Diabetes and Health-Friendly Food Pantry Shelf Design and Implementation
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Diabetes and Health-Friendly Food Pantry Shelf Design and Implementation A thesis submitted to the Graduate School of the University of Cincinnati in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE Department of Rehabilitation, Exercise, and Nutrition Sciences College of Allied Health Sciences Madison Kelly Busch, RD, LD B.S., Miami University 2016 Oxford, Ohio Committee Chairs: Seung-Yeon Lee, Ph.D. Francoise Knox Kazimierczuk PhD, RDN, CSSD, LD, ATC, CSCS, NSCA-CPT, FAND ABSTRACT Objectives: The objective of this pilot study was to develop and implement the “Most Diabetes and Health Friendly” Shelf Initiative in an urban choice food pantry. Methods: The “Most Diabetes & Health Friendly” shelf initiative was developed using grocery store marketing techniques and community based participatory research (CBPR). The program aimed to assist food pantry clients in identifying healthier food options available in a choice-food pantry. The criteria for healthier food options were established based on a literature review and current dietary recommendations. The healthiest options within each pantry section were highlighted using grocery store marketing techniques: priming, colored labeling, framing, and placement. The initiative was pilot tested in a choice pantry in Cincinnati, OH and usage was tracked for 6 months. The number of items on the intervention shelf versus general shelf was counted before and after pantry sessions. The total number items available, number items taken, and percentage items taken was tracked, calculated, then compared by section and shelf. Results: A higher total number of items was taken from the intervention shelf (1987 items) compared to the general shelf (1863 items). The intervention shelf had a higher percentage of items taken per month (32-47%) compared to the general shelf (25-45%); however, the percentage items taken from the general shelf increased overtime. There was no clear pattern of choices shown across food sections. Conclusions and Implications: Findings suggested the initiative was feasible to implement within a choice food pantry. A higher percentage of food items were taken from the intervention shelves compared to regular shelves. Further qualitative research is needed to determine whether the initiative is able to impact food pantry client’s dietary intake, as well as which outside factors most influence food choices within this population. ii iii ACKNOWLEDGEMENTS There have been many individuals who have dedicated time and energy to assist with this project, in which this would have not been possible without. I would first like to thank my advisor, Seung-Yeon-Lee, PhD, for her guidance and mentorship throughout this study as well as graduate school. I would also like to thank Francoise Knox Kazimierczuk PhD, RDN for her willingness to serve on my thesis committee. I am also grateful for Claire Moorman, who volunteered to assist in data collection and was a pleasure to work with. Additionally, I would like to thank the Jewish Family Service Heldman Family Food Pantry, especially Sandee Golden and Ali Ulanski, who welcomed us in with a strong passion to better serve their community. I would also like to express my gratitude for the Community Based Participatory Research team who volunteered their time and energy to help create an effective and realistic intervention for their peers. Finally, I would like to thank my family and friends for their unwavering support and encouragement while furthering my education. iv TABLE OF CONTENTS Introduction………………………………………………………………………………………..1 Literature Review………………………………………………………………………………….2 Significance………………………………………………………………………………………14 Methods…………………………………………………………………………………………..15 Setting…………………………………………………………………………………....15 Development of the Diabetes and Health-Friendly Food Pantry Shelf Initiative………..17 Finalizing the Most Diabetes and Health-Friendly Food Pantry Shelf Initiative………..22 Implementation & Monitoring…………………………………………………………...25 Results………...