The Lunchtime Comics

Initiative

Sana CharaniaNgozi Okaru

Alexis Oni-EselehAlisha Dua

Table of Contents:

Executive Summary ----------------------------------------------------------------------- 3

Our Expertise ------------------------------------------------------------------------------- 4

Situational Analysis ------------------------------------------------------------------------ 6

Lunchtime Comics ------------------------------------------------------------------------ 8

Financial Projections --------------------------------------------------------------------- 10

Appendix ------------------------------------------------------------------------------------ 11

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Executive Summary

In the United States, there is a growing problem of elementary school students not obtaining sufficient nutrition education needed to develop healthy eating habits. This is especially a problem since many children eat more than half their meals at school. Previous studies have examined the consequences of limited health literacy, which include less participation in disease detection activities, riskier health choices, poor management of chronic diseases, increased hospitalization and rehospitalization, and premature death. Health is a basic human right, and the deficit in adequate health literacy is one of the greatest barriers to health. It is our responsibility to act to minimize limited health literacy and to encourage healthy habits for future generations. Our solution is Lunchtime Comics.

Lunchtime Comics is a health literacy tool that focuses on improving the dining experience for children while also resolving a bioethical problem: health disparities. Access to proper servings of fruits and vegetables, in addition to regular exercise, is a privilege. Access to education should not be. Lunchtime Comics targets an untapped market, in an attempt to combat health disparities. Fast food companies spend millions of dollars a year marketing directly towards children, and the World Health Organization (WHO) estimates that nine percent of preschoolers worldwide will be obese by the year 2020. Those two facts are related. With “a standard of living adequate for the health” outlined as a basic human right in the United Nations Declaration of Basic Human rights, possessing such a tool and failing to implement it in one of the most vulnerable populations would be ethically unsound.

As future scientists, policy makers, teachers, and physicians, we study the effects of limited health literacy and are aware of these problems. We can maximize the impact that we have using our knowledge on the matters at hand. To improve health literacy and promote nutritious habits in young children, we created Lunchtime Comics, a series of placemats with fun and informative activities for the elementary school lunchroom. The placemats are character driven and interactive, yet educational at their core. Our current installment of Lunchtime Comics was highly successful when tested with hundreds of students at Brent Elementary School and Thomas Elementary School, and has received support from health and nutrition professors. We are pilot testing at more schools to recognize whether our product is adequately designed for the target demographic. We plan to

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reach out to health nutritionists to improve on the content on the placemats. It is our overarching goal to create a well-developed product to pitch to the Let’s Move Campaign, the School Nutrition Association and/or Action for Healthy Kids, for broader deployment of the placemats.

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Expertise

Our team consists of four undergraduate Georgetown students: Sana Charania, Ngozi Okaru, Alexis Oni-Eseleh, and Alisha Dua. We are all passionate about working towards overcoming barriers to health by increasing health literacy among elementary school students. Addressing issues of health and nutrition education becomes highly complex because knowledge of politics, economics, sociology, and science are all needed to accurately understand these issues and counteract them. Our team’s strength lies in our interdisciplinary science backgrounds. Three members of this team, Sana, Alexis, and Ngozi, will receive degrees in Biology of Global Health. This program teaches science in a socially conscious manner and educates students about the intersection of science with law, policy, and economics. Sana is uniquely able to address the psychosocial aspects of issues with nutrition education as a result of her minor in psychology and her work as a research assistant in a children’s psychology laboratory. Prior to coming to Georgetown, Ngozi was involved in programs where she volunteered to sort and distribute food to people, many of whom were parents and children, while educating them on the importance of healthy choices. Thus, she has seen firsthand the need for nutrition education. At Georgetown, she continues to search for more knowledge on the subject, joining groups such as the Georgetown University Minority Association of Prehealth Students (GUMAPS) that have regular discussions on bias in the health industry, mental health, and reaching out to underserved communities that do not receive and adequate amount of health education. Alexis spent the past year teaching in the D.C. Public School System teaching high school Biology. By incorporating herself as a member of the D.C. community, she’s gained crucial perspective on the expectations set for the target audience. The last member of this team, Alisha, is a double major in Neurobiology and Government. Much like the rest of this team, Alisha is passionate about understanding how policies and social issues impact a person's interactions with science and their experience of health. Her technical science education and 2.5 years as a research assistant has allowed Alisha to develop strong analytical skills that have been useful in the effective integration of current nutrition and food literacy research into the project. Alisha’s past experience in art, specifically sculpture, was vital for the design of the placemats.

