CHOP-International: an open access nutrition education tool for physicians, resident doctors, and medical and public health students

Abstract

Dietary diseases drive some of this century’s most pressing and costly global public health challenges, ranging from malnutrition-related infectious diseases such as HIV infection to overfeeding