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CAPSTONE REPORT Alleviating Childhood Obesity on the Central Coast: Cunningham 1

Capstone Report—Alleviating Childhood Obesity on the Central Coast

Hannah Cunningham

Collaborative Health and Human Services—400B

California State University Monterey Bay

29 April 2016


ABSTRACT

I served as an intern with the Nutrition Obesity Education Prevention Bureau (NEOPB)

for three semesters, and through my experience I learned about the needs of residents in

Monterey County. My research showed a high prevalence of obesity in children of low-income

families. Given this reality, I implemented a capstone project that encourages the spread of the

health message. Designed for teachers, program directors, and educators in general, I created a

toolkit that has resources to teach several lessons on healthy eating, drinking water, and physical

activities. I created three toolkits of evidence-based resources that are pieced together in an

organized, creative way. Using worksheets, activities and other toolkit materials I created a

lesson plan from one of my toolkit sections, which I presented to a 3rd grade class at an

elementary school in Salinas.


PROBLEM STATEMENT

I have spent a year with the Nutrition Education Obesity Prevention Bureau (NEOPB), a

program of the Monterey County Health Department whose mission is to lower the risk for

obesity by focusing on education, services, and resources for low-income Californians in

Monterey County. During my internship I have worked with people of all ages, but for my

capstone I wanted to focus on the children of Supplemental Nutrition Assistance Program

(SNAP) recipients.

MONTEREY COUNTY

The obesity rate for Monterey County SNAP recipients is too high, and children are

especially at risk. In the county, SNAP adults are more likely to be obese, with a rate of 31.8%

obesity compared to the county’s rate of 25.1% (California Department of Public Health, 2014).

Children are even more likely to be obese as the adults in the family take care of them. in

Formerly known as food stamps, SNAP) is a valuable resource for families who are living at or

below 185 percent of the federal poverty level; as this benefit helps families buy food. With the

SNAP benefit, families can purchase most cereals/breads, produce, meat and dairy products at

accepting stores (United States Department of Agriculture, n.d.). However, there are many

factors that affect what food items SNAP users purchase. Market Match Bill AB 1321’s recent

passing allows incentives for those who shop at farmer’s markets to use their benefits there.

However, many families continue to purchase less healthy foods with their benefits for

circumstantial reasons (United States Department of Agriculture, n.d.).

Overweight and Obesity has been a long-established problem in the America, yet some

states are worse than others. For California, Monterey County has high obesity rates, especially


among those who receive SNAP benefits. Located on the Central Coast of California, it is ironic

that this agriculturally-rich land is at such high risk for obesity. In 2014, there were an estimated

431,344 residents in Monterey County, with a 57 percent Hispanic population, 31 percent White

with slightly over 10 percent of all other races combined (United States Census Bureau, 2015).

The County is split into five districts that have 12 cities and 30 unincorporated communities,

with 126 residents per square mile. Seventeen percent of persons who live in Monterey County

are below the national poverty line (United States Census Bureau, 2015).

BODY MASS INDEX (BMI)

The Centers for Disease Control and Prevention uses the BMI (Body Mass Index) Scale

as a way to measure body fat to determine overweight and obesity. The equation is the ratio of

ones’ height compared to their squared weight (BMI= kg/m2). An adult with a BMI resulting in

a BMI of 18.5-24.9 is considered of healthy weight, where those at 25-29 are deemed as

overweight and those with a BMI over 30 are considered obese (Harvard TC Chan School of

Public Health, 2015). Although this ratio is not a complete depiction of a person’s health status,

higher BMIs are consistently associated with heart disease, diabetes, cancers, and general

mortality rates, making it a useful tool to help determine the health status of an individual

(Centers for Disease Control and Prevention, 2013). The BMI rates for children are difficult to

define as a child is still undergoing development, but a more accurate reading can be given with

additional information, such as the child’s age and sex, with exact numbers for height and

weight. With this, a child under age 20 must be below the 85th percentile to be considered a

healthy weight. Numbers over the 85th percentile place a child overweight, and those over the

95th percentile are considered obese (Harvard TC Chan School of Public Health, 2015).


SNAP RECIPIENTS IN MONTEREY COUNTY

Monterey County has higher rates of overweight and obese populations compared to

some counties. There is a total of 148,968 Monterey County residents who fit the criteria to

receive SNAP, accounting for 37 percent of the entire Monterey County Population. However,

only 16 percent of those eligible are receiving the benefits (California Department of Public

Health, 2014). About half of SNAP-Ed eligible persons are below the age of 18, and over three-

quarters of the population eligible are Hispanic (California Department of Public Health, 2014).

Children of the SNAP-Ed community are at high risk for obesity, and Monterey County’s

numbers show the severity of the issue. Although double the population, San Francisco County

shows lower obesity rates within their SNAP-Ed Community. The percentage of people below

the poverty line are similar (13 in living in San Francisco and 16 percent in Monterey County),

but Monterey County still has a higher prevalence for obesity and lack of access to healthy food.

The County has ten percent more food insecure children than S.F., and the obese population for

SNAP-Ed recipients is double the rate for San Francisco County. (California Department of

Public Health, 2014). For the size and density of the area, Monterey County has especially high

obesity rates within their SNAP-Ed Community.

