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The Impact of a Community Nutrition Program on the Nutritional Status of an Urban Population Group*t EDWARD G. HIGH, Ph.D., ELENORA R. HINES, M.S., M.Ed.j JAMES P. CARTER, M.D., D.P.H,§ ELIZABETH SHUTE, M.S., AND MICHAEL ZUBKOFF, Ph.D.,** Departmnent of Biochemistry and(l Nuitritioni, Meh qrr-y Medical College, Nash ville, Tennes.ee

FULLY recognizing the importance of nutrition in the health status and in the primary health care of a population group, we were interested and concerned with several segments of an urban population in Nashville, Tennessee. This interest was furthered enhanced by previous studies in developing countries1'2 and more recently in the United States, particularly in South Carolina, 3'4 Georgia5 6 and Tennessee.7 In fact, we found significant nutritional problems in these population groups. More recently, a number of other surveys have pointed to similar pioblems in other population groups reported in the Ten State Nutrition Survey,8 the First Health and Nutrition Examination Survey,9 and the WIC Medical Evaluation Program.10 In this paper, we will report on a Community Nutrition Demonstration Project which was designed to improve the nutritional and health status of a population group among the poor in Nashville, Tennessee. Various techniques and procedures were employed which included a multidisciplinary and a multi-dimensional approach centered around the concept that good nutritional practice and good primary *Presented in part at the American Institute of Nutrition Meetings, Federation of American Societies for Experimental Biology, Atlantic City, N.J., April 1975. tSupported in part by grant No. CC/D/000013/0/01 from the National Institutes of Health. tPresent address: Department of Home Economics, Tuskegee Institute, Tuskegee, Alabama. §Present address: School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisana.

**Present address: School of Medicine, Dartmouth University, Hanover, New Hampshire.

health care go hand in hand and that it is possible for a progressive urban community to be organized around good nutritional and health practices. Some of these techniques and approaches are as follows: 1. Involving people in a self-help type program of nutrition improvement; 2. Increasing access to food in a community by various means which included the transportation to food stores for those who had no means of transportation; 3. Increasing the utilization of, and participation in, various Supplemental Food Programs as well as the Food Stamp Program by eligible persons; 4. Intensive education activities at the project site, at the site of purchase, as well as in the homes and various places in the community; 5. Providing the consumer group with different ways and means of obtaining more, better and different kinds of foods and thereby improving the nutritional status of individuals and the quality of their lives; and 6. Centering all of these activities around a core community nutrition group with volunteers from the community and the colleges, particularly Fisk, Tennessee State and Vanderbilt Universities, as well as Meharry Medical College. The residential areas involved were two inner-city neighborhoods, predominantly black, deprived and low-income. The demonstration area was called Edgehill which was an Urban Renewal area in South Nashville, and in close proximity to Edgehill. The estimated household population was 453,500. Since 1965, Edgehill has changed

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from a deteriorating, older-housing, college neighborhood to a "refugee camp". At least three federally subsidized public works projects have contributed materially to its residential and transportation problems. Edgehill currently has two separate Nashville Housing Authority Projects, Edgehill Homes (380 units; 1,397 population) with an average family size of 3.7 and I. W. Gernert Homes for the aged (181 units; 252 population) and a privately subsidized housing unit called Edgehill Village. Our project site was located in one of the new units of the Edgehill Homes. The Edgehill area was remarkable for having no super-markets, no large retail stores, and a growing population with a scarcity of residential housing. There was no direct access to large shopping centers except by ineffective public bus transportation with massive construction activity contributing to transportation problems. Both the target population and the comparison population are in the area serviced by the Matthew Walker Neighborhood Health Center. These close ties with the Health Center were further encouraged during the community demonstration project. There were neighborhood health workers and public health nurses from the Health Center assigned to the Edgehill area. Medical students were involved at the Neighborhood Health Center and at the Nutrition Site Center. The nutrition community project emphasized areas and activities as follows: Nutrition Education. Coffee hours were held regularly with the time being set by residents. Response was slow at first, but it gradually improved. Also informal consumer discussion groups were held durin'i the day. In addition, planned discussion sessions were sponsored that featured local persons representing organizations concerned with the general health and welfare of the people of the area. Others were held with only community people coming together. Flyers for these activities were distributed door to door; placed in churches, washerterias, and other places where there was a heavy flow

