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Community Outreach Project Summary NUTN 500, Winter 2014 Lindsey Patterson & Chelsea Small

Title: Vegetarian & Vegan Diets: a Class for WIC Parents and their Children Goal: To promote good health through nutrition education for WIC participants following
vegetarian, vegan or other restrictive diet patterns.

WIC Clients who attend the group appointment will: 1. Verbally participate in discussion at least once 2. Be able to list at least one change that they want to make to their diet to better meet their/and their childs nutrient needs 3. Verbally state the most interesting thing they learned during the class

Literature Review
Favorable Impact of Nutrition Education on California WIC Families This study focused on the effectiveness of education given to 3,000 WIC participants to eat more and greater variety of fruits and vegetables, whole grains and switch to low-fat milk. Participants were randomly sampled and cross-sectional surveys given before and after nutrition education. The study found that after nutrition education, women and caregivers reported increased recognition of nutrition messages, positive movement in stage of change for target food items, and significantly increased family consumption of fruits and whole grains and replacement of whole milk with low-

fat milk. Study concluded that coordinated nutrition education in WIC can significantly influence consumption of more healthful food choices.1

Using Learner-Centered Education to Improve Fruit and Vegetable Intake in California WIC Participants This study used a learner-centered class (focus group) to improve fruit and vegetable consumption in 60 Californian WIC mothers with young children. The most significant difference between the intervention and comparison groups' reports was that intervention participants identified more value, importance, and relevance of the fruit and vegetable information and adopting new fruit and vegetable practices after attending the class. California WIC demonstrated that messages delivered through this process can be retained and integrated into family life practices.2

Infants and Children Consuming Atypical Diets: Vegetarianism and Macrobiotics This study summarized the potential problems with atypical diets, which are more likely to cause problems of malnutrition in children than in adults due to their greater nutrient requirements relative to body weight. The growth of a child is a sensitive indicator of the potential negative effects of restrictive diets. Problems found included; vegan and vegetarian children younger than two years of age exhibiting significantly lower mean weight and length velocities and overall lighter in weight and smaller in stature than reference populations, vitamin B12 deficiency in children on vegan and macrobiotic diets without supplementation, major skin and muscle wasting in 30% of macrobiotic infants and seven infants exclusively breastfed by vegan mothers developing vitamin B12 deficiency. The study also reviewed past cases of vegan parents accused of child abuse after their children were found to be severely malnourished, which in one case resulted in the death of an infant.3

ADA Position Paper Vegetarian or vegan diets can be healthful and nutritionally adequate for all stages of the lifecycle if well-planned. Supplements or fortified foods can provide useful amounts of needed nutrients. Vegetarians tend to have lower LDL, rates of hypertension and cancer, risk of heart disease, incidence of type 2 diabetes, and lower BMI scores. However, such diets may have lower intakes of B12, Ca, Vitamin D, zinc and omega 3 fatty acids. Protein needs may be higher in vegetarian and specifically vegan diets due to reliance on poorly digested protein sources. The recommended iron intake for vegetarians is 1.8x higher than for non-vegetarians and zinc requirements of vegetarians may exceed the RDA. Vegetarians have not met dietary standards for B12, zinc, folate and iron in at least one country. It is essential that vegans regularly utilize vitamin B12 supplements or fortified foods to meet needs. Rates of bone fracture among vegans is 30% higher than non-vegans due to low Ca consumption. Low vitamin D status has also been reported in vegan groups who do not consume vitamin D fortified foods or supplements. Needs are easier to meet by consuming calcium and vitamin D fortified foods or supplements. Studies suggest vegan children are slightly smaller but within normal ranges, however, children on very restrictive diets have poor growth. Extremely restrictive diets such as fruitarian or raw food diets are not recommended for children. The Academy suggests that health professionals provide information about meeting requirements for vitamin B12, calcium, vitamin D, zinc, iron, and n-3 fatty acids because poorly planned vegetarian diets may sometimes fall short of these nutrients.4

How Prevalent is Vitamin B12 Deficiency Among Vegetarians? The goal of this review was to assess B12 deficiency in people adhering to various types of vegetarian diets. Among the most significant findings in this review is that vegetarians develop vitamin B12 deficiency regardless of demographic characteristics, age, or type of vegetarian diet consumed. Based on this study it is clear that it is not only vegans who are at risk for B12

deficiency. This review also found that the deficiency rate among infants and children is at least equal to that of adults. Additionally, higher rates of deficiency were found in children who followed a vegan diet from birth compared to those who adopted the diet later in life. While in theory it is possible for vegetarians to get enough B12 through dairy, eggs, and fortified foods, this review suggests that vegetarians and especially vegans would benefit from taking supplemental vitamin B12 in order to prevent or reverse deficiency. 5

Creating a class specifically designed for WIC participants following a vegetarian or vegan diet is an extremely important way of insuring optimal nutrition in a vulnerable and at risk population. While vegetarian and vegan diets can provide proper nutrition when implemented correctly, these diets involve restrictions that can make it difficult to meet the needs of certain nutrients including Calcium, Zinc, Iron, B12, Omega 3 fatty acids and Vitamin D when poorly planned. Because WIC participants are either growing children or pregnant or breastfeeding women, they are a population even more susceptible to insufficient nutrient intake. Pregnant women have increased nutrient needs and because children are still growing, it is crucial that they meet all of their nutrient needs.

