Upfront: Efforts to change the food culture in San Antonio

We are what we eat

For decades, health experts have been encouraging Americans to consume fewer calories, eat less fat and sugar, buy fewer processed foods and, generally, pay more attention to their diet and health. Yet obesity rates kept going up and with them the incidence of diabetes, cardiovascular disease, respiratory problems and some types of cancer. But there are signs of positive change. A recent New York Times report noted that the message is being increasingly heard by families, institutions and governmental entities, all of which have finally started taking measures that promote a healthier lifestyle. For the first time in four decades the average daily calorie intake of adults and children has actually started to decline. Here in San Antonio, a number of initiatives have helped people to make better food and physical activity choices (See sidebar).

“We have made incredible progress in the past 10 years,” says Jennifer Herriott, assistant director of community health at the Metro Health District.

One of the statistics reported by SA2020, for instance, indicates that the obesity rate has significantly gone down, from 35 percent in 2010 to 28 percent in 2012, and new data for the subsequent two-year period are expected to show sustained progress. But there’s a lot more to be done. The three stories below reflect the growing efforts to turn around the unhealthy trend of the recent past by embracing a more salutary course.

Guiding Young Mothers

On a sunny July morning, I join a small group of people at the Southside H-E-B for a cooking and grocery shopping lesson. A registered dietitian assembles everyone in an upstairs room, where she proceeds to make several dishes from scratch, explaining along the way which ingredients and products she is using and why she chose them. In a low-key way, she talks about eating more fish, using less salt and incorporating more veggies. On the side of her work table hangs a demonstration plate that shows the portion sizes of protein, vegetables and grains you should aim to consume in a meal.The lesson and tour that follows are part of the innovative hands-on program named CHEF, for Culinary Health Education for Families, launched by the Children’s Hospital of San Antonio in partnership with H-E-B, the Culinary Institute of America (CIA) and the Goldsbury Foundation, which came up with the basic concept and provided the funds. It’s a pilot study directed by pediatrician and child-health advocate Dr. Julie LaBarba, who, with the help of an expert panel, keeps an eye on everything to make sure the program is scientifically sound. Included in the panel are several physicians as well as Ph.D.-level dietitians from the Baylor College of Medicine’s Children’s Nutrition Research Center in Houston.

The idea behind the demonstration is to teach pregnant women and new mothers the basics of healthy nutrition for themselves and their families. The dietitian starts with a seafood dish prepared with rice, red quinoa, onions and jalapeño peppers, but while that’s cooking, she whips up a tasty kale-based salad and a nontraditional pico de gallo with fruit. To assuage thirst, she has prepared a blueberry and mango-infused water. The drink is pleasantly refreshing, and the foods we get to sample are all tasty. There are a few questions from the participants as well as from us, the few observers. Then we all troop downstairs for a tour of the store.

In the dairy section, we look at a variety of yogurts. You can buy a plain yogurt that’s good for you or one laden with fruit and sugar that’s not so good. Grabbing containers of both, the dietitian points out the nutrition information on each, explaining what to look for. At the frozen vegetable case, a discussion about added sauces develops as well as comparisons of fresh versus frozen. Frozen is fine and can even be better if the veggies were frozen soon after being picked. As the tour proceeds, there’s more to be learned about meats, breads and canned goods.

UpFront-LaBarba“We start with food that people are familiar with and show them how to make it better,” says Dr. LaBarba, after the tour. “Everything has to be practical, accessible and affordable. And it has to taste good and fill you up. I want these women to feel ‘I can actually do this!’ so they would continue to shop and cook this way after the program is over.”

Called Prescriptions for Produce, the pilot initiative started with 60 women recruited by their doctors at the CentroMed South Park Medical Clinic. Each received $40 a month for up to 11 months to spend on fruits and vegetables at H-E-B, and each had to participate in a class like the one described above. In addition, they had to show up once a month for their clinic appointments, have a nutritional consultation and participate in surveys that help researchers assess the success of the initiative. As an assistant professor of pediatrics at Baylor, Dr. LaBarba is also the principal investigator of the study. (A new USDA-financed study involving 200 women will follow the pilot project.)

“The demonstrations are very important, showing people how to prepare food, like sautéing and peeling, and other cooking skills,” says the doctor. “It’s no use telling them about healthy foods if they don’t know how to make the dishes. Also, we teach them how to combine certain foods for a bigger nutritional impact, such as beans and limes and avocados and tomatoes, for instance. I would like to do more of it. The women are often surprised by how much they learn here.”

