Program Planning Team: Julie Garden-Robinson (chair), Dave DeCock, Jamie DeVries, Suzanne Fundingsland, Gayle Gette, Connie Gulleson, Linda Hauge, Marcia Hellandsaas, Barb Holes-Dickson, Edna Holm, Tom Jirik, Cindy Ketterling, Deb Lee, Macine Lukach, Marty Marchello, Teresa McElroy, Anita Rohde, Eunice Sahr, Gail Slinde, Brad Strand, Colleen Svingen, Rita Ussatis.

Overall Situation
Nutrition and Health
Risk for several chronic diseases such as heart disease, cancer and diabetes is related to diet and physical activity. According to the USDA, better nutrition could reduce health-care cost by at least $71 billion each year. Despite the evidence supporting consumption of a varied diet with less than 30 percent of total calories from fat and regular, moderate physical activity, Americans in general and North Dakotans in particular are not meeting national nutrition goals.

Among the Healthy People 2010 objectives for prevention and control of chronic diseases are the following: to increase the proportion of persons aged 2 years and older who consume no more than 30% calories from fat from 33% (1994-96 rate) to 75%; to increase the proportion of persons aged 2 years and older who consume at least two daily servings of fruit from 28% (1994-96 rate) to 75%; to increase the proportion of persons aged 2 years and older who consume at least three daily servings of vegetables, with at least one-third being dark green or deep yellow vegetables, from 3% (1994-96 rate) to 50%; to reduce the proportion of adults who engage in no leisure-time physical activity from 40% (1997) to 20%; and to increase the proportion of adults who engage regularly, preferably daily, in moderate physical activity for at least 30 minutes per day from 15% (1997) to 30%.

Food Safety
According to the Centers for Disease Control and Prevention (1999), foodborne illness is responsible for approximately 5,000 deaths, 325,000 hospitalizations and 76 million cases of illness in the United States each year. Among the most vulnerable are the elderly, the very young, pregnant women and people with compromised immune systems. The definition of potentially hazardous foods, which includes high-protein foods like meat and seafood, has expanded to include atypical foods such as alfalfa sprouts, melons, and other types of fresh produce.

Food safety has become a priority at the national level and much research is underway to reduce food safety risks. New technology is increasingly being used to detect and identify bacteria more rapidly. Federal regulations addressing inspection methods have changed. In 2000, for example, all federally-inspected meat processing plants were required to have a Hazard Analysis Critical Control Point (HACCP) plan in place. National consumer food safety education campaigns, including "Fight BAC! Keep Food Safe from Bacteria" and the "Thermy" campaign promoting food thermometer use, are underway. To further assist consumers, warning labels are required on unpasteurized juices, and safe handling directions are listed on fresh meat packages.

PROGRAM COMPONENT
NUTRITION -- CHILDREN AND ADULTS

Persons Responsible
Julie Garden-Robinson, Food and Nutrition Emphasis Group

Situation
Most health care dollars are spent on treatment rather than on prevention. Nationally, researchers estimate that unhealthy eating and physical inactivity are responsible for 35% of premature deaths in the U.S., or about 1,200 deaths per day. Cardiovascular disease is the leading cause of death for North Dakotans, causing 178.9 deaths/100,000 people in 1997. About 30% of North Dakotans in 1997 were told by a health professional that their blood cholesterol was high and 28% indicated never having had a cholesterol check. Cancer, the second leading cause of death in North Dakota, accounted for 23% of deaths in 1997.

North Dakotans are falling short of the recommendations for a healthy diet consisting of a variety of foods and no more than 30 percent of calories from fat in the total diet. Despite research on the health benefits of fruits and vegetables, particularly for reducing the risk of cancer, less than 23% of North Dakota adults consumed five or more servings of fruits and vegetables a day in 1998.

Overweight status and physical inactivity are among the contributing factors for cardiovascular disease and other chronic illnesses. About one-third of North Dakotans were overweight in 1998 according to the North Dakota Behavioral Risk Surveillance Survey. About 32% of North Dakotans surveyed indicated they were trying to lose weight in 1998.

