Healthcare professionals are increasingly using practical nutrition education to educate patients on the importance of healthy eating and the impact

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1 Healthcare professionals are increasingly using practical nutrition education to educate patients on the importance of healthy eating and the impact of food choices on their health. The advantage of embedding nutrition education into a health care facility is that as a primary care destination, patients with young children are constantly coming in for wellchild visits, flu shots and immunizations. Health care centers are seen as a place of trust and authority. By adding nutrition education, health care centers can ensure that patients access nutrition education as part of their daily life.

2 No child should grow up hungry in America, but one in five children struggles with hunger. Share Our Strength s No Kid Hungry campaign is ending childhood hunger in this nation by ensuring all children get the healthy food they need, every day. In Massachusetts, where health insurance is mandatory, families who would typically not have health insurance access health services through benefits provided by the state. Many low-income families that did not have access to health insurance are now utilizing their benefits to attend hospitals and health centers throughout the state. Through regular interactions with a previously underserved population, health care providers noticed a trend families were struggling to afford healthy food and poor eating habits were negatively impacting patients health. One program in Massachusetts is working to combine health care with nutrition education to combat the health consequences of food insecurity and hunger. BACKGROUND: CHELSEA, MASSACHUSETTS Massachusetts General Hospital s Chelsea HealthCare Center (MGH) serves the residents of Chelsea, Massachusetts, a community in which five out of six neighborhoods are classified as poor neighborhoods and 32 percent of households struggle with hunger. In 2003, Dr. Ronald Kleinman, Chief of MGH, began a six year study of families visiting the hospital, screening patients for food insecurity and giving patients the option of asking for a follow-up meeting for further assistance. Between 2003 and 2008, more than 11 percent of families screened reported at least one person in the household went hungry because the family ran out of money for food. Of these families, 40 percent carried a nutrition-related diagnosis, such as diabetes or anemia, and a significant percent of those food insecure families were also obese. ASSESSING THE PROBLEM: LAUNCHING FOOD FOR FAMILIES Physicians at the hospital recognized the basic fact that when a household does not have enough money to afford adequate food for the family, a patient s health is negatively impacted. For patients with a nutrition-related medical problem, such as diabetes, running out of food can be even more critical. In 2009, Dr. Kleinman founded Food for Families to give physicians a proactive way to identify families in need of food assistance without waiting for a major health-related crisis to occur. Food for Families is a patient care intervention designed to reduce the prevalence of hunger primary care patients, develop strategic partnerships with organizations and local agencies working to reduce hunger, and provide patients with concrete resources and strategies to improve access to healthy food. Food for Families screens patients in primary care, pediatrics, obstetrics and urgent care departments for food insecurity and hunger and connects them with resources to access food. Food for Families also accepts referrals from the hospital s financial services team, the WIC clinic and adult medical care departments.

3 A full-time MGH employee reviews patient screening forms on a weekly basis and follows up with patients requesting additional assistance with a one hour interview to determine household needs, household resources and federal and state resources already being utilized. MGH staff connect patients with resources they qualify for, such as the Special Supplemental Nutrition Program for Women, Infants, and Children Program (WIC) and the Supplemental Nutrition Assistance Program (SNAP), school meal applications, processes SNAP applications on site, and connects patients with emergency food pantries. While successfully connecting patients with federal nutrition programs and emergency food assistance programs, MGH staff recognized that they needed a sustainable solution, especially for an immigrant population that may not qualify for SNAP benefits. Additionally, patients expressed an understanding about the importance of eating healthy foods, so a question was added to the food screening to help determine if patients wanted to learn more about eating a healthy diet. PARTNERING WITH COOKING MATTERS TO TEACH FOOD SKILLS As Food for Families worked to promote healthy eating, staff realized that patients were also having difficulty eating on a budget. In 2010, MGH began partnering with Share Our Strength s Cooking Matters to deliver tailored nutrition education to hospital patients and to provide information about buying and preparing healthy food on a limited budget. According to the Massachusetts Director of Cooking Matters, Alicia McCabe, Food for Families recognizes that food insecurity negatively impacts families health. The program is designed to take a proactive approach to fighting food insecurity and Cooking Matters is a logical fit for them. Cooking Matters empowers low-income families with the skills to shop for and cook healthy meals on a budget. Low-income families in America report that cost is their biggest barrier to making a healthy dinner at home. Cooking Matters empowers families to stretch their food budgets so their children get healthy meals. Participants learn to shop smarter, make healthier food choices, and cook delicious, affordable meals. Nutrition education through programs like Cooking Matters can help combat the impact of chronic diseases and help patients achieve better health outcomes. Cooking Matters six-week courses cover nutrition and healthy eating, food preparation, budgeting and shopping. Share Our Strength also offers Shopping Matters, interactive grocery store tours with a focus on buying healthy foods on a budget. Courses and tours are led by volunteer chefs and nutrition educators and offered to more than 30,000 families a year across the U.S. Since Cooking Matters launched programming in Boston in July 1994, more than 8,000 families have participated in over 730 nutrition education classes throughout Massachusetts. An additional 68,000 families have been served through grocery store tours, nutrition fairs and other health-related events.

