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RUNNING HEAD: Using TBLD to Solve for the Obesity Epidemic 1

Using a Triple Bottom Line by Design Approach to Solve the Obesity Epidemic:

Understanding the Culture of Obesity and Motherhood in the Urban Environment

Dok Chon, Hyunjung Kim, Jennifer Laga,

Meghan K. Bumbaugh, Quentin Koopman, Rebecca Paul

Pratt Institute 2013

Using TBLD to Solve for the Obesity Epidemic

Abstract

This report examines the obesity epidemic and the conditions that have lead to the

increasing rates of obese individuals living specifically in low-income urban areas. Systemic

changes within the food retail industry including, farming, distribution and marketing have all

contributed to this complex issue. Several entities, both public and private have allocated

substantial resources towards the research and development of obesity treatment and prevention

programs. However, many of the conclusions and subsequent actions derived from these efforts

have proven to be unsuccessful. In order to identify reasons for why these previous

intermediations have not lead to the reduction of obesity rates throughout the world this research

paper has analyzed the social, environment and economic factors contributing to the epidemic.

The data collected within this breakdown varied across all three areas of focus. However the

increased instance of obesity within low-income areas was consistent. Based on this analysis it

has also been concluded that the obesity epidemic is a multi-faceted problem that cannot be

attributed to any one individual cause. Therefore future research, and prevention and treatment

programs need to be multi-faceted. This report builds the following case: to improve results for

future prevention programs, research needs to extend beyond the current scientific, theoretical

approach to also include hands on fieldwork that allows for real-time feedback and iteration. To

further test the viability of these conclusions this research report has identified East Harlem as a

viable area for a pilot program based on this multi-faceted approach. Using the neighborhood of

East Harlem as a focus various objectives and components for this type of program have been

outlined. Specific steps for implementation have also been considered and identified within this

report.

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INTRODUCTION

Obesity has become a twenty first century epidemic in American culture. The Merriam

Webster dictionary defines epidemic as, “affecting or tending to affect a disproportionately large

number of individuals within a population, community, or region at the same time” (Epidemic,

n.d.). Over the last 30 years, the number of overweight or obese individuals has continued to

rise, signaling an alarming trend among both adults and youth. As stated in a recent report from

the National Center for Health Statistics, in 2009–2010, more than 78 million U.S. adults and

approximately 12.5 million U.S. children and adolescents were obese (Ogden, Carroll, Kit, &

Flegal, n.d.).

Regardless of heightened attention to obesity, food initiatives, and health-based efforts to

change this reality, the situation continues to worsen. Jennifer Marks from the American

Diabetes Association stated:

Despite the attention of the health profession, the media, and the public, and mass

educational campaigns about the benefits of healthier diets and increased physical

activity, the prevalence of obesity in the United States has more than doubled over the

past four decades (Marks, 2004, p. 1).

When examining demographics, statistics, and trends related to obesity epidemic in the

United States, we have concluded that the current methods being used to identify and address the

problem are insufficient. There is a disconnection between what is perceived to be the root cause,

and the actual cause of the epidemic. Until this disconnect is articulated and addressed, the

solutions currently in place will continue to fail.

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Problem Validation

Population growth worldwide. The current world population is now over seven billion

people, and the United Nations Population Division anticipates the world’s population will

continue to increase rapidly, reaching 8 billion by 2025, 9 billion by 2043, and 10 billion by

2083 (Cohen, 2011). The United Nations Millenium Development Goal #1, to eradicate extreme

poverty and hunger, ties into this increase in population (UNMDG, 2013). On a global scale,

there are one billion people suffering from food insecurity while another 1 billion are overweight

(30 Project, n.d.).

Population growth in urban areas. As of 2007, over 50 percent of the population lives

in cities; this number will grow to five billion by 2030 (UNFPA, 2007). As the population

continues to grow and the percentage of people living in urban areas continues to increase,

addressing food system failures within these ecosystems is imperative.

Obesity in the US. Food is fundamental to our life cycle, and has a far-reaching effect on

a broader set of issues in the United States including healthcare, fuel and energy consumption,

the environment, and the economy. Food insecurity has reached record levels, and continues to

rise both in the United States and on a global scale. Such data have led some investigators to

suggest that by 2050, an enormous percentage of Americans — perhaps approaching 100% —

will be overweight (Yanovski & Yanovski, 2011).

One symptom of the obesity epidemic is the declining health of Americans. In a recent

report conducted by the CDC there were roughly 75 million obese American adults in 2009, up

by 2.4 million from 2007, and the total medical cost for these Americans ran over $150 billion

per year (Zoller, 2010). Obesity is the cause of a number of chronic and ultimately fatal

conditions, and affects quality of life.

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Obesity in urban areas. This problem is further exacerbated when examining the

prevalence of obesity in urban areas. Cited in an article published by the Harvard Gazette,

Ronald Kupka a nutritionist with UNICEF stated, “This trend of rising obesity in the cities is of

particular concern because projections see continued rapid increase in urban populations”

(Powell, 2011).

We applied the “4D” model in our approach to this project. This methodology includes

four phases labeled Discovery, Define, Design, and Deliver. Concurrently, this paper is divided

by those corresponding phases. The discovery phase has been divided into two distinct sections.

The first section addresses food insecurity, malnutrition, and obesity within the scope of the

United States. The second section then explores food system in the United States, and the

definition and relevance of food deserts and food swamps, within the context of urban

environments. The Define phase has also been divided into two sections. The first section

includes primary and secondary data collection, explaining methodology and results. The second

section of the Define phase explores obesity treatment and prevention programs. Our Design

phase explains our approach to solutions to obesity through mothers and family. Lastly, our

Deliver phase is in the form of an introduction to, and business plan for an obesity prevention

program.

I. DISCOVERY PHASE

Within each section of our Discovery phase we have deduced several key insights

regarding food insecurity in the United States. Findings from Section I led to the

following decisions regarding the intent of our proposed design solution; within the scope

of food insecurity in the United States, we will be addressing the problem of malnutrition

in the form of obesity. In Section II of our Discovery Phase, our findings that informed

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our proposed design solution include: the systemic change of the farming and grocery

retail industry influencing access, and being consequently majorly causal to the obesity

epidemic.

SECTION I

Within the past ten years the concept of food insecurity in the United States no longer just

includes hunger; this term is now being used to describe other food related problems including,

obesity, malnutrition and overnutrition. Recent reports reveal there are key demographics related

to food insecure households in the United States.

Based on the research conducted during this section of our Discovery Phase we have

concluded that food insecurity in the US, specifically within urban areas comes in the form of

obesity; this condition most prevalent in low-income single parent homes.

Food Insecurity in the United States

Hunger has plagued segments of the population of the United States for decades, and

government funded supplemental food programs have been in place since 1939. However, it was

not until the 1960’s that food insecurity became a public issue (Panel to Review U.S Department

of Agriculture's Measurement of Food Insecurity and Hunger, National Research Council, 2006).

Recently, the Food and Agriculture Organization (FAO) of the United States, and the U.S.

Department of Agriculture (USDA) have organized studies of global food insecurity. Since 1995,

the Department of Agriculture has conducted a yearly Food Security Survey as a supplement to

the U.S. Census Bureau’s Current Population Survey (USDA, Food Security in the US: History

& Background, 2012).

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Definition of food insecurity. The term “food insecurity” has become commonly used to

describe varying situations of food crisis in the United States. For the purpose of this paper, the

term “food insecurity” will be used in reference to the following definition,

According to the Food and Agriculture Organization of the United Nations (2003):

Food insecurity exists when people do not have adequate physical, social or

economic access to … sufficient, safe and nutritious food, which meets their dietary

needs and food preferences for an active and healthy life. Household food security

is the application of this concept to the family level, with individuals within

households as the focus of concern (p 29).

By looking at this definition of food insecurity, it is clear that the FAO takes a holistic approach

to defining people’s relationship with food. Rather than just focus on malnutrition, or hunger, as

was typical for governmental definitions up until the last decade, the FAO considered different

types of access to food, along with types and quality of food.

In 2006 the USDA followed suit, and replaced the word “hunger” with the term “food

insecurity” as the definition for their previous standardized measure of hunger. The department

also amended the labeling of its food insecurity ranges to remove the term hunger. Their reason

for this change was that hunger, “is an individual level physiological condition that may result

from food insecurity” (USDA, Definitions of Food Security, 2012). Due to the USDA’s refined

methodology, the following four categories have been devised to analyze food insecurity in the

United States:

Food Security

High food security (old label=food security). No reported indications of food-access

problems or limitations.

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Marginal food security (old label=food security). One or two reported indications--

typically of anxiety over food sufficiency or shortage of food in the house. Little or no indication

of changes in diets or food intake.

Food Insecurity

Low food security (old label=Food insecurity without hunger). Reports of reduced

quality, variety, or desirability of diet. Little or no indication of reduced food intake.

Very low food security (old label=Food insecurity with hunger). Reports of multiple

indications of disrupted eating patterns and reduced food intake (USDA, Definitions of Food

Security, 2012).

These changes in definition are indicative of the varying conditions that fall under the

umbrella of “food insecurity.” Under these new categories, food insecurity describes conflicts

surrounding food as it relates to socioeconomic, cultural, and physical conditions.

People affected by food insecurity in the US. Starting in 1995, the USDA Current

Population Survey Food Security Supplement has been compiling statistics on the number of

households experiencing food insecurity in the US. Between 1995 and 2004, there were minor

fluctuations in the number of food insecure households in the US, and these numbers continued

to remain relatively level between 2004 at 3.9 percent, and 2007 when it reached 4.1 percent.

However, in the three years following the 2007 economic crisis, food insecurity in the United

States spiked to 17.2 million households (14.5 percent). This number is the highest level ever

recorded in the United States, and the numbers of food insecure households continue to rise (See

Appendix A and B).

According to the USDA Current Population Survey Food Security Supplement reports,

50.1 million people lived in food insecure households (2012). These reports also revealed several

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key factors affecting the condition of food security in the United States including: family

structure, ethnicity, income and location.

As for family structure, households with children had a substantially higher rate of food

insecurity at 20.6 percent— than those without children at 12.2 percent. A further breakdown of

the USDA research revealed that 36.8 percent of food insecure households were single mother

parented. Further racial disparities continue, with 51.3 percent of households were minority

households with Black, non-Hispanic households at 25.1 percent and Hispanic households at

26.2 percent. For low-income households in the U.S., those making under $22,811 per year for a

family of four accounted for 34.5 percent (See Appendix C). As published by Office of the

Federal Register, the current federal poverty guidelines indicate that the annual income for a

household of four as being $23,550 or below (Health and Human Services Department, 2013).

Perhaps the most interesting statistic from the survey was the prevalence of food

insecurity by region, with insecurity at its highest for households located in principal cities of

metropolitan areas at 17.7 percent compared with only 13.2 percent in nonmetropolitan areas

(USDA, Key Statistics & Graphics, 2012) (See Appendix D and E). This statistic we found

compelling because when picturing a metropolitan or urban area one does typically imagine

reduced quality, variety, or desirability of diet, and little or no indication of reduced food intake.

Typically, one would assume that a more metropolitan would have more options for food intake

than nonmetropolitan areas because urban areas are inherently denser. Our team was surprised by

this paradoxical thinking, and continued to research food insecurity further in order to find the

connection between high rates of food insecurity within an urban area.

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Malnutrition in the United States

The Food Research and Action Center in Washington, D.C. is committed to the issues of

hunger and poverty, and has indicated in related articles and reports that food insecurity has been

a hidden crisis in America and malnutrition is the direct consequence of this crisis. While much

media emphasis has been placed on other developing countries in Africa and elsewhere suffering

from hunger and malnutrition, less focus is placed on the fact that America is faced with these

same problems.

If food insecurity and malnutrition are a hidden crisis, how can an individual be identified

or diagnosed as malnourished, and what is malnutrition? The Johns Hopkins University website

definition explains that when the body is deprived of vitamins, minerals, and other nutrients it

needs to maintain healthy tissues and organ function, the condition of malnutrition develops as a

result (Johns Hopkins Children's Center, n.d.). From this definition, we understood that a lack of

nutrients was causal to malnutrition, and initially assumed that hunger would be what would

cause a person to receive inadequate nutrients.

A LiveStrong Foundation article, Malnutrition in America, reported that according to the

Child Welfare League of America more than 30 million people in the U.S. experience hunger

regularly or are at risk of going hungry (Braconnier, 2011). Some 8.5 million Americans,

including nearly 3 million children, experience hunger on a daily basis. Many of them must rely

on food banks and church-sponsored hot meals programs to get by. Of course, those who do not

have a sufficient amount of food to eat are at risk of becoming malnourished (Braconnier, 2011).

After finding research stating that there are high numbers of people living in the U.S.

who are experiencing hunger, we also found that there are high numbers of people who have

limited access to food. Louisiana State University Agricultural Center reported that in 2009 some

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13 million American children who live in homes have limited access to food (2012). Nationwide,

an average of one in three children received food assistance substantially through the

Supplemental Nutrition Assistance Program (SNAP), previously known as the food stamp

program. These findings not only conclude that there are many people suffering from hunger in

the United States, but there are also many people without sufficient access to food, many of

whom are of a low economic status and therefore eligible for SNAP benefits. Particularly glaring

are the amount of children receiving SNAP assistance, because our research identified a

connection between malnutrition and illness in children.

Effects of malnourishment. Malnutrition is one of the main causes for children’s

vulnerability to illness and infection. It can also affect a developing child's ability to learn as well

as higher levels of aggression, hyperactivity and anxiety (LSU AgCenter, 2012). Compared to

children who receive adequate nutrition, children in food-insufficient homes do not do well in

school. If malnutrition in children persists in the long term, it can lead to mental and physical

disabilities (LSU AgCenter, 2012). In the Shipler Report: Invisible Malnutrition and America's

Future, author David K. Shipler explains how malnutrition is causal to these disabilities:

A raft of research has found that the timing of nutritional deficiency during the most

sensitive periods of brain growth can determine which mental capabilities are damaged.

During the second trimester of pregnancy, the creation of neurons can be affected. During

the third trimester, neuron maturation and the production of branched cells called glia,

can be inhibited. From until about age two, food scarcity can assault the rapidly

developing brain enough to lower I.Q. And even if good nutrition is restored later, there

is no full recovery. Early deprivation creates lifetime cognitive impairment (2012, p. 1).

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Vitamin deficiencies are also considered a form of malnutrition. According to research published

in 2009 by The Archives of Internal Medicine, more than 75 percent of Americans were deficient

in Vitamin D. Vitamin D deficiency is associated with a rickets in children, autoimmune

diseases, certain cancers and obesity. Vitamin D supplements were developed in the early 20th

century along with foods fortified in Vitamin D, and since then rickets, a form of osteomalacia in

children, has been a dormant condition. However as a result of malnutrition, cases of rickets in

the United States has begun to increase (Ginde, Liu, & Camargo, 2009).

Malnutrition and the Hunger/Obesity Paradox. Though our initial assumption was

that hunger was wholly causal to malnutrition, further investigation concluded that there was

another cause of malnutrition. In the same way that “hunger” and “food insecurity” are often

used interchangeably, and incorrectly, “malnutrition” is also a misrepresented term. Often, the

image of a thin or skinny person is associated with the idea of malnutrition. This misconception

of malnutrition hinders Americans from realizing the true implication of malnutrition in the

United States. The United Nations Children's Fund, formerly United Nations International

Children's Emergency Fund (UNICEF) has defined malnutrition in a more broad and holistic

perspective, clarifying why malnutrition in the United States is an immediate and serious threat:

Malnutrition is a broad term commonly used as an alternative to under-nutrition but

technically it also refers to over-nutrition. People are malnourished if their diet does not

provide adequate calories and protein for growth and maintenance or they are unable to

fully utilize the food they eat due to illness (undernutrition). People are also malnourished

if they consume too many calories (overnutrition) (n.d.).

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The terms undernutrition and overnutrition are also being used as part of the vocabulary

associated with this epidemic. The two terms are directly connected to food intake, but in

different ways and with varying factors.

