1

Healthy Eating in Practice

2018 Conference

Translating the Mediterranean Diet in

the South

Thomas C. Keyserling, MD, MPHProfessor of Medicine

Alice S. Ammerman, DrPHKaufman Distinguished Professor of Nutrition

UNC-Chapel Hill

August 26-29, 2018Asheville, NC

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Disclosures

Financial: none

Guidelines:

»Most recommendations consistent with

current guidelines

»Some are different, but consistent with

literature

Presenter Disclosure Information

Good Bowls LLCHealthy affordable frozen meals

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Outline

What is a Mediterranean (Med) diet?

How effective is a Med Diet at improving health outcomes

» PREDIMED diet and cardiovascular (CVD) outcomes

» Med diet and other common health outcomes

The adapted Med diet (Med-South)

Experience with Med-South in Hearth Health Lenoir Project

Review of selected Med-South materials

Good Bowls

Questions/Comments

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What is a Med Diet?

Many different definitions, but this is the one use by Appel and Van

Horn* in their New England Journal of Medicine editorial published

on the PREDIMED RCT outcomes:

“Mediterranean diets are not a single dietary pattern, but they do

have common features -- an emphasis on vegetables, fruits,

beans, nuts, seeds, breads, unrefined grains, and olive oil (but not

necessarily extra-virgin olive oil); inclusion of fish and wine; and

minimal intake of meats and full-fat dairy products. Such diets are

rich in total, monounsaturated, and polyunsaturated fat and are

lower in saturated fat.”» *Appel LJ, Van Horn L. Did the PREDIMED trial test a Mediterranean diet? N Engl J Med. Apr 4

2013;368(14):1353-1354

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More on Definition of Med Diet

Quotation from Hu et al* entitled, “The Mediterranean Diet and Mortality –Olive

Oil and Beyond.”

» “Thus, a Mediterranean-type diet, when translated into other cultures, can

use food options beyond olive oil for increasing the intake of

monounsaturated fats and polyunsaturated fats at the expense of saturated

and trans fats and refined carbohydrates. It is worth noting that traditional

diets from the Mediterranean and Asian countries share most dietary

characteristics, such as a relatively high intake of fruits, vegetables, nuts,

legumes, and minimally processed grains, despite the use of different

sources of plant oils.”

*Hu FB. The Mediterranean diet and mortality--olive oil and beyond. N Engl J Med. Jun 26

2003;348(26):2595-2596.

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Dietary Recommendations

“Expert Panels”

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10

How Effective is a Med Style

Diet at Reducing

Cardiovascular Disease (CVD)

Events?

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Primary Prevention of Cardiovascular

Disease with a Mediterranean Diet

NEJM, Estruch R et al., 2/25/13, NEJM.org.

Parallel group multi-center randomized

controlled trial

Participants

»Men: 55 to 80 years of age

»Women: 60 to 80 years of age

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Primary Prevention of Cardiovascular

Disease with a Mediterranean Diet

Inclusion Criteria

» No CVD

» But at high risk for CVD

–Type 2 diabetes OR

–At least 3 of the following major risk factors

Smoking, hypertension, elevated LDL, low

HDL, overweight or obese, family history of

CHD

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Randomization and Interventions

Beginning on Oct 1, 2003, participants

randomized in 1:1:1 ratio to

»Med diet plus extra virgin olive oil

»Med diet plus nuts

»Control diet (lower fat diet)

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Med Diet

Recommendations

Food Goal

Olive Oil (extra virgin olive oil) (1 tbsp = 14 gms) ≥ 4 tbsp/day

Tree nuts and peanuts (30g, 15g walnuts, 7.5g almonds,

7.5g hazelnuts)

≥ 3 servings/wk

Fresh fruits ≥ 3 servings/day

Vegetables ≥ 2 servings/day

Fish (especially fatty fish), seafood ≥ 3 servings/wk

Legumes ≥ 3 servings/wk

Sofrito (sauce made w/ tomatoes & onions, often including

garlic and herbs simmered slowly with olive oil)