Additionally, this team has a strong background in design thinking. This allowed us to create placemats that are not only informative, but also

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engaging for students. The activities teach kids about different nutrition topics, while the comics provide a fun story for students to read and enjoy. Although each member of the team participates in virtually all aspects of Lunchtime Comics, we each have primary roles. Sana is in-charge of communications and helps with layout of the placemats on Adobe Photoshop. Ngozi researches organizations for us to connect with and helps create activities for the placemats. Alexis conducted most of our research on the Let’s Move Campaign and helps create activities for the placemats. Alisha is in charge of printing, as well as design and layout of the placemats utilizing Adobe Photoshop.

Our progress would not have been possible without key individuals who helped shape Lunchtime Comics. We have listed a few of these individuals below.

Principal Peter Young: Principal of Brent Elementary School (368 students; 64% white, 21% black, 7% Hispanic/Latino; 13% on free and reduced price lunch). He let us pilot the first iteration of our placemats with two first grade classrooms and the entire lunchroom. We received valuable feedback from both the teachers and students during this pilot.

Arjun Dhillon: Founder of Mighty LLC, a design studio, and head of studio at Georgetown University’s Ethics Lab. Arjun gave us critical feedback on the design and layout of our placemats.

Jenny Sinding: Has experiences related to child development, including curriculum development and teaching through her work at Discovery Channel in their youth programming division. Jenny connected us with online educational resources and reviewed our placemats. She suggested that we cut down on text and use a bigger font for the younger grade levels.

Professor Susan Coleman and Professor Diane Davis: Susan Coleman is an adjunct instructor in the School of Nursing and Health Studies at Georgetown University. Diane Davis is the coordinator for clinical and course faculty also in the School of Nursing and Health Studies. Both of them have backgrounds in health nutrition and public health, and offered us critical feedback on our placemats. The suggested we use Microsoft Word’s reading level assessment tool to evaluate the reading level for our placemats and make the placemats more picture friendly.

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Saundra Butler: School counselor of Thomas Elementary School (408 students; 98% black, 2% Hispanic/Latino; 99% free and reduced price lunch), which is located near Anacostia. She let us pilot our most recent iteration of our placemats with all the students in the lunchroom.

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Situational Analysis

There is an urgent need for consistent health curricula to teach young students the importance of a holistic diet. One third of children under the age of eight have health literacy below their grade level.1 Children in grades K-5 should receive at least fifty hours of nutrition education per year in order to make an impact on behavior, yet many are receiving substantially less according to the National Center for Educational Statistics. In fact, recent reports state that, on average, teachers are only required to address ‘Nutrition and Dietary Behavior’ topics in elementary school classroom for an average of just 4.6 hours per a year.2 Part of the deficit in early nutrition education can be attributed to the fact that available health curricula are often written for students above the eighth grade level. Additionally, teachers can encounter a variety of barriers when trying to teach nutrition education, including little to no cooperation with the schools’ meal programs, lack of clarity in what activities would best communicate health material, and difficulty in scheduling time to incorporate the material during the school day.3 Thus, there is a clear need for more effective health literacy materials in the public primary education system.

Through our research, we have determined that elementary school students are the most important age group to target to make a significant impact on nutritional habits. Studies show that elementary school students are an effective audience for initiating lifestyle changes because their eating habits can be heavily influenced by their school and home environments.4 Furthermore, data shows that the earlier children learn healthy eating habits, the more likely those habits will carry on through adulthood.5 A research study of food waste in one Ohio lunchroom showed that elementary school students produced the most fruit and vegetable waste compared to middle and high school age students, across many different fruit and vegetable types. This being the case, intervention during elementary school has the largest opportunity for making a significant

1 Rothman, Russel. “Measuring and Assessing Health Literacy in early years.”  Vanderbilt University Medical Center, 2011.2National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. “Results form the School Health Policies and Practices Study 2014”. Center for Disease Control, 2015.3 National Center for Educational Statistics, 2000.4 “Shape Your Family’s Habits”. NIH News in Health, 2013.5 Ibid.

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impact on students’ eating habits.6 Finally, a survey of 364 elementary school parents indicated that communicating, “Why it is important to eat healthy food”, is the most highly desired food-related learning activity by parent, above school gardening programs and even table manners.7

Currently, very few innovative projects exist outside of basic classroom nutrition programs to encourage students to eat healthy. Ohio Smarter Lunchrooms recommends naming vegetable in a creative and age-appropriate manner, like “X-Ray Vision Carrot”, as a study had previously shown that this increased vegetable consumption in elementary aged students.8 Another study suggested that helping students identify fruits and vegetables during the school lunch period with positive reinforcement for fruit/vegetable consumption, led to a measurable increase in students’ fruit and vegetable knowledge.9

IDEO, a design firm, worked in conjunction with the San Francisco Unified School District in 2013 to re-imagine the lunch experience. The results of their work led to the recommendation that elementary school lunchrooms shift to more communal style meals with direct adult interaction at each table. The IDEO recommendations also suggested “Table Topic Placemat” be used to teach students fun facts about their meals, while providing stories or even recipes to take home to parents.10 Data on whether such placemats were successfully implemented has not been released. Most new programs, however, are working to get students more involved with the cultivation and preparation of their lunches through gardening and cooking programs. Although these programs have highly positive results, schools with limited resources may not have the capacity to successfully implement sustainable gardening/ cooking programs.

