a daughter, son, or friend while they are, for example, stepping up to You Are What You Drink, selecting a beverage and seeing how long it takes to work it off. In fact, such interactions and the health behavior- related conversations, goal-setting, etc. that they invoke are one of the most exciting and powerful dynamics of the H-E-B Body Adventure. The POWERpass system of networked exhibition components, together with a ‘back-end’ SQL server database developed in collaboration with Catapult Systems LLC, also allows for the collection of entirely de-identified and completely anonymous aggregate data metrics. Such data are of a type never-before available for the purpose of assessing community attitudes and behavior, as well as height and weight. The public is informed through visible signage and letters to all field trip participants and parents regarding the anonymous, non-personally identifiable nature of all data collection. The project was reviewed and approved by the Institutional Review Board for the Protection of Human Subjects of the University of Texas Health Science Center at San Antonio. While estimates of the prevalence of obesity, nutrition and physical activity behaviors are available for some middle and high school students via the CDC’s Youth Risk Behavioral Surveillance System (YRBS) and for adults via the Behavioral Risk Factor Surveillance System (BRFSS), these are based on smaller sample sizes far below the thousands of records generated by the H-E-B Body Adventure. While it should be noted that POWERpass data is in essence a
7 convenience sample and thus the generalizability of the data to larger populations remains to be tested, Bexar County has never before had estimates of the prevalence of many of these key health behaviors at the zip code level for a sample size this large and diverse. The following descriptive data report, therefore, represents a thoroughly unique snapshot of community health, unprecedented in the nation. While internal Quarterly reports are already beginning to show some seasonal trends and provide a sense of the expected range of variation for variables, it is important to note that interpreting longitudinal annual trends is still somewhat premature. For this reason, in consultation with leadership at the San Antonio Metropolitan Health District, it was decided that no significant longitudinal interpretations would be made until Year 3 results have been reported. This ensures that what statisticians term “random error” is more securely controlled. Year-to-year comparisons should be made cautiously as they are not the exact same populations each year. Therefore, they do not indicate behavior change at the individual level. This is, of course, the case in most longitudinal community or school-based health surveys. Nonetheless, the H-E-B Body Adventure represents a thoroughly unique broad community sample hitherto unavailable. The tables in the present report will show metrics for Year 2; that is, the period from May 25th, 2015 through May 25th, 2016. Additionally, however, the report includes cumulative results for the entire 2-year period since Grand Opening on May 24th, 2014 through May 25th, 2016 in the form of maps. These maps use zip-code-level data to aggregate responses by zip code and also 8 subsectors. These subsectors are comparable to the 8 healthcare subsectors used in the Bexar County Community Health Improvement Plan, a key guiding document for public health strategic planning prepared by the Health Collaborative.3 Some maps show cumulative findings for Years 1 and 2 at the individual zip code level. RESULTS During Sign-In, a visitor enters their age, gender and zip code and selects a Buddy. Age and Gender Consistent with Year 1 results, a slight majority (54.1%) of visitors signing-in and receiving POWERpass cards during Year 2 were female. This difference was slightly more pronounced among Bexar County POWERpass users.
All Bexar County POWERpass Users POWERpass Users Gender Number (%) Number (%) Male 65,675 (45.9%) 31,971 (43.6%) Female 77,374 (54.1%) 41,328 (56.4%) Total 143,049 (100.0%) 73,299 (100%)
Table 2: Gender of POWERpass Users; 5/25/15-5/25/16
The average age of POWERpass users was 17 years old this year, which was slightly higher than last year’s age of 16. Given the positive skew of the age distribution (minimum 1, maximum 99),4 the median age (50th percentile) 10 is still a more accurate reflection of the typical POWERpass visitor.
All Bexar County POWERpass Users POWERpass Users Gender Number Avg/Mean (SD) Median Age Number Avg/Mean (SD) Median Age Male 65.052 16.2 (17.1) 10 31,971 14.7 (14.5) 9 Female 77,022 17.0 (16.0) 11 41,328 16.5 (14.4) 11 Total 142,0744 16.6 (16.5) 10 73,299 41,328 10 Table 3: Age by Gender of POWERpass Users; 5/25/15-5/25/16
8 The Witte Museum has seen a slight increase in the percentage of visitors in older age groups, particularly in the 8 to 12 year old age groups and the 45 and older age groups. We suspect that this may be a reflection of both targeted outreach to these age groups and increasing efforts by the Witte Museum to offer robust multigenerational programming in the H-E-B Body Adventure. For instance, several health- themed Family Days, the Summer Wellness Series at the Witte, and the evening Salud! Culinary Nights program have continued to expand the reach of the H-E-B Body Adventure to a diverse age group of family members. Salud!, which continues to routinely sell out, is a series of tasty and interactive evening programs for adults featuring local chefs and a diverse array of cuisines and topics in the Children’s of Hospital of San AntonioTM Demonstration Kitchen. Cooking demonstrations for each program spotlight culturally and seasonally themed menu items. Visitors meet top local chefs, farmers, ranchers and food historians in an intimate setting as they present information, history and stories about the selected menu enjoyed by all. Each program also features wine or beer pairings from the finest Texas wineries and breweries. This year, visitors were treated with a vast array of events, including even a dinner of edible insects from partners Bug Vivant featuring Executive Chef Stephen Paprocki and Ernest Lopez, Pastry Chef of Eilan Hotel, with pairings from Karbach Brewing Co. Dr. Harry Shafer, the Witte Museum’s Curator of Archaeology, discussed the nutritional content and history of indigenous cuisines in South Texas and the Lower Rio Grande Valley as found in its rich archeological record. Nowhere else but the Witte Museum is healthy cuisine, South Texas Heritage and history brought together in such a unique fashion. #1 School-aged children, ages 5 through 18, continue to represent 69% POWERpass users overall and 66.3% of Bexar County users. School-aged children (that is, visitors 5 years old through 18 years old) continue to represent the majority (69%; n=98,031/142,074) of POWERpass card users. The San Antonio Metropolitan Health District has identified children in grades 3 through 5, that is ages 8 to 12, as a particularly important age group for behavioral change and public health education and outreach. This age group represents the largest user group of the H-E-B Body Adventure, representing 38% (n=53,610) of POWERpass cards overall and 32.4% (n = 23,741 of Bexar County users. (Table 4).
9 During Year 2, more than 5,000 youth have also been served in formal educational programs, which build upon and enhance the experience of the H-E-B Body Adventure exhibition itself. These programs, such as Put Your Heart Into It!, The Machine Within: Muscle Mechanics, Food is Fuel, Super You! workshops, Kids in the Kitchen museum camps not only teach about the science and technology of the human body, physical activity, culinary heritage and nutrition, but also spark excitement and interest in future careers in San Antonio’s burgeoning health, biotechnology and community health sciences. Healthcare and Bioscience continues to be one of San Antonio’s largest industries, adding 41,567 new jobs over the past decade (a 40% increase) and fueling San Antonio’s growth. Its economic impact in 2013 was $23.9 billion measured conservatively, and approximately $30.6 billion by a more comprehensive estimate.5 The H-E-B Body Adventure promises to ensure South Texas youth are equipped with the inspiration, wonder, and creative innovation necessary to continue to sustain this leadership in health and wellness fields. Geography During Year 2, 74% (106,067 of 143,049) of POWERpass users entered a valid U.S. zip code during sign-in; 96,283 (91% of total) of these were in Texas, while 9,427 (9% of total) were non-Texas.6 Of the 96,283 valid Texas zip codes, 76% (n=73,299) were from Bexar County. The following Maps 1 through 3 show POWERpass use throughout the U.S. by state, throughout Texas counties, and within Bexar County for those visitors who entered a valid zip code during the past year.7 These maps show the museum’s continuing strong reach nationwide and especially in Texas. Map #2 shows that the Witte Museum’s visitation is also reaching throughout the state with significant draw from central Texas, the major cities (Dallas/Ft. Worth, Houston, Corpus Christi) and also along the Texas-Mexico border region (Laredo, McAllen, Eagle Pass, Del Rio, etc). Not shown on Map #1 for reasons of scale are an additional 272 individuals from Alaska and Puerto Rico who also experienced the H-E-B Body Adventure.