NOVEMBER, 1976

of people. Announcements were also made on the radio. Food shopping trips were made by individuals and small groups. Pick-up materials on food and nutrition were made available as were recipes at the project center. Through a coordinating council, a newsletter with recipes and food shopping tips was prepared. Various types of food demonstrations employing supplemental foods were held. Participatimi demonstrations were planned around the food problems listed on the individual survey forms. Homemakers were encouraged to bring their children to center activities. Snacks, made at the center, were provided for them. Food coloring books, donated by the local Food and Nutrition USDA Office, were used for the children's education in nutrition. This was well accepted. Also, a small store, which opened on the fringes of the area and accepted food stamps, agreed to the placement of nutrition education material in the store. Cooperation and Coordination with Existing Nutrition Services. a) Demonstrations of the use of supplemental foods were given the nutrition aides from the locally sponsored program. b) Referrals were made to certifying agents for supplemental foods and food stamps. c) Other departments and agencies that were available for cooperative work and which provided materials were: 1) The Nashville Dairy Council 2) State Director of Public Health Nutrition 3) Tennessee State University 4) The Division of Nutrition of Vanderbilt University d) Our programs were designed to complement, to cooperate or to coordinate and to extend existing nutrition programs as the need was seen by the community. There was no duplication of existing services. The Population Sample, Nutritional and Health Evaluation. Seventy-five families of low income in an urban renewal area in South Nashville were involved in the study. In addition to the adult participants' (17

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Niutritional Program

years of age and older) nutritional status being determined by biochemical analysis, they were examined in the Multiphasic Screening Laboratory of Meharry Medical College. Due to progress made and activities at the community nutrition center, this project was selected as a model in the region and a report on the nutrition program was presented to the Association of State and Territorial Public Health Nutrition Directors."1 Approximately 15 months after the initial evaluation, the follow-up study was made for comparison with data from a control group of 75 families from the Sudekum area of South Nashville. The residents of this area had substantially the same socioeconomic status as the Edgehill participants. Residents were given survey forms to complete which indicated their interest in the nutritional and health evaluation component. Practically all of the residents exhibited interest in the program, and this phase was coordinated through the Matthew Walker Health Center, the Multiphasic Screening Laboratory, and the Health Services Research Unit, all of Meharry Medical College. Families from the Edgehill area who were not previously registered with the Health Center were registered and brought to the Neighborhood Health Center for examination and for collection of blood and urine for nutritional evaluation. Those persons over 17 years of age went through the multiphasic screen for further health evaluation. Community Organization. The community organization was developed around the philosophy of improving the quality of life and toward meeting the long range needs of the people. A community council was formed consisting of nine members. This group described itself as a Select Committee Organized for Progress (SCOPE). The Council chairman presided at projecthosted meetings concerned with recreational space and activities for area children. These meetings were attended by local officials, representatives of local agencies, parents, and principals of schools as well as

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the Project Director, chairman of the Department of Biochemistry and Nutrition. Other Activities. A number of other activities were carried out at the project site which were designed for motivation, education and service. These included: a) Demonstrations and discussions in food preparation, purchasing and utilization, as well as other areas of home and family living; b) Information regarding all food and nutrition programs and services were kept current and available; c) Nutrition related activities were provided on a daily basis for a small number of pre-school children that otherwise would have been participating in no pre-school activity; d) Planned weekly activities for preteens, visual aides and relevant pass-out materials were available at the project site at all times; e) A "Crisis Pantry" was maintained at the project site on an honor system to assist families' immediate needs; f) Small plant and container gardening was a "grow your groceries" demonstration that resulted in numerous families doing the same in community; g) Seed and some vegetable plants were provided through the project site and in cooperation with Tennessee State University; h) Demonstration and assistance were provided to senior citizens including a Christmas dinner and party; i) Daily nutritious snacks were provided for small children in connection with the viewing of Sesame Street, sponsored by the Urban League; and j) Utilization of medical student volunteers and social science students from Fisk University in working with families and children on a limited basis and Health Forums in which medical students were involved. METHODS EMPLOYED IN BIOCHEMICAL ASSAYS