CONTRIBUTING FACTORS AND CONSEQUENCES

Figure 1: Problem Model Diagram) This diagram shows the causes and effects of the social

problem I am presenting. In the middle is my problem statement. On the left side of the diagram

are three causes to my problem, and the right side of the diagram has three consequences to the

problem.

CAUSE 1: LACK OF ACCESS TO HEALTHY FOODS


Monterey County grows a large amount of the countyy’s produce, but the people living

here have limited access to fruits and vegetables within walking distance of their homes. As a

result, many of these shoppers have to buy their groceries at a convenience store or other

alternative food outlets that serves more unhealthy options than healthy ones.

The plethora of unhealthy foods in low-income Monterey County communities in

comparison to healthy ones is one of the reasons that obesity is so widespread. Many families in

low-income areas have more access to energy-dense foods, such as snack items like cookies and

chips. As they consume more calories than are being burned off, the overweight and obesity

epidemic worsens (Ernersson, A., Lindstrom, T., Nystrom, F., & Frisman, G., 2015). Unhealthy

foods are considered to be energy-dense because they are packed with large amounts of sugar,

oil, salt and calories. Because unhealthy foods are so low in nutritional content, many feel

hungry afterwards and thus are tempted to eat even more junk food (Sarvottam, K., & Yadav, R.

(2014). A study conducted on 18 healthy individuals with no biological ties to obesity and

lifestyle diseases showed how rapidly someone can be affected by this lack of healthy food

access. When the group doubled their food intake, many reported feeling physically

uncomfortable with a severe lack of energy. For those who are already overweight or obese,

these symptoms were only heightened (Ernersson, A., Lindstrom, T., Nystrom, F., & Frisman,

G., 2015).

CONSEQUENCE 1: LIFESTYLE DISEASES

Obesity has long been associated with lifestyle diseases such as cardiovascular disease

(CVD), high blood pressure (HBP) and diabetes. Scientifically, the process of getting obese can

lead to these greater complications. When adipocytes experience an overload of nutrients (often


caused by overeating), inflammation occurs and causes low-grade, chronic stress on these cells,

putting the body at increased risk for obesity (Sarvottam, K., & Yadav, R. (2014). The

adipocytes being inflamed, the body is less likely to transmit inflammatory mediators which help

out the balance of nutritional overload, making it even more difficult for someone experiencing

this inflammation to lose weight (Sarvottam, K., & Yadav, R. (2014). If this constant

inflammation is not treated, it can lead to CVD or other diseases.

A majority of people experience weight gain in their abdomen as a side effect to obesity.

Called visceral fat, excess amounts of it have been linked to chronic kidney disease (CKD),

which has a relationship with HBP and diabetes. CKD is a growing disease, and the United

States has over ten percent of its population with some form of it (Hall, M., Do Carmo, J., Da

Silva, A., Junco, L., Wang, Z., et al. (2014). Because the body has to work harder to sustain an

obese person, obesity is related to high blood pressure, putting the obese population at a 70

percent higher chance of HBP later in life (Hall, M., Do Carmo, J., Da Silva, A., Junco, L.,

Wang, Z., et al. (2014).

CAUSE 2: UNSAFE NEIGHBORHOODS

Lack of access to fruits and vegetables can also be caused by living in an unsafe

neighborhood. Conditions such as poor lighting, little or no sidewalks, and gang activity make

people feel unsafe in their neighborhoods (Monterey County Health Department, 2011-2015). If

a family does not feel safe where they live it is highly unlikely that they will walk further

distance to go to a healthier grocery store or be willing to take the bus to do so.. Many families

have to purchase groceries at stores that are near their homes, and in the case of low-income

neighborhoods, these stores often sell more junk food than healthy food. . In studies conducted


in four states, it was found that a higher BMI was positively associated with a communities

where grocery stores were further away. participants in the study who were 3.5 miles away or

further from the nearest grocery store had a higher likelihood of being obese, with 47 percent of

the observed population being obese (Ghosh-Dastidar, B., Cohen, D., Hunter, G., Zenk, S.,

Huang, C. et al. (2014). The reverse was also true: having a grocery store within a half mile of

the person’s home lowered the community’s obesity prevalence 9 percent (Ghosh-Dastidar, B.,

Cohen, D., Hunter, G., Zenk, S., Huang, C. et al. (2014). Monterey County residents in low-

income areas report distance being an obstacle to their health. A South County resident claimed

“…it takes a long time on the bus and walking is dangerous” (Monterey County Health

Department, 2011-2015). It shows that many Monterey County residents have limited access to

healthy foods.

CONSEQUENCE 2: INACTIVITY

Low-income neighborhoods are characterized as underserviced, often with fewer

resources than a safe neighborhood typically has. There are fewer sidewalks, less lighting at

night, fewer parks and recreation centers, and further distance from healthy places to shop. Due

to these conditions, higher crime rates are common in low-income neighborhoods (Singh, G.,

Siapush, M., & Kogan, M., 2010). Residents in a low-income neighborhood often do not want to

risk going outside to get exercise, and many parents will not allow their children outside to play.

Because of this, there is a 40 percent chance that a person from an unsafe neighborhood is obese.

A person from a low income community has decreased opportunities for performing physical

activity due to the lack of space in their home and the safety conditions outside of their home

(Singh, G., Siapush, M., & Kogan, M., 2010). Due to this safety concern, girls are at an even

greater risk of obesity in low-income neighborhoods, especially those below age ten. Girls from


these neighborhoods are three times more likely to be obese than girls their age from safer living

areas (Singh, G., Siapush, M., & Kogan, M., 2010).

