Trimming the Fat: A Heart-Healthy Approach to Cooking

A Continuing Education Program for Chefs and Cooks

Specific Objectives

• To increase knowledge of basic nutrition concepts and heart-healthy eating practices.
• To increase knowledge of available lower-fat food products.
• To increase skill level of chefs in lower-fat cooking methods, ingredient substitution/recipe modification, and analysis of products to determine fat content.
• To increase the number of lower-fat foods and menu choices offered by the restaurants of the participating chefs.
• To increase knowledge of resources (program, financial, human and written) related to the planning and preparation of lower-fat foods.

Intervention Components

• A pre- and post-test on knowledge and attitudes was administered.
• Ten, full day education seminars were developed and taught by dietitians. Topics included were: vegetarian diets, processed meats, food additives, organic foods, dietary cholesterol, and the relationship between Cardiovascular disease and diet.
• Chefs practiced alternative cooking methods with lower-fat recipes.

Key Points/ Lessons

• Evaluation of test results showed an increase in knowledge and positive attitude of all participants.
• Information regarding 'intention to change' was collected and was positive in that many chefs said that they would decrease the amount of fat they use and offer more low-fat choices to customers.
• No measures were taken to assess chef's practices subsequent to the learning opportunities.

A Program to Examine Accessibility of Low-Fat Foods

Objective: To revise, develop, and validate food baskets to incorporate current dietary recommendations and examine the availability, accessibility, and cost of heart-healthy dietary changes.

Type of Program: Survey of Products.

Targeted Population: Grocery stores, supermarkets, and superstores across the province.

Specific Objectives

• To develop and validate a food basket based on regional consumption patterns and current nutrition recommendations (Consumption Food Basket (CFB).
• To validate a food basket with low-fat alternatives such as "lite" or fat-modified foods (Alternative Food Basket (AFB).
• To assess the availability of food items found within revised food baskets (CFB and AFB).
• To compare the cost and availability of foods in the revised baskets (CFB and AFB) with the current baskets (Agriculture Canada's Nutritious Food Basket (NFB) and Thrifty Nutritious Food Basket (TNFB), both are nutritionally adequate but do not meet current nutrition recommendations), in a sample of stores province-wide.

Intervention Components

• Standardized food baskets have been used within Canada to assess the costs of nutritionally adequate diets for members of various age/sex groups.
• The baskets were created specifically for the nutritional needs of women aged 25-49.
• A nutritional analysis of existing food baskets.
• The AFB and the CFB were developed and the CFB was validated through focus groups to ensure that the basket contained foods that provincial residents eat on a regular basis.
• To examine the availability, accessibility and cost of the food baskets across the province, permission was obtained from grocery stores to conduct a pricing and availability survey.
• Systematic sampling to ensure appropriate representation of stores within each county, 86 stores were then randomly selected.
• A product survey was conducted to examine the availability, accessibility, and cost of the food baskets in the grocery store sample.

Key Points/ Lessons

• The nutrient analysis indicated that the current standardized food baskets (NFB and TNFB) failed as they provided a diet higher in fat and lower in carbohydrate than current recommendations.
• Using the NFB as the current standard for assessing the cost of a nutritiously adequate diet, findings indicated that it cost between 12-18% more to meet current nutrition recommendations.
• Food products in the two heart-healthy baskets were less available and more expensive.
• Choosing specially modified 'lite' products was the least economical means of modifying diet to meet current nutrition recommendations.
• More than 10% of the stores surveyed did not carry a sufficient variety of lower-fat foods (mainly in rural areas).
• Mean cost for all food baskets decreased as store size increased and the mean costs were lower in central, densely populated areas.

A Program to Create Ownership among Citizens for Community Heart Health

Goal: To empower citizens to make heart-healthy changes in the community

Objective: To mobilize citizens to advocate for healthy public policy, to make heart-healthy changes in the environment and to develop unique approaches to community heart health

Specific Objectives

• To identify key informants and develop a local action group to coordinate and implement the project within each of the five demonstration sites.
• To produce a community map of services, information and statistics for each site.
• To initiate consciousness raising activities and a community needs assessment process.
• To define the heart health environmental changes that community residents want to make.
• To develop, implement and evaluate skills within the community.
• To monitor environmental changes through community tracking every six months.
• To increase awareness of existing healthy public policy and gaps.

