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Empowerment through experience : skill practice to learn healthy habits

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Empowerment through experience : skill practice to learn healthy habits
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Brown, Maggie
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Denver, Colo.
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Metropolitan State University of Denver
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Empowerment through Experience: Skill Practice to Learn Healthy Habits
By Maggie Brown
An undergraduate thesis submitted in partial completion of the Metropolitan State University of Denver Honors Program
May 2016
Melissa Masters
Dr. Jennifer Weddig
Dr. Megan Hughes-Zarzo Honors Program Director
Primary Advisor
Second Reader


EMPOWERMENT THROUGH EXPERIENCE: Skill Practice to Learn Healthy Habits
Maggie Brown
Bachelor of Science Candidate Human Nutrition-Dietetics Honors Program, MSU Denver
Primary Advisor: Melissa Masters, PhD, RDN Second Reader: Jennifer Weddig, PhD, RDN Honors Program Director: Megan Hughes-Zarzo, PhD
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Introduction
While poor health is strongly evidenced in populations that are less educated, less financially fortunate, and have less food literacy, it is clear that nutrition education and food skill training are crucial for both long-term health for individuals and overall well-being for communities. While the nonprofit sector can provide valuable assistance in the way of information and food, such assistance can often be for naught if the recipients are not educated in lay and multicultural application of practices to best utilize the resources provided. In 2014, Centers for Disease Control and Prevention (CDC) reported $3.0 trillion was spent on healthcare in the U.S. Countless donors provide funding to nonprofit organizations that serve less fortunate individuals and families.1 And yet, the nation viewed as one of the strongest and most economically stable in the worldis still suffering from preventable, nutrition-related health conditions that are extremely costly. A problem exists when such large amounts of capital flow into this arena for public health and wellness, yet the goal of increased longevity and improved overall health is not achieved. The nation is home to food deserts, areas characterized by poor access to healthy and affordable food,1 a 15% decline in nutrient content in fruits and vegetables (from 1950 to 1999),2 and an increased prevalence of overweight and obesity from 56.0% to 68.7% (years 1988 to 2012).1 Overweight and obesity are correlated with excess morbidity and mortality.1 At the same time, convenience and manufactured foods have increased in production and availability, which simultaneously allows meals on-the-go and decreases the need for meal preparation at home. The professions of public health and nutrition must work toward identifying and strengthening the missing link. The Papua New Guinea (Asaro Tribe) saying, Knowledge is only a rumor until it is in the muscle, sheds light on simple, yet ancient wisdom that applies to this concept. It is the position of this paper that the extant model of nutrition education is lacking a crucial mode of delivery, specifically skill-based practice and experiential
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learning, which could improve the development and long-term maintenance of healthy habits and wellness in low-income or minimally educated populations.
Nutrition can improve the physical well-being of an individual through various methods (as related to visceral and somatic protein stores, antioxidant properties from vitamins, and cell depolarization capabilities because of mineral prevalence). These methods can lead to improved productivity in the practice of physical activity and the workplace, as well as improved quality of life.2 Better nutrition practices also encourage more awareness of the individuals connection to food and the process of food production. The consideration of the effects of food as medicine, rather than only subsistence, can affect the way one looks at foodadding value to the food and its origins.
This, in turn, increases the awareness of environmental conditions as these affect the nutrient quality and are often affected by the industrialization of food processing. Nutrition can also play a significant role in the prevention of health conditions, such as cancer, cardiovascular disease, diabetes, kwashiorkor (a form of protein energy malnutrition), and various ailments caused by vitamin deficiencies.3 Current and ongoing research suggests further ties between nutrition and brain health, specifically tying the health of the gastrointestinal microbiota (which is influenced by diet) to behavior and development.3Prevention of these conditions and improved nutrition could have a serious impact to reduce health care costs of the nation simply by reducing prevalence and incidence.
As mentioned, funders (government or private donors) of both federal programs and nonprofit organizations do currently provide substantial amounts of resources toward the nutritional and overall health status of the nation. The creation and extension of programs like the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides evidence that the government is indeed on the path of addressing health disparities and decreasing the gap in health status between low-income and high-income individuals and families. Additionally, nonprofit entities
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like No Kid Hungry and The Growhaus (federal and Colorado state level programs, respectively) are specifically designed to positively impact those most vulnerable. These programs have spanned many years and have impacted many lives. This paper is not to discredit the actions of the government and the intentions of nonprofit organizations; rather, it is to drive an alteration of application. The goal is to make these resources more efficient and effective.
Health disparities in less fortunate people must be addressed more efficiently to best utilize resources from the government and to reduce health care costs for all U.S. citizens. With the Affordable Care Act and its minimum essential coverage responsibility requirement, the health status of individuals will affect the prices of health care insurance for many others.4 On a more altruistic level, the health and well-being of community members provides a better environment for the whole. Health, as defined in the constitution of the World Health Organization, is the Complete state of physical, mental, and social well-being, and not merely the absence of disease or infirmity.5 Thus professionals in public health, health care, and specifically nutrition, must consider these aspects of health and their impacts on nutrition. The social aspect involves the community and/or environment of the individual or group. The surrounding social influences include family, friends, school, the workplace, and media in all forms. The relevance of mental health to the overall health status of an individual involves, undoubtedly, the ability and flexibility of the mind to receive new information and apply it to the practice of life. Finally, the physical aspect of health involves anthropometric measures, muscular and cardiovascular fitness, and proper nutrition, among other things. The three aspects of well-being are intertwined, compounding one another. Thus, the importance of proper nutrition impacts physical health, which can affect the level of mental and social health. This paper will focus primarily on physical health, with social health as a secondary emphasis and mental health addressed in conjunction with physical health (through the mind-body connections).
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The external influences to physical (as well as social) health can be summarized into three categories: education, income, and experience. In individuals and families, lower status in either the education or income categoriesa combination termed low socioeconomic status (low SES)has been associated with higher health disparities since the early 1990s.6 Common sense tells one that, without the means, there can be no end. If an individual is in a situation of low-income or no income, it is not surprising that proper nutrition, and as an extension physical health, is not the highest priority concern. This point is particularly significant when the income must be spread across families or a larger household. Importance of price is more and more prevalent with larger family sizes.8 Additionally, the price differences between convenience or prepackaged foods and foods perceived as healthy is significant enough, especially for larger families, to deter such purchase (either in frequency or at all). From another perspective, the level of education has an impact on the practices and behaviors of an individual.7 When individuals receive higher levels of education, that information can be stored and later utilized for making decisions. The third influence that will be highlighted in this paper is that of experience. Hands-on, skill-based, experiential learning is critical for success in most practices because it allows an individual (or community) to learn through action. This concept has been utilized in the old-fashioned practice of apprenticeships and is still utilized through the practice of internships. Experience, unlike income and education, is more readily applicable for the individual or group and can be more efficient for government programs and nonprofit organizations to provide to less fortunate populations.
Shifts in the nations health care coverage and the existence of programs such as those listed above bring the topic of nutritional and physical well-being to the forefront of concern for health care professionals, yet the concern should exist in many others sectors. Nutrition is important for overall health and well-being, but the effects extend beyond personal well-being. As WHO includes social well-being in its definition of health, the outreaching effects of health can help improve the
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community and, in the spectrum of this analysis, can improve the costs shared by the larger community for health care. Further, the greater awareness of nutrition could help address ecological challenges through a shift in consumer demand for more mindful environmental practices in food production. One day the The Asaro tribes saying, Knowledge is only a rumor until it in the muscle, may meet Maya Angelous sentiment: I did then what I knew how to do. Now that I know better, I do better.10
2. Background of Disparities
Poor health is strongly evidenced in populations that are less educated, less financially fortunate, and that have less food literacy. In other words, prime indicators of poor health in the United States are related to education, income, and experience. Such groups of people are the working poor and/or those experiencing homelessness, the rural/geographically inaccessible populations, and minority groups (especially those born in other regions of the world).9 Internationally speaking, the people experiencing the greatest health disparities are those that are in developing countries with poor infrastructure.10 Poor infrastructure is also prominent in some rural or low-income urban areas of the U.S., which is evidenced through the poor health status in those areas. This report focuses on these populations because they suffer significant health disparities, which can be prevented and/or addressed with improved resources that focus on experience with the problem at-hand.
On a local level, the concentration is toward the working poor and those experiencing homelessness, especially those with children in the family. Data from The Bell Policy Center (2005) shows that, since 2004, the the number of working poor families grew slightly, from 32,052 to 32,467.11 However, the number of working low-income families fell by 1,500, from 133,799 to 132,386. This report also revealed the facts that 32,000 of the jobs added in Colorado were in the
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low-wage sector, that 36,000 more adults were working these low-wage jobs, and that 13,000 more people held more than one job (at various levels of income). 11Their updated data also showcased a new perspective: that 25% of working poor families and 32% of working low-income families had at least one immigrant parent.11 Given the date of this report, the authors could not have taken into consideration the recent mass influx of people to Colorado. Aldo Svaldi of the Denver Post reported in 2014 that Colorado was 4th in the nation for population gain in the previous 12 months, detailing that 60% of that growth was from net migration with 45% of those migrating being between the ages of 18 and 34. In total, that years gains were 1.5%; the article further noted that the expected gain through 2016 would be 1.7%.12 Svaldi followed up in 2015 to report that Colorado had gained 101,000 people in the previous 12 months, 1.89% growth, which was more than double the nations average population increase.13 Approximately 80% of these migrators are settling in the Front Range of Colorado, increasing population density and driving up the cost of living, especially in terms of the housing market.13 As suggested by The Bell Policy Centers 2005 report, the skyrocketing cost of living and competition for living space makes life even more difficult for Colorados working poor and low-income families, decreasing the availability of affordable housing and increasing the need for support from outside the family.11 One could further assume that, with a large portion of employment in the low-wage sector, the and the rising cost of housing in Colorado reducing the amount of expendable income for food and healthy living habits, that the prevalence of struggling individuals and families may very well increase. Moreover, the referenced report does not take into consideration those experiencing homelessness, likely due to the difficulty in studying this undoubtedly growing population.
Across the nation, those at risk are the urban/rural and tribal populations, particularly those with low-income or that reside in isolated or difficult-to-reach areas. It has become clear that rural populations suffer health conditions in disparate prevalence when compared to their suburban
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counterparts.14'15 As alluded in the paragraph above, the distribution of income affects the distribution of health and now the distinction falls between rural/urban and suburban in light of evidence that wealthier residents of suburban areas were healthier than the rural and urban (including urban core and small urban) residents.14 The traditional interpretation of Rural vs. (Sub)Urban information is that funding and interventions should be directed to address rural access to medical providers (improving the ratio of population to providers) and distance to nearest hospital; however, when one interprets this disparity from a population health approach, these aspects are no longer sufficient to impact the health status of rural dwellers.15 Hartley reports that, According to the Chartbook, rural residents smoke more, exercise less, have less nutritional diets, and are more likely to be obese than the suburban residents.15 These factors were termed part of the rural culture, but they are also correlated with lower levels of income and education and it is well-established that efforts to change unhealthy behaviors are less successful among low-income or minimally-educated populations.15 Another factor in the Rural vs. (Sub)Urban disparity is related to access to food.16 An article published in 2009 in the American Journal of Preventive Medicine reviewed 54 articles published between 1985 and 2008 to discover differences in access to food and the related forms of presence, nature and implications.16 This research group found that: rural areas had 86% as many chain supermarkets than did urban areas; low-income areas had 75%; black neighborhoods had only 50% as many chain supermarkets than white neighborhoods; and Hispanic areas were supplied by only 32% compared to non-Hispanic neighborhoods.16 The concluding remark of this research review group was that Research designed to evaluate proposed interventions, build broad support for their implementation, and identify other effective means for improving neighborhood access to healthy foods should be made a priority.16
Finally, in a global scope, less-developed nations face significant health disparities among their constituents. While it is reasonable to assume that developing nations suffer some of the same
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issues as above (education, income, urbanization), these countries face other hardships that nations like the U.S, in large part, do not understand. These disparities stem from a lack of infrastructure that prevents health care and medical resources from reaching those in needeither from reaching them at all or from reaching them in the quantity needed.10 Additionally, some of these countries have experienced exponential growth due to industrial or commercial labor cost exploitation. People in regions such as Southeast Asia and West Africa are at risk for serious health impacts due to the drastic change in lifestyle. These lifestyle changes now involve more consequences of modernized health risks, such as those from tobacco and alcohol usage, physical inactivity, overweight/obesity, and air quality or occupational risksmany of which are undoubtedly due to the imposition of Western culture and commercialization.17 Specific nations like Ghana and Cote dIvoire have experienced a massive shift in lifestyle to accommodate the international demands for cacao products; for example, air quality and occupational risks include high exposures to pesticides and other harmful chemicals used in commercial cultivation of increasingly demanded cacao.18'24
To explain why this paper chose to focus on disadvantaged populations, it is advantageous to consider a 2013 study published in the Journal of Health Communication, which reports findings that health literacy was found to partially mediate the association between low education and low self-reported health status.25 While other studies had shown the existence of such a relationship, the significance of this study lies in its claim as the first to explore health literacy as a pathway to understand the connections and differences between education and health.25 The research group reviewed data for 5,136 respondents, 25 years or older, of the Adult Literacy and Life Skills Survey (ALL); the main variables were education (used categorically), health literacy and health status (used as continuous variables).25 Existing research had shown that low health literacy is associated with low self-reported health (general, physical and mental) and this studys results confirmed that, with higher levels of education, the proportion of respondents that demonstrated adequate or strong
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health literacy also was higher.25 One might question the validity of self-reported health status, as
this can be quite subjective and should involve some sort of objective measurement. Yet it makes sense that low health literacy would impact the health status of an individual via a lack of understanding of how to measure and administer prescription medication or a lack of understanding in visits with ones healthcare provider. However, notably, the mediating role of health literacy did not hold as a linear gradient as education increased; this was evidenced by the result that health literacy played a more important role in mediating the difference between education and health status for participants at the lower secondary education level than those at preprimary/primary level.25
Another important finding of this study that was corroborated by similar studies in Australia and in the U.S. is that health literacy levels are not equivalent to the level of education. This is indicated in the result that even some highly educated participants scored in the low health literacy categorya matter which requires exploration in future research.25 In all, it appears that health literacy holds an important role in self-reported health status, but this ability is not guaranteed to anyone. Health literacy, as defined by the U.S. Department of Health and Human Services (HHS), involves the ability to: navigate the healthcare system, share personal information and health history, understand concepts of risk and probability, andmost importantlyengage in self-care and chronic disease management.26 For the purpose of this paper, the health literacy skills involving self-care and disease management center on an emerging term food literacy, due to the fact that both abilities require lifestyle behaviors that promote healthy diet (and physical activity). A definition for food literacy was proposed in 2015 in an article from the Canadian Journal of Dietetic Practice and Research to include the positive relationship built through social, cultural, and environmental experiences with food enabling people to make decisions that support health.27 These skill-based experiences should be cultivated and strengthened to ensure not just longevity, but quality of life.