CAUSE 3: STRESS AND DEPRESSION

Obesity and obese-contributing behavior have a positive correlation with stress,

depression, and other issues pertaining to mental health. The side effects overlap and cause a

domino effect: obese persons are more likely to feel lethargic due to their eating habits, which

results in trouble focusing and being motivated, which can lower a person’s self-esteem and

cause depression (Ernersson, A., Lindstrom, T., Nystrom, F., & Frisman, G., 2015). Being in a

low-income family can have a greater impact on the situation. The person may feel anxious and

stressed due to their financial and living situations (Ghosh-Dastidar, B., Cohen, D., Hunter, G.,

Zenk, S., Huang, C. et al. (2014). A resident who is undergoing emotional health issues has

needs they prioritize above taking care of their bodies, so when focusing on survival, physical

health is ignored, possibly leading to obesity. Stress-eating can also be a link between stress and

obesity. A person undergoing severe amounts of stress has fluctuating cortisol levels, impacting

appetite and metabolism levels. Even on a scientific level, emotional distress can impact the

body’s physical health (Chowdhury, P. Balluz, L., Zhao, G., & Town, M. (2014). Hispanics with

diagnosed depression are at higher risk for obesity than any other racial group with the same

disorder; with a 17 percent higher chance of not engaging in physical activity (Chowdhury, P.

Balluz, L., Zhao, G., & Town, M. (2014).

CONSEQUENCE 3: POOR HEALTH CHOICES

People who are overweight or already obese are more likely to make poor health choices.

Seeing that damage has already been done, people who are overweight continue their diet and


exercise habits. A person with depression- may feel hopeless about becoming healthier when

they are already at risk for obesity and its negative side effects. Many people continue and even

adopt new bad habits when they feel it is too late (Ghosh-Dastidar, B., Cohen, D., Hunter, G.,

Zenk, S., Huang, C. et al. 2014). “Depression can increase ones’ risk for becoming obese and

adopting unhealthy behaviors such as smoking, physical inactivity and heavy and binge-level

consumption of alcohol (Chowdhury, P. Balluz, L., Zhao, G., & Town, M. 2014). When the risk

factors are already present, and life feels hopeless and scary, people tend to neglect their health

and physical activity and cope negatively through substances and binge-eating as means to

relieve stress (Ghosh-Dastidar, B., Cohen, D., Hunter, G., Zenk, S., Huang, C. et al. (2014).

Feeding habits become skewed with the presence of stress, and those who have a higher

BMI are 40 percent more likely to overeat when they are under stress (Dallman, M., 2010). The

part of the brain that controls stress levels also is in charge of memory, awards, and pleasure, so

when the body is feeling stress, eating rewards the brain with pleasurable feelings that seemingly

lessen the stress. Often called ‘comfort food’, foods high in fat and sugar are often craved when a

person undergoes high-stress situations (Dallman, M., 2010).


Figure 1: Problem Model Diagram

HEALTHFUL PRACTICES TO ALLEVIATE OBESITY IN CHILDREN

For my internship, I was placed with the Nutrition Education Obesity Prevention

Bureau (NEOPB), a program of the health department whose mission is lowering the

risks for obesity through education, services, and resources. Second semester in, I

worked side-by-side with my mentors Christine Moss and Charmaine Kaplan, along with

other employees of NEOPB to improve the health conditions of families and where they

live, work, play, and shop. Through my hands-on experience I unexpectedly discovered

that I wanted to work with children. Taking this idea I have implemented a capstone

project that addresses health topics not consistently discussed with the grade school

population, hoping to increase awareness of healthy eating, drinking and exercise as

means to lower obesity rates for Monterey County.


AGENCY DESCRIPTION

This agency was originally known as the Nutrition Network but was later adopted

under a new name a few years ago, due to issues in agency funding. Now called NEOPB,

the agency is a small sector of the health department that leaves a huge impact on

Monterey County. The program has several partners from the community, California, and

the United States working collectively to improve health conditions for low-income

families. Because of the variety in partnerships, NEOPB has an advantage of reaching its

population from all angles. There are educational programs which go out into the

community and deliver information and knowledge about a healthy lifestyle for children,

teens, adults and the elderly. Many of these programs such as Harvest of the Month

(HOTM) go out into the communities of low-income persons to educate the population

on obesity prevention and nutrition education. Brochures, informational sheets, and

pamphlets are provided. Resources are also provided for low-income families to help

them increase their produce consumption and physical activity, such as SNAP-Ed

(Supplemental Nutrition Assistance Program-Education), WIC (Women Infants

Children), senior vouchers for farmer’s markets, and other food assistance programs.

NEOPB also conducts informational surveys to identify community risks and raise

awareness of health disparities. The tri-county survey Rethink your Drink and the

Walkable Communities project have opened the eyes of the community, media, and

elected officials to the health issues around Monterey County. Overall, NEOPB has an

ultimate goal of doing what it can to increase physical activity and vegetable

consumption for low-income areas.

CAPSTONE PROJECT


My agency has a variety of resources available for obesity prevention education. There

are pamphlets, diagrams, facts sheets, studies, videos, books and other sources for people we

serve from all walks of life. As a starting intern, I was overwhelmed by the amount of

information available and confused as to why so few understand the basics of a healthy lifestyle.