Intervention Components

• The community activation process was used to assist the demonstration communities in planning their heart health activities. This process assists individuals and communities to identify their own health issues and decide what to do about them. The process used by the local communities consisted of assessing community needs and resources; forming partnerships; planning, implementing and evaluating heart health initiatives.
• Five demonstration sites were chosen: four rural communities and one urban community.
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• Community health centers were the entry points into the rural communities and the municipal government was the entry point into the urban community.
• Local coordinators were hired, building local capacity, and increasing the opportunity to transfer skills into the community.
• During the following 2½ years, each site completed a community needs assessment (they consulted local citizens about local health issues, local resources, perceived needs and priorities in the community); and formed a Community Advisory Committee of local citizens and leaders to plan, implement, and evaluate heart health intervention.
• Training sessions were developed for the coordinators and community volunteers to address relevant topics such as health promotion, group dynamics, nutrition and low-fat eating, working with the media, community activation process, goal and objective setting.
• Information and program materials were gathered from across the country and were modified to meet the needs of the local communities.
• Eight to ten interventions were organized by the Advisory committee in each community to address issues concerning nutrition, physical activity, communication, community pride, and environmental concerns. Examples of activities are the following: leisure activity fairs, community walking groups, sports clinics and play days, an active living program, a moms and tots program, community cleanup, and heart smart cooking.
• The programs served multiple purposes but in general they were designed to increase awareness about heart health through participation in some form of activity.
• Staff at Heart Health Nova Scotia made site visits to each community. The staff provided assistance with specific tasks such as analyzing information and reviewing available resources to help develop programs.
• Promotion of the local programs and health issues was accomplished through radio and television, local newspapers and newsletters, bulletins, flyers and posters.
• Evaluation interviews was collected through key informant interviews and questionnaires, interviews with the community coordinators, and the coordinators' quarterly reports.

Key Points/Lessons

• Numerous creative health programs were developed therefore, community activation is a successful strategy for implementing community-based health promotion programs.
• It is important to enter a community through a lead organization, for they are integral in hiring the local coordinator, providing administrative assistance, supporting the local project and sustaining interventions.
• All five communities found similar focus group results. Residents expressed a need for leadership, restored community pride/spirit, improved communication/education, better nutrition, and increased opportunity for physical activity.
• The needs assessment methodology should be adapted to respond to local preferences while maintaining data collection quality and representation across the community.
• Establish partnerships to plan and deliver programs. This provides valuable resources including staff, time, and expertise and can also help ensure sustainability of interventions.
• Skills were transferred into the community through workshops, practical experience, and partnerships.
• Ninety-eight per cent of the Advisory Committee who responded to a survey agreed that their local heart health program was effective and increased awareness about heart-healthy behaviors.

A Program to Effect Change in a Chef School's Curriculum

Goal: To increase the lower-fat choices available within a restaurant setting

Specific Objectives

• To introduce nutrition education and lower-fat cooking methods into the curriculum.
• To educate students on incorporating healthy principles into the work place.

Intervention Components

• Presentation to the Curriculum Advisory Committee on the shared objectives of the education and health sector.

Key Points/ Lessons

• The Curriculum Advisory Committee was disbanded leaving the decision to the college administration.
• Proposal to assist with the incorporation of heart-healthy nutrition practices into the curriculum was not accepted by the college administration.

Program to Market Heart Health

Objective: To bring the heart health message to key stakeholders in the food industry.

Type of Program: Marketing of heart health to food manufacturers, distributors, and service personnel.

Targeted Population: Participants at the food exhibition, who represented restaurants, hotels, bakeries, and cafes and occupied positions such as buyers, owners, managers, chefs, and dietitians.

Specific Objectives

• To increase awareness of the rising consumer demand for lower-fat foods and menu items.
• To increase awareness of the link between diet and the risk factors associated with CVD.
• To increase knowledge of lower-fat food preparation techniques and heart-healthy menu planning.
• To increase knowledge regarding the incorporation of heart health concepts into existing menu items and the environment of the food establishment.

Intervention Components

• Participation at the food exhibition through a public education display.
• Staff distributed brochures on the need for collaboration between the food and health sectors.
• Distribution of free low-fat food recipe cards and low-fat food samples to participants.
• A seminar series on heart-healthy cooking consisting of a presentation and a practical demonstration.
• Exhibitors were encouraged to feature their lower-fat food products to lend support for the heart health message.