Childhood obesity, inadequate calcium intake and low fruit and vegetable intake during childhood and adolescence are emerging issues. About 80% of North Dakota senior high school students ate a vegetable serving once a day or less during the previous week in 1999, and 70% of senior high students ate a fruit serving once a day or less during the previous week in 1999. About one-third of senior high students drank three or more glasses of milk per day during the previous week in 1999.

Anticipated Measurable Outcomes (Objectives)
As a result of participation in Extension Food and Nutrition programs, participants will show:

• Increased knowledge of the importance of variety in the diet, especially fruit and vegetables and whole grain consumption, coupled with reduced fat consumption in reducing the risk of chronic diseases.
• Increased knowledge of the importance of moderate physical activity in reducing the risk of chronic diseases.
• Behavior changes regarding consumption of a varied diet and moderate physical activity on a regular basis.

Educational Program

• 5 Plus 5 Coalitions including NDSU Extension personnel, North Dakota Department of Health Nutritionists, hospital/wellness center staff, commodity group representatives, Parks and Recreation staff, school representatives, decision makers and/or community members will promote variety in the diet (particularly 5 A Day), decreased fat consumption and regular moderate physical activity in a variety of settings including grocery stores and worksites. The community plans will be established at the local level and will use/adapt materials (lesson plans, handouts, press releases, etc.) developed by NDSU Extension Specialist(s) and North Dakota Department of Health staff and other members of the North Dakota Healthy Heart Council. A copy of a 5 Plus 5 display will be distributed to each county extension office.
• In-services and printed summaries of recent research in physical activity and human nutrition will be provided to extension agents and other collaborators. Information releases, and other tools to support the 5 Plus 5 program will be developed/adapted.
• Materials targeting calcium consumption among children and pilot-tested in North Dakota counties will be made available statewide. Lesson plans based on the Food Guide Pyramid with hands-on activities for children will be made available for check-out. NDSU Extension Service staff will participate in the planning and promotion of a statewide childhood obesity conference (2001).

FY2000/2001: Lesson plans, handouts and information releases will be developed on herbs and physical activity. Current recommendations regarding nutrition throughout the life cycle will be developed/adapted. An aging resource manual with background information, handouts and a lesson plan based on the Food Guide Pyramid for seniors will be distributed. A child nutrition resource manual including background information and handouts will developed.

FY2001/2002/2003: Lesson plans, handouts, public service announcements and information releases will be developed based on current issues in nutrition and food selection/purchasing, including research on food components (calcium), functional foods and phytochemicals.

Evaluation Plan

• Pre/post surveys to determine change in knowledge and awareness of the importance of a varied diet and moderate physical activity will be administered in multi-session classes.
• Records of self-reported fruit and vegetable consumption and physical activity will be evaluated and summarized to determine changes in behavior. Participant comments/success stories also will be summarized.

PROGRAM COMPONENT
FOOD SAFETY

Persons Responsible
Julie Garden-Robinson, Marty Marchello, Edna Holm, Food and Nutrition Emphasis Group

Situation
About half of the consumer's food dollar is currently spent on food eaten away from home. Nationally, foodservice establishments are linked with the most food-related outbreaks. North Dakota has had a number of publicized cases of foodborne illness including hepatitis, E. coli O157:H7 and others. In 1999, a life-threatening case of botulism in North Dakota was linked to food improperly canned at home.

Hazard Analysis Critical Control Point (HACCP) methodology has been successfully used in the food industry to assure and document safe food handling practices. HACCP programs are required for the seafood and meat industries, and other industries such as the produce industry are applying similar principles.

Along with the increase in commercial foodservice operations, greater numbers of children and the elderly are participating in daycare. Many North Dakotans also are becoming food entrepreneurs and starting small-scale food processing businesses.

Community dinners through nonprofit organizations, such as fraternal organizations, congregations and 4-H clubs, also remain popular. The volunteer food handlers are often untrained in quantity food production and handling. All of these trends present unique food safety concerns.

Anticipated Measurable Outcomes (Objectives)

• Increased knowledge of food safety/HACCP principles and implementation among foodservice managers, meat processors, sanitarians, and food processing entrepreneurs.
• Increased collaboration among Extension agents, sanitarians, commodity groups and food distributors in providing food safety training.
• Increased knowledge and awareness of safe food handling practices among consumers, daycare/eldercare providers and volunteer food handlers.
• Increased knowledge of farm-to-table food safety issues among extension staff.
• Changes in food handling practices to reduce risk of foodborne illness outbreaks.