Undernutrition. occurs when meals are of a low nutritional value or when nutrients move

through the body more rapidly than they can be replaced.

Overnutrition. occurs when people eat too much and/or eat high calorie, nutrient

deficient meals, and participate in insufficient physical activity. Being more than 20 percent

overweight increases the risk of overnutrition. About 1 percent of children in the United States

suffer from chronic malnutrition due to dietary imbalances rather than nutritional deficiencies.

(The Johns Hopkins University, n.d.)

Therefore, malnutrition must be evaluated in the context of the environment. It can be

used to describe a variety of nutritional circumstances, and in the United States malnourishment

not only describes the condition of being skin and bone, but also increasingly of being skin, bone

and fat, commonly referred to as overweight or obese. This anomaly has been coined “the

hunger-obesity paradox” (Dolnick, 2010). In the Shipler Report: Invisible Malnutrition and

America's Future, David K. Shipler also illustrates “the hunger-obesity paradox,” and how

malnutrition is invisibly threatening the health of America:

Obesity, partly from eating unhealthy food, is seen as evidence of indulgence, but its

epidemic scope among the low-income can also mask malnutrition. Overweight people

are often getting the wrong kind of food, lacking key nutrients. So malnutrition rarely

presents itself in America as vividly as in Somalia. Unless you hang out in malnutrition

clinics in Baltimore, Boston, Philadelphia, and elsewhere, you’re not likely to see

emaciated children like the ones on TV (2012, paragraph 6).

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Today, malnutrition in America exists in the form of "too much" rather than “too little,” too

much saturated fat, too much sodium, too much refined sugar, and too many calories. This

unhealthy food excess has resulted in an added burden to the health of individuals and American

society as a whole resulting in an overfed and undernourished nation.

Obesity. In the past few decades, obesity has become a severe global health concern. In

the United States, the number of people classified as obese continues to increase dramatically,

and it is expected that within the next two decades an additional 32 million people will be

classified as obese (Hellmich, 2012). Obesity not only takes a toll on the health of individuals,

increasing the risk for type two diabetes, heart disease, stroke, cancer, and other debilitating and

chronic illnesses, but also takes a toll the fiscal health of the country. In the United States,

obesity now accounts for approximately 9 percent of healthcare spending, which is 147 billion

dollars a year (Hellmich, 2012). In addition to loss of productivity, there are also other indirect

costs (see Appendix F and G). Other indirect costs such as loss of revenue due to a decrease in

worker productivity, on account for days lost.

Obesity is defined as abnormal or excessive fat accumulation that may impair one’s

health. Obesity is calculated by using a formula called body mass index (BMI), dividing a

person’s weight in kilograms by the square of his/her height in meters (kg/m2). Overweight and

obese individuals are classified by the number of their BMI (World Health Organization, 2013).

A BMI greater than 35 is considered as severe-obesity, morbid-obesity or super-obesity. In

comparison, a healthy adult’s BMI will fall within the range of 18.5 – 24.9 (see Appendix H).

● Overweight - BMI greater than or equal to 25

● Obese - a BMI greater than or equal to 30

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Causes of Obesity. The fundamental cause of obesity is an imbalance between the

consumption of calories and the burning of calories. When an individual consumes calories

through food but does not engage in adequate physical activity that will burn the same number of

calories they have consumed, the remaining calories are stored in the body as fat. This results in

an increased body weight. However, obesity is not as simple as overeating and a lack of exercise.

Why has obesity become a serious global issue only within the past few decades when for

centuries, humans have consumed food for survival, to appease physical hunger, or simply for

enjoyment? According to several different articles and reports, including one from the World

Health Organization in 2012, and the New York Times:

● High Caloric Food Intake. Since the food system has been inundated with fast food, our

eating habits have also changed. Individuals are consuming record levels of high calorie

foods that including high fat, salt, and sugar content (World Health Organization, 2013).

According to Magnolia Pictures documentary, Food, Inc., “The way we eat has changed

more in the last 50 years than in the previous 10,000… Over the course of human history,

we were struggling to make sure we had enough food and enough calories for a sizable

percentage of the human race. Now the problem is too many calories…we are hardwired

to go for three tastes-salt, fat and sugar. Now sugar is available 24/7 in tremendous

quantities” (Kenner, 2008).

● Physical Activity. As a result of technological developments in transportation, changes in

lifestyles, and work environments, less physical activity is required aspect of daily life

(World Health Organization, 2013). One study in 2011 found that decreased physical

workplace activity in particular, is one of the major contributors to the obesity epidemic.

Over the last 50 years in the United States, daily occupation-related energy expenditure

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has decreased by more than 100 calories and it accounts for a portion of the increase of

body weight in United States (Church et al., 2011) (see Appendix I).

● Genes. Obesity is also linked to family genetics. If one or both parents are overweight or

obese, the chance of their children being overweight or obese is triple that of a child of

healthy weight parents. (University of Michigan Health System, n.d.).

● Family Culture. Because family members have similar eating and physical activity

habits, family culture also plays a large role in obesity. If parents eat high-fat or high-

calorie foods such as fast food and snack foods, eat at irregular times or skip meals, it

increases the likelihood that the whole family will have body weight issues.

● Triggers in the Brain. A study found that low blood sugar in obese people makes them

desire high-calorie foods. It is not clear if that is a consequence of obesity of a contributor

to obesity, but researchers say the brain or an obese individual may trigger an increase in

eating and desiring food (Dotinga, 2011).

● Low Income/Education. A national study sampling by the Food Research and Action

Center (FRAC), revealed that the BMI of adults in the lowest income and lowest

education group with higher than the BMI of individuals in the highest income and

education groups. The same phenomenon is observed in children. While obesity rates

increased 10 percent for all children in the United States between 2003 and 2007, the

number was 23 percent for low-income children. Rates of severe obesity were roughly

1.7 times higher among poor adolescents and children aged 2 to 19. Low-income children

had an increased BMI as well as a higher chance of becoming obese as adults (Food

Research and Action Center [FRAC], 2010).

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● Accessibility. Over the past 20 years, more than 130 studies found a relationship between

access to healthy food and obesity. Those who live in neighborhoods with better access to

healthy foods enjoy better health. According to a study in the American Journal of

Preventative Medicine, children living in neighborhoods with healthy food are 56 percent

less likely to be obese than children in neighborhoods without access to healthy food

(Policylink, n.d.).

Prevalence of Obesity in the U.S. The latest research from OECD, reported in 2012,

identifies the United States as the most obese country in the world (See Appendix F).

According to the Food Research and Action Center (2013), two-thirds of adults in the United

States are overweight or obese. About a quarter of 2-5 year olds and one-third of school-age

children, including adolescents, are overweight or obese in the United States. And these numbers

are expected to continue to increase (Food Research and Action Center [FRAC], 2010).

The obesity rate in the United States was stable at 15 percent until 1980 but it increased

dramatically during the 1980s and 1990s, and by 2010 it reached 35 percent (Hellmich, 2012).

The rate of overweight people continues to rise as well, with more than 60 percent of Americans

overweight, increasing their risk of becoming obese (Hellmich, 2012) (see Appendix K).

The America’s Health and Robert Wood Johnson Foundation’s report in 2012, stated that

twelve states have the highest obesity rates, starting at 30 percent. If obesity rates continue to

rise, by 2030 more than 60 percent of adults in America will be obese in 13 states; over half of

the adult population will be obese in 39 states; and more than 44 percent will be obese in all 50

states (see Appendix L).

Childhood Obesity in the U.S. Obesity rates in children tend to increase more rapidly

over time. About a quarter of 2-5 year olds and one-third of school age children are overweight

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or obese in the United States. Almost 31 percent of low-income preschoolers are overweight or

obese (Centers for Disease Control and Prevention, 2012). Childhood obesity can be more

serious than obesity in adults, because children with a high BMI are more likely to stay obese as

adults. Approximately 80 percent of children who were overweight at 10 to 15 years old were

obese at 25 years old, and 25 percent of obese adults were overweight as children. This study

also concluded that if children are overweight before 8 years of age, obesity in adulthood is

likely to be more severe (Bellows & Roach, 2009). Childhood obesity can affect a child’s

physical health and mental health. Obese children have a greater risk of social and psychological

problems, such as discrimination and poor self-esteem, which can continue into adulthood

(Centers for Disease Control and Prevention, 2012).

Obesity and Race in the U.S. In the United States, there are racial and ethnic disparities

in the rates of obesity. National data show that the rate of obesity for African-American women

is the highest, next to Hispanic men and women. Among children, African-American and

Hispanic children have higher rates than Caucasian children (Food Research and Action Center

[FRAC], 2010) (See Appendix M and N).

What these research findings conclude is that obesity is a major problem in the United

States, and that it affects the minority demographic of a low socioeconomic status the most, with

the most serious side effects of obesity prevalent in children, specifically minority children of a

low socioeconomic status in the U.S.

Economic Effects of Obesity. Obesity increases the risk of non-communicable diseases

such as heart disease, stroke, diabetes, musculoskeletal disorders and some cancers. Due to the

growth of obesity rates, obesity has been one of the biggest contributors in driving up health care

spending over the past 20 years. A study in 2006, by the Centers for Disease Control and

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Prevention (CDC) estimated that nationally medical costs related to adult obesity were as high as

$147 billion a year, or roughly 9 percent of medical expenditures (Hellmich, 2012). Direct costs

from childhood obesity are estimated at $14.1 billion (America’s Health and the Robert Wood

Johnson Foundation, 2012).

As obesity rates continue, the costs of preventative health care related to obesity are

estimated to increase from $48 billion to $66 billion in next two decades (Gate, 2012). In an

interview with ABC News, Jeff Levi, the Executive Director of Trust for America’s Health

explained the financial toll associated with obesity:

If the obesity rate stays at 2010 levels, 36 percent, instead of rising to 42 percent as

predicted, the country could save more than $549.5 billion in weight-related medical

expenditures from now till 2030 (Justin Trogdon, a research economist with RTI

International, a non-profit organization in North Carolina's Research Triangle Park,

2012) (Hellmich, 2012, paragraph 12).

Obesity in Urban Areas. Based on this broad level research surrounding food insecurity

and obesity in the United States, we further refined our efforts to understand its presence in the

urban landscape. With this focus we identified New York City, as a viable case study to further

inform our parameters for our solution because of it is accessibility in terms of location,

availability to resources and potential subjects for primary research. Furthermore, we then

identified East Harlem as our designated neighborhood of focus because it falls within the

definitions outlined above in regards to income, ethnicity and obesity rates.

New York Statistics. “Over the past 20 years, obesity in New York City has doubled”

(Food Works, 2010, p. 54). More than half of New York City adults, 58 percent, are overweight

or obese (see Appendix O). It is not only an adult health issue, 21.3 percent of New York City

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children ages 6-11 years are obese in comparison to 19.6 percent nationally (NYC.gov, 2012).

Nearly 40 percent of public school students in grades K-8 in New York City are overweight or

obese.

Obesity kills an estimated 5,800 New Yorkers per year. One in three adults in New York

City suffer from diabetes or are likely to develop diabetes due to obesity. These health problems

directly affect the city’s economy. In New York City, roughly four billion dollars are spent for

health care cost related to obesity (Mike Bloomberg.com, n.d.), and about 80 percent of

expenditures are paid by Medicare and Medicaid that comprise 30 percent of all state revenues

(Food Works, 2010).

SECTION II

The second part of our Discovery Phase is centered around the different structures,

process, procedures and institutions associated with food systems in the United States. This

covers the evolution of agriculture, and the shift in American culture from small farms to the

commodification of the food industry; the sociological and economic changes that came as a

result to this shift; and how all of these factors have affected the health of the American

population. This systemic change is another contributing factor to the increased obesity rates in

the United States. The purpose for this part of our Discovery phase is to understand these

changes and to identify areas where this information can inform our design as we move forward.

We also examined the methodology being used to evaluate these changes, specifically

when the terms “food desert” and “food swamp” are being applied. Within that scope we have

identified possible gaps in this approach, and have used these findings to draw additional

conclusions and further refine our “problem definition.” These conclusions include the question

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of access as a major cause to the obesity epidemic and the influence of fast food marketing in

low-income urban areas.

Food System Overview

Over the past century the macro-system of agriculture in the US has taken the form of

mass commercialization, commodification and industrialization. The technological, political and

economic developments that led to this shift has caused the consolidation of many small and

local food businesses and replaced them with a small number of mega businesses (Dimitri,

2005). As documented by countless books, reports, and documentaries this consolidation into

“Big Food” business has changed the types and quality of food being consumed by the American

people. The underlying causes for this shift reveal key insights into the declining health and

rising health costs in the United States.

By including this overview and short history of the food system in the US, we intend to

illustrate the connection between high-level infrastructure and its effects on people at a base-

level. These effects on people and their personal food relationships and eating habits are

influenced by the social, environmental, and economic factors brought on by the larger food

system structure that we outline in this section.

Shifts in the U.S. Farming Industry

There are various causes for changes in the food production system over the past century.

Farms, like any business, are always striving for more efficiency, cost savings, consistency, and

profit. Systemic changes have been influenced by, “a mixture of technological developments, the

rise of consumer influence in agricultural production, and the increasing integration of American

farming into national and global markets” (Dimitri, 2005, p. 9).

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New technology in farming has led to many changes such as the industrialization of food

production and transformative government policy and regulation. As a core industry in the

United States, agriculture has been punctuated with manufacturing innovations and concurrent

policy and regulation changes on a state and national level to implement and encourage sustained

growth in the industry (USDA, n.d.). Over the years there have been policy and regulation

changes in the form of subsidies meant to stabilize crop prices, keep farmers farming, and

provide U.S. families with an affordable, reliable supply of food. Though, farmers are

overwhelmingly focusing on planting subsidized crops like wheat, soybeans, and especially corn.

A 2004 article in Environmental Health Perspectives, a peer-reviewed open access journal

published by the National Institute of Environmental Health Sciences, reported:

Support for these few crops, critics say, has compelled farmers to ignore other crops such

as fruits, vegetables, and other grains. The market is flooded with products made from the

highly subsidized crops, including sweeteners in the form of high-fructose corn syrup

(HFCS), fats in the form of hydrogenated fats made from soybeans, and feed for cattle

and pigs. This flood, in turn, drives down the prices of fattening fare such as prepackaged

snacks, ready-to-eat meals, fast food, corn-fed beef and pork, and soft drinks. Worse yet,

some scientists say, paltry support for foods other than these staples increases the contrast

between prices of fat-laden, over sweetened foods and those of healthier alternatives,

offering poor folks little choice but to stock their pantries with less nutritious foods

(Fields, 2004, p. 2).

The prohibitive costs of the technological advancements in the farming industry have

resulted in further changes. Up through the 20th century in the US, there was high quantity of

small individual farms and farmers operating at a local level. Utilizing technological

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advancements, farms have been able to grow exponentially and sell their products all over the

world. Into the 21st century, the overall quantity of farms has significantly decreased while the

size and output of each individual farm has exponentially increased (Dimitri, 2005).

Furthermore, the individual farmers who remain must conform to the stipulations of their

distribution channels. As described in a 2011 article, Teaching the Food System, out of Johns

Hopkins Center for Livable Futures, the food system structure has many producers at the top,

and millions of consumers at the bottom. There are a small number of companies that control

production and how food is passed on to consumers. These industries at the top, including food

processors and retailers have considerable influence over how and who produces food, and

therefore what the consumer eats.

In this new environment, the food that consumers typically interact with is more likely to

be processed. As noted in The New York Times, “Americans eat 31 percent more packaged food

than fresh food” (Fairfield, 2010, p. BU5). These high consumption levels of processed foods

show that Americans are not necessarily getting the appropriate nutrition from their food.

Food Retail in the U.S.

In correlation with the industrialization of food products, food retail in the United States

has also seen significant change. Since the introduction of grocery retail in the early twentieth

century, the way food has been procured and the type of food people are eating has changed

dramtically. There has been an increase in the processed, packaged food sold in grocery stores.

In addition to the previously outlined factors regarding the changed farming industry, and how it

is more cost-effective for them to distribute processed foods to retailers, there are other various

factors which are cost-effective for retailers that contribute to the increase of processed foods in

retail stores. These factors include the added value of convenience for consumers, the

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consistency and ease of production, and the economic benefits of increased efficiencies, cost

savings, buying cheap and selling high.