A survey from Oregon reported that approximately 97% of surveyed teachers felt nutrition education in elementary school was either very or somewhat important. In the same study, teachers suggested that the lack of

6 Riegel, Haley R. “Fruit and Vegetable Consumption Patterns among Children During School Lunch”. Wright State University, 2014.7 “SFUSD’s Future Dining Experience”. IDEO, 2013: pg 165. 8 Riegel, Haley R. “Fruit and Vegetable Cosumption Patterns among Children During School Lunch”. Wright State University, 2014.9 Blom-Hoffman, J., Kelleher, C., Power, T. J., & Leff, S. S. Promoting healthy food consumption among young children: Evaluation of a multi-component nutrition education program. Journal of School Psychology, 2004: 42(1), 45.10 “SFUSD’s Future Dining Experience”. IDEO, 2013: pg 165.

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health curricula reinforcement in the lunchroom is detrimental to the success of current nutrition programs already in place in the classroom.11 This lack of reinforcement is especially problematic when considering that students in the United States eat over half of all their meals at school. We wanted to create a product that could teach students about healthy eating in their school lunchrooms and act as a bridge to current nutrition programs. This is how Lunchtime Comics was born.

11 Perera, Thushanthi, et al. Improving Nutrition Education in U.S. Elementary Schools: Challenges and Opportunities. Journal of Education and Practice, 2015: 6, 30.

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Lunchtime Comics:

Over the course of six months, we have created a project that is centered on the idea of increasing children’s health literacy. We planned to address the growing obesity problem and the lack of health education that children in K-5 are experiencing. We have researched how severe the lack of health education has become, along with what has been done combat this dearth. For example, we looked into the WHO’s analysis on how limited health literacy is associated with less participation in health promoting activities and choices. We also turned to the U.S. Department of Health and Human Services’ National Action Plan that has a goal of “incorporating accurate, standards-based, and developmentally appropriate health and science information and curricula in child care and education through the university level”. Finally, we looked at past and present projects, such as the San Francisco United School District case study, which, in collaboration with the IDEO industrial firm, experimented with different ways to improve health literacy in schools. As a result, we designed a product that could participate in the movement to improve health literacy. We created Lunchtime Comics.

Lunchtime Comics is a fun, yet educational series of placemats that students in K-5 schools would be able to use during their lunch period that teaches them health nutrition facts. The placemats would include a character driven story along with engaging activities that students could do while eating their lunches. If Lunchtime Comics were to be implemented into the schools, the placemats would, ideally, be placed in the lunchroom every Friday, each with an overarching story and an activity. Each month, there would be a new topic involving health, such placemats for each of the food groups (fruits, vegetables, grains, protein, dairy), and other nutritionally-focused topics (e.g. nutrition labels).

We have designed placemats focusing on fruits and grains. We have piloted them in a range of settings where the key components included children in K-5, a social setting, and food. These included pilots at a science party attended by students in grades 4-6, two first grade classrooms at Brent Elementary School, a lunch period at Brent Elementary attended by students in grades 1-5, and a lunch period at Thomas Elementary attended by students in grades K-5. We collected data during these pilots where we were given general praise for the placemats from the students and the teachers.

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We found that the placemats were highly social and that student learned from the placemats. We tested our placemat at Brent Elementary School in the lunchroom with 129 kids in grades 1-2 and 130 kids in grades 3-5. To minimize printing cost for this pilot, we printed single sided placemats. Across both lunch periods, 65.24% of kids took their placemat home, 30% of kids left their placemat on the lunchroom table, and 4.76% of kids threw their placemat out in the trash. The placemat was surprisingly social, with 37 groups of two or more students interacting with each other to complete the activities. The most popular activity for the younger grades was the word search, while for the older grades it was the quiz. One girl was reading during most of the lunch period, but during the last five minutes she began working on the wordsearch with her friend. It is important to note that there were some kids who ignored the placemat, did not want to do it, or drew on the back of the placemat. The teachers also loved the placemats. The kids were occupied and engaged during the entire lunch period, and the noise level was lower than usual. One teacher said, “We should print out a bunch of these. Best lunch I’ve ever had”. Another teacher said, “I think we as teachers just had an ah-ha moment. We should do this every Friday”.