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When one considers the other main factors in health status, education and income, the notion of
promoting food literacy and health literacy skill-based experiences becomes much more attractive from a financial standpoint, as it does not evoke the political tensions found around economic stimuluses or subsidization of public education. So how does one go about cultivating food and health literacy skills, especially when already hard-pressed? The following chapters explore that very question.
3. How we Learn (Brain-Body Connections)
In Papua New Guinea, the Asaro Tribe has a saying: Knowledge is only a rumor until it is in the muscle. Modern technology and computational neuroscience has helped to identify some of the specific muscles that work to store and incorporate knowledge. However, the human being is complicated. Humans do things for any number of reasons, including none or multiple of the following: physical, emotional, and social, economic, ecological, etc. The understanding of the learning process is also quite complex. The brain is not the only part of the equationoften, internal genetics and external environment can have an influence on perceived memories, experiences, or information. This section will explore the way humans learn, investigating the connections between mind and body. Because there are many options for the learning environment, it is important to understand the various pieces involved with the reception of information before addressing intervention techniques to further public health.
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A 2002 study from TRENDS in Cognitive Sciences explored the distinctions and overlapping functions between the hippocampus and the neocortex through a unified cluster of small experiments, examining episodic memory and learning paradigms such as cued recall, recognition and nonlinear discrimination, habituation, fear conditioning and transitive inference.28 The physiological functions of the hippocampus and neocortex are differentially indicated in the firing levels of each; for example, the hippocampal areas having sparser levels, which have been shown to have reduced overlap between representation (pattern separation).28 A more macroscopic view of the functions of these structures may be summarized as follows: the hippocampus rapidly encodes conjunctions of existing cortical representations, avoiding interference across memories, while the neocortex slowly overlaps representations to encode shared structure of many experiences, thereby creating a general structure of existing knowledge with newly integrated information.28 The hippocampus is part of the limbic system, which is called the Lizard Brain because it provides for the most animalistic roles: fight, flight, fear, freezing, feeding, and
fornication.29 The hippocampus in particular reacts quickly, automatically encoding information from
an experience (or episode); the pattern separation mentioned above refers to the result that the hippocampus keeps information separate in order to delineate experiences in an effort to not mix up or confuse the data.28
Lizard Brain
Breathing/temperature -Avoidance/survival Hunger/thirst 'Territoriality
Balance -Reproductive drive
Mammalian Brain
Neocortex
Language
Morality
Logic & analysis Rational thought Control of emotions
Maternal love Anxiety Fear/hate ealousy
Memory
Sociability
Attack
Anger
This function is critical, as it allows the brain to remember, for example, different places that
an individual parks the car each eveningif this information were overlapped, the individual would
have difficult time finding the car each new morning because the individual days data would be
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muddled. In comparison, the neocortex (the newer part of the brain, anthropologically speaking) works more slowly, forming generalizations and extracting relevant information from the hippocampus over time.28 In reference to the parking example, the neocortex encodes overlapping information to accumulate experience and allow the individual to create patterns relating to how to park the car (i.e. forming best practices). The study from TRENDS in Cognitive Sciences is centered around a Complementary Learning Systems, (CLS) compiling information from widely-held ideas about hippocampal and neocortical functions toward memory that have accumulated from significant research between 1957 and 2002.28 This CLS theory emphasizes the importance of a complementary relationship between the two systems of memory formation and serves as a framework to conceptualize the contributions of both the hippocampus and neocortex by way of graded architectural differences between these structures.28 Further, the CLS model comes out of dual-process recognition theories that are defined by the idea that an individual can recognize a previously studied item as such based on (1) recall of specific details... or (20) a non-specific sense of familiarity that tracks the global match between the test item and stored memory traces.30
The aforementioned study included several models to monitor and assess the synapsing of neural areas in the hippocampus and cortex in response to stimulation by a studied item. This gave rise to the discovery of a sharpening dynamic that increases the contrast between the more active and less active neurons, as presentation of the stimulus increases. This is particularly fascinating because the model shows that the most active units will tune their weights (via [a complex system called] Hebbian learning), and will therefore become more activated upon subsequent presentations of the item.28 In essence, the more the neurons are subjected to an experience or episode, the stronger they become and more quickly they will differentiate information. This allows the uploading of that information to the neocortex for long term storage and adoption, but the encoding of novel representations into the neocortex requires more learning trials and specific task demands.
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Interestingly, one of the conclusions of the study was that pattern flexibility completion was stronger in the hippocampus than in the neocortex, but the cortex has the special ability to support familiarity judgements via the sharpening mechanism mentioned above.28 This in-depth analysis of the physiological and neurological functioning of each of these regions of brain leads one to believe that the repeated exposure to an experience will indeed increase ones ability to perform in accordance with that experience, as well as upload that information to the neocortex for long-term memory allowing retention and future use.
The reader may be familiar with the various learning styles such as visual, auditory, and tactile-kinesthetic (or any combination of these). While this paper seeks to explore a bit more deeply how learning methods affect retention and long-term adoption of the information in order to create habitual practice, it is prudent to briefly consider these learning styles to familiarize the reader. Much research and development have focused on the Visual, Auditory, Kinesthetic, and Tactile (VAKT) learning styles.31 These are rather self-explanatory, denoting the preferred sense for interaction used by each learning style group (the Kinesthetic/ Tactile learners, for example, prefer to move and/or touch tangible objects to reinforce information). It is also important here to acknowledge conflicting arguments against this concept. Competing ideas about learning include a derivation of established psychological theories, such as personality traits, intellectual abilities and fixed traits that may lead to the formation of learning styles.31'32 Research has also indicated that claims about these learning styles may controversially portray predictive characteristics of the learner; for example, the belief that people from socially disadvantaged groups tend to have a particular style.31'32 However, these types of controversies over the formation of learning styles are not necessarily applicable to the research of the current paper because the research herein is concerned not with the formation of learning styles, but with the best method to approach the styles of learning that apply to the widest
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range of learners (young and old). Thus, in order to make progressive change, this paper focuses on the experiences and motivation that encourage growth and value of learning within the learner.
Of particular interest in this paper is the Tactile-Kinesthetic style of learning as related to anecdotal success from application of hands-on learning methods from various interview sources (to be discussed in Chapter 5). The tactile-kinesthetic learning method may hold some potential to enhance the brain-body connection and further encourage healthy behaviors by way of (internal, physiological) positive reinforcement. In the Foreword of The Kinesthetic Classroom, Jean Blaydes Madigan reports that Educational research tells us that a majority of school-age students are predominately kinesthetic processors. They crave movement to understand concepts.32 The authors of The Kinesthetic Classroom Traci Lengel and Mike Kuczala investigate five, potentially interwoven, pathways to move information from working memory to long term memory (moving information from hippocampus to neocortex).32 One of the resources that provides great insight for Lengel and Kuczala is from a report from the educational consultant Lee Oberparleiter (2004); his report, originating from a large-scale literature review on brain research and over 35 years personal experience as a public and private school instructor, detailed five key roles that movement can play within the classroom experience:
1. The brain is attracted to novelty. The six purposes of movement can be used to provide this desired novelty.
2. The brain pays attention to movement. Movement with purpose acts to keep the attention and focus of students.
3. The brain needs to interact with people and things in its environment. Class cohesion activities using movement build a sense of community and interaction among classmates.
4. Learning is easier to store, remember, and retrieve if it has an emotional base. Movement activities often create positive emotional states causing students to link positive emotions with learning.
5. The brain operates from concrete experienceeverything stems from that. Nothing is more concrete than using movement to learn or review a concept.
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These roles offer much potential in the way of improved learning through physical activity and direct
experience with the concepts and material. The five roles of movement capture the very aspects of the environment that this paper claims are conducive to learning, such as improved focus and attention, social interaction, and positive neurologic associations with the content, (via endorphins released from movement and physical activity). The neurological stimulation to release endorphins, especially, serves as positive reinforcement and motivation for the learner to repeat the experience (i.e., continue the skill practice).
More recent proof of this movement-based model is found in the research of Wendy Suzuki, a renowned neuroscientist at New York University (NYU) and author of the book, Healthy Brain, Happy Life.33 Suzuki anecdotally discovered a change in herself after adopting a more active lifestyle and began an experiment to test this theory on NYU students. Her personal explorations of movement-based neuroplasticity (the ability of the brain to adapt to changes in environment) revealed increased mood, attention span, social interactions, and retention of information to be called upon during challenging tasks like writing grants. To better understand these changes, Suzuki conducted a study: an hour of physical activity was incorporated before a two-hour class period and the cognitive abilities were compared to a control class. Findings in response to aerobic exercise included significant improvement in the ability to encode new long-term memories and increased generation of new hippocampal neurons. An exciting exemplification of this data might be imagined as a low-intensity aerobic walking exercise for an obesity/diabetes education course or light harvesting of urban garden produce before learning to cook a heart-healthy family meal. Further extrapolation of Suzukis data may even hold promise to improve creativity through greater stimulation of the hippocampus, which increases the overall communication within the different regions of the brain.33 The benefit of improved creativity in terms of healthy habits are related to improvisations within practices like cooking with new foods or integrating new ideas into current
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practices. Both applications, increased long-term memory and increased creativity, would be beneficial in the educational environment for developing healthy habits.
Self-proclaimed Researcher/Storyteller/Social worker Brene Brown, in her book Rising Strong, states that, We move what were learning from our heads to our hearts through our hands.34 Browns iteration of this theory of experiential learning, while centered more on the use of creativity, expresses the way humans integrate knowledge about ones self, environment, or desired subject matter in order to adopt that knowledge into part of ones being and cultivate it as a regular practice.34 Hands-on experience and handling of information, as noted by the Oberparleiter, helps the individual conceptualize and understand given information. Brown advocates the rumble with ones emotions, the exploration of the experiences in various situations or responses to the environment, leads to emotional growth and increased self-awareness. This rumble with experience mimics the method of experiential learning because it directly engages the learner with the information or skill to be learned: actively jumping into the arena to be a dynamic participant with what one is learning, rather than be a passive observer or receiver of information. Thus, the model of experiential learning allows one to appreciate the interconnectedness between creativity, physical activity, neural activity, and the conversion of information to learned habits. In nutrition, it is debated that the benefits of a specific micronutrient may not be as effective when that nutrient is isolated; some claim that these benefits derive from the interactions of the body with the synergistic combinations of phytochemicals in the whole food.35'37. An example would be the resveratrol found in red wine: the health effects from the red wine (the whole food) are more evident than when only the resveratrol is supplemented. This paper proposes that the same is true for the individual and the learning experience; the benefits will be greater when the individual is exposed to whole experience (including the various challenges of skill-practice that would be encountered in the real world).
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4- The Existing Model
If the method of experiential learning holds such potential, why is it that current educational modalities do not incorporate it more often? What barriers and challenges exist to prevent Public Health programs from adopting experiential learning as the new gold standard for health education, especially in disadvantaged populations? This chapter explores such barriers and challenges in order to understand the resistance to the option of skill-based learning and to identify potential areas for convergence. The first of these barriers is the industrial complex, which has played a large role in the propagation of education methods to promote large-scale efficiency. Further, certain educational philosophies dominate the delivery of education in the nation and set standards for the material and the methods used to teach it. Additionally, the limited availability of resources in terms of finances, space, and/or materials, inhibits the implementation of some educational techniques in order to better serve society at large. While the combination of these issues undoubtedly creates reasonable opposition, a shift in the status quo may very well be in the best interest of society at large.
The industrial complex has left a metallic taste on the system of education. Since the Industrial Revolution, more and more businesses have pursued the idea of economies of scale. This idea places value on the quantity of products produced, even at low prices, in order to earn profits from the sheer volume of output. Similarly, the educational processes have taken on a tendency that parallels the manufacturing processpumping out mass numbers of students, but only equipping them with generalized knowledge and basic life skills. With the large increase in demand for secondary and post-secondary education to keep up with population growth and the demand for skilled or educated workers, it makes sense that the education system aims to be extremely efficient in the way it handles such a high volume of students.38 There are, unsurprisingly, economic drivers for this efficient processing of students through the current system of education. For example,
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due to state revenue shortcomings in 2009, the University of California suffered 20% budget cuts; this
caused significant financial repercussions to the system and forced even greater efficiency, meaning fewer faculty and staff, fewer openings for students, and greater tuition prices.39 Basic economics dictates that this supply and demand relationship results in greater prices for the same product (in this case, inflation of education). Maintaining a standardized system for education is a more predictable and cost-effective method to provide education to the masses because it holds constant the arenas for learning (the classroom) and the objectives for learning (to succeed in life). This paper does not refute the need for certain principles and procedures to impart a standardized knowledge to students; instead, the notion herein is to introduce flexibility into that standardized learning experience to allow creativity, critical thinking, confidence, and informed decision-making in order to develop and maintain lifestyle habits that promote health.
To understand the basic framework for the varied approaches to education, including public health education, one would be wise to consider the standard philosophies of education: Essentialism, Progressivism, Perennialism, Existentialism (which includes experimentalism), and Behaviorism. The current model of public health promotion rests heavily on the public school system, which is predominantly shaped by Essentialist education philosophy.38 Essentialism is teacher-centric and aims to impart a sense of common culture and essential knowledge and skills that should be conveyed to students through a systematic, disciplined manner to create productive citizens.38 This systemic, disciplined manner is also beneficial to maintain cost and minimize challenges in the classroom, which serves to ease the process of education and increase efficiency. The essential knowledge and skills promoted by Essentialist philosophy include writing, computing, measuring, history, and the more recent additions of investigation, invention, creativity, and health.38 However, the actual practices of Essentialist education do not foster individuality or specialized learning styles, especially in regard to health education.
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The World Health Organization (WHO) has recommended forty to eighty hours of health education, per academic year, respectively, in grades Kindergarten-2nd and 3rd through 12th.40 When this recommendation is more deeply considered, one could conclude that 40-80 hours per academic year per student is rather insufficient to impart crucial health information that is needed to carry the individual through the rest of life. In the United States, it appears that only a small fraction of public schools (Kindergarten-i2th grade) provide health classes that incorporate nutrition education. Therefore, unless these skills are imparted in home-life, graduating high school students are, for the most part, unskilled in healthy dietary practices and unable to implement preventive methods of self-care to avoid common chronic disease states. The situation worsens for school districts that are more inhabited by conservatives, as health education typically falls in the same arena as sex educationa controversial topic in some regions. As such, parents are often permitted to withhold their child from these educational segments, which results in lower attendance and a further lack of knowledge. While the parent or family also controls education at home (which could be beneficial or harmful), the consequence of this is clearly a lack of comprehensive education for safe sexual practices for youth, but also a disadvantaged situation for the nutritional health and overall wellness in young people. A lack of funding for these educational programs in public schools may affect low-income areas in the same way, furthering the characteristic health disparities that are found in low-income areas and food deserts.