The evolution of traditional grocery retail. The first grocery stores in America were

started as small, local, family run business. They were specialized by product, and the consumer

needed to make several stops to procure all of the items they needed. The butcher supplied

meats, the greengrocer fresh vegetables and fruits, the baker baked goods, and the dry goods

store supplied all canned and nonperishable items. These independent stores were often

conveniently located within close proximity to one another. However, this ecosystem began to

break down starting in 1916 when Clarence Saunder at his Piggly Wiggly stores introduced the

first “self-service” grocery store. This innovative approach provided the foundation for grocery

stores and supermarkets of the next ninety-seven years (Piggly Wiggly, n.d.).

By the 1920’s, the economic success of the “self-service” model in food retail brought

about an expansion of local grocery stores in the form of grocery store chains. With the

introduction of the grocery chain stores in the 1920’s, grocers began experimenting with small,

consolidated stores that featured at least a small selection of fresh meats and produce along with

other dry grocery items (Gwynn, 2013). By the end of the 1930’s chain grocery stores like A&P

and Kroger consolidated their grocery stores that had spread nation wide into new larger

supermarkets. As David Gwynn writes in A Quick History of the Supermarket, the

transformation of grocery chain consolidation and it’s effects are explained:

...thousands of small service stores (became) larger supermarkets, often replacing as

many as five or six stores with one large, new one. By 1940, A&P’s store-count had

been reduced by half, but its sales were up. Similar transformations occurred among

all the “majors”; in fact, most national chains of the time saw their store counts

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peak around 1935 and then decline sharply through consolidation. Most chains

operated both supermarkets and some old-style stores simultaneously for the next

decade or so, either under the same name (like Safeway, A&P, and Kroger) (2013,

The Supermarket (1930s and 1940s), paragraph 3).

By the 1950’s most food retailers were operating as supermarkets, and the decade

between 1950 and 1960 was labeled the golden age of supermarkets. These markets expanded

with the consumer into ever-growing suburban populations with larger, new stores and easily

recognizable logos and architecture.

Since the 1980’s the food retail market segmentation has divided into several branches

that the modern grocery consumer would be familiar with; warehouse discounters like Costco

and Sam’s Club, supercenters including Wal-Mart and Target, national supermarkets like

Safeway and Kroger, local supermarkets like Piggly Wiggly and Publix in the South, plus new

upscale specialty stores like Whole Foods, and new specialty discounters like Trader Joes.

Traditional grocery retail food distribution in the U.S. The shift in food retail from

local, specialized stores of the early 1900’s to modern supermarkets has required changes in food

distribution to fit the needs of retail and a growing American population. A food distribution

report by Rich Pirog and Tim Van Pelt of the Leopold Center for Sustainable Agriculture

(LCSA) examined the food miles (distance) food travels from farm to market in the United

States. This report entitled “Food, Fuel and Freeways”, used data from a 1998 study to track 30

fresh produce categories transported from locations across the United States and Mexico arriving

at the Chicago Terminal Market, one of the largest fruit and vegetable distribution points in the

US. Only pumpkins and mushrooms traveled less than 500 miles to reach the Chicago market,

25


while six fruits and vegetables (broccoli, cauliflower, table grapes, green peas, spinach, and

lettuce) traveled over 2,000 miles to reach their destination (Pirog, R., & Benjamin, A. 2003).

It should be noted that the additional travel time from the Terminal Market to

independent retail locations or institutional organizations was not factored into this study. In

addition, Pirog & Benjamin found that 70 percent of the produce varieties tracked in the study

originated outside of US, with 21 out of 30 types of produce originating in Mexico:

An increasing proportion of what Americans eat is produced in other countries, including

an estimated 39 percent of fruits, 12 percent of vegetables, 40 percent of lamb, and 78

percent of fish and shellfish in 2001. The typical American prepared meal contains, on

average, ingredients from at least five countries outside the United States (2003, p. 3).

Overall, food mileage from the farm to the consumer has increased 22 percent between 1981

and 1998 in the US. This increase in the distance these vegetables must travel is due to US

farms’ shift towards subsidized crops like wheat, corn, and soy, so other fruits and vegetables

like those listed previously must travel from outside the US. This system creates higher prices for

those vegetables, which travel long distances, while keeping costs and prices low for subsidized

crop vegetables and processed foods.

When looking specifically at the economic impact and exchange between the farmer,

retailer, and consumer, the change to the farming and grocery retail industries may seem

mutually beneficial. Though upon further analysis, this shift has created a food system which is

dependent on government subsidies, cheaply producing predominantly processed foods, and

subsequently monopolizing grocery environments to pass on those malnutritious foods to

consumers who are unable, whether through economic struggle or deficiency in nutrition

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education, to purchase more wholesome alternatives. Due to the inflexibility of the traditional

grocery retail food system, alternative retail and distribution methods emerged as a result.

Alternative business models for food retail. In addition to traditional food retail, other

forms of food retail have evolved over time such as Cooperatives (Co-ops), and Community

Supported Agriculture (CSA). While Food Co-ops have been in existence since the early 19th

century in England, it was not until the 1970’s that they became prevalent in the United States

(Greenberg & Watts, 2009).

Cooperatives are differentiated from traditional food retail in many ways. They are

democratically organized and run completely by member volunteers who make the decisions as

to what products to sell, where to purchase them, and how to distribute them. Cooperatives are

able to reduce their costs by staffing their retail space with member volunteers rather than paying

employees. Many co-ops only accept members on the basis that they complete a certain number

of work hours per week.

Community Supported Agriculture offers another form of non-traditional grocery retail.

The CSA business model links farmers directly with consumers. Local farmers, and families

within a community enter into an agreement or contract. In some cases, farms will partner with

one another, enabling them to offer a larger food selection to the consumer. In a basic CSA

structure, local farmers offer their harvest in return for financial support from the community.

Typically, families buy into a CSA partnership early in the growing season, which finances the

farmers ability to produce their crops. Depending on the geographic location, CSA supporters

receive a variety of fresh, organic, seasonal fruits, vegetables, and occasionally other non-food

items like flowers. Like Cooperatives, CSA’s are able to cut costs to their members by utilizing

the services of member volunteers at harvest times, and are able to forgo costs associated with

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owning or renting a store. Additionally, food prices from a CSA are typically lower than items

bought in a grocery store because items are not subject to additional costs associated with the

various stages of transportation used in traditional retail distribution systems outlined previously.

Members of a CSA typically come to a designated location, the farm itself or a farm stand, once

a week to pick up their food assortment. Waste from over-planting is reduced, and farmers are

assured payment for their crops when members invest upfront and commit to a CSA (History of

Community Supported, 2010).

These alternative business models present in the food retail industry reveal an opportunity

for small farmers to circumvent the restrictive nature of the large-scale industrialized farming

industry outlined previously. Co-op and CSA models offer affordable, non-processed food that

differs from the types typically available at traditional grocery retailers, benefitting those

consumers financially and nutritionally. Though, while effects of these alternative business

models can be viewed as ideal, they currently operate against the grain of the larger

industrialized farming system, and can be difficult to operate outside its massive influence.

Design and marketing in the retail food industry. The massive influence of the

industrialized food system can be seen across all sectors, though none other more clearly than the

marketing industry. As the food system has shifted, food companies have begun to utilize a

variety of different techniques to market and sell their food products to customers. Processed

foods are designed to taste good. Advertising and packaging are designed to promote ease of use

and quality of food, and prices are held at low levels through government subsidies.

In a report published by the New York City Coalition Against Hunger, author J.C. Dwyer

describes how governmental policy mixed with private corporate interest shaped the processed

food marketing and consumption trends that we continue to see today, beginning with Secretary

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of Agriculture Earl Butz artificially lowering fast-food prices in the 1970s. Concurrently, new

staples were being created within agriculture technology like High Fructose Corn Syrup (HFCS)

to replace traditional ingredients. Marketing tricks like “value-sizing” at restaurant chains

influenced the increase of sales cheaply by combining HFCS into their ingredients (Dwyer,

2005). The report continues to elaborate on those changes in agriculture has influenced eating

habits and behaviors:

It is estimated that the average American increased his/her daily food consumption by

200 calories between 1977 and 1995. Fast food restaurants contributed to the bulk of this

trend. The USDA has called this trend towards eating out “the biggest challenge to those

seeking to promote fruit and vegetable consumption.” They found that restaurant-goers

typically eat only 1.25 servings of vegetables and .50 serving of fruit in a typical

restaurant meal – and half of those vegetables are French fries (Dwyer, 2005, p. 12).

These marketing trends directly relate to our research because of their presence in low-income

urban areas. We have found that in opposition to the idea of “food deserts” within the areas we

have focused for this analysis, marketing for processed and fast food is dominating the visual

landscape, and has significantly influenced the behaviors and habits for those living there. In a

2003 article published by Psychology Science, authors Judy M. Price and Vid Pecjak support this

conception, specific to food and eating habits:

Advertising and other kinds of propaganda also play important roles in the genesis of

obesity. People are perpetually bombarded with food advertising. The same ads are

repeated again and again. Some studies (e.g., Osgood & Tzeng, 1990) suggest that after

such repetitions people unconsciously follow the instructions provided. As harmful

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advertising (e.g., for cigarettes and alcohol) is forbidden in some countries, it is

surprising that food advertising is not (p. 6).

We dive further into these behaviors and their relationship to marketing during the design phase

of our process.

Food Access

Additionally the problems associated with food retail marketing were revealed while

examining the research methodology and subsequent findings associated with “food deserts” and

“food swamps.” In this section we identify these conflicts and how they relate to finding

solutions to the problem of malnutrition in the form of obesity.

Food deserts and food swamps. Many aspects of this topic have been touched upon,

such as, what are the health effects of a food desert, what is a reasonable walking distance

considering the weight of the groceries and the physical capability of the person, and comparing

methods of evaluating a food desert (Mikelbank & Russell, 2012). Recent literature identifies

“disadvantaged neighborhoods lacking access to healthy food as food deserts where limited food

choices may affect health and socioeconomic outcomes” (Leete, Bania, & Sparks-Ibanga, 2011,

p. 204). Community food security is a concept that suggests entities such as the Cooperative

Extension Service and community development organizations should use a more holistic way of

addressing these issues (Lutz, Swisher, & Brennan, n.d.). These insights suggest that

environment plays a pivotal role in the behaviors of people living in communities where obesity

has become endemic; and that in order to solve for obesity problem within these communities,

the multiple facets of methodology in defining food deserts must be addressed.

Problems with methodology, identifying food deserts. The definition and existence of

food deserts may be inaccurate. Areas where obesity among young people is most prevalent do

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not necessarily have limited access to food. Studies suggest that in fact these areas have more

food establishments, however many of those options include fast food restaurants and many

experts are now replacing the term “food desert” with “food swamp.” Quoted from his recent

article “Time to Revisit Food Deserts”, David Bornstein of The New York Times weighs in on

the definition of food deserts:

I’m still convinced that convenient access to fresh food remains a significant barrier for

many low-income people around the country, but I have been persuaded that the standard

way “food deserts” have been defined may overemphasize—and in some cases

mischaracterize—the problem of access and draw attention from other factors that

influence what people buy and eat, like food prices, preparation time and knowledge,

marketing, general levels of education, transportation, cultural practices and taste (2012,

p. 1).

His statement supports that the issue of poverty and obesity is extremely complex and the current

methodology being used to identify the common factors present within these areas is

inconsistent. The conclusion made using current methodologies limit the possibilities of creating

viable solutions, and consequently, for influencing behavioral change.

Paradox of food swamps and food deserts in urban areas. In a 2012 article, Gina

Kolata of The New York Times, discusses food access in poor urban neighborhoods, stating,

“Such neighborhoods not only have more fast food restaurants and convenience stores than more

affluent ones, but more grocery stores, supermarkets and full-service restaurants, too. And there

is no relationship between the type of food being sold in a neighborhood and obesity among its

children and adolescents” (p. A1). In the same article Ms. Kolata continues to describe findings

about low-income urban areas’ access to food, “[they] had nearly twice as many fast food

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restaurants and convenience stores as wealthier ones, and they had more than three times as

many corner stores per square mile. But they also had nearly twice as many supermarkets and

large-scale grocers per square mile” (p. A1). These insights support the replacement of the term

food desert with food swamp, when regarding the issue of food access in poor urban

communities.

In addition to the number of fast food restaurants in low-income areas, there is also the

issue of lack of affordable choices for healthy foods. There is a relationship between the types of

foods available at traditional grocery retail in low-income urban areas, because of the economic

status of those areas. As suggested in a recent report from The Brookings Institution in

Philadelphia, the ‘poor pay more’ because businesses perceive the personal and economic risks

of operating in low-income communities as higher, subsequently charging higher prices to

compensate for those risks (Cummins & Macintyre, 2005).

Understanding access and causes for food swamps in urban areas. In a low-income

urban neighborhood, high caloric intake, lifestyle factors, absence of greenspace and low

physical activity all relate to the presence of food swamps. Education about healthy eating habits

are not an established norm in the United States, and accessibility is hindered by the nature of the

supermarket industry, and food marketing produced by large food producing companies. These

factors causing obesity are substantially significant among children in low-income urban areas,

where the consequences can be much greater.

As outlined previously, there is research supporting the diagnosis linking obesity in low-

income urban neighborhoods with the lack of access to healthy, wholesome foods. Additionally,

our research shows there to be limited access to these wholesome foods through traditional food

suppliers and distribution systems.

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II. DEFINE PHASE

Through our discovery phase, food insecurity was identified as a main factor in

malnutrition within the United States. Food insecurity and malnutrition can assume various

forms, though we have chosen to narrow our focus to malnutrition resulting in obesity, caused by

food insecurity, in the form of nutritional deficit.

Objective

Our research purpose was to apply the Triple Bottom Line by Design (TBLD)

approach, with a focus on social, environmental, and economic issues to design a sustainable

solution to the rise in obesity in urban areas. Our solution objective is to incorporate seamlessly

into the community and reverse unhealthy eating patterns, create economic value, encourage

community, and end (reduce) the obesity epidemic in New York City.

Working within a specific community, the New York City neighborhood of East Harlem,

we have identified East Harlem Block Nursery #1 (EHBN1) as our case study. Using the

preschool as our study site, we will design a tailored solution addressing the following goals:

Identify the source of food related issues in the neighborhood.

Reinforce healthy lifestyles by changing the consumption habits of both children

and parents.

Work alongside (utilize) mothers as the key decision makers for the family.

Encourage the exchange of information and increase comprehension of nutrition.

Build community through parent, family, and school engagement.

Create economic development.

Strategically impact the problem of malnutrition in the form of obesity in the

United States.

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Supported by research regarding food insecurity, malnutrition and obesity rates in the

United States, we have distinguished that a high percentage of populations suffering from obesity

often live in low-income, urban areas. Our define phase is divided into two sections. First, we

include the primary and secondary research where we investigated the link between obesity and

access to healthy foods in low-income urban areas through a case study analysis of the New

York City neighborhood of East Harlem.

Our primary and secondary research was collected in, and specifically relates to the

neighborhood of East Harlem. Historically, an area of Manhattan suffering from epidemics of

unemployment, crime, and poverty, East Harlem has recently become part of a larger,

nationwide epidemic; obesity. Secondary research data were collected prior to primary research

and support our selection of neighborhood, East Harlem, and case study school, East Harlem

Block Nursery #1.

The second section of our define phase includes research summarizing existing obesity

prevention and treatment programs. In addition to isolating a low-income neighborhood in

Manhattan, we have also selected a target segment, young mothers, as there is evidence to

support that their choices within the household have the largest effect and reach within the

community.

SECTION I

Secondary Research

Secondary data have been selectively collected to compare and contrast the neighborhood

of East Harlem and the neighborhood of the Upper East Side, Manhattan, and New York City as

a whole. New York City Department of Health studies, data from the American Heart

Association, city data, and neighborhood programs were evaluated. Our findings illustrate

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differences in key social issues related to the rise in obesity, the environment and issue of food

accessibility, as well as dissect the interwoven economic and socio-economic issues that impact

the obesity epidemic in East Harlem. This section is divided by social, environmental, and

economic analysis of our target location of East Harlem.

