Community kitchens and the joy of working with kids.

This week I was able to participate in a community cooking class, my first time doing so. The class was geared towards children, with their parents accompanying them to help with anything beyond their skill level.

It turned out that most of the kids ran off and their parents ended up doing most of the cooking. There were a few kids that participated during the class, but it was difficult to engage children in the cooking process. Short attention spans make even the 10 minutes to cook ground beef feel like an eternity. Other kids disagreed about proper hand sanitizing, and deemed it acceptable to simply wipe their hands on their pants after handling raw meat. Fair enough!

There were moments that made it worthwhile. Watching kids getting involved with cooking, and developing cooking skills, even if at the most basic level, is an incredibly rewarding experience. You can't help but smile when watching a 6 year old peel a carrot for the first time, or watch in a trance his mother cutting up a pepper.

Basic cooking skills are so important to develop, yet are not commonly taught in the school system. I received no cooking or food education during school, and if it weren’t for my parents I would not have any sort of base to work with. Unfortunately not all children are as lucky to have parents that teach them to cook, either for lack of time or lack of cooking skills.

This is part of the reason why processed foods are so popular. Many people are growing up with cooking simply meaning reheating frozen products. That’s why cooking needs to be part of school’s core curriculum.

A recent article, by Thomas & Irwin (2013) in the Canadian journal of dietetic practice and research, looked at what aspects facilitate and act as barriers towards applying skills learned in a cooking class, among high risk youth in Toronto.

Four aspects that promoted the application of cooking skills were identified:

1) Aptitude, which is the possession of knowledge and skills to prepare food at home.

2) Food literacy, which is an understanding and knowledge of food preparation from start to finish, including food selection, purchasing, preparation, and preservation.

3) Local and fresh ingredients, which were identified as important to making healthy and delicious meals.

4) Connectedness, which is related to the youths’ connection to the food and the farmers that grew the food, and also their relationship with health, family, and culture.

Only one barrier was identified, and that was easy access to fast food restaurants, which deterred people away from making home cooked meals.

While the food industry has taken advantage of our desire to have quick meals that meet are busy lifestyle. These products are far from a necessity, and do not benefit our health. It is unlikely that we would starve if these products weren't  available, and more likely that it would force us to incorporate more time to prepare food. Unfortunately we have created a food system that promotes these types of convenience foods.

What we eat is dependant on many factors, including cost, availability etc., but if we want to give kids a chance to eat nutritiously, basic cooking skills are a must. Providing children cooking and nutrition classes from a young age will create a population that is able to choose between eating nutrient poor convenience foods, and cooking nutritious meals at home using fresh local ingredients, when available.

 A choice between health and illness.

JK



   

The Food Industry and You!

The New York Times recently published an article entitled "The extraordinary science of addictive junk food". The article, written by Pulitzer prize winning investigative journalist Michael Moss, paints a frightening picture of how the food industry attempts to hook customers to their products, under the guise of "Giving the customer what they want".

A few passages that really caught my eye I have included below, while the full article can be found here.

The article features a section on Howard Moskowitz, who is a consultant for the food industry, and is hired by companies wishing to create the best possible product. In this case "best product" simply refers to a product that sells.

Ordinary consumers are paid to spend hours sitting in rooms where they touch, feel, sip, smell, swirl and taste whatever product is in question. Their opinions are dumped into a computer, and the data are sifted and sorted through a statistical method called conjoint analysis, which determines what features will be most attractive to consumers.

The mathematical model maps out the ingredients to the sensory perceptions these ingredients create,” Moskowitz said, “so I can just dial a new product. This is the engineering approach.”

Moskowitz describes the ultimate product as having a perfect sensory specific satiety level.

In lay terms, it is the tendency for big, distinct flavors to overwhelm the brain, which responds by depressing your desire to have more. Sensory-specific satiety also became a guiding principle for the processed-food industry. The biggest hits — be they Coca-Cola or Doritos — owe their success to complex formulas that pique the taste buds enough to be alluring but don’t have a distinct, overriding single flavor that tells the brain to stop eating.

An example of this may be a good quality chocolate, which is almost too rich. You can have a little bit, and it is amazing, but it is a hard food to eat in large quantities even though it tastes amazing. In this way cheap snack foods are actually designed to not overwhelm and instead encourage people to eat as much as possible.

Another food industry insider describes the idea of "vanishing caloric density".


This,” Witherly said, “is one of the most marvelously constructed foods on the planet, in terms of pure pleasure.” He ticked off a dozen attributes of the Cheetos that make the brain say more. But the one he focused on most was the puff’s uncanny ability to melt in the mouth. “It’s called vanishing caloric density,” Witherly said. “If something melts down quickly, your brain thinks that there’s no calories in it . . . you can just keep eating it forever.”

This design, coupled with the flavour design described above, represents a powerful attack on will power.

