1. Corson 1
Diet-Related Health Disparities and Nutrition Education
Solutions Among Latino and African American Populations
in the United States and Baltimore City; Best Practices and
Strategies for Designing Effective Programs
February 15, 2016
Chelsea Corson, Nutrition Student
Johns Hopkins Bloomberg School of Public Health
Public Health Rotation: University of Maryland Extension, Expanded Food and
Nutrition Education Program (EFNEP)
Baltimore City, Maryland

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Table of Contents
Part 1: Diet-Related Health Disparities and Nutrition Education Solutions Among Latino and African
American Populations in the United States and Baltimore City; Best Practices and Strategies for Designing
Effective Programs ()
Diet-Related Health Disparities Among United States Latino and African American Populations (3)
Food Shopping, Preparation, and Consumption Behaviors Among US Latino Populations (4)
Food Shopping, Preparation, and Consumption Behaviors Among US African American Populations (5)
The Status of Food Security and Food Shopping, Preparation, and Consumption Behaviors Among Low-income
African Americans in Baltimore City, Maryland (5)
Non-dietary Factors Influencing Health Disparities and the Role of Nutrition Education (8)
Effective Nutrition Education Interventions to Reduce Health Disparities Among Minority Populations (9)
Cultural Values, Beliefs, and Considerations for Latino American Populations (10)
Cultural Values of and Considerations for African American Populations (12)
Overcoming Resistance to Dietary Behavior Change (12)
Formative Research to Inform the Design of Effective Nutrition Education Interventions Among Latino Populations
(13)
Formative Research to Inform the Design of Effective Nutrition Education Interventions Among African American
Populations (15)
Methods of Nutrition Education Intervention (16)
Educational Theories and Models to Enhance Nutrition Education Interventions Among Latino and African
American Populations (17)
The Expanded Food and Nutrition Education Program (EFNEP): An Example of a Cost-Effective Nutrition
Education Program Delivered Nationwide and in Baltimore City (19)
Methodology of Literature Review (21)
Discussion of Nutrition Education Interventions Among Latino Populations (22)
Discussion of Nutrition Education Interventions Among African American Populations (30)
Conclusion (39)
Part 2 Summary of Best Practice Recommendations for Nutrition Education Intervention Among Latino and
African American Populations; Conclusions Based on Literature Review and Baltimore City EFNEP
Implementation and Observation (41)
Part 3: Summary of Outcome Indicators for Evaluating the Effectiveness of Nutrition Education
Interventions (43)
References Cited (44)

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Part 1: Diet-Related Health Disparities and Nutrition Education Solutions Among Latino
and African American Populations in the United States and Baltimore City; Best Practices
and Strategies for Designing Effective Programs
Diet-Related Health Disparities Among United States Latino and African American Populations
“Health disparities” can be defined as “gaps in health status (e.g., life expectancy,
infant and maternal mortality rates, obesity and diet-related disease, and other measures) among
groups of people”1
. In the United States today, diet-related health disparities are remarkably
prominent among minority populations. For example, the rapidly growing Latino American
population is especially burdened with chronic diseases, exhibiting a higher prevalence of
obesity, elevated blood pressure, and elevated blood lipids than non-Hispanic whites2
.
Problematically, African American populations exhibit higher rates of death from cancer, stroke,
diabetes, and heart disease than Caucasian, Hispanic, Asian, or Pacific Island populations3
.
Many factors are thought to have contributed to the development of diet-related
health disparities among minority populations, including differences in genetic makeup, cultural
practices, educational opportunities, and socioeconomic status, reduced access to quality
healthcare and opportunities for physical activity, and increased exposure to unhealthy
advertisements, stress, and trauma1, 4, 5
. Nutrition research has found however, that one of the
most influential factors in determining dietary behaviors is the quality of the surrounding food
environment6
. Unfortunately, the quality of the food environment surrounding predominantly
Latino or African American communities tends to be poorer than that of predominantly white
communities6
.
Compared to their mostly white counterparts, low-income Hispanic or African
American communities typically possess fewer supermarkets and more fast-food restaurants,
convenience stores, and small grocery stores where healthy options are both limited and more

4. Corson 4
expensive6,7
. In fact, one study found that there were nearly 4 times more convenience stores in
neighborhoods with a higher percentage of Mexican American residents compared to
neighborhoods with a lower percentage of Mexican American residents6
. Access to larger
supermarkets has been shown promote consumption of fruits and vegetables, indicating that
individuals without access to such establishments are vulnerable to inadequate intake7
. In
addition, food cost and convenience have been found most influential in determining food-
purchasing behaviors among low-income populations8
, suggesting that nutritional information is
considered less valuable in dietary decision-making, and that easier access to convenience stores
and foods may promote consumption of less healthy, more processed items. As a result of these
factors, individuals residing in minority communities tend to consume calorie-dense and
nutrient-poor diets6
. Long-term consumption of these poor quality diets thus perpetuates current
disparities in the prevalence of diet-related diseases6
.
Food Shopping, Preparation, and Consumption Behaviors Among US Latino Populations
According to Baquero et al, Latino populations are known to consume more fresh
fruits and vegetables (versus canned or frozen), and dietary fats than other minorities9,10
. In a
study conducted by Ayala et al, investigators found that most Latino families stocked their
pantries with staple items such as cereal, rice, pasta, beans, cheeses, tortillas, lettuce, carrots, and
potatoes. Observation of food shopping behaviors also revealed a tendency to purchase cheaper
foods, even if they were less healthy than available alternatives10
. Many Latino individuals report
being unable to afford healthy or traditional foods and instead selecting foods based on
appearance rather than nutrient profile11
. In some cases, unhealthy items may even be added to
meals to make them look and taste more desirable11
. For example, high sodium products such as
sauces may be added to a dish to give it color, while lard may be added to a stew to improve the

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texture and flavor11
. Lifestyle changes that accompany immigration (working long or labor-
intensive hours, etc.) may also reduce the time and energy available for cooking, promoting
increased reliance on processed or fast-food items11
. Even when food is prepared in the home
however, previous research suggests a preference for convenient recipes, and high fat cooking
methods such as frying10
.
Food Shopping, Preparation, and Consumption Behaviors Among US African American
Populations
According to Houts et al previous research suggests that African American
populations consume a diet high in saturated fat, cholesterol, and sodium and low in fruits,
vegetables, and other sources of dietary fiber12
. Shanker et al also report that African American
individuals tend to consume more smoked and cured meats than Caucasian populations13
.
Sharma et al add that dietary patterns also tend to contain more sugar, less milk, and fewer whole
grains3
. These dietary behaviors may help to explain the high prevalence of obesity,
cardiovascular diseases, and various cancers among the African American population, and
highlight the necessity of effective nutrition interventions to promote positive behavior change13
.
The Status of Food Security and Food Shopping, Preparation, and Consumption Behaviors
Among Low-income African Americans in Baltimore City, Maryland
In 2009, 96% of the residents in East Baltimore and 92% of the residents in West
Baltimore were estimated to be African American3
. According to a 2010 study by Suratkar et al,
approximately 32% of these individuals were thought to experience food insecurity14
, or the
inability to obtain enough nutritious food due to seasonal or consistent limited resources or food
access15
. Of these individuals, nearly 38% were estimated to be enrolled in the Supplemental
Nutrition Assistance Program (SNAP, formerly known as “Food Stamps”), while 2.5% were
enrolled in Women, Infants, and Children (WIC), and 13.5% were enrolled in both assistance

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programs14
.
Upon further analysis of food insecure versus food secure households, the
investigators discovered that protective factors included employment, smaller household size,
and residence in West versus East Baltimore14
. Of note, food insecure families also exhibited
poorer nutrition label-reading skills and dietary habits, and were more likely to obtain their foods
from fast-food or carryout restaurants14
. Additional food shopping outlets available to this
population include convenience markets, corner stores, liquor stores, and supermarket chains3
.
In an effort to more specifically characterize the dietary patterns of low-income,
Baltimore City African American residents, Sharma et al used a 24-hour recall tool to collect
dietary data (foods, portion sizes, condiments added, locations where food was purchased, etc.)
from 60 women and 24 men between the ages of 18 and 24 years. Upon analysis, the median
number of calories consumed among both male and female African American Baltimore City
residents (2,407 and 1,989 calories respectively) was found to be higher than the median number
of calories consumed by male and female African American individuals in the third National
Health and Nutrition Examination Survey (1,764 and 2,379 calories respectively)3
. Of note, the
greatest source of caloric intake among Baltimore City residents was soda, which accounted for
roughly 10% of total calories, with fried chicken accounting for 8%, bread comprising 6%, and
cakes and pastries comprising roughly 4%3
. In addition, the participants were noted to consume
more meat and fewer vegetable and dairy servings than are recommended by the United States
Department of Agriculture (USDA) for African Americans. The women were also found to
consume fewer servings of grains and fruit than are recommended3
. Problematically, roughly
75% and 66% of the total sample reported consuming no vegetables or fruits respectively.
Finally, the participants were found to consume excessive amounts of added sugar from items