Social Analysis

In our social analysis we examine multiple factors, which ultimately relate to how we

define the social aspects of our final design solution. We include here, statistical information

regarding the demographics of East Harlem, how American food culture affects women and

obesity in low-income urban areas, the physical and psychological relationship to food within

mothers, their children and communities, and the trend and factors of obesity which include

behavioral causes. In our social analysis the link between these social factors frame the focus and

decisions we made for our final design solution, which will be be discussed more thoroughly in

our Design Phase section.

Demographics of East Harlem. Significant differences in demographics between East

Harlem and Manhattan as a whole include race/ethnicity, socioeconomic levels and differences

in age of the population. More than 108,000 people live in the neighborhood of East Harlem. The

Hispanic/Latino population is significantly higher in East Harlem at 55 percent, compared to 27

percent in Manhattan as whole, and followed by African-American with 33 percent vs. 15

percent in Manhattan. In contrast, Caucasian/White and Asian races account for substantially

lower percentages of the population in East Harlem, 7 percent and 3 percent respectively (Olson

et al., 2006). Another unique finding is the percentage of East Harlem residents who were born

outside the United States (21 percent). This statistic is lower than the number of people born

35


outside of the US that make up New York City overall (36 percent) (New York City Department

of Health and Mental Hygiene, 2006).

East Harlem is a young neighborhood, with more youth under the age of 17 (28 percent)

than Manhattan (17 percent). The same is true for 18 to 24 year olds, making up 12 percent of

the population of East Harlem and only 10 percent of Manhattan’s population.

The number of births to women under 20 years old (16 percent) directly correlates with

the high youth population in East Harlem noted above (East Harlem Neighborhood Health Plan,

2000). Between 2003 and 2004 in East Harlem, 141 of 1,000 births were to women between 15

and 19 years of age. In comparison, during the same years in Manhattan, the births to teenage

mothers were substantially lower, less than 75 of 1,000 births (Olson et al., 2006). The

Department of Health, and other city organizations place a strong emphasis on the health and

wellbeing of young mother’s in this neighborhood, particularly associated with their food intake,

and healthy eating behavior.

The trend and factors of obesity. A report by the East and Central Harlem District

Public Health Office, conducted in 2007, used four sources of data to conclude its findings on the

rate of obese and overweight individuals in East Harlem. These sources included the heights and

weights of children attending Head Start beginning in 2004, height and weight surveys

conducted on public school students in kindergartners and 5th grade in 2003 and 2005. Also

2005 data on adolescent obesity and lifestyle from the Youth Risk Behavior Study performed by

the Centers for Disease Control and Prevention, and the 2004 Community Health Survey on

adult obesity, overweight, exercise, and eating behaviors.

Using these sources, the 2007 report concluded that obesity and overweight are common

conditions among residents of all ages in Harlem, and that many individuals do not eat the daily

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recommended amount of fruits and vegetables. In fact, 83 percent of adolescents reported eating

fewer than the recommended five servings of fruit and vegetables each day. Over 42 percent of

children in Head Start and the public elementary school system are obese; more than four in ten

children. Among high school aged children, the number of obese children is nearly one in three

(32 percent) (see Appendix P). Statistics for adults are only slightly better with one in four adults

identified as obese. When these numbers are compared to Manhattan’s obesity statistics, they

align with an overall trend of increasing obesity among youth citywide and nationwide.

However, the number of obese adults over age 45 illustrates a drastic difference between

Manhattan and Harlem. Overall, one third of adults in East Harlem are overweight and an

additional one third are obese (New York City Department of Health and Mental Hygiene,

2006). Among 45 to 64 year olds living in East and Central Harlem, 39 percent are obese as

opposed to only 19 percent of those living in Manhattan. In those persons over 65, the number of

obese Harlem residents is double that of Manhattan residents; 40 percent, compared to 20

percent. Additionally, obesity in East Harlem also varies by racial and ethnic group. Black and

Hispanic residents (34 percent and 33 percent, respectively) are more likely to be obese than

white residents (18 percent) (New York City Department of Health and Mental Hygiene, 2006).

Although obesity is a growing trend among youth throughout New York City, the number

of obese adults in East Harlem suggests a lifelong struggle with obesity. If these trends continue,

the number of obese adults in East Harlem will continue to increase, as obese children become

obese adults. According to the 2012 American Heart Association Statistical Fact Sheet on

Obesity, overweight adolescents have a 70 percent chance of becoming overweight adults, which

increases to 80 percent if one or both parents are overweight or obese (Go et al., 2012).

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When factors that affect obesity were analyzed, the report found that lack of exercise in

combination with poor nutrition accounted for the prevalence of obese and overweight

individuals in East and Central Harlem. The number rose to over 90 percent of adults reported

the same lack of nutrition (Matte et al., 2007). In light of the health and nutrition statistics

compiled, recommendations of the report included increased exercise opportunities, portion size

and calorie awareness campaigns and education, encourage Harlem groceries to stock and

promote health foods (fruit, vegetables, reduced-fat dairy, and whole grains), encourage

restaurants to remove trans and saturated fats, and offer low calorie options, promote nutrition

education programs and healthy cooking classes, and bring farm markets and CSA’s to the

neighborhood (See Appendix P).

Women and obesity in low-income urban areas. Though we have been able to define

through identifying young mothers as a target demographic for the area of East Harlem, it is

necessary to show how connecting American culture and psychology, women and obesity in

low-income urban areas demonstrates why it is important to focus a design solution around this

specific demographic.

To start from the broader context, looking at American culture as a whole one can derive

many conclusions as to why the issue of obesity has grown into an epidemic. In their 2003 book,

Obesity and Stigma: Important Issues in Women's Health, authors Price and Pecjak explain how

many people see the obesity epidemic as a result of consuming too much fast food, e.g., pizza,

candy, cheeseburgers, tacos and fried chicken. They go on to explain, “Children like this food

because it is simple and edible. Parents like it because it is relatively inexpensive, and relieves

them of having to cook every day” (Price & Pecjak, 2003, p. 6). They also explain how the

variety of food available to Americans are due largely in part to the various cultures whom have

38


moved to the U.S. and brought their traditional foods with them (Price & Pecjak, 2003).

However the most important part of what Price and Pecjak describe is that “for purposes of mass

production and provision the recipes for preparing these foods have often been changed to

include greater amounts of fat” (Price & Pecjak, 2003, p. 6).

With this as the foundation for the relationship that all Americans have with food, women

living in low-income areas are at an even greater disadvantage. Additionally, J.C. Dwyer writes

in a report for the New York City Coalition Against Hunger, “FRAC’s ‘culture of scarcity’ or

‘hoarding’ hypothesis makes sense; as Harlem dietician Cathy Nonas notes, “When you have

food insecurity, you are not going to buy lettuce that costs $1.29 a pound and might go bad. You

are going to buy a liter of Coke and a bag of chips” (Dwyer, 2005, p.10).

These key insights demonstrate how parents or mothers are interwoven into the American

culture and psyche surrounding food, and that being part of a low-income demographic

exacerbates the situation.

Mothers and the psychological relationship with food. “There is a substantial body of

research demonstrating that external factors can influence people’s food consumption and

behaviors. For example, a robust influence on people’s eating behavior is the presence and

behavior of others. People model the intake level of their eating partners, eating as much as, or as

little as, their eating partner. Modeling of food intake occurs even under conditions of extreme

hunger or fullness” (Vartanian, Herman, & Wansink, 2008, p 533).

Research has shown that individuals develop a relationship with food, from both a

physical and psychological standpoint and that this influence stems from their primary caregiver,

in most cases, the child’s mother. A physical relationship to food develops while in utero, as the

fetus receives nutrients directly from the mother. Therefore, the nutrient intake of mothers, while

39


pregnant, plays a large role in the predisposition of their child’s health as an infant. When

examining the importance of prenatal health as it is related to obesity there is no question that the

nutrition a fetus receives during this stage of development will affect their ability to maintain

their own health through their childhood, adolescence and adulthood. There is extensive research

to support this statement. The impact of nutrition on later outcomes begins in utero. Malnutrition

in the third trimester of pregnancy, for example, research has shown that there is a relationship

between low birth weight and other negative birth outcomes. Damage to genetic potential also

can begin with fetal malnutrition, which is a reflection of the mother’s nutritional status and

health (Dubois, 2006, p. 145).

Psychological conditions associated with obesity are developed after birth and throughout

childhood. Physiotherapist, Kathy Leach, stated in her book, The Overweight Patient: A

Psychological Approach to Understanding and Working with Obesity:

The potential for the misuse and misunderstanding of the primary function of food begins

as life begins at birth and continues in the subsequent months when holding and bonding

between caretaker (usually mother) and infant are experienced significantly at meal times

(Leach, 2006, p. 13).

Additionally, the mother and child relationship and its effects on food behaviors can be inferred

from insights gleaned from looking at the connection between children and their philosophy of

self-management as determined by a parental relationship. To support this, Linda Kosa-Postl

writes in “Stay Smart: Lost Weight: Childhood Obesity and Health Education”, an article

published in Forum on Public Policy: A Journal of the Oxford Round Table:

As adults, the assumption is produced that they have gained the knowledge to make

choices shaped by organization of intelligence and environmental stimuli. Children, on

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the other hand, rely on a dominant individual(s) to influence their thought process to

make good judgments. Albeit, their capacity to control their surroundings is reflected on

partially understood needs and emotions. The interjection of bias only leads to more

confusion and lack of consequential forecasting. Within the framework of a child's mind,

the philosophy of self-management and personal direction over health is minimized by

cognitive progress in age related mental processes. Therefore, children trust their parents,

guardians and teachers to lead them in a direction that enhances self-esteem, maintains

beliefs in personal efficacy, and promotes an optimistic view of the future (2006,

Mind/Body Connection, paragraph 2).

The author continues to elaborate on the connection between the mother’s effect on a child’s

relationship with food and food behaviors. When these individuals are living in a low-income

urban area, this connection can lead to a relationship where food behaviors develop into obesity:

Although parents may be aware of their child's weight status, many are not willing to

publicly recognize or label their child as overweight. Parents do not define obesity by

where a child fits on the growth chart. The vast majority of them consider overweight a

cosmetic issue, not a health issue. The language used around conversations with parents

or guardians can be simplified through nutrition education. Families serve as an

important role model and as powerful reinforcers of the knowledge and behavior children

learn in school. Raising awareness of health risks and motivating appropriate action is a

delicate proposal and one needs to tread lightly to assure provocative discrimination does

not take place (Kosa-Postl, 2006, Introduction, paragraph 5).

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This connection between the role that parents and families serve in shaping food behaviors of

children supports the need for implementation of nutrition education in order to thwart the

chances of obesity among growing children.

Environmental Analysis

In this environmental analysis examined multiple factors that ultimately relate to how we

define the environmental aspects of our final design solution. We include here, food access and

location in East Harlem, an overview of the retail food industry in the neighborhood, the

restaurant choices available, and alternative access models currently in place. In this

environmental analysis the link between these environmental factors frame the focus and

decisions we made for our final design solution.

Food access and location in East Harlem. Given the lack of access to nutritious food,

urban setting, demographics, and socio-economic factors of East Harlem, it is a prime example

of a food swamp. Furthermore, research indicates that limited access to healthy food, specifically

fresh produce, is a source of frustration for residents of East Harlem. According to a report

published in April of 2008 by the New York City Department of City Planning, East Harlem is

an area of the city with the highest levels of diet-related diseases due to limited opportunities for

citizens to purchase fresh foods. Citizens of East Harlem are likely to buy food from stores that

have a limited supply of fruits and vegetables, which are often poor quality and generally more

expensive than the same products sold at supermarkets in other neighborhoods of Manhattan.

Without access to affordable, fresh produce, East Harlem residents will continue to have

difficulty eating a healthy diet, contributing to the neighborhood's already high rates of obesity

and diabetes (Morland, K., Roux, A., & Wing, S., 2012).

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East Harlem’s status as a food swamp and the disparity between obesity rates in East

Harlem and Manhattan, led us to examine the connection between fresh food/produce access and

obesity in East Harlem. As Peter Pringle wrote in A Place at the Table, “In New York’s East

Harlem neighborhood, four out of every ten residents surveyed did not follow the recommended

dietary guidelines because the necessary foods were less available and more expensive in their

neighborhood stores” (2013, p. 52). We began by exploring food accessibility in East Harlem

compared to the neighborhood of the Upper East Side, a section of Manhattan that borders East

Harlem along 96th Street from Central Park to the East River. Although East Harlem and the

Upper East Side are neighboring communities, the socioeconomic status of their residents are

drastically different which directly correlates to the food availability and quality for both

communities.

East Harlem food industry. A 2007 Department of Health Report entitled “Eating Well

in Harlem: How Available is Healthy Food?” compared food store distribution and classification

between East Harlem and a selection of stores on the Upper East Side. The methodology of this

study included a block-by-block investigation of food retail stores in the neighborhood of East

Harlem and a sample of Upper East Side food retail locations selected to reflect land use

distribution similar to East Harlem. Food retail stores in this study were grouped into categories:

small grocery stores, commonly known as bodegas, Supermarkets (chains and independently-

owned), Specialty stores (for example, bakeries and meat markets), Gas station convenience

stores and Drugstores (chains and independently-owned). Food retail locations exclusive to the

Upper East Side, such as full-scale delis with salad bars, were excluded from the findings.

The first area of access inequality reported in this study exists within the number and

classification of food retail locations in each community. Bodegas in East Harlem offer

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convenient hours and locations, however the product selections have historically been limited to

preserved and non-perishable goods, and offer a limited selection compared to supermarkets and

grocery stores. While most supermarkets carry a wide selection of dairy, only three in ten

bodegas in East Harlem carry low fat milk, compared with six of ten bodegas on the Upper East

Side. In addition, 20 percent of Upper East Side bodegas offer leafy greens, compared to only

three percent of East Harlem bodegas. Advocates at the Food Research and Action Center in

Washington, D.C. explain in a paper published in 2004 that consumers’ food purchasing

decisions are based on a trade-off between short-term survival and long-term health. In an article

published by the New York City Coalition Against Hunger, J.C. Dwyer contends that similar

trade-offs exist within choices made by the retailers in the East Harlem neighborhood:

FRAC’s hypotheses explain consumer behaviors and choices – but the same logic could

be applied to sellers. It makes “market” sense for a store owner in a low-income

neighborhood to sell low-quality, processed food for the same reasons it makes sense to

buy this food – it lasts a long time, is cheaper to stock, and offers a high return (whether

this is measured in calories or profits) for a low-risk investment. From this perspective,

the local market for food is driven not by personal tastes, but by poverty (2005, p. 11).

Food retail in East Harlem vs. the Upper East Side neighborhood. There are

substantially more bodegas and fewer supermarkets in East Harlem compared with the Upper

East Side, with bodegas accounting for approximately 66.2 percent of food stores in East

Harlem, compared with 33.1 percent of the food stores surveyed on the Upper East Side. An

equally striking fact, the entirety of East Harlem has only 21 supermarkets, when compared with

26 supermarkets located within only the sample (83 block) area of the Upper East Side. The

sample location surveyed within the Upper East Side also had more specialty stores (meat and

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fish markets, mobile vendors, and bakeries), 48 stores as compared to only 34 in the entirety of

East Harlem (See Appendix Q).

The 2007 Department of Health report mentioned above, indicates that supermarkets

provide the greatest choice and selection of healthy foods, but are not as equally dispersed

throughout Harlem as they are on the Upper East Side. Statistics from the study assert there are

three supermarkets per 10,000 people on the Upper East Side compared to only two

supermarkets per 10,000 people in East and Central Harlem combined (See Appendix R).