Food companies shave also been known to target ethnic minorities that traditionally consume more of their product. In the U.S this has often been African-American, and Hispanic populations. This practice has been the subject of much criticism lately, with Beyonce becoming the new face of Pepsi. Some suggest this is a merely a strategy to encourage Pepsi consumption among young African-American girls.

In an effort to control as much market share as possible, Coke extended its aggressive marketing to especially poor or vulnerable areas of the U.S., like New Orleans — where people were drinking twice as much Coke as the national average — or Rome, Ga., where the per capita intake was nearly three Cokes a day.

By targeting the most vulnerable, the for-profit food system is actually increasing food insecurity, by creating addiction to processed food, and encouraging their consumption. It is incredible the lengths companies will go to turn a profit, and then rationalize it by suggesting if it's not them someone else will do it.

As a dietitian it is important to keep in mind the affect the food industry has on what people eat. While we may encourage people to consume less processed food, and provide an understanding as to why, this may not be enough. You can't underestimate the role that advertising, convenience, taste, and even addiction have on what people eat.

This is why policy is so important. Clearly personal responsibility does not work, at least not at the population level. Restrictions on advertising (especially to children), salt, and trans fat are good places to start. Since we've grown up with processed food, seeing it on a regular basis seems normal, but their is nothing normal about processed food. It is designed purely for profit, with only enough quality to makes us crave more.

JK

Barriers to care

Since working in Moose Factory, one thing that has really stood out has been the high no show rates. I am doing considerably more outpatient counselling here than in Nova Scotia, but the 50% show rate for appointments has been surprising. As a practitioner it is frustrating because you feel that people could benefit by seeing you, and it tends to be the most complicated cases that do not show. I was interested in exploring this further, as it occurs not just in dietetics but also in other outpatient services. There must be some barriers that overwhelm people’s desire or ability to attend.

Barriers to accessing health care differ from one person or population group to another, and what we may think of as routine, may in fact be an insurmountable barrier for another. It tends to be the most vulnerable populations that face these barriers, as health care services are not designed to meet their needs.

The SOGC journal, has an excellent policy statement on recognizing barriers to care in Aboriginal communities. They list potential categories of barriers including: attitudinal, values and beliefs, socioeconomic, and language and communication.

Attitudinal barriers include racism and prejudice, which can be subtle yet incredibly damaging. Differences in values or beliefs can cause people to feel alienated in an unfamiliar environment; First Nation governance was traditionally based on non-interference, this stands in stark contrast to Western medicine featuring an “expert” practitioner who makes a diagnosis and controls the care process. Socioeconomic barriers may include poverty, inadequate housing, low education, and substance abuse; all of which are correlated and contribute as barriers to access. Finally language and communication can become a barrier, not just because of the need for direct translation, but also for interpretation of content to be culturally appropriate.

As Ensor & Cooper (2004) suggest the usual strategy to increase accessibility to health care services has been to supply more health care professionals or increase the quality of care to vulnerable populations, but this may not be the best strategy. More attention needs to be made to the barriers that affect people’s desire to seek care, these include the cultural barriers that hinder the relationship between the community and health care services/practitioners.

Providing traditional native healing in health care institutions is one way to overcome some of these barriers, this is a service that does exist at the hospital here in Moose Factory. However, as my supervisor has mentioned, some people within the community are strongly opposed to this type of care, which puts a whole new spin on cultural appropriateness. Other barriers include the high turnover of health care professionals. In the 6 weeks I have been here I think I have met at least a dozen people that are moving to jobs elsewhere, this lack of continuity does little to improve the community’s relationship with the health care system.

 While many issues exist to increase accessibility, there are no simple solutions. The most important thing is to create open channels of communication between the community and health care services. Culturally appropriate care will need to balance traditional and modern health care, while allowing input from community members.

Telemedicine and a Nutrition North update

This past week I was able to experience counselling through telemedicine, which is basically talking to someone through video/webcam, for the first time. Telemedicine allows consults to occur in outlying communities without the practitioner having to travel to their location.

Telemedicine reduces barriers to accessing care, as it allows for more frequent and flexible scheduling compared to site visits alone. Since nurses are the only permanent staff at the health clinics outside of Moose Factory, this is especially valuable for any "specialized" service. Dietetics, physio, and any appropriate medical consults can use telemedicine to consult clients. That is not to say that telemedecine is a replacement for visiting communities, but with limited health care resources it is a valuable complementary service. 

Where telemedicine lacks, is the difficulty in connecting with clients over a pixelated video screen. What I expected was somethign similar to skype, where you are basically face to face with the individual, but in reality it is closer to speaking to someone on the opposite side of a room. Since there is often multiple people involved in a consult, the cameras and screens are positioned some distance away from the person, and while you can zoom in, it still makes for an interesting dynamic. 

