Part 1: Written Project Proposal

Christina Drobisch, Natalie Gavi and Kayla Guillory

Mentor: Kori Hatfield - Kori.hatfield@lifeworksnw.org

________________________________________________________________________

TITLE: From Garden to Table: Increasing Nutritional Knowledge and Health Outcomes in
Adolescents with Psychiatric Disorders

GOALS:
Goal #1: To increase the nutritional knowledge of adolescents (12-18 y/o) with psychiatric
disorders.
Goal #2: To increase health outcomes in adolescents (12-18 y/o) with psychiatric disorders.

OBJECTIVES:
Outcomes for Goal #1: To increase the nutritional knowledge of adolescents (12-18 y/o) with
psychiatric disorders.
1. By the end of the project duration, the majority of participants in the Garden to
Table community outreach program will be able to demonstrate how to prepare a
meal that meets MyPlate.gov guidelines
2. By the end of the project duration, students will increase their post evaluation test
scores by at least a 10%. in comparison to their pre-evaluations.
Outcomes for Goal #1: To increase the nutritional knowledge of adolescents (12-18 y/o) with
psychiatric disorders.
1. Students should be able to identify wholesome/ healthy food options using
MyPlate.gov guidelines when given the option in real life situations.
2. By the end of the project duration, student meals served at LifeWorks will follow
the DASH guidelines and be at least 5% more nutritious than previous menu
items.
3. Students will have increased exposure to the outside environment by utilization
of their garden.

LITERATURE REVIEW:
Barton J, Pretty J. What is the Best Dose of Nature and Green Exercise for Improving
Mental Health? A Multi-Study Analysis. Environ. Sci. Technol. 2010; 44: 39473955.
Internet: http://paperzz.com/doc/1749917/what-is-the-best-dose-of-nature-and-greenexercise---jule. (accessed 8 November 2014).

Meta-analysis methodology
o Included 10 UK studies involving 1252 participants to assess the best regime of
dose(s) of acute exposure to green exercise required to improve self-esteem and
mood (indicators of mental health).
Results
o Overall effect size for improved self-esteem was d=0.46(CI 0.34-0.59,
p<0.00001) and for mood d=0.54 (CI 0.38-0.69 p<0.00001).
Conclusions drawn from study:
o Showed large benefits from short engagement in green exercise.
o Greater change in mood and self-esteem were seen in adolescent aged
participants and those with mental illness.
o High levels of self-esteem are associated with healthy behaviors, such as healthy
eating, participating in physical activities, not smoking, and lower suicide risks

Burton, A. Gardens that take care of us. 2014;13: 447-448. Internet:

http://dx.doi.org/10.1016/ S1474-4422(14)70002-X. (accessed 7 November 2014).

Article from History of Hospital Gardens

o Therapeutic gardens (healing gardens) can have calming, restorative and even
healing effects.
o Healing gardens are designed to provide relief from the psychological distress of
a disease.
o These gardens are designed to help people set and attain measurable
therapeutic goals.
o Simply moving plant material around and doing different gardening activities
helps with recovery of a range of motions, strength, and coordination.
o Horticultural therapists from New York University use gardening and nature
activities on people with brain injuries to reach rehabilitation goals.
o This is done by teaching the process of planting in an atmosphere that offers the
chance of socialization and fun, reducing the feeling of isolation while developing
their language and interpersonal skills.

Clatworthy J, Hinds J, Camic P. Gardening as a mental health intervention. Mental Health

Review Journal 2014; 18:214-225. Internet: http://summit.worldcat.org/title/gardening-asa-mental-health-intervention-a-review/oclc/5169470328&referer=brief_results (accessed 8
November 2014).

Critical Review of relevant research published since Sempik et als (2003).