Restaurant choices in East Harlem. The second area of food inequity involves restaurant

and fast food dining choices. Despite the fact that both neighborhoods have an abundance of

restaurants, the type of food served is radically different. Defined in the Department of Health’s

Eating Well In Harlem report as national or local chains with no wait staff, fast-food restaurants

are the predominant restaurant option in East Harlem. The report indicates that of the 177

restaurants in East Harlem, 15 percent are fast-food restaurants, while only four percent of the

184 restaurants in the survey area of the Upper East Side are fast-food restaurants. Overall, East

and Central Harlem have 24 fast-food establishments per 100,000 residents compared with the

Upper East Side’s eight fast-food restaurants per 100,000 residents (New York City Department

of Health and Mental Hygiene, 2007).

New food access models. Initial research directly linked the rates of obesity in East

Harlem and lack of access to fresh produce. Research and statistics have pointed to the lack of

access to nutritious foods, including fresh fruit and vegetables, as the main reasoning behind East

Harlem’s increasing rates of obesity. However, upon further research we identified three new

food distribution models attempting to reverse the problem of food access plaguing the

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neighborhood of East Harlem. These new models have shortened the distribution cycle from

farmer to consumer, challenging our research regarding access to fresh, healthy food options.

Farmer’s markets. Grow NYC, a non-profit program, has initiated Greenmarket

Farmers’ Markets across Manhattan and Brooklyn. A 2012 report by State Comptroller Thomas

DiNapoli reports farmers’ markets are growing both statewide and across the boroughs of New

York City. Manhattan alone has 39 farmers’ markets, however only two of these markets are

located in East Harlem (Norberg-Hodge, Merrifield, & Gorelick, 2002). Furthermore, the

seasonality and hours of these markets differ from those in other parts of Manhattan. For

example, the 82nd Street St. Stephen’s Greenmarket on the Upper East Side (82nd street,

between 1st and York Avenues) is open Saturdays, year round between 9am and 2:30pm.

Perhaps the largest Greenmarket in Manhattan, Union Square Greenmarket operates 8am to 6pm,

Mondays, Wednesdays, Fridays and Saturdays, year round.

However, the Greenmarket serving East Harlem, Mt. Sinai Greenmarket at East 99th

Street between Madison and Park Avenues, functions under a different structure. Despite similar

hours 8am to 4pm, this market is only open on Wednesdays five months of the year from June

through November. The second farmers market serving East Harlem, Harvest Home, located on

104th street at 3rd Avenue is only open four months of the year, operating on Thursdays from

8am to 4pm. Given this data, we are left to conclude that either the farm markets have been

deemed unsuccessful, and do not warrant year round access by East Harlem residents, or they

simply do not choose to offer a continuation of their services to these patrons throughout the

winter months (See Appendix S).

Veggie Van. In New York City, Manhattan Borough President, Scott Stringer, is

attempting to lead a progressive food policy. Through the city’s existing Go Green initiative, he

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instituted the Veggie Van Project. This initiative is slated to address the issue of accessibility in

low-income urban areas, specifically East Harlem. The project is designed to increase access to

fresh fruits and vegetables for seniors, the disabled, and Harlem residents who have difficulty

shopping at a supermarket, green grocer or farmers market due to lack of transportation. The

Veggie Van will travel to senior citizen centers, nursing homes and public housing sites. A NYC

licensed fruit and vegetable vendor will be selected to operate the Veggie Van and sell organic

and locally grown fruits and vegetables, and the operator will accept EBT, cash, credit card and

debit payment to ensure accessibility for all consumers (2012). The Veggie Van Project was

announced in 2011, however as of March 2013 no new information has been given regarding the

project. We are left to conclude that this initiative has either fallen through, or is not yet up and

running.

Green Carts. An initiative of the Mayor’s office, Green Carts are located within

designated areas of all five New York City boroughs. The New York City Green Cart initiative

offers similar selection as farmers markets on a smaller scale, and with year round accessibility.

Founded by a grant from the Laurie M. Tisch Illumination Fund in 2008, through the Green Cart

Initiative, the New York City Council and Mayor Bloomberg authorized 1,000 new street

vending permits to enable entrepreneurs to sell fresh fruits and vegetables exclusively in low-

income neighborhoods where consumption of fresh produce is low and rates of obesity, diabetes

and heart disease are high (LMT Illumination Fund, 2013). New York City’s official website

describes Green Carts as mobile food carts that offer fresh produce in certain neighborhoods

throughout the city. Since the program’s start in 2008, nearly 500 vendors have opened Green

Carts in City neighborhoods; helping many New Yorkers buy fresh fruits and vegetables close to

home (2013).

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Economic Analysis

Our economic analysis investigates multiple factors that ultimately relate to how we

define economic and socioeconomic aspects of our final design solution. “The economic costs of

obesity may be divided into two classes: direct costs, those costs to the healthcare system

resulting from the disorders caused by obesity, and indirect costs, those costs to the individual or

the community such as days lost from work, lost income, etc.” (Price & Pecjak, 2003, p. 6).

Socioeconomic statistics of East Harlem. Reported in 2009, there is a large difference

in annual median income between East Harlem ($27, 604) and New York City ($50,033) as a

whole (City-Data.com, 2011). Based on this data, it is no surprise that the number of people

living in poverty in East Harlem (39%) is equal to more than twice that of the city as a whole.

Further data that supports the conditions of high poverty in East Harlem is that almost half of

adults in East Harlem are unemployed (47%) and approximately 23% of households in East

Harlem are headed by single mothers (Andrew Glover Youth Program, n.d.). Additionally, 30

percent of the population of East Harlem resides in government-funded public housing (New

York City Department of Health and Mental Hygiene, 2006).

Education plays an important role in income, as median income increases with higher

levels of education. According to the East Harlem Neighborhood Health Plan published by the

New York City Department of Health and Mental Hygiene in 2000, more than half of the adults

in East Harlem are without a high school diploma (51% vs. 32%). Additionally, only 54 percent

of high school students complete the high school program and graduate (Andrew Glover Youth

Program, n.d.).

Economic status causal to food behaviors. Many factors contribute to an individual’s

overall diet, body weight, and the risk of developing diet-related diseases, such as diabetes or

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cardiovascular disease. Individual factors can explain some but not all of the differences in the

rates in which different population groups experience these problems. Focus on food access has

increased as researchers try to better understand the factors besides individual behaviors that may

lead to differences in diet and health outcomes (Diez-Roux, 2009). As previously mentioned, the

issue of food swamps and food access affects the food behaviors of an individual among the

community, and of the community itself, and the socioeconomic status of those people

determines in part, what types of foods they can afford to purchase and consume. A recent paper

published in the International Journal of Epidemiology examines observational studies that found

an increased prevalence of obesity and the consumption of a poor diet to be associated

specifically with those living in low-income neighborhoods (Cummins & Macintyre, 2005).

Particularly among women, there is a correlation between food behaviors and

socioeconomic status. Aside from all other factors impacting on obesity, the lack of money to

purchase foods that are not energy dense is a major barrier for people who are poor, particularly

women. It is possible that continuing to inform people of low income about the importance of a

healthy diet leads to additional stress as they do not possess the resources to purchase what they

know are healthier foods (Thomas, 2006).

Interest in the relationship of food access to diet and health is also rooted in a substantial

body of literature that shows disparities in many health outcomes across race, ethnicity, and

socioeconomic status (Institute of Medicine, 2003; National Research Council, 2004). It is

hypothesized that differences in food access across race, ethnicity, and socioeconomic status may

contribute to or reinforce these health disparities (Diez-Roux, 2009).

Economic status causal to health status. There is a strong correlation between one’s

socioeconomic status and health. According to researchers, socioeconomic status has strong

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influence in the issues of health and access to health care. The percentage of heart disease, type

two diabetes, rheumatoid arthritis, certain types of cancer, and premature aging is higher in East

Harlem than New York City as a whole, according to Community Health Profiles conducted by

New York Government. In the year 2002 and 2004, the rate of uninsured individuals has more

than doubled in East Harlem. Health insurance is important for access to health care, and

preventative treatment. The lack of health insurance in this community is a serious indication of

the continued prevalence of conditions such as heart disease, and type-two diabetes (New York

City Department of Health and Mental Hygiene, 2006).

Early, or young deaths include individuals under 75 years of age. Cancer related deaths

account for the majority of early deaths in Manhattan, while in the same age bracket; Heart

Disease is the number one reason for early death in the neighborhood of East Harlem. Factors

that increase the risk for Heart Disease include high blood pressure and high cholesterol, both of

which are linked to poor diet and both of which are reported at high rates in East Harlem.

Diabetes, another health condition related to diet, is present in 13 percent of adults in East

Harlem compared to only 7 percent of those in Manhattan. Of the 13 percent of those suffering

with diabetes in East Harlem, the majorities are obese (18 percent) compared with 11 percent

who are not obese (New York City Department of Health and Mental Hygiene, 2006). The

correlation between diet and health is highly visible through these statistics. Overweight and

obese individuals are at a higher risk for a multitude of conditions in addition to those mentioned

above. Health concerns associated with obesity not only take a toll on the individual and their

family, but also strain the resources of the community and the city as a whole, including public

health resources and subsidized health care.

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Economic status causal to mental health status. Another popular theory of etiology

focuses on psychological factors. Stressful life events have long-term effects on physical health,

many causing either overeating or undereating. Frequently, people report eating in response to

negative emotions such as boredom, sadness, anxiety and anger, though most overweight people

do not have more psychological problems than people of normal weight. “Clinical psychologists

and psychiatrists are often visited by obese women with psychological problems, especially

depression and low self-esteem” (Price & Pecjak, 2003, p. 6). According to this theory, people

are drawn to eat by the pleasure of eating (food's positive incentive values), and are repelled by

food's negative incentive values. “People normally develop their likes and dislikes through the

interactions of their genetic program and their experience” (Price & Pecjak, 2003, p. 6).

Primary Research

The primary research in this section was collected during the month of February 2013 in

East Harlem at both East Harlem Block Nursery #1 (EHBN1) and neighborhood food retail

locations. Our primary research was conducted in three phases. The first phase included

interviews with parents whose children attend EHBN1. Additional information was collected in

the form of surveys, and findings were refined in phase two, which included interviews with the

Director and Head Cook at EHBN1. Finally, in phase three, a retail survey of food stores was

conducted in the neighborhood surrounding EHBN1. This survey further supports and refines

both our primary and secondary research findings.

Results: East Harlem Block Nursery #1 Parent Interviews

The neighborhood of East Harlem in the borough of Manhattan was identified as an

initial site for primary research. As mentioned, East Harlem has historically been home to a large

concentration of both African American and Hispanic/Latino populations. The neighborhood of

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East Harlem, also referred to as Spanish Harlem, is a culturally diverse location, but it also

suffers from high levels of unemployment, crime, and obesity. One third of East Harlem’s

population is overweight and another third is obese. (Olson, Van Wye, Thorpe, & Frieden, 2006)

East Harlem Block Nursery #1 (EHBN1), is a non profit, bilingual, community preschool

that accepts children between two and five years old from low income families. Located on East

106th street and Third Avenue, the preschool provides nutrition and social services as well as

early childhood education (Substance Abuse and Mental Health Services Administration & New

York City Department of Health and Mental Hygiene, 2012).

Interview methodology. Twelve women and one man (n=13) participated in the first

round of interviews at EHBN1. Interviews were conducted on Friday, February 15, 2013 with

individuals as they came into the preschool to pick up their children. Respondents were asked a

series of twenty-three questions pertaining to food. The first half of the interview included a

series of background questions including age, marital status, number of children, and work

hours. In the second half of the interview, subjects were asked about their food shopping, food

consumption, and cooking habits (See Appendix T and V).

Background of respondents. With an average age of 31, three respondents had lived in

East Harlem their entire life. These three people were part of an overall trend with 41 percent (5)

of respondents having lived in East Harlem for more than half their lives. Based on this

information, we concluded that there is not the same type of residential migration in East Harlem

as in other parts of Manhattan. Our findings were further supported in speaking with the Director

of EHBN, who confirmed that many of the preschool’s parents had attended EHBN as children

themselves.

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85 percent (11) of respondents were employed and worked an average of 32 hours per

week. Employment was heavily swayed towards the healthcare industry, with four people

working in medical billing, pharmacy, occupational therapy, and home health aid. The remaining

(7) workers were equally dispersed between the categories of janitorial/cleaning, and security,

with one person doing factory work and one in a government job.

All respondents were the primary caregivers to at least one child, and 70 percent (9) were

single parents. 100 percent (13) of those interviewed had at least one child less than five years of

age. An interesting finding from the interviews was the number of parents with only one child.

This could be explained by the age of the parents. Five of the eight parents interviewed who had

only one child were under 30 years old.

Current food program participation of respondents. Respondents were asked if they

had participated in any food programs. Food program choices included CSA, Greenmarkets/

Green market Co, Green Carts, SNAP, WIC, Student Lunch Program, and TANF. Parents were

generally unfamiliar with the choices of CSA, Greenmarkets/ Greenmarket Co, and Green Carts.

However, 69 percent had participated in a form of government issued food program. Six families

participated in both WIC and SNAP, one family participated in WIC, SNAP, and the Student

Lunch Program, one family in only the Student Lunch Program, and one family in only WIC.

Food consumption habits of respondents. When asked if their families ate healthy on a

regular basis, respondents overwhelmingly said yes, at 70 percent (9). However, “healthy” can

mean different things to different people. Prior to asking this question, respondents were shown a

picture page featuring different types of food with corresponding numbers and asked to select

which they believed were healthy (See Appendix U). They could select more than one image.

The pictures of Light ‘n Fit strawberry yogurt, salad with grilled chicken, and orange juice

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received the most votes for healthy items. However, votes were also given to Horizon organic

strawberry milk, the Healthy Choice sesame chicken frozen meal, macaroni and cheese,

submarine sandwich, sports drinks, and Natures Path buckwheat frozen waffles. This suggests

some confusion on the part of consumers as to which foods are truly healthy for their families.

Cooking habits of respondents. The parents interviewed were asked to identify the

types of foods they cooked at home for their families, and how often they cooked. 40 percent (5)

listed vegetables as a food they regularly cook at home, followed by rice at 31 percent (3),

Spanish food at 23 percent (2), and pasta, meat/steak, fish/salmon, and chicken tied at 15 percent

(2). On average, respondents said they cooked five and a half times per week, and 54 percent (6)

cooked seven days a week. Reasons for cooking at home varied, but most respondents equated

cooking at home to health, caring for their children, and avoiding fast food. Those who cooked at

home only three days a week cited lack of time, and being tired as reasons that prevented them

from cooking.

As a follow up question, respondents were also asked what they enjoyed most about

cooking at home. Over half of the respondents’ cited “spending time together”, 46 percent (5)

said “cooking for my family is a way to show them I love them”, while 38 percent (4) enjoyed

trying new recipes.

Food shopping habits of respondents. The responses regarding food shopping were

some of the most interesting. In the past, East Harlem had been identified as a food desert, but

through our research we found that general food availability was not a major concern.

Respondents were asked, “How many food stores (grocery, deli, corner market) are located in

their neighborhood?” Seven of thirteen surveyed answered five or more, with an average of four

supermarkets or food retail locations within walking distance of their homes. The most popular

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shopping locations were supermarkets with 100 percent of respondents claiming them as their

main shopping choice. Three also chose grocery stores as an additional source of food retail and

one respondent chose restaurants.

Parents were then asked to list the names of the food retail locations they frequent the

most often. Pioneer Supermarket was listed by 38 percent of respondents. Pioneer is a franchise

chain of markets operating in the New York metropolitan area, and each store is independently

owned. The Pioneer name is trademarked by White Rose Inc., a local food brand that offers low

priced foods in the categories of grocery, frozen food and dairy (Pioneer Supermarkets, 2013).

Other markets that were mentioned included Mauricio’s Marketplace, a licensee of the

New Jersey based Foodtown franchise (since our interviews, this store has become a

Metropolitan City Market); Met Foodmarkets, a franchise trademarked by White Rose Inc. and

independently operated throughout the New York metro area; Fine Fare; and Pathmark. National

chains like Target, Costco and Aldi were also mentioned.