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such as sodas, fruit juice, fruit punch, and sweet teas3
.
Due to the characteristics of these dietary patterns, it is not surprising that the
investigators also noted lower median levels of fiber, calcium, zinc, and vitamin consumption
(A, C, D, E, and many B vitamins) among participants in their sample versus the national
sample3
. In addition to consuming a diet deficient in micronutrients, studies suggest that food
preparation methods among low-income African American individuals living in Baltimore City
are less healthy. For example, Suratkar et al found that the most common cooking method
consisted of using butter, oil, or margarine to pan-fry foods14
. They also noted that chicken was
most often deep fried, and that food insecure families were more likely to fry their foods than
food secure families14
.
In a subsequent study conducted by many of the same investigators, the food
shopping and purchasing behaviors of 175 adult, non-pregnant, low-income African American
Baltimore City residents was evaluated7
. This study revealed that nearly 75% of individuals
reported purchasing most of their food at supermarkets; however, only 12% reported using a
large supermarket, while the rest reported shopping at smaller outlets with fewer healthy
options7
. Roughly 18% reported obtaining food from local corner stores, while approximately
7% cited indoor or outdoor markets, carryout and fast-food restaurants, shelters, and wholesale
clubs as their primary food sources7
.
Regarding selection of primary food shopping destinations, the investigators found
that most individuals cited convenience and cost as most influential, identical to the factors
reported by Silk et al7
. Less frequently cited factors included food quality and store cleanliness7
.
In addition, the most common mode of transportation reported among all participants was
walking (overall 57%, approximately 49% among supermarket shoppers and 97% among corner-

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store shoppers), followed by taking a car (approximately 31% overall) or public transportation
(8% overall)7
. Finally, more than 80% of the participants reported a commute time of 15 minutes
or less when performing their food shopping7
. Upon comparison of food purchasing behaviors,
investigators discovered that individuals shopping at corner stores, more frequently, or for larger
households tended to purchase more unhealthy items such as chips and soda than those who
shopped at supermarkets, less frequently, or for smaller households7
. In addition, participants
under the age of 40 tended to purchase significantly greater amounts of unhealthy foods than
those over the age of 55, suggesting that intervention may be especially critical amongst younger
populations7
.
Non-dietary Factors Influencing Health Disparities and the Role of Nutrition Education
In addition to dietary behaviors, factors shown to magnify the degree of health
disparities include language barriers, low literacy, and lower likelihood of possessing health
insurance2
. Individuals unable to read or understand English do not have access to untranslated
written or spoken health information and may therefore be unaware of the behavioral changes
that are necessary to reduce their risk of disease2
. Addressing health disparities therefore requires
that the US healthcare system possesses “cultural competence”, or “a set of congruent behaviors,
attitudes, and policies that come together in a system, agency or amongst professionals and
enables that system, agency or those professionals to work effectively in cross-cultural
situations”16
.
According to Brach and Fraserirector, embodying cultural competence to improve
health outcomes among minorities requires that both clinicians and healthcare systems put forth
effort to change their approach to providing care16
. For example, they suggest hiring interpreters
and minority staff, integrating family members into the healthcare process, providing translated

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patient education materials in a format compatible with beliefs and practices, providing training
to staff members regarding elements of culturally-sensitive care, and offering community health
workers to guide patients through the unfamiliar healthcare system16
. While these methods are
proposed for the healthcare setting, many could also be applied to public health efforts and
outreach programs, such as nutrition education initiatives.
According to Esters, nutrition education is key method by which the prevalence of
obesity, cardiovascular disease, type 2 diabetes, and high blood pressure among minority
populations could be addressed5
. When delivered properly, culturally-tailored nutrition education
interventions can change dietary behaviors and reduce the risk of diet-related chronic diseases5
.
The results of the aforementioned studies in Baltimore City highlight the necessity of nutrition
education and environmental interventions to improve food preparatory skills and self-efficacy,
nutrition knowledge, and ultimately diet quality among low-income local minority residents.
Specifically, interventions should aim to reduce the consumption of dietary sugar and fat, and
increase the consumption of fruits, vegetables, low-fat dairy, and whole grains amongst this and
similar populations. Problematically however, efforts to intervene in minority communities have
been fraught with challenges. For example, effectively identifying and penetrating the social
networks of low-income, unemployed individuals can be difficult without extensive knowledge
of the community and culture13
. Despite these barriers, much effort has been invested in the
design of nutrition education intervention programs for Latino and African American
populations.
Effective Nutrition Education Interventions to Reduce Health Disparities Among Minority
Populations
To begin reducing health disparities among US minorities, the “nutrition literacy” of
these populations must be improved8
. Nutrition literacy can be defined as “the degree to which

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individuals can obtain, process, and understand the basic health (nutrition) information and
services they need to make appropriate health (nutrition) decisions”8
. Nutrition literacy can be
increased via delivery of effective nutrition education interventions, which according to Elder et
al, should be multifaceted; simultaneously targeting the community, family, and individual2
. In
Latino and African American populations, diet and cultural identity are closely intertwined13
.
Gans et al, therefore add that interventions should also be “culturally appropriate”, and address
“traditional eating patterns” and dietary changes that occur with immigration11
. When designing
a nutrition education intervention to meet this criterion, it should be noted that US minority
populations (for example Mexican, Puerto Rican, Colombian, Dominican, etc.) will likely have
different eating patterns due to variations in their location and culture of origin11
. Finally, the
nutrition education messages and setting, timing, and channels of delivery must also be
appropriate for the intended audience2
. Consideration of these and other cultural factors is vital
when planning interventions for this population2
.
Cultural Values, Beliefs, and Considerations for Latino American Populations
In addition to dietary behaviors, there are a multitude of Latino cultural values which
should be considered when developing educational interventions for this population. These
values include: resilience, “esperanza” (hope), “confianza” (trust), “personalismo” (interpersonal
relationships), “familismo” (family unity) and “comunitarismo” (community togetherness)17
. For
example, “personalismo” suggests that social interaction between participants and nutrition
educators is critical to the success of an intervention11
. In addition, individuals of Latino origin
are typically closely connected to and supported by both immediate and extended family
members (“familismo”), suggesting that it may be beneficial to tailor interventions to reach the
whole family versus the individual2
. In family-based interventions, messages should be

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“collectivistic” in nature, emphasizing the negative impact of poor health behaviors on the entire
family unit2
. When designing such interventions however, it is important to consider the
alterations that may occur to the family dynamic upon immigration to the US.
While elderly family members are typically respected as authority figures in Latino
cultures, their influence on younger generations may wane following immigration2
. Similarly,
children are taught to respect their parents; however, Latino parents and elderly individuals may
find themselves relying on children to translate and assist in settings where their involvement
may otherwise have been considered inappropriate2
. This shift in family dynamic and authority
may cause friction and should be factored into program planning. In addition, as is evidenced by
the cultural value of “machismo” (patriarchic lifestyle), men are often viewed as household
authority figures11
. As a result, preparing new, healthier foods may be avoided if not approved by
the man of the house. In an interview, one Latino individual stated that “serving new foods is
like asking for divorce”11
. In this case, behavior change may be impeded by the fear of disrupting
relationships and losing cultural identity11
.
Despite these factors, it is likely that the “primary female” of the household will still
serve as the agent of change and may therefore be an ideal target for family-based interventions2
.
Previous research suggests that interventions which promote positive interaction between
children and parents, preservation of culture, and solidarity within the family unit can be highly
effective2
. Challenges remain however, such as the common belief that illness is inevitable as a
punishment for wrongdoings2
. If a population does not believe in a connection between diet and
disease, encouraging behavior change to reduce the risk of illness becomes futile. Such
considerations highlight the importance of establishing a comprehensive understanding of the
target population to inform the development of applicable nutrition education messages.

