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Community Education Intervention Project:

How Does Your Salad Grow Class

Mesa County WIC

February 10th, 2016
Lisa Homiak
ARAMARK Dietetic Internship

The Mesa County Health Department provides Community Health Services
including WIC (Women, Infants, and Children). Mesa County WIC is a special
supplemental nutrition program for women, infants and children located in the towns
Fruita and Grand Junction of Colorado. WIC provides nutrition education, free nutritious
foods, referrals, and breastfeeding promotion. The eligibility requirement is that the
combined gross family income cannot exceed 185% of the federal poverty income
guideline for nutritional risk. Those already enrolled in Medicaid, Food Stamps or TANF
(temporary assistance for needy families) automatically qualify for WIC. The majority of
participants receiving WIC in Mesa County are Caucasian (the racial makeup of the
county is 89.4% white1), so it is important to keep their cultural practices in mind when
providing services.
One educational session about eating vegetables was provided to parents and
children ages 2-5 years old in the How Does Your Salad Grow class. The outcomes of
the class was 100% of participants could state the recommended amount of fruits and
vegetables a 2-5 year old should consume each day, and 50% of participants (applies
to parents only) could learn at least one tip to incorporate more produce into their
childs diet. Limitations included getting people to come to the class and attention span
of the children throughout the class. All written materials developed for the successful
implementation of this education class are available in the Appendix section.
Nutrition Assessment
Food/Nutrition-Related History (1)

Food and beverage intake (1.2), Food intake (1.2.2)

The predominant race receiving these services is Caucasian, which refers to
populations of European origin who have paler skin. Whites constitute the majority of
the U.S. population at 77.35%. According to Boyle et al., European Americans
commonly consume beef, chicken, pork, pasta, rice, bread, dairy foods, potatoes,
bananas, apples, citrus juices, and lettuce. They also have a high intake of fat, salt,
sugar, and fast foods.2
The WIC program is designed to improve the health status of participants. The
supplemental food part of the program includes fresh milk, eggs, beans, cheese, whole
grains, peanut butter, cereal, tuna, fruits, vegetables, juice, baby food and special infant
formula. Tofu and soy beverages are also available as alternative foods for those with
food allergies or personal preferences (vegetarian, vegan). These foods meet the
following nutrient needs: protein, iron, calcium, Vitamin A and Vitamin C. Mesa County
WIC is currently using checks, but will be transitioning to an EBT (Electronic Benefit
Transfer) card in October 2016. WIC educators complete the nutrition interview portion
of the appointments with participants who are not considered to be at high nutritional
risk, and Registered Dietitians counsel those that are at high risk.
Client History (CH):
Personal Data (1.1), Patient/Client/ Family Medical/Health history (2), Social History

The population served by the WIC community practice site consists of

pregnant or lactating women, infants, and children up to the age of 5 years old in Mesa
County. The county seat is Grand Junction City with Fruita City and the towns of
Palisade, Collbran and De Beque surrounding it. The socioeconomic status of the WIC
population is 185% of federal poverty income guideline. 18% of children fewer than 18
years of age fall below federal poverty level in Mesa County compared to 17.1% in the
state of Colorado1. Socioeconomic conditions (such as poverty, low level education, and
lack of health insurance) are associated with poor health status and chronic disease.
21.4% of adults ages 18-24 years in Mesa County are uninsured. 23.8% of children in
Mesa County are eligible but not enrolled in Medicaid or CHP+. Non-Hispanic whites
have the lowest percentage of lack of insurance compared to all other minorities. Health
history is pulled from the Mesa County Health Departments Data & Statistics: 23.7% of
children ages 2-14 years are overweight or obese compared to 25.8% in the state of
Colorado. (22.5% of adults 18+ are obese in Mesa County). There is no significant
difference between county and state percentages. Physical inactivity and unhealthy
eating contribute to overweight/obesity and a number of chronic diseases. Those who
eat more generous amounts of fruits and vegetables as part of a healthful diet are likely
to have reduced risk of chronic diseases. 14% of low-income people in Mesa County
have limited access to healthy foods (do not live close to a grocery store), as compared
to 6% in the state of Colorado.1
Caucasian people in North America and Western European countries tend to
seek western medicine, which is a type of medical treatment based on the use of drugs