Despite the number of food retail locations mentioned by respondents, 64 percent said

they were unsatisfied with the food choices in their neighborhood. Therefore, satisfaction did

equate to the number of food retail locations or number of restaurants. Rather, respondents stated

they were unsatisfied due to too much fast food and unhealthy foods, and high prices. The major

points of dissatisfaction were the lack of options and fresh, high quality fruit and vegetables.

East Harlem Block Nursery #1: Staff Interviews

Following our first round of primary data collection, we returned to East Harlem Block

Nursery #1 (EHBN1) at 106th Street and 3rd Avenue to interview the pre-school’s Director and

Head Cook.. The Director, Tammie, who is in charge of supervising the staff, budget and

recruitment of both children and staff, has been working in early childhood education for 20

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years. Her position as director at EHBN1 began in August 2012. The pre-school’s Head Cook,

Lily has a 26 year career working at EHBN1. As the Head Cook, she works within a budget to

purchase food, plan meals, cook and create food production forms that include nutritional

information about her meal plans (See Appendix W).

Interview methodology. This interview was conducted to learn about the structure of

EHBN1, its internal operational procedures, and to gain insight into the organization. On March

7, 2013, interviews were conducted separately with both the Director and Head Cook. The Head

Cook was interviewed with the Director present. A series of 31 questions were asked to the

Director. These included the subcategories of Job Title and Description, About EHBN1, How

EHBN1 Runs, About the Students, About the Parents, Food, and Future Plans. The Head Cook

was asked a series of 24 questions including subcategories of Job Title and Description, Work,

and Food. Two questions were asked to both the Director and Head Cook, in order to compare

and contrast their answers.

Structure of EHBN1. A government-funded and facilitated low income preschool, East

Harlem Block Nursery’s objective and mission is to promote child-centered learning, prepare

children for public school, and work with families to build stronger home life and educational

opportunities. There are three Block Nurseries located throughout the neighborhood of East

Harlem (EHBN1, EHBN2, EHBN3) and each serves the community in their own unique way,

while still falling under the guidelines and funding of the Administration for Children’s Services

(ACS). EHBN1 has served the community for 48 years in its current location on 106th street and

3rd Avenue. Due to nursery’s longevity in the community, parents who once attended as

students now bring their children to the program. EHBN1 has therefore educated an entire

generation and is ingrained in fabric of the community.

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All East Harlem Block Nurseries fall under the governance of the New York City

Administration for Children’s Services (ACS). Funding for the Block Nurseries is provided

through ACS, however currently only EHBN1 and EHBN3 are funded through ACS, while

EHBN 2 is funded through discretionary funds from the New York City Council because

guidelines and contract set forth by ACS were not met and as a result, funding to the nursery

through ACS was cut.

Organizational operations of EHBN1. In addition to the guidelines and contract set

forth by ACS, EHBN1 is also governed by their Board Members, the Department of Health, and

the Department of Education. The director, Tammie, is responsible for decision making on site,

while the Board have the responsibility for overall day-to-day decision making. As mentioned

previously, ACS provides overall guidelines and regulations for running all three Block

Nurseries.

Within the nursery’s internal structure, there are currently 14 staff members including the

Director (Tammie), The Head Cook (Lily), Cook’s Assistant, Parent Coordinator, Teachers and

Teachers Aids, and Custodians. While the Department of Health has authorized the preschool to

hold up to 47 students, they currently have a roster of 45 students between the ages of two and

five. The preschool’s curriculum is a holistic approach to learning, and the children learn through

play, music, movement, and games; focused around language skills, interaction, and pre math

skills. The base of the curriculum is built around New York State standards for pre-kindergarten

learning, and aims to have the children prepared for entering public education.

Due to EHBN1’s affiliation with New York State and City government, there are both

work and income requirements related to the program. If a child’s parent is working (full or part

time), and they fall within the income guidelines, they are enrolled to the program directly

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through ACS. However, if the child’s parent is attending an educational institution or work

training program, they are enrolled through the Human Resources Administration (HRA).

Children of parents who are neither working nor pursuing education are not eligible for any of

the East Harlem Block Nurseries, and parents must maintain their work or educational status to

continue within the program. The nursery's Parent Coordinator serves as a liaison, and works

with parents to find educational opportunities and provides in home follow up. Because EHBN is

a low-income preschool, the tuition is based on a sliding scale, and parents pay between $5.00

and $250.00 per week depending on their income and the number of children they have.

Parents of children attending EHBN1. Due to the work/school requirement of the

EHBN1 program, parents are busy and both the Director and staff have a hard time getting them

involved in the school’s programs and the Parent Committee. Parents share the goals of EHBN;

assuring their children are well prepared for kindergarten. However, as with many preschool

programs, some parents see the program as child care rather than a school. Therefore, they feel

more detached and are less involved in the program’s structure and curriculum. For example,

EHBN1 had a parent/child after school music program, however due to a lack of parent

participation and budget issues the program was discontinued. Lack of funding is often a hurdle

for the school. For example, the nursery has limited computer access, and there is no functional

website. They are working on funding computers for the children to use, but in the meantime

information from school to parents is presented through letters, bulletin board postings and word

of mouth.

Food program operation. There are three different roles the Head Cook plays in running

the food program at EHBN1. Lily monitors a food budget, creates food production forms which

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track the details of what is bought and served on a monthly basis for approval by ACS, and

purchases, cooks and serves food to the children.

Lily’s food budget is dictated by ACS, and EHBN1’s Board and allocated by the

bookkeeper. The Director, Tammie, signs off on the budget and each year it is reported to Board

Chair. ACS’s involvement is crucial in EHBN’s funding. The school must serve the nutritional

components required by ACS. If they do not meet ACS requirements, they will not be

reimbursed for their food purchases. Food production forms are part of the contract between

EHBN1 and the Administration for Children’s Services (ACS) and are submitted on a weekly

basis by Lily (See Appendix X and Y).

The students at EHBN1 are provided three meals a day, a morning snack, lunch and

supper. The Head Cook plans these meals herself and orders food accordingly, once every two

weeks, from local food distributor, Trooper Foods. ACS only authorizes food orders from certain

vendors. They are Trooper Foods, Victory and Drisco. EHBN1 has chosen to work exclusively

with Troopers Foods as their main vendor. Over the years, Lily has built a good relationship with

the company. She trusts the vendor to provide fresh, good quality food and provides feedback to

the company when she is dissatisfied with the products she has received. In the past, Trooper

Foods has also donated food to the school allowing Lily to provide food assistance to parents and

students in need.

In addition to her duties as Head Cook, Lily takes the most pride in feeding the children

good food, getting nutrition into them, and sending them home with a full belly. She puts special

effort into providing nutritional meals, and making sure the children eat as she doesn’t know

what type of food her students receive at home. This is where food donations and food overages

become an important part of her work. On Fridays, she is sure to send the children home with a

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fully belly and a snack, because she will not be there to feed them over the weekend. She often

sends home food donations with the parents as well.

Current food initiatives at EHBN1. EHBN1’s food program follows both the ACS and

Child and Adult Care Food Program‘s (CACFP) regulations. There are annual CACFP training

sessions that provide updated nutrition requirements and regulations on the types of food that can

be served at EHBN1. Some recent CACFP requirements, and changes to food service at all

EHBN’s included the elimination of all peanut products (allergy concerns), the elimination of all

trans fats, and a recent push to eliminate gluten. All staff members are required to attend these

annual training sessions, and the Head Cook, Lily, attends additional sessions every three

months.

The EHBN curriculum is hands on, which extends to the kitchen. Teachers are

encouraged to do cooking projects with their students, and the children have made cookies,

jellos, tacos and waffles in their classroom with the teacher and Lily’s help in the kitchen. Lily

mentioned that the children enjoy what she serves and are opened to trying new meals. When

there is the occasional small class size, she will bring the kids into the kitchen and test run new

recipes with them to get their opinions. Often, during meal times she will come into classroom to

see how the students are enjoying the meal. This helps her gauge reaction to new recipes, and

know when to not re-order a product.

The school doesn’t have a specific time for communication with parents regarding meal

plans, dietary restrictions, or other food related concerns. However, sometimes parents will come

to Lily to ask for recipes she served, that their child enjoyed. Due to her schedule, and the

parent’s schedule it is hard to give information tailored to each parent's needs regarding nutrition

and planning balanced meals.

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In 2012, EHBN1 participated in the Department of Health’s “Eat Well, Play Hard”

program. The program focused on food choices, portion control, and provided cooking lessons to

the kids. EHBN plans to participate in this program again in 2014. As part of the ACS “Early

Learning Contract” the preschool is encouraged to foster community partnerships, like the “Eat

Well, Play Hard” program, including physical health and wellness, mental wellness, education,

music, and arts programs.

Food access concerns. In our interviews, we asked the same question to both the

Director and Head Cook independently: “What is the main food issue your students and parents

face?” Both women responded in the same manner. They expressed their frustration and the

parents’ frustration with the lack of fresh fruits and vegetables available in the neighborhood.

They discussed the fact that local supermarkets do not provide produce at reasonable prices and

that both quality and selection need improvement. When we asked about existing food programs

like farmers markets, Greenmarkets, Green Carts, and others currently doing business in East

Harlem, they said the Greenmarket, farmers market, and Green Carts do not satisfy the demand

for fresh produce because they offer poor quality produce at a high price.

Focus was also placed on government subsidized WIC and SNAP programs which

support low-income families, and on which many families in East Harlem rely. While these

programs provide much needed food assistance, they do not support the purchase of healthy

fresh produce due to price. With a limited amount of money to spend, SNAP recipients will

purchase foods that give them the most caloric intake for their dollar. There has also been a lot of

fraud associated with SNAP because bodegas accept food assistance money for items that are not

allowed by the program. Many bodegas have been shut down as a result. Additionally, many

stores have increased the price of products that fall under WIC assistance, such as eggs, fortified

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cereal, milk, cheese, and dried beans knowing that the government will pay the full amount. This

however inflates the prices for non-WIC customers who want to buy the same foods.

Both women expressed concern about the number of fast food restaurants in the

neighborhood and their appeal to children. With a McDonalds, Dunkin’ Donuts, Popeyes, and

Burger King along their walk to school, the children are constantly influenced by fast food

advertising and marketing. As was mentioned earlier, the Head Cook, Lily places emphasis on

providing healthy food to the students, because she does not know what they eat away from the

school. In her 26 years at EHBN, she has watched the neighborhood become inundated with fast

food, and has seen obesity, especially in children, get progressively worse. She and Tammie both

see a direct correlation between obesity and the lack of fresh, quality, well-priced produce, and

continued presence of fast food in the neighborhood of East Harlem.

East Harlem Retail Survey

Based on the findings from our interviews with the parents, and Director and Head Cook

at East Harlem Block Nursery #1, we concluded that access to fresh, healthy, high quality

produce is the main challenge facing the families of EHBN1 and the community as a whole. As a

supplement to our findings, a retail survey was conducted in the neighborhood surrounding our

case study school, East Harlem Block Nursery #1.

Survey methodology. Three East Harlem supermarket food retail locations were selected

for the survey based on responses from interviews of EHBN1 parents. These supermarkets

included Mauricio’s Marketplace (which had become a Metropolitan City Market, at the time of

the survey) at 2076 1st Avenue near 108th Street, Pioneer Supermarket at 235 E. 106th Street

between 2nd and 3rd Avenues, and Fine Fare Supermarket at 1891 3rd Avenue and 105th Street.

Additionally, one supermarket was selected in the bordering neighborhood of the Upper East

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Side; Food Emporium at 1175 3rd Ave. between 68th and 69th streets. Food Emporium was

selected as a comparable retailer to obtain a better sense of the reality of shopping condition in

East Harlem. This in person survey was necessary to confirm the validity of the primary and

secondary data and also, more importantly, to identify if there are any gaps between what people

in East Harlem perceive as a problem in terms of food accessibility and the real food shopping

condition they are facing. It was important for us to diagnose the psychological barrier as well as

the actual barrier of food accessibility in order to deliver the right solution to this neighborhood.

Supermarkets were surveyed for two dairy items (low fat milk and low fat yogurt) two

fruit items (bananas and Gala apples) and two vegetable items (broccoli and iceberg lettuce).

Dairy was included in the survey to reflect the secondary data collected on the number of

bodegas and supermarkets in East Harlem that carry low fat dairy items. Price was collected for

each category, and quality/freshness was gauged for each. An identical survey procedure was

conducted at each of the four supermarkets included in the survey.

Additionally, four randomly selected bodegas were surveyed within a five-block radius of

EHBN1. These bodegas were surveyed for one product specifically mentioned within our

secondary research; low fat milk. The intention of the bodega survey was to compare bodegas

and supermarkets in the neighborhood. However, the lack of fresh fruit and vegetables at the

bodegas surveyed, left lowfat milk as the only comparable item. Therefore, the information

gathered for low fat milk is on a price basis alone, and eggs were included in the survey as a

staple food item sold by bodegas.

Food Shopping in East Harlem vs. Upper East Side. As previously mentioned, low-fat

milk, low-fat yogurt, bananas, Gala apples, broccoli and Iceberg lettuce were the items chosen to

compare the price and quality of retail stores in East Harlem and Upper East Side. As expected,

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the prices did not differ dramatically among the supermarkets in East Harlem, however, the

prices among bodegas varied. While all three supermarkets surveyed in East Harlem had both

low-fat milk and low fat yogurt as well as the four fruit and vegetable categories, all four

bodegas surveyed lacked fresh fruit, vegetables or low fat yogurt. Three of four bodegas visited

had low-fat milk, however the milk was not visibly labeled with price. In the stores where prices

were not marked, the prices were quoted at the whim of the cashier and ranged from $3.99 to

$4.50 per gallon. With the a gallon of low fat milk coming in at $3.89 at all three supermarkets,

one bodega owner, not included in the survey, quoted an exorbitant $10.00 for a gallon of milk

without a visible price tag.

Prices for the two dairy categories, low fat milk and yogurt held relatively steady in each

of the three supermarkets surveyed in East Harlem, however the same could not be said for the

fruit and vegetable categories which varied only slightly. Banana’s ranged between $0.59/lb to

$0.75/lb, Gala apples ranged between $1.69/lb at two locations and $1.89/lb. Vegetables

fluctuated slightly more, with broccoli between $1.89/bunch and $2.69/bunch and Iceberg lettuce

between $0.99/head and $1.49/head.

Unlike the price similarities in East Harlem, the Food Emporium supermarket on the

Upper East Side had major differences in price, but with drastic improvements in quality,

freshness and retail layout. Following the same categories and contrasting them against the

highest recorded prices in East Harlem; a gallon of low fat milk at Food Emporium was $1.01

higher, while low fat yogurt was $0.10 cheaper, banana’s were $0.04/lb more expensive, along

with Gala apples ($1.30 more per pound), broccoli ($0.30 more per bunch), and Iceberg lettuce

($1.00 more per head). However, these elevated prices on the Upper East Side came with large,

well-lit aisles, produce selections that included organic products and many options including

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different types and brands of bananas, as well as pre-washed and prepared produce. On the

whole, the fresh produce at Food Emporium looked to be of higher quality and fresher.

Produce in all three East Harlem supermarkets was placed at the far end of the store,

away from the entrance, unlike Food Emporium where the fresh produce was located directly at

the entrance. Another observation was the wide range of Hispanic/Latino brand name products

and White Rose brand products available in East Harlem supermarkets that were not visible at

the Food Emporium. Finally, strong focus was placed on sodas and snack foods in all three East

Harlem supermarkets including large displays at the end caps of isles and special promotions on

preserved food and junk foods (See Appendix Z).

Discussion of Results

According to our secondary research findings, there is a strong correlation between the

socio-economic status of East Harlem residents, access to fresh, healthy foods, and the increase

in prevalence of obesity and overweight in the neighborhood. The intertwined internal and

external conditions affecting individuals and the community as a whole creates a never-ending

cycle of poor nutrition, obesity, and illness. The high prevalence of obesity in East Harlem

causes other health issues, including heart disease and diabetes, and drains an already

marginalized community of its resources. Fresh options are offered to the community but not on

the same scale as are offered in more affluent parts of Manhattan. Finally, the rise in obesity

among the youngest members of the community perpetuates the disadvantaged condition of East

Harlem, and its residents. From our analysis we identified the following design problem: “How

can we bypass the channels of poor nutrition already ingrained in the neighborhood and culture

of East Harlem, and provide year round, fresh and healthy alternatives to individuals, families,

youth, and the community?”