Ten papers were identified through a search of online electronic databases using
specific text terms, and restricted to after 2003).
o Papers involved gardening and mental health
Results:
o All reported positive effects of gardening as a mental health intervention for service
users, including reduced symptoms of depression and anxiety.
Conclusions drawn from study:
o There is now a substantial body of research demonstrating that garden-based
interventions can benefit people experience mental health difficulties.
o Limited Randomized Control Trails done in this field, however research drawing
on a range of methodological approaches suggests these interventions to be
beneficial.
o Garden interventions best conceptualized as a longer-term therapeutic option.
o The benefits of gardening-based mental health interventions, found in these
papers include:
Significant reduction in depression and anxiety
Significant increase in attentional capacity and self esteem
Reduced stress and improved mood
Improved social skills
Change in attitude towards work
Vocational benefits from new learned skills
Improved sleep and physical health.
o Participants reported that they enjoyed being in the fresh air and doing
meaningful activity, where they felt productive and useful. (Self-Efficacy)

Fagiolini A, Goracci A. The effects of undertreated chronic medical illnesses in patients

with severe mental disorders. J Clin Psychiatry. 2009;70 Suppl 3:22-9. doi: 10.4088/JCP.
7075su1c.04.

Journal of Psychiatry:
o Many with a severe mental illness do not know the components of a health diet, and
tend to have unhealthy habits and lifestyles; both which are contributing factors
towards mental illness.
o Severe mental disorders such as bipolar disorder and schizophrenia often co-occur
with chronic medical illnesses, especially cardiovascular disease and diabetes.
o These comorbidities are associated with worsening mental illness, reducing the
quality of life and premature death.
o The life expectancy for individuals with serious psychiatric disorders is approximately
30% shorter, than the general U.S population
o Implementing behavioral health interventions in the treatment plan of people with
mental illness may help to improve the persons overall health and prevent chronic
medical conditions.
o Fast weight loss can result in cholesterol gallstones, and since many toxins are
stored in fat tissue, a rapid weight loss may release those toxins too quickly.

Gonzalez M, Hartig T, Patil G, et al. A prospective study of group cohesiveness in

therapeutic horticulture for clinical depression. International Journal of Mental Health

Nursing 2011; 20:119129 doi: 10.1111/j.1447-0349.2010.00689.x. (accessed 7 November

2014).

Single group design intervention:

o Study Design: composed of 3-7 participants, repeated with different samples in
successive years (pooled n=46). In each year, five groups went through a 12week therapeutic horticulture intervention. All participants suffer from a range of
different mental illnesses
Results:
o The analysis of the pooled data confirmed significant beneficial change in all
mental health variables during the intervention.
o 38% of participants reported increased social activity after the intervention and
changes from baseline in depression severity persisted at 3-months follow up.
Conclusions drawn from study:
o Therapeutic horticulture is a nature-based intervention that involves social and
behavioral activation, participation in enjoyable activities, and moderate levels of
physical activity in a pleasant surroundings.
o Study also assessed group cohesiveness, which correlated positively with the
average level of the group, however not significantly with all mental health
outcome variables. May increase group cohesiveness.

Hert M, Cohen D, Bobes J, et al. Physical illness in patients with severe mental disorders
part 2. Barriers of care. World Psychiatry 2011:10:138-151. Internet: http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3104888/. (accessed 8 November 2014).

Educational Module; related to population with severe mental disorders.

o Education gathered from Module related to treatment with mental ill
o Background Information on Populations with Mental Illnesses:
o The excess mortality rates in persons with severe mental illnesses are largely
due to modifiable health risk factors.
o Up to 85% of individuals with a severe mental illness will die/ and/or have a
reduced quality of life because of tobacco-related diseases.
Goals of Psychiatric Care:
o The ultimate goal of psychiatric care is to provide optimal services to this
vulnerable population because it represents one of the most important
challenges for psychiatric care today.
Weight and Mental illness:
o Increased weight and excess visceral fat distribution have been reported
common from those suffering with a mental illness. (Reports suggest but data
isnt always consistent).
o Weight loss in people with a severe mental illness has many health related
benefits, including a reduction in risk of DM and CVD, reduction in serum TG
and LDL cholesterol, etc.
o People with schizophrenia are significantly more sedentary than the general
population:
o Nutrition, Diet Education and Mental illness

It is commonly known that patients with schizophrenia have a diet higher in

fat, higher in refined sugar, lower in fiber, and poor in fruits and vegetables.
Therefore nutrition education may be beneficial.
Although educating patients and their families about health food, it is
important to understand that lifestyle changes should be gradual.
We know that nutrition education works, however they typically dont work
because they often are not considered a routine part of psychiatric care.

o
o

Gracious B, Finucane T, Friedman-Campbell M, et al. Vitamin D deficiency and psychotic

features in mentally ill adolescents: A cross-sectional study. BMC Psychiatry 2012,12:38.
doi:10.1186/1471-244X-12-38.