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Cultural Values of and Considerations for African American Populations
Similar to those of Latino populations, traditional “Afrocentric” cultural values
include interpersonal relationships, respect for elders, community togetherness, and spirituality4
.
While African-American culture has historically centered around togetherness (social and
spiritual connections to family and community members), research indicates that exposure to
racism, poverty, and educational and cultural suppression may have diminished the value placed
on both of these entities18
. As a result, research suggests that African American populations tend
to respond more effectively to “individualistic” intervention approaches, which emphasize the
negative impact of poor health behaviors on the individual versus the family unit2
. Importantly
however, African American women report being more motivated to make behavior changes that
would benefit their families and more attentive to nutrition education materials that consider
“family concerns”19
. The specific target population should therefore be considered carefully
when choosing between these two approaches. Also similar to Latino populations, barriers to
dietary change noted in formative research amongst African American women included that
purchasing and preparing new, healthy foods could be expensive, time consuming, and wasteful
if other family members would not consume them19
. According to Houts et al the African
American community strongly values its existing food culture, which may present a significant
challenge to the promotion of behavior change12
.
Overcoming Resistance to Dietary Behavior Change
When faced with resistance to dietary behavior change, encouraging small, gradual
changes, recipe modification (versus replacement), and control of portion sizes may be more
effective than promoting drastic measures. Of note however, there may still be many challenges
to this approach. For example, in some Latino cultures, it is custom to eat large meals and extra

13. Corson 13
servings in order to remain satisfied until the next eating occasion. For these individuals, it may
be more appropriate to emphasize frequent consumption of small, healthy meals to prevent
extreme hunger and overeating and to promote attendance to satiety signals.
When considering cultural factors, it becomes clear that comprehensive study of the
target population is critical to the design of effective and applicable nutrition education
interventions. To acquire this understanding, many researchers conduct “formative research”10
.
Formative research is a method that can include conducting participant interviews or focus
groups, or performing behavior observation10
with the ultimate goal of characterizing the cultural
practices and educational or economic needs of a particular population20
. Formative research
conducted among minority populations has assisted in identifying more strategies to overcome
encountered barriers and preferred methods and content of nutrition education interventions.
Formative Research to Inform the Design of Effective Nutrition Education Interventions Among
Latino Populations
In a comprehensive formative research study conducted by Gans et al, bilingual
Latino community members were trained to conduct interviews amongst their peers to
characterize meal planning, shopping, and consumption behaviors11
. The investigators also
obtained recipes, assessed the food environment of participants’ households, observed the
preparation of culturally-relevant recipes, visited Hispanic grocery stores, and read food labels to
identify healthier alternatives to popular foods11
. Gans et al then repeated these methods for
multiple cultural subgroups, and in doing so, were able to characterize dietary quality and
behaviors and identify areas for improvement11
.
From this investigation, Gans et al concluded that nutrition education interventions
for the Latino population should:
1. Emphasize the connections between diet and health

14. Corson 14
2. Encourage consumption of healthy, culturally-relevant foods
3. Suggest healthy methods of food preparation
4. Emphasize the importance of moderation and portion control
5. Provide a list of healthier alternatives to popular unhealthy foods and where they can be
purchased
6. Encourage slow and gradual behavior change
7. Explain how a healthy diet can be affordable
8. Encourage participants to act as healthy role models for their families
This inclusive study provided many examples of how formative research can inform
program planning; however, many other investigators have employed similar methods with
comparable success. In a study by Ayala et al, formative research was performed among Latina
populations in San Diego County, California to determine effective methods of customizing and
delivering nutrition education interventions10
. The investigators coordinated small focus groups
(2 to 13 individuals each) and performed interviews and observation of food purchasing and
preparation among 218 study participants10
. The focus groups were conducted in community
settings, such as homes, schools, and clinics and featured topics such as food shopping and
cooking methods, the importance of nutrition in health and illness, the design of intervention
materials, and strategies of dietary change10
.
Through these efforts, Ayala et al identified cost, convenience, participant body
image, and chronic illness of a family member as population-specific determinants of dietary
behaviors10
. They also discovered that participants preferred images to text and incorporation of
lessons into general lifestyle themes10
. Of note, these findings were corroborated by Gans et al,
who also noted that visual models and interactive activities were favored, especially among low
literacy audiences11
. Finally, assessment of nutrition knowledge also revealed that most
individuals did not understand the connections between dietary habits and health status10
. The
findings of these studies have critical implications for both intervention content and delivery
method among Latino populations.

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Formative Research to Inform the Design of Effective Nutrition Education Interventions Among
African American Populations
According to Shankar et al, formative research suggests that in many African
American populations, the women of the household are primarily responsible for food planning
and preparatory activities13
. The investigators therefore suggest supporting women in their
efforts to make healthier choices by improving their ability to identify and prepare healthy and
affordable meals through nutrition education intervention13
. In another study by Medina et al
titled the “Heart Healthy and Ethnically Relevant Tools” (HHER Tools) study, the investigators
conducted formative research to create a framework for the development of educational materials
and messages that would effectively encourage nutrition and physical activity behavior change
among low-income African American women19
. They conducted focus groups with the target
population, from which they sought to determine where African American women obtained
information about nutrition and physical activity and what components they considered
necessary for effective educational programs19
.
From the focus groups, Medina et al determined that most gathered physical activity
information from family, friends, or physicians and nutrition information from nutritionists or
physicians19
. The women stated that they would also consult print sources (such as magazines)
and food stores that they perceived to be healthy19
. Regarding components of effective nutrition
and physical activity educational materials, the participants expressed a preference for visually-
appealing materials, such as those with pictures, large fonts, and bright colors19
. They also
favored concise materials with less text provided in a format that was small, durable, and
portable (such as a “pocket guide”)19
. Of note, these preferences for visual graphics and images
mirror those expressed by Latino populations. Multiple studies evaluating the effectiveness of
picture-based nutrition education have revealed that it can improve comprehension, retention,

16. Corson 16
and recall of material and encourage behavior change, especially among low literacy audiences12
.
Shankar et al add that the use of pictures can better hold participants’ attention, enhance
understanding, and emphasize key messages13
.
To improve the materials, the participants suggested using laymen’s terms and
providing a place to write notes or keep an activity “log”19
. They also requested pictures of
African American women performing activities to make them appear more realistic. Of note,
they stated that the pictures should feature women of various body sizes, as materials that
showed “only skinny people” were viewed negatively19
. In addition, they requested that physical
activity information include a rationale for being active and nutrition education material include
a rationale for eating healthfully19
. Finally, the participants stated that physical activity
information should include “safety tips”, and requested that nutrition information include sample
healthy meal plans19
. These findings provide valuable insight into the educational needs and
preferences of the African American population.
Methods of Nutrition Education Intervention
Over time, much effort has been invested in developing interventions to improve
dietary behaviors, nutritional status, and nutrition knowledge among minority populations.
Methods that have been used include: telephone interviews, mail-delivered materials, various
forms of media, and community-based programs2
. Each method confers unique advantages and
disadvantages, depending on the objective of the study and the resources available. For example,
telephone interviews or counseling sessions require no transportation and little monetary
investment and have shown success in promoting interest in health behavior change in low-
income populations2
. Mailed materials and media interventions may also be beneficial; however,
these methods must be culturally-appropriate to maximize impact2
. More intensive interventions

17. Corson 17
typically involve the in-person delivery of nutrition education by trained individuals who may be
professionals or serving as “peer educators”. Importantly however, regardless of the method of
intervention, most successful nutrition education programs are constructed using a theoretical
framework.
Educational Theories and Models to Enhance Nutrition Education Interventions Among Latino
and African American Populations
Through years of research, many educational theories and models have been
developed and utilized to enhance the effectiveness of health and nutrition education
interventions. Popular examples include: the “Social Cognitive Theory” (SCT), the
“Transtheoretical Model of Behavior Change” (TTM), the “Adult Learning Theory”, the “Social
Learning Theory”, the “Elaboration Likelihood Model”, and the “PEN-3” model. The SCT and
TTM have been used frequently to design health and nutrition behavior-change interventions
among minority populations such as Latino and African Americans, while the Elaboration
Likelihood and PEN-3 models have more recently become popular9,13,21
.
The SCT’s popularity may be owed to the fact that it seeks to understand the
complex interactions which take place between the individual and his or her surrounding
environment22
. This theory strives to elucidate how these interactions influence decision-making
and the development of habitual behaviors22
. Understanding these interactions can help to design
interventions that target appropriate elements of the built environment or individual perceptions.
In the TTM, an individual is categorized into one of the following “readiness to change” stages:
“pre-contemplation”, “contemplation”, “preparation”, “action”, or “maintenance”22
. When
designing a nutrition education intervention, gauging the individual or population’s level of
motivation or capacity to make change can help to ensure that the program is of the appropriate
duration and intensity to enhance nutrition knowledge and motivation for lifestyle change22
.