≥ 2 servings/wk

White meat Instead of red meat

Wine with meals (optional, only for habitual drinkers) ≥ 7 glasses/wk

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Med Diet

Discouraged

Food Goal

Soda Drinks < 1 drink/day

Commercial bakery goods, sweats, and pastries < 3 servings/wk

Spread Fats < 1 servings/day

Red and processed meats < 1 servings/day

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Low-Fat Diet

Recommended

Food Goal

Low-fat dairy products ≥ 3 servings/day

Bread, potatoes, pasta, rice ≥ 3 servings/day

Fresh fruits ≥ 3 servings/day

Vegetables ≥ 2 servings/wk

Lean Fish and seafood ≥ 3 servings/wk

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Low-Fat Diet

Discouraged

Food Goal

Vegetable oils (including olive oil) ≤ 2 tbsp/day

Commercial bakery goods, sweats, and pastries ≤ 1 serving/wk

Nuts and fried snacks ≤ 1 serving/wk

Red and processed fatty meats ≤ 1 serving/wk

Visible fats in meats and soups Always remove

Fatty fish, seafood canned in oil ≤ 1 serving/wk

Spread fats ≤ 1 serving/wk

Sofrito (sauce made w/ tomatoes & onions, often

including garlic and herbs simmered slowly with

olive oil)

≤ 2 serving/wk

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Diet Intervention--Format

Dietitians ran individual and group sessions

at baseline and quarterly thereafter

14 item dietary screener was used to assess

adherence to the Med Diet

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Study Outcomes

Primary was composite of:

»Myocardial infarction

»Stroke

»Death from CVD

Secondary

»Above and death from any cause

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Results

Participants

Enrollment: 10/2003 to 6/2009

Screened: 8713

Randomized: 7447

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Baseline Characteristics

Characteristic Med Olive Oil

N = 2543

Med Nuts

N = 2454

Control

N = 2450

Female, % 59% 54% 60%

Age, years 67 67 67

White, from Europe, % 97% 97% 97%

Current smoker, % 14% 14% 14%

BMI, kg/m2 30 30 30

Hypertension, % 82% 82% 84%

Type 2 diabetes, % 50% 47% 48%

Dyslipidemia, % 72% 73% 72%

Family history premature CHD, % 23% 22% 23%

Statins, % 41% 39% 40%

Score for adherence to Med diet 8.7 8.7 8.4

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Follow-up

Median 4.8 years

As of 12/2010:

»523 (7%) lost to follow-up

»Drop out higher in control (11%) then in

Med groups (5%)

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Compliance with Diet

Similar diets at baseline per 14 item

screener

During follow-up, significant differences for:

»12 of 14 items

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Diet Compliance—Cont.

Fish increased 0.3 servings per wk

Legumes increased 0.4 servings per wk

Med diet olive oil

» Olive oil 50 g/day and 0.9 servings nuts per wk

Med diet nuts

» Olive oil 32 g/day and 6 servings of nuts per wk

Control diet

» Olive oil 25 g/day and 0.7 servings per wk (from appendix)

Main nutrient change was in fat content of diet, though all diets

higher fat: Med 41%/42%, control 37%

No adverse effects of diet

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Outcomes

End Point Med Olive Oil

N = 2543

Med Nuts

N = 2454

Control

N = 2450

P

Olive

P

Nuts

Person-yr follow-up 11,852 10,365 9763

Primary End point

Primary--Events 96 83 109

--Rate/1000 person-yr 8.1 8.0 11.2 .009 .02

Secondary end points

Stroke 49 32 58

-- Rate/1000 person-yr 4.1 3.1 5.9 .03 .003

Myocardial infarction 37 31 38

--Rate/1000 person-yr 3.1 3.0 3.9 .31 .25

Death from CVD 26 31 30

--Rate/1000 person-yr 2.2 3.0 3.1 .15 .85

Death from any cause 118 116 114

--Rate/1000 person-yr 10.0 11.2 11.7 .11 .68

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Adjusted Hazard Ratios

Compared to Control Diet

End Point Med

Olive Oil

Med

Nuts

Med

Both

P

Olive

P

Nuts

P

Both

Primary end point .70 .72 .71 .01 .03 .005

Secondary end

points

Stroke .67 .54 .61 .04 .006 .005

Myocardial

infarction

.80 .74 .77 .34 .22 .20

Death form CVD .69 1.01 .83 .17 .98 .41

Death from any

cause

.82 .97 .89 .15 .82 .32

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Primary Endpoint

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Discussion--Authors

Energy unrestricted Med Diet associated

with a 30% decrease in risk for CVD events

in high risk population (roughly equivalent to

effect of statins)

Consistent with prior observational studies

about diet and heart disease

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Discussion--Authors

Major between group difference involved the

supplements.