Educational Program

• HACCP/food safety training workshops will be offered in collaboration with extension agents, Aging Services and the North Dakota Department of Health. Workshops will target foodservice and food processing employees across North Dakota.
• A resource manual for food entrepreneurs will be developed and distributed to all counties. A food entrepreneur website will be developed.
• A train-the-trainer educational package based on food safety issues associated with seniors will be developed (2000-01) and distributed to the Family and Community Educator clubs.
• Materials from the national "Fight BAC" and "Thermy" consumer food safety campaigns will be distributed to county extension service offices for use in schools and community settings. Food safety lessons for elementary students will be distributed (2000-01).
• Farm-to-table food safety training programs will be held for extension agents/EFNEP/FNP staff in collaboration with faculty from the College of Agriculture and Veterinary and Microbiological Sciences (2000-01). A farm-to-table website will be developed.
• Food preservation circulars will be updated, and a salsa lesson plan will be developed for use in workshops (2000-01).
• Food safety research updates will be provided to staff in written form, in meetings, by IVN training and by conference calls. Information releases on consumer food safety issues will be provided to staff. The NDSU Extension Service web site food and nutrition links will be updated. Interactive CD-ROM and other computer-based learning tools will be identified for use in programming.

FY 2001/2002: Develop handouts and lesson plans based on the most current issues in food safety, including food safety issues for children and their caregivers/daycare operators. Adapt materials for teens employed in foodservice establishments.

FY 2002/2003: Develop handouts and lesson plans based on current issues in food safety, including food safety issues for pregnant women and immune-compromised individuals.

Evaluation Plan

• Pre/post surveys will be used at food safety workshops to measure increased knowledge, awareness and intentions to change behavior.
• Six-month follow-up surveys on changed practices will be mailed to participants in food safety workshops.
• Pre/post tests will be used to measure increased knowledge, awareness and intentions to change behavior among participants in volunteer food handler training and food preservation training.

PROGRAM COMPONENT
EXPANDED FOOD AND NUTRITION EDUCATION PROGRAM (EFNEP)

Persons Responsible
Margaret Tweten, Interim EFNEP/FNP Coordinator, Julie Garden-Robinson, Food and Nutrition Specialist, EFNEP Supervisors, and EFNEP Nutrition Education Assistants

Situation
The composition of North Dakota families continues to change in important ways. The percentage of families with children headed by a single parent has increased from 13% in 1985 to 18% in 1995. Of particular concerns are children in families headed by single teen parents and children whose parents are struggling to meet their basic needs.

Economic pressures within the state have increased the number of parents working outside the home. Demand at local food banks is on the increase due to the downturn in agriculture and the decrease in assistance programs available such as TANF.

The target audiences for the EFNEP include: 1) low-income individuals/households living in either rural or urban areas who are responsible for planning and preparing the family's food, with emphasis on households with young children; 2) low-income youth who live in rural or urban areas and who meet the state's definition of 4-H age, which, in North Dakota, is 8 to 18 years.

North Dakota's EFNEP program is offered in six locations: two urban centers (Cass and Grand Forks Counties) and four Native American reservations (Fort Berthold, Rolette County, Sioux County, and Spirit Lake Nation.) Site selection is based on poverty figures and criteria affected by poverty.

Anticipated Measurable Outcomes (Objectives)

• Data from the EFNEP Evaluation/Reporting System is used to measure food practice improvement and dietary improvement. Low-income families and youth will acquire the knowledge, skills, attitudes, and changed behavior to form nutritionally-sound diets and significant improvements in daily living skills.
• Collaboration between EFNEP and agencies with similar target audiences will continue to increase.
• Upon successful completion of the EFNEP curriculum, participants will be encouraged to explore participation in other extension educational programs and even become active volunteers to assist with future EFNEP lesson series.

Educational Program

• EFNEP participants are taught in an informal educational group setting or in individual sessions by nutrition education assistants. Using Eating Right is Basic Curriculum, nutrition education assistants working with program families focus on dietary quality, menu planning, food safety, food budgeting, and food selection. Indirect contact may occur with program families through the use of telephones, newsletters, calendars, and displays which are used to supplement the face-to-face teaching.
• Each year, one component of the core elements will be a major focus of educational training for the nutrition education assistants. Using the train-the-trainer concept, these workshops will occur at the annual EFNEP/FNP conference and/or at the regional EFNEP/FNP meetings held across the state.