Foods and nutrient deficiency issues common among adolescents with mental
illness:
o Vitamin D low in mentally ill adolescence:
Low levels of vitamin D are associated with depression, seasonal
affective disorder, and schizophrenia in adults, but little is known about
vitamin D and mental health in the pediatric population.
Results of Study:
o Thirty-five (33.7%) adolescents were vitamin D deficient (<20ng/ml), and an
additional 40 (38.4%) were vitamin D insufficient (2030ng/ml). Of those with
vitamin D deficiency, 40% had psychotic features compared to only 16% of the
sample who were not vitamin D deficient (p<0.007). Those with D deficiency
were 3 times more likely to have psychotic features (OR 3.52, CI 1.38-8.95,
1df). Of those with normal vitamin D status, 79% (N=23/29) did not have
psychotic features.
Conclusions drawn from study:
o Low Vitamin D intake is associated with increased heart disease risk. Dairy is a
key DASH diet foods, and an important source of vitamin D.

SIGNIFICANCE:
The goal of this intervention is to address the components of nutrition, diet and
gardening (horticulture) in our specific behavioral health adolescent population. The
implementation of behavioral health interventions in people with mental illness may help to
improve the persons overall health and prevent chronic medical conditions (1). The Journey of
Psychiatry explains that many with a severe mental illness do not know the components of a
healthy diet, and tend to have unhealthy habits and lifestyles; both which are contributing factors
towards mental illness.
Our first goal is to increase the nutritional knowledge within our population. We will
achieve this through making specific changes to Lifeworks current menu, and implementing
nutrition education directed to the students. Our menu will model the DASH diet, because these
are guidelines that not only promote intakes of fruit and vegetables, but are also low in fat and
refined sugar (2). The DASH diet will also address certain Vitamin deficiencies commonly seen
in our population (3).

Our second goal is to increase health outcomes within our population. Health outcomes
have been identified as being measured by certain factors as, self-esteem, mood, depression,
anxiety and quality of life (4). A meta-analysis methodology, included 1252 participants suffering
from a mental illness, found that a small exposure to green environment improved self-esteem
and mood profoundly (self-esteem was d=0.46(CI 0.34-0.59, p<0.00001) and for mood d=0.54
(CI 0.38-0.69 p<0.00001) (5). In the last 5 years there has been a substantial body of research
demonstrating that garden-based interventions can benefit people experience mental health
difficulties (4)(6). After researching the components of successful interventions that have been
conducted our community outreach project, we hope to implement gradual and individualized
nutrition education, and expose our population to environmental horticulture therapy through
gardening exercises and hands on plant-based learning.

METHODS & DESIGN:

Target Audience: Adolescents with psychiatric disorders aged 12-18 y/o at LifeWorks
Northwest Adolescent Day Treatment Program in Tigard, Oregon. There are approximately 30
students at LifeWorks Day Treatment Facility Program. Students have a variety of psychiatric
disorders such as: Schizophrenia, Bi-Polar Disorder, Manic Depression, Drug/Alcohol
dependency, etc. This target population requires special learning environments in order to be
successful in their behavioral health interventions. Our programs approach will use learning
techniques that have been shown to have successful learning outcomes within this special
population.
Implementation Details:
6 week Cyclic Menu: We will determine cost per meal. Costing will be based off of LifeWorks
monthly budget ($217.00) and the number of meals to be prepared each day. Meals served at
LifeWorks are for students who qualify for free or reduced breakfast/lunches. Approximately
6-10 students receive free or reduced meals. The 6 week cyclic menu will be created based on
MyPlate.gov and DASH guidelines. This menu will consist of breakfast, snack and lunch for 5
consecutive weekdays (M-F). Excluding Holidays. To determine if menu items fit within the
budget, price of ingredients will be based off of Fred Meyer and/or Costco prices. Most
importantly, vegetables from their garden will be incorporated into the menu. After the cyclic
menu is completed, a nutrient analysis will be performed.