18. Corson 18
In addition to the SCT and TTM, many previous nutrition education efforts have
incorporated tenets of the “Adult Learning Theory”22
. The Adult Learning Theory states that
adults learn most effectively when presented culturally-adapted materials that are appropriate for
their pre-existing level of knowledge and education22
. The theory also states that adults should be
made aware of their learning opportunities and permitted to participate in engaging activities and
problem-solving challenges22
. This theory thus provides basic guidelines for the design of
nutrition education interventions. Additional guidance may be provided by the “Social Learning
Theory”, which suggests that learning experiences can be enhanced by behavior observation,
modeling, and improvement in self-efficacy10
.
While the aforementioned models are well-established in the health and nutrition
education literature, more recent research has resulted in the development of the “Elaboration
Likelihood Model”10
. This model suggests that interventions should be designed to match the
participants’ level of “cognitive and behavioral” engagement with the material10
. For example,
the authors suggest that an intervention designed for a less engaged audience should contain
highly visual and simplified materials, while an intervention designed for a highly engaged
audience should provide more in-depth material and intellectual interaction10
. In addition to the
Elaboration Likelihood Model, the “PEN-3” model, has been recently adapted for use among
Latino and African American populations2,21
. The PEN-3 model considers the following:
“cultural identity”, “relationships and expectations”, and “cultural empowerment”, and is broken
down into 3 “dimensions”: 1. “Health Education” (where PEN stands for “Person”, “Extended
Family”, and “Neighborhood”), 2. “Educational Diagnosis of Health Behavior” (where PEN
stands for “Perceptions”, “Enablers”, and “Nurturers”), and 3. “Cultural Appropriateness of
Health Beliefs”(where PEN stands for “Positive”, “Exotic”, and “Negative”)21
.

19. Corson 19
According to Kannan et al and Elder et al, the PEN-3 model was adapted for use
among Latino and African Americans to assess the interactions between health behaviors and
cultural influences, though it was originally intended for use among African populations2,21
. This
comprehensive model may become increasingly popular with time, due to its consideration of
cultural influences (beliefs, values, etc.) and socioeconomic factors which may influence health
status and health-seeking behaviors2
. According to Kannan et al, the model is especially useful in
the design of culturally-sensitive health interventions, and can be used for nutrition education
interventions as well21
. Due to the unique advantages of these various theories and models, the
most appropriate choice(s) for a specific intervention should be determined based on the study
population as well as the objectives of and resources available to the investigators.
The Expanded Food and Nutrition Education Program (EFNEP): An Example of a Cost-
Effective Nutrition Education Program Delivered Nationwide and in Baltimore City
The Expanded Food and Nutrition Education Program (EFNEP) is a successful
nutrition education and outreach program delivered to low-income minority populations. The
EFNEP, funded by the United States Department of Agriculture (USDA), is just one example
among others such as WIC and SNAP-ED23
. According to Baral et al, the EFNEP is currently
delivered by paraprofessional nutrition educators to approximately 500,000 participants in all 50
states of the US. The curriculum features interactive and hands-on activities, covering topics
such as healthy meal planning and shopping, management of a food budget, Food Label reading,
portion control, physical activity, food safety, etc., which are delivered in a series of lessons over
weeks to months23
.
The USDA evaluates the EFNEP based on 3 “outcome indicators”, which include:
“food resource management practices (FRMP)”, “nutrition practices (NP)”, and “food safety
practices (FSP)”23
. According to Baral et al, participants who complete the EFNEP are likely to

20. Corson 20
exhibit positive behavior changes in each domain. For example, in a 2015 study conducted by
Guenther and Luick among mostly Hispanic EFNEP participants, dietary quality, as measured by
the Healthy Eating Index (HEI) was significantly improved, with greater consumption of whole
fruits, vegetables, whole grains, and milk, and reduced consumption of sources of added sugar,
saturated fat, and alcohol24
. In addition to improving participant’s dietary behaviors, multiple
cost-benefit analyses suggest that the EFNEP is well worth the investment. Individual state-level
studies conducted nationwide indicate that for every dollar invested in the EFNEP, the value of
the “benefit” returned ranges between $3.62 and $12.50 with an average of $9.0023
.
Since the EFNEP is delivered nationwide, there exists considerable variation in both
the curricula and methods of delivery utilized. Studies comparing more effective to less effective
EFNEP programs have revealed that more successful programs are those which operate with
more involvement from professionals, offer individual or small group classes (versus large group
classes), are delivered by experienced nutrition educators, and are of longer versus shorter
duration23
. In addition, Baral et al suggest that offering nutrition educators opportunities to
collaborate and share ideas on a regular basis, as well as participate in adequate training and re-
training initiatives could be highly effective23
. Overall however, the results of numerous cost-
benefit analyses suggest that the EFNEP is one of the US’s most cost-effective nutrition
education programs23
.
In Baltimore City, the EFNEP is delivered by experienced paraprofessional nutrition
educators in various community settings including public schools, shelters, churches, and
community centers to low-income Latino and African American populations. The participants
are required to complete pre and post-intervention dietary recalls and behavior-based surveys,
the results of which are entered into an online database for analysis to determine program impact

21. Corson 21
and provide feedback to participants regarding their diet quality.
The nutrition education lessons are provided in a series of 6 to 8, 60 to 90-minute
classes and are adapted from the “Eating Smart, Being Active” curriculum. This curriculum is
based on the SCT and designed to promote adherence to the United States Department of
Agriculture (USDA)’s “MyPlate” and “Dietary Guidelines for Americans 2010”25
. It includes the
following lessons: “Get Moving”, “Plan, Shop, $ave”, “Fruits and Veggies: Fill Half Your
Plate”, “Make Half Your Grains Whole”, “Build Strong Bones”, “Go Lean with Protein”, “Make
a Change”, and “Celebrate! Eat Smart & Be Active”, each consisting of engaging, interactive
activities, (worksheets, cooking or taste-testing activities, physical activities, etc.) and features
“giveaways” such as measuring cups and vegetable brushes as incentive for attendance25
. In Part
2, titled “Summary of Best Practice Recommendations for Nutrition Education Intervention
Among Latino and African American Populations”, educational recommendations from the
author’s observation and delivery of the EFNEP in Baltimore City are summarized.
Methodology of Literature Review
Literature was gathered from databases such as “PubMed” and “PsycINFO” by
conducting multiple searches using keywords and terms such as: “health disparities among US
minority populations”, “food insecurity among African Americans in Baltimore City”, “effective
nutrition education programs for Latino Americans”, “effective nutrition education programs for
Latino Americans in Baltimore City”, “effective nutrition education programs for African
Americans”, “effective nutrition education programs for African Americans in Baltimore City”,
“effective methods of nutrition education intervention among minority populations”,
“effectiveness of peer health education among minority populations”, “nutrition education of
minority populations”, “culturally sensitive methods of nutrition education”, “culturally sensitive