10 11 Background/Ethnicity The Witte is proud to represent the diversity of the community and to be known as the “People’s Museum”. POWERpass users who complete the All About You activity on the Blue Cross Blue Shield of Texas Wellness Floor have a voluntary option of self-reporting ethnic background. In contrast to how such data are often gathered in surveys, the Witte believes it is important to allow individuals the option of selecting multiple ethnicities. This better reflects the increasingly complex blend of cultural backgrounds and families in South Texas and the nation. Table 5 shows the backgrounds of All About You respondents who entered a valid Bexar County zip code, compared with the 2014 Bexar County population according to the U.S. Census Bureau’s American Community Survey of Families (ACS)7. The higher percentage of individuals in the ‘Other’ category may reflect differences in data collection methodology between the Body Adventure and the ACS.
Self-reported H-E-B Body Adventure American Community Background Bexar County Respondents Survey8 Bexar County Total 20,624 (100%) 1,855,866 (100%) Hispanic or Latino (any race) 10,030 (54.3%) 1,100,164 (59%) White non-Hispanic 5,473 (29.7%) 538,621 (29%) Black or African American non Hispanic 1,148 (6.2%) 132,209 (7%) Other 1,810 (9.8%) 84,872 (5%) Skipped (Not included in percent calculations) 2,163 N/A Table 5: Self-reported Background of All About You Respondents; 5/25/15-5/25/16
POWERpass Stations Of the nine POWERpass stations within the H-E-B Body Adventure, the most popular and most visited on the first floor were the South Texas Trailblaze stationary cycles and the See Your Own Heartbeat. On the Blue Cross Blue Shield Wellness floor, the most popular activity is You Are What You Drink, where visitors choose a beverage and see how long it takes to work it off. The You Are What You Drink stepper is also where the visitor’s weight variable is captured, so its popularity is encouraging. Most importantly, its popularity is extremely promising given the urgent problem of excessive liquid calories and sugar-sweetened beverage consumption in South Texas and the nation. As shown later in this report, this urgency is also reflected in the survey responses to All About You, where a very high proportion of visitors report daily consumption of sodas. The All About You kiosks, made possible through the generous support of the San Antonio Metropolitan Health District, also remain extremely popular, being completed by nearly a third of visitors. Additionally, more than 52,000 individuals left the H-E-B Body Adventure with a personalized take-home POWERprofile upon Sign-Out to remember their visit and compare with future visits.
POWERpass Activity % of Visitors who completed: First Floor See Your Own Heartbeat 64,691 (45.5%) South Texas Trailblaze 63,515 (44.7%) Pick Up Your Pace: Walk 54,563 (38.4%) Pick Up Your Pace (Height) 24,419 (17.2%) Pick Up Your Pace (both stations) 23,820 (16.8%) Blue Cross Blue Shield of TexasTM Floor You Are What You Drink (stepper) 52,213 (36.8%) All About You 36,582 (25.8%) Build A Balanced Meal 36,336 (25.6%) Relax Your Brain 22,795 (16.0%) Sign-Out 52,561 (37.0%) Table 6: Individual POWERpass Station Completion; 5/25/15-5/25/16
12 Inside You Anatomy Table While not captured in the POWERpass database, one station on the Blue Cross Blue Shield of Texas Wellness floor nonetheless bears specific attention given its tremendous popularity. The Inside You Anatomy Table, made possible through the generous support of Dr. Dacia Napier, is a life-size, touch screen virtual dissection table. It is programmed for in-depth, hands-on exploration of body systems based on real, thin-layer human anatomy scans. This high-tech tool has been an astounding success and has become the focus of groundbreaking teaching, training and mentoring opportunities for future healthcare leaders. Through formal collaborative agreements with the University of the Incarnate Word and the University of Texas Health Science Center at San Antonio (UTHSCSA) Medicine, Nursing, Dental and Allied Health schools, the Witte Museum has enrolled more than 60 medical, rehabilitation science and physical therapy students in a structured program of training, presentation and self-reflection as facilitators. Inspired by the Witte’s efforts to creatively support a changing culture of healthcare, medical students from UTHSCSA organized and joined together with Dr. Bayles, under the additional faculty guidance of Dr. Jeff Jackson, Director of Academic Programs in the UTHSCSA Medical School Dean’s Office and Dr. Joshua Hanson (Assistant Professor /Clinical, Dept. Medicine) to form a University-sanctioned Student Organization dedicated to education and service- learning partnerships with the Witte Museum. Student officers were selected, bylaws created and recruitment of interested students began. The formal approval of the Witte as a work-study site by the UTHSCSA Office of Financial Aid provides a financial incentive for time spent training and working in the H-E-B Body Adventure. This project builds upon the existing partnerships forged during the H-E-B Body Adventure’s first year to examine whether a structured program of training, presentation and self-reflection in a unique informal learning environment can improve interpersonal communication skills and increase self-efficacy for engaging in discussions about physical activity, nutrition and wellness topics among future physicians. A collaborative study coordinated by the Witte Museum, Metro Health and the UTHSCSA Dept. of Family and Community Medicine titled Enhancing Empathy and Communication Skills among Future Health Professions Students through Partnership with a Community Museum was recently selected to receive funding from the 2016 Community Engagement Small Project Grants program of The Institute for Integration of Medicine and Science’s (IIMS). Data results of this project will not only be included in future reports, but also presented at the IIMS Community Engagement Symposium scheduled for Fall of 2017. A consensus has arisen among medical governing bodies that competent interpersonal and communication skills are a core element of effective medical care. Enhancing communication skills has been demonstrated to improve patient and physician satisfaction, patient adherence to recommendations, safety, malpractice claim rates and health outcomes.8 Interpersonal Skills and Communication is one of six required competencies identified by the Accreditation Council on Graduate Medical Education (ACGME). The Institute of Medicine highlights communication skills as one of six essential curricular domains and the National Board of Medical Examiners (NBME) is requiring Objective Standardized Clinical Examinations (OSCEs) to assess interviewing and communication skills. Increasingly, communication is formally evaluated to determine a trainee’s suitability for promotion, graduation, and licensure.9-11
13 An important quality that has been hypothesized to promote communication skills in medicine and be an integral component of physician competence and patient-centered care is empathy.12 A number of studies have examined empathy scores using a variety of well-validated scales over the course of training and practice, with several reporting erosion of empathy, particularly in the clinical years.13 Similar declines in empathy have been observed in other clinical health profession training, such as dentists.14 Researchers report that empathy is a state (like mood) and is amenable to change during and after training. Training scripts and activities developed by the Witte Museum provide tips on inquiry-based learning and bridging the discussion between anatomical systems and basic health promotion messaging. These messages focus specifically on the empowering health benefits of physical activity, increased fruit and vegetable consumption, staying hydrated with water rather than sugar-sweetened beverages and basic hygiene and safety.