CHART 1: COST PER MEAL BREAKDOWN

*Meals are for students who qualify for free or reduced meals
(10 students)(24 days) = 240 | $217 / 240 meals =$ 0.90 per student per day
Meal

Cost Breakdown (per meal)

Breakfast

$0.70

Lunch

$0.70

Snack

$0.20

MyPlate.gov Lesson Plan: One lesson plan will be implemented during our programs
duration. This lesson plan will be designed around myplate.gov guidelines and the importance
of balanced meals. The lesson plan will be interactive and hands-on, which are highly
recommended teaching techniques for this population.
CHART 2: LESSON PLAN (TENTATIVE)
Date: TBD
Time: 8:45 - 9:55 am
Approx: 8-10 students
PREP
Arrive at least 30 minutes early to set up and get settled in. The following materials are required for lesson plan:

Flip charts
Markers
Pre/Post tests
Food cutouts
MyPlate.gov handouts
INTRODUCTION (5 minutes)

Introduce ourselves by informing the students who we are and why we are here. We will start things off with an ice breaker
by asking them what their favorite healthy food is.
PRE-TEST (7 minutes)
Students will take a pre-test before the lesson plan begins. Pre-test will consist of 5 multiple choice questions. Time of the
test should take no longer than 7 minutes.
CAROUSEL ACTIVITY (15 minutes)
This lesson plan will be interactive and hands-on. Prior to the start of class, we will come into the classroom to set up 4
flip charts around the room. We will label each flip chart in the following manner:
Team #1: Fruits and Vegetables.
Team #2: Proteins.
Team #3: Grains.
Team #4 Dairy and Fats.
After all students have completed the pre-test, we will have them count off to 4. We will then instruct them to head to
the flip chart according to their numbers. The classroom will consist of 8-10 students, coming out to four groups of 2-3.
We will give them time to discuss amongst themselves once theyre in their designated groups. We will have the
following questions on each flip chart for them to discuss:
Give examples of foods found in this group.
Which ones are your favorites?
Which ones are you LEAST favorite?
Health benefits of this group.
While each group is filling out the chart, we will walk around and meet with each group to ensure students understand
and stay on track.
PRESENTATIONS (20 minutes)
We will ask each group to present to the rest of class about their assigned food group. This is the time where students from
other groups can also provide feedback or add additional information. Presentations are short and simple, no longer than 5
minutes each group.
BALANCED MEAL & CLOSING (15 minutes)
Using the food models, we will ask the students to return to their desks, where they will have a number of food cutouts.
We will ask students to work together to construct a meal that fits MyPlate.gov guidelines. We will then ask if anyone
would like to present their meal and explain why they chose each item they did.
POST TEST (7 minutes)
We will conclude the lesson with a post-test. The post test will be identical to the pre-test in order to analyze whether our
lesson met our program objectives.

Cooking Demonstration: [write info here]

CHART 3: COOKING DEMO (TENTATIVE)

Date: TBD
Time: 12:00PM - 1:10PM
Approx: 8-10 students
PREP
Arrive at least 30 minutes early to set up and get settled in. The following materials are required for cooking
demonstration:
Cooking ingredients
Kitchen & cooking utensils
Pre/post tests
Basket & name paper slips
INTRODUCTION (10 minutes)
We will start by reviewing the previous lesson and ask students to tell us what food components make up myplate.gov.
In order to fairly choose student helpers to help serve lunch after it is cooked, we will have the students write their
names on slips of paper and collect them in a basket.
PREPARTATION (30 minutes)
As we prepare the ingredients, we will use this time to continue our discussion. We want this time to be interactive.
Students are encouraged to ask questions and share their experiences.
COOKING (20 minutes)
As we begin cooking, we will incorporate the previous classroom lesson by asking students to identify each food
were preparing and tell us what part of myplate.gov it belongs to. We will also discuss different health benefits and
engage in an interactive conversation about their garden and how their new menu utilizes the produce they grow.
SERVING (10 minutes)
We will draw the a few names out of the basket to determine which students will be our student helpers. Once
lunch is ready to be served, we will ask everyone to take their seats at the table and have the student helpers dish
and serve the food to the students and teachers.
LUNCH
Our cooking demonstration will end with the students eating lunch

CHART 4: PROJECT TIMELINE

Implementation Date/Time

Agenda

October

Program proposal approval by Project Mentor

Determine lesson plan time slots by consulting with GPHN,
Project Mentor and Lifeworks Teachers