and surgery to treat symptoms, rather than focusing on preventative care.3 Some people
do also seek alternative or complimentary medicine for more intensive diseases.
Knowledge/Beliefs and Attitudes (4)
Beliefs and attitudes (4.2)
The predominant religious group that the Caucasian race belongs to is Lutheran.
They also tend to belong to the Baptist, Methodist, Episcopal, Presbyterian, Jewish, and
Catholic church.4 The majority of this race identify with religious faith and have a belief
in God. For Roman Catholics, meat is not consumed on Fridays during Lent (40 days
before Easter). Jewish dietary laws are complex and follow kosher guidelines, such as
pork and shellfish being prohibited. The laws define how birds and mammals must be
slaughtered, prepared, and when they may be consumed.2
Factors affecting access to food and food nutrition-related supplies (6)
Food/nutrition program participation (6.1)
According to Health Department data & statistics, 15.6% of adults 18+ years of
age reported that their general health was fair to poor in 2010, with a mean number of
3.9 days in the last 30 days that their physical health was not good.1 In 2009, 23.7% of
children ages 2-14 years old were overweight or obese. In 2012, it was reported that
14% of Mesa County residents had limited access to healthy foods (low-income people
who do not live close to a grocery store). In 2011, 21.4% of adults ages 18-24 years
were uninsured. In 2010 statistics show 18% of children less than 18 years fell below

the federal poverty level, and in 2011 44.1% of students were eligible for free and
reduced school lunch.
Nutrition Diagnosis
PES Statement
Food- and nutrition-related knowledge deficit related to lack of prior nutrition-related
education as evidenced by verbal group reports indicating needs for fruit and vegetable
intake education.
Limited access to food related to lack of financial resources to purchase a sufficient
quantity or variety of culturally appropriate healthful food as evidenced by lack of
resources and need for WIC program for free nutritious foods and education to improve
health status of participants.
Nutrition Intervention
Nutrition Education-content related to nutrition relationship to health/disease as
evidenced by food- and nutrition-related knowledge deficit.
To address the nutrition diagnoses an education intervention toward eating five
fruits and vegetables a day as they relate to health/disease prevention, one of the major
dietary flaws of the clients served, was planned and provided.
Nutrition Education (E-1.5) Recommended modifications
Nutrition Education (E1.4) Nutrition relationship to health/disease
Nutrition Monitoring & Evaluation

Healthy People (HP) 2020 Goal and Objective

Healthy People 2020 continues the tradition of the 10-year agenda for improving
the Nations Health: the result of a multiyear process to provide measureable goals that
promote a society in which all people live long, healthy lives. The education intervention,
providing monthly group education for children age 2 years and older and their parents,
contributes to addressing the nutrition problem of healthy diet knowledge deficit at my
site, and the larger goal and objective in HP 2020 related to obesity. This intervention is
related to an emerging trend in dietetics as it pertains to an HP 2020 health trend goal
of nutrition and weight status with the objective to reduce the proportion of children aged
2 to 5 years who are considered obese.
HP 2020 Goal: Promote health and reduce chronic disease risk through the
consumption of healthful diets and achievement and maintenance of healthy body
weights. Nutrition and Weight Status; (NWS-10) Reduce the proportion of children and
adolescents who are considered obese. HP 2020 Objective: (NWS-10.1) Reduce the
proportion of children aged 2 to 5 years who are considered obese.5 Baseline: 10.4% of
children aged 2 to 5 years were considered obese in 2005-08 (10.2% in 2009-12).
Target: 9.4% (10% improvement). This goal uses the SMART (specific, measurable,
attainable, realistic, timed) criteria as it clearly identifies a specific population of children
aged 2 to 5 years, a measurable target of 10% improvement (also attainable and
realistic) over a 10 year time period (timed).
The Education Intervention Program Goal: Increase daily intake of fruits and
vegetables to 5 per day in WIC participants ages 2 years- 5 years old over the time

span of three months. The Education Intervention Program Objective: Increase parents
and childrens (ages 2+ yrs) understanding of fruit and vegetable servings per day for
age in one class education session.
Lesson Plan
How Does Your Salad Grow educational class will be presented to parents and
children 2+ years of age that are WIC participants. The goal of the class is to provide
information and literature to increase knowledge of a healthful diet. This class is to be
30 minutes in duration and be held monthly at the WIC office. The class focuses on the
following: each child participating can name and identify the color of one vegetable,
each parent can report understanding of appropriate vegetable servings/intake per day
specific to their childs age, and each family goes home with a handout, gift, and check
to implement what theyve learned. (See Lesson Plan Template in the Appendix
This education opportunity will be advertised verbally over the phone when
appointments are scheduled for check pickups. This provides the opportunity to join a
free class when they would have already been coming into the office anyways. This
addresses the 4 Ps of marketing: price (free), product (fun and informational class with
take home gifts), promotion (receptionist calls to schedule), and place (conveniently
located at WIC office where you have to come anyways to pick up your checks). In the
future, it may also be advertised via social media on the Health Departments Face book