Key Points/ Lessons

• Results show a positive and receptive climate exists within the food industry for the development and distribution of heart-healthy products.
• Taste-testing of lower-fat foods and the free recipe cards were well received.
• Sixty-eight per cent of the companies who responded to the follow up questionnaire said their company featured or provided information about their lower-fat products at the exhibition.

A Nutrition Education Program

Objective: To encourage eating lower-fat, nutritious breakfasts and increase awareness of CVD.

Specific Objectives

• Promote the benefits of grains and cereals in a healthy diet.
• Educate consumers about the benefits of regularly eating a lower-fat breakfast.
• Promote the consumption of a lower-fat, fiber-rich diet.
• Increase awareness on the link between diet and CVD.
• To determine if consumers are supportive of a partnership between private companies and a government agency.

Intervention Components

• Campaign breakfast launch with media and local celebrities.
• Free community breakfasts were held at local schools or community halls and were advertised through flyers, television and radio announcements.
• Activities at the breakfasts varied and included local bands and celebrities, children's choirs', an informative dramatic play, face painting, and door prizes.
• After the breakfast adults participated in a 30-minute nutrition seminar led by a dietitian, while the children played organized games and activities.
• Sponsors donated the breakfast food and prizes.
• In-store promotions in numerous grocery stores included a staffed educational display to provide practical information and to assist in positive behavior change. Free low-fat food samples, recipes and coupons were available to attract customers.
• Grocery store tours led by dietitians for a variety of people and groups such as: weight loss groups; seniors; members of a recreation center; patients from a CVD risk factor clinic; a university hockey team; and low income women from a community health center.
• Free nutrition education materials were distributed to consumers at the in-store events and the community breakfasts. An education brochure was also distributed to homes province-wide.
• Television commercials were broadcasted on the benefits of consuming a lower-fat breakfast.
• A toll-free number for further information on CVD was included on brochures and flyers. Callers to the toll free number were mailed a nutrition education package.
• Promotional material included the governmental logo and the logo of the corporate sponsors.
• A telephone survey was conducted to assess awareness of the campaign and eating behaviors.
• A variety of health promotion activities were developed by community groups, such as: nutrition presentations in senior's clubs, resource centers, and work sites; 'muffin mania' a radio contest for low-fat/high fiber muffin recipes; 'munch on the move' involved distributing low-fat muffins and juice to morning exercisers at local walking tracks; educational displays in malls and hospitals; and radio and television programs.

Key Points/ Lessons

• Nutrition education campaigns in partnership with a corporate sponsor is a feasible and acceptable endeavor.
• Many participants stated they did not know how to interpret food labels but were interested in learning.
• Telephone survey results showed a positive change in attitude and behavior related to the consumption of lower-fat foods at breakfast and throughout the day for those who were aware of the campaign.
• Consumer response was very positive to the in-store displays with the dietitians: consumers wanted fast, practical answers, making point-of-sale information very appropriate.

A Program to Improve Heart Health and Knowledge in the Workplace

Goal: To increase employee awareness and knowledge of CVD risk factors and to encourage positive changes in behavior.

Objective: To screen individuals' for risk facators, set goals and follow-up, and to create an environment supportive of a heart-healthy lifestyle.

Type of Program: Worksite cardiovascular disease prevention program.

Targeted Population: Employees at three demonstration industries.

Specific Objectives

• To encourage positive changes in employees' attitudes and behaviors.
• To assess employees risk factors for CVD.
• To provide information and support to help employees reduce modifiable CVD risk factors.
• To promote the development of a heart-healthy environment in the workplace by encouraging the creation of healthy policies and programs that would support employee health.
• To plan, develop and implement a community-based approach to CVD risk factor reduction within three demonstration industries.
• To foster linkages with voluntary health agencies and other community service organizations.

Intervention Components

• Working With Heart consisted of the launch, follow-up, policy and program development.
• A program launch in each worksite involved a health risk assessment event called Heart Check to increase awareness of CVD, risk factors and to motivate employees to improve their own heart health. A team of health personnel and volunteers offered the Heart Check in each industry.
• Heart Check was a series of stations were physiological measurements, demographic and lifestyle information was collected and individual's results were compared with data to produce a personalized risk score. The risk score was divided into risk factors that could or could not be modified.
• Each employee was given the opportunity to participate and were given 30 minutes away from their work. Each industry paid five dollars for each participant.
• At the end of the Heart Check Event, each participant attended a goal setting session to assist in behavior change with a public health nurse. The nurses helped employees interpret their risk score and motivate them to make a goal around a specific risk factor. Each employee was then given an educational package on the risk factor they chose to modify.
• Participants attended three follow-up sessions with a health nurse after the Heart Check Event. This provided the opportunity to give social rienforcement and feedback as employees continued with the same goal or committed to a behavior change around a different risk factor.
• Working groups were established to divide the program into manageable pieces. The 4 working groups were:
  