22. Corson 22
nutrition interventions”, and “innovative health education methods”. Studies excluded were those
which did not measure outcomes of nutrition education exposure or training (dietary behaviors,
nutrition knowledge, etc.), those that did not include Latino and/or African American individuals
in the study population, and those which did not address health disparities, food insecurity,
nutrition/health education, or cultural values/ nutrition practices.
Discussion of Nutrition Education Interventions Among Latino Populations
Previous research suggests that the delivery of nutrition education to Latino
populations by “peer mentors” (individuals of the same race or ethnicity as the recipients) may
assist in dissolving cultural barriers and enhancing effectiveness17
. Peer mentor programs
facilitate culturally-sensitive education, as mentors possess an understanding of cultural values
and practices, enabling them to connect with their participants17
. For example, by understanding
the value of “comunitarismo”, a peer mentor could design socially interactive group classes to
increase participant engagement and retention17
. Similarly, mentors who understand the concept
of “confianza” may spend additional time building rapport before delving into educational
topics17
. The effectiveness of peer mentors has been assessed in many nutrition education
interventions for Latinos.
In an innovative study conducted by Serrano et al, 36 “abuelas”, or Hispanic
grandmothers, underwent training to deliver nutrition education to their families and
communities as peer mentors. The ultimate goal of this intervention was to gain a better
understanding of how best to prepare individuals to effectively deliver nutrition education to
Latino populations to improve dietary behaviors and reduce the risk of chronic diseases26
. This
intervention embraced the Latino cultural value “respeto”, in which elder individuals are
respected as authority figures17
. Abuelas were thus chosen due to their pre-existing role as

23. Corson 23
esteemed mentors for topics such as nutrition and family health26
.
To prepare the abuelas for delivering nutrition education, each was trained in subjects
such as food safety and adherence to the dietary guidelines26
. The curriculum was comprised of
five lessons featuring discussion-provoking topics and interactive activities and rewarded
attendance by offering a large set of kitchen utensils for a perfect record26
. At the end of the
training period, each “abuela” was interviewed to elicit her feedback regarding the program. As
this time, the abuelas identified review of the dietary guidelines as the most important nutrition
message of the curriculum, stating that it provided valuable information and promoted healthy,
balanced eating behaviors26
. They also identified the food safety component as valuable and
reported a general lack of food safety knowledge among Latino populations. To improve the
curriculum, the abuelas suggested incorporating a supermarket tour.
Regarding elements of program design, the abuelas reported that using kitchen
utensils as attendance incentives was highly effective, and they recommended scrub brushes,
cutting boards, and cookbooks as other options26
. They also reported that their low-literacy
participants struggled most with the meal planning and label-reading sections, and preferred
visual aids to paper materials26
. Of note, separate analysis revealed that community members
became more knowledgeable and skilled regarding healthy eating practices as a result of the
abuela-led nutrition education classes, and that these improvements endured for at least six
months post-intervention26
.
This intervention provides evidence to support the effectiveness of using peer
educators, especially those respected in the community, to deliver nutrition education to low-
income Latino populations. Of note however, peer educators often lack a formal nutrition
education background, which may result in the potential dissemination of inaccurate information.

24. Corson 24
As a solution, Serrano et al propose providing intensive training, easy to use resources, and a
detailed script to follow26
. Such training can be time consuming and expensive however, which
should be considered during program planning. Of note, many other studies have evaluated the
effectiveness of peer educators in delivering nutrition education interventions with inconsistent
results.
In a Latino community, a female peer mentor may also be referred to as a
“promotora”9
. “Promotoras” are women of the same race or ethnicity who understand the culture
and language of the target population9
and have access to hard to reach populations through
“informal social networks”2
. These individuals have established ties with the community that
allow them to connect minorities with healthcare and other services22
. Promotoras are known to
be highly successful in raising awareness of chronic diet-related diseases such as diabetes and
cardiovascular disease22
.
In a study titled “Secretos de la Buena Vida” Baquero et al, employed promotoras to
deliver nutrition education to 238 Latina women between the ages of 18 and 65 years.
Participants were randomly assigned to receive either: interaction with a promotora and a
culturally-appropriate newsletter (group 1), the culturally-appropriate newsletter only (group 2),
or other educational materials (group 3)9
. The goal of this study was to determine effective
methods of eliciting behavior change regarding dietary fat and fiber consumption among Latina
women9
.
The intervention period was 14 weeks in duration, and outcomes were assessed via
comparison of dietary behaviors at baseline, at the completion of the intervention, and after 15
months post-intervention9
. Dietary behaviors were assessed via collection of 24-hour recalls at
all three time points, which were analyzed and compared via the “Nutritional Data System”. All

25. Corson 25
3 interventions emphasized the health benefits of a high fiber, low-fat diet. Dietary behavior
“change” was said to have occurred if a participant reduced her fat consumption by 10 grams or
increased her fiber consumption by 2 grams per day on average9
.
In this intervention, group 1participants received home visits (or calls) from a
promotora and a newsletter each week. The promotoras spent an average of 45 minutes per home
visit and 31 minutes per phone call9
. Group 2 participants received only the weekly newsletter,
and group 3 participants received culturally-specific nutrition education materials from the
National Heart, Lung, and Blood Institute (in Spanish)9
. Of note, participants in groups 1 and 2
also received weekly homework assignments and encouraging “healthy lifestyle messages”9
.
Information collected at baseline was used to customize each participant’s weekly newsletter and
homework assignment to match their level of interest and provide tips to improve current dietary
habits and guidance regarding goal-setting and self-monitoring9
.
At the end of the study, 30% of the participants had made changes in their
consumption of dietary fiber, while 44% had made changes in their consumption of dietary fat.
Baquero et al found no significant differences in the percentages of participants who made these
changes by intervention group. Interestingly however, group 1 participants reported the average
level of support they received from their promotoras to be “moderate”9
. The investigators
suggest that more support from community mentors or longer interventions may thus be
advantageous9
. It is also possible that this Latino population may have benefited more from a
less individualized and more community-based education format (“comunitarismo”). The
effectiveness of such a community-based health education intervention led by promotoras was
investigated in “Salud Para Su Corazon”, a study conducted by Spinner and Alvarado.
The “Salud Para Su Corazon” intervention was intended to promote behavior change

26. Corson 26
to improve cardiovascular health in 7 different US Latino populations22
. The intervention was
comprised of 10 interactive lessons taught in series in community settings by promotoras trained
using the National Heart Lung and Blood Institute curriculum (NHLBI). The curriculum
provided participants with information regarding heart healthy, affordable meal planning, label
reading, weight maintenance, and other topics22
. Improvements in health behaviors or knowledge
were assessed via pre and posttest tools22
. Dietary consumption of sodium, fat, alcohol, and
cholesterol, weight management, engagement in physical activity, self-confidence regarding
behavior change, and understanding of the heart healthy diet were also assessed22
.
At the end of the intervention, analysis of pre and posttest data revealed that on
average, participants had achieved significant improvement in their their dietary behaviors
pertaining to consumption of: sodium, sugar sweetened beverages, desserts, vegetables, and
dietary sources of fat and cholesterol22
. In addition, 37% more participants reported engaging in
non work-related physical activity when compared to baseline22
. Finally, self-confidence
regarding the ability to change dietary behaviors improved significantly following the
intervention22
. From these results, Spinner and Alvarado conclude that promotoras can serve as
critical components of nutrition education interventions in community-based settings for Latino
populations.
In addition to promotora-led programs, many studies have attempted to identify the
most appropriate format and content of nutrition education programs for the Latino population.
In a study conducted by Davis et al, the effectiveness of an individualized home-based nutrition
education intervention to improve dietary behaviors among adolescent Latinas was compared to
that of a group-based classroom format27
. 23 young women completed the study, all of whom
were overweight (BMI value above the 85th percentile as classified by the Centers for Disease

27. Corson 27
Control and Prevention Charts for age and sex) and of Hispanic origin27
. Both intervention
formats were designed to promote reduction in dietary sugar intake and increased dietary fiber
intake27
. Changes in dietary behaviors were assessed and compared between the two groups via
analysis of 3-day diet records completed at baseline and one week after intervention using the
“Nutrition Data System for Research” (NDS-R)27
.
The nutrition interventions consisted of 12 weekly, 90-minute interactive nutrition
lessons delivered from the same “culturally-tailored curriculum”27
. The group-based classroom
format was delivered to small groups of students (4 to 12 per session) and covered topics such as
improving the quality of dietary carbohydrates, reading food labels, eating behaviors, body
image, controlling portion sizes, and dining out27
. Each classroom lesson was taught by 2 to 3
nutrition educators (supervised by a Registered Dietitian) and contained goal setting and game
activities, cooking and snacking opportunities, information in the form of handouts, and
feedback pertaining to dietary recalls. At the end of each lesson, the students were given a gift
card valued at $25 for the purchase of groceries27
.
The home-based intervention also consisted of 12, 90-minute weekly nutrition
education lessons delivered by a nutrition educator. The educator also delivered a collection of
groceries valued at $25 each week, to encourage healthier eating habits in line with the goals of
the intervention27
. In addition, the educator assisted in setting reasonable goals for dietary
behavior change based on individual food preferences and current eating behaviors. Of note, the
parents of the students in both groups were required to observe a minimum of one third of the
nutrition education lessons; however, in both groups, average attendance exceeded this
requirement at 7 lessons27
. Other family members were found to attend fewer than 5% of the
classroom-based sessions and approximately 25% of the home-based sessions27
.

