Final Grant Proposal

I've completed my grant proposal! While my project isn't entirely set in stone, this is a big step forward towards collecting and analyzing data! The complete grant proposal is below:

How Differences in Food Choice Decision Making Affect Diet and Health Outcomes in Neighborhoods with Different Socioeconomic Statuses

Project Summary/Abstract A combination of social factors, increasingly known as the Social Determinants of Health (SDOH), are thought to be responsible for 80 to 90 percent of a person’s health status.(13) With food and nutrition being one of the six main determinants of health, understanding the process by which food choices are made is essential in order to address health outcomes closely associated with diet. Published data already show that, whereas the rates of obesity and Type 2 Diabetes are 20-25% amongst residents of Princeton, they are 45-50% amongst the residents of Trenton. The actual diets consumed by the residents of these two communities, and the different food choice processes that result in those diets are not as well understood. This project is intended to ll that gap. It is hypothesized that the different rates of obesity and Type 2 Diabetes seen in the two communities result from different food choice processes, which then lead to different diets. A survey, which collects information on the food choice decision making process, will be distributed to approximately 150 residents in Trenton and an equal number in Princeton. Purchasing data will be collected from grocery stores in order to understand the differences between the diets consumed in both communities. The nutritional content of the diets will be analyzed utilizing an online USDA nutrient database.

Introduction One of the most common misconceptions is that any given person’s health status is mainly influenced by their genetic makeup; 91 percent of Americans believe that their genetic information has a large effect on managing their health.(3) It is commonly assumed that some people are genetically gifted, and others are genetically not. In fact, genetics only account for 10 to 15 percent of someone’s health status.(13) Additionally, many people agree that the second most significant determinant of someone’s health status is the quality of their health care. While health care does play a more minuscule role in health outcomes, these two misconceptions are not only incorrect, but also extremely dangerous. Although Princeton, New Jersey and Trenton, New Jersey are only twelve miles apart, the life expectancy gap between these two N.J. cities is fourteen years, with the average life expectancy being 87 years in Princeton, and 73 years in Trenton.(1) Whereas it is commonly thought that health outcomes are mainly influenced by genetics and the degree of access to a high quality health care system, in fact, there are a number of social factors that are more important to determining health outcomes. (2) These factors are increasingly referred to as the Social Determinants of Health. The Social Determinants of Health include economic stability, neighborhood and physical environment, education, food and nutrition, community and social context, and accessibility to a high quality health care system, and are estimated to account for 80 to 90 percent of people’s health status.(13,14) The World Health Organization stated that “a combination of faulty social policies, economic arrangements, and politics are accountable for the inequities in daily life which engender avoidable inequities in health.” These six determinants are responsible for health inequities and the unjust, avoidable differences in health status seen within nations, states, and even counties. Arguably, health care has greatly impacted health outcomes when it comes to increasing life expectancy, however, MD Donald Berwick shares that the benefits of being on a cholesterol-lowering statin for twenty years are completely negated by living 43 feet further uptown in the journey from Midtown Manhattan to the Bronx (in life expectancy). Other than life expectancies rates, Princeton and Trenton have significantly different rates of obesity and Type 2 Diabetes . In Princeton, 22% of men are obese, and 25% of men have type two diabetes. On the other hand, in Trenton, 48% of men are obese and 44% of men have type two diabetes. These disparities are assumed to be related to dietary patterns, however, the topic has not been thoroughly investigated or corroborated yet. This research will carefully investigate (1) what differences in food choice processes exist, and (2) how those differences affect diet in neighborhoods with different socioeconomic statuses, resulting in the current disparities in rates of obesity, and rates of Type 2 Diabetes. The food choice process relates to how people select the food they eat. It comprises psychological and sociological aspects, economic issues and sensory aspects.(4) It is hypothesized that the different rates of obesity and Type 2 Diabetes seen in the two communities result from different food choice processes, which then lead to different diets.

Figure 1 This figure depicts the overall layout of my research project.

The specific aims for this research project are: 1. To identify the differences in the food choice processes of residents in Princeton, New Jersey versus Trenton, New Jersey. This will be done through conducting a combination of interviews and surveys with representative samples of residents in both communities. The surveys will consist of questions regarding the respondents’ food choice process, and interviews will be conducted, as necessary, to gain a better sense of the food choice process of Princetonians and Trentonians. 2. To determine whether differences in the food choice processes correlate with differences in diet in both communities. In addition to the survey data collected in aim 1, I will collect purchasing data from the managers of popular grocery stores in either neighborhood. Purchasing data will be used to determine the average diet in both communities. I will compare and contrast the food choice processes and diets in both communities to accomplish this second aim. 3. To determine whether any differences in diet are associated with different health outcomes in the two communities. I will conduct nutritional analyses of the diets using the USDA Food Data Central Tool and see if they potentially explain differences in health outcomes for the two communities. I will mainly be looking at the average fat and sugar consumption rates, as foods high in fat and sugar lead to obesity and diabetes, however I am not restricting my search to only levels of fat and sugar.