To address the disparities caused by the ineffective or improper amounts of health education, the U.S. government launched programs such as the Supplemental Nutrition Assistance Program (SNAP). Such programs are designed to help lessen the effects of common factors related to health disparities, particularly low-income. These low-income households are, as previously stated, more likely to suffer health disparities as related to the limited access to and limited affordability of nutritious foods. SNAP, though, does not provide nutrition education; it simply provides monetary
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benefits to recipients that may be used to purchase foodliberally defined to include junk items (such as soda, ramen noodles, or processed/refined grainsoften less expensive than wholesome, fresh food items). To accompany these government programs, the nonprofit sector provides various types of assistance to further help people in need, especially in regard to public health. Yet, these nonprofit organizations operate on limited budgets and generally follow similar educational practices as the traditional institutions in order to mediate their limited personnel and funds. Current programs available through the government and non-profit organizations are well-intentioned, but the health outcomes fall short.
The one-size-fits all concept for public health is indeed more amenable for large-scale implementation, especially when most public health promotion is delivered through public education or government agencies that do not allow sufficient budgets for individualistic interactions or a focus on the learners current situation. From a macroscopic lens, it makes sense that governing bodies or large-scale nonprofit organizations will utilize a method that can reach as many people as possible. However, this does not guarantee success for all those learners. Instead, it may inhibit successful learning for many because they do not feel a connection to the learning environment (including the instructor) or to the value of the learning objectives. A powerful quote from a rigorous review of health education cites, The overall impression from much of the literature on health education is that too much of the health education practiced is inappropriate for many, perhaps the majority, of the people for whom it is supposedly intended.41 As one sees in the mass-production of consumer goods and agricultural products (including both crops and animal meats), the allure and value of factory processing fades as the quality of the products diminishes. But this does not only apply to academic educationthese practices contaminate the practices of health education, as well.
The education-industrial complex perpetuates the dominant educational philosophy, specifically Essentialism. Essentialism favors certain subject matter over others, which leaves health
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education in an unfairly discriminated position. To alleviate the disparities caused by the improper amounts of health education, the government has created programs designed to help reduce some common factors related to health disparities; to accompany these government programs, the nonprofit sector provides various types of assistance to further help people in need. Conservatives may believe that the status quo is sufficient to aid those in need, that the system of education and capitalism in the nation is designed to allow those who work hard to succeed; but is it truly enough? Even when the government provides for assistance programs and public health resources, they do not eliminate health disparities. Something is missing from these efforts at public health promotion: perhaps socioeconomically appropriate education techniques such as experiential learning via skill-based practice would better impact the majority of people for whom it is intended.
5. Skill-Based Practice [Case Studies]
In contrast to the predominant educational philosophy, Progressivism developed from the works of a man named John Dewey. In the late 19th and early 20th centuries, Dewey made his case for Experiential learning.38 In his work, Experience and Education, he stated that Experience is a moving force.42 This moving force has the power to grow and spread, like a wave or a forest fire, inciting further reinforcement to either promote or inhibit a given experience. While Deweys successor George Counts later developed the Existential educational philosophy (now home to Experimentalism), the notion of Experiential Learning is nothing new to education academics. Dewey also put forth the idea that Experience is not simply inside the person, which is to say that experiences do not occur in a vacuum.42 So why does the existing model for education attempt to educate in a vacuum? Moreover, why does it make sense to promote health education in one? Interrelation (interaction) occurs between the learner and the environment. Therefore, cultivation of this relationship, this connection between subjective and objective experiences, is necessary to truly
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educate individuals on health practices. Recalling the conditioning of Pavlovs dogs, the repeated
exposure to experiences provides a platform to shape the individuals memory and ability to respond to the conditions.43 Or, in Deweys words, Every experience enacted modifies the one who enacts... [it] affects the quality of subsequent experiences.42 Thus, it follows to use this model of experiential learning, via skill-based practice, to promote long-term behavior change to improve public health and wellness.
Examples of this sort of skill-based practice come in many forms. Experiential learning, in the context of this paper, utilizes a combination of tactile-kinesthetic, audio, and visual learning styles. This practice is evidenced in several disciplines such as Musical & Movement arts (playing the piano or learning to dance, for example); Vocation and trade schools (or old-fashioned apprenticeships in fields such as carpentry); and even in scientific lecture courses with supplementary lab (college-level Chemistry or Anatomy and Physiology). These skills are not simply mastered via auditory and visual observationthey must be developed over time with repeated exposure and interactive practice. Hence, upon this model of skill-based practice, this paper considers several organizations that have enacted this type of experiential learning to improve public health. The first to be featured, Cooking Matters (a subsidiary of Share our Strength and No Kid Hungry), is a national program that provides nutrition education primarily through grocery shopping tours and family-focused cooking classes.44 The next featured organization is Growing Power, a Milwaukee-based non-profit that promotes sustainable food practices through urban gardening efforts and a return to healthy cultural foods.45 Finally, this report reviews the Slow Food Movements Garden to Cafeteria initiative, which supports the connections between food producers and consumers by way of locally- and/or sustainably-grown produce in school gardens to educate children, families, and school workers about the benefits and methods to grow and eat healthy, wholesome foods.46
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i. Cooking Matters
Share Our Strengths Cooking Matters has been serving Colorado for over 22 years and as part of the No Kid Hungry campaign working to end childhood hunger in America, Share Our Strengths Cooking Matters Colorado empowers low-income families to stretch their food budgets so their children get healthy meals at home. Participants learn to shop smarter, use nutrition information to make healthier choices, and cook delicious, affordable meals. Cooking Matters courses and tours equip families with the skills they need to stretch their food dollars and maximize the benefits they receive through public nutrition programs like SNAP ([Supplemental Nutrition Assistance Program, formerly known as] Food Stamps) and WIC ([Special Supplemental Nutrition Program for] Women, Infants and Children).
Cooking Matters, Lead Partner (Colorado) Report Introduction47
With the program goals and implementation techniques, Cooking Matters Colorado has been able to improve outcomes among its participants in various ways. An interview with Cooking Matter Denvers Community Engagement Manager Becky Mares shed light on many aspects of the program. The typical course lasts six weeks and entails grocery store tours, cooking demos led by volunteers and nutrition educators, and a take-home bag of groceries. The grocery store tours take advantage of the SNAP or WIC benefits, teaching adult participants to plan and budget for healthy, affordable, and delicious meals for their families, all for under $10. By comparing pre-course surveys to postgraduation surveys, it is evident that the Colorado level of this program is effective in increasing consumption of fruits (37%), vegetables (64%), low-fat or fat-free dairy (55%), whole grains (39%), water (17%), and confidence in cooking (69%). While some of the statistics are less impressive (such as the increase in eating non-fried vegetables, only 4% in the state compared to 11% nationally), the overall improvements to lifestyle are impressive for a six-week course. Also impressive are the decreases in cooking barriers for Colorado parents: the average response that Cooking takes too much time decreased by 20%; Cooking is frustrating decreased 22%; and It is too much work to cook decreased 24%. Additionally, survey responders reported a 17% increase in the behavior to Adjust meals to be more healthy. These figures are extremely encouraging for public health, as they reflect the parents ability to model healthier behaviors in the home for the children.
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Cooking Matters for Kids results show a 13% increase (compared to the national 5% increase) in the confidence to make health choices when Im out to eat category, which is particularly exciting when one considers the frequency with which families eat out. Teenage participant responses are also positive, giving hope for this intermediate age groups health. Colorados teen results report an increase of 9% in the frequency of eating beans and a decrease of 10% in consumption of soda, sports drink, or energy drink. This group also reported an increase of 11% in Confidence in healthy food preparation, a 23% increase in behavior frequency for using the Nutrition Facts on food labels, and 7-8% increases in the frequency to eat something for breakfast, eat food from each food group, and to make homemade meals with mostly whole ingredients (national averages 4-6% increase). One teen even shared that Cooking Matters gave me more confidence with cooking. I never really held a knife until [this course] and now feel I could make dinner for my family. These points are especially exciting to use skill-based practice to instill healthy food habits in this generation before moving out of the house or having their own children.
While there is certainly room to improve more healthy habits in each group, it would be outlandish to expect total change in six weeks with every age range. Change is difficult, especially when related to intimate aspects of life like food. The progress is mild in some cases, but slow, continuous modifications are ideal. The limitations of this data are most prominently in the short scope of analysis: the graduates in these reports were surveyed after completion. It would be beneficial to see similar data after one year, several years, or even more time to determine the efficacy in developing very long-term behavior change. Additionally, it would be pertinent to analyze any health risks before the course and after, as well as several years after (assuming behavior change was maintained). Another area that may prove beneficial for Cooking Matters is a more in-depth financial literacy education for participants. Usually, if families are struggling to afford food, there are other financial concerns that may require attention. The addition of financial literacy might prove
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even more helpful for parents and families to budget income to afford cooking equipment or new varieties of produce that are otherwise outside of their fiscal means. Overall, this program positively represents the possibilities in implementing skill-based practice for healthy habits. Cooking Matters holds much potential for the improvement of Public Health in Colorado and in the nation.
2. Growing Power
Since its inception, Growing Power has served as a living museum or idea factory for the young, the elderly, farmers, producers, and other professionals ranging from USDA personnel to urban planners. Training areas include the following: acid-digestion, anaerobic digestion for food waste, bio-phyto remediation and soil health, aquaculture closed-loop systems, vermiculture, small and large scale composting, urban agriculture, permaculture, food distribution, marketing, value-added product development, youth education, community engagement, participatory leadership development, and project planning.
Growing Power45
Will Allen created Growing Power in 1993 to provide access to high quality, healthy, and affordable food and to inspire sustainable, local, community-based food systems and to promote social justice through food. Allens urban farm has been praised as a model for urban agriculture, complete with worms, goats, hens, solar panels, and community outreach and education. With a family history in sharecropping, Allen particularly desired to work with black communities to remove the tarnish from their associations with farm work. In his book The Good Food Revolution, Allen states that, as people moved away from agricultural practices, the after-effects of generational sharecropping, made people feel powerless; stripped of dignity to provide for themselves.48 This strong aversion to agriculture and tendency toward processed foods, especially in low-income urban areas, was leading to increased rates of chronic disease, which prompted Allen to take action. His lot was the last one zoned for agricultural use in the city and it began with a rocky start (vandalism by local youth, pushback from local farmers market consumers, etc.). Over time, the community came
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to trust and appreciate Allens efforts and the citys youth that once vandalized the property became
program participants, volunteers, or even employees of Growing Power. This impressive shift has allowed Allen to develop Growing Power, Inc. into an expansive organization that hosts community outreach, education workshops, food activism groups, and much more. Growing Power has also expanded into the Chicago area, even renovating a Chicago Transportation Authority bus to function as a mobile farmers market.49 The Growing Power Highlights 2015 proudly displays bits from the years accomplishments, such as:
Provided employment and enrichment programming for 300+ teens.
Taught over 150+ head-start preschoolers how to grow, harvest, play and eat at our preschool farm.
Grew produce and provided programming on seven urban farm sites in Chicago.
These experience-based learning opportunities are to satisfy Allens dream for children to
have to get excited about growing and tasting REAL food... [and] to have access to healthy, sustainable food thats grown without chemicals.45 The Youth Corps programs from Growing Power focus on job-training and development of life skills to provide academic and professional experience in under-served youth. During the summer, the youth are exposed to all agricultural demonstration areas in order to fully engage and impart occupational and leadership skills to encourage growth into responsible and employable adults. Beyond the agricultural experiences that these youth receive is the exploration of the science behind farming, including nutrition, hunger, cooking, art, food justice, and food politics activities.45
Yet, no program is perfect. These experiential learning opportunities come at a price. The one-day workshops (10am 5pm) in Milwaukee go for $150 per session, including lunch and dinner; two-day workshops in a New Jersey location cost $200 each; the new two-day From the Ground Up workshops are currently $400 per person; and the three-day aquaponics workshops are listed at $600, including all 3 meals each day. And any commercial enterprises that wish to adopt practices
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from Growing Power are exposed to five, three-day weekends of hands-on skill practice at the cool price of $2800 (including meals). These prices do not include any necessary lodging for out-of-town visitors and the amounts are rather high to allow a majority of low-income individuals or families to partake in the experience.50 While the Youth Corps and partnerships with day care facilities are nonprofit efforts, the fees for education for adults (beyond volunteering or 3-month internship opportunities) are limited by the ever-familiar affordability barrier. In all, while Growing Power has an admirable business model and makes a significant impact on its community and others, it is not widely accessible to some of the people that need it most. If Growing Power were to adopt a sliding scale payment option for its hard-pressed community members, they may be able to reach even more families in need and further improve the health of the local community.
3. Slow Food's National School Garden Program & Garden To Cafeteria
The Garden To Cafeteria (GTC) program teaches students how to grow and harvest food safely to be used in the school cafeterias on the salad bars and in some cases, in scratchcooking recipes. Using proper Food Safety Protocols, students sell fresh produce from the school gardens to the school kitchens with proceeds supporting the sustainability of the school garden.
Using fun signage, produce is identified on the salad bars as having come from the garden, and it is well received by the students. The garden programs benefit, and as their balances grow, schools can learn to grow even more of the produce that a district or food service department is eager to buy.
- Slow Food USA National School Garden Program & Garden to Cafeteria46
The Slow Food movement began on December 10,1989, when delegates from 15 nations signed a manifesto from Folco Portinari. The Slow Food Manifesto undertakes the idea to rid humanity of the follies of Fast Life through a truly progressive defense that is Slow Food. Slow Food USAs National School Garden Program (NSGP) takes this concept to the children, implementing school garden to improve effective sustainability practices in communities. Further, the NGSPs
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creation of Garden to Cafeteria extends this goal to impact the consumption of fresh produce by all students in the participating school. In Denver, the Garden to Cafeteria program is now in its fourth year and has resulted in over 3,000 pounds of school garden produce going into the salad bars at about 20 schools. Overall, the GTC program has raised $3,000 for the garden programs at those schools.46
The beauty of Slow Foods NSGP and Garden to Cafeteria program lies within the educational curriculum it has created to implement education for Good, Clean, and Fair food practices.51 They propose that education for Slow Food should be about pleasure, respect, hands-on experience, diversity, multi-disciplinary approaches, internalization of ones own vision and personal journey, active participation, community exchange, self-awareness, curiosity and promotion of change to generate responsible thoughts and behaviors. Slow Food seeks to reconnect people with each other, as well as with traditions, animals, plants, and healthy soils and waters that produce our food. The unique contributions that Slow Food provides to school gardening practices include:
1. Activities and instruction regarding growing food.
2. Activities that center around cooking and eating.
3. Promoting the enthusiastic enjoyment of good, clean and fair food for all.
These ideals are reflected through engaging learners through experiential and emotional methods to
impart meaningful context, allowing the learner to better understand and appreciate the intricate
connections between humanity and the natural environment.