The education class will require a space large enough to hold the number of
attendees, which for now can be one of the WIC educator offices. The staff required for
the class will consist of the WIC educator whose office is being used along with the RD
hosting the class. If the group grows to a larger number in subsequent warmer months,
the class can be held outside of the Health Department building on a large area of
grass. All materials required for the handouts and coloring activity (printer, ink, paper,
stapler, pens, crayons, copy machine) as well as the book and gift will be provided by
the WIC facility. Since these items are already part of the WIC budget, there will be no
expenses to budget for above and beyond normal operation.
Nutrition Monitoring and Evaluation
The method of obtaining measurement for the objectives are a pre-test and posttest for parents, with verbal affirmation from children. Tests were collected and results
were analyzed for evaluation of learning achievement. The results indicated 100% of
participants could report the recommended amount of fruits and vegetables a 2-5 year
old should consume each day, and 50% of participants (applies to parents only) could
learn at least one tip to incorporate more produce into their childs diet. 100% of parents
found the class helpful and enjoyable. Factors hindering results were the lack of detail
provided by participants on the test answers. The pre- and post-test can be located in
the Appendix section.
Other positive or negative outcomes: there were originally two classes
scheduled, but only one was accomplished despite several efforts. The receptionist was

in charge of trying to get people to come to the class during her scheduling calls. The
WIC staff and dietetic intern also went through lists of people who still needed these
months checks and fit the criteria for the class to come up with more people to reach
out to. The cancellations are out of our control, however, the hope is that the class will
consist of up to 10 children in the future.
Future plans for nutrition care, monitoring, and follow-up: at the next appointment
the class participant comes in for, ask the parent how many fruits and vegetables their
child is eating each day and what size the servings are. See if they retained and applied
information from the education class into daily life. Monitoring shows success of the
intervention toward the diagnoses I established by confirming that in the 3 months
following the class the participants improved upon their fruit and vegetable intake due to
what they learned in the class. The results may have contributed to the success of the
targeted HP 2020 goal by potentially reducing the proportion of children aged 2 to 5
years who are considered obese through an increase in healthy diets consisting of more
fruits and vegetables in place of less healthful food choices.
Appendix A: Lesson Plan
The title of the lesson is: How Does Your Salad Grow?
The target audience: WIC participants with children ages 2 years and older.
Duration: 30 minutes.
Introduction (5 minutes),
Body of the Lesson: 20 minutes total: reading the book with participation 10 minutes, activity and action plan - 10 minutes
Conclusion: (5 minutes).


Goal: Increase daily intake of fruits and vegetables to 5 per day in WIC
participants ages 2 years- 5 years old over the time span of three months.
Specific Objectives



(State how each specific

objective will be met)



Have everyone sit criss-cross
applesauce in a circle on the rug
and share his or her name and age.



Hand one color plastic vegetable to

children and have them report their
Explain that today we are going to
read a book about vegetables, but
we need their help as we read, so
when they see their color in the
book they need to raise their hand
and tell us the name of the
vegetable that matches their color.


Evaluate parents knowledge of fruit

and vegetables servings, portion
sizes for their child(s) age, and one
trick they use to get their child to eat
more fruits or vegetables via a pretest questionnaire.

Body of Lesson
1. Participant (child)
will be able to
identify the color and
name of one
vegetable in the
book, and state how
many fruits and
vegetables they


Read Book

Verbal Q&A

1. Read book titled, How Does

Your Salad Grow.6 Children identify
vegetables in the book that match
their color as we read.
2. Activity: Have children report
what vegetables go in a salad,

should eat daily.

S specific to child
M measureable
verbal results
A attainable
information during
class time

which ones they like, and how many

fruits and vegetables they should
eat each day as they use crayons to
color in their salad bowl picture.
3. Ask the children how many fruits
and veggies they should eat each
day, and once they say five ask
them to give you a high five for 5
fruits and vegetables a day.