………………………………………………………………………………….28 Discussion………………………………………………………………………………………..40 Conclusion……………………………………………………………………………………….46 References………………………………………………………………………………………..47 Appendix 1……………………………………………………………………………………….51 v LIST OF TABLES Table 1. JFS food pantry users…………………………………………………………………...28 Table 2. Combined number of all items taken by month………………………………………...29 Table 3. Percentage of total items taken per month……………………………………………...30 Table 4. Total number of items taken by food category per month……………………………...31 Table 5. Percentage of items taken by food category per month………………………………...31 vi LIST OF FIGURES Figure 1. Procedures for the development of the intervention…………………………………...18 Figure 2. Combined percentages of all items taken per month…………………………………..30 Figure 3. Percentage of applesauce taken………………………………………………………..32 Figure 4. Percentage of beans/lentils taken………………………………………………………33 Figure 5. Percentage of bread taken……………………………………………………………...34 Figure 6. Percentage of canned fruit taken………………………………………………………35 Figure 7. Percentage of canned vegetables taken………………………………………………..36 Figure 8. Percentage of cereal/oatmeal taken……………………………………………………37 Figure 9. Percentage of pasta taken……………………………………………………………...38 Figure 10. Percentage of rice taken………………………………………………………………39 vii INTRODUCTION Food insecurity—defined as a lack of dependable access to adequate, safe, and nutritious food for all household members to live a healthy life—is a risk factor for developing type 2 diabetes and other diet-related chronic diseases.1-15 This association is thought to be related to the poor nutritional quality of easily-accessed, cheap foods and a lack of nutrition education.7-15 Despite the immense problem, a literature search revealed a lack of substantial interventions to target the serious, yet preventable public health burden. Choice food panties, which are a medium for food insecure individuals to choose and obtain food, are an ideal site for nutrition and health-related intervention.5 Applying consumer marketing techniques within a choice food pantry may promote healthier food selections. Consumer marketing techniques have historically been used by large companies to increase item sales, however have more recently been utilized in nutrition research to study the impact of utilizing the techniques on the promotion of healthy food options.16-18 The literature review revealed several successful techniques to improve selection of healthy foods including priming, colored labeling, framing, and product placement.18-31 It is hypothesized that the combination of these techniques used in a choice food pantry may improve the clients’ choices in the food pantry. If successful, this would provide a feasible and affordable solution for food pantries to adopt in order to improve client awareness to choose the most healthful options available for his or her condition regardless of income status or nutrition knowledge. The purpose of this study was to develop a diabetes-friendly food shelf intervention to target the food insecure population, then to track the number of food items taken from the intervention shelves compared to the general shelves. 1 LITERATURE REVIEW Food Insecurity Food insecurity is the lack of dependable access to adequate, safe, and nutritious food necessary for a healthy life. There are three categories to describe the severity of food insecurity including marginal food security, low food security, and very low food security. Marginal food security consists of those who may not always be defined as food insecure, however are households that have problems, at times, or anxiety about acquiring adequate food, but the quality, variety, and quantity of their food intake is not substantially reduced. Households with low food security report frequent reduced quality, variety, or desirability of the typical diet. Households with very low food security are the most insecure, having multiple indications of disrupted eating patterns and reduced food intake.1 The common worries of food insecure individuals include running out of food, inability to afford balanced meals, and having to eat less or skip meals.2 Within the United States, 12.3% of households suffer from food insecurity with an additional 4.9% suffering from very low food security.2 In 2017, Cincinnati, Ohio identified a higher prevalence of food insecurity than the national average, with 19-31% of the adult population as food insecure, depending on county.3 Food security has been associated with multiple negative health outcomes for adults including physical impairments, obesity, psychological suffering, socio-familial disturbances, and increased risk for diet-related chronic diseases.4 Many of the associated chronic conditions are diet-related and could be prevented with access to adequate nutrition and basic health care including hypertension, chronic heart disease, chronic kidney disease, stroke, and type 2 diabetes.1 Food insecurity is considered an independent risk factor for the development of type 2 2 diabetes, which is problematic considering the already high national diabetes prevalence.5 According to the 2017 National Diabetes Statistic Report, an estimated 23 million people in the United States have diagnosed diabetes. An additional 7.2 million people are estimated to have undiagnosed diabetes, with an added 84.1 million people with prediabetes.6 Moreover, an estimated 13% of adults in the Greater Cincinnati area had diagnosed diabetes, which is above the national average. This percentage