Significance and Innovation Obesity and diabetes are very serious public health problems in the United States of America. According to the CDC, 42.2% of American citizens were obese in the year of 2017. (18) This number equates to over 138 million Americans with obesity. The CDC also reports over 30 million citizens with Type 2 Diabetes in 2018 alone. (19) Other than the health related downsides of obesity and diabetes, the United States government spends a total of 517 billion US dollars per year, treating the two chronic diseases. (21)(22) The main causes linked towards both obesity and Diabetes are related to diets and exercising. It is extremely evident that there needs to be a dietary intervention, however in order to make a dietary intervention, the types of diets themselves have to be known, and the process by which people make their food choices also must be known. Interventions would save lives, and

money. This research would ll major gaps in the eld as the diets in different areas and food choice processes remain unknown. With new information surrounding why people purchase the foods that they purchase, communities can reconstruct more efficiently and effectively. As food is one of the determinants of health, anything that helps scientists understand this determinant more thoroughly will help the public good.

Approach and Data Analysis Abridged Procedure: 1. Develop a detailed survey which examines all factors that play into the food choice process. (The survey will inquire about factors such as hunger, appetite, taste, cost, income, availability, access, education, cooking skills, cooking amenities, culture, meal patterns, and family (16)) (Finalize survey by July, 2020)

Figure 2: Sample survey questions This figure shows some examples of questions that I may use on my survey.

1. Connect with multiple organizations (churches such as Princeton United Methodist Church; Nassau Christian Center; Union Baptists Church; community centers such as the YMCA; and the YWCA) in both communities to distribute my survey to a wide range of residents. (Start finding connections in the month of July, 2020) 2. Collect purchasing data (over a month) from prominent grocery stores in both Trenton and Princeton. (I plan on contacting Aldi’s, McCareys, Stop and Shop and Whole Food Princeton. If store managers are unwilling to share purchasing data with me, I will utilize food diaries to estimate the diets consumed by residents of both communities.)(Unsure due to Covid-19) (If I digitize my survey, It will be sent out and completed in the months of July and August 2020) 3. Perform a nutritional analysis using the USDA FoodData Central database to observe any significant differences in nutritional content between the two diets. (I plan on calculating the average consumption of dietary carbohydrates, dietary proteins, dietary fats, simple sugars, dietary cholesterol, calcium and total calories per capita in both Princeton and Trenton) (If digitized, September-October 2020) 4. I will be calculating means, standard deviations, and variance for variables such as the # of grams per capita of dietary carbohydrates, dietary proteins, dietary fats, simple sugars, dietary cholesterol, calcium and total calories consumed in both communities daily. (If digitized, September-October 2020) 5. To analyze the influence of dietary variables on obesity and Type 2 Diabetes health outcomes, ANOVA tests will be performed. (19)(February 2021-)

I plan COMPLETE status epidemiology data and food purchasing data in both Trenton and Princeton. Survey data will be inserted on an excel file, and I will analyze this data using a comparative analysis method. Survey data will be put through statistical significance tests to statistically prove different food choice processes. I will analyze purchasing data through the USDA FoodData Central database, which allows me to insert types of foods, and get access to nutritional information about these foods. Based on the results acquired from these nutritional analyses, I will use scientific inquiry/ reasoning to link the differing diets in the two communities to the differing health outcomes in the two communities. on collecting data on the food choice process in neighborhoods with different socioeconomic through surveys and interviews . Additionally, I plan on sourcing published disease

Budget

1) Survey Materials

• - 1000 sheets (2 reams) of 8.5x11” copy paper (Staples- $12)

• - 2 sets of Canon printer ink cartridges (Staples- $144)

• - 60 (2 packs) Bic pens (Staples- $10)

• - 30 Clipboards (Staples- $58.40)

2) Research Subject Participant Lottery

3) $50 monetary gift cards for a research lottery ($150)

Organizations

- Robert Johnson Wood Foundation (no fee)

- Henry J. Austen Health Center

- Society for Epidemiological Research (deadlines have not been disclosed)

Presentation Opportunities

- Junior Science and Humanities Symposium (2021 date has not been disclosed. It will most likely be around mid April) - New Jersey Shore JSHS

- New Jersey at Rutgers University JSHS

- North Jersey Regional Science Fair (Dates not disclosed. The exhibit will most likely be around mid March)

Summary According to the CDC, over 30 million US Citizens have Type 2 Diabetes, and over 130 million are obese.(20)(18) More than 327 billion dollars, and 190 billion, respectively, are spent annually on these diseases.(21)(22) Firstly, researchers do not yet fully understand what differences in diets lead to the differences in obesity and Type 2 Diabetes that are seen in Princeton and Trenton. Secondly, researchers have not identified the differences in the process by which food choices are made for residents in the two communities. Understanding these differences will be critical in the effort to address disparities in the prevalence of obesity and Type 2 Diabetes.