Extra virgin olive and nuts were probably responsible for

most of the benefit

Differences (relatively small) were observed for fish and

legumes, but not for other foods

For most participants, baseline diet was similar to the

Med Diets studied, suggesting a potentially greater

benefit for Med Diet compared to Western diets (i. e.,

greater benefit in NC and US)

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Additional Discussion Points

Effect might be greater with longer duration

Diet intervention developed in early 2000’s.

Refinement might be associated with better

outcomes.

»More whole grains

»Healthful full fat spreads (mayonnaise)

and dressings (salad dressings)

»Tub margarine with healthful fats

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What About Dietary Pattern and

Other Common Diseases?

Diet Quality as Assessed by the Healthy

Eating Index, Alternate Healthy Eating

Index, Dietary Approaches to Stop

Hypertension Score, and Health Outcomes:

An Updated Systematic Review and Meta-

Analysis of Cohort Studies

J Acad Nutr Diet. 2018;118:74-100.

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Main Findings

Diets that score highly on the HEI, AHEI, and

DASH were associated with a significant reduction

in the risk of all-cause mortality, cardiovascular

disease, cancer, type 2 diabetes, and

neurodegenerative disease by 22%,22%, 16%,

18%, and 15%, respectively.

Moreover, high-quality diets were inversely

associated with overall mortality and cancer

mortality among cancer survivors.

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Adapting the PREDIMED Diet for

the Southeastern US

The next slide illustrates how 9 of the 13

major PREDIMED recommendations are

virtually identical to the diet we tested in the

Health Healthy Lenoir Project

The slides after that offer rationale for

adaptations

PREDMED Dietary Recommendations Goal Included

in Med-South*Recommended Goal

Olive Oil Arm: extra virgin olive oil ≥ 4 tbsp/day modified

Nut Arm: tree nuts and peanuts (30g, 15g

walnuts, 7.5g almonds, 7.5g hazelnuts)

Daily consumption yes

Fresh fruits ≥ 3 servings/day yes

Vegetables ≥ 2 servings/day yes

Fish (especially fatty fish), seafood ≥ 3 servings/wk modified

Legumes ≥ 3 servings/wk yes

Sofrito (sauce w/ tomatoes & onions, including

garlic & herbs simmered with olive oil)

≥ 2 servings/wk modified

White meat Instead of red yes

Wine with meals (optional, only for habitual

drinkers)

≥ 7 glasses/wk yes

Discouraged

Soda Drinks < 1 drink/day yes

Commercial bakery goods, sweats, and pastries < 3 servings/wk yes

Spread Fats < 1 servings/day modified

Red and processed meats < 1 servings/day yes

*Yes indicates identical (or almost) to PREDIMED

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Modifications

Olive Oil

Given the benefits of extra virgin olive oil as

demonstrated in PREDIMED, we encourage

generous consumption of extra virgin olive

oil for those who like the taste and can afford

it

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Modifications

Olive Oil

As an alternative, the intervention recommends frequent

consumption of low cost and familiar oils such as soybean, peanut,

and canola oil. Our rationale:

» unlike Spain, large amounts of olive oil are not commonly found

in the southern diet

» high consumption of extra virgin olive oil may not be feasible for

low income participants (at a local grocery store, extra virgin

olive oil cost $9 per quart compared to $1.99 for canola and

$1.72 for soybean oil)

» there is compelling scientific evidence that vegetable oils with

high PUFA content (like soybean, canola, and most other oils)

are also associated with decreased CVD risk, including a meta-

analysis of RCTs and observational cohort data

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Modifications

Fish

Rationale for recommending fish once or

more per week vs. 3 or more as in

PREDIMED is

»economical, as fish can be expensive

»scientific, as most of the benefit from fish

consumption is realized with 1 serving per

week

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Modifications

Spread Fats

PREDIMED limited spread fats to < 1

serving per week, but now that non trans fat

tub margarines are available with high

quality fat content (e.g. Smart Balance™

and others), we recommend modest portions

of high quality spreads

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Modifications

Sofrito sauce

As Sofrito sauce is not commonly consumed

in the US, we are not recommending this,

but instead, familiar foods made with

tomatoes, onions, and garlic

Center for Population Health and Health Disparities:

The Heart Healthy Lenoir Project

Research TeamUniversity of North Carolina at Chapel Hill

East Carolina University

Lenoir County Alliance for a Healthy CommunityHeart Healthy Lenoir Community Advisory Committee

Many other community-based organizations and agencies

Funded byNational Heart, Lung and Blood Institute

National Institutes of Health

Lenoir County Partners

Heart Healthy Lenoir

NIH Centers for Population Health and Health Disparities

Community-Based Participatory Research

• Driven by the community

• Nature of intervention not

predetermined. Developed in

collaboration with community partners

• Limited use of control groups – rather

focus on reducing health disparities

• Implement the intervention with

feasibility and sustainability in mind

Community Advisory Committee

• Met quarterly with research team

• Represented public health, medical, business, policy, faith-

based, and other community organizations

• Provided project guidance to assure the research efforts

were meeting the needs of and were sensitive to the community culture

Project Timeline

Year 1: Learn about

Community

Years 2-4: Conduct Studies

and Deliver Intervention

Year 5: Analyze Data and

Report Findings

Heart Healthy Lenoir

High Blood Pressure Study

Improve blood pressure control by working with

medical practices and patients.

Lifestyle Study

Create lifestyle program with individual support

and community changes that promote healthy

eating, PA, and weight control.

Genomics Study

Study genetic factors related to heart disease and needed treatments.

Thomas C. Keyserling, MD, MPHCarmen D. Samuel-Hodge, PhD, MS, RD

Lifestyle Study

Lifestyle Program Phases & Options

• Focus on improving eating habits and increasing physical activity

• 4 individual or group counseling sessions

• At conclusion, choose weight loss or LS maintenance

Lifestyle Phase (LS)

(Months 1-6)

• Option for those with BMI > 25 kg/m2

• 16-week, behavioral weight loss program

• 2 delivery options: Weekly group sessions (16) or combination of group sessions (5) & phone contacts (10)

Weight Loss Phase

(Months 7-12)

• Entry criteria ≥8 lbs wt loss; others receive lifestyle maintenance

• Randomized study

• 2 groups receiving different #s of phone contacts

Maintenance of Weight Loss

(Months 13-24)

• Improve eating and physical activity habits

• 4 individual or group counseling sessions

• At 6 months, choose weight loss or LS maintenance through 24 months

Phase I

Lifestyle Phase (LS)

(Months 1-6)

• For BMI > 25 kg/m2

• 16-week, behavioral weight loss program

• 2 formats: Weekly group sessions (16) OR 5 group sessions + 10 phone contacts

Phase II

Weight Loss Phase

(Months 7-12)

• Entry criteria ≥8 lbs wt loss; all others receive lifestyle maintenance

• Randomized controlled trial

• 2 groups – different number of phone contacts

Phase III

Maintenance of Weight Loss

(Months 13-24)

Guiding Principals

• Evidence-informed

– Developed before publication of PREDIMED randomized trial, but intervention very similar (as noted)

• Culturally appropriate for participants

• Focus on behaviors supported by strongest evidence

• Prioritize: do the easy things first

• If there is not strong evidence, don’t recommend it

• Palatable and not expensive

• Appropriate for participants with type 2 diabetes

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Eating more high quality

fat, including more fried

foods (fried in good fats)

DOESN’T mean more of

this kind of meal...

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53

Sliced red

cabbage roasted

in olive oil

Avocado, olive

oil, lemon juice,

and garlic

dressing

Chicken sausage,

nuts, vegetables,

whole wheat pastaButternut squash

soup with whole fat

yogurt, VERY whole

grain bread. Tub

margarine

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Mustard mayo on

vegetables

roasted in lots of

olive oil

Pesto mayo on

collards sautéed

with chicken

sausage, onions,

garlic, peppers

Chicken in gravy

with beans on

wheat berries

and quinuo

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Color as an indicator of a healthy choice!