The most difficult issue is sharing resources with clients. Holding food models to the camera, to show what a healthy plate of food looks like or to gain a sense of their pop intake, is far from ideal. In this sense the quality of care suffers when compared to an in person consult, but overall care is improved by greater access. 

There is no doubt that telemedicine needs to be balanced with adequate in person care, but I wonder what the future of telemedicine looks like? Will we one day be able to do "home" visits via telemedicine, or maybe consults on smartphones, that would surely improve show rates!

Nutrition North update:

Olivier De Schutter the United Nations special representative on the right to food included a specific section on the Nutrition North Canada program. A couple of sections in paticular caught my eye:

Nutrition North Canada provides subsidies to retailers operating in NNC-eligible communities and to food suppliers operating in southern Canada. The subsidies are intended to be passed on to consumers through lower retail prices for eligible items. However, in the absence of adequate monitoring by those it is intended to benefit, it is unclear whether the programme is achieving its desired outcome.

Nutrition North Canada currently publishes the subsidy per kilogram for each eligible community, but it does not require retailers to inform Aboriginal Affairs and Northern Development Canada or the public of their airfreight costs. As such, the federal Government has no way of verifying if the subsidy is being passed on...

While monitoring of the program has been a huge critisicm from Northern food activists, other concerns surrounding implementation and efficacy of the program were also raised in the special rapporteur's report.

 The Special Rapporteur recognizes that neither Nutrition North Canada nor the Food Mail Program could address other factors responsible for the high food costs in northern communities, such as the high cost of energy for heating and refrigeration, electricity generation, building construction, equipment maintenance, etc. Food costs remain higher in the North than elsewhere in Canada for legitimate reasons, but more needs to be done to improve the effectiveness of Nutrition North Canada. 

Now that  Canada has been investigated by an international organization, I wonder if the government of Canada will take note?

JK

Comparing the cost of food.

Coming to Moose Factory I knew I would be spending significantly more on food than when I was in Nova Scotia, but it wasn't until I took part in a food costing activity this past week that I realized just how much more. As part of an online course, I was to cost a weeks worth of healthy food for a family of 3 (2 adults, 1 child), and compare with other students located across Canada/World. The values that came out were simply astounding.

While the food plan we used is far from a rigorous research study, the cost comparison is very interesting. For Moose Factory a healthy diet for a family of 3 according to our meal plan is $190.11, while in Ottawa and Montreal the cost came out to ~$104.25. Prices that are nearly double! The fact that this comes as a surprise for me after 5 weeks also shows how poor I am at paying attention to my expenses.

To give these values more context we can match it to social assistance and minimum wage:

 A) The family is receiving Ontario Works (OW) social assistance (for a couple and 1 child under the age of 17):

Annual income: $9,948.00

Monthly income: $829.00

Allows for distribution of a weekly income of: $190.00

It almost seems silly to implement the food values into this number, as clearly it is unaffordable. But if a family receiving social assistance in Ontario were to eat healthy according to our meal plan:

Weekly income: 190.00

Cost of healthy food basket in Montreal/Ottawa: $104.25

% of income spent on food: ~55%

Cost of healthy food basket in Moose Factory: $190.11

% of income spent on food: 100%

And if one parent is working a full-time (40 hours/week), minimum wage job ($10.25/hr):

Annual income: $19, 680.00

Monthly: $1,640.00

Weekly income: $379.00

% of income spent on food in Montreal/Ottawa: ~28%

% of income spent on food in Moose Factory: ~50%

It is pretty clear from these values that support for people is too low to allow them to eat a healthy diet. I think spending half of your pay check on food is pretty unrealistic, and food tends to be an “elastic” component of the household budget, in the sense that people can be more flexible with food than they can with housing and related expenses such as heat, power etc.

  The sad part is that Moosonee and Moose Factory actually have the lowest prices for the area,  people from up the coast drive down the winter ice road to shop in Moosonee. The cost of some items can be double in the communities up the coast. Though I haven't traveled to any of the coastal communities yet, I've heard horror stories of people placing locks on their fridge, because of the high price, food is sometimes stolen. It is hard to imagine this happening in Canada today, and even harder to accept! 

Working as a dietitian in these communities is especially challenging, while you try to offer suggestions for healthy low cost meal alternatives, you can tell that people have tried every way they can to save money on food. At that point it becomes more about assuring they take their multivitamin on a regular basis, not exactly ideal.

JK

  

A nature hike and country food

Yesterday I was able to go on a hike to another island on the Moose River, just across from Moose Factory. Even though I was assured it was normal and safe, I must admit that the giant cracks on the ice were a little unnerving. But after making it across the river the hike was great, and we had beautiful weather.

The most interesting part of the hike was learning about the different animals that reside in the area, and which are used as food or trapped for their fur. It was interesting to see traps for beaver and pine marten, as people in the area still rely on animals to supplement their income and diet. As well as berries still ripe for picking in the winter.