To that end, the lessons that Slow Food provides in its curriculum are process-driven, relying on a combination of observational and skill-based experiences to increase enthusiasm for learning about gardening and cooking. These lessons are intended to be adapted and diversified to fit many types of conditions, even pointing out that they may occur without the formal school garden setting. The key aspects of each lesson are the Observation, Research, Experimentation or Action, and
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Reflection. These aspects provide a nice balance between the physical act of experiential, skill-based learning and the internalization of that knowledge to allow the student to develop awareness of emotions or other factors that may have played a role in the way that he or she absorbed the information. The learners develop the skills in critical observation and research by learning to ask questions beyond surface level and seek the answers. Experimentation or Action allows the learner to delve into the learning environment and continue developing skills necessary for growing and preparing foods (for example, measurements and fractions used in cooking, as well as judgment and decision-making for planting and harvesting). It must also be noted that this reflection is indeed an experience in and of itself, emphasizing the psychological experiences that are involved with sensory and physical activities, such as smelling or touching soil or plants and tasting different types of foods. Reflection also serves as a method to deepen the learners engagement and encourage development of critical thinking skills.
Slow Foods NSGP aims to empower children to become informed and active participants in the food system in order to create a positive impact in the larger world of food. The curriculum places particular emphasis on the sensory experiences of growing and cooking good food, while focusing on sustainability and social justice, respectively, in the Clean and Fair sections. Taking these concepts into the cafeteria has been very meaningful to many students, allowing them to see the produce they cultivated on the salad bar at lunchwhich increases the likelihood that they will eat more fresh vegetables and fruits. But these practices also have an impact beyond the students and parents/volunteers. When NSGP introduced the Garden to Cafeteria concept, it had to overcome some operational barriers of the school kitchensor lack thereof. Slow Food USAs National School Garden Program Director Andrew Nowak, in a personal interview, shared that many schools do not have full kitchens, and those that do may employ kitchen staff with limited skills in working with fresh produce. Unfortunately, as mentioned in the previous chapter, the industrial complex of
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education has pushed for the fastest and most efficient method of preparing foods; thus, bringing
fresh foods from school gardens into the kitchens entailed an overhaul of the system. Slow Food incorporated a training program to familiarize staff with food safety training, knife skills, cooking from scratch, and occupational culture shifts (some even wear chef coats in place of old lunch-lady look of aprons and hairnets). While this was met with initial resistance, many of the employees later shared their excitement in developing these skills because they felt they were actually cooking now.
There are a few limitations to Slow Foods NSGP and Garden to Cafeteria. The program does permit parents and volunteers to join, but the education is more tailored to the children. This might prevent the opportunity for adults to continue growing and developing their skills in the group environment, which is a significant limitation because parents shop, plan, and prepare meals. Thus, it may prevent the long-term behavior changes desired for best health. Stagnation, mentally, for the older learners may lead to decreased interest over time or to an assumption that they have mastered certain skills or practices, which counteracts the ideals of continuous experiences for lifelong learning. It would behoove the organization to identify methods for the adults to be more engaged in the learning and teaching process to involve all levels of participants in the experiences and reflections that the children undertake. This is especially important for the school kitchen staff that work with the produce from the gardensthese employees should be exposed to continuous trainings to encourage constant development of their food literacy skills, not only to serve healthy and varied foods, but also to improve their own health and serve as models for the students.
Another limitation, more relevant to this paper, pertains to the data collection from these school garden efforts. There is very little data available to properly analyze the efficacy and efficiency of Slow Foods NSGP and Garden to Cafeteria endeavors. Without quantitative and qualitative data, Slow Food may miss out on opportunities for grants to expand their efforts. Further, a lack of program outcome data keeps the public in the dark in terms of social benefits from these particular
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practices and, by default, allows the continuation of more traditional food and nutrition education.
While Slow Food does provide research-based information for program leaders to validate the methods for its education techniques, that research does not substitute information for Slow Foods program. The provided research reviews list benefits in regard to increased vegetable and fruit consumption, increased self-efficacy, increased confidence and ability in food preparation skills, and willingness to try new foods, yet there is not yet a report to determine efficacy or efficiency toward long-term behavior change in the participants.52'58
In all, the efforts of these featured organizations are based on experiential learning and skill-based practice to impart healthy habits and multi-disciplinary thinking in regard to food production and the impact it has on the earth. These goals are well-intended and the methods used to achieve them are mostly sound. Flowever, questions remain regarding the length of time needed from these experience-based models in order to get the long-term health benefits and the true efficacy for longterm behavior change to exhibit improvements to health status. The book Outliers addresses the former question about length of exposure, citing the magic number of 10,000 hours of practice for true expertise and the author proves his point with examples from The Beatles, Bill Joy, Bill Gates and even Mozart.59 Flowever, a number of that magnitude is extremely dauntingthe average person might not see how they can possibly incorporate such massive amounts of practice to be healthy and may indeed feel too overwhelmed to even try. So there must be a more happy medium, a solution that encourages continuous skill-based practice throughout life while simultaneously encouraging creativity and innovation to keep things interesting and engaging. As Bruce Lee said, Absorb what is useful, discard the rest, and uniquely make it your own. It seems that this old adage from a martial arts master also holds true in the effort to learn healthy habits. By continuing to engage in skill-based practice and experiential learning, individual learners can absorb what is applicable and interesting, without being clouded by superfluous or nonessential information, and
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combine that new knowledge with their own unique life experiences and culture to develop a personalized practice for lifelong health.
6. Impacts & Implications
How does one measure the efficacy or success of these educational methods? It is difficult to compare the traditional system to the one proposed in this paper. While the trials featured herein are representative of success and hope for the future, the reader would be just in asking how to be sure that one is, in fact, better than the other. One way to measure these methods is through the metric of cost versus benefits, which theoretically takes into account the externalities of each, which will be discussed in this chapter. In order to address rural-urban cultural differences as discussed by Hartley (the rural culture mentioned in Chapter 2),15 public health promotion avenues should adopt a more ethnographic methodology. This type of approach is more apt to consider cultural (socio- or otherwise) differences that might imbue health characteristics or behaviors that are targeted for change. Sensitivity to various cultural differences in public health promotion methods provides more multi-disciplinary, holistic, appropriate, and effective education to improve the overall wellness in a community through open-minded practices or freedom to tailor the experiments to fit the individuals needs. Experiential, skill-based learning in the realm of public health and wellness has far-reaching implications, too. There are potential benefits to societyboth in the present and in the futureand to the environment that could lead to the reduction of health disparities and of chronic disease throughout the community, the nation, and by extension, the world.
In lieu of adequate data, this paper supposes a cost-benefit analysis to determine the most effective methods of public health education for disadvantaged populations. The most obvious barrier or cost to the implementation of experiential, skill-based learning methods is the financial cost to operate such a program. However, the featured case studies operate mostly through
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volunteers, making use of the community stakeholders that are directly impacted by the very health
of their community. By cultivating relationships with community members, a Public Health Program could capitalize on this option for labor and save time, effort, and dollars. Further relationshipbuilding in the area could glean sponsorship from local businesses or individuals that are aligned with the programs vision for a healthier and more productive community.
This suggested Public Health Program could also take advantage of Extension Services, the very groups that support research and education out of Land-Grant institutions in the given state. These institutions, as part of the funds that they receive from the state, are required to provide support and/or education to the local community. This requirement could easily be used to obtain assistance in the design and development of effective, evidence-based Public Health Education techniques. Additionally, community support such as sponsors or the Extension Service could aid in the execution of data collection to showcase successes and regularly analyze efficacy for the overall impact of the program in order to continuously grow and develop best practices. Data collection is a very powerful way to demonstrate impact, efficacy, and efficiency. With sufficient information through well-executed data collection practices, an experiential public health program could investigate relationships between experiential learning and retention of health information on longterm improvement of health outcomesa piece of this puzzle that is still missing. The internal study that evaluated the effectiveness of Cooking Matters, for example, determined that between 63% and 91% of participants displayed improvements;44,47 another reported that behavior changes were no different between 3-month follow-up and 6-month follow-up.60 While this data is positive and helpful, the length of time between intervention and follow-up does not necessarily equate to very long-term retention and behavior change. The featured programs and organizations are making great strides, but economic minds prefer to make change based on figures for Return on Investment. Without that data, it is difficult to accurately determine which methods are more effective and
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efficient; and further, it would be quite difficult to realize such a drastic shift in the practices for Public Health Promotion.
This analysis utilizes a Social-Ecological behavior theory in order to incorporate the independence of and interactions between multiple levels of health. At the heart of the Social-Ecological model is the Individual with her skills, knowledge, beliefs, and attitudes. Moving outward, there are Interpersonal relationships like family and friends; next is the Organizational level which incorporates organizations such as educational or social institutions. Closer to the periphery are the arenas of the Community (interactions among organizations) and Public Policy found in local, state, or federal laws. This paper asserts that the Public Policy level of the social-ecological model could have a much more beneficial impact on the individual (and all other levels) if appropriate skill-based learning experiences are implemented in wide scale application. Thus, it is necessary to develop working relations between all these organizations to create more integrated social construct. This could push people to a more community-based value system, increasing the potential for interpersonal and international partnerships to make the world better for generations to come. These community partnerships would help to mitigate the actual cost to an organization to execute this sort of refurbished Public Health Education. If government subsidies like those given to monoculture farming operations are allocated based on merit for impact, the communitys health may improve significantly. The other benefits of this method of health education may include, as mentioned above, the improvement in health status, reduction of cultural health disparities and chronic disease, such as obesity, diabetes, hypertension and heart failure, nutrient deficiency, etc.
Through a Social-Ecological application of these experiential, skill-based practices for public health, one can see promising opportunities for a bottom-up, rather than trickle-down, solution to health disparities and even greater concerns like the environmental impact of food choices. Beginning with the individual, there are multiple benefits, such as improved mental faculties /self-
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confidence), allowing creativity as higher mental function/ problem-solving, increased exposure to new practices that cultivate variety and adaptability (cultural foods, cooking techniques). Interpersonal relations are the next level of Ecological advancement. There is evidence to support that community-building and support systems release cortisol to stimulate conversation in times of stress.61 For a community as a whole to overcome adversity, it will require significant amounts of interpersonal relationship development and sharing of best practices. Thus, the social aspects of skill-based, experiential learning in group environments increases the impact of the learning methods. A personal account from a Cooking Matters supervisor depicts the friendly, constructive interactions of different Arabic groups during cooking demonstrationsinteractions that would have otherwise likely not occurred.44This story shows the potential for hands-on learning to overcome cultural barriers and help build the community to embrace diversity and become stronger for it.
At the organizational and community levels, long-term benefits of skill-based practice and experiential learning methods could include a decrease in costs of health care and new opportunities for growth within the sustainable agriculture industry. Recent shifts in the health status of the nation are reflected in the insurance costs for individuals and groups; just as car insurance increases depending on the risky driving behavior of the local region, so too does health insurance increase in price depending on the risky health behaviors that people have. Moreover, the inability of low-income people to afford healthcare costs (especially emergency care) affects taxpayers because the federal government often steps in with programs like Medicare or Medicaid. If effective and efficient methods of Public Health promotion were more widely implemented, the local communities and the nation at large could see a meaningful decrease in poor health status and a subsequent decrease in shared healthcare costs. In the sustainable agriculture industry, a shift in market demand for healthier food production practices would allow more innovation. Techniques to improve nutrition
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intake within various socioeconomic cultural groups include targeted marketing, lowered prices for sustainable produce due increased production efficiency, or even fortification of foods. A greater sense of inter-relatedness among individuals and communities could ease the necessary actions to decrease negative effects on climate change from agricultural and lifestyle practices. Thinking globally, but acting locally, skill-based practice in Public Health promotion will extend substantial benefits to the health of disadvantaged individuals and communities on local, national, and international levels.
7. Conclusions & Call to Action
It is clear that health education via skill training is essential for long-term health for individuals and overall wellness for communities, particularly those that are low-income or minimally-educated. Populations with limited income, access, health literacy and skills are at greater risk for poor health and chronic disease development.6,9'1114'24,47'60 More experiential, skill-based practice methods for public health promotion are the key to change this. The current research reviewed the physiological ways that humans learn, highlighting the need for repeated exposure to retain and build experience to develop critical thinking and best practices and, potentially, creativity and innovation within that knowledge base. Subsequent chapters explored the reasons for the status quo in educational practices, including the industrial complex, conflicting educational philosophies, limited health education requirements, and the limitations of government or nonprofit sector assistance. Featured case studies analyzed the practices of forward-thinking organizations that focus on skill-based experience to educate participants about healthy habits. Finally, the large-scale impacts of this proposed shift in Public Health Promotion present a wide array of social, environmental, and of course, health benefits for generations to come.
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While government assistance programs and non-profit resources can provide valuable
assistance in the way of information and food, such assistance can often be for naught if the recipients are not educated in lay and multicultural application of practices to best utilize the resources that they receive from assistance programs. The locally-focused, experience-based health promotion programs that exist in disadvantaged communities must be supported and shared by health professionals. Without full governmental support for the educational methods proposed in this paper, the progress is occurring in relatively small pockets of the public health field. In order to best support progress, health professionals need to be involved with these types of programs and refer clients to them to take advantage of the success. All health professionals must also stay current with information and research to carry out further development and evaluation of these interventions. With the innate difficulty to objectively and quantitatively measure a subjectively qualitative experience such as learning, the evaluation of educational techniques can seem intangible. However, with continued partnership, cultural consideration, and longitudinal study design, it is possible to one day reach more cohesive conclusions regarding long-term efficacy of these skill-based practice methods.
Both education and health professionals are needed to work together to continue developing best practices. It is also important for these professionals to practice the advice they give to continuously assess efficacy and efficiency and to discover innovative ways to deliver critical health education to the people that need it most. To truly improve community, public and global health and wellness, all health professionals must remember to focus on the skill-based practice that the learner experiences. As Confucius said, I hear, I forget. I see, I remember. I do, I understand. This venerable phrase holds truth in the efforts to better health across the globe. With skill-based, experiential learning, both health professionals and health learners of any level can empower change to improve the health status of countless individuals and communities, one experience at a time.
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8. References
Chapter 1 (Intro)
1. National Center for Health Statistics staff. Health, United State, 2014: With special feature on adults aged 55-64. Centers for Disease Control and Prevention. 2015. http://www.cdc.gov/nchs/fastats/health-expenditures.htm. Accessed Novembers, 2015.
2. WHO Staff. Workplace health promotion. World Health Organization. http://www.who.int/occupational_health/topics/workplace/en/indexi.html.Accessed Novembers, 2015.
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Full Text