  1) Training: This working group developed training manuals and conducted training workshops to ensure that the public health nurses and volunteer staff had the skills necessary to be part of the program.
  2) Resources: This working group developed and distributed resource packages specific to each risk factor at the Heart Check Event.
  3) Implementation: This working group developed an Organizer's Manual, posters, sign up sheets, payroll stuffers and large displays.
  4) Data Management: This working group coordinated the information to be collected, created registration forms, monitoring forms and consent forms for the program.
• Within each industry an Internal Worskite Heart Health Committee (WHHC) was established to develop the program activities around risk factor areas. The WHHC consisted of representatives from the union, occupational health, employees and management. The committee was responsible for the development and the implementation of at least one worksite program and one health policy.
• The committees explored existing community resources for program areas where employees expressed interest and need. These areas were weight reduction, healthy eating, physical activity, CPR, blood pressure and stress. A variety of health organizations joined together to collectively develop, and implement Working With Heart.

Key Points/ Lessons

• The program was directed at reducing risk factors which are modifiable. There was a significant reduction in mean scores when all industries combined and for 2 industries independently.
• The Heart Check event took 2-3 days to administer, dependent on the size and shift work cycles of the industry. On the average, 70 people could participate in the Heart Check event on a given day.
• The goal setting exercise with frequent follow-up periods was an effective mechanism for employees to make lifestyle behavior changes. The goals established were always realistic, short-term and flexible. These small steps in behavior change led to positively changed CVD risk factor levels, especially in the areas of physical activity and blood cholesterol.
• Participants who had a level of knowledge below the median showed a significant improvement in all levels of CVD knowledge.
• Physical activity was the behavior that was the most popular for the establishment of goals. WHHC's developed programs such as, lunch walking groups, Sneaker Day challenge events and secured corporate rates at local fitness facilities. Significant improvements were seen in the levels of pysical activity with employees becoming more active.
• Nutrition programs such as, cooking demonstrations and healthy cafeteria food choices were offered at 2 worksites. These programs offered educational opportunities and environmental support to help employees change their eating habits. In the two industries where nutrition programs were offered, improvements in blood cholesterol measurements were seen. The industry where a nutrition program was not offered, blood cholesterol levels remained the same.
• The risk factor where it appeared to be difficult to meet behavior change goals was achievement of a healthy weight. For every industry, goal achievement rates were consistently low. Weigh-to Win a wieght management program, was offered in two worksites and focused on lifestyle change in employees with a body mass index over 27. This program had low employee participation rates. None of the industries saw significant changes in body mass index levels during the program. Future programming will need to explore weight control programs that could generate more interest and enrollment.
• It is recommended that future health risk assessments include a Waist-Hip-ratio measurement to determine, of those with a BMI>27, who are at greater cardiovascular risk by fat distribution.
• Smoking reduction had the lowest achievement rate in meeting behavior change goals. Of the employees who where recommended to alter their smoking behavior habits at the Heart Check, only 17-43% of smoking empolyees at the three worksites chose to establish a smoking behavior change goal. Overall, there was a significant change in smoking scores when all industries were combined.
• Certain risk factor behavior changes may require more frequent follow-up sessions such as smoking reduction and weight control.
• Supportive physical environment: Committees at two worksites successfully increased the healthful food choices available in the cafeteria. All three committees pursued enhanced facilities and workout areas, changes included better showers, outdoor walking trails, and an indoor fintess center.
• Supportive corporate policies: CPR training in the three workplaces was completed during work time. One industry successfully developed and implemented an enhanced no smoking policy.
• Night-shift workers and seasonal workers had to participate in programs on their own time as most programs were offered during noon meal breaks. Shift and seasonal work made in challenging for the committees to get the message out, reach people, and offer accessible programs.
• The development and implementation of policies supportive of heart health behaviors proved to be more challenging and was not done as effectively as program development and implementation.
• Union labor forces are an important factor within the workplace that can be a barrier or facilitator to program and policy implementation.