Educating WIC participants on how they can meet their nutrient needs given their diet restrictions will positively impact their health and growth. This class will focus on using participant centered education as a way to hone focus, need and increase understanding as well as positively impact behavior change. By using this approach, WIC participants will be more likely to participate and will feel that their input and participation in the discussion is valued. The goal of this class is to create a non-judgmental, open, collaborative environment in which participants feel empowered to make educated diet changes that will increase the health and wellbeing of their families.

History of WIC and Vegetarian and Vegan Clients Until recently WIC did not offer vegetarian and vegan food alternatives, such as tofu and soy milk. Training for WIC certifiers on providing appropriate nutrition education for vegetarian and vegan diets is lacking, if not often altogether absent. Handouts and classes on vegan and vegetarian nutrition are also not available. According to WIC counselors and Candy Butler, the Registered Dietitian who attends WIC clinics in Ashland, Oregon, almost all WIC clients in Ashland follow vegan, vegetarian or other restrictive diet patterns. This project hopes to help fill this gap for WIC participants and their children.

Methods & Design

Target Audience The target audience is women who are currently pregnant, postpartum women up to 6 weeks if not breastfeeding and up to one year if breastfeeding and infants and children up to the childs 5th birthday who meet WIC income eligibility and residency requirements and who have been found to have a nutrition risk. The audience will be these WIC participants that follow or are interested in vegetarian, vegan or other restrictive diet patterns. The income of the target audience will be between 100 percent of the Federal poverty guidelines but not more than 185 percent of the Federal poverty income guidelines issued yearly by the Department of Health and Human Services. A portion of the audience is likely to participate in SNAP benefits, Medicaid or Temporary Assistance for Needy Families. Nutrition risk, of the target audience is established by a health professional such as a physician or a WIC employee through height, weight, hemoglobin levels and diet analysis. A nutrition risk, can be any medical or dietary based condition on Oregons list of WIC nutrition risk criteria. The audience may have nutrition risks, such as anemia, underweight, poor diet, history or poor pregnancy outcomes and many others. Due to a larger proportion of the population of Ashland, Oregon, following vegetarian and other restrictive diet patterns and the lack

of a WIC clinic in the immediate area, this project is targeted to the above described audience living in Ashland, Oregon. Attendance and participation in this 45 minute activity is optional through WIC.

Implementation Details for 45 minute Group Education Activity, March 11th 2014 at 10:45am
Introduction Activity Thank participants for attending & introduce ourselves. Describe what we will be discussing and welcome participation. Example: Well be focusing on important nutrients to include in vegetarian and vegan diets; Calcium, Zinc, Iron, B12, Omega 3 fatty acids and Vitamin D. Questions to ask to start class, guide topics and encourage participation: Would any of you be willing to share if you follow a vegan or vegetarian diet and why? Any other diet restrictions or allergies? Whats your favorite thing about your diet? Do you have any concerns about your own or your childs diet? Reaffirm their choice in following their chosen diet and benefits of vegetarian diets and go into providing information. Present PowerPoint on calcium, Vitamin D, Zinc, B12, iron and omega 3 fatty acids throughout the lifecycle in vegetarian and vegan diets and their respective food sources/supplements/fortified foods, one at a time. Pass around colored nutrient-food handouts and encourage questions as they come up Hand-outs will include many food sources of nutrients as well as specific WIC food sources of all 6 chosen nutrients Summarize key points and take-away message. Questions to ask: What are some practical ways you could include these nutrients in your diet (offer ideas) Ask final evaluations questions of participants (use going around the circle to take turns to share and review information) for final 5-10 minutes Thank participants, answer any questions they may have and offer handout and recipes to take home

Question Stage

Information Stage

Summary Stage


Dietetic Interns will only facilitate this class once on March 11th 2014; however, Jackson County WIC will have access to the education materials and will lead the class for 2 future sessions in 2014 and perhaps cycle the class in their regular schedule for upcoming years.

Theory/Model The model which this project is designed around is the Participant Centered Education, (PCE) model widely used by WIC. This model was chosen due to its success in individual and group

education activities at WIC.7 PCE places the client at the center of the education process. Instead of focusing on problems and negatives, the focus is on the participants strengths and abilities. A participant is able to decide their own goals, interests and motivation to change.7 The educators role is to listen, offer useful information and encourage change that leads to a healthy lifestyle. The relevant principles of PCE include; collaboration, engagement, respect, ambivalence, autonomy, voice, and prioritizing needs. Some of the relevant techniques used in PCE include; change talk, pair share, presentation and facilitation, motivation, explore/offer/explore, affirmation and reflect and summarize.6 Evaluation The objectives of this project will be measured through open dialogue with participants throughout and at the end of the class. We will take note of active participation and answers to evaluation questions during class, and will ask final evaluation question using a group sharing method where we go around the room and have participants share answers: Attendance What changes can you make to your diet to help you get the nutrients you need? What is the most interesting thing you learned today? Any other comments or questions? Did clients participate? How many? Did everyone participate?