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Overall, our primary research findings mirrored our secondary research, however new

insights were found that pertained directly to our case study of East Harlem Block Nursery #1.

The number of single parents, and mothers heading households, as well as the age of

parents and children reinforced our conclusions that East Harlem is a young neighborhood. The

number of young mothers, also correlated to the high rate of teenage mothers, and the fact that

12 of 13 respondents were female all confirmed the findings of our secondary research.

The employment hours and job titles supported our secondary socioeconomic research

that East Harlem is a low-income neighborhood, and its residents are for the most part educated

at or below a high school degree. The low socioeconomic status further supported by the number

of parents who had used government subsidized food programs (WIC/SNAP).

Regarding our questions pertaining to food, the types of foods respondents reported

cooking at home (Spanish, rice, meat, chicken, fish) again, confirmed secondary research

pertaining to the predominantly Hispanic/Latino culture of East Harlem.

However, there were a number of new insights acquired through our interviews at

EHBN1, which refined our view of the community. For example, we were surprised to learn that

many of the parents at EHBN1 have lived in the neighborhood of East Harlem for the majority of

their life. Some parents had even attended EHBN1 themselves as children. This speaks to the

sense of community, and trust that has been built by the preschool.

Additionally, the resounding concern from parents regarding the options for healthy food

choices in the neighborhood correlates with our finding that 83 percent of adolescents and 90

percent of adults in East Harlem do not eat the recommended five fruit and vegetable servings

per day. This concern included the lack of selection and poor quality of fruit and vegetables

available at local food stores, farm markets, and Greencarts as well as frustration associated with

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the number of fast food restaurants located in the neighborhood. This lack of quality, fresh

produce directly impacts the numbers of obese and overweight individuals in the community,

and particularly the health of children who are still developing.

SECTION II

Existing Obesity Prevention and Treatment Programs

“It has recently been suggested that individually focused interventions attempting to

reduce obesity have had limited success, and that the widespread and increasing prevalence of

obesity is inadequately explained by individual-level psychological and social factors associated

with diet or physical activity” (Cummins & Macintyre, 2005, p. 100). To better understand what

Cummins and Macintyre are saying we will review existing research evaluating the results of

existing obesity prevention and treatment methodology. In conclusion we will identify key

learnings that will later be incorporated into our design solution

For the purpose of this examination we have reviewed several studies focused on

previous obesity prevention and treatment methodologies. We are using these studies to further

identify areas of inadequacy, as well as methods that have proven to be successful in either the

treatment or prevention of obesity. From these evaluations we will identify key findings to

inform later design decisions. The studies that we have selected for this portion of our analysis

include: Pathways to Obesity Prevention: Report of a National Institutes of Health Workshop, A

Systems-Oriented Multilevel Framework for Addressing Obesity in the 21st Century, and

Increasing Fruit and Vegetable Intake and Decreasing Fat and Sugar Intake in Families at Risk

for Childhood Obesity.

Pathways to Obesity Prevention. A special article that was written in response to a

National Institutes of Health Workshop titled, Pathways to Obesity Prevention: Report of a

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National Institutes of Health Workshop. This report summarizes results from the workshop

designed to stimulate novel research for obesity prevention. By looking at 20 different pilot

studies, the investigators were able to address the types of issues and challenges that varied

across different areas. The focus panel considered issues working with different types of

organizations: churches and other religious institutions, primary care clinics, schools, day care

centers, federal feeding program sites, and not-for-profit women's health care organizations.

From this report, we were able to gather key insights into the many facets of what goes into the

design of a successful versus unsuccessful obesity prevention program.

Investigators working with clinical and community. These investigations were focused

on clinical and community settings where each environment was viewed by investigators as a

means of connecting with the population of interest. The goal was to incorporate obesity

prevention services into an ongoing program or service delivery framework. The relationship of

the participating organization partner and the role they played in defining the research agenda

and other partnering organizations, and ultimately the addition of obesity prevention to their

primary agenda were key. Though, even when investigators and organizers were highly

committed, it was difficult for the project to be consistent with program-related variables. Listed

below are variables and issues that impeded progress within their project:

Program-related variables and issues

• Issues of unbudgeted but necessary costs were critical;

• In-kind contributions (time from staff, equipment) did not come through and needed to be

covered by research budget;

• Compensation for data collection required but not included in original budget;

• Lack of motivation from participants regarding obesity prevention when compared to

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programs focused on obesity treatment;

• An approach and timetable for a program able to accommodate changes in staff, policy,

budget or unanticipated shifts in the size or needs of client populations; and

• Differences in policies or organizational capabilities across sites within the same project

posed implementation problems.

Several theoretical and conceptual frameworks were used as reference points to identify and

understand problems related to the process and outcomes of the tested programs.

Pertinent to community and organizational studies were Green’s PRECEDE-PROCEED

(respectively, for Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis

and Evaluation and Policy, Regulatory, and Organization Model, which guides systematic,

theory-based planning of community-based health interventions. Important methodologies to

note were “up-stream” strategies such as changing community or organizational environments,

practices, and policies, and direct “downstream” interventions to improve individual knowledge

and skills. Additionally, socioecologic theory, which emphasizes the multi level and interactive

forces influencing effective health promotion strategies were also considered (Kumanyika &

Obarzanek, 2003). Other tools include frameworks that guide thinking through cultural

influences on health behaviors and planning culturally-appropriate health education programs.

Investigators working with obesity prevention in family settings. The project focused

on children and adolescents in a family environment. Children and adolescents are an important

determinant in the design of an obesity prevention program because there are numerous ways

that families influence their eating and physical behavior. In the positive aspects to this approach,

other family members could potentially benefit from prevention methods. However, this also

means that all family members are intervention participants and their motivational and practical

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concerns should be addressed. Theories of childhood development and models of family

organization and process including conflict resolution, communication patterns, and parenting

style guided these family-based interventions.

Key Learnings

• Nutrition and physical messages should be positive, promoting healthy growth;

• Optimum level parental involvement relative to child age and stage of development -

needs to be defined from theoretical and practical perspectives;

• Participation in time-consuming intervention activities may not be feasible for busy

parents;

• Complexity and amount of information to be delivered should be considered carefully;

• Design considerations for family-based weight management interventions include

interactions a month family member (e.g., parenting styles, sibling or spousal

interactions and family members as role models); and

• Motivation of parents and family members may be mixed particularly depending on

weather they have to meet weight eligibility criteria and whether their own weight is

also a focus of the intervention.

In the project, the intervention of family provided further insights about the design of an

obesity prevention program. Many of the challenges related to an obesity prevention program

arose not from the family itself, but from the nature of addressing prevention. Specifically,

design problems arose from the fact that the outcome for prevention is essentially that there will

be no change, in contrast to treatment where the outcome of weight loss is measurable, and many

times physically noticeable. In regards to counseling is was suggested that it would be more

effective to advise periodic cycles of modest weight reduction to balance out expected periods of

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transient weight gain. Ultimately, the project gleaned from the intervention that more incentives

for both recruitment and attendance might be needed for obesity prevention programs in

comparison to programs in which the outcome (weight loss) is itself more motivating.

Findings related to race and ethnicity. It was important that the investigators look at

theoretical frameworks, cultural and racial/ethnic factors and physiological measurements

because those factors all have the potential to influence obesity research. As the report states,

within cultural factors, there were a multiplicity of aspects in all populations to consider,

particularly for women, “The importance of formative data collection in identifying important

cultural variables was highlighted, as was the need to build on existing traditions with respect to

food, music and types of activities, rather than attempt to “force-fit” participants into a

preconceived model (Kumanyika & Obarzanek, 2003, p. 8).

Directions for future intervention research. The report supports the need for an

intervention that approaches obesity more holistically and at the ground-level, rather than

theoretical:

More creative and diverse interventions should be studied, including attempts to find

effective societal and policy-level interventions that the science of obesity prevention

should follow more systematically from observations about determinants of weight gain

and weight maintenance and that approaches tested should build more specifically on

what we already know (Kumanyika & Obarzanek, 2003, p. 8).

Additionally, a key insight from the project was that there are fundamental differences between

studying obesity treatment vs. studying obesity prevention, and that prevention research requires

more applied and interdisciplinary approaches than treatment-oriented research. Challenges

faced in many of these obesity prevention studies have a striking similarity to research issues that

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are well known to those studying models for substance abuse prevention, HIV/AIDS prevention,

or smoking cessation. Particularly difficult, is maintaining experimental designs in natural setting

that can neither be standardized nor structured for the delivery of standardized treatments, the

need to meet people in the community much more than “halfway” to keep research going.

Study conclusion. Using obesity treatment as the primary paradigm may be limiting to

our ability to develop effective obesity prevention approaches. Movement toward a paradigm

that will inform creative and powerful obesity prevention research is critically needed to address

the challenging and now urgent needs in the field. From the insights and findings within the

report, a paradigm designed to meet the needs of people as a more interactive experience.

Areas of focus for design solution. This extensive study raises some important

considerations that we will be using to inform later design decisions. The areas that we have

selected to focus on within our design include the following:

• Address all logistics and plan for anticipated and unanticipated obstacles that working

with a community based organization.

• Incorporate both “down-stream” and “up-stream” approaches to obesity prevention that

include organizational and environmental changes coupled with individual behavioral

based interventions.

• Program should be designed for the specific cultural and lifestyle for the participants of

the program on a case-by-case basis (cultural sensitivity).

Framework for Addressing Obesity in the 21st Century

The second study that we reviewed was titled, A Systems-Oriented Multilevel

Framework for Addressing Obesity in the 21st Century. This study is also focused on prevention,

and is based on the conclusion that the solution to the obesity epidemic lies in policies and

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interventions that alter contextual forces driving individual behavior beyond their rational

control, taking the individual biology and preferences into account. For the purpose of their study

they framed obesity as:

A complex system in which behavior is affected by multiple individual-level factors and

socio-environmental factors (ie. factors related to the food, physical, cultural, or

economic environment that enable or constrain human behavior, or both). These factors

are heterogeneous and interdependent and they interact dynamically (Huang,

Drewnowski, Kumanyika, & Glass, 2009, p.2).

They reference models from Glass and McAtee that present a multilevel approach to

address the complex context associated with obesity prevention (see Appendix AA). As it states

in their report “The model is consistent with economics and psychology in that people are

assumed to engage in behaviors based on preferences and attitudes. It becomes multilevel in that

a person is constrained by factors that exert regulatory control on those behaviors” (p. 2). The

example they give is that “food choices are not made on the basis of preference but also the price

of food, the cultural meaning of food, the availability of food, and the biological responses to the

reward value of food” (Huang, Drewnowski, Kumanyika, & Glass, 2009, p.2).

They also recognize that one of the problems associated with using a systems-oriented,

multi-level framework for obesity is attributed to the fact that key influences, within the physical

or economic environment, might not fit within conventional definitions of causes e.g., social

inequality and poverty (Huang, Drewnowski, Kumanyika, & Glass, 2009).

They also refer to food distribution systems as a contributing factor, and how changes

within those systems have the ability to influence on a population level that could align in ways

leading to different rates of obesity (Huang, Drewnowski, Kumanyika, & Glass, 2009, p.3).

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Taking into consideration these inconsistent variables, and their multi-level approach requires a

bridging structure connecting the individual and the community. These structures will “act as

conduits between macro-level forces and the factors in the local environment that govern eating

and activity” (Huang, Drewnowski, Kumanyika, & Glass, 2009, p.3). The examples of conduits

they provide include, cultural norms, social networks, local food availability, food prices and

taxes, physical activity amenities, psychosocial stress, or economic insecurity (Huang,


They also make the case for a cross-disciplinary approach to the issue of obesity. As they

have already identified, factors associated with obesity range from the individual level to the

international level, and potential sectors of influence might include agriculture, urban

developments, education and media, just to name a few. They look at obesity as a function of

biology, the built environment, the social environment and economics. Therefore the methods

and expertise used to solve for this epidemic should mirror each sector.

Obesity as a function of biology. This section is focused on the biological process that are

associated with obesity as a physical condition and the chemical processes that lead to behaviors

associated with obesity.

Obesity as a function of the built environment. Within these areas they look at obesity

within the context of the built environment. The research they present in this section supports our

conclusion related to the marketing of food, and its influence on consumption patterns (either

enabling or constraining food choices). This focus also includes the issue of availability and

accessibility of healthy foods (ie. fresh produce is not available in low-income areas). Other

elements of the built physical environment include proximity to, or lack there of facilities that

promote physical activity. The consideration of the built environment and its relation to obesity

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has only recently become part of the broader conversation, “Mechanisms of the association

between the built environment and obesity remain poorly understood, particularly in terms of

how the built environment interacts with biology to influence obesity related behaviors” (Huang,


Obesity as a function of the social environment. Understanding obesity as a function of

the social environment is also a factor when using a multi-level approach. First they outline the

varying attitudes about body image depending on the preferences of a specific culture,

“Overweight in a child, for example, is viewed as a symbol of health by some cultures” (Huang,

Drewnowski, Kumanyika, & Glass, 2009, p.3). What they are trying to show in this example is

that, as society becomes increasingly obese, they themselves could propagate obesity (Huang,

Drewnowski, Kumanyika, & Glass, 2009).

Cultural pressures also present a different set of barriers to obesity prevention. This

example evaluates the American attitude that emphasizes the individual and personal

responsibility for their life and the life of their child. The cultural implications of this attitude in

part led to previous prevention research and programs that educate or train people about healthy

behaviors. Unfortunately these types of individual-oriented approaches did not take into account

the biological and socioenvironmental drivers of behavior, and have rarely worked in the long

term (Huang, Drewnowski, Kumanyika, & Glass, 2009).

The issue of stress as a social construct is also a potential barrier for obesity prevention.

In most instances stress is a biological response to social conditions. This relationship where,

stress is a stimulant opioid release in the reward center of the brain. This response is one of the

body’s defense mechanisms to prevent the harmful effects caused by stress. In cases of chronic

stress when this response happens on a regular basis it can lead to the reward of pathways that

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heighten the reward value of food and can contribute to increased consumption and fat

accumulation (Huang, Drewnowski, Kumanyika, & Glass, 2009, p.5).

Obesity as a function of economics. This section further supports the role of economic

status and the instance of obesity in low-income areas, a reality that is most prevalent in the US.

They cite the same causes for this relationship that have already been presented such as: greater

access to energy-dense and nutrient poor foods.

Of their research this connects the psychological burden of financial insecurity with the

biological response mechanisms associated with stress as a possible cause for increased obesity

rates for individuals living with limited financial resources. “Subsequently, increased obesity in

the population can perpetuate itself through intergenerational epigenetic programming” (Huang,


As for the food industry, agricultural production, food manufacturing, processing,

packaging, transport, retail and marketing can affect food consumption patterns. On the supply

side, the food chain is subject to influence from agricultural policies on farming output, where

the demand side is subject to variables like availability, pricing and income. Additionally

agricultural policies require farmers are to grow certain types of food; the most telling example is

the support of these policies on soy and corn over fruits and vegetables. Currently there is not

enough research about the specific economic factors that can be associated with obesity in

relation to the role of policy and how it affects producer and consumer habits, or in what ways

the food supply chain can be altered to reshape consumer demand to favor healthier food options

in the future (Huang, Drewnowski, Kumanyika, & Glass, 2009).

Modifications and multilevel interventions. In this section they suggest structural

modifications to currents methods of obesity research, prevention and treatment to include

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multilevel interventions. Their first suggestion outlines the need for obesity interventions to

begin at the community level (or higher) to connect people, families, schools, government and

the private sector. Also, interventions should not be limited to educational methods alone but

also include environmental adjustments that can change social norms and enable the adoption of

healthy behaviors on a daily basis (everyday life). More specifically they state, “The family,

schools, primary care settings, and municipalities can be targeted simultaneously as catchment

sites to interface with children and parents” (Huang, Drewnowski, Kumanyika, & Glass, 2009,

p.5).