“I would definitely recommend volunteering at the Anatomy Table! The whole building is a great educational tool.”
“This helped me improve my communication skills. In my future profession I have to be able to speak with all the different demographics.”
The Witte Museum’s innovative Inside You Anatomy Table training program highlights the documented efficacy and importance of clinician advice to patients regarding physical activity, nutrition and wellness15,16 and reinforces the critical role that students will play in their future careers as trusted sources of behavioral lifestyle advice. In addition to offering a safe, fun space for inspiring behavior change, the H-E-B Body Adventure is also fostering a stronger sense of clinician self-efficacy for preventive health communication around physical activity and nutrition. This is an area clinicians have reported feeling underequipped to discuss with their community.17,18 South Texas Trailblaze (Cycle) and You Are What You Drink (Stair Stepper) South Texas Trailblaze remains a very popular activity that encourages heart-healthy aerobic activity in a fun, locally relevant setting. Visitors are challenged to reach a target heart rate while cycling their virtual avatars along the Mission Reach of the San Antonio River, accompanied by their Buddy. Target Heart Rates, of course, vary by age and gender and were set in consultation with San Antonio Metropolitan Health and American Heart Association guidelines. Targets are set as 70% of a visitor’s estimated maximum heart rate (220 minus their age) with some adjustment for younger ages (American Heart Association).
National Physical Activity Guidelines for Americans suggests that taking part in aerobic and muscle-strengthening activities each week will improve one’s physical and emotional well-being. Children and adolescents should engage in at least 60 minutes of physical activity every day. Most of the 60 minutes or more a day should be either moderate or vigorous intensity physical activity and should include vigorous activity at least 3 days a week. Adults need at least 150 minutes of moderate intensity aerobic activity (i.e. brisk walking) every week as well as activities that work all major muscle groups, at least two days per week. In 2011, only 1 in 5 of U.S. adults 18 years of age and older met these guidelines based on
14 National Center for Health Statistics data. According to the San Antonio Metropolitan Health District 68% of Bexar County high school students were not active for at least 60 minutes a day during the prior seven days.19 Thus, the H-E-B Body Adventure is providing a critical opportunity for children, adolescents and adults to engage in moderate and vigorous physical activity towards the end of increasing these rates and meeting SA2020,20 Health Collaborative Community Health Improvement Plan21 and national goals.22
All About You Despite the undisputed benefits of regular physical activity, increased consumption of fruits and vegetables, and reduced consumption of sugar-sweetened beverages, too few Americans engage in these behaviors. According to the Trust for America’s Health, chronic diseases such as type-2 diabetes and heart disease are responsible for seven of 10 U.S. deaths, 75% of the $2.5 trillion spent on medical care costs and billions of lost dollars in productivity each year.23 Located on the Blue Cross Blue Shield Wellness floor, the All About You interactive kiosks made possible through the generous support of the San Antonio Metropolitan Health District has been running exceptionally smoothly and remains very popular. At this station, visitors take a picture of their face (not saved in the database) and through interactive, questions about their health behaviors and preferences, build a fun, animated avatar that is then printed on their take-home POWERprofile next to that of their selected Buddy.
15 The following charts and tables show counts and percentages obtained from the All About You station during its second year of operation. Of the 142,074 individuals under age 100 who signed-in and received a POWERpass card this year, 36,582 (25.8%) scanned their card at one of the two All About You stations. Furthermore, 20,778 (56.8%) of these were from identifiable Bexar County zip codes. Table 7 shows the percentage of All About You responders from Bexar County by Age Group, showing that the bulk of responses, like that of general visitation come from the Target Age group of 8 to 12 year olds, and school-age youth in general.
Table 8 below shows the rankings of the ‘Favorite Ways to Stay Physically Active’ selected by All About You participants. Overall, males showed a higher preference for Team Sports than girls (23.9% vs. 11.4%). The top 3 favorite activities chosen by males were Team Sports (23.9%), Running (19.7%) and Swimming/Water sports (15.5%), while the most popular activities among females were Dancing (19.7%), Swimming/Water sports (19.1%) and Walking (17.1%). Dancing and Walking, both low cost activities that require no equipment, were significantly more popular among females, as was Yoga (5.5% among females vs. 1.9% among males). Interestingly, at the national level, gentle, mindful movement practices like yoga has become steadily more popular. In 2012 (the most recent year for which there is nationally representative data), approximately 21 million adults—nearly double the number from 2002—and 1.7 million children practiced yoga. Body Adventure data regarding popularity of these activities is also reflected at the national level. Yoga, tai chi and qi gong, all meditative movement therapies, are significantly more common in female youth ages 17 and under compared to boys (4.2% vs. 1.0% respectively). There is a growing body of evidence that certain mind and body practices can help people better manage pain and reduce stress.24,25
What is your favorite way to stay active and get moving? Males Females Activity Frequency (%) Activity Frequency (%) Team Sports 3,477 (23.9%) Dancing 4,351 (19.7%) Running 2,868 (19.7%) Swimming / Water Sports 4,200 (19.1%) Swimming / Water Sports 2,248 (15.5%) Walking 3,778 (17.1%) Walking 1,793 (12.3%) Running 2,918 (13.2%) Biking 1,439 (9.9%) Team sports 2,512 (11.4%) Weight lifting 1,180 (8.1%) Biking 1,592 (7.2%) Dancing 743 (5.1%) Yoga 1,212 (5.5%) Yoga 271 (1.9%) Weight lifting 689 (3.1%) Gardening 251 (1.7%) Gardening 502 (2.3%)
Skipped 273 (1.9%) 285 (1.3%) Total 14,543 (100%) 22,039 (100%) Table 8: Favorite Physical Activities by Gender; All Ages; 5/25/15-5/25/16
16 The lower involvement in team or organized sports among females is also evident in the higher proportion of females responding ‘No’ to having played any sports during the year (not including PE): 41% vs. 34% for males (Table)
Did you play any sports this year, not including PE classes at school? Males Females Frequency (%) Frequency (%) Yes, 3 or more times a week 4,870 (33.5%) 5,942 (27.0%) Yes, once or twice a week 3,088 (21.2%) 4,474 (20.3%) Yes, less than once a week 1,408 (9.7%) 2,159 (9.8%) No 4,881 (33.6%) 9,133 (41.4%)
Skipped/blank 296 (2.0%) 331 (1.5%) Total 14,543 (100%) 22,039 (100%) Table 9: Sports Involvement by Gender; 5/25/15-5/25/16
This gender difference was also apparent, but less pronounced, when examining Bexar County school-age respondents ages 8-18 (Chart 1).