Facilities, Personnel Required & Budget

Rogue Valley Unitarian Universalist Fellowship: This organization allows Medford WIC to host a clinic day once a month for WIC clients in and around Ashland to receive vouchers and nutrition and health education. This 45 minute class will use this facility, its utilities and chairs to host the class during the once monthly clinic hours. One or two OHSU dietetic interns or 1 WIC employee trained in nutrition education and motivational interviewing for 2 hours labor Projector, 1 day rental

Estimated Cost Rental space for half day: $100* $100* $99*

Handouts: 6 full-page nutrient, learning aids in color 20 copies double-sided of our general vegetarian/vegan nutrition handout 20 copies of our 2 page, double sided, nutrient-rich vegetarian and vegan recipe handout OHSU Dietetic Interns 2013 design labor (powerpoint and handout design) Portable computer, 1 day rental Total Estimated Cost: Actual Cost to WIC:


$0 $50* $384 $0

*These items are provided by WIC, OHSU dietetic interns, or are on a volunteer-basis and not contributing to the actual cost Implementation Details This class took place on March 11th 2014 at 10:45 in Ashland, Oregon during a Jackson County WIC distance clinic. The class took place at the Unitarian Universalist Church which hosts the distance clinic on a volunteer basis. This class lasted roughly 1 hour. The audience consisted of WIC clients (parents and small children) from Ashland Oregon and surrounding areas. The class structure followed the now updated Implementation Details that can be found earlier in this paper. Data/Results

Pre-Presentation Questions
Attendance Would any of you be willing to share if you follow a vegan or vegetarian diet and why?


6 Lacto-Ovo-Vegetarian (3) due to intolerance to meat, dislike of fish and preference Omnivore (2) no reason stated Vegan (1) due to diabetes diagnosis Allergy to nuts (1) Eating lots of vegetables (1) Variety (1) Meat (2) Feel better and weight control (2) No concerns

Any other diet restrictions or allergies? Whats your favorite thing about your diet?

Do you have any concerns about your own or your childs diet?

Post-Presentation Questions
What changes can you make to your diet to help you get the nutrients you need?


Increase iron rich foods with vitamin C (3) Vitamin D supplementation (6) Increasing omega 3 foods or supplements (4) B12 supplementation and fortified foods (3) Multi-vitamin for adult and child (2) Increase Ca rich foods (1) That everyone in Oregon does not get enough Vitamin D from sun and needs a supplement Less iron in plant sources Importance of iron for women Importance Vitamin D during breastfeeding That vegetarians may have trouble getting enough B12 What vitamins are dangerous to get too much of? Can you get too much of a vitamin from food sources? Does my child get enough Ca from milk? How much milk does my child need? What kind of eggs have omega 3? How much Vitamin D do I need? How much Ca do I need? Should I continue taking my prenatal vitamin after Ive had my baby? What are good sources of omega 3? What are flax seeds and can I take them while breastfeeding? 6 (all)

What is the most interesting thing you learned today?

Any other comments or questions? How many participated?

Summary The things that went well include; lots of participation, lots of good questions, good conversation, comfortable/safe environment for sharing and well structured. Attendees seemed very focused and involved with discussions and were able to demonstrate understanding of the material. We were able to discuss very applicable diet changes, such as eating more iron foods with a source of vitamin C (noted many real-life examples during class). All participants left the class with a packet of recipes for nutrient-rich vegan and vegetarian foods and a handout on what to include in a vegetarian diet. All participants stated motivation to increase vitamin D intake/supplementation and other nutrient-rich foods. Improvements that could have been made include a more private setting (not a shared space) and more attendees. Other than those few things, the class was very

successful and it was felt by WIC employees and us that it had a very positive outcome. In the future this class might be better held in the Medford WIC clinic to draw more attendees.

References 1. 2. Ritchie LD, Whaley SE, Spector P, et al. Favorable Impact of Nutrition Education on California WIC Families. J Nutr Educ Behav. 2010;42(3):2-10 Gerstein DE, Martin AC, Crocker N, et al. Using Learner-centered Education to Improve Fruit and Vegetable Intake in California WIC Participants. J Nutr Educ Behav. 2010;42(4):216 224. Di Genova T, Guyda H. Infants and children consuming atypical diets: Vegetarianism and macrobiotics. Paediatr Child Heal. 2007;12(3):185188. Position of the American Dietetic Association: Vegetarian Diets. J Am Diet Assoc. 2009;109(7):12661282. Pawlak R, Parrott SJ, Raj S, Cullum-Dugan D, et al. How prevalent is vitamin B12 deficiency among vegetarians? Nutr Rev. 2013;71(2):110117. California WICs Participant Centered Education (PCE): Overview. 2013. Available at: http://www.cdph.ca.gov/programs/wicworks/Pages/ParticipantCenteredEducation.aspx.

3. 4. 5. 6.