This is the sixth and final post in a series sharing the story of the process, challenges, and lessons learned in a pilot study aimed at applying clinical research in a community setting.
The experience of the Sorter School project answered some questions about possible connections between nutrition and adolescent behavior, but it also highlighted challenging realities, notably that children’s ability to eat nutritionally balanced meals, even if they want to, is severely constrained by social, economic and environmental factors over which they have little, if any, control. And, that there are serious institutional hurdles that must be navigated to translate the findings of clinical research into community settings.
Todman and her team intended that the Sorter project determine if it were logistically possible to provide school children with a nutritionally-balanced, omega-3 fortified diet, and whether the children would actually eat such a diet. As an added bonus, they wanted to determine if an enhanced diet could, in any way, be associated with improved behavioral health in the children.
The raw data from the psychological assessments suggest, but do not prove, such associations. Because of the inability to control for exogenous factors, such as what children ate when they were not in school, and the presence of confounding variables, such as the consistent presence of caring adult volunteers and project staff, it is not possible, at this point, to link definitively any behavioral improvements to changes in the children’s diets. Nevertheless, the raw data lead Todman to believe that there is merit in continuing to advance this work of translating the clinical science on the link between nutrition and behavior into community-based settings.
The most notable findings from the raw data of the post-intervention psychological assessments suggest decreases in indicators of emotional distress, including anxiety and depression symptoms, difficulty getting along with others, aggressive behaviors, inattentive and hyperactive/impulsive behaviors, and disruptive behaviors. There are also improvements in indicators of self-concept. It is important to note that this is raw data and more analysis must be done to assess statistical significance.
A Key Lesson from Sorter: Collaboration is Critical
Todman understands that the Sorter project was, in many ways, unique. But she believes it embodies important lessons for anyone seeking to replicate and improve efforts to understand the behavioral effects of improved nutrition in a community setting. As for Sorter, Todman said, “It was almost magical the way it came together. It was a very organic process of getting people involved and many of the positive outcomes were the result of serendipity.”
Those positive outcomes also were rooted in Todman’s work as the team’s leader in setting the stage for the project by forging relationships with the key players, including colleagues at a federal health agency and the regional health system to the school district’s superintendent, the school building staff, and the students and their families. As a result, when problems arose, solutions were developed through synergistic interactions of diverse people, with different intuitions and ways of thinking. In spite of their differences, everyone had a common desire to ensure the project’s success.
What Sorter showed was that children from underserved communities, including those with behavioral problems, will make better food choices if they have the opportunity, the guidance, and the support of caring adults. Meals included more fruits, vegetables, whole grains, protein, and omega-3 fatty acids, and fewer additives, colorings, sugar and unhealthy fats. The enhanced menus were honed over the course of the intervention through weekly oral and written input from the students. This ensured that, unlike the school vendor-provided meals, they would actually eat what was served. As a result, the students broadened their palates, and eventually came to enjoy kiwi, yogurt, turkey burgers and other foods they’d never tasted before.
Todman acknowledges that the Sorter School project would not have happened without the generous support of many donors and volunteers. Benefactors provided much of the food, as well as the kitchen space, cooking equipment and staff; food acquisition and logistics expertise; and, appliances like refrigerators, freezers and blenders. “We spent only 50 percent of the budgeted project cost.” Given that, “The replicability of the project may be limited because the real project cost exceeded and, in fact, was multiples, of what we actually spent.” However, that’s not to say it can’t be done at another school.
Todman says the nutritionally-enhanced menu was not extraordinary or exotic; it was consistent with USDA school meal requirements. So the obvious way to replicate the intervention would be for school food vendors to provide such menus. She said, “This could certainly be replicated with a supportive and cooperative vendor.”
Understanding Costs and Political Will
There’s a larger obstacle though –political will. Todman believes that more nutritionally dense meals can be provided to children in schools, but only if there’s a policy shift in school meal programs away from the current objective of feeding children the cheapest foods available. Todman says, ultimately, providing children with better quality food, will mean spending more money on the meals.
For instance, Todman noted, “During the period of the Sorter project, the Benton Harbor Area School district’s food vendor provided its other schools breakfasts that cost $.90 per meal, and lunches that cost $1.10 per meal.” Even a rough estimate would put the cost of the meals served to Sorter students at more than twice those figures. If the Sorter menu were offered district-wide, economies of scale may reduce the unit cost somewhat, but it would still be higher than what the district was accustomed to spending on meals.
Institutional Review Board Challenges
To Todman, the most surprising experience of the Sorter School project was the need to have to navigate biases against and institutional obstacles to community-based efforts. Todman found that institutional review boards (IRBs) often apply a clinical lens to projects like this without regard for or understanding of the numerous exogenous or “x-factors” that characterize real world settings. “IRBs operate under and make judgments based on the erroneous idea that communities function in predictable ways. But, communities are comprised of people, and people are notoriously unpredictable. Communities do not operate in ways that are manageable, or like ‘subjects’ in clinical settings.”
Todman also found it surprising that these IRBs referred to the community residents involved in community-based projects, such as Sorter, as “subjects”, not partners. This type of reference depersonalizes community residents, trivializes their roles and interests in research, and is indicative of a deeply patronizing attitude toward communities, especially the underserved. For reasons such as these, Todman notes that many universities are establishing IRBs for the social sciences that are different from the boards overseeing clinical and biomedical studies.
Because the Sorter project brought together disparate groups, culture clashes were inevitable. Translating the nutrition-behavior connection demonstration from a clinical to a community setting involved academics, teachers and school administrators, hospital staff, businesses, community members, students and their parents working together outside of their comfort zones and their conventional ways of doing things.
Todman found that while some clashes were easy to overcome, others were not. An example involved the project team, on one hand, and the students, parents and staff of the Sorter School on the other: the latter did not always adhere to the research protocol. In addition, Todman found herself coaching some project team members in appropriate language and comportment when engaging with the school-based project participants.
Then, there were the issues of class and race that emerged in her interactions with the IRB. Dr. Todman had to directly and forcefully address insensitive questions and comments made about the Sorter project and its participants in order to ensure the project’s fidelity. In addition to a lack of preparation to evaluate a community-based project that involved community members as partners, Todman found the IRB poorly prepared to evaluate a project involving people and a community that was culturally, socially and economically “different” from their perception of what constitutes “normal”.
Next Steps for the Sorter School Project
The Sorter School initiative will not be repeated in the same way; the school building has closed, and its population of students has been mainstreamed into regular schools. But Dr. Todman sees the Sorter School project as a harbinger of how translational work involving community-based interventions, which are so very critical to social change efforts, can be accomplished.