28. Corson 28
At the end of the intervention period, 11 students had completed the individualized
home-based intervention, while 12 had completed the group-based classroom intervention27
.
Analysis of dietary behaviors post-intervention revealed an overall significant (44%) increase in
the consumption of dietary fiber to 12.4 grams per 1000 calories per day (from 8.6 gm/1000
calories/day), and an overall significant reduction (34%) in the consumption of added sugars
from 18.6% to 12.5% of total daily calories27
. In addition, the study participants were found to
consume significantly fewer servings (30% fewer) of refined carbohydrates each day, with an
average consumption of 2.7 servings per day post-intervention compared to 4.1 servings at
baseline analysis27
. Of note, no significant differences in the magnitude of change in dietary
behaviors were observed between the two intervention groups27
.
From these results, Davis et al concluded that the use of a culturally-appropriate
nutrition curriculum was effective for eliciting dietary behavior change in this adolescent Latina
population; however, individualization and delivery of the intervention in the home environment
was not more effective than the group-based approach27
. These findings thus support that Latino
individuals may benefit most from “collectivist” approaches. The investigators suggest that the
group intervention may have created an environment of social interaction and support to enhance
effectiveness. They also state that delivering the intervention in the home cost approximately
$1,425, while the group-based intervention was more cost-effective at approximately $94527
.
They propose however that home-based interventions may impact the family environment,
promoting implementation of long-term dietary behavior change27
. Additional studies with larger
sample sizes and diverse age groups are therefore necessary before concluding that home-based
interventions are not more effective than group alternatives. Previous studies suggest however,
that group-based classroom education can also be effective for adult Latino populations.

29. Corson 29
In an innovative study, Elder et al attempted to address both health disparities and
language barriers by providing nutrition education while teaching Latino individuals English as a
second language (ESL). According to the investigators, integrating health education into ESL
may be beneficial due to the simultaneous provision of language instruction and social support28
.
The intervention, titled “Language for Health”, was intended to encourage behavior change for
the prevention of heart disease among low-literacy audiences28
. The impact was compared to that
of a “control” group, which received ESL-incorporated stress management education28
.
Outcomes assessed included: self-reported dietary behaviors, nutrition knowledge,
attitudes towards nutrition, blood pressure, cholesterol levels, weight, and waist to hip ratio,
which were compared at baseline, and 3 and 6 months after intervention28
. All measurements
were obtained by trained study staff, while self-reported information was obtained via a paper-
based survey. 817 students over the age of 18 were enrolled in the study and received up to 5, 3-
hour classes during a 1 or 2-week period28
. Nutrition education topics addressed included
understanding the relationship between dietary sodium consumption and high blood pressure,
improving eating behaviors, reducing dietary fat and cholesterol consumption, and reading food
labels. Topics addressed in the stress management group included recognizing and modifying
stress28
.
Following data analysis, the investigators noted that the students who received
nutrition education exhibited a greater reduction in systolic blood pressure and total to HDL
cholesterol ratio than the stress management group; however, these differences were not
maintained 6 months after intervention28
. As expected, the nutrition education group also showed
a greater improvement in nutrition knowledge and indicated that they would be more likely to
avoid consumption of dietary fat than the stress management group28
. In both groups,

30. Corson 30
participants reported greater self-efficacy for improving their dietary behaviors and a better
understanding of the connections between diet and health status28
. Further analysis revealed that
the participants with higher pre-existing literacy levels exhibited greater increases in nutrition
knowledge28
.
The results of this study suggest that delivering nutrition education in the classroom
setting (specifically within ESL classes) can have positive health and behavioral outcomes
among Latino populations. In addition, improving the literacy level of Latino populations could
increase the benefit of educational interventions. Finally, these findings highlight the importance
of tailoring nutrition education interventions to low-literacy audiences and delivering outreach
programs in settings which attract hard-to-reach populations. From these diverse studies,
conclusions can be reached regarding “best practices” for nutrition education programs among
Latino populations (Part 2).
Discussion of Nutrition Education Interventions Among African American Populations
Similar to the interventions performed among Latino populations, the effectiveness
of delivering nutrition education via peer-educators was investigated in a population of 153, 18
to 45-year-old, low-income African American women in Genesee County, Michigan21
. The
intervention, titled “Healthy Eating and Harambee” (“pulling together”), targeted women of
childbearing age in attempt to improve maternal and infant health outcomes21
. The program was
culturally adapted and designed to: increase self-efficacy regarding the selection of healthy foods
and realistic goal setting, enhance understanding of the relationships between diet and health,
and improve dietary behaviors (reduce consumption of dietary fat and salt and increase
consumption of fruits, vegetables, herbs, and spices)21
. To deliver the program, the investigators
employed peer educators, who would also act as “role models”21
.

31. Corson 31
The Healthy Eating and Harambee curriculum was designed to cater to visual,
cognitive, kinesthetic and affective learning styles and addressed a variety of topics including:
African American diet history, nutrients, diet-related disease, Nutrition Facts label-reading,
dining out, gardening, cooking, menu planning, food tasting, body image, physical activity,
etc.21
. Importantly, the majority of the material was written at a 6 to 8th grade reading level, and
emphasized culturally appropriate food preparation methods and items that contained nutrients
necessary in excess during pregnancy (iron, folate, etc.). The curriculum was delivered once per
week for 13 consecutive weeks (to provide sufficient time to elicit behavior change). The
effectiveness of the program was assessed using a pre and post-intervention test, which included
specific questions about dietary behaviors such as consumption of fruits, vegetables, and
sodium21
.
To raise awareness of the intervention and recruit participants, investigators reached
out to WIC, local health departments, food pantries, health clinics and other entities and placed
advertisements on local bulletin boards and in newspapers, church flyers, and radio
announcements21
. Peer leaders selected were “senior women” determined to be influential in the
community and intended to be viewed as “experts in cooking, nutrition, and health matters
during pregnancy”21
. To prepare the educators, the investigators provided training in nutrition
and group teaching, facilitated by university nutrition experts. For ease of implementation, they
were also provided slide shows, talking points, and other teaching materials.
Upon program evaluation, the investigators discovered that 77% of the women who
participated in the study self-reported improving one aspect of her diet, while 23% had adopted
two or more new, healthy behaviors21
. Of note, the peer educators reported enjoying their
involvement in the educational efforts, and put forth the effort to add to the existing workshops

32. Corson 32
and interactive activities while sharing their own personal experiences and knowledge21
. To
determine participant’s satisfaction with the lessons, the investigators distributed a survey, the
results of which indicated that all participants would “recommend the program to others” and
85% perceived the lessons to be either “useful” or “very useful”21
.
Regarding the structure of the program, the participants requested combining lessons
to permit fewer sessions, or shortening the length of the existing sessions. They also requested
adequate background information, and expressed preference for interactive activities and
visually-oriented educational materials, especially for more complex topics21
. The results of this
study suggests that a 13-week, comprehensive, culturally-sensitive, and multifaceted nutrition
education intervention delivered by respected peer educators can effectively promote behavior
change and enhance self-efficacy among low-income African American women. In addition to
these efforts, many other investigators have sought to determine effective and preferred materials
and methods for/of nutrition education among African American populations.
In a study by Houts et al published in 2006, a nutrition education intervention was
designed for 118 low-income African American women living in Washington D.C. to increase
their intake of fruits and vegetables. Distinguishing features of this intervention included the use
of fewer text-based materials and more pictures12
. Picture-based materials included posters,
handouts, laminated placemats, and recipes with minimal text that depicted visual instructions
regarding how to prepare each ingredient. Nutrition education was delivered throughout 6
weekly, 2-hour sessions with a 2-hour follow-up session 1 month after completion of the weekly
series. The curriculum covered topics such as meal planning, the importance of fruit and
vegetable consumption, a grocery store tour, and hands-on fruit and vegetable cooking
activities12
.