4 Melissa Dimond, Manager of Community Initiatives/Healthy Living for MGH, learned about Cooking Matters from a Chelsea Head Start program and piloted the first class with 17 participants. The initial participants attended every session and gave such positive feedback that the hospital decided to continue to offer the classes. By securing partial funding, allocating staff time, and providing interpreters and childcare for course participants, MGH was able to offer four courses every year for three years, which covers approximately 60 patients a year. Dimond and her staff continue to meet with many of the graduates once a month for lunch, where the participants make Cooking Matters recipes to share with the group. Dimond explained At the very first lunch, one month after the class ended, we asked people to talk about Cooking Matters and what they learned. The participants repeated almost the entire curriculum the retention was incredible! The participants also shared tips about where and when to shop to maximize their food budgets. Since Cooking Matters participants are feeding their families on a limited budget the majority of families who participate in our courses are regularly cooking meals at home. Although everyone is excited to improve their cooking skills and learn new techniques and recipes the true value in these courses is that families develop lifelong skills such as label reading and utilizing unit pricing that enables them to confidently select the best foods for their family and prepare them in ways that taste great. Over and over our graduates tell us that because of Cooking Matters they are now able to get more food for less money and the foods they are buying are healthier. According to MGH staff, there aren t enough Cooking Matters classes for patients to attend. The courses run approximately four times a year and there is a growing waiting list of patients who would like to participate. Dimond explains We can t get everyone in to the class; there aren t enough days in the year for it. TAILORING CLASSES TO MEET A NEIGHBORHOOD S NEEDS The Chelsea neighborhood is home to a large number of refugees and 58 percent of residents speak a language other than English. Cooking Matters adapted existing curriculum in conjunction with MGH staff to meet the needs of non-english speaking patients. In October 2011, MGH American Sign Language Interpreter Laurie Rothfeld reached out to patients in the deaf community and provided technical assistance to Cooking Matters to adapt the standard curriculum and presentation style for deaf participants who do not read English or America Sign Language. Cooking Matters Massachusetts staff created pictures for every step in the recipe-making process and interpreters demonstrated what the Cooking Matters instructors were teaching.

5 Following the success of this class, Cooking Matters staff worked with MGH staff in March 2012, to meet the needs of a growing Arabic-speaking population. Working with Javad Rajai, MGH Chelsea Community Health Improvement Interpreter and community health worker, Cooking Matters reached out to MGH patients who speak Arabic, most of whom came to the United States from the Middle East and Northern Africa, and began offering classes at the Jordan Boys and Girls Club. Building on the success of Cooking Matters, MGH started offering Shopping Matters, a guided grocery store tour that helps parents and caregivers on a limited budget make healthy choices at the supermarket, in June By offering classes once a month, they can provide an alternative nutrition education program in addition to Cooking Matters and offer programming to people that cannot commit to six weeks of classes. Food for Families staff have been trained to act as Shopping Matters tour facilitators and offer the class at least once a month in English and Spanish. LOOKING TO THE FUTURE As MGH and Cooking Matters plan for 2013, they are considering ways to broaden access to nutrition education. They plan on offering one-time classes on specific topics, such as how to make healthy snacks. They are also exploring how to further integrate Cooking Matters graduates into the community, including connecting moms with school district wellness committees and recruiting graduates to help advocate for healthier food in corner stores. Both organizations are committed to continuing to offer Cooking Matters classes to MGH patients. Dimond emphasized the advantage to offering the classes for all stakeholders, explaining that clinicians can talk to patients about healthy eating, but if people cannot make the leap from hearing about something to actually knowing how to do it, behaviors will never change.