After the pilot at Brent Elementary, we had a second pilot at Thomas Elementary School, a school that also has children in grades K-5, but has a different background of students than the students at Brent Elementary. We found that most students did not engage with the comic initially, but were mostly interested in the activities; some did return to the comic if they were not talking with other students or if they were done with the other activities. Among K-2 students, most of the students were willing to draw in the “Draw Yourself as a Grain” activity, but the matching activity had to be explained to some of them. We found that the students couldn’t understand the words on the mat, which led us to conclude that the placemats for these grades should be more visual-based than text-based. For students in grades 3-5, many of the students enjoyed the Boggle activity and were able to complete it, but some needed help with the crossword. In both groups, there was a question of what, exactly, is a grain, which informed us that it would be important to include similar definitions on future placemats. However, we observed that, similar to the pilot at Brent Elementary, the placemats encouraged social activity between the students, many students working together in groups of two, three, or four to discuss and complete the placemats. The teachers also commented on how the placemats kept them students engaged during the lunch period, keeping them calmer than usual. Two of the teachers also worked on the placemats to insure that the placemats could be completed and offered to give us feedback.

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Based on the different pilots, we restructured and redesigned the placemats (Figure 1). We contacted Jenny Sinding, a specialist in child development, who connected us with online resources that targeted the same age groups that we were. She suggested that we reduce the amount of text and to use bigger fonts for the different grades, which led us to a 16pt font minimum for 1st and 2nd graders and a 14pt font minimum for 3rd-5th graders. We also met with Professor Susan Coleman and Professor Diane Davis, who teach classes in the NHS and have backgrounds in health nutrition and public health. Their biggest concern was that the placemat might be too hard for the younger kids and for kids whose first language isn’t English. They encouraged us to lower the reading level, add an easier activity, and make the placemat more picture friendly. Upon their recommendation, we utilized Microsoft Word’s reading level assessment tool to make these changes and added a maze to the placemat. As a result, our current product is much more streamlined, more involved with the characters, and is concentrated on one activity that educates students on the topic.

In the future, we would like to pilot our placemats in more schools. We would also like to have more resources to create more placemats that could more effectively address the different topics. For instance, it would be helpful to get into contact with a health nutritionist who could insure that we are addressing the right topics in the right way. Eventually, we want to implement these placemats in multiple elementary schools or classrooms through different programs, such as the Let’s Move Program, or other non-profits organizations, such as the School Nutrition Association and Action for Healthy Kids.

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Financial Projections:

The goal of Lunchtime Comics is to increase health literacy among elementary school students with minimal implementation costs to the schools themselves. In order to develop an effective, low-cost program we wanted all designs and material to be free-of-charge, making the only costs associated with this program the printing of the placemats and provision of writing utensils.

In terms of creating the placemats themselves, associated costs include developing the content (the comics and grade appropriate activities) and designing the layout using Adobe Photoshop or some similar program. This was accomplished with help from health nutritionists, child development specialists, design experts, and students. Currently, we are working towards finishing a complete set of placemats for a one year program by creating additional placemats and/or partnering with an organization that has the resources to develop the placemats for us.

There are many viable options for which medium of paper is best for printing our placemats onto. Depending on what the organization or school we partner with can afford, there are benefits and drawbacks associated with each of these mediums. The cheapest option is multipurpose paper, which costs $18.99 for 500 sheets of 11x17 paper (Staples.com). A more durable option is cardstock, which costs $47.78 for 500 sheets of 11x17 paper (Staples.com). The most sustainable option is waterproof paper, which costs $431.60 for 500 sheets of 11x17 paper (Igage.com) and can be reused. For 500 golf pencils, the cost is $89.25 (Amazon.com).

The ultimate goal is to establish a partnership with a health literacy or food literacy organization, such as Michelle Obama’s Let’s Move Campaign. Partnering with an organization would help us implement placemats in elementary schools and/or give us resources to develop Lunchtime Comics. In addition, it will allow this project to be sustainable, especially since the members of this team are either juniors or seniors.

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AppendicesAppendix A: Grades 1-2 Grains Placemat (Part 1)

Appendix B: Grades 3-5 Grains Placemat (Part 1)

Appendix C: Grades 1-2 Grains Placemat (Part 2)

Appendix D: Grades 3-5 Grains Placemat (Part 2)

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Appendix E: Grades 1-2 Grains Placemat (Part 3)

Appendix F: Grades 3-5 Grains Placemat (Part 3)

Appendix G: Grades 1-2 Grains Placemat (Part 4)

Appendix H: Grades 3-5 Grains Placemat (Part 4)

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