Phase I—Lifestyle Intervention

• 4 monthly sessions delivered by trained counselor, group or individual

– Nuts, Oils, and Spreads

– Vegetables, Fruit, Whole Grains, and Beans

– Drinks, Desserts, Snacks, Eating Out, and Salt

– Fish, Meat, Poultry, Dairy, and eggs.

• Intervention began August 2011

• Also promoted walking ≥ 7,500 steps per day or 30 min per day of other moderately intensive activity

Behavioral Intervention was Theory Informed

• Recommendations tailored to baseline behaviors

• Participant and counselor developed an individually tailored action plan

– Select 2 achievable goals to work on for the next session

– Specify first steps

Participant Characteristics

CharacteristicsAll

N = 339African American

N = 219Caucasian

N=117

Age 56 54 58

Female 260 (77%) 181 (83%) 76 (65%)

Education: high school or less

189 (56%) 140 (64%) 48 (41%)

Hypertension 291 (86%) 195 (89%) 95 (81%)

Fruit and vegetable servings per day

3.4 3.4 3.5

Walking time, min/wkb 91 100 73

Weight, kg 98 100 94

BMI 36 37 34

Systolic BP, mm Hg 135 136 132

Diabetes 124 (37%) 89 (41%) 34 (29%)

Intervention Participation (N = 339)

Attendance:

Follow-up at 6 months 251 (74%)

Session 1st 2nd 3rd 4th

Attendance 291 (86%) 255 (75%) 236 (70%) 227 (67%)

40% Group

60% Individual

Lifestyle Intervention (Phase I) ResultsAll Participants

Outcomea n Baseline 6 MonthsChange

(6M minus baseline, 95% CI)

p-value

Diet quality, total scoreb 235 27.6 31.9 4.3 (3.7 to 5.0) <.001

Fat quality screenerscoreb 229 15.3 16.7 1.4 (1.0 to 1.7) <.001

Walking time, min/wkc 249 97 161 64 (19 to 109) .005

Systolic BP, mm Hg 249 134 128 -6.4 (-8.7 to -4.1) <.001

Diastolic BP, mm Hg 249 82 78 -3.7 (-5.0 to -2.5) <.001

Taking BP lowering Medication, No. (%)

249 193 (77%) 198 (79%) 2.0% (-0.3 to 4.4) .10

Weight, kg 248 98 97 -0.7 (-1.2 to -0.3) .002aData are means (SE) except where notedbHigher score indicates improved diet qualitycIncludes walking for transportation and exercise

Phase I Acceptability• 242 completed the acceptability survey

• Most rated the program highly

“I would recommend the program to others.”

• 170 (70%) Strongly Agreed

• 66 (27%) Agreed

• Information on nuts, spreads, dressings and oils was considered most helpful

All Participants (Phases II and III)Weight Loss (kg) at 12 and 24 Months

12 Mouth Weight Outcomes 24 Mount Outcomes

Intervention Format N Change (95% CI) N Change (95% CI)

--group weight loss 50 -3.1

(-4.9 to -1.3)

52 -2.1

(-4.3 to 0.0)

--combo weight loss 75 -2.1

(-3.2 to -1.0))

72 -1.1

(-2.7 to 0.4)

--lifestyle only 125 -0.9

(-2.1 to 0.2)

124 -1.7

(-2.9 to -0.5)

Participants with DiabetesWeight Loss at 12 and 24 Months

12 Mouth Weight Outcomes 24 Mount Outcomes

Intervention Format N Change (95% CI) N Change (95%

CI)

--with diabetes, group weight loss 17 -3.9

(-7.4 to -0.4)

18 -5.2

(-9.6 to -0.8)

--with diabetes, combo weight loss 27 -2.6

(-5.0 to -0.2)

25 -2.2

(-4.6 to 0.1)

--with diabetes, lifestyle only 52 -0.2

(-2.0 to 1.6)

50 -3.8

(-5.9 to -1.8)

Other Phase II and III Outcomes

• SBP reductions sustained through 24 months

• Dietary improvements maintained through 24 months (not so for physical activity)

Limitations

• pre-post comparison study with no control group

• observed changes could be due to secular trends or other factors.