Fortunately, CHEF will soon have its own CIA-designed Teaching Kitchen inside the Children’s Hospital as well as a Healing Garden, a 2.4-acre green space where fruits and veggies will be grown and prayer and meditation will find a welcoming environment. The new kitchen will teach patients with specific conditions such as diabetes or epilepsy how to improve their health through “culinary medicine,” as well as educate medical residents so that they can talk to patients about nutrition in the language that the latter understand. It is also hoped that other community organizations could use the facility for their own programs.

At the same time, the hospital is working with its food service partner, Aramark, “to walk the talk” and introduce healthier options for all patients and staff. “We are changing the food culture in the hospital,” notes the doctor. “Food and health are linked. We really are what we eat… My family was in the produce business, so this is in my blood,” she adds. “I want to make real food available to everyone, food that grows from the ground and on trees. I get quite emotional about it.”

School Meals Keep Getting Healthier
French fries and cupcakes are no longer available in school cafeterias. Or if “fries” are offered, they are no longer actually fried, they are baked, explains Sally Cody, a registered dietitian (RD) and senior executive director of Child Nutrition Services for the San Antonio ISD. Sugary Jell-O is gone, too, and whole grain has replaced white flour. Every meal must have a serving of fruit or vegetables, and salt and fat are substantially restricted.

Improving the nutritional standards of school meals has been part of federal policy for decades, but new twists and regulations keep cropping up in keeping with the new urgency to stem the rise of harmful eating habits. The 2010 Healthy Hunger-free Kids Act has gone further than any previous regulations in defining what schools can and cannot use when designing meal plans. And since July 2014, the U.S. Department of Agriculture has required all foods and beverages sold to students on school property to follow the same nutritional requirements already in place for the National School Lunch Program. Thus, vending machines, a la carte cafeteria items, snack bars and even fundraising events must comply by offering healthier versions of everything.

“Students are used to diets without all these restrictions, but in school we must follow the regulations. The challenge is to make the food taste good,” says Cody, who has been in the child nutrition field for 32 years. “The rules now prescribe how many times a week we must serve green leafy vegetables or orange-colored ones. The amount of bread is also regulated very specifically. Standards have become very strict. Not much flexibility there. One dietitian on my staff is in charge of doing the nutritional analysis of all the menus. But we have a chef and nutritionists who work on making our offerings as appealing and fun as possible.”


All items are kid-tested, and the aim is to get an 80-percent approval rate across the board, from elementary school children to high school students, notes the director. Certain traditions are maintained but tweaked to comply with the latest requirements. Wednesday is Mexican food day, fish is served on Friday, and there’s also Italian day featuring a whole grain pizza. Among the items kids enjoy are turkey lasagna, low-fat macaroni and cheese, roasted chicken and Crispitos, rolled tacos filled with seasoned chicken meat. If a dish passes the taste test but doesn’t fare well long term, it’s scrapped.

To help students understand the role of various food groups in the diet, the district’s website features games for kids to play, including one with characters such as Proto (for protein), Minnie (for minerals), Fatto (for fat),Vity (for vitamins) and Carbo (for starches). The youngest ones, in the Head Start program, eat family style with their teachers, who use the time to talk about what’s good and not so good for them.The SAISD Nutrition Services Department provides meals to 95 district sites, serving about 45,000 lunches and breakfasts a day, and that includes special diets for diabetics, kids with food allergies, celiac disease, lactose intolerance and various other conditions.

“We spend a lot of time on these special diets, and our managers have to get special training for each,” remarks Cody.

As if to impress upon me the magnitude of the task, she takes me to the district’s food distribution warehouse, which is an enormous space housing gigantic refrigerators and various other equipment pieces. In the summer, it’s all quiet, but during the school year this is the place where pallets upon pallets of bulk foods are unloaded, sorted and stored and then sent to various school cafeterias according to their orders. Altogether, Cody oversees nearly 600 employees who work in Nutrition Services.

In the 2015-16 school year, the district will also expand yet another federal program called Fresh Fruit and Vegetables. These healthy goodies will be served outside of regular meals and aim not only to encourage the consumption of produce but also to expose students to foods they may not be familiar with, such as kiwi, snap peas or jicama. For Cody and her staff it means more work, but that’s not a problem.

“What’s interesting about our department is that people who apply for jobs here don’t understand fully what these programs entail,” observes Cody. “These are important programs that make a difference in a child’s life. Then, like me, they never leave because they become passionate about what they do.” Yet she hesitates when asked if kids are getting healthier. “School meals are healthier for sure, but we don’t control what they bring to school or eat outside of school. Yet I don’t see many overweight kids anymore.”