Food Safety: FY 2000/2001- focus on cooking protein foods and food storage temperatures
Food Purchasing: FY 2000/2001 - focus on menu planning
Dietary Quality: FY 2000/2001 - focus on increasing the consumption of grain products

• Educational instruction will continue to focus on the core elements, with NEA's selecting nutritional topics based on the needs of the target audience within their community. Community-based needs education will continue to provide the NEA with the direction of nutrition programming at the local level.
• A curriculum developed for 4th grade will focus on diabetes education that will provide information targeted to Native American youth at the Native American reservations.

Evaluation Plan
Data from the ERS-4 (Evaluation and Reporting System) is used to measure food practice improvement and dietary improvements. Pre-and post-assessment and observed behavior changes of participants will be the primary measures of program effectiveness. Results from the ERS-4 to be measured are: improved in one or more food resource management practices, improved in one or more nutrition practices, improved in one or more of the food safety practices, and improved in dietary intakes of six key nutrients.

PROGRAM COMPONENT
FAMILY NUTRITION PROGRAM (FNP)

Persons Responsible
Margaret Tweten, Interim EFNEP/FNP Coordinator, Barb Holes-Dickson, FNP Specialist, Julie Garden-Robinson, Food and Nutrition Specialist, FNP Supervisors, Nutrition Education Assistants/Agents, FNP

Situation
Food Stamp regulations allow states to submit a nutrition education plan to reach food stamp recipients and eligibles with education in nutrition, food purchasing and food safety. North Dakota has chosen to submit such a plan, as there are currently 31,321 persons in 13,411 North Dakota households receiving food stamp benefits each month. Monthly benefits for the state's food stamp program exceed $2,000,000.

In North Dakota, over 25,000 children under the age of 18, or 15.3 percent of that population, live in poverty. About one in six North Dakota children live below the poverty level. Another 13 percent live in near-poor families. Together, these two figures account for nearly 1/3 of all North Dakota children. (U.S. Department of Health and Human Services, 2000). Of the children living in poverty a high proportion are Native American children. According to Kids Count Facts!, during an average day, nearly one in three children in the state receive either a free or reduced-price lunch because of their economic situation.

Because of limited resources, the diets of individuals and families experiencing those circumstances may be inadequate. The objective of the Family Nutrition Program is to help food stamp participants acquire knowledge, skills, attitudes and changed behavior necessary for maximizing resources to achieve nutritionally sound diets.

FNP is operational in 52 of North Dakota's counties and reaches 88% of the state's food stamp population with education in nutrition, food purchasing and food safety.

Anticipated Measurable Outcomes (Objectives)

• 60% of participants surveyed will increase their consumption of grain products.
• 75% of participants surveyed will make food purchasing changes through menu planning.
• 75% of participants surveyed will improve hand-washing techniques.
• 55% of participants surveyed will be assured access to enough food.

Educational Program

• Each year, one component of the core elements will be a major focus of educational training for the nutrition education assistants. Using the train-the-trainer concept, these workshops will occur at the annual EFNEP/FNP conference and/or at the regional EFNEP/FNP meetings held across the state.

Food Safety: FY 2000/2001- focus on cooking protein foods and food storage temperatures
Food Purchasing: FY 2000/2001 - focus on menu planning
Dietary Quality: FY 2000/2001 - focus on increasing the consumption of grain products
Food Security: FY 2000/2001 - focus on using food assistance programs

• Demonstrations and displays will be provided at all project area food stamp offices, and at other sites the target audience frequents.
• Monthly newsletters will be developed and sent to each food stamp household in FNP counties.
• Classes designed for the target audience will be presented in group sessions or individually.
• An educational calendar will be developed and distributed to the target audience in FNP counties.
• "Building a Healthy Diet" curriculum materials from Iowa State University Extension will serve as the core educational resource.

Evaluation Plan

• Quarterly, semi-annual and annual reports will document program activities and participation.
• Survey instruments have been designed and piloted and will be implemented statewide to measure outcomes in dietary quality, food safety, food purchasing, and food security.