 The top of a beaver trap, you must chisel through the ice to see if you have caught anything.

Moose berries, growing all over the place had a mild ciitrus flavour.

Country foods are still on the plate of people in Moose Factory, it is not uncommon for someone to list moose or rabbit when doing a diet recall during a counseling session. For myself I believe it's important to learn more about the role of country foods in peoples diet and what amounts are appropriate.

While Canada's food guide for aboriginal people has been adapted to include country foods it is still based on "European" Canadian research. The First Nations people of North America lived on a diet consisting primarily of protein and fat, and their bodies have in turn adapted to this diet, so that the recent shocks to their dietary patterns have caused major health issues (Young et al., 2000). Studies have shown that people of First Nation descent who eat higher amounts of country food have a reduced risk of developing obesity and other chronic disease.  First Nations people have been affected by a rapidly changing food culture that has caused a diabetes epidemic, due to drastic sociocultural changes and a history of colonization (Young et al., 2000).

 The "Westernization" of their diet, has no doubt been a major factor. It is the same reason why we see obesity and non-communicable chronic disease flourishing world wide. Easily accessible energy dense nutrient poor food, coupled with the destruction of a way of life, has paved the way for chronic illness to take hold of indigenous communities in Canada.

Most people that come for diet counseling require basic teaching on how to eat healthy, reduce processed foods, and strategies on how to eat on a budget. There have been a few cases where an elder, who's diet contains country foods, has been referred for diet counseling. While I have no problem suggesting they reduce the amount of sugar and cream in their tea, or reduce their portion sizes, I still do not feel totally comfortable suggesting they make half their plate contain fruits and vegetables and to select lean meats.

I'm still trying to understand the role of traditional food, and while I realize that especially among young people in the area country foods make up a very small part of their diet, I wonder if diet recommendations for First Nations people should better reflect their history and physical anthropology.

JK


Young K., Reading J., Elias B. & O'Neil J. (2000). Type 2 diabetes mellitus in Canada's First Nations: Status of an epidemic in progress. Canadian Medical Association Journal. 163(5).

A day in the life

So I haven't had too much to reflect on this week. I just finished up two days of hospital orientation, in which I learned proper hand washing technique and that I probably don't need to worry about what happens in a bomb threat because "those may happen down South, but we've never had them up here".

I thought I would do a photo blog this week to give an idea of what things look like up here. I'm also going on a nature hike on Saturday so I'll post some photos from that as well. 

So one thing I was quite excited about when I came here was the opportunity to work out in an old ambulance garage. I successfully found a gym grungier then the YMCA in Saskatoon, though I definitely feel more comfortable working out in Moose Factory, as there aren't 5 guys that look like they just got out on parole giving me dirty looks. Plus it doesn't get much more Canadian than working out in an old ambulance garage when it's -40 out!

I haven't took many photos since being up here, which I regret, but I thought I'd share a few more from around the island and a couple from the train ride up from Cochrane to Moosonee.

Linking the community and clinical settings

Coming into my clinical nutrition placement I did not expect to find many connections with my other interests of community development and food security. In my previous clinical experience, working in a large hospital, it seemed half the time I was figuring out how much to give someone in their tube feed. One thing I knew for sure was that this calculating side of dietetics is not for me, incredibly important, but not something I enjoyed doing on a regular basis.

What I'm realizing in this current setting is how deeply rooted food security is in  the dietetics profession.  Food security isn't just about the affordability of a nutritious diet, but is also about health literacy, participation, and the availability of nutritious food.

When counselling a client who knows what to eat, but just can't afford to buy food to keep her family healthy, this is a food security issue. As is when an individual does not know how to cook anything but kraft dinner and hotdogs, or someone that is reliant on others for transportation and can't go out to the store to get food on a regular basis.

Of course as a new graduate who's been trained to give diet advice, helping a client come up with solutions is quite challenging. Canada's food guide will only get you so far.

As an outpatient or inpatient dietitian you are working on food security issues at the individual level. I am developing a better understanding of food issues in Moose Factory, but understanding is not always enough. It gets frustrating having to work through limitations imposed by the political, social, and economic environment.

This diagram from the Ryerson University food security program provides a good depiction of how individual nutritional outcomes are shaped by the environment. It is important to have an understanding of how each level impacts nutrition status and eating habits, in order to help someone come up with ideas to overcome these barriers.

While it can be frustrating when you realize the difficulties people face to eat healthy. These limitations, imposed on us by our environment, force people to become creative problem solvers, and aiding a client navigate these challenges can be a rewarding experience.

The importance of advocating for clients, and developing programs in the community is important. To move forward as a profession, and affect healthy change, dietitians need to blur the line between the "clinical" and "community" settings. This will foster creative solutions to the complex issues we face in our food environment.

JK