33. Corson 33
At the end of the intervention, the participants who completed the program were not
found to have significantly increased their fruit and vegetable consumption, however, they were
found to consume fewer calories overall and less dietary fat12
. Many of the participants also
reported that they enjoyed the picture-based format and had shared the pictures and healthy
recipes with their families12
. The results of this intervention suggest that a series of nutrition
education lessons delivered in a picture-based format can effectively improve the dietary
behaviors of low-income African American women.
In 2007, a similar study was published by many of the same investigators to assess
the effectiveness of another nutrition education intervention in increasing fruit and vegetable
consumption among 187 African American women (ages of 20-50 years) residing in public
housing in Washington D.C.13
. The intervention consisted of 6 biweekly 90-minute lessons
delivered in series to small groups (5-17 women each) in a community setting by a female
African American dietitian over the course of 3 weeks13
. 6 weeks later, the final lesson was
delivered13
. Dietary assessment took place at baseline, and at weeks 4 and 20, and consisted of
completing 3 24-hour dietary recalls (averaged for each variable per assessment), which were
subsequently analyzed using the NDSR software to detect short and long-term changes in dietary
behaviors13
. Interviews were also conducted at weeks 4 and 20 to assess participants’ knowledge
and obtain relevant feedback13
.
According to Shankar et al, this intervention was designed to not only improve
dietary behaviors, but to improve the skills and self-efficacy needed to support behavior change.
The curriculum was interactive, family-oriented, and included opportunities for goal-setting,
parenting, and meal planning activities and information regarding food safety, shopping on a
budget, label-reading, and cooking skills13
. Interestingly, the investigators also incorporated an

34. Corson 34
element of community “togetherness”, by encouraging participants to work in pairs and support
one another by communicating, shopping, and cooking together in addition to the class
sessions13
. Similar to their previous study, the investigators also used a picture-based format for
nutrition education materials and cooking instructions. In this study, they employed an artist to
develop materials depicting African American individuals consuming fruits and vegetables.
Participants were given copies of these images and asked to review and use them as resources
outside of class13
.
After delivering the intervention, the investigators compared fruit and vegetable
servings, total calories, and calories from fat consumed at all time points to assess the
effectiveness of the classes13
. Assessment of dietary data revealed that at baseline, the program
participants consumed 2416 calories (nearly 36% from fat) and approximately 3 servings of
fruits and vegetables per day13
. Similar to their previous study, fruit and vegetable consumption
did not increase significantly after intervention; however, analysis revealed that participants who
attended most of the classes consumed, on average, 0.26 more servings of fruits and vegetables,
while those who attended only some of the classes consumed only 0.17 more servings of fruits
and vegetables13
. Individuals who did not attend the classes consumed an average of 0.13 fewer
servings. These results suggest that exposure to the curriculum may have had a “dose effect” on
fruit and vegetable consumption behaviors13
.
In addition to these findings, the participants were noted to consume an average of
225 fewer calories at week 4, and an average of 300 fewer calories at week 20 (compared to
baseline)13
. Of note, separate analysis of dietary change among those who attended 5 or more
lessons revealed that caloric intake decreased by an average of 251 calories at week 4 and 331
calories at week 20, suggesting greater improvement among those who received more exposure

35. Corson 35
to nutrition education13
. Finally, overall calories from fat decreased significantly by 3% at week
413
.
In their discussion section, the Shankar et al state that their study methods conferred
many advantages, including the use of a validated nutrient assessment software system and
extensive formative research. They also report however that factors such as loss to follow up,
program attrition, competition from other concurrent public health community programs, and
heavy curricular emphasis on fruits and vegetables may have negatively impacted their results13
.
These two studies provide valuable information regarding the effectiveness of nutrition
education interventions for African American women; however additional studies have also been
performed with younger populations in Baltimore City.
In a study conducted by Shin et al, the effectiveness of a community-focused
nutrition education intervention titled the “Baltimore Healthy Eating Zones (BHEZ)” for African
American youth residing in Baltimore City was evaluated. Previous studies have suggested that
nutrition interventions in predominantly African American communities can have positive
impacts on the accessibility and consumption of healthy foods, therefore, the investigators chose
to intervene in Baltimore City corner stores (as an alternative to school-based interventions)29
.
Corner stores are popular food destinations among African American youth, but are known to
offer limited healthy items and an abundance of unhealthy alternatives29
.
The BHEZ intervention took place over a period of 8 months, and was delivered in 7
of 14 locally recruited community recreation centers and 3 corner stores and/or carryout
restaurants surrounding each center29
. The remaining community recreation centers served as
control sites. The intervention consisted of taste-testing opportunities, distribution of educational
materials and incentives, and cooking instructions/demonstrations29
. The education topics

36. Corson 36
focused on healthy foods, beverages, meals, and snacks. Importantly, the investigators recruited
and trained a peer educator to partake in the intervention at each participating center29
.
242 pairs of African American youths and their caregivers (individuals who
purchased and prepared food for the youth) were initially recruited. The intervention was
multifaceted in design; however, study participants were not required to attend any classes or
activities in a structured format, resulting in different levels of exposure amongst individuals. At
the end of the intervention period, 67% of the initially recruited caregivers and 63% of the
initially recruited youths provided follow up data29
. To evaluate program effectiveness,
participating youth were asked to complete a series of questions which solicited a variety of
information including youth height, weight, self-efficacy, knowledge, typical food purchasing
behaviors (items purchased and money spent), food preparation behaviors, and food shopping
locations (corner stores, markets, etc.). The investigators collected responses from individuals in
both the intervention and control groups before and after intervention29
.
Comparison of the data collected pre and post-intervention revealed that percentiles
for body mass index (BMI) by age had not decreased in the control group, but had significantly
decreased in the intervention group, especially among participants who were overweight or
obese at the time of intervention29
. Of note, overweight girls who received more nutrition
education experienced significantly greater reductions in BMI than those who received less,
suggesting that such intervention may be especially effective among this population29
.
While these findings suggest that this program may have been effective at
encouraging dietary behavior change among Baltimore City Youth, it should also be noted that
results suggest overweight and obese girls in both groups actually reported purchasing fewer
healthy food items at the end of the intervention29
. In addition, regression analysis revealed that

37. Corson 37
the intervention did not improve self-efficacy or healthy food preparation or consumption
behaviors among any group29
. In fact, participants with more exposure to the intervention were
found to purchase significantly greater amounts of unhealthy items than those with less
exposure29
. Interestingly however, both the intervention and control groups exhibited a
significant increase in food-related knowledge scores.
The BHEZ intervention was multifaceted in design and attempted to improve the
eating behaviors of Baltimore City youth by changing their surrounding food environment. The
results of this study suggest that community-based nutrition education interventions that feature
interactive curricula intended to improve nutrition knowledge and skills can be effective in
reducing BMI among African American youth. While no positive impact was observed among
food purchasing and consumption behaviors, the investigators suggest that the tools used to
identify these changes or the intervention period itself may have been insufficient29
. Given that
attendance of the nutrition education components was not mandatory, it is also possible that a
more structured program may have better elicited desired behavior changes. Finally, the sample
size was smaller than expected, which may have impaired statistical analysis29
. The investigators
state that since many previous studies support the effectiveness of interventions that combine
nutrition education with improvement of the food environment, further research with a larger
population and dietary analysis should be conducted in this area29
.
While many of the aforementioned nutrition education interventions feature a more
traditional, classroom or lesson-based design, Silk et al suggest that various forms of media can
be effective additions to such initiatives. For example, songs, television shows, and computer
games have previously shown to be effective methods for delivering or reinforcing health
education messages8
. Of note, these methods can be easily distributed and cost-effective, since

