Erin Moore-Miner WaiSze Tam (Rickie) Kyla Channell Fawaz Aljanar NUT 118B Grant Proposal 03/12/14 Teen

Diabetes Assistance Program Program: We are writing to propose a nutrition and health intervention program to address the increasing prevalence of Type II Diabetes Mellitus (T2DM) in children ages 15 19 in Cape Town, South Africa. Teen Diabetes Assistance Program targets teenagers who have been diagnosed with T2DM with interventions to reduce diabetes and associated overweight and obesity, improve their nutrition status, and prevent future health decline. Problem: Cape Town is a densely populated urban village that lacks the availability of nutrient- dense foods. Foods commonly consumed contain high calories, but poor nutrient content. Obesity is rapidly increasing among children and adults. Teens in Cape Town have experienced an 18% increase in T2DM from 2005 to 2012. In addition, 25% of this population is overweight and 15% are obese. Teens are of interest to our program because they lack access to nutritional foods and tools to maintain healthy blood glucose levels to control their diabetes which contributes to health decline. There is also little access to clean water and proper sanitation. Reasoning: Our target population of teens with diabetes is of interest to our program because they lack access to nutritional foods, education about nutrition, and the opportunity to engage in aerobic exercise. By providing this population with nutritious

foods and nutrition education, we will promote reduced incidence of T2DM, overweight and obesity. Program Design: Teen Diabetes Assistance Program will provide families with children ages 15 19 with T2DM in Cape Town with general nutrition education and specific information related to diabetes and obesity, food preparation instruction, access to resources including a food bank and solar cookers, and aerobic dance classes to increase physical activity in our target population. Goal: Our goal is to provide intervention strategies to ameliorate diabetes by providing nutrition education and resources to teens with diabetes and their families in Cape Town to reduce the prevalence of T2DM, overweight and obesity. Our objectives for the program include: ! 1) Health Objectives: By 2016, the prevalence of overweight (BMI 25-29.9) and obesity (BMI 30-34.9)

among the 15-19 year will be reduced by 5% to normal weight (BMI 18.5-24.9). 2) By 2016, the incidence of Type II Diabetes Mellitus in Cape Town teens ages 15

19 will be decreased by 5%. ! Behavioral Objective: By 2016, 50% of teens ages 15 19 with diabetes will be

able to list three foods high in carbohydrates. ! Process Objective (System Based): By 2015, the programs nutrition educators

will have provided a nutrition class with information on diabetes and obesity management to 25% of teen diabetics in Cape Town.

Prevention Level: Our program is aimed towards tertiary prevention for our four objectives as we will work with teens to help them manage and reduce symptoms and health risks associated with diabetes and obesity. First Approach: Our program will implement two approaches to reduce the incidence of T2DM and obesity, and improve nutrition in teens. Our first approach provides cooking instruction that includes nutrient-dense foods and solar cookers to teens and their guardians to increase the nutrient content in their daily diet while focusing on meals that improve healthy blood glucose levels and promote healthy weight. We plan to utilize a mobile kitchen with a foodservice truck for cooking class instruction. We will provide a short information session at the beginning of the cooking class that introduces a topic related to nutrition for diabetes and weight management. Then, we will provide a cooking demonstration. Participants will have the opportunity to sample the prepared foods at the end of the class. We will also provide solar cookers to participating families and instruction on how to prepare meals using this method. We will provide food and water subsidies to participants in the Teen Diabetes Assistance Program that includes ingredients used in cooking demonstrations. Our team of registered dietitians and health professionals will include a Certified Diabetes Educator. We will measure fasting blood glucose levels to assess the effectiveness of our first approach of our first approachs goal to improve blood glucose levels in teens with diabetes. Our first approach is aimed at tertiary prevention to reduce the diabetes and prevent further health issues associated with diabetes and obesity. Operating Effectiveness: A preliminary evaluation of our program plan revealed that our first approach will have coverage for our target population with some leakage due to

possibility of siblings and parents being present during cooking demonstrations who will consume prepared foods and food subsidies being consumed by members of the family other than teens with diabetes. Leakage may occur if food that is given away from the food bank to teens is given away to their families or sold to make money. Coverage will focus only on teens 15-19 years old with T2DM that participate in the program. The efficiency ratio will be 1:20 dietitians to teens. This ensures that teens receive adequate advice from dietitians and we will be able to provide cooking/nutrition classes regularly. Permanency may be at risk due to lack of adherence to the program and the instability of the target populations living environment. Second Approach: We will implement exercise sessions multiples times per week involving cultural dance as part of the Teen Diabetes Assistance Program. We will focus on aerobic activity that works different muscles groups and promotes an increased heart rate with the use of music generated from instruments and singers found locally. Operating Effectiveness: The coverage we are focusing only on teens 15-19, there are no other target groups to take the benefits of our population. There may be leakage to younger children while the dance classes are in session if they are being watched by their teen diabetic older siblings who attend. The efficiency ratio will be 1 dance teacher to every 30 teens. Permanency will also be at risk due to lack of adherence to the program and the instability of the target populations living environment. Measurement/data collection: Upon registering in Teen Diabetes Assistance Program, participants will take part in baseline data collection including HBA1C, postprandial blood glucose levels, height, weight, BMI, weight-for-height ratio, and abdominal circumference. We will measure weight, height, blood glucose and calculate

BMI monthly to chart changes over time. We will measure HBA1C and abdominal circumference to monitor visceral fat quarterly. We will document when a participant attends a cooking/nutrition education class or dance session. We will give small verbal diet recall questionnaires to teens about weekly food intake and weekly physical activity. We will assess our data by checking our attendance lists to compare health outcomes in those who exclusively attended dance classes to teens who exclusively attended cooking classes. We will compare that data to those who attended both cooking classes and dance classes to see which group saw the most benefit in decreasing their BMIs to normal range and decreasing their blood glucose levels. We will assess the number of participants in the program who have received a cooking/nutrition education class. We will conduct an annual data analysis to measure program effectiveness at addressing our health objectives. Confounding Variables (2): One confounding variable is an individuals desire and motivation to incorporate our educational lessons and materials into their daily lives. We would control this by providing incentives to participate in the program including food, water, and a cooking device that enables them to implement diet changes. Our second confounding variable would be the inability to get the teens to become involved in our exercise/dance classes. To control for this we would invite locals to play music and sing at dance exercise classes to use socially acceptable music and songs which would provide a familiar and inviting way for the teens to exercise. One reason for a lack of participation in the exercise class may be that some teens may be responsible for attending to younger siblings and other children. Our exercise/dance classes would be open to including younger children to control this confounding variable.

Cost-effectiveness: Our program will use cost-effective analysis. We will assess which approach, 1 or 2, produced the largest decrease in T2DM for the target group compared to the cost spent. Conclusion/Outcome: The mission of Teen Diabetes Assistance Program is to reduce the prevalence of T2DM, provide nutrient-dense foods, reduce the incidence of obesity and prevent future associated health complications in children ages 15 - 19 in Cape Town, South Africa. The rising development of nutrition-related diseases including diabetes and obesity in teens is estimated to continue to increase if no change is implemented. Our approach encompasses nutrition intervention and physical activity to benefit our target group, allowing them to adapt to a healthier lifestyle, minimize diabetes symptoms and prevent further health decline. Our program will be beneficial to their long-term health. To conclude, our programs goal is to promote a healthy generation as they enter adulthood by breaking the cycle of nutrition-related diseases and improving community life.!