I made it my goal to bring the resources to the population in a manner that is easier to memorize

and understand. As my project, I am developing a resource kit for elementary school educators to

perform lessons on mindful eating, drinking water, and exercise.

These three sections (healthy eating, drinking water, and physical activity) have one or

more lesson plans inside so educators can pick and choose what they teach their students. All

teaching tools and resources are provided in the box.

PART ONE

Part one is a lecture component on seasonal nutrition, inspired by Harvest of the Month

lectures. Appendix A shows this component in detail. There are four produce lesson plans

available for each season, complete with a newsletter that has nutritional content, history, and

other facts about the particular vegetable of fruit (A2); and recipe cards to create samples for

educators and students to try (A1). I also have Nutrition Education Reinforcement Items (NERI)

available as incentives for children who answer correct questions during lecture. NERI items

come in for the form of stickers and bookmarks, both with templates that can be re-printed (A6

& A7). To take home to parents or guardians are newsletters for all Harvest of the Month items

(A3).


Included with the produce lessons is an activity. In the box is a Velcro human-shaped cutout

(A4) , and a picture of each produce item (A5) with matching velcro on the back. Educators can

ask the students to place the produce item on the Velcro human wherever the produce is helpful.

For example, carrots are high in vitamin A, which is good for the eyes, so the student can place

the velcro carrot over the eye area on the velcro human. This activity is interactive and makes a

powerful visual for the learner.

PART TWO

Also shown in Appendix B are activities and worksheets that stress the importance of

drinking more water. I am using popular items derived from the Rethink Your Drink toolkit,

premeasured sugar amounts for popular sugary beverages, such as soda, sweetened tea, juice,

energy drinks, and sports drinks (B2). This section of the kit also has drink labels for the

drinks (B1) Potter the Otter Who Loves to Drink Water (children’s book) (B8) and NERI

stickers (B9), and a parent newsletter for students to take home to their families (B10).

This section of the toolkit also has worksheets that can be suitable for most

elementary school grades, such as a ‘How Much Sugar?’ label calculating activity (B4) , a

Go for H20 activity sheet (B6), and a “What are my Influences?” worksheet (B5) that allows

the children to brainstorm why they may drink water and to discover reasons why they

choose other unhealthy beverages. For more information about sugar sweetened beverages,

vocabulary and nutrition lessons are ‘Learning the Facts’ cards (B7), where each card has an

informative message related to the Rethink Your Drink section of the toolkit.

PART THREE


Part three is my exercise portion of the capstone, in which there are 3 different

physical activities described and complete with the tools needed. For this section, I pulled

activities from Champions for Change resources that can be used as indoor or outdoor

complete workouts. All of the physical activities are designed to be full-body workouts, to

complete the theme of taking care of the entire body, inside and out. In the toolkit is the

Shape of Yoga booklet (C1), the Power Play! Power Cards (C2) and a worksheet listing the

rules for The Color Game (C3). A detailed list of the activities in part three are explained in

depth in Appendix C.

These three parts work of my toolkit work remarkably well together to share my

message: students will learn about nutrients (part 1), cleaning out their insides by drinking

water (part 2), and doing a physical activity to take care of their insides (3). It is

comprehensive—take care of the body on the inside, and you’ll shine bright on the outside.

That is my goal.

Figure 2 Gantt Diagram: this is a timeline and activities for my capstone project. This

helps me organize my future to ensure my project goes smoothly.


FIGURE 2: PROJECT ORGANIZATION

ActivityCurriculum developmentCondense lesson plan (3 plans/3 pages each)Practice presenting the projectAny needed revisions/gather materialsRecruitmentDevelop list of potential participantsSend InvitationsWorkshop implementationCall and confirm workshop attendanceWorkshop presentationEvaluationImput data from surveysAnalyze dataFinal write up and capstone presentationWrite implementation paperWrite results from evaluationCompile capstone reportGraduate!

HOW DOES THIS REACH MY GOAL?

With my capstone, students will better understand their health as they understand the

way their bodies work and how to treat them right. I notice that many people know what to

do to take care of themselves but few understand why, and keeping the child’s constant

curiosity in mind, I wanted to deliver answers in a way that was engaging and would make a

lasting impression.

Obesity in Monterey County is a big issue, and the widespread problem starts early.

Teaching a holistic approach on health can be the answer to the obesity crisis. This approach

makes a healthy lifestyle achievable and participants are more likely to reach their desired

results because they are addressing more than one component of health. Someone may

understand all there is about healthy eating, but that is nothing if they suffer emotionally. On

the contrary, someone can be spiritually sound but if they don’t engage in physical activity

their health can suffer. There are a number of examples for people who neglect parts of their

health. Putting too much emphasis on any one component of health can be detrimental and


cause burnout, and in our fadist society this is all too common. I offer well-rounded, healthy

lifestyle—nobody is perfect, and making an effort wherever you can is a sure way to stay

healthy.

CAPSTONE IMPLEMENTATION

The first words of wisdom from my mentors were about getting used to rolling with the

changes that occur in an agency. Government funded or non-profit, the field of Health and

Human Services is full of continuous change- from big policies to small, every day schedule and

task changes. With my capstone presentation, I expected things to run smoothly simply because

of my status as a college student. However, during the implementation phase I began to truly

understand how agency changes can impact me in this line of work.