Bibliography

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2. https://www.healthcarevaluehub.org/cost-and-quality-problems/browse-cost-driverquality-iss ue/social-determinants-health/#notes

3. “91 Percent of Americans Know Genetic Information Can Inuence Their Health.” 23andMe Media Center, 23 Apr. 2014, mediacenter.23andme.com/press-releases/dna_day_2014/.

4. “Food Choice: List of High Impact Articles: PPts: Journals: Videos.” IMedPub LTD, www.imedpub.com/scholarly/food-choice-journals-articles-ppts-list.php

5. Contento, Isobel R., et al. “Understanding the Food Choice Process of Adolescents in the Context of Family and Friends.” Journal of Adolescent Health, Elsevier, 22 Apr. 2006, www.sciencedirect.com/science/article/abs/pii/S1054139X05002934.

6. Köster, E.P. “Diversity in the Determinants of Food Choice: A Psychological Perspective.” Food Quality and Preference, Elsevier, 19 Nov. 2007, www.sciencedirect.com/science/article/abs/pii/S0950329307001589.

7. Sobal, et al. “Constructing Food Choice Decisions.” OUP Academic, Oxford University Press, 29 Sept. 2009, academic.oup.com/abm/article-abstract/38/suppl_1/s37/4569654?redirectedFrom=fulltext.

8. “Obesity and the Food Environment.” Social & Spatial Epidemiology Unit, 11 Aug. 2015, blogs.cuit.columbia.edu/socialepicluster/obesity-and-the-food-environment/.

9. “Adult Obesity Facts.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 27 Feb. 2020, www.cdc.gov/obesity/data/adult.html.

10. “Obesity and the Food Environment.” Social & Spatial Epidemiology Unit, 11 Aug. 2015, blogs.cuit.columbia.edu/socialepicluster/obesity-and-the-food-environment/.

11. https://health.montgomery.nj.us/wp-content/uploads/2018/10/GMPHP-CHA-DRAFT_0 92118.pdf

12. Braveman, P. and Gottlieb, L., 2014. The social determinants of health: it's time to consider the causes of the causes. Public health reports, 129(1_suppl2), pp.19-31.

13. “Racial and Ethnic Health Disparities.” National Conference of State Legislatures, 2013, www.ncsl.org/portals/1/documents/health/HealthDisparities1213.pdf.

14. Hayes, Tara O'Neill, et al. “Understanding the Social Determinants of Health.” AAF, 4 Sept. 2018, www.americanactionforum.org/research/understanding-the-social-determinants-of-health/.

15. Muchmore, Shannon. “Hospitals Spent $2.5B on Social Determinant Programs from 2017 to 2019.” Healthcare Dive, 4 Feb. 2020, www.healthcaredive.com/news/hospitals-spent-25b-on-social-determinant-programs-from-20 17-to-2019/571646/.

16. “The Factors That Inuence Our Food Choices.” The Factors That Influence Our Food Choices: (EUFIC), 6 June 2006, www.euc.org/en/healthy-living/article/the-determinants-of-food-choice.

17. Balentine, Jerry R. “Obesity Denition, Charts, BMI, Causes, Treatment.” MedicineNet, MedicineNet, 2 Dec. 2019, www.medicinenet.com/obesity_weight_loss/article.htm.

18. “Adult Obesity Facts.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 27 Feb. 2020, www.cdc.gov/obesity/data/adult.html.

19. Schuler, Gerhard. “Regular Physical Exercise and Low-Fat Diet Eects on Progression of Coronary Artery Disease” Circulation, 1992;86:1-11, https://www.ahajournals.org/doi/pdf/10.1161/01.CIR.86.1.1

20. “Type 2 Diabetes.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 30 May 2019, www.cdc.gov/diabetes/basics/type2.html.

21. Lindberg, Sara. “The Cost of Type 2 Diabetes.” Healthline, Healthline Media, 17 May 2019, www.healthline.com/health/cost-of-diabetes.

22. “National League of Cities Institute for Youth, Education & Families.” Healthy Communities for a Healthy Future Economic Costs of Obesity Comments, www.healthycommunitieshealthyfuture.org/learn-the-facts/economic-costs-of-obesity/.