R realistic
expectations of
learning servings
T timely
achievement of
2. Participant
(parent) will
understand the
vegetable serving
size specific to their
childs age and
recommended intake
of fruits and
S specific to parent
M measureable
results on post-test
A attainable
information during
class time

1. Discuss with parents tips to
increase vegetable consumption,
appropriate serving sizes for their
childrens age, and how many
servings the kids should eat each
day while kids do the coloring
activity and their checks are issued.

Tips &


2. Evaluate parents knowledge of

fruit and vegetables servings,
portion sizes for their child(s) age,
one trick they learned to get their
child to eat more fruits or
vegetables, and if they enjoyed the
class via a post-test questionnaire.

R realistic
expectations of
learning servings
T timely
achievement of



The education intervention,

providing a monthly group class for
children age 2 years and older and
their parents, contributes to
addressing the nutrition problem of
a healthy diet knowledge deficit.
Parents need help increasing daily
intake of fruits and vegetables to 5
per day in WIC participants ages 25 years old. These needs can be
addressed in a How Does Your
Salad Grow class. Parents get
incentives to participate: WIC
checks are issued, a handout is
given, and a plate or toothbrush is
given to their child.

Materials List
1. Colored plastic vegetables
2. Book, How Does Your Salad Grow?
3. Crayons and paper with picture of salad bowl
4. Recipes, tips, and portions handouts
5. Pre-tests and post-tests with pens
6. Plate and toothbrush take-home gifts

Appendix B: Handout

Fun Veggie Recipes!

1. Easy Cold Veggie Pizza


1 package (8 ounces) refrigerated crescent rolls
1 package (8 ounces) 1/3 fat cream cheese, softened
1 tablespoon mayonnaise
1 garlic clove, minced
1 teaspoon dried dill weed
Salt and ground black pepper to taste
2 cups assorted fresh vegetables such as broccoli, cauliflower, cucumber, green or red
bell pepper, tomato, green onions, mushrooms, carrot, zucchini or yellow summer
(No oven? Try whole wheat tortillas, bagels, English muffins, or pita bread!)

Preheat oven to 350F. Unroll crescent dough; separate into eight triangles. On a sheet
pan, arrange triangles in a circle with points in the center and wide ends toward the
outside. Using lightly floured roller, roll dough to a 12-inch circle, pressing seams
together to seal. Bake 12-15 minutes or until light golden brown. Remove from oven;
cool completely.
In a big bowl, combine cream cheese, mayonnaise, garlic and dill weed. Season with salt
and black pepper; mix well. Spread cream cheese mixture evenly over crust.
To prepare vegetables, coarsely chop broccoli or cauliflower. Dice or slice cucumber, bell
pepper, green onions, tomato, mushrooms, yellow squash or zucchini. Grate carrots.

Sprinkle vegetables over pizza. Cut into squares and serve!

2. Sweet Potato Chips


2 or 3 sweet potatoes, washed

3 tablespoons canola oil
Salt and/or other seasonings to taste (garlic, brown sugar, paprika, chili powder,

Preheat oven to 400 degrees.
Spray a cookie sheet with non-stick cooking spray.
Prepare the sweet potatoes. You can leave the skin on if you choose. Make slices
about 1/8" thick. Place in a large bowl with the oil and any seasonings. Toss to coat.
Spread the slices in a single layer on the cookie sheet.
Bake for about 15 minutes until they are golden brown. Turn halfway through the
baking time.


Carefully spread the baked chips on a paper towel to drain any excess oil.
(Baked sweet potato chips can be stored up to a week in an airtight container)

3. Ants on a Log

Celery sticks
Peanut butter
Raisins (or dried cranberries for fire ants)

Fill the center of the celery stick with peanut butter.
Place a few raisins on top to be your ants.
Eat and enjoy!

4. Carrot Fries

1 lb carrots
1 tbsp cornstarch (or 2 tbsp all purpose flour)
1 tbsp canola oil
1 tsp dried tarragon (or rosemary)
Black pepper + salt

Preheat oven to 400 degrees.
Cut carrots into fries, about 1 cm thick, and mix with cornstarch and a little black
Toss with canola oil, spread in a single layer on a baking tray lined with parchment.
Bake for 40-45 mins, turning halfway.
Mix a little salt with tarragon and toss through the cooked fries.