The methods employed for the determi-

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nation of serum ascorbic acid, urinary thiamine and urinary riboflavin was substantially the same as that employed in the ICNND Surveys.12 Serum vitamin A and carotene were determined by a modified procedure of Neeld and Pearson.13 Folic acid assays were carried out in accordance with the procedure of Cooperman.14 Serum iron and total iron binding capacity were determined by a modified automated method of Giovanniello et al.15 employing a Technicon Auto Analyzer and creatinine in urine was determined by the automated method of Chasson, Grady, and Stanley16 employing a Technicon Auto Analyzer System for Simultaneous Analyses. RESULTS

Serum Ascorbic Acid. Employing a value of less than 0.3 mg of ascorbic acid per 100 ml. of serum as being unacceptable, in the initial evaluation, 7% of the participants were found inadequate in vitamin C nutriture. However, the majority of the unac-* ceptable vitamin C values were found in the older participants. For example, no vitamin C unacceptable values were found in the 0-5 age group. On the other hand, 2.0%, 12.7%, and 11.0% unacceptable ascorbic acid values were found in the 6-20, 21-50, and over 50 age groups, respectively. The follow-up study revealed a decrease of approximately 43% in vitamin C nutritional problems with only 4% being inadequate as compared to the 7% in the initial and control groups. The only vitamin C unacceptable values were found in the 21-50 age groups. Urinary Riboflavin. Employing the ICNND12 suggested guide to interpretation of urinary vitamin excretion data, we found that at the beginning of the program the unacceptable riboflavin level among the participants was 19% with the unacceptable values being higher in the children and teenage groups than in adults. For example, 50% of the children in the age group 0-5 years exhibited unacceptable riboflavin values and in the age group 21-50 the unacceptable values were 16%.

NOVEMBER. 1976

In the follow-up study the unacceptable riboflavin values in the 0-5 age group were reduced from 50% to 9%, 6-20 age group from 26% to 0%, and in the 21-50 age group from 16% to 0%. The over-all riboflavin nutriture was found to be unacceptable in 5.3% of the population as compared to 19% initially. Urinary Thiamine. In the case of thiamine and employing the ICNND12 suggested guide to interpretation of urinary vitamin excretion data, in the initial study we found that 7.9% of the population had unacceptable thiamine values with the incidence being greatest in the 0-5 age groups (at a 17% inadequacy level) and being least in the 50 and over age group (at 0% level). It is interesting that the follow-up study revealed no thiamine inadequacy in any of the age groups. As previously reported,12 we found the urinary excretion of thiamine in mg./gm. of creatinine excreted to decrease with age. For example, age groups 0-5, 6-20, and 21-50 the ,xg. of thiamine excreted in the urine per gram of creatinine were 750 ,xg., 650 yg. and 350 ,ug., respectively. Plasma Vitamin A. Employing as borderline and unacceptable vitamin A levels of less than 25 ,Ag. per 100 ml. of plasma, the total population initially exhibited 30% vitamin A inadequacy with the greatest unacceptable values in children. In general, the level of serum vitamin A increased with age and in the over 50 age group, no vitamin A inadequacy was observed. The follow-up study indicated that still 28.6% of the population had borderline to deficient vitamin A levels. The reason for the apparent lack of change of vitamin A nutriture is not apparent at this time. Other secondary factors such as absorption may have been involved. Serum Iron and Folic Acid. Initially it was found in the population that the serum iron, folic acid and hemoglobin levels were unacceptable in 37%, 25%, and 8% respectively. The reevaluation of the population group in the follow-up study suggested slight improvement in these areas. For example, the unacceptable value for

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serum iron was reduced to 26.2% and for folic acid to 23.7 %. DISCUSSION

As well as this project improving the nutritional status of the population group as expressed by the laboratory data, there were many positive spin-offs in the community and the population group as a whole. The impact of some of these are still in the process of being evaluated. However, among those from which we have feedback may be listed the following: 1. Medical students involved in the project and also the community became much aware of the importance of nutrition in primary health care. 2. Students at neighboring institutions, Fisk University, Tennessee State University and Vanderbilt University became more aware of the team approach to health care. 3. This program served as a model for the importance of "Pot Gardening" or "Container Gardening" (Home Gardening) in improving the nutritional and health status of a low income population. The Task Force on World Hunger, Presbyterian Church, U.S. has funded a program through the Metropolitan Action Commission (Davidson County), for supplying seeds, fertilizer, etc. to 1,000 low or poverty level families for the purpose of planting home gardens throughout the metropolitan area of Nashville with the assistance of the State Agriculture Extension staff and members of the Tennessee State University staff. An eavluation of the effectiveness of these programs is being done. At present we are involved in this program in an advisory and consultant manner. 4. Qualitative reports from various departments at Meharry indicate that the health status of persons from the Edgehill Nutrition Area (general health status) had improved since the inception of the program. This was particularly true in the area of OB-GYN patients. 5. A number of our participants were in the class of senior citizens or elderly and reports that we continuously receive have all been positive. In fact a continued inter-