Deciding on an idea for my Capstone was a major challenge in the beginning. Interning

for a government-funded organization, I was discouraged from many of my ideas. I found many

of my suggestions on improvement were being met by countless other programs implemented by

the Health Department. It seems my agency already ‘had it all’.

As I continued to think about what I would do, I thought of many creative ideas that were

unfortunately unfit for the county format. The Health Department is respectfully picky with what

they can and cannot represent, so even though my ideas were new, I was unable to implement

due to government rules. I began to feel stuck trying to create my capstone.

Around December an idea finally clicked with me. The information is all provided from

the Health Department. I was trying to reinvent the wheel in the way I tried to implement

entirely new programs. Coming up with more information was not getting me results because I

do not need to add more information to the Health Department- they are a ‘one stop shop’-


everything they need is already provided, as my mentors would say. From there, I determined

that lack of information was not the problem; it was the lack of distribution of the resources. The

Health Department has all the information needed to educate the public, but how does it get to

the public? I then received the idea of creating a teaching toolkit. I liked the idea because I was

able to pull together already approved, successful, evidence-based resources in a creative way.

My toolkit idea was quickly approved by my mentor Ms. Moss and co-mentor Ms.

Kaplan, who seemed very excited about my Capstone. The plan was to piece together resources

already provided by the Health Department in one briefcase style kit. I wanted to put educational

books, handouts, NERI (incentive items), pamphlets, and other items that can help educators

teach nutrition and physical activity lessons to grade-school children. I would do a presentation

explaining how the kit works and what is inside, and teachers or after school program directors

can request a kit for free.

I was excited, but a few roadblocks were coming my way. My mentors stressed ideas of

sustainability, meaning the kit would be most effective if items can be duplicated and replaced at

little to no cost. With the unpredictability of agency funding, it is important to provide resources

that can be fluid with the changes of funding. While I found many of the teaching resources

printable and available online, I spent hours looking for online organizations that offer free NERI

(Nutrition Education Reinforcement Items- incentives). I wanted to hand our free nutrition and

recipe books as I see my agency do, but I was told it was not acceptable because teachers cannot

receive these NERI items in bulk free of cost. That was the most challenging endeavor I had

while making this kit.


Fortunately, after an undefinable amount of corrections and redo’s, I created a toolkit that

is widely informational, cost-friendly, and sustainable throughout agency funding and other

changes. Now it is time to find participants for my Capstone Presentation.

On February 24th I gave a short description of my project to approximately 30

representatives from health departments in Monterey, Santa Cruz, and San Benito Counties at

our quarterly Tri-County meeting. Out of that number, a woman named Ms. Cheryl Camany

displayed her interest to me. She is a Homeless Liaison Teacher on Special Assignment at

Sherwood elementary, an elementary school who is heavily involved with the community. She is

the perfect recipient for my educator toolkit and she also has valuable connections to whom I can

share the kit with. She asked me to create a 30-45 minute interactive presentation for a number of

teachers that can request a free toolkit if interested.

Essentially, my ten-minute toolkit description would not be used for my capstone, as I

had to make a lesson plan out of my toolkit contents. I was disappointed as I went from being

ahead on my project to being behind, but I do not want to show my mentors that I have difficulty

adjusting to change. I prepared myself to start over and create my interactive adult presentation. I

was a third completed, and feeling confident about the presentation. I have more experience

interacting with adults that I do with children, so I was happy that I did not have to present to

kids. I feel it is important for me to focus on the positive in this situation- if I cannot find

something about this presentation that makes me feel like it’s going to be okay, my capstone

experience will be a nightmare. I began making the needed changes from scratch.


Unfortunately agency changes never stop, as I soon learned. I receive an email from Ms.

Camany on March 9th, explaining that I would be presenting to the children instead, as she would

like know what grades I would like to present to.

Overwhelmed with more sudden changes and frustrated about having to present to

children now, I contact my mentors, hoping that they would tell me that this was unacceptable. A

lot of my capstone work was being undone due to the changes, and I was worried about time. My

mentors agreed that Ms. Camany was not being clear in what she was looking for, but that I had

to ‘roll with the punches’, as many agencies experience abrupt and large changes such as this.

After all, Ms. Camany knows Sherwood Elementary’s needs better than I do, so I have to give

her the benefit of the doubt. Ms. Kaplan was a great help in picking me back up. She empathized

with me, which was just enough to mentally prepare me for a presentation to a third grade class.

Even if the situation is wrong, it feels much better knowing that I am not the only one feeling a

certain way. I was even more determined to display to Ms. Camany how calm and collected I

was despite the change in direction. The situations actually gave me even more confidence to do

better.

I discussed the idea with Ms. Camany about presenting just a section of my toolkit so that

I do not stress the students out with too much information. We agreed that the Harvest of the

Month section was not interactive enough and the Physical Activity section would make the

students restless afterwards. The Rethink Your Drink section of the toolkit is interactive,

informative, and I have not seen the message discussed by the Health Department since my first

semester, so I was happy that we chose to do my presentation on this section.


Ms. Kaplan helped me with the order and layout of my presentation. It is 30 minutes and

action packed, with activities involving, cups, pouring sugar, making a healthy beverage, and

interactive discussion with hidden survey questions embedded in the lesson plan. Without taking

up extra time a teacher cannot spare, I can still get my data points for my evaluation without

handing out a survey. On March 28th, Ms. Moss and I spent hours practicing the presentation.