Chart 1: Percent of Bexar County School-Age Youth (ages 8-18) responding ‘No’ to the Question ‘Did you play any sports this year, not including PE classes at school? 5/25/15-5/25/16
After careful review of visitor feedback, the Witte team has decided that a more powerful multigenerational question about physical activity is warranted to replace the current child-specific wording about PE classes. The current question has been reprogrammed and will go live October 2016. The following wording will more accurately capture both child and adult physical activity levels, while also allowing for more direct comparison to the YRBS and other widely used surveys that monitor the nation’s achievement of national recommendations for moderate and vigorous physical activity (at least 60 minutes per day for youth): Were you physically active for a total of at least 1 hour this week? (The following is audio, but not shown on screen: ‘Physically active means your heart beats faster and you breathe hard some of the time.’) -Yes, 3 or more times a week -Yes, once or twice a week -Yes, less than once a week -No
17 Sedentary Behavior: Screen Time As a key metric of sedentary behavior, All About You also includes a question about time spent watching TV or at a computer screen. The American Academy of Pediatrics recommends that children and teens should engage with entertainment media for fewer than two hours per day, and that this should be high-quality content.26 Across all ages and respondents, greater than 50% of the All About You participants reported two or more hours of screen time per day (Table 10). High proportions of Bexar County respondents spend more than 2 hours per day watching television or playing video games (Table 11).
On an average school or workday, how many hours do you watch TV or play video games? Ages 8+ ‘School Age’ Ages Ages Ages (% of total) Ages 8-18 8-12 13-18 19+ None 2,440 (11.8) 1,223 (12.6) 918 (12.8) 305 (12.0) 468 (8.8) Less than 1 hour a day 6,908 (33.5) 3,253 (33.5) 2,485 (34.7) 768 (30.2) 1,731 (32.6) 2 to 3 hours a day 7,168 (34.8) 3,074 (31.7) 2,247 (31.4) 827 (32.5) 2,223 (41.9) 4 or more hours a day 3,737 (18.1) 2,020 (20.8) 1,398 (19.5) 622 (24.4) 856 (16.1) Skipped 371 (1.8) 128 (1.3) 105 (1.5) 23 (0.9) 34 (0.6) Total 20,624 (100%) 9,698 (100%) 7,153 (100%) 2,545 (100%) 5,312 (100%)
Table 11: Reported Screen Time among ‘All About You’ Respondents; Bexar County, by Age Group; 5/25/15-5/25/16 According to this year’s data, 57.5% of Bexar County youth ages 13 to 18 spent 2 or more hours watching TV or playing video games on an average school day. One in four (24.7%) of these youth report spending four or more hours on an average school day. Screen time of 4 or more hours per day among school-aged youth ages 8-18 years old in Bexar County was higher among boys (26%) than among girls (18%) (Table 12).
On an average school or workday, how many hours do you watch TV or play video games? Males Females Total Frequency (%) Frequency (%) Frequency (%) None 417 (11.7%) 806 (13.2%) 1,223 (12.6%) Less than 1 hour per day 1,050 (29.4%) 2,203 (36.0%) 3,253 (33.%%) 2 to 3 hours per day 1,113 (31.2%) 1,961 (32.0%) 3,074 (31.7%) 4 or more hours per day 933 (26.1%) 1,087 (17.7%) 2,020 (20.8%) Skipped/blank 59 (1.7%) 69 (1.1%) 128 (1.3%) Total 3,572 (100%) 6,126 (100%) 9,698 (100%) Table 12: Average School Day Screen Time among youth ages 8-18; Bexar County by gender; 5/25/15-5/25/16
18 Extensive studies have shown that excessive media use can contribute to attention problems, school difficulties, sleep and eating disorders, as well as contribute to childhood obesity. A significant proportion of youth are clearly exceeding recommended levels of screen time, and this remains an important issue for continued educational outreach and awareness campaigns in the public health sector. By limiting screen time and offering high quality educational media as well as non-electronic formats for physical education and activity such as books, newspapers and board games, parents and community members can help guide youth towards healthier behaviors. The Witte Museum’s H-E-B Body Adventure educational programs incorporate a diversity of such educational media as well as indoor and outdoor physical activity; reading, writing and problem-solving skills fully aligned with the Texas Essential Knowledge and Skills (TEKS) standards. Leading by doing is what the Witte wishes to partner with others on to encourage behavior change toward more movement and less sedentary lifestyles. Environment for Physical Activity When asked whether they believed there were fun, safe places to go outside and play near where a respondent lived, the vast majority of visitors (90.4% or 43,936 of 47,525 total respondents) answered ‘Yes’. More than 53% responded “Yes, a lot” (25,372 respondents.) As the physical and built environment, urban design, parks, trails, and safe spaces like the Witte Museum are crucial to physical and emotional well-being.27 Table 13 shows responses to this question broken down by age group for those respondents with valid Bexar County zip codes.
‘Are there fun, safe places for you to go outside and play near where you live?’ Ages 8+ ‘School Age’ Ages Ages Ages (% of total) Ages 8-18 8-12 13-18 19+ No 2,010 (9.8) 1,092 (11.3) 655 (9.2) 437 (17.2) 526 (9.9) Yes, a few 8,024 (38.9) 4,044 (41.7) 2,969 (42.0) 1,075 (42.2%) 2,117 (39.9) Yes, a lot 10,207 (49.5) 4,431 (45.7) 3,421 (48.0) 1,010 (39.7) 2,634 (49.6) Skipped 383 (1.9) 131 (1.4) 108 (1.5) 23 (0.9) 35 (0.7) Total 20,624 (100%) 9,698 (100%) 7,153 (100%) 2,545 (100%) 5,312 (100%) Table 13: Outdoor Environments for Safe Physical Activity by Age Group: Bexar County by Age; 5/25/15-5/25/16
19 High percentages of school-aged youth in Bexar County report that there are “a lot” of fun, safe places to play outside near their homes. This is a testament to the remarkable efforts of the City of San Antonio to enhance and enlarge its public parks, walking trails and bike lanes and its recognition that the built environment plays a key role in public health and well-being. The maps below (Maps 4a and 4b) also demonstrate the Witte’s ability to identify specific zip codes in which respondents report relatively abundant and fewer such resources, as perceived by school-age youth ages 8-18. Map 4a: ‘Are there fun, safe places for you to go outside and play near where you live?’: ‘Yes, a lot’ Percentage of respondents (ages 8-18) who responded ‘Yes, a lot’; Bexar County by zip code; 5/24/14-5/25/16
Map 4b: ‘Are there fun, safe places for you to go outside and play near where you live?’: ‘No’ Percentage of respondents (ages 8-18) who responded ‘No’; Bexar County by zip code; 5/24/14-5/25/16
20 A young visitor enjoys the fresh air during a University Health System Family Day These unprecedented data provide important clues to assist in identifying targeted outreach efforts and city-wide planning across institutions. The San Antonio Metropolitan Health District, for example, is currently working closely with ten identified neighborhoods in its “Neighborhood Boundaries Projects,” collaborating with resident community health workers and elementary schools as neighborhood ‘hubs’ for health promotion and outreach. The Witte’s ability to track zip codes provides powerful data for informing strategic planning and evaluation of such efforts. The Witte Museum has also already used generous funding from the Harvey E. Najim Family Foundation to provide targeted outreach and field trips to the H-E-B Body Adventure to Title 1 schools in targeted zip codes identified collaboratively with Metro Health.