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est and application of good nutritional practices as promulgated in the program are still adhered to by many of the former participants and many with whom they are in contact. 6. This community project has had in a subtile way more impact on the area and care of patients than can be quantitatively documented at this time. At present we are developing a strong nutrition component concerned with health care at Meharry and we intend to reopen a Nutrition Service Center (Satellite Center) in Nashville and in cooperation with Meharry's primary health care activities. 7. Finally, we are in the process of reevaluation of the program since we have terminated our direct activity in the area for the purpose of ascertaining whether the initial impact and if any behavior changes of the participants as well as the community as a whole has been sustained. ACKNOWLEDGEMENTS

The authors gratefully acknowledge the able technical assistance of Mrs. Mary Scales Farris and Dr. Wanda B. High.

LITERATUJRE CITED 1. Nutrition Survey, Republic of Paraguay, May-August 1965, U.S. Dept. of Health, Education, and Welfare, Public Health Service Publication 1967; Nutrition Survey of the Armed Forces, Republic of Paraguay, May-

2. 3.

4.

5.

6.

August, 1965, Public Health Service Publication, 1967. Nutrition Survey, Institute of Nutrition for Central America and Panama, 1965. HIGH, E. G. Some Aspects of Nutritional Vitamin A Levels in Pre-School Children of Beaufort County, South Carolina, Am. J. Clin. Nutri., 22:1129-1132, 1969. CARTER, J. P. and R. VANDERZWAG, W. J. DARBY, E. J. LEASE, F. H. LAUTER, B. W. DUDLEY, E. G. HIGH, J. D. WRIGHT, and T. MURPHEE. Nutrition and Parasitism Among Rural Pre-School Children in South Carolina. J.N.M.A., 62:181-191, 1970. SIM PSON, 0. A Nutrition Survey to Document the Extent of Malnutrition in a Rural Georgia County. Bulletin, Fort Valley College, 1:6, 1969. SIMPSON, 0. and E. G. HIGH. Intercorrelations of Physiological Measurements and

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7.

8.

9.

10.

11.

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Body Mass. Bulletin, Fort Valley College, 1:18, 1969. Nutritional Status of Participants in the Children and Youth Program of Meharry Medical College, 1970 (An unpublished report) Ten-State Nutrition Survey, 1968-1970, U.S. Dept. of Health, Education, and Welfare, Health Services and Mental Health Administration, DHEW Publication No. (HSM), 72-8132. Preliminary Findings of the First Health and Nutrition Examination Survey, United States, 1971-1972. U.S. Dept. of Health, Education, and Welfare, Public Health Service, DHEW Publication No. (HRA), 74-1219-1. EDOZIEN, J. C. and B. R. SWITZER, and R. B. BRYAN. Medical Evaluation of the Special Supplemental Food Program for Women, Infants, and Children (WIC), Dept. of Nutrition, School of Public Health, Univ. of North Carolina, Chapel Hill, N.C., 1976. Association of State and Territorial Public

12.

13.

14. 15.

16.

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Health Nutrition Directors, Annual Meeting, March 30-April 1, 1971. Center for Disease Control, Atlanta, Georgia, U.S. Dept. of Health, Education, and Welfare, Public Health Service. Manual for Nutrition Surveys, ICNND, National Institute of Health, Bethesda, Md. Second Edition 1963. Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. NEELD, J. B., JR., and W. N. PEARSON. Macro- and Micromethods for the determination of Serum Vitamin A Using Trifloroacetic acid. J. Nutri., 79:454-462, 1963. COOPERMAN, J. M. Microbiological Assay of Serum and Whole-Blood Folic Acid Activity. Am. Jour. Clin. Nutri., 20:1015-1024, 1967. Technicon Auto Analyzer, Method No. N-621/11, October 1970. CHASSON, A. L. and H. G. GRADY, and M. A. STANLEY. Determination of Creatinine by means of Automated Chemical Analysis. Amer. J. Clin. Path., 35:83-88, 1961.

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