• Small Ns in subgroups

Conclusions

• In this study promoting a Mediterranean style dietary pattern, the large majority of participants reported substantial improvement in dietary intake and a meaningful percentage lost weight and maintained weight loss.

• As lifestyle and weight loss changes were similar for African American and white participants, this type of culturally tailored intervention has the potential to reduce both CVD risk and disparities in CVD rates.

Conclusions

• Participants with diabetes experience similarly favorable outcomes

• Unlike many study, those with diabetes lost more weight

Implications

• Future research should include RCTs enrolling similar high risk populations that assess change in CVD risk factors and ultimately change in CVD events

• Lifestyle intervention probably ready for prime time

– Working on dissemination plans

Session Components

• Dietary Assessment

• Review of session educational content

• Selecting 2 dietary goals

• Specifying first steps to achieving goals

• At beginning of follow-up sessions review success at achieving goals

Representative “Screen Shots” from the Intervention Section on Nuts

--Assessment

--Educational content

--Tips

--Goals and first steps

Selected “Screen Shots” from the other Sections that Address

“conflicted” Dietary Content Areas

A new respect for southern food Starting with the BBQ Festival…

After: “I’ve eaten eastern style BBQ all my life and love it.. But I think preparing it this way is just as good and I would definitely eat it again!”

Before…

Overall Results

3%4%

5%

54%

35%

3%4%

6%

54%

33%

3%5%

22%

45%

25%

1%4%

10%

52%

33%

0%

10%

20%

30%

40%

50%

60%

Strongly Disagree Disagree Neutral Agree Strongly Agree

Question 1 Question 2 Question 3 Question 4

Question 1 Question 2 Question 3 Question 4

The BBQ dish tasted good to me.

I would be willing to make this dish at home.

My family would enjoy a dish like this.

I would like more information.

BBQ Festival on the NeuseWil King Hog Happenin’

Results 2013

Lumbee Homecoming/Pow Wow – Robeson County, July 2012

Quote of the day:

“Dawg that’s good!”

A new approach to another southern classic… Hush Puppies

BBQ Festival 2014

The Heart Healthy Lenoir team entered the 1st annual Southern Sides

Competition.

Contest Hosted by Vivian

Howard… Chef and the Farmer

BBQ Festival – Survey Feedback

20 consumer surveys

• 100% said the hush puppies

tasted good

• 90% would order in a

restaurant

• 75% said their family would

enjoy them

Number of contestants?? 2

And the envelope please….

Availability of MaterialsLifestyle Intervention

• PDF format currently available

– http://hpdp.unc.edu/research/medsouth/

Good Bowls – An Approach to Healthy Food Access and Economic Opportunity

105

Thomas Frieden, Former Director of CDC

The Problem(s)

Lack of Access to Healthy Affordable

Food ->Obesity, Heart

Disease, Diabetes

Limited market opportunities for Small Farmers ->

Rural Poverty

Underutilized Value Added Processing

Facilities (VAPFs)

The Solution – Good Bowls

• A healthy meal product based on the Mediterranean diet

-> culturally relevant/acceptable

• Frozen

-> eligible for SNAP (Food Stamp) purchase

-> longer shelf life in C-stores

• Made from locally grown food

-> recipes adapted to the seasons

-> uses “cosmetically challenged” food often wasted

• Produced in local VAPFs (Commercial/Community Kitchens)-> creates jobs among food entrepreneurs-> local business opportunity

What is the Evidence?

• The Mediterranean diet prevents heart disease and a number of chronic conditions

• Corner Stores are critical sources of food for many in “Food Deserts”

• New market opportunities for farmers increase revenue and reduce rural poverty

• VAPFs can support economic opportunity for farmers and food entrepreneurs

But is it Affordable?