She pretended to be Joshua, a pesky 3rd grader and my worst critic. Handling awkward and

difficult situations during presentations to children is very important to plan for, and the

scenarios she gave helped me with my presentation skills.

On March 30th, I was on my way to my internship site, and was feeling very confident

about giving my presentation to Ms. Camany. Unfortunately on my way to the site I got into a

car accident and had to cancel my appointment, setting me back a week on my Capstone

presentation. Devastated by the results, I still feel okay about my project, and I am thankful for

these tough past weeks that have strengthened my coping skills. Given this circumstance, I will

present my presentation to Ms. Camany on April 6th. and will be giving the presentation to a third

grade class on April 14th.

Ms. Camany had more suggestions of other things I can do that the students at Sherwood

Elementary would understand, such as hand signals to be quiet and seated. I appreciate this

information because with the use of these signals, the students will view me as less of an insider.

I am communicating with body language they understand. With that, I suspect that my

presentation on April 14th will go very well. I am prepared and excited to see the results.

REFLECTION AND ANALYSIS

EXPECTED OUTCOME


The goal of my capstone project and report was to create a sustainable toolkit that can be

easily navigated by educators- and as the process unfolded my end product was much more than

that. I created three reusable, information packed toolkits, a presentation for one of my toolkit

sections that is appropriate for elementary school children, and I presented to a third grade class

an important lesson derived from my toolkit contents. I stepped out of my comfort zone much

further than I was expecting to, and I revised my presentation more times than I could count, a

presentation I was not even planning to do. This capstone project has been developed and

reviewed to a point where I could not be more proud of my work. I am grateful for all the

experiences I have had during my capstone implementation.

OUTCOME MEASURES

Because of my addition of the schoolchildren presentation I decided to implement survey

questions inside of my presentation as a sneaky way of evaluating the experience. The students

can raise their hands if they agree with what I say, and my mentor takes the hand count. I like the

survey questions embedded into the presentation because students are given the opportunity to

review what they were learned without taking extra time to fill out a questionnaire. It also is a

great way to reinforce the message and help the students remember.

I handed out stickers for all participants. I knew my presentation involved a great deal of

discussions and activities, but I was still worried that I would not have the chance to give each

student at least one sticker. I called on two girls then two boys each time until I noticed each

student had at least one sticker on his or her desk. About half of the students had more than one

sticker, and 3-6 students had three stickers. I tried to ensure a student did not have more than four


stickers, and as the students laid their stickers out neatly on their desks, I was able to see how

interactive my presentation was.

RESULTS

For the first activity of my presentation the students and I reviewed five reasons why

water is important to drink. I asked the students to help me brainstorm, and at the end of our

discussion, we took a hand count for the number of students who felt a particular reason was

their favorite for why they drink water. The first reason discovered was “after we exercise” (18),

followed by “it is free (2)”, “to live and grow” (3), “cleans your insides” (9), and “when we are

thirsty” (21). I found it interesting that the last answer to be discussed, “when we are thirsty”,

had the most hands raised as the most important reason to drink water. The less popular reasons

“it is free” and “to live and grow” were given low scores for why water is important to drink.

The two most popular answers, “after we exercise” and “when we are thirsty” were given high

scores, and this data is somewhat alarming to me. If children believe that water is most important

for thirst and exercise, they may only drink water when they are thirsty or when they exercise.

During my second activity I had a participant help me demonstrate how many cups of

water to drink a day. The participant set a cup on the table and we asked the students if this was

enough water for the day. As most of the class agreed that more water was needed, the

participant put 3 cups on the table, in which 4-6 students felt this amount of water was sufficient

each day. After 5 cups were placed on the table, approximately ¾ of the classmates felt 5 cups of

water each day was enough, even with physical activity. A few of the students were stunned

when they learned about 8 glasses a day being a sufficient minimum for water drinking.

According to my responses, I can conclude that many students are not drinking enough water.


My third activity was viewing the sugar content of various popular drinks, and my

reactions were delightfully and surprisingly shocking. As I showed the students the amount of

sugar inside of sodas, energy drinks, and popular juice drinks, they seemed very surprised and

intrigued at the amount of sugar inside. The first time I heard students speak other than when

they raised their hands was a collective “woah” as I showed them the amount of sugar in a 12

ounce bottle of Sprite. This was my most rewarding feeling throughout the presentation, and I

am confident that the students will remember this for a long time.

After all of the learning and with the help of 6 volunteers, we created “Real Fruit Punch”,

a healthy beverage with seltzer water and a variety of fruits without added sugar. The students

were very eager to volunteer and many of them displayed appreciation for the drink and all of the

fruits inside. This point of the presentation was where I received the most student interaction.

Most of the students wanted to join in creating and distributing the drink and were much more

excited than students who were responding to my lesson questions. I can understand, at least for

this classroom, the students enjoy participating and kinetic learning but may be nervous about

displaying their knowledge verbally. From 24 students, 21 of them enjoyed the beverage and the

same number would recreate the drink for their families and friends to try.