38. Corson 38
many individuals own a computer and materials can often be downloaded for free. When
designing a nutrition education intervention, it may therefore be advantageous to incorporate
various forms of media. According to Silk et al media components could increase retention of
information8
. In their study, these investigators attempted to identify forms of media which may
be most appropriate for delivering nutrition education to low-income African American women.
According to Silk et al, previous research suggests that video games are capable of
capturing and holding players’ attention due to their interactive nature, and thus have the
potential to effectively convey nutrition knowledge, especially among younger audiences8
. They
argue that playing a nutrition education video game permits exploration of the material in an
autonomous and unique manner. Of note however, video games may be less appealing to
audiences who are unfamiliar or uncomfortable with using technology. In addition, they may
require a computer or other technological equipment, which may render them inaccessible to
some low-income audiences who need them most8
. One potential solution may be to utilize
games which are comparable with a smartphone; however, such technology may still be
inaccessible to a portion of the target audience. Finally, video games may not be appropriate for
some audiences such as single mothers, who may not have adequate time to utilize them.
For their study, the investigators recruited 155 low-income women who were either
pregnant or already mothers between the ages 18 and 50 years. Of note, 25% of this population
identified as African American and 5% identified as Latino8
. In this study, the effectiveness of 3
possible interventions was evaluated, including use of the “Fantastic Food Challenge” game, a
Web site, or printed education materials, to one of which each participant was randomly
assigned. The “Fantastic Food Challenge” game consists of a series of interactive activities
designed for low-income audiences8
. The investigators ensured that each intervention contained

39. Corson 39
the same material, which included food safety, recipes ideas, food groups, portion sizes, and food
cost; however, the game format was intended to be most interactive, while the paper-based
format was least interactive8
. Each participant received 20 to 30 minutes of exposure to their
assigned intervention material, then was asked to rate their experience and demonstrate their
knowledge using Likert and multiple choice-style questions in a post-test format8
.
Upon analysis of the results, the investigators discovered that the Web site received
the highest participant ratings, indicating that it held their attention, provided useful information,
and was a resource they would consider consulting in the future for more information8
. In
addition, the women who used the Web site or read the paper-based materials demonstrated
significantly greater knowledge gains than the women who played the video game8
. The
participants who used the video game reported more difficulty in learning the format, which may
have impaired their ability to attend to and retain the nutrition information8
.
The results of this study suggest that video games may be more effective at raising
awareness of nutrition amongst rather than instilling nutrition knowledge within this population.
It could also be argued however, that such resources (along with Web sites and other online
entities) could serve as supplements to public heath nutrition education efforts, in order to
enhance their effectiveness. The needs and resources of the population under study should
therefore be considered when determining if the use of such media would be appropriate to
accompany a specific intervention. From these diverse studies, conclusions can be reached
regarding “best practices” for delivering nutrition education programs to African American
populations (Part 2).
Conclusion
In conclusion, the magnitude of diet-related health disparities that exist among Latino
and African American populations nationwide highlights the necessity of effective nutrition

40. Corson 40
education interventions to promote increases in nutrition knowledge, self-efficacy regarding the
ability to identify and prepare healthy foods, healthy cooking skills, and the quality of overall
dietary patterns. In many minority communities, the quality of the food environment is poor;
characterized by an abundance of fast and convenience food options and fewer healthy
alternatives, which promotes consumption of calorie-dense, nutrient-poor diets. In Baltimore
City, the African American population is no exception, and has been estimated to consume a diet
of lower nutritional quality than the national African American population.
Resolution of diet-related health disparities in the US will require a multitude of
interventions including alterations to clinical care and the structure of the domestic healthcare
system. From a public health perspective, intensive study of Latino and African American
populations has revealed that when delivered properly, nutrition education programs (such as the
EFNEP), can be highly effective in eliciting dietary behavior change. Some components of
effective programs identified through years of nutrition research include collectivistic, culturally-
appropriate messages, incorporation of educational theories and models, employment of
respected community members, distribution of useful incentive items, and the use of visually
appealing materials, interactive and socially-supportive curricula, and small group formats.
While many challenges remain, such as alterations to family dynamics and strict adherence to
cultural dietary patterns, it is likely that persistent efforts to reach and impact Latino and African
American populations with nutrition intervention will continue to uncover successful strategies
to guide program development and improvement, while closing gaps in the prevalence of chronic
diet-related diseases.

41. Corson 41
Part 2: Summary of Best Practice Recommendations for Nutrition Education Intervention
Among Latino and African American Populations
Conclusions Based on Literature Review and Baltimore City EFNEP Implementation and
Observation
Best Practice Recommendations for Program Design
• Conduct formative research (focus groups, interviews, behavioral observation, etc.) to
characterize the dietary behaviors and cultural beliefs, values, and practices of the target
population3,7,8,9,10,11,12,13,14
.
• Design a “culturally appropriate” curriculum based on the findings of formative research.
Address “traditional eating patterns” and acknowledge variation by subgroup11
. Incorporate
cultural values to enhance applicability and reach17
.
• Target the intervention towards the specific needs of the population (identified through
formative research).
• Utilize validated educational theories and models (SCT, TTM, Social Learning Theory,
Adult Learning Theory, etc.) to enhance the organization and impact of nutrition education
interventions2,10,21,22
.
• Utilize research-based information and cover practical curricular topics. For example,
discuss healthy meal planning and shopping, management of a food budget, Food Label
reading, portion control, food safety, and physical activity while utilizing information
gleaned from the most recent dietary guidelines and USDA educational materials
(MyPlate)25
.
• Choose “collectivistic” or “individualistic” approach. Focus on the “primary female” as
the targeted “agent of change” for collectivistic approaches2,18,19
.
• Design programs to enhance self-efficacy regarding the ability to make healthy behavior
changes and identify, budget for, and prepare healthy foods by modeling behaviors and
providing opportunities to practice skills necessary for behavior change13,25
.
• Create visually appealing and engaging educational materials with pictures, large fonts,
and bright colors, especially for low-literacy audiences to enhance attention, comprehension,
retention, and recall12,13,19,26
.
• Cater to diverse learning styles and levels (visual, kinesthetic, affective, and cognitive) by
designing multifaceted, interactive programs that match participant education level (use
laymen’s terms, avoid jargon, etc.)19,21
.
• Promote slow, gradual dietary behavior change (versus drastic changes) to reduce
resistance (recipe modification, portion control, etc.)

42. Corson 42
Best Practice Recommendations for Program Delivery and Implementation
• Employ respected peer/community mentors/members to act as “role models”, target “hard
to reach”, populations and enhance educator-participant relationships2,9,10,13,17,21,22,26,29
.
• Provide adequate training/re-training opportunities and standardized curricular
materials to nutrition educators and permit them the opportunity to collaborate, exchange
ideas, and provide feedback regarding the intervention and participants26
.
• Deliver programs in locations convenient for participants (community centers, WIC,
daycare centers, community clinics, public schools, etc.) to promote convenient attendance.
• Deliver classes/lessons in series to individuals or small groups (versus large groups) to
promote increased engagement/interaction and the development of valuable interpersonal
relationships23
.
• Encourage social support and interaction within and outside the intervention13
• Offer practical incentives to maximize participant engagement and attendance25,26,27,29
.
• Consider providing supplemental print or web-based materials (such as health
magazines or interactive web sites)8,19
.
• Include a supermarket tour in the community in which the participants reside, to
demonstrate healthy food shopping behaviors and provide the opportunity to ask questions26
.

43. Corson 43
Part 3: Summary of Outcome Indicators for Evaluating the Effectiveness of Nutrition
Education Interventions
• Dietary behaviors
o Self-reported dietary behaviors as evidenced by 24-hour or other dietary recall tool
and subsequent nutrient analysis using a validated database such as NDSR
o Healthy Eating Index
• Self-reported parameters
o Self-efficacy regarding the ability to identify, purchase, and prepare healthy foods
o Intention/motivation to change dietary behaviors
o Physical activity levels
o Food safety behaviors
o Food shopping behaviors (corner stores, carryout restaurants, etc.)
o Preparation/ cooking methods (deep frying, pan-frying, baking, broiling)
• Nutrition knowledge outcomes
o Basic nutrition knowledge gains (key nutrients, components of healthy foods,
vitamins, minerals, etc.)
o Food safety knowledge gains
o Nutrition resource management knowledge gains
• Anthropometric measures
o BMI
o Weight
o Waist-to-hip ratio
• Biochemical parameters and indicators of health status
o Blood pressure
o Serum triglycerides
o Serum cholesterol levels (HDL, LDL, total cholesterol)
• Other
o Cost-effectiveness

44. Corson 44
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