21 All About You Questions on Nutrition The City of San Antonio and the Mayor’s Fitness Council recently launched the Veg Out SA! Campaign to increase daily consumption of fruits and vegetables. With a goal of ultimately reducing rates of obesity and chronic diseases such as diabetes in the city, the Veg Out SA! campaign seeks to encourage San Antonio residents to make a healthy choice at each meal that will impact their overall health for the better. The Witte Museum is proud to work closely with its partners and the city to share unprecedented amounts of data on San Antonio’s fruit and vegetable consumption in a format and scale that has never before been available. The interactive All About You activity allows visitors to create a cartoon avatar with their photograph attached that reflects their personal preferences for specific healthy foods. The most frequently selected favorite healthy foods are shown below:
Favorite Healthy Food Frequency (%) Fruit (apples, oranges, etc) 19,736 (54.0%) Crackers & Cheese 4,730 (12.9%) Chips with Salsa 4,158 (11.4%) Vegetables 3,987 (10.9%) Trail Mix 3,462 (9.5%) Skipped 509 (1.4%) Total 36,582 (100%) Table 14: Favorite Healthy Food Choices among All About You Respondents; 5/25/15-5/25/16
The preference for fruit as a healthy snack held across genders, with vegetables preferred among only about 11% of respondents.
Males Females
Frequency (%) Frequency (%) Fruit Fruit (apples, oranges, etc) 7,357 (50.6%) (apples, oranges, etc) 12,379 (56.2%) Crackers & Cheese 1,969 (13.5%) Crackers & Cheese 2,761 (12.5%) Chips with Salsa 1,928 (13.3%) Vegetables 2,438 (11.1%) Vegetables 1,549 (10.7%) Chips with Salsa 2,230 (10.1%) Trail Mix 1,495 (10.3%) Trail Mix 1,967 (8.9%)
Skipped 245 (1.7%) Skipped 264 (1.2%) Total 14,545 (100%) Total 22,039 (100%) Table 15: Favorite Healthy Food Preference among All About You Respondents by Gender; 5/25/15-5/25/16
22 Fruit & Vegetable Consumption It is very encouraging that fruits were found to be the favorite healthy food chosen by the majority of visitors. Visitors, however, were given only a limited selection of choices (derived from focus groups conducted in 2012). According to the San Antonio Metropolitan Health District, more than 95% of people in San Antonio eat less than the recommended five servings of fruit and vegetables daily. As previously noted, the Mayor’s Fitness Council Executive Committee is currently focused on increasing both fruit and vegetable consumption. The Dietary Guidelines for Americans recommends vegetables and fruits, whole grains and low-fat dairy products in order to reduce the risk chronic disease and obesity. The All About You kiosk helps the Witte and its partners monitor community-wide achievement of these Dietary Guidelines. The low percentage of respondents selecting vegetables as a favorite food has already had an impact on specific messaging for the Witte’s interactive demonstrations to school groups and families. In collaboration with the Children’s Hospital of San AntonioTM Culinary Health Education for Families (CHEF) program’s Chef Maria Palma and Medical Director Julie LaBarba, MD, FAAP, the Witte continues to develop an array of diverse recipes and scripts for H-E-B Body Adventure presenters that focus specifically on how to “dress up” or make vegetables more appealing as fun snacks. The Witte is also targeting fun ways to make water both tasty and the drink of choice over sugar- sweetened beverages, these efforts are strongly informed by baseline findings from the All About You station and the high popularity of You Are What You Drink stair stepper.
Recipes for simple, healthy home cooking
23 Consistent with the higher preference for fruits as a favorite healthy snack compared to vegetables, Bexar County school-age youth (ages 8-18) were more likely to report eating fruits daily compared with vegetables. Whereas 33.5% of youth said they ate ‘no vegetables’ the previous day, 23.1% said they ate ‘no fruit’. Whereas 27.5% of youth reported eating fruit 3 or more times the prior day, only 20.2% said they ate vegetables (Table 16)
28 29 Did you eat any ____ yesterday? Fruit Vegetables Frequency (%) Frequency (%) No, I didn’t eat any vegetables. 2,240 (23.1) 3,250 (33.5) Yes, I ate vegetables 1 time yesterday. 2,459 (25.4) 2,552 (26.3) Yes, I ate vegetables 2 times yesterday. 2,225 (22.9) 1,849 (19.1) Yes, I ate vegetables 3 or more times yesterday 2,663 (27.5) 1,959 (20.2) Skipped 111 (1.1) 91 (0.9) Total 9,698 (100%) 9,698 (100%) Table 16: Fruit and Vegetable Consumption among School-Age All About You Respondents (ages 8-18) in Bexar County; 5/25/15-5/25/16
The following tables provide a descriptive look at those respondents with a valid Bexar County zip code with regards to fruit and vegetable consumption by age group.
Did you eat any Ages 8+ ‘School Age’ Ages Ages Ages FRUIT yesterday? (% of total) Ages 8-18 8-12 13-18 19+ No, I didn’t eat any fruit. 4,831 (23.4) 2,240 (23.1) 1,460 (20.4) 780 (30.6) 1,605 (30.2) Yes, I ate fruit 1 5,464 (26.5) 2,459 (25.4) 1,750 (24.5) 709 (27.9) 1,548 (29.1) time yesterday. Yes, I ate fruit 2 4,776 (23.2) 2,225 (22.9) 1,616 (22.6) 609 (23.9) 1,329 (25.0) times yesterday Yes, I ate fruit 3 or 5,290 (25.7) 2,663 (27.5) 2,238 (31.3) 425 (16.7) 800 (15.1) more times yesterday Skipped 263 (1.3) 111 (1.1) 89 (1.2) 22 (0.9) 30 (0.6) Total 20,624 (100%) 9,698 (100%) 7,153 (100%) 2,545 (100%) 5,312 (100%) Table 17: Fruit Consumption among All About You Respondents with a valid Bexar County zip code, by Age Group; 5/25/15-5/25/16
Did you eat any Ages 8+ ‘School Age’ Ages Ages Ages VEGETABLES yesterday? (% of total) Ages 8-18 8-12 13-18 19+
No, I didn’t eat 6,117 (29.7) 3,250 (33.5) 2,337 (32.7) 913 (35.9) 1,143 (21.5) any vegetables. Yes, I ate vegetables 5,574 (27.0) 2,552 (26.3) 1,842 (25.8) 710 (27.9) 1,518 (28.6) 1 time yesterday. Yes, I ate vegetables 4,541 (22.0) 1,849 (19.1) 1,329 (18.6) 520 (20.4) 1,623 (30.6) 2 times yesterday
Yes, I ate vegetablesr 4,163 (20.2) 1,959 (20.2) 1,573 (22.0) 383 (15.0) 1,006 (18.9) 3 more times yesterday Skipped 229 (1.1) 91 (0.9) 72 (1.0) 10 (0.7) 22 (0.4) Total 20,624 (100%) 9,698 (100%) 7,153 (100%) 2,545 (100%) 5,312 (100%) Table 18: Vegetable Consumption among ‘All About You’ respondents; Bexar County, by Age 24 Looking at the first two years of cumulative, aggregated zip code data in Bexar County by region, the percentage of school-age youth who ate fruit ‘3 or more times yesterday’ ranged from a low of 22% in the Northeast to 33% in the Near Northside and Near Eastside (Map 5a). Map 5a: ‘Did you eat any FRUIT yesterday?: ‘3 or more times’ Percent of respondents (ages 8-18) who responded ‘Yes, I ate fruit 3 or more times yesterday’; by Bexar County healthcare subsector; 5/24/2014-5/25/2016
Alternately, the proportion of school-age youth eating ‘no fruit’ the previous day ranged from lows of around 17% to highs of nearly 26% (Map 5b). Map 5b: ‘Did you eat any FRUIT yesterday?: ‘None’ Percent of respondents (ages 8-18) who responded ‘No, I didn’t eat any fruit yesterday.’; Bexar County by zip code; 5/24/2014-5/25/2016
25 Maps 6a and 6b show different views of regional variation in vegetable consumption within Bexar County using Healthcare subsectors and zip codes respectively. Map 6a: ‘Did you eat any VEGETABLES yesterday?’: ‘3 or more times’ Percent of school-age respondents (ages 8-18) who responded ‘Yes, I ate vegetables 3 or more times yesterday’; Bexar County by Healthcare sectors; 5/24/2014- 5/25/2016
Map 6b: ‘Did you eat any VEGETABLES yesterday?’: ‘None’ Percent of school-age respondents (ages 8-18) who responded ‘No, I didn’t eat any vegetables yesterday’; Bexar County by zip code; 5/24/2014-5/25/2016
26 Previous Quarterly data reports submitted to the San Antonio Metropolitan Health District have demonstrated that the proportion of visitors by gender and month who report eating NO fruit the previous day varies throughout the year. With the exception of a small increase in fruit consumption among males corresponding to the beginning of the school year, rates of fruit consumption held relatively steady, with females generally slightly more likely to eat some fruit and vegetables. The high percentages reporting no vegetable consumption at all, however, are alarming. Unfortunately, it is in line with regional and national data.