5. Kale Chips

2 large bunches of kale, rinsed, dried, and torn into 1-2 inch pieces
2-3 tbsp olive oil (or canola oil)
2 tsp coarse salt

Preheat oven to 350 degrees.


Toss kale pieces with oil and salt, spread in a single layer on a baking sheet.
Bake for 10-12 mins (or until crisp) and serve.

Tip #1: Time
Grab and go foods: fresh apples, ripe plums, pears, grapes, carrots, and celery. Have
these foods washed and ready for eating on your refrigerator shelf.
Dried fruit like raisins, apricots, cranberries and others: Add to salads, mix with nuts, or
add to cottage cheese or yogurt.
Vegetable and fruit juice remember cup = adult serving.
Stock up on frozen vegetables- they are easy to do in the microwave and great
additions to canned soup or casseroles.
Canned fruit in the fridge ready to add to cereal or as the start of a fruit salad
Roasting is a quick, easy way to bring out the best flavors of much vegetable such as
carrots, eggplant, red peppers, squash, onions, sweet potatoes, and mushrooms.
Use fruit chutneys or fruit such as pineapple, apple or papaya to complement meat
Blend it. Use any combination of fresh, frozen or canned fruit to make a smoothie.

Tip #2: Cost

Buy fruits in season.
Discount/bulk- Costco, Sams Club, etc.
Compare price of fruit or vegetable pound per pound with typical junk food like cookies
or chips. Example: One pound bag of potato chips cost around $ 4.00
One pound bag of potatoes cost around $0.40 cents

Tip #3: My Kids Wont Eat Vegetables

Encourage parents to shop with their children in the produce department to get kids
interested. Talk about shape, color and maybe where the fruit or vegetable comes
from. A tree or in the ground?
Include children in the cooking experience like grating or chopping the fruit or
vegetable. If kids are involved in the food preparation they usually will eat it.
Keep offering small portions even if they dont eat it.


Serving Size Examples

Easy rule of thumb: 1 tbsp food per year of age
Serving Sizes for Ages 2 and 3
1/2 slice of bread
1/4 muffin or bagel
1/2 cup of dry cereal
1-2 crackers
1/4 cup of pasta, rice or potatoes
1/4 cup of pureed fruit or fruit juice
1 egg
1 ounce of meat, poultry, or fish
1 tablespoon of peanut butter
1/4 cup of cooked beans
3/4 ounce of cheese
1/2 to 3/4 cup milk or yogurt
1/4 cup of vegetables
1/2 to 1 teaspoon of fat
Servings for 4 and 5 Year Olds
1 slice of bread
1/2 of a muffin or bagel
3/4 of a cup of dry cereal
1/2 cup of pasta, rice or potatoes
1/2 cup of fruit or fruit juice
1 egg
1-2 tablespoons of peanut butter,
1-2 ounces of meat or poultry,
1-2 ounces of fish,
1 ounce cheese
1/3 cup cooked beans
3/4 cup milk or yogurt
1/4-1/3 cup of vegetables
1 teaspoon of fat
Appendix C: Evaluation Tool
Pre-Class Questions
1. How many servings of fruits and vegetables should a 2-5 year old eat each day?
2. How old is your child, and what would a serving size be for him/her?
3. What is one trick to get your child to eat more fruits or vegetables?


4. If you could choose when the class was held, what day(s) and time(s) would be
the most convenient for you?
Post -Class Questions

How many servings of fruits and vegetables should a 2-5 year old eat each day?
How old is your child, and what would a serving size be for him/her?
What is one tip you learned to get your child to eat more fruits or vegetables?
Did you find this class helpful? Enjoyable?

Appendix D: Coloring Activity


1. Mesa County website. Published 2004. Accessed
January 28, 2016.
2. Boyle MA, Holben DH. Gaining Cultural Competence in Community Nutrition. In:
Boyle MA, Holben DH. Community Nutrition in Action: an entrepreneurial approach.
6thed. Belmont, CA: Wadsworth; 2013:555-588.
3. Macmillan Dictionary website.
Published 2009. Updated 2016. Accessed January 31, 2016.
4. Pew Research Center website. Published 2016. Accessed
January 30, 2016.
5. Office of Disease Prevention and Health Promotion website. Retrieved February 20,
2016, from
6. Alexander F. How Does Your Salad Grow? Scholastic; 2004.