November

Calculate costing for 6 week cyclic menu

Start planning 6 week cyclic menu
Start planning lesson plan

Date: TBD
Time: 8:45am 9:55am

Implement nutrition lesson plan

Date: TBD
Time: 12:00pm

Perform nutritional analysis on completed 6 week cyclic

menu
Perform nutritional analysis on Lifeworks current menu
Compare nutritional analysis and make adjustments to fit
projects objectives if needed

Date: TBD
Time: 12:00pm 1:10pm

Implement cooking demonstration

Date: TBD
Time: TBD

Meet with Project Mentor to go over completed

EVALUATIONS:
Pre and post evaluations will be given to students before and after each lesson and food
demonstration. Evaluations will be used to assess whether objectives were met. Questions on
the Pre/Post evaluation are designed to specifically assess whether the objectives of this
program were met. Nutrient analyses of the 6 week cyclic menu and LifeWorks current menu
will be performed. Nutrient content of our cyclic menu versus LifeWorks current menu will be
compared to determine if objectives were met.

FACILITIES AND PERSONNEL REQUIRED:

Project Coordinators: Christina Drobisch, Natalie Gavi and Kayla Guillory are responsible for
planning, implementing and coordinating the Garden to Table project. They are expected to
communicate with the Project Mentor efficiently and effectively to ensure desired outcomes are
being met.
Project Mentor: Kori Hatfield is our programs mentor. She responsible for facilitating with
teachers to coordinate time slots for our lesson plan and food demonstration that best fits their
class schedules. Kori will also contact Wholefoods to get food items donated for the food
demonstration. Throughout the planning and implementation process, we will work with Kori to
ensure that the program is implemented properly and efficiently.

LifeWorks Teachers: LifeWorks teachers must be present and interactive during our lesson
plan and cooking demonstration, in order to successfully use the educational material we
provide for future students.
LifeWorks Garden: The garden will be used as a teaching tool, to address the components of
nutrition, diet and gardening (horticulture) in our specific behavioral health adolescent
population.
Classroom: A classroom or designated learning area will be required for our lesson plan.
Kitchen and Dining Area: The kitchen at LifeWorks will be used to prepare and cook food
items for our cooking demonstration. Cooking utensils and equipment are provided within the
kitchen. Children will eat their lunches in the dining area.

BUDGET:

Cyclic Menu
Monthly budget for Lifeworks meals: $217
Lesson Plans
Flip charts (4)
Printed pre & post tests
Printed handouts
Food Demonstration
Food items will be donated by Whole Foods.
Total: $

REFERENCES:
Fagiolini A, Goracci A. The effects of undertreated chronic medical illnesses in patients with
severe mental disorders. J Clin Psychiatry. 2009;70 Suppl 3:22-9. doi: 10.4088/JCP.7075su1c.
04.
Hert M, Cohen D, Bobes J, et al. Physical illness in patients with severe mental disorders part 2.
Barriers of care. World Psychiatry 2011:10:138-151. Internet: http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3104888/. (accessed 8 November 2014).
Gracious B, Finucane T, Friedman-Campbell M, et al. Vitamin D deficiency and psychotic
features in mentally ill adolescentrs: A cross-sectional study. BMC Psychiatry 2012,12:38. doi:
10.1186/1471-244X-12-38.
Clatworthy J, Hinds J, Camic P. Gardening as a mental health intervention. Mental Health
Review Journal 2014; 18:214-225. Internet: http://summit.worldcat.org/title/gardening-as-amental-health-intervention-a-review/oclc/5169470328&referer=brief_results (accessed 8
November 2014).
Barton J, Pretty J. What is the Best Dose of Nature and Green Exercise for Improving Mental
Health? A Multi-Study Analysis. Environ. Sci. Technol. 2010; 44: 39473955. Internet: http://
paperzz.com/doc/1749917/what-is-the-best-dose-of-nature-and-green-exercise---jule.
(accessed 8 November 2014).
Burton, A. Gardens that take care of us. 2014;13: 447-448. Internet:
http://dx.doi.org/10.1016/ S1474-4422(14)70002-X. (accessed 7 November 2014).
Gonzalez M, Hartig T, Patil G, et al. A prospective study of group cohesiveness in therapeutic
horticulture for clinical depression. International Journal of Mental Health Nursing 2011; 20:119
129 doi: 10.1111/j.1447-0349.2010.00689.x. (accessed 7 November 2014).