All About You Question on Soda Consumption Drinking enough water each day is very important for hydration and good health, particularly in the South Texas heat. According to the San Antonio Metropolitan Health District, drinking soft drinks such as soda, sports drinks, fruit drinks and sweetened milk are best when enjoyed as occasional treats. The Bexar County Commissioner’s Court recently passed a resolution that called for a communitywide effort to educate and encourage individuals and families to reduce their consumption of sweetened beverages in favor of healthier choices such as water. Two days after the Commissioner’s Court passed the resolution, the federal government’s advisory panel on nutrition released new recommendations that for the first time advised specific limits on how much sugar people should consume, and specifically recommended that people choose water over sugary beverages. The Witte Museum’s close partner University Health System has been asked to take the lead on this important community public health endeavor. As Dr. Bryan Alsip, Executive Vice President and Chief Medical Officer at University Health System notes, excess sugar can lead to tooth and gum decay, type 2 diabetes and obesity, which contribute to heart disease and a host of other illnesses which increase mortality and reduce quality of life. Table 19 shows Bexar County visitors’ responses to a question on All About You about daily soda consumption. While it is encouraging to see 35% of visitors reporting not drinking sodas, clearly there remains significant work to be done. Daily soda consumption (one or more per day) was more or less equivalent in the age groups 8 to 12 and 13 through 18, at approximately 37%. Adult consumption tends to be slightly lower, with 33% of adults ages 19 and older reporting drinking at least one soda per day. It is important to note that these estimates are very likely an under-estimate of the true consumption of Sugar-Sweetened Beverages (SSBs), as the question only asks about soda. There are many additional sources of added sugar in the diet, many of which are popular drinks, such as sweet tea, fruit juices, energy and sports drinks.
27 How often do you Ages 8+ ‘School Age’ Ages Ages Ages drink SODA? (% of total) Ages 8-18 8-12 13-18 19+ I do not drink soda. 7,208 (35.0) 2,783 (28.7) 2,068 (28.9) 715 (28.1) 1,916 (36.1) Less than 1 per day 6,197 (30.1) 3,274 (33.8) 2,390 (33.4) 884 (34.7) 1,650 (31.1) 1 per day 3,891 (18.9) 1,948 (20.1) 1,520 (21.2) 428 (16.8) 861 (16.2) 2 or more per day 2,990 (14.5) 1,571 (16.2) 1,076 (15.0) 495 (19.4) 853 (16.1) Skipped 338 (1.6) 122 (1.3) 99 (1.4) 23 (0.9) 32 (0.6) Total 20,624 (100%) 9,698 (100%) 7,153 (100%) 2,545 (100%) 5,312 (100%) Table 19: Soda Consumption among ‘All About You’ Respondents; Bexar County, by Age Group; 5/25/2015-5/25/2016
Map 7a and 7b below show soda consumption patterns of Bexar County school-age youth (ages 8 through 18) during the past two years. Map 7a: How often do you drink soda?: None Percent of respondents (ages 8-18) who responded “I do NOT drink soda”; Bexar County by Healthcare Sector; 5/24/2014-5/25/2016
28 Map 7a: How often do you drink soda?: None Percent of respondents (ages 8-18) who responded “I do NOT drink soda”; Bexar County by Healthcare Sector; 5/24/2014-5/25/2016
Health Equity The preceding data also contributes to the evidence base that significant geographic disparities in health behaviors and outcomes are apparent throughout Bexar County. The San Antonio Metropolitan Health District has recently begun creating an Office of Health Equity to improve the health and well-being of populations throughout San Antonio by increasing capacity to respond effectively to critical public health needs. The primary focus will be on disparities among communities in San Antonio, and “promoting health equity to ensure that all people have the opportunity to thrive and no one is limited in achieving comprehensive health and wellness because of their social position or any other social factors/determinants of health (i.e. income, education, race/ ethnicity, sexual identity, disability).”30 The Witte Museum’s H-E-B Body Adventure’s unprecedented metrics are one key source of data for examining such inequities that exist in San Antonio. The Witte is tremendously proud to work closely with Metro Health to use this data for Strategic Planning and outreach to ensure underserved members of the community are targeted for outreach, field trips and enhanced services.
29 Build a Balanced Meal Nutrition is an absolutely vital part of a healthy lifestyle and well-being, so it should be noted here that the Witte has several exhibits in the H-E-B Body Adventure that address the importance of good nutrition. For instance, 45,598 individuals have played the fun, interactive game Build A Balanced Meal, where visitors are challenged to select nutritious foods from the major food groups according to MyPlate.gov national dietary recommendations. By selecting a balanced mix of foods, visitors fuel their selected Buddy on an interactive walking trek along the San Antonio River from Mission Espada to the Witte Museum. This has proven to be an extremely popular game, as visitors repeatedly play to meet the challenge of adequately balancing their plate. What is particularly encouraging is that the age distribution of visitors playing this game mirrors that of the general POWERpass users. That is, visitors of all ages are enjoying this interactive nutrition education game. Overweight AND Obesity Body Mass Index (BMI) is a number calculated from a person’s weight and height (weight (kg) / [height (m)]2). BMI can be calculated for a significant subset of visitors to the H-E-B Body Adventure, providing estimates of overweight and obesity on a scale heretofore unavailable. BMI is calculated using the same formula for children and adults. Because the amount of body fat changes with age and is different between boys and girls, however, BMI is both age- and gender-specific for children and adolescents. The CDC BMI-for-age growth charts take into account these differences and visually show BMI as a percentile ranking. Since age and gender are captured during Sign-In with the POWERpass, if a visitor experiences both the Pick Up Your Pace Walk Investigation Station (where height is measured) and the You Are What You Drink stepper (where weight is measured), the Witte is able to calculate age and gender-specific weight status categories for both children and adults according to CDC standards. The height sensor is an industrial ultrasonic sensor from Senix (model TSPC-15S) and communicates over a standard serial port using a Modbus serial protocol. At You Are What You Drink, visitors step up to a giant, colorful soda cup. Using a commercially available exercise stepper and scale that was sensitized, calibrated and integrated into the design, visitors select water or a sugary beverage and learn from their selected Buddy how long it will take to burn off the calories. Visitors weight is read here, though not displayed to the visitor. This decision was made in consultation with community Science Summit participants in order to avoid stigmatization and a misguided focus on pounds as opposed to overall wellness. It is important to emphasize that even in the absence of weight loss, significant improvements in health and well-being can be achieved through increased physical activity, healthy eating and proper rest and relaxation. Nonetheless, BMI continues to be a helpful measure in estimating general population status and is commonly reported in state and national surveys.