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Empowerment through Experience: Skill Practice to Learn Healthy Habits By Maggie Brown An undergraduate thesis submitted in partial completion of the M etropolitan State University of D enver Honors Program May 2016 Melissa Masters Dr. Jennifer Weddig Dr. Megan Hughes Zarzo Primary Advisor Second Reader Honors Program Director

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1 EMPOWERMENT THROUGH EXPERIENCE: Skill Practice to Learn Healthy Habits Maggie Brown Bachelor of Science Candidate Human Nutrition Dietetics Honors Program, MSU Denver Primary Advisor: Melissa Masters, PhD, RDN Second Reader: Jennifer Weddig, PhD, RDN Honors Program Director: Megan Hughes Zarzo, PhD

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2 1. Introduction While poor health is strongly evidenced in populations that are less educated, less financially fortunate, and have less food literacy, it is clear that nutrition education and food skill training are crucial for both long term health for individuals and overall well being for communities. While the nonprofit sector can provide valuable assistance i n the way of information and food, such assistance can often be for naught if the recipients are not educated in lay and multicultural application of practices to best utilize the resources provided In 2014, Centers for Disease Control and Prevention (CDC ) reported $3.0 trillion was spent on healthcare in the U.S. Countless donors provide funding to nonprofit organizations that serve less fortunate individuals and families. 1 And yet the nation viewed as one of the strongest and most economically stable in the world is still suffering from preventable, nutrition related health conditions that are extremely costly A problem exists when such large amounts of capital flow into this arena for public health an d wellness, yet the goal of increased longevity and improved overall health is not achieved. The nation is home to food deserts, 1 a 15% decline in nutrient content in fruits and vegetable s (from 1950 to 1999), 2 and an increased prevalence of overweight and obesity from 56.0% to 68.7% (years 1988 to 2012). 1 Overweight and obesity are correlated with excess morbidity and mortality. 1 At the same time, convenience and manufactured foods have the decreases the need for meal preparation at home. The professions of public health and nutrition must work toward identifying and strengthening the missing link. The Papua New Guinea (Asaro wisdom that applies to this concept. It is the position of this paper th at th e extant model of nutrition education is lacking a crucial mode of delivery, specifically skill based practice and experiential

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3 learning, which could improve the development and long term maintenance of healthy habits and wellness in low income or minimally educated populations. Nutrition can improve the physical well being of an individual through various methods (as related to visceral and somatic protein stores, antioxidant properties from vitamins, and cell depolarization capabilities because of mineral prevalence). These methods can lead to improved productivity in the practice of physical activity and the workplace as well as improved quality of life 2 Better nutrition practices the process of food production. The consideration of the effects of food as medicine, rather than only subsistence, can affect the way one looks at food adding value to the food and its origins. This, in turn, increases the awareness of environmental conditions as these affect the nutrient quality and ar e often affected by the industrialization of food processing. Nutrition can also play a significant role in the prevention of health conditions, such as cancer, cardiovascular disease, diabetes, kwashiorkor (a form of protein energy malnutrition), and vari ous ailments caused by vitamin deficiencies. 3 Current and ongoing research suggests further ties between nutrition and brain health, specifically tying the health of the gastrointestinal microbiota (which is influenced by diet) to behavior and development. 3 Prevention of these conditions and improved nutrition could have a serious impact to reduce health care costs of the nation simply by red ucing prevalence and incidence. As mentioned, funders (government or private donors) of both federal programs and non profit organizations do currently provide substantial amounts of resources toward the nutritional and overall health status of the nation. The creation and extension of programs like the Special Supplemental Nutrition Program for Women, Infants, and Childr en (WIC) provides evidence that the government is indeed on the path of addressing health disparities and decreasing the gap in health status between low income and high income individuals and families. Additionally, nonprofit entities

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4 like No Kid Hungry a nd The Growhaus (federal and Colorado state level programs respectively) are specifically designed to positively impact those most vulnerable. These programs have spanned many years and have impacted many lives. This paper is not to discredit the actions of the government and the intentions of nonprofit organizations; rather, it is to drive an alteration of application. The goal is to make these resources more efficient and effective. Health disparities in less fortunate people must be addressed more effi ciently to best utilize resources from the government and to reduce health care costs for all U.S. citizens. With the Affordable Care Act and its minimum essential coverage responsibility requirement, the health status of individuals will affect the prices of health care insurance for many others. 4 On a more altruistic level, the health and well being of community members provides a better environment for the st ate of physical, mental, and social well 5 Thus professionals in public health, health care, and specifically nutrition, must consider these aspects of health and their impacts on nutrition. The so cial aspect involves the community and/or environment of the individual or group. The surrounding social influences include family, friends, school, the workplace, and media in all forms. The relevance of mental health to the overall health status of an in dividual involves, undoubtedly, the ability and flexibility of the mind to receive new information and apply it to the practice of life. Finally, the physical aspect of health involves anthropometric measures muscular and cardiovascular fitness, and prope r nutrition, among other thing s. The three aspects of well being are intertwined, compounding one another. Thus, the importance of proper nutrition impacts physical health, which can affect the level of mental and social health. This paper will focus prima rily on physical health, with social health as a secondary emphasis and mental health addressed in conjunction with physical health (through the mind body connections).

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5 The external influences to physical (as well as social) health can be summarized into t hree categories: education, income, and experience. In individuals and families, lower status in either the education or income categories a combination termed low socioeconomic status (low SES) has been associated with higher health disparities since the early 1990s 6 Common sense tells one that, without the means, there can be no end. If an individual is in a situation of low income or no income, it is not surprising that proper nutrition, and as an extension physical health, is not the highest priority concern. This point is particularly significant when the income must be spread across families or a larger household. Importance of price is more and more prevalent with larger family sizes. 8 Additionally, the price differences between convenience or prepa ckaged foods and foods perceived frequency or at all). From another perspective, the level of education has an impact on the practices and behaviors of an individual. 7 When individuals receive higher levels of education, that information can be stored and later utilized for making decisions. The third influence that will be highlighted in this paper is that of experience. Hands on, skill based, experiential learning is critical for success in most practices because it allows an individual (or community) to learn through action. This concept has been utilized in the old fashioned practice of apprenticeships and is still utilized through the practice of intern ships. Experience, unlike income and education, is more readily applicable for the individual or group and can be more efficient for government programs and nonprofit organizations to provide to less fortunate populations. above bring the topic of nutritional and physical well being to the forefront of concern for health care professionals, yet the concern should exist in many othe rs sectors. Nutrition is important for overall health and well being, but the effects extend beyond personal well being. As WHO includes social well being in its definition of health, the outreaching effects of health can help improve the

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6 community and, in the spectrum of this analysis, can improve the costs shared by the larger community for health care. Further, the greater awareness of nutrition could help address ecological challenges through a shift in consumer demand for more mindful environmental pra ctices in food production. One day may meet 10 2. Background o f Disparities P o or health is strongly evidenced in populations that are less educated, less financially fortunate, and that have less food literacy. In other words, prime indicators of poor health in the United States are related to education, income, and experience. Such groups of people are the working poor and/or those experiencing homelessness, the rural/geo graphically inaccessible populations, and minority groups (especially those born in other regions of the world). 9 Internationally speaking, the people experiencing the greatest health disparities are those that are in developing coun tries with poor infrastructure. 10 Poor infrastructure is also prominent in some rural or low income urban areas of the U.S., which is ev idenced through the poor health status in those areas. Th is report focuses on these populations because they suffer significant health disparities, which can be prevented and/or addressed with improved resources that focus on experience with the problem at hand. On a local level, the concentration is toward the working poor and those experiencing homelessness especially those with children in the family. Data from The Bell Policy Center ( 2005 ) es grew slightly, from 32,052 to 32,467. 11 However, the number of working low income families fell by 1 5 00, from 133,799 to This report also revealed the facts that 32,000 of the jobs added in Colorado were in the

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7 low wage sector, that 36,000 more adults were working these low wage jobs, and that 13,000 more people held more than one jo b (at various levels of income). 11 Their updated data also showcased a new perspective: that 25% of working poor families and 32% of working low income families had at least one immigrant parent. 11 Given the date of this report, the authors could not have taken into consideration the recent mass influx of people to Colorado Aldo Svaldi of the Denver Post reported in 2014 that Colorado was 4 th in the nation for p opulation gain in the previous 12 months, detailing that 60% of that growth was from net migration with 45% of those migrating being between the ages thro ugh 2016 would be 1.7%. 12 Svaldi followed up in 2015 to report that Colorado had gained 101,000 population increase 13 Approximately 80% of these migrators are settling in the Front Range of Colorado, increasing population density and driving up the cost of living, especially in terms of the housing market 13 As suggested by The report, the skyrocketing cost of and low income families decreasing the availability of affordable housing and increasing the need for support from outside the family. 11 One could further assume that, with a large portion of employment in the low wage sector, the and the rising cost of housing in Colorado red ucing the amount of expendable income for food and healthy living habits that the prevalence of stru ggling individuals and families may very well inc rease Moreover, t he referenced report does not take into consideration those experiencing homelessness, likely due to the difficulty in studying this undoubtedly growing population. Across the nation those at risk are the urban/ rural and tribal populations, particularly those with low income or that reside in isolated or difficult to reach areas. It has become clear that rural populations suffer health conditions in disparate prevalence when compared to the ir sub urban

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8 counterparts. 14 15 As alluded in the paragraph above, the distribution of income affects the distribution of health and now the distinction falls between rural/urban and suburban in light of evidence that wealthier residents of suburban areas were healthier than the rural and urban ( including 14 The traditional interpretation of Rural vs. (Sub) Urban information is that funding and interventions should be directed to address rural access to medical provi ders (improving the ratio of population to providers) and distance to nearest hospital; however, when one interprets this disparity from a population health approach, these aspects are no longer sufficient to impact the health status of rural dwellers. 15 H artley reports that, 15 The se factors were termed part of t lower levels of income and educatio n and it is well established that efforts to change unhealthy behaviors are less successful among low income or minimally educated populations. 15 Another factor in the Rural vs. (Sub)Urban disparit y is related to access to food. 16 An article published in 2009 in the American Journal of Preventive Medicine reviewed 54 articles published between 1985 and 2008 to discover d ifferences in access to food and the related forms of pre sence, nature and implications. 16 Th is research group found that: rural areas had 86% as many chain supermarkets than did urban areas; low income areas had 75%; black neighborhoods had only 50% as many chain supermarkets than white neighborhoods; and Hispanic areas were supplied by only 32% compared to non Hispanic neighborhoods. 16 The concluding remark broad support for the ir implementation, and identify other effective means for improving 16 Finally, in a global scope, less developed nations face significant health disparities among their constituents. W hile i t is reasonable to assume that developing nations suffer some of the same

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9 issues as above (education, income, urbanization), these countries face other hardships that nations like the U.S, in large part, do not understand. These disparities stem from a lac k of infrastructure that prevents health care and medical resources from reaching those in need either from reaching them at all or from reaching them in the quantity needed 10 Additionally, some of these countries have experienced exponential growth due to industrial or commercial labor cost exploitation People in regions such as Southeast Asia and West Africa are at risk for serious health impacts due to the drastic change in lifestyle These lifestyle changes no w involve more consequences of modernized health risks, such as those from tobacco and alcohol usage physical inactivity, overweight/obesity, and air quality or occupational risks many of which are undoubtedly due to the imposition of Western culture and commercialization 17 Specific n have experienced a massive shift in lifestyle to accommodate the international demands for cacao products; for example, air quality and occupational risks include h igh exposures to pesticid es and other harmful chemicals used in commercial cultivation of increasingly demanded cacao. 18 24 To explain why this paper chose to focus on disadvantaged populations it is advantageous to consider a 2013 study published in the Journal of Health Communication, which reports findings self 25 While other studies had sh own the existence of such a relationship, t he significance of thi s study lies in its claim as the first to explore health literacy as a pathway to understand the connections and differences between education and health. 25 The research group reviewed data for 5,136 respondents 25 years or older, of the Adult Literacy and Life Skills Survey (ALL) ; the main variables were education (used categorically), health literacy and health status ( used as continuous variables). 25 Existing research had shown that low health literacy is associated with low self esults confirmed that, with higher level s of education, the proportion of respondents that demonstrated adequate or strong

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10 health literacy also was higher. 25 One might question the validity of self reported health status, as this can be quite subjective and should involve some sort of objective measurement. Yet it makes sense that low health literacy would impact the health status of an individual vi a a lack of understanding of how to measure and administer prescription medication or a lack of understanding in H owever, notably, the mediating role of health literacy did not hold as a linear gradient as education i ncreased ; t his was evidenced by the result t hat health literacy played a more important role in mediating the difference between education and health status for participants at the lower secondary education level than those at preprimary/primary level 25 Another i mportant finding of this study that was corroborated by similar studies in Australia and in the U.S. is that health lite racy levels are not equiv alent to the level of education. This is indicated in the result that even some highly educated partic ipants scored in the low health literacy category a matter which requires exploration in future research. 25 In all, it appears that health literacy holds an important role in self reported health status, but this ability is not guaranteed to anyone. Health literacy, as defined by the U.S. Department of Health and Human Services (HHS), i nvolves the ability to: navigate the healthcare system, share personal information and health history understand concepts of risk and probability, and most importantly engag e in self care and chronic disease management. 26 For the purpose of this paper, the health literacy skills involving self care and disease management center on an emerging term food literac y due to the fact that both abilities require lifestyle behaviors that promote health y diet (and physical activity ). A definition for food literacy was proposed in 2015 in an article from the Canadian Journal of Dietetic Practice and Research h social, cultural, and environmental 27 These skill based experiences should be cultivated and strengthened to ensure not just longevity, but quality of life.