RECOMMENDATIONS

Overall, I am pleased with the data I received and I feel so clever with how I snuck

survey questions into the presentation. In the end, I am happy I had to present to the students

because I received good data without taking up the time of teachers or other adults, and I also

made a lasting impact on these third grade students. I taught a lesson that is not often covered in


my agency’s line of work, and I created a resource that will be sustainable throughout all agency

changes.

If I could go back and change parts of my capstone I would have wished to give my

message to a few more classrooms. I would have made a larger impact and would have more

reliable data if I executed my presentation to more than one classroom, or even to more schools.

The extra time in presenting would also strengthen my message and give me more confidence.

Ms. Casteanoz commented that every teacher would benefit from this lesson , which makes me

proud but also makes me wish that I had presented to more classes.

Although my presentation was only thirty minutes, I created a toolkit that will last for

years, through all sorts of agency changes, and with a trusted name as the Monterey County

Health Department, I am confident that my toolkits will find their way into the hands of people

who will need and use them. I created three toolkits. I will give one toolkit to Ms. Casteanoz for

allowing me to present to her class, and I do not have plans for the other two kits. I hope one of

my toolkits will get to stay with the health department- there are so many resources that the kit

may be forgotten for some time, but occasionally one of the women of the office will rummage

around and find it and perhaps use the tools again. My agency will likely keep my original kit as

a template for future kits to be made. I anticipate two toolkits to be given away to needed

agencies or organizations and to have one template toolkit for the health department to keep.

I believe my Capstone project is going to be sustainable even after my internship is

terminated. I have created a resource that is sustainable through agency funding that is a great

display of resources offered by NEOPB. I have also gained understanding about elementary

school students and how they learn, as well as share a health message with 24 students from


Sherwood Elementary. The internship has shaped me into a better professional and I am grateful

I was able to make an impact at my agency.


REFERENCES

Chowdhury, P., Balluz, L., Zhao, G., & Town, M. (2014). Health behaviors and obesity among Hispanics with Depression, United States 2006. Ethnicity & Disease, 24(1), 92.

Dallman, M. (2010). Stress-induced Obesity and the Emotional Nervous System. Trends in Endocrinology & Metabolism, 21(3), 159-165.

Defining Overweight and Obesity. (2013). Centers for disease control and prevention. Retrieved from www.cdc.gov/obesity/adult/defining.html

Ernersson, Å., Lindström, T., Nyström, F., & Frisman, G. (2010). Young Healthy Individuals Develop Lack of Energy When Adopting an Obesity Provoking Behaviour for 4 weeks: A Phenomenological Analysis. Scandinavian journal of caring sciences, 24(3), 565-571.

Ghosh-Dastidar, B., Cohen, D., Hunter, G., Zenk, S., Huang, C., et al. (2014). Distance to Store, Food Prices, and Obesity in Urban Food Deserts. American journal of preventive medicine, 47(5), 587-595.

Hall, M., Do Carmo, J., Da Silva, A., Juncos, L., Wang, Z., et al. (2014). Obesity, Hypertension, and Chronic Kidney Disease. International journal of nephrology and renovascular disease, 7, 75.

Michimi, A., & Wimberly, M. (2010). Associations of Supermarket Accessibility with Obesity and Fruit and Vegetable Consumption in the Conterminous United States. International journal of health geographics, 9(1), 49.

Monterey County, California. State and County Quickfacts. (2015) United states census bureau. Retrieved from quickfacts.census.gov/qfd/states/06/06053.html

Monterey County Community Health Assessment (2013) Monterey county health department. Retrieved from https://www.cdph.ca.gov/data/.informatics/Documents/Final_CHA_pdf_11_12_13.pdf

Monterey County Supervisors and Their Districts (n.d) Clerk of the board, county of monterey. Retrieved from www.co.monterey.ca.us/cob/supervisor.htm

Obesity Definition. (2015) Harvard t.h. chan school of public health. Retrieved from www.hsph.harvard.edu/obesity-prevention-source/obesity-definition/

Riobó Serván, P. (2013). Obesity and Diabetes. nutrición hospitalaria, 28 Suppl 5, 138.

Sarvottam, K., & Yadav, R. (2014). Obesity-Related Inflammation & Cardiovascular Disease: Efficacy of a Yoga-Based Lifestyle Intervention. The indian journal of medical research, 139(6), 822.


Singh, G., Siahpush, M., & Kogan, M. (2010). Neighborhood Socioeconomic Conditions, Built Environments, and Childhood Obesity. Health affairs, 29(3), 503-512.

SNAP-Ed County Profiles. (2014). California department of public health. Retrieved from https://www.cdph.ca.gov/programs/cpns/Pages/2014SNAP-EdCountyProfiles.aspx

Strategic Plan (2015). Monterey county health department. Retreived from www.co.monterey.ca.us/cob/Supplemental_Addendum%202011/December%2013%202011/5-3%20Final.Health%20Strat%20Plan%20Proposed.pdf

Supplemental Nutrition Assistance Program Education SNAP-Ed (n.d). United States Department of Agriculture. Retrieved from www.fns.usda.gov/sna[supplemental-nutrition –assistance-program-education-SNAP-ed


APPENDIX A

1) Recipe Cards: For all/most of the produce items are recipe cards that use one or more

of the produce items presented in the teaching kit. The recipe cards come in English and Spanish

on the reverse side.