30 For adults BMI is interpreted through categories that are not dependent on gender or age. While BMI does not measure body fat directly, research has shown that it correlates to more direct measures of body fat, such as underwater weighing and dual energy x-ray absorptiometry (DXA). The correlation between the BMI and body fatness is fairly strong, but some important caveats remain regarding interpretation of weight status using BMI. Even if two people have the same BMI, it is possible that their level of body fatness may differ and the Witte Museum and its partners recommend that all individuals consult a trained healthcare provider to perform appropriate assessments in order to evaluate an individual’s health status and risks.1,30 Table 20 shows BMI categories by age groups with valid Bexar County zip codes and combines both Years 1 and Years 2 data to ensure more reliable sample sizes. As agreed with Metro Health leadership, longitudinal trends in BMI status will begin being examined in earnest and reposted in Year 3. Methodologies for identifying outliers are being refined and Quarterly data points ensure the ability to determine statistical ‘random error’ (noise) from meaningful changes in community-wide trends.
Percentile Weight ‘School Age’ Ages Ages Range Category Ages 8-18 8-12 13-18
Less than the Underweight 356 (5.4%) 296 (5.7%) 60 (4.3%) 5th percentile 5th percentile to less Normal 3,206 (48.8%) 2,492 (48.2%) 714 (51%) than the 85th percentile
85th to less than Overweight 1,155 (17.6%) 906 (17.5%) 249 (17.8%) the 95th percentile Equal to or greater than Obese 1,851 (28.2%) 1,475 (28.5%) 376 (26.9%) the 95th percentile Total 6,568 (100%) 5,169 (100%) 1,399 (100%) Table 20: Weight Status using BMI for School-Age Youth, by Age Groups for visitors with valid Bexar County Zip Codes; 5/24/2014-5/25/2016
The following map displays regional variation in obesity status within Bexar County youth ages 8-18 by healthcare subsector aggregation of zip codes. Map 8: CDC Weight Category: ‘Overweight or Obese’ Percent of respondents (ages 8-18) with a valid Bexar County zip code who were overweight or obese according to Body Mass Index (BMI) 5/24/2014-5/25/2016
31 REST AND RELAXATION Rest, relaxation and proper sleep hygiene are vital for good health and sustained wellness throughout life. Studies show that focused mindfulness, rest, and a good night’s sleep improves learning and attention, decreases irritability, anger and mood disorders. Rest and relaxation are also crucial in healing and repairing the heart and blood vessels, with sleep deficiency and stress linked to increased risk of heart disease, kidney disease, obesity, high blood pressure, diabetes and stroke.31 The Witte Museum incorporates activities using principals of participatory biofeedback and self-monitoring to encourage families to experience the relationships among mental health, rest and focus and to set attainable goals for behavior change to nurture sustained wellness. A new program that was piloted this year, for example, was a series of participatory Meditation courses which took place in the H-E-B Body Adventure’s beautiful Charles Moulton Serenity Floor. More than 50 participants of all ages enthusiastically grabbed their chairs and cushions and learned centuries-old simple and empowering techniques of focus, visualization and relaxation to rest and rejuvenate. The course was so popular it was extended into a five-part evening series to delve deeper into interactive, guided relaxation practices. Evaluations demonstrate the immense popularity of this program and the strong desire for additional programming in rest, relaxation and mental health and wellness.
“Thanks so much for introducing me to meditation practice. I hope the Witte will continue to offer these type of classes.” –Mind-Body Wellness Series participant
32 A CATALYST FOR A CITY ON THE RISE The Witte Museum has been an integral leader within the City of San Antonio’s major initiatives to improve the health of its citizens. In 2010, when former Mayor Julián Castro appointed the Mayor’s Fitness Council challenging San Antonio to be one of the healthiest and most active communities in the nation, the Witte was already underway transforming its popular H-E-B Science Treehouse into the H-E-B Body Adventure to address these issues. With over 3 million delighted visitors in its first decade, the Witte’s H-E-B Science Treehouse provided the ideal place to ignite transformative health behavior change in physical activity and nutrition through engaging interactive and educational museum experiences. The Witte’s location at the trailhead of the beautiful 13-mile linear park along the San Antonio River also makes it ideal for embodying the key role that natural and built environments play in sustaining wellness. Where and how we live, work, play and learn create an interconnected web, or social matrix, that profoundly influences our health. Evidence-based public health science has demonstrated that strategies most likely to have high impact are precisely those that nurture this social and environmental matrix by building partnerships within and outside the healthcare field.2 Leveraging cross-sector community partnerships to offer new tools to advance public learning and well-being is at the very core of the Witte’s strategy. Despite the significant challenges facing South Texas and the nation with respect to preventable chronic diseases, the future of the H-E-B Body Adventure and public health in South Texas is bright. The Witte Museum is dedicated to ensuring that the H-E-B Body Adventure Powered by University Health System continues to serve the community and nation. Guided by ongoing data metrics and the support of its outstanding and unprecedented collaborative group of partners, the Witte Museum will continue to expand the H-E-B Body Adventure’s reach to the most vulnerable residents. while facilitating data collection, sharing and research among its partners. Continuation and expansion of the H-E-B Body Adventure’s vital educational programs, demonstrations and InterActor encounters to all sectors of the community are essential to the impact of the H-E-B Body Adventure and the elimination of health and educational disparities. Through close coordination of resources, targeted outreach, and cross-promotion made possible through the Witte’s enduring cross-sector private and public community partnerships, the H-E-B Body Adventure POWERpass system provides data that can be explored through in- depth analyses and comparative research with other important public health datasets, such as the outstanding work of the Health Collaborative’s Bexar County Community Health Improvement Plan, SA2020 and more. Ongoing upgrading and refinement of interactive kiosk design and staff training, as well as continuous maintenance by a dedicated IT and Exhibits team led by Vice President of Exhibitions Randall Webster, are continually implemented and evaluated to ensure the thoroughness and joy of each visitor’s experience.
33 The Witte Museum’s H-E-B Body Adventure Powered by University Health System brings families together in fun, non-intimidating settings that build mutual health and wellness knowledge, skills and self-efficacy. The Witte can think of no stronger partnership than one that engages multiple generations of families through a community-wide hub of health awareness, empowerment and fun. With the sustained support and participation of its powerful partners, the H-E-B Body Adventure represents a new national model of community collaboration and educational experiences to revolutionize the fight against preventable chronic disease. With your help, the Witte Museum is creating a culture of wellness that will have a lasting impact on the health of our region and the nation.