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11 When one considers the other main factors in health status, education and income, the notion of promoting food literacy and health literacy skill based experiences becomes much more attractive from a financial standpoint, as it does not evoke the political tensions found aro und economic stimuluses or subsidization of public education. So how does one go about cultivating food and health literacy skills, especially when already hard pressed? The following chapters explore that very question. 3. How we Learn (Brain Body Connection s) In Papua New Guinea the Asaro Tribe has a saying : Modern technology and computational neuroscience has helped to identify some of the specific muscles that work to store and incorporate knowledge However, the human being is complicated. Humans do things for any number of reasons, including none or multiple of the following: physical, emotional, and social, economic, ecological, etc. The understanding of the learning process is also quite complex. T he brain is not the only part of the equation often, internal genetics and external environment can have an influence on perceived memories, experiences or information This section will explore the way humans learn, investigating the connections between mind and body. Because there are many options for the learning environment it is important to understand the various pieces involved with the reception of information before addressing intervention techniques to further public health.

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12 A 2002 study from TRENDS i n Cognitive Sciences explored the distinctions and overlapping fun ctions between the hippocampus and the neocortex through a unified cluster of small experiments, examining episodic memory and learning paradigms such as cued recall, recognition and nonlinear discrimination, habituation, fear conditioning and transitive inference. 28 The physiolog ical functions of the hippocampus and neocortex are differentially indicated in the firing levels of each; for example, the hippocampal areas having sparser levels, which have been shown to 28 A more macroscopic view of the functions of these structures may be summarized as follows: the hippocampus rapidly encodes conjunctions of existing cortical representations, avoiding interference across memories, while the neocortex slowly overlaps representations to encode shared structure of many experiences, thereby creating a general structure of existing knowledge with newly integrated informatio n. 28 The hippocampu s is because it provides for the most animalistic roles: fight, flight, fear, free zing, feeding, and fornication. 29 The hippocampus in particular reacts quickly automatically encoding information from an experience (or episode) ; the pattern separation mentioned above refers to the result that the hippocampus keeps information separate in order to delineate experiences in an effort to not mix up or confuse the data. 28 This function is critical, as it allows the brain to remember, for example, different places that an individual parks the car each evening if this information were overlapped, the individual would have difficult time finding the car each new morning becaus

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13 muddled. In c omparison, t he neocortex (the newer part of the brain, anthropologically speaking) works more slowly, forming generalizations and extracting relevant information from the hippocampus over time 28 In reference to the parking example, the neocortex encodes overlapping information to accumulate experience and allow the individual to create patterns relating to how to park the car (i.e. forming best practices). The study from TRENDS in Cognitive Scienc es is centered around a Complementary Learning Systems, (CLS) compiling information from widely held ideas about hippocampal and neocortical functions toward memory that have accumulated from significant research between 1957 and 2002. 28 This CLS theory em phasizes the importance of a complementary relationship between the two systems of memory formation and serves as a framework to conceptualize the contributions of both the hippocampus and neocortex by way of 28 Further, the CLS model comes out of dual a specific sense of 30 The aforementioned study included several models to monitor and assess the synapsing of and less active neurons, as presentation of the stimulus increases. This is particularly fascinating called] Hebbian learning), and will therefore become more activated upon subsequ ent presentations 28 In essence, the more the neurons are subjected to an experience or episode, the stronger they become and more quickly they will differentiate information. This allows the uploading of that information to the neocor tex for long term storage and adoption, but the encoding of novel

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14 Interestingly, one of the conclusions of the study was that pattern flexibility completion was s tronger in the hippocampus than in the neocortex, but the cortex has the special ability to support familiarity judgements via the sharpening mechanism mentioned above. 28 This in depth analysis of the physiological and neurological functioning of each of t hese regions of brain leads one to believe accordance with that experience, as well as upload that information to the neocortex for long term memory allowing rete ntion and future use. The reader may be familiar with the various learning styles such as visual, auditory, and tactile kinesthetic (or any combination of these). While this paper seeks to explore a bit more deeply how learning methods affect retention an d long term adoption of the information in order to create habitual practice, it is prudent to briefly consider these learning styles to familiarize the reader. Much research and development have focused on the Visual, Auditory, Kinesthetic, and Tactile (V AKT) learning styles. 31 These are rather self explanatory, denoting the preferred sense for interaction used by each learning style group (the Kinesthetic/ Tactile learners, for example, prefer to move and /or touch tangible objects to reinforce information). It is also important here to acknowledge co nflicting arguments against this concept psychological theories, such as personality traits, to th e formation of learning styles. 31 32 Research has also indicated that claims about these learning styles may controversially portray predictive characteristics of the learner; for example, the be lief 31 32 However, t h ese types of controversies over the formation of learning styles are not necessarily applicable to the research of the current paper because th e research herein is concerned not with the formation of learning styles, but with the best method to approach the styles of learning that apply to the widest

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15 range of learners ( young and old ) T hus, in order to make progressive change this paper focuses on the exp erience s and motivation that encourage growth and value of learning within the learner. Of pa rticular interest in this paper is the Tactile Kinesthetic style of learning as related to anecdotal success from methods from various interview sources (to be discussed in Chapter 5) T he t actile kinesthetic learning method may hold some potential to enhance the brain body connection and further encourage healthy behaviors by way of (internal, physiological) positive reinforcemen t. In the Foreword of The Kinesthetic Classroom Jean Blaydes age stu dents are 32 The authors of The Kinesthetic Classroom Traci Lengel and Mike Kuczala investigate five, potentially interwoven, pathways to move information from working memory to long term memory (moving information from hippocampus to neocortex) 32 One of the resources that provid es great insight for Lengel and Kuczala is from a report from the educational consultant Lee Oberparleiter (2004); his report, originating from a large personal experience as a public and private school instructor, detailed five key roles that movement can play within the classroom experience: 1. The brain is attracted to novelty. The six purposes of movement can be used to provide this desired novelty. 2. The brain pays attention to movement. Movement with purpose acts to keep the attention and focus of students. 3. The b rain needs to interact with people and things in its environment. Class cohesion activities using movement build a sense of community and interaction among classmates. 4. Lea rning is easier to store, remember, and retrieve if it has an emotional base. Movement activities often create positive emotional states causing students to link positive emotions with learning. 5. The brain operates from concrete experience everything st ems from that. Nothing is more concrete than using movement to learn or review a concept.

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16 These roles offer much potential in the way of improved learning through physical activity and direct exp erience with the concepts and material. The five roles of movement capture the very aspects of the environment that this paper claims are conducive to learning, such as improved focus and attention, social interaction, and positive neurologic associations with the content. (via endorphins releas ed from movement and physical activity ) The neurological stimulation to release endorphins, especially, serves as positive reinforcement and motivation for the learner to repeat the experience (i.e., continue the skill practice ) More recent proof of thi s movement based model is found in the research of Wendy Suzuki, a renowned neuroscientist at New York University (NYU) and author of the book, Healthy Brain, Happy Life. 33 Suzuki anecdotally discovered a change in herself after adopting a more active life style and began an experiment to test this theory on NYU students Her personal explorations of movement based neuroplasticity (the ability of the brain to adapt to changes in environment) revealed increased mood, attention span social interactions and r etention of information to be called upon during challenging tasks like writing grants. To better understand these changes, Suzuki conducted a study: an hour of physical activity was incorporated before a two hour class period and the cognitive abilities w ere compared to a control class. Findings in response to aerobic exercise included s ignificant improvement in the ability to encode new long term memories and i ncreased generation of new hippocampal neurons. An exciting exemplification of this data might b e imagined as a low intensity aerobic walking exercise for an obesity/diabetes education course or light healthy family meal. Further extrapolation of data may even hold promise to i mprove creativity through greater stimulation of the hippocampus, which increases the overall communication within the different regions of the brain. 33 The benefit of improved creativity in terms of healthy habits are related to i mprovisations within p ractices like cooking with new foods or integrating new ideas into current

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17 practices. Both applications, increased long term memory and increased creativity, would be beneficial in the educational environment for developing healthy ha bits. Self proclaimed ocial worker Bren Brown in her book Rising Strong states that, 34 of this theory of experiential learning, while centered more on the use of creativity expresses t he way humans self, environment, or desired subject matter in order to adopt that knowledge into cult ivate it as a regular practice. 34 Hands on experience and handling of information, as noted by the Oberparleiter, helps the individual conceptualize and understand given information. Brown advocates t the experiences in various situations or responses to the environment lead s to emotional growth and increased self awareness. experience mimics the method of experiential learning because it directly engages the learner with the information or skill to be learned: actively jumping into the arena to be a dynamic participant with what one is learning ra ther than be a passive observer or receiver of information. Thus the model of experiential learning allows one to appreciate the interconnectedness between creativity, physical activity, neural activity, and the conversion of information to learned habits. In nutrition, it is debated that the benefits of a specific micronutrient may not be as effective when that nutrient is isolated ; some claim that these benefits derive from the interactions of the body with the synergistic combinations of phytochemicals in the whole food. 35 37 An example would be the resveratrol found in red wine : t he health effects from the red re more evident than when only the resveratrol is su pplemented. This paper proposes that the same is true for the individual and the learning experience ; the benefits will be greater when the individual is exposed to w hole experience (including the various challenges of skill practice that would be encountered in the real world).

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18 4. The Existing Model If the method of experiential learning holds such potential why is it that current educational modalities do not incorporate it more often? What barrie rs and challenges exist to prevent Public Health programs from adopting e xperiential learning as the new gold standard for health education especially in disadvantaged populations ? This chapter explores such barriers and challenges in order to understand the resistance to the option of skill based learning and to identify potential areas for convergence. The first of these barriers is the industrial complex, which has played a large role in the propagation of education methods to promote large scale efficiency Further, certain educational philosophies dominate the delivery of education in the nation and set standards for the material an d the methods used to teach it. Additionally, th e limited availability of resources in terms of finances, space, and/or materials, inhibits the implementation of some educational techniques in order to better serve society at large. While the combination of these issues undoubtedly creates reasonable op position, a shift in the status quo may very well be in the best interest of society at large. The i ndustrial complex has left a metallic taste on the system of education. S ince the Industrial Revolution, more and more businesses have pursued the idea of economies of scale. This idea places value on th e quantity of products produced, even at low prices, in order to earn profits from the sheer volume of output. S imilarly, t he educational processes have taken on a tendency that parallels the manufacturing pr ocess pumping out mass numbers of students but only equipping them with generalized kn owledge and basic life skills. With the large increase in demand for secondary and post secondary education to keep up with population growth and the demand for skilled or educated workers it makes sense that the education system aims to be extremely efficient in the way it handles such a high volume of students. 38 There are unsurprisingly, economic drivers f For example,

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19 due to state revenue shortcomings in 2009 the University of California suffered 20% budget cuts; this caused significant financial repercussions to the system and forced even greater efficiency meaning fewer faculty and staff, fewer openings for students, and greater tuition prices 39 Basic economics dictates th at th is supply and demand relationship results in greater prices for the same product (in this case, inflation of education). Maintaining a standardized system for education is a more predictable and cost effective method to provide education to the masses because it holds constant the arenas for learning (the classroom) and the ob jectives for learning (to succeed in life) This paper does not refute the need for certain principles and procedures to impart a standardized knowledge to students; instead, the notion herein i s to introduce flexibility into that standardized learning exp erience to allow creativity, critical thinking confidence, and informed decision making in order to develop and maintain lifestyle habits that promote health. To understand the basic framework for the varied approaches to education, including public healt h education, one would be wise to consider the standard philosophies of education: E ssentialism, P rogressivism P erennialism, E xistentialism (which includes experimentalism ), and B ehaviorism The current model of public health promotion rests heavily on the public school system, which is predominantly shaped by E ssentialist education philosophy 38 Essentialism is teacher centric and aims to impart a sense of common culture and essential knowledge and skills that should be conveyed to students through a sy stematic, disciplined manner to create productive citizens. 38 This systemic, disciplined manner is also beneficial to maintain cost and minimize challenges in the classroom which serves knowledge and skills promoted by Essentialist philosophy include writing, computing, measuring, history, and the more recent additions of investigation, invention, creativity, and health. 38 However the actual practices of Essentialist education do no t foster individuality or specialized learning styles, especially in regard to health education

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20 The World Health Organization (WHO) has recommended forty to eighty hours of heal th education, per academic year, respectively, in grades Kindergarten 2 nd and 3 rd through 12 th 40 When this recommendation is more deeply considered, one could conclude that 40 80 hours per academic year per student is rather insufficient to impart crucial health information that is needed to carry the individual through the re st of life. In the United States, it appears that only a small fraction of public schools (Kindergarten 12 th grade) provide health classes that i ncorporate nutrition education. Therefore, unless these skills are imparted in home life, graduating high schoo l students are, for the most part, unskilled in healthy dietary practices and unable to implement preventive methods of self care to avoid common chronic disease states The situation worsens for school districts that are more inhabited by conservative s a s health education typically falls in the same arena as sex education a controversial topic in some regions. As such, parents are often permitted to withhold their child from these educational segments, which results in lower attendance and a further lack of knowledge. While the parent or family also controls education at home (which could be beneficial or harmful), the consequence of this is clearly a lack of comprehensive education for safe sexual practices for youth, but also a disadvantaged situation for the nutritional health and overall wellness in young people A lack of funding for these educational programs in public schools may affect low income areas in the same way, furthering the characteristic health disparities that are found in low income areas and food deserts. To address the disparities caused by the ineffective or improper amounts of health education, the U.S. government launched programs such as the Supplemental Nutrition Assistance Program (SNAP). Such programs are designed to help le ssen the effects of common factors related to health disparities, particularly low income. These low income households are, as previously stated, more likely to suffer health disparities as related to the limited access to and limited affordability of nutr itious foods. SNAP, though, does not provide nutrition education; it simply provides monetary

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21 benefits to recipients that may be used to purchase food ( such as soda, ramen noodles, or processed/refined grains ofte n less expensive than wholesome, fresh fo od items ). To accompany these govern ment programs, the nonprofit sector provides various types of assistance to further help people in need especially in regard to public health Yet, these nonprofit organizations operate on limited budgets and generally follow similar educational practices as the traditional institutions in order to mediate their limited personnel and funds. Current programs available through the government a nd non profit organizations are well int entioned, but the health outcomes fall short. The one size fits all concept for public health is indeed more amenable for large scale implementation, especially when most pub lic health promotion is delivered through public education or government agencies that do not allow sufficient budgets for individualistic interactions or a focus large scale nonprofit organizations will utilize a method that can reach as many people as possible. However, this does not guarantee success for all those learners. Instead, it may inhibit successful learning for many because they do not feel a connection to the learning environment (including the instructor) or to the value o f the learning objectives. A powerful quote from a rigorous review of that too much of the health education practiced is inappropriate for many, perhaps the majority, of the people for whom it is supposedly 41 As one sees in the mass production of consumer goods and agricultural products (including both crops and animal meats), the allure and value of factory processing fades as the quality of the products diminishe s. But this does not only apply to academic education these practices contaminate the practices of health education, as well The education industrial complex perpetuates t he dominant educational philosophy specifically Essentialism. Es sentialism favor s certain subject matter over others, which leaves health