Tom’s Shoes model but better – “buy one give one”

•Higher end consumers (Food Co-ops, Whole Foods, Local Health Foods Stores etc.) pay more

•C-Store customers pay less

Tom’s Shoes Good Bowls

Provides a needed product to disadvantaged populations

Builds on Altruistic Spirit

Transfers wealth

Supports local businesses XBuilds capacity XEncourages local entrepreneurship

X

Why it’s a better model than Tom’s Shoes

Financials – Dual Value Chain Model

C-s

tore

Hig

her

En

d

Veggies: $0.31Meat: $0.50Carbs: $0.24Labor: $0.40

Freezing: $0.25Packaging: $0.20

Total Inputs: $1.90

Internal Margin Distributor Margin

Retail MarginConsumer

Purchase Price

Delivered $4.0910% Margin

Delivered: $1.30Margin: 30%

Delivered: $4.5435% Margin

$1.86

$6.9954% MarginMake $2.19

-62% MarginLose $0.73

Delivered: $1.17Margin: 10%

Who Benefits?

• Lower income families at high risk for chronic disease and food insecurity.

• C-store/small food retailers in need of SNAP-eligible healthy/tasty/affordable/shelf stable/convenient food options

• Local value-added processing facilities – increased kitchen use

• Small to mid-sized farmers seeking market opportunities

• “Foodies” (socially conscience consumers with means) seeking locally sourced, convenient and good tasting meals while “giving back” to their community.

Warren County Food Hub - Rural

Burgaw Incubator Kitchen - Rural

Key

Higher end retailer – Food Coop, Wholefoods, universities, worksites etc.

Corner store, small grocery store

Farm supply organization

Working Landscapes Feast Down East Burgaw Food Hub

Recipe DevelopmentFood Safety, Labeling

MarketingProvide packaging

Coordinate DistributionManagement

Evaluation

KeySells Good Bowls to Retailers

Technical Assitance

Evaluation

Good Bowls LLC

Piedmont Food and Agriculture

Processing Center (PFAP)

Farmer Foodshare,Others

Higher End Retailers and Co-ops

So nice to hear about your project on NPR after sampling those delicious meals at Weaver Street Market! They even got good reviews from my teens.

The Good Bowls project made me think about the family medicine building at 590 Manning where I work. Despite being on campus, it is a food desert, because one cannot easily walk anywhere close to get food (It takes about 25 minutes to walk up

the hill to the hospital cafeterias). So, most of the clinical staff (especially the lower paid folks) use the junk food machine to get their lunch. It is a sad sight.

I would be very interested in doing this with the good bowls!

We are gathering coolers. I will plan to bring enough to handle 65 boxes with icepacks too.I think this will be great!John

Alice,

We had the vending machine gone by the time I got back from Raleigh with the bowls thanks to Jackie.

Warren County Food Hub - Rural

Burgaw Incubator Kitchen - Rural

Key

Higher end retailer – Food Coop, Wholefoods, universities, worksites etc.

Corner store, small grocery store

Farm supply organization

Working Landscapes Feast Down East Burgaw Food Hub

Recipe DevelopmentFood Safety, Labeling

MarketingProvide packaging

Coordinate DistributionManagement

Evaluation

KeySells Good Bowls to Retailers

Technical Assistance

Evaluation

Good Bowls LLC

Piedmont Food and Agriculture

Processing Center (PFAP)

Farmer Foodshare,Others

Warren County – Tier 1 most economically distressed

Warren County Food Hub - Rural

Burgaw Incubator Kitchen - Rural

Key

Higher end retailer – Food Coop, Wholefoods, universities, worksites etc.

Corner store, small grocery store

Farm supply organization

Working Landscapes Feast Down East Burgaw Food Hub

Recipe DevelopmentFood Safety, Labeling

MarketingProvide packaging

Coordinate DistributionManagement

Evaluation

KeySells Good Bowls to Retailers

Technical Assistance

Evaluation

Good Bowls LLC

Piedmont Food and Agriculture

Processing Center (PFAP)

Farmer Foodshare,Others

Mobile Market Traveling to 8 Housing Authority Locations in Wilmington

“It’s hard to imagine a product that is a better fit with our work than Good Bowls. It would allow us to create jobs by making use of both the food hub and the incubator kitchen, will help support limited resource farmers, and will help us get healthy food to lower income consumers – it’s win-win-win!”

Sarah Daniels,Executive Director, Feast Down East

Excited Partners

UNC Home pagehttps://www.unc.edu/discover/bringing-healthy-food-to-all-consumers/

Questions??