If You Need Help

Since most of us take care of our own food shopping and cooking, where do we turn for help when we need it? Yes, there are books and articles galore on healthy nutrition, but how do you apply all that information in ways that work for you? That’s where a qualified nutritional consultant like Jan Tilley comes in. A registered dietitian with a master’s degree in nutrition, Tilley and her associates at JTA Wellness will hold your hand as they teach you how to eat right to maintain or improve your health. On the day I arrive in her office to interview her, she introduces me to a client I’ll call Mary who lost 50 pounds and slashed her cholesterol levels significantly since she’s been following Tilley’s advice. Mary says she knew quite a bit about what to do to help herself but “general knowledge doesn’t always translate into a change of behavior.” At JTA she got a personalized plan and someone to monitor her progress while she developed the discipline to put it into daily practice.

To design a customized plan, Tilley collects all the pertinent information — height, weight, age and activity level — and plugs it into an equation called the Mifflin-St. Jeor formula to calculate first the Resting (or Basal) Metabolic Rate (BMR) and then the total calorie expenditure per day. Armed with these data, she can determine how many calories a person should consume to lose weight in a sustainable way. Then she goes one crucial step further by translating that calorie intake into the types and quantities of food a client should consume per meal.
In addition, she advises them to follow the five steps she considers essential for healthy nutrition: 1. Eat every three hours; 2. Since carbs are digested quickly, combine them with protein to feel satisfied longer; 3. Don’t let your hunger get ahead of you (eat before you are starving); 4. Exercise, ideally for 30 minutes six days a week, and 5. You are only one meal away from success. The latter is her “cheerleading statement,” says Tilley.UpFront-Tilley

“The only meal you need to get right is your next one. If I can get a client to follow this regimen for 30 days, I know they’ll be successful. They start feeling better and they see weight loss, and then they are motivated to continue.”

“I focused on a day at a time,” adds Mary. “There was definitely a learning curve, but it worked. Cravings are gone, and I feel so much better.”

Tilley, who worked for United Supermarkets in Lubbock and with H-E-B before opening her own practice, has also compiled a book of good-for-you recipes, Healthy Meals for Hurried Families, that are easy to fix and enjoyable to eat. (This writer has sampled several, and they all pass the taste test!) Like Dr. LaBarba, she believes that nutrition can heal, or at least ameliorate, a number of chronic conditions, and she collaborates with physicians who refer certain patients to JTA Wellness. Her practice also accepts insurance. One thing she especially emphasizes is the anti-inflammation diet.

“Research shows that chronic inflammation is a root cause of a number of diseases, such as diabetes, lupus, fibromyalgia, rheumatoid arthritis, even cognitive decline (dementia),” notes the dietitian. “In one recent study 11 people in the beginning stages of Alzheimer’s disease were put on an anti-inflammatory diet, and after six months they were all able to return to work.” (Published in the journal Aging, September 2014).

Not surprisingly, the anti-inflammatory diet consists of the now familiar good aliments such as fruits and veggies, oily fish, whole grains, beans… you know! But there are two additions – spices like ginger and turmeric and probiotics found primarily in yogurt. Her new book, Eat Well to Be Well, which focuses on this subject, will be published this fall. “I spent a lot of time developing the recipes for this book. Fortunately, I love to cook,” says the mother of four and grandmother of 11, who is the picture of good health.

While the anti-inflammatory diet is good for everyone, some clients may require more specific help for conditions such as IBS (Irritable Bowel Syndrome), MS, kidney disease, cancer or any of the aforementioned diseases.

“A good nutritional program can help you manage and even reverse diabetes,” Tilley points out. “It’s really pretty amazing. We see it all the time.” Other times, success may be more elusive, but she will not give up. One recent client was a woman who suffered from not one but three illnesses — MS, diabetes and IBS. After dealing with a variety of doctors, she came to see Tilley, accompanied by her daughter who was taking care of her. “She had no hope, and I was able to offer that glimmer of hope. Both she and the daughter cried with relief. It was so rewarding to see that glimmer of hope,” says the dietitian.

In addition to individual counseling, the practice offers group classes, including some for children, and works with corporate clients, offering counseling for their employees, who again are often covered by insurance. As a motivational speaker, Tilley also delivers her message to audiences across the country.
So I ask her the same question posed to Dr. LaBarba. What’s the one piece of advice she would like everyone to hear?

“I would say, every time you eat, make sure that you include some protein in your snack or meal. It stabilizes not only your blood sugar but also your energy level and your ability to focus and be productive.”

By Jasmina Wellinghoff
Photography by Jessica Giesey

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