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22 education in an unfairly discriminated position. To alleviate the disparities caused by the improper amounts of health education, the government has created programs designed to help reduce some common factors related to health disparities; to accompany these government programs, the nonprofit sector provides various types of assistance to further help people in need. Conservatives may believe that the status quo is sufficient to aid those in need, that the system of education and capitalism in the nation is designed to allow those who work hard to succeed; but is it truly enough? Even when the government provides for assistance programs and public health resources, they do not elimina te health disp arities. Something is missing from these effo rts at public health promotion: perhaps socioeconomically appropriate education techniques such as experiential learning via skill based practice would better impact the majority of people for whom it is intended. 5. Skill Based Practice [Case Studies] In contrast to the predominant educational philosophy, Progressivism developed from the works of a man named John Dewey. In the late 19 th and early 20 th centuries, Dewey made his case for Experiential learning. 38 In his work, Experience and Education is a moving force 42 This moving force has the power to grow and spread, like a wave or a forest fire, inciting further reinforcement to either promote or inhibit a given exper George Counts later developed the Existential educational philosophy (now home to Experimentalism), the notion of Experiential Learning is nothing new to education academics Dewey also put forth the idea E xperience is not simply inside the person, which is to say that experiences do not occur in a vacuum. 42 So why does the existing model for education attempt to educate in a vacuum? M oreover, why does it make sense to promote health education in one ? Inter relation (interaction) occurs between the learner and the environment Therefore, cultivation of this relationship, this connection between subjective and objective experiences is necessary to truly

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23 educate individuals on health practices. Recalling the repeated exposure to ex periences s memory and ability to respond to the conditions. 43 [it] affe 42 Thus, it follows to use this model of experiential learning, via skill based practice, to promote long term behavior change to improve public health and wellness. Examples of this sort of skill based practice come in many forms. Experiential learning, in the context of this paper, utilizes a combination of tactile kinesthetic, audio, and visual learning styles. This practice is evi denced in several disciplines such as Musical & M ovement arts (playing the piano or learning to dance, for example); V ocation and trade schools ( or old fashioned apprenticeships in fields such as carpentry ) ; and even in scientific lecture courses with supplementary lab (college level Chemistry or Anatomy and Physiology). These skills a re not simply mastered via auditory and visual observation they must be developed over time with repeated exposure and interactive practice Hence, upon this model of skill based practice, this paper considers several organizations that have enacted this type of experiential learning to improve public health. The first to be featured, Cooking Matters (a subsidiary of Share our Strength and No Kid Hungry), is a national program that provides nutrition education primarily through grocery shopping tours and f amily focused cooking classes 44 T he next featured organization is Growing Power, a Milwaukee based non profit that promotes sustainable food practices through urban gardening efforts and a return to healthy cultural foods. 45 Finally, this report reviews t the connections between food producers and consumers by way of locally and/or sustainably grown produce in school gardens to educate children, families, and school workers about the be nefits and methods to grow a nd eat healthy, wholesome foods. 46

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24 1. Cooking Matters Share has been serving Colorado for over 22 years and as part of the No Kid Hungry campaign working to end childhood hunger in A merica, Share Our Colorado e mpowers low income families to stretch their food budgets so their children get healthy meals at home. Participants learn to shop smarter, use nutrition information to make healthier choices, and cook delicious, affordable meals. C ooking M atters courses and tours equip families with the skills they need to stretch their food dollars and maximize the benefits they receive through public nutrition programs like SNAP ( [Supplemental Nutrition Assistance Pro ) and WIC ( [Special Supplemental Nutrition Program for] Women, I nfants and C hildren). Cooking Matters, Lead Partner (Colorado) Report Introduction 47 With the program goals and implementation techniques, Cooking Matters Colorado has been able to improve outcomes among its participants in various ways. An interview with Cooking Matter Community Engagement Manager Becky Mares shed light on many a spects of the program. The typical course lasts six weeks and entails grocery store tours, cooking demos led by volunteers and nutrition educators, and a take home bag of groceries. The grocery store tours take advantage of the SNAP or WIC benefits, teachi By comparing pre course surveys to post graduation surveys, it is evident that the Colorado level of this program is effective in increasing consumption of fruits (37%), vegetables (64%), low fat or fat free dairy (55%), whole grains (39%), water (17%), and confidence in cooking (69%). While some of the statistics are less impressive (such as the increase in eating non fried vegetab les, only 4% in the state compared to 11% nationally), the overall improvements to lifestyle are impressive for a six week course. Also impressive are the much ior to es are extremely enco uraging for public health, as

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25 Cooking Matters for Kids results show a 13% increase (compared to the national 5% increase) exciting when one considers the frequency with which families eat out. Teenage participant responses are also positive, giving hope for this intermediate results rep ort an increase of 9% in the frequency of eating beans and a decrease of 10% in consumption of soda, sports drink, or energy drink. This group also reported an increase of 11% in Nutrition Facts on food labels, and 7 8% increases in the frequency to eat something for breakfast, eat food from each food group, and to make homemade meals with mostly whole ingredients (national averages 4 6% increase). One teen even s hared that confidence with cooking. I never really held a knife until [this course] and now feel I could make These points are especially exciting to use skill based practice to instill healthy food habi ts in this generation before moving out of the house or having their own children. While there is certainly room to improve more healthy habits in each group, it would be outlandish to expect total change in six weeks with every age range. Change is difficult, especially when related to intimate aspects of life like food. The progress is mild in some cases, but slow, continuous modifications are ideal. The limitations of this data are most prominently in the short scope of analysis: the graduates in these reports were surveyed after completion. It would be beneficial to see similar data a fter one year, several years, or even more time to determine the efficacy in developing very long term behavior change. Additionally, it would be pertinent to analyze any health risks before the course and after, as well as several years after (assuming be havior change was maintained). Another area that may prove beneficial for Cooking Matters is a more in depth financial literacy education for participants. Usually, if families are struggling to afford food, there are other financial concerns that may requ ire attention. The addition of financial literacy might prove

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26 even more helpful for parents and families to budget income to afford cooking equipment or new varieties of produce that are otherwise outside of their fiscal means. Overall, this program positi vely represents the possibilities in implementing skill based practice for healthy habits. Cooking Matters holds much potential for the improvement of Public Health in Colorado and in the nation. 2. Growing Power Since its inception, Growing Power has se young, the elderly, farmers, producers, and other professionals ranging from USDA personnel to urban planners. Training areas include the following: acid digestion, anaerobic digestion for food waste, bio phyto remediation and soil health, aquaculture closed loop systems, vermiculture, small and large scale composting, urban agriculture, permaculture, food distribution, marketing, value added product development, youth education, community engagement, part icipatory leadership development, and project planning. Growing Power 45 Will Allen created Growing Powe r in 1993 to provide access to high quality, healthy, and affordable food and to inspire sustainable local, community based food systems and to promote has been praised as a model for urban agriculture, complete with worms, goats, hens, solar panels, and community outreach and education. With a family histo ry in sharecropping, Allen particularly desired to work with black communities to remove the tarnish from their associations with f arm work. In his book The Good Food Revolution Allen states that, as people moved away from agricultural practices, the after effects of generational 48 This strong aversion to agriculture and tendency toward processe d foods, especially in low income urban areas, was leading to increased rates of chronic disease, which prompted Allen to take action. His lot was the last one zoned for agricultural use in the city and it began with a rocky start (vandalism by local youth

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27 program participants, volunteers, or even employees of Growing Power This impressive shift has allowed Allen to develop Growing Power, Inc. into an expansive organization that hosts community outreach, education workshops, food activism groups, and much more. Growing Power has also expanded into the Chicago area, even ren ovating a Chicago Transportation Authority bus to function as a mobile farme r 49 The Growing Power Highlights 2015 proudly displays bits from the Provided employment and enrichment programming for 300+ teens. Taught over 150+ head start preschoolers how to grow, harvest, play and eat at our preschool farm. Grew produce and provided programming on seven urban farm sites in Chicago. These experience based learning opportunities are ildren to 45 The Youth Corps programs from Growing Power focus on job training and development of life skills to prov ide academic and professional experience in under served youth. During the summer, the youth are exposed to all agricultural demonstration areas in order to fully engage and impart occupational and leadership skills to encourage growth into responsible and employable adults. Beyond the agricultural experiences that these youth receive is 45 Yet no program is perfect. T hese experiential learning opportunities come at a price. The one day workshops (10am 5pm) in Milwaukee go for $150 per session, including lunch and dinner; two day workshops in a New Jersey location cost $200 each; the new two orkshops are currently $400 per person; and the three day aquaponics workshops are listed at $600, including all 3 meals each day. And any commercial enterprises that wish to adopt practices

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28 from Growing Power are exposed to five, three day weekends of han ds on skill practice at the cool price of $2800 (including meals). These prices do not include any necessary lodging for out of town visitors and the amounts are rather high to allow a majority of low income individuals or families to partake in the experi ence. 50 While the Youth Corps and partnerships with day care facilities are nonprofit efforts, the fees for education for adults (beyond volunteering or 3 month internship opportunities) are limited by the ever familiar affordability barrier. In all, while Growing Power has an admirable business model and makes a significant impact on its community and others, it is not widely accessible to some of the people that need it most. If Growing Power were to adopt a sliding scale payment option for its hard press ed community members, they may be able to reach even more families in need and further improve the health of the local community. 3. Slow Food National School Garden Program & Garden T o Cafeteria The Garden To Cafeteria (GTC) program teaches students how to grow and harvest food safely to be used in the school cafeterias on the salad bars and in some cases, in scratch cooking recipes. Using proper Food Safety Protocols, students sell fresh produce from the school gardens to the school kitchens with pro ceeds supporting the sustainability of the school garden. Using fun signage, produce is identified on the salad bars as having come from the garden, and it is well received by the students. The garden programs benefit, and as their balances grow, schools c an learn to grow even more of the produce that a district or food service department is eager to buy. Slow Food USA National School Garden Program & Garden to Cafeteria 46 The Slow Food movement began on December 10, 1989, when delegates from 15 nations signed a manifesto from Folco Portinari. The Slow Food Manifesto undertakes the idea to rid humanity of the follies of Fast Life through a truly progressive defense that is Slow Food. Slow Food USA s National School Garden Program (N S G P) takes this concept to the children, implementing

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29 creation of Garden to Cafeteria extends this goal to impact the consum ption of fresh produce by all year and has resulted in over 3,000 pounds of school garden produce going into the salad bars at about 20 schools. Overall, the GTC program has raised $3,000 for the garden programs at those 46 The and Garden to Cafeteria program lies within the educational curriculum it has crea air food practices. 51 They propose that education for Slow Food should be about pleasure, respect, hands on experience, diversity, multi personal journey, active participation, community exchange, self awareness, curiosity and promotion of change to generate responsible thoughts and behaviors. Slow Food seeks to reconnect people with each other, as well as with traditions, animals, plants, and healthy soils and waters that produce our food. The unique contributions that Slow Food provides to school gardening practices include: 1. Activities and instruction regarding growing food. 2. Activities that center around cooking and eating. 3. Promoting the enthusiastic enjoyment of good, clean and fair food for all. These ideals are refle cted through engaging learners through experiential and emotional methods to impart meaningful context, allowing the learner to better understand and appreciate the intricate connections between humanity and the natural environment. To that end, the lessons that Slow Food provides in its curriculum are process driven, relying o n a combination of observational and skill based experiences to increase enthusiasm for learning about gardening and cooking. These lessons are intended to be adapted and diversified to fit many types of conditions, even pointing out that they may occur wi thout the formal school garden setting. The key aspects of each lesson are the Observation, Research, Experimentation or Action, an d

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30 Reflection. These aspects provide a nice balance between the physical act of experiential, skill based learning and the int ernalization of that knowledge to allow the student to develop awareness of emotions or other factors that may have played a role in the way that he or she absorbed the information. The learners develop the skills in critical observation and research by le arning to ask questions beyond surface level and seek the answers. Experimentation or Action allows the learner to delve into the learning environment and continue developing skills necessary for growing and preparing foods (for example, measurements and f ractions used in cooking, as well as judgment and decision making for planting and harvesting). It must also be noted that this reflection is indeed an experience in and of itself, emphasizing the psychological experiences that are involved with sensory an d physical activities, such as smelling or touching soil or plants and tasting different types of foods. development of critical thinking skills. empower children to become informed and active participants in the food system in order to create a positive impact in the larger world of food. The curriculum places particular emphasis on the sensory experiences of growing and cooking good food, while fo Taking these concepts into the cafeteria has been very meaningful to many students, allowing them to see the produce they cultivated on the salad bar at lunch wh ich increases the likelihood that they will eat more fresh vegetables and fruits. But these practices also have an impact beyond the students and parents/volunteers. When NSGP introduced the Garden to Cafeteria concept, it had to overcome some operational barriers of the school kitchens or lack thereof. Garden Program Director Andrew Nowa k in a personal interview, shared that m any schools do not have full kitchens, and those that do may employ kitchen staff with limited skil ls in working with fresh produce. Unfortunately, as mentioned in the previous chapter, the industrial complex of

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31 education has pushed for the fastest and most efficient method of preparing foods; thus, bringing fresh foods from school gardens into the kitc hens entailed an overhaul of the system. Slow Food incorporated a training program to familiarize staff with food safety training, knife skills, cooking l ook of aprons and hairnets). While this was met with initial resistance, many of the employees later shared their excitement in developing these skills because they felt they were actually cooking now. T permit parents and volunteers to join, but the education is more tailored to the children. This might prevent the opportunity for adults to continue growing and develo ping their skills in the group environment, which is a significant limitation because parents shop, plan, and prepare meals. Thus, it may prevent the long term behavior changes desired for best health. Stagnation, mentally, for the older learners may lead to decreased interest over time or to an assumption that they have mastered certain skills or practices, which counteracts the ideals of continuous experiences for lifelong learning. It would behoove the organization to identify methods for the adults to b e more engaged in the learning and teaching process to involve all levels of participants in the experiences and reflections that the children undertake. This is especially important for the school kitchen staff that work with the produce from the gardens these employees should be exposed to continuous trainings to encourage constant development of their food literacy skills, not only to serve healthy and varied foods, but also to improve their own health and serve as models for the students. Another limi tation, more relevant to this paper, pertains to the data collection from these school garden efforts. There is very little data available to properly analyze the efficacy and efficiency tative and qualitative data, Slow Food may miss out on opportunities for grants to expand their efforts. Further, a lack of program outcome data keeps the public in the dark in terms of social benefits from these particular