Technical Notes and References 1. Obesity / BMI data should be interpreted with caution, and only in the context of other data sources available, including localized clinical studies that include anthropometric measurements, National Health Interview Survey and self-report data such as the YRBS. The Witte Museum data represents an entirely unique method of collection for height and weight data; methods are still being reviewed as to how best to interpret trends and outliers. A separate publication reviewing this and other methodological innovation of the H-E-B Body Adventure is currently in preparation. 2. The World Health Organization. 2015. Social Determinants of Health. http://www.who.int/social_determinants/en/ 3. Health Collaborative. 2014. Bexar County Community Health Improvement Plan. Available online at http://iims. uthscsa.edu/sites/iims/files/Newsletters/Bexar%20County%20SA%20CHIP_Full%20copy.pdf 4. Individuals with ages 100 and up were replaced as missing values. There were 975/143,049 (<1 %) individuals who entered an age 100 through 125. It is possible some of the 100 year olds are 10 years, 111 year olds could be 11 year olds, and so forth—i.e. that these may be typos in data entry on the part of the visitor. 5. RV Butler and ME Stefl. 2014. 2014 San Antonio Healthcare and Bioscience Economic Impact Study. San Antonio Chamber of Commerce. Available at http://biomedsa.org/pdf/economic_impact_study.pdf 6. Because of formatting differences, the zip codes do not include U.S. P.O. Box addresses and possible Mexican postal addresses of which we know there are a significant and possibly growing number, given the strong reach along the Texas-Mexico border counties. Examining these additional zip code captures, as well as international zip codes is the subject of current investigation, given the Witte Museum and San Antonio’s increasing draw as an international travel destination. 7. All map key categories are shown using Quintiles. 8. United States Census Bureau, Quick Facts. Accessed Aug 14, 2016. https://www.census.gov/quickfacts/table/ RHI125215/48029,00#headnote-js-a 8. Kurtz S, Silverman J & Draper J. 2005. Teaching and Learning Communication Skills in Medicine (2nd ed.). Oxford: Radcliffe Medical Press. 9. Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialties. General competencies: Minimal program requirement language. September 1999. http://www.acgme.org/ outcome/comp/ compMin.asp. Accessed July 8, 2009. 10. Institute of Medicine. Improving medical education: enhancing the behavioral and social science content of medical school curricula. Washington, DC: Institute of Medicine, 2004.
11. Schirmer JM, Mauksch, Lang F et al. Assessing Communication Competence: A Review of Current Tools. Fam Med 34 2005;37(3):184-92. 12. Hojat M. Empathy in Patient Care. New York, NY: Springer, 2006: 181. 13. Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Academic Medicine. 2009;84(9):1182-91. 14. Sherman JJ, Cramer A. Measurement of changes in empathy during dental school. Journal of Dental Education. 2005;69(3):338-45. 15. Institute of Medicine. Improving medical education: enhancing the behavioral and social science content of medical school curricula. Washington D.C.: Institute of Medicine, 2004. 16. Grandes G1, Sanchez A, Sanchez-Pinilla RO, Torcal J, Montoya I, Lizarraga K, Serra J; PEPAF Group. Effectiveness of physical activity advice and prescription by physicians in routine primary care: a cluster randomized trial. Arch Intern Med. 2009 Apr 13;169(7):694-701. 17. Lin JS, O’Connor EA, Evans CV, Senger CA, Rowland MG, Groom HC. (Eds) Behavioral Counseling to Promote a Healthy Lifestyle for Cardiovascular Disease Prevention in Persons With Cardiovascular Risk Factors: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2014 Aug. Report No.: 13-05179-EF-1. U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews. 18. Kushner R. Barriers to providing nutrition counseling by physicians: a survey of primary care practitioners. Prev Med 1995;24:546–552 19. San Antonio Metropolitan Health District. Physical Activity in Bexar County. Chronic Disease Prevention Program Fact Sheet. 2013. 20. SA2020. The Data Dashboard. Accessed July 8, 2015. Available online at http://www.sa2020.org/what-is-sa2020/ 21. Health Collaborative. 2014. Bexar County Community Health Improvement Plan. Available online at http://iims. uthscsa.edu/sites/iims/files/Newsletters/Bexar%20County%20SA%20CHIP_Full%20copy.pdf 22. Healthy People 2020 [Internet]. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion [Accessed July 8, 2015] Available from: http://www.healthypeople.gov/ 23. Trust for America’s Health (2013) A Healthier America 2013: Strategies to Move from Sick Care to Health Care in the Next Four Years. Available at www.healthyamericans.org 24. Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL. Trends in the use of complementary health approaches among adults: United States, 2002–2012. National health statistics reports; no 79. Hyattsville, MD: National Center for Health Statistics. 2015. See also Use of Complementary Health Approaches in the U.S. National Health Interview Survey. https://nccih.nih.gov/research/statistics/NHIS/2012. Accessed August 18, 2016. 25. Black LI, Clarke TC, Barnes PM, Stussman BJ, Nahin RL. Use of complementary health approaches among children aged 4-17 years in the United States: National Health Interview Survey, 2007-2012. National health statistics reports; no 78. Hyattsville, MD: National Center for Health Statistics. 2015. 26. American Academy of Pediatrics. Media and Children. (2013) Available at https://www.aap.org/en-us/advocacy-and- policy/aap-health-initiatives/pages/media-and-children.aspx 27. RJ Jackson with S Sinclair (2012). Designing Healthy Communities. Jossey-Bass; APHA Press: San Francisco. 28. The audio in this question adds the following clarification prompt: “Do not count fruit juice. Fruit may be fresh, canned, frozen or dried.” 29. The audio in this question adds the following clarification prompt: “Do not count French Fries or chips. Vegetables include carrots, broccoli, celery, and salads or baked potatoes. They can be raw or cooked, fresh or frozen, canned or even dried.” On a methodological aside, it is important to note that the high proportion of individuals reporting no vegetable consumption (together with other ‘undesirable’ behaviors elsewhere) appears to indicate that visitors are being quite honest in their responses to All About You. Indications suggest that there does not appear to be a ‘desirability’ bias whereby visitors are just telling us “what they think we want to hear”-- a frequent problem in survey research. 30. San Antonio Metropolitan Health District. Health-e-News; August 2016. 31. For more detailed references on BMI and its correlation to body fat and interpretation, please see the Centers for Disease Control and Prevention. About Adult BMI. Division of Nutrition, Physical Activity and Obesity. National Center for Chronic Disease Prevention and Health Promotion. U.S. Department of Health and Human Services. Accessed July 8, 2015. Available at: http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html 32. National Institutes of Health, National Heart, Lung and Blood Institute. Why is Sleep Important? Accessed August 19, 2016. Available online at: http://www.nhlbi.nih.gov/health/health-topics/topics/sdd/why
35 NOTES NOTES The H-E-B Body Adventure Powered by University Health System is generously supported by
Susan Moulton in honor of Charles Moulton Children’s Hospital of San AntonioTM San Antonio Metropolitan Health District The Aetna Foundation Baptist Health Foundation of San Antonio Dr. Dacia Napier in honor of her parents, Dr. John and Noreen Hammerick
Saint Susie Chariable Foundation Witte Museum members
The development of educational programs for the The H-E-B Body Adventure was generously supported by the Semp Russ Foundation of the San Antonio Area Foundation, with initial support from the Genevieve and Ward Orsinger Foundation and a grant from the Beulah M. and Felix J. Katz Memorial Trust, Dan and Gloria Oppenheimer Fund, Valley View Trust of the San Antonio Area Foundation and the Najim Family Foundation.
The H-E-B Body Adventure is made possible through collaborative partnerships with H-E-B, The University of Texas Health Science Center at San Antonio, San Antonio Metropolitan Health District, YMCA of Greater San Antonio, the Culinary Institute of America, the San Antonio Botanical Garden, BioMed SA, The Synergy Studio and the Pearl Farmer’s Market
www.WitteMuseum.org 3801 Broadway | San Antonio, Texas | 78209-6396