2) HOTM Educator Newsletter: A two-page fact sheet for each of these 12 produce

items:

Winter: apples, persimmons, tomatoes, winter squash

Spring: grapefruit, mandarin, beets, cabbage

Summer: carrots, cucumber, strawberries, avocados

Fall: pepper, corn, grapes, peaches

Each newsletter has botanical information, history, fun facts, nutritional content, and sample

recipes for each item listed above.

3) HOTM Parent/Guardian Newsletters: A one-page fact sheet for the 12 produce items.

It is a condensed version of the educator newsletter.

4) Hungry Human: A 2ft x 1ft human shaped silhouette laminated and covered with soft

Velcro dots. Produce items with the complementing Velcro can be placed on parts of the human

to visualize and understand how the [nutritional breakdown/content] of produce items have an

impact on our health.


5) Produce for Pinning: Each produce item is available in a laminated picture with rough

Velcro dots on the back. Used in conjunction with the Polka-Dot Human. The laminated produce

pictures can also be modified into an activity [see The Color Game].

6) Sticker Template: “Ask me about _________” stickers. A sticker template is provided

via CD with pictures of the produce items. Educators can change the sticker depending on the

produce item they are that but I don’t know how to phrase this better)

7) Bookmarks: There are two different bookmarks for that can be given out as prizes, one

promoting water and one promoting produce consumption. One side of the bookmark has a list

of demands for produce consumption and water drinking, and the other side has the dangers of

the opposing bad habits and tips on how to make healthier choices.

APPENDIX B

1) Drink Labels: Labels are provided for 12 different drinks. The Nutrient Facts table is

also present along with a generic picture of the drink type. Beverage containers are not included.

Educators can use the drink labels to put on their own containers to show students how much

sugar is in their drinks. Bottles are washed out and relabeled with their beverage type. The

purpose is visual, so students can see how much sugar is in their bottled beverage.

2) Premeasured Sugar Baggies: The number of grams of sugar inside each beverage type

above have been measured in grams and poured into individual bags with the appropriate label.

These will be used to display how much sugar is inside the particular beverage, as the students

pour the bag contents into the beverage container.


3) Funnel: To be used to pour premeasured sugar into the beverage container.

4) How Much Sugar Worksheet: This worksheet is for students to fill out to calculate the

amount of sugar that is in the beverage. It is a template that can be used for any nutrition label.

The purpose is for students to practice reading labels and to understand how much sugar is in

their favorite drinks. The worksheet is appropriate for 4th-6th grades.

5) What Are My Influences Worksheet: This worksheet is a great brainstorming activity

that students can fill out that helps them explore their beverage choices. Students are prompted to

think about what drinks they have consumed over the course of 1-3 days, and write about why

they choose the drink they did. It also encourages students to think about how they will make

healthier choices in the future. [The wording on this worksheet is above the intended grade level

(1st-3rd grade) So perhaps this worksheet will not work, or it can be filled out in groups/as a class

to get everyone together and talking about beverages and why they drink them. I have a few hard

copies of this worksheet so I can show you next time we share a visit.] Make one yourself and

make it for 1st-3rd grade. Words must have one syllable and make it as short as possible.

6) Go for H20 Worksheet: This worksheet is appropriate for any students from

Kindergarten to 3rd grade. In the water bubbles, students can write their own reasons for why

they choose to drink water every day. It can be fun to share the different answers with the class.

Educators may choose to perform this exercise before and after the lesson to compare knowledge

and answers.

7) Learning the Facts Cards: These fact cards explain to students the definitions of terms

regarding beverage consumption, such as ‘added sugar’, ‘nutrients’, ‘liquids’ or ‘tooth decay’.


Cards can be used by themselves or can be modified into an activity [see The Color Game]. I

have these cards hard-copy.

8) Potter the Otter: This children’s book can be used for Kindergarteners to promote

water over sugar sweetened beverages. The book has games and tips about making healthier

choices, with English and Spanish on the same page.

9) Potter the Otter Stickers: Inside of the toolkit are two rolls of Potter the Otter stickers,

with all the characters from the storybook on the sticker with messages that promote drinking

water. Sticker messages come in English and Spanish on both rolls.

10) Making Healthy Beverage Choices (parent/guardian newsletter): The newsletter has

ten tips about how to make healthy beverage choices, how to add more water into the diet and

tips on drinking more water. Information available in English and Spanish.

APPENDIX C

ols needed to teach these physical activities.

ITEMS FOR THIS SECTION

1) Shape of Yoga (booklet): Created by Power Play! Is a basic yoga routine that is

suitable for all ages. Each pose has a picture, instructions on how to perform it, and how that

particular pose is beneficial for the body. This is designed to give a full body workout for any

student and helps them connect their minds and bodies together. [Also, I want to show workouts

that require little or no tools so that any child can perform them at home.]

2) Power Play! Power Cards: Created by FitDeck, Inc., These cards can help Educators

create a unique workout with the help of their students. There are 50 cards with workout moves


for upper middle, lower, and full body workouts. Also present are 6 healthy tip cards,

instructions, frequently asked questions and examples of games that can be used with these

cards. The cards are interactive and all students can have a chance to pick a card or perform the

activity.

3) The Color Game: The Color Game is an easy-to understand game that gets kids

moving and comes with several variations. As a bonus, the Color Game has several

modifications. Students can also get educated about produce and water consumption by using

resources from parts 1&2 of the Capstone project. Game directions and modifications are

provided in a worksheet.


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