Moreover, media organizations and businesses also have the ability to change norms, as

they are in a position to influence both the supply and demand sides of the equation. As an

example to support this conclusion they provide the example from the North Karelina Project in

Finland. In this example Finland’s public health agency was successful in reducing smoking

rates and improving dietary practices. To achieve this goal they did not rely solely on the

intervention of individually focused educational programs. Instead they created new incentives

for farmers to move from the production of meat to the production of fruits and vegetables, and

used regulatory policies on production to increase the nutrient content in food (i.e., requiring

sausage producers to decrease the fat content of their products). As a result of their efforts they

saw a greater than 50 percent reduction in coronary heart disease related deaths, in addition to

stroke, cancer and other diseases across the whole country in a 20 year period of time (Huang,

Drewnowski, Kumanyika, & Glass, 2009).

All of their findings support the conclusion that as multilevel interventions are slowly

being adopted, what is currently being done, specifically on the grassroots level, needs to be

leveraged, including “rigorous evaluations to determine the effect of community-initiated

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interventions (40).” (Huang, Drewnowski, Kumanyika, & Glass, 2009, p.6).

Capacity building for multilevel research and action. They back up the previous

statement by also providing action-oriented agenda items that outline next steps for the inclusion

of public-private partnerships, national governments, and training for future multi level

researchers and policy makers.

Areas of focus for design solution. The information reviewed within this report is more

heavily based on more theoretical approaches to obesity prevention. However, there are several

insights from this report that are important for making our case. First this approach further

validates the value and necessity that as a team of designers bring to the conversation about

obesity prevention. Second there are several key findings that will be directly related to

subsequent design decisions.

To provide a point of contrast to the research outlined within the first two reports of this

review, we believe that it was necessary to analyze an individual program that has reported

successes in results to their efforts. We also believe that we could further inform our design

solution if the program that we selected shared some of the components that we planned to

include in our design solution. For these reasons we have selected, Increasing Fruit and

Vegetable Intake and Decreasing Fat and Sugar Intake in Families at Risk for Childhood

Obesity, as the third and final report for this review.

Program Objective: The goal for this particular study was to evaluate the impact of

parent-focused behavioral intervention in regards to the eating habits for both the child and

parent, and the percentage of change in families that contain at least one obese parent and one

non-obese child.

Utilizing parental influence in for child obesity prevention and treatment. Components of

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programs to prevent obesity in at-risk children can include modifying environmental cues

leading to positive energy balance, changing parental eating habits, thereby providing healthy

models for children to observe. This program also focused on teaching new parenting skills that

reduce using food as a reward. Because parental obesity represents one of the major risk factors

for pediatric obesity, many at-risk children will live in families with obese parents. The inclusion

of parental behavior change as a target for obesity prevention programs may have benefits

beyond prevention of pediatric obesity, because a change in the eating habits related to parental

obesity may result in a reduction in parental obesity. If obese parents of at-risk children reduce

access to low-nutrient dense foods available in the shared family environment, model healthier

eating and activity habits, and share positive food-related family experiences that reinforce

eating high-nutrient dense foods, the parents may reduce the risk of their child becoming obese

as well as modify their own body weight.

The methods used in this program involve an increase in fruit and vegetable intake over

high-fat/high-sugar intake in parents eating and parent-initiated changes on fruit and vegetable

intake. Program components also taught pre-planning and problem solving to facilitate the

decisions associated with activities that involved eating such as parties, holiday gatherings,

school functions and work functions.

III. DESIGN

There is an abundance of research available that has been conducted over the past thirty

years or so that attempt to identify and isolate the possible causes and potential solutions to the

obesity epidemic. However, as it has been stated time and again many of these theories and

practices either, do not affect marked changes to obesity rates, or remain in theory based practice

with little or no practical insight. What we are proposing is a two-fold approach to this problem

79


that goes a step beyond the traditional methods that have already or are currently being applied to

the issue of obesity. Based on this extensive research, we have been able to construct a viable

and applicable program that can serve as a pilot study to further validate or disprove the

conclusions offered from previous system-oriented approaches to this problem. What we are

proposing in the implementation of a highly interactive program that indirectly addresses the

issue of obesity by changing the experience that people living in low-income areas have with

food.

Additionally we are also questioning how policy makers and other interested parties are

valuing the type of current research that is typically being funded. From our research we

identified a substantial number of reports dissecting and analyzing the problem of obesity in

order to solve it without considering integrated designs or approaches. We were left to question

what the value is of a 10-page report that analyzes a neighborhood in demographic statistics

alone, without interest in designing a solution utilizing analysis from social, environmental, and

economic factors. We question the affect these types of reports have had on lowering the rates of

obesity. We propose that these questions become part of the larger conversation regarding

obesity prevention and treatment. Using these questions to also inform our approach to the

problem, we have created a program that allows for evaluation in real-time, and positions our

team to iterate and change program components as needed, while also setting up a system to

track our own success and failures.

The design solution presented below has been structured as a multifaceted program that

integrates the principles of Triple Bottom Line by Design to change negative behaviors

associated with obesity, while also creating economic value and supporting environmentally

beneficial systems.

80


The Reverse Causal Effect: Obesity, Education

and Socio-economic Cycle. As we have already defined,

the target user for our program are young mothers living in

low-income areas, and there are many issues which factor

into the propensity of obesity within women as a

demographic and as the targeted user of our design.

Obesity relies on the interaction of multiple genetic,

cultural, socioeconomic, behavioral, physiologic, metabolic, cellular, and molecular influences

within any person or group of people. The specific combination of education and socioeconomic

status contribute most in the equation when looking at the levels of obesity within the target

segment of women. As expressed in an article from the ABNF Journal, the official journal of the

Association of Black Nursing Faculty, Inc., within all racial and ethnic groups combined, women

of a low socioeconomic status and lower education, are approximately 50 percent more likely to

be obese than those of higher socioeconomic status (Montague, 2003).

Within any context, the complex interdependence between women, obesity,

socioeconomic status and education presents an extremely challenging set of variables. To better

understand this relationship we looked at the reverse causal effect described in recent report from

the OECD Journal: Economic Studies. This report identified several points of research that

support the existence of the reverse causal effect, that obesity in young age determines the level

of educational achievement of an individual:

Sargent and Blanchflower (1994), using panel data, showed an inverse relationship

between obesity at age 16 and earnings at 23 in young women. Gortmaker et al. (1993)

found that women who were overweight in childhood completed fewer years of school.

Figure 1. How the reverse causal effect is a cycle of socioeconomic status, education levels, and instance of obesity.

81

http://www.abnf.net/


(Devaux, Sassi, Cecchini, Church, & Borgonovi, 2011, p. 135).

Understanding the reverse causal effect is imperative to our design solution because it describes

the cyclical nature of obesity for women in these demographic areas (See Figure 1). Our intent is

to incrementally break down this cycle by addressing some of the challenges these women face.

The specific areas that we will be focusing on will be defined in the following sections.

Approaching Solutions to Obesity with Mothers and Family

In 2007 the Journal, Epidemiologic Reviews published an article titled, The Obesity

Epidemic in the United States Gender, Age, Socioeconomic, Racial/Ethnic, and Geographic

Characteristics: A systematic review and Meta-Regression analysis stating, “the large

racial/ethnic differences in the prevalence of overweight and obesity suggest that culturally

sensitive and appropriate approaches are needed in promoting healthful eating in fighting the

obesity epidemic” (Wang & Beydoun, 2007).

Prevention and Treatment. In her book, The Overweight Patient: A Psychological

Approach to Understanding and Working with Obesity, Dr. Kathy Leach explains her guiding

principle for treating obese patients, “Ultimately the patient needs to establish a sense of self-

worth, self-esteem, self-love and self-validation and from this position she can decide whether

she can and will lose weight or not. The psychotherapeutic goal is the autonomy and

empowerment of the patient” (Leach, 2006, p. 14).

Recent work has also shown that modification of home food environments, such as the

visibility and convenience of access to certain foods, has been effective in reducing overeating in

laboratory studies and has been correlated with weight loss in short-term field studies (Faith et

al., 2012).

IV. DELIVER

82


We have designed an obesity prevention program that incorporates key leanings and

conclusions extracted from the research presented above. This final deliverable for our multi-

level project required us to understand each step needed to establish key partnerships (public,

private and community and individual), design holistic and efficient systems relevant to obesity

prevention, and establish best practices and consistent and efficient processes for our

organization. We then needed to synthesize all of these steps into a format that can be

implemented with the resources and networks that are currently available. The business plan

presented below outlines how this program will be executed, and how the company will be

organized in regards to structure, position and responsibilities and expectations. It also outlines,

what we expect from our various partners, and a step-by-step process for how this project can be

implemented immediately.

83


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APPENDICES

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APPENDIX A

Trends in Prevalence Rate of Food Insecurity and Very Low Food Security in U.S.

Households, 1995-2011

APPENDIX B

101


Households by Food Security Status, 2011

APPENDIX C

102


U.S. Households with Children by Food Security Status of Adults and Children, 2011

APPENDIX D

103


Prevalence of Food Insecurity, 2011

APPENDIX E

104


Prevalence of Very Low Food Insecurity, 2011

APPENDIX F

105


Obesity Rates

Organization for Economic Co-operation and Development [OECD]. (2012). Obesity Update

2012.

APPENDIX G

106


Overweight Rates

Organisation for Economic Co-operation and Development [OECD]. (2012). Obesity Update

2012.

107


APPENDIX H

Body Mass Index Calculator

Vita Clinics UK. (n.d.). Morbidly Obese Definition. What is Morbid Obesity?

108


APPENDIX I

Occupational METs and Energy Expenditure Since 1960

Church, T., Thomas, D., Tudor-Locke, C., Katzmarzyk, P., Earnest, C., Rodarte, R., … Bouchard, C. (2011). Trends Over 5 Decades in U.S. Occupation-Related Physical Activity and Their Association with Obesity.

109


APPENDIX J

Obesity Over Time

Hellmich, N. (2012, May 8). Obesity could affect 42% of Americans by 2030. USA TODAY.

110


APPENDIX K

2011 Obesity Rates

America’s Health and the Robert Wood Johnson Foundation. (2012). F is Fat: How Obesity Threatens America's Future.

111


APPENDIX L

2030: Adult Obesity Rates If the Current Trajectory Continues

America’s Health and the Robert Wood Johnson Foundation. (2012). F is Fat: How Obesity Threatens America's Future.

112


APPENDIX M

U.S. Prevalence of Adult Overweight and Obesity


and Obesity in the U.S.

113


APPENDIX N

U.S. Prevalence of Childhood Overweight and Obesity


and Obesity in the U.S.

114


APPENDIX O

Adult Obesity in New York City

Food Works. (2010). New York City Council.

115


APPENDIX P

Adult Obesity in New York City

Department of Health and Mental Hygiene. (2007). Obesity in East and Central Harlem: A Look Across Generations (Rep.).

116


APPENDIX Q

Bodegas Far Outnumber Supermarkets in East and Central Harlem

The East and Central Harlem District Public Health Office. (2006). Eating Well in Harlem: How

Available Is Healthy Food?

117


APPENDIX R

Healthy Food Availability by Neighborhood

The East and Central Harlem District Public Health Office. (2006). Eating Well in Harlem: How

Available Is Healthy Food?

118


APPENDIX S

Local Farmers’ Markets

119


APPENDIX T

Parents Interviews

120

Using TBLD to Solve for the Obesity Epidemic 121


APPENDIX U

Parents Interviews – Food Sample Images

125


APPENDIX V

Parents Interviews – Statistics

126


APPENDIX W

Interview Questions

Interview with Director of EHBN1

A. Job title/ description1. What is the description of your job?

2. What challenges, if any, have you faced since accepting the position?

3. What do you feel is the most important part of your job? What is the most rewarding?

4. Childhood obesity is becoming a major health issue in NYC. Have you found a need to address this in your work/ in the community?

B. About EHBN 11. How many years has EHBN served the community?

2. Please explain EHBN’s objective and mission statement.

2a. What role does EHBN serve in the surrounding community? (Outreach)

3. How does EHBN run? Is EHBN1 connected in any way to EHBN2 and EHBN3? If so, how?

3a. Is EHBN affiliated with any other organizations or programs?

3b. Who is responsible for making final decisions in the program, and what stakeholders are involved?

3c. How many people work at EHBN, what does the organizational chart look like?

3d. From where does EHBN receive its funding?

3e. How many people work at EHBN, what does the organizational chart look like?

C. About the students1. How many students are enrolled currently?

2. How many children do you care for on a yearly basis?

3. How many years do children typical stay in your care? All 3 years that they are eligible for the program or less?

130


4. How do people enroll their children? Is there a lottery system? If so, what happens to kids who can’t get in?

5. What is the curriculum like? What types of things are the children learning and what types of activities do they engage in?

D. About the parents 1. What are parent’s expectations of this program?

2. What are your expectations of the parents?

3. How involved are parents in the school’s programs/activities? Do they actively seek involvement?

3a. Would you like parents to be more involved in their students education and care?

4. What types of issues are your parents facing at home? Do these issues affect/change the pre-school’s outlook/program?

5. Are there any EHBN programs that involve both parents and children doing activities together? (Arts and crafts, cooking, etc.)

6. What is the income threshold for parents for their child to be considered for the program?

E. Food1. Do you have any programs related to food?

2. Who manages the food program at the school, and how is it managed?

3. Are there any obstacles you see the food program facing currently, or in the future?

4. In your opinion, what is the main issue your students and parents face regarding food? Such as food insecurity, finding fresh, healthy foods, price issues?

5. Do you have any insights from the preschool regarding food that you think may be helpful for us?

F. Future plan1. Are you considering any plans or programs in the near future?

Interview with Head Cook of EHBN1

A. Job title/ description1. What is your position at EHBN?

2. Please describe your job and job responsibilities.

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3. How many years have you been with EHBN? Have you served in the same capacity for that time?

B. Work1. Do you have a budget for feeding students? If so, who dictates that budget?

1a. Is the budget dictated yearly, or quarterly?

1b. What is your budget for feeding the students? 2. What obstacles do you face in serving healthy food to your students?

3. Do you have communication with parents regarding meal plans, dietary restrictions, and suggestions?

4. Do you know the eating habits of your students outside of school?

5. What do you feel is the most important part of your job? What is the most rewarding?

C. Food1. How many meals do you serve the children each day?

1a. What is the standard rotation for meals?

2. Where do you source/order the food used in the preschool?

2a. Are you familiar with Hunts Point Market in the Bronx? Does any of your food come directly from this supplier?

3. Would you please walk us through a day in your position?

4. How open are the children to trying new meals?

5. Is cooking ever part of the children’s curriculum?

6. How do you see food impacting the students? (Attention, mood, behavior, learning, achieving developmental milestones)

7. As a cook, what do you see as the biggest food issues in NYC and East Harlem?

8. What do you see as the biggest obstacle to healthy eating habits in this neighborhood?

9. Do you think the existing healthy food programs are working well in East Harlem?

9a. Are you familiar with the city wide greenmarkets and neighborhood green carts?

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10. Childhood obesity is becoming a major health issue in NYC. Have you found a need to address this in your work/ in the community?

11. Have you received any training or guidelines/government initiatives on teaching healthy eating habits or working against obesity?

Additional Facts:- School does not have computers for the students- Most parents have smart phones- School communication to parents is done through letters, postings and word of mouth

133


APPENDIX X

Sample of Weekly Menu Plan of EHBN1

Source by East Harlem Block Nursery #1, 2013

134


APPENDIX Y

Sample of Food Production Record of EHBN1

Source by East Harlem Block Nursery #1, 2013

135


APPENDIX Z

Price and Quality Comparison in Retail

136


APPENDIX AA

Multi-level Approach to Obesity Prevention

Huang, T. T., Ph. D. , MPH, Drewnowski, A., Ph. D., Kumanyika, S. K., PhD, MPH, & Glass, T.

A., PhD. (2009). A systems-oriented multilevel framework for addressing obesity in the

21st century.

137


Figure 1. How the reverse causal effect is a cycle of socioeconomic status, education levels, and

instance of obesity.

138

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