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32 practices and, by default, allow s the continuation of more traditional food and nutrition education. While Slow Food does provide research based information for program leaders to validate the methods for its education techniques, that research does not substitute information for Slow Fo program. The provided research reviews list benefits in regard to increased vegetable and fruit consumption, increased self efficacy, increased confidence and ability in food preparation skills, and willingness to try new foods, yet there is not yet a report to determine efficacy or efficiency toward long term behavior change in the participants. 52 58 In all, the efforts of these featured organizations are based on experiential learning and skill based practice to impart healthy habits and multi disci plinary thinking in regard to food production and the impact it has on the earth These goals are well intended and the methods used to achieve them are mostly sound. However, questions remain regarding the length of time needed from these experience based models in order to get the long term health benefits and the true efficacy for long term behavior change to exhibit improvements to health status. The book Outliers addresses the former 10,000 hours of practice for true expertise and the author proves his point with examples from The Beatles, Bill Joy, Bill Gates and even Mozart. 59 However, a number of that magnitude is extremely daunting the average person might not see how they can poss ibly incorporate such massive amounts of practice to be healthy and may indeed feel too overwhelmed to even try. So there must be a more happy medium, a solution that encourages continuous skill based practice throughout life while simultaneously encouragi ng creativity and innovation to keep things interesting and engaging. A s Bruce Lee said, It seems that this old adage from a martial arts master also holds true in the effort to lear n healthy habits By continuing to engage in skill based practice and experiential learning, individual learners can absorb what is applicable and interesting, without being clouded by superfluous or nonessential information, and

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33 combine that new knowledge with their own unique life experiences and culture to develop a personalized practice for lifelong health. 6. Impacts & Implications H ow do es one measure the efficacy or success of these educational methods? It is difficult to compare the traditional system to the one proposed in this paper. While the trials featured herein are representative of success and hope for the future, the reader would be just in asking how to be sure that one is, in fact, better than the other. One way to measure these methods is through the metric of cost versus benefits, which theoretically takes into acc ount the externalities of each, which will be discussed in this chapter. In order to address rural urban cultural differences as discussed by Hartley ( the mentioned in Chapter 2 ), 15 public health promotion avenues should adopt a more ethnographic methodology. This type of approach is more apt to consider cultural (socio or otherwise) differences that might imbue health characteristics or behaviors that are targeted for change. Sensitivity to various cultural differences in public health promotion methods provides more multi disciplinary, holistic, appropriate, and effective education to improve the overall wellness in a community throug h open minded practices or freedom to tailor the experiments to fit the Experiential, skill based learning in the realm of public health and wellness has far reaching implications, too. There are potential benefits to society both in th e present and in the future and to the environment that could lead to the reduction of health disparities and of chronic disease throughout the community, the nation, and by extension, the world. In lieu of adequate data, this paper supposes a cost benefi t analysis to determine the most effective method s of public health education for disadvantaged populations The most obvious barrier or cost to the implementation of experiential, skill based learning methods is the financial cost to operate such a progra m. However, the featured case studies operate mostly through

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34 volunteers, making use of the community stakeholders that are directly impacted by the very health of their community. By cultivating relationships with community members, a Public Health Program could capitalize on this option for labor and save time, effort, and dollars. Further relationship building in the area could glean sponsorship from local businesses or individuals that are aligned with the vision for a healthier and more produc tive community. This suggested Public Health Program could also take advantage of Extension Services, the very groups that support research and education out of Land Gran t institutions in the given state. These institutions, as part of the funds that they receive from the state, are required to provide support and/or education to the local community. This requirement could easily be used to obtain assistance in the design and development of effective evidence based Public Health Education techniques. Addi tionally, community support such as sponsors or the Extension Service could aid in the execution of data collection to showcase successes and regularly analyze efficacy for the overall impact of the program in order to continuously grow and develop best pr actices. Data collection is a very powerful way to demonstrate impact, efficacy, and efficiency. With sufficient information through well executed data collection practices an experiential public health program cou ld investigate relationships between expe riential learning and ret ention of health information on long term improvement of health outcomes a piece of this puzzle that is still missing. The internal study that evaluated the effectivene ss of Cooking Matters, for example, d etermined that between 63% and 91% of participants displayed improvements; 44, 47 another reported that behavior changes were no different between 3 month follow up and 6 month follow up. 60 While this data is positive and helpful, the length of time between intervention and follow u p does not necessarily equate to very long term retention and behavior change. The featured programs and organizations are making great strides, but economic minds prefer to make change based on figures for Return on Investment. Without that data, it is di fficult to accurately determine which methods are more effective and

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35 efficient; and further, it would be quite difficult to realize such a drastic shift in the practices for Public Health Promotion. This analysis utilizes a Social Ecological behavior theory in order to incorporate the independence of and interactions between multiple levels of health. At the heart of the Social Ecological m odel is the I ndividual with her skills, knowledge, beliefs, an d attitudes. Moving outward, there are I nterpersonal relationships like f amily and friends; next is the O rganizational level which incorporates organizations such as educational or social institutions. Closer to the periphery are the arenas of the C ommunit y (interactions among organizations) and Public Policy found in local, state, or federal laws. This paper asserts that the Public Policy level of the social ecological model could have a much more beneficial impact on the individual (and all other levels) if appropriate skill based learning experiences are implemented in wide scale application. Thus, it is necessary to develop working relations between all these organizations to create more integrated social construct. This could push people to a more commu nity based value system, increasing the potential for interpersonal and international partnerships to make the world better for generations to come. These community partnerships would help to mitigate the actual cost to an organization to execute this sort may improve significantly. The other benefits of this method of health edu cation may include, as mentioned above, the improvement in health status, reduction of cultural health disparities and chronic disease, such as obesity, diabetes, hypertension and heart failure, nutrient deficiency, etc. Through a Social Ecological applic ation of th e s e experiential, skill based practices for public health, one can see promising opportunit ies for a bottom up, rather than trickle down, solution to healt h disparities and even greater concerns like the environmental impact of food choices. Beg inning with the individual, there are multiple benefits, such as improved mental faculties /self

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36 confidence), allowing creativity as higher mental function/ problem solving, increased exposure to new practices that cultivat e variety and adaptability ( cultural foods, cooking techniques) Interpersonal relations are the next level of Ecological advancement. There is evidence to support that c ommunity building and support systems release cortisol to stimulate conversation in times of stress. 61 For a commu nity as a whole to overcome adversity, it will require significant amounts of interpersonal relationship development and sharing of best practices. Thus, the social aspects of skill based, experiential learning in group environments increases the impact of the learning methods. A personal account from a Cooking Matters supervisor depicts the friendly, constructive interactions of different Arabic groups during cooking demonstrations interactions that would have otherwise likely not occurred. 44 This story sh ows the potential for hands on learning to overcome cultural barriers and help build the community to embrace diversity and become stronger for it. A t the organizational and community level s long term benefits of skill based practice and experiential lea rning methods could include a decrease in costs of health care and new opportunities for growth within the sustainable agriculture industry. Recent shifts in the health status of the nation are reflected in the insurance costs for individuals and groups; j ust as car insurance increases depending on the risky driving behavior of the local region, so too does health insurance increase in income people to afford he althcare costs (especially emergency care) affects taxpayers because the federal government often steps in with programs like Medicare or Medicaid. If effective and efficient methods of Public Health promotion were more widely implemented, the local commun ities and the nation at large could see a meaningful decrease in poor health status and a subsequent decrease in shared healthcare costs. In the sustainable agriculture industry, a shift in market demand for healthier food production practices would allow more innovation. Techniques to improve nutrit ion

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37 intake within various socioeconomic cultural groups include targeted marketing, lowered prices for sustainable produce due increased production efficiency, or even fortification of foods A g reater sense of inter relatedness amo ng individuals and communities c ould ease the necessary action s to decrease negative effects on climate change from agricultural and lifestyle practices. Thinking globally, but acting locally skill based practice in Public Health pro motion will extend substantial benefits to the health of disadvantaged individuals and communities on local, national, and international levels. 7. C onclusions & C all to Action It is clear that health education via skill training is essential for long term h ealth f or individuals and overall wellness for communities particularly those that are low income or minimally educated Populations with limited income, access, health literacy and skills are at greater risk for poor health and chronic disease development. 6,9 11,14 24, 47 60 M ore experiential, skill based practice methods for public health promotion are the key to change this. The current research reviewed the physiological ways that humans learn, highlighting the need for repeated exposure to r etain and build experience to develop critical thinking and best practices and, potentially, creativity and innovation within that knowledge base Subsequent chapters explored the reasons for the status quo in educational practices, including the industria l complex, conflicting educational philosophies, limited health education requirements, and the limitations of government or nonprofit sector assistance. Featured case studies analyzed the practices of forward thinking organizations that focus on skill bas ed experience to educate participants about healthy habits. Finally, the large scale impacts of this proposed shift in Public Health Promotion present a wide array of social, environmental, and of course, health benefits for generations to come.

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38 While government assistance programs and non profit resources can provide valuable assistance in the way of information and food, such assistance can often be for naught if the recipients are not educated in lay and multicultural application of practices t o best utilize the resources that they receive from assistance programs The locally focused, experience based health promotion programs that exist in disadvantaged communities must be supported and shared by health professionals. Without full governmental support for the educational methods proposed in this paper, the progress is occurring in relatively small pockets of the public h ealth field In order to best support progress, health professionals need to be involved with these types of programs and refe r clients to them to take advantage of the success. All health professionals must also s tay current with information and research to carry out further development and evaluation of these interventions. With the innate difficulty to objectively and quantita tively measure a subjectively qualitative experience such as learning the evaluation of educational techniques can seem intangible. However, with continued partnership, cultural consideration, and longitudinal study design, it is possible to one day reach more cohesive conclusions regarding long term efficacy of these skill based practice methods. Both education and health professionals are needed to work together to continue developing best practice s. It is also important for these professionals to practi ce the advice they give to continuously assess efficacy and efficiency and to discover innovative ways to deliver critical health education to the people that need it most. To truly improve community, public and global health and wellness, all health profe ssionals must remember to focus on the skill based practice that the learner experiences I hear, I forget. I see, I remember. I do, I This venerable phrase holds truth in the efforts to better health across the globe. With skill based, experiential learning, both health professionals and health learners of any level can empower change to improve the health status of countless individuals and communities, one experience at a time.

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39 8. References Chapter 1 (Intro) 1. National Center for Health Statistics staff. Health, United State, 2014: With special feature on adults aged 55 64. Centers for Disease Control and Prevention. 2015. http://www.cdc.gov /nchs/fastats/health expenditures.htm Accessed November 12, 2015. 2. WHO Staff. Workplace health promotion. World Health Organization http://www.who.int/occupational_health/topics/workplace/en/index1.html Accessed November 12, 2015. 3. gut brain axis: from bowel to behavior. Neurogastroenterol Motil. 2011;23(3): 187 92. Doi: 10.1111/j.1365 2982.2010.01 664. 4. Centers for Medicare and Medicaid Services staff. Minimum essential coverage (MEC). Healthcare.gov. https://www.healthcare.gov/glossary/minimum essential coverage/ Acce ssed November 12, 2015. 5. WHO Staff. Health. World Health Organization. http://www.who.int/trade/glossary/story046/en/ Published 2015. Accessed July 2015. 6. Winkleby M, Jatulis D, Frank E, Fortmann S. Socioeconomic status and health: How education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Pub Health 1992;82(6):816 820. 7. Cutler DM, Lleras Muney A. Education and health: Evaluating Theories and Eviden ce. National Bureau of Economic Research 2006; w12352. 8. Goodreads Staff. Maya Angelou Quotes. Goodreads Inc. https://www.goodreads.com/author/quotes/3503.Maya_Angelou Accessed Nove mber 12, 2015. Chapter 2 (Background) 9. Beckles GL, Truman BI. CDC health disparities and inequalities report United States, 2013. Education and income United States, 2009 and 2011. Morbidity and Mortality Weekly Report. Surveillance Summaries. 2013 ;62:9 19. 10. Fauci AS. Ebola: Underscoring the global dispar ities in health care resources. N Eng J Med. 2014;371:1084 1086. Doi: 10.1056/NEJMp1409494 11. Protopsaltis S. Issue Brief: The state of low income working families in Colorado improves slightly, but man y working families still face enormous barriers to opportunity. The Bell Policy Center. 2005. Available from https://bellpolicy.org/sites/default/files/PUBS/IssBrf/2005/06OpLostUpdate.pdf 12. Svaldi A. Colorado ranks fourth among states for population gains. The Denver Post http://www.denverpost.com/business/ci_27195411/colorado ranks fourth among states population gains Published December 23, 2014. Accessed March 31, 2016. 13. The Denver Post http://www.denverpost.com/business/ci_29298860/colorados population jumped by 101 000 Published December 22, 2015. Accessed March 31, 2016. 14. Eberhardt MS, Ingram DD, Makuc DM, et al. Health United States 2001.Urban and Rural Health Chartbook. Hyattsville, Md: National Center for Health Statistics; 2001. 15. Hartley D. Rural health disparities, population health, and rural culture. Am J Public Health. 2004;9 4(10):1675 1678. Doi: 10.2105/AJPH.94.10.1675 16. Larson NI, Story MT, Nelson MC. Neighborhood environments: disparities in access to healthy foods in the US. American journal of preventive medicine. 2009;36(1):74 81. 17. WHO staff. Global health risks: Mortality and burden of disease attributable to selected major risks Geneva, Switzerland: WHO Press; 2009. https://books.google.com/books?hl=en&lr=&id=Ycbr2e2WPdcC&oi=fnd&pg=PR5&dq=western+behavior+s preading+international+health&ots=afD_0wWe6u&sig=qDL 1m1CfsQ6RFNlnASK9cqWj6E#v=onepage&q&f=false Accessed April 14, 2016. 18. Berlan A. Child labour and cocoa: whose voices prevail? International Journal of Sociology and Social Policy 2009 ; 29 (3/4), 141 151.

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42 60. Swindle S, Baker SS, Auld GW. Operation frontline: Assessment of longer term curriculum effectiveness, evaluation strategies, and follow up methods. J Nutrition Edu Behav 2007;39:205 213. 61. McGonigal K. How to make stress your friend. [video]. TED Global. https://www.ted.com/talks/kelly_mcgonigal_how_to_make_stress_your_friend?language=en Published June 2013. Accessed February 2016. *Brain Image C redit http://futurehumanevolution.com/wp content/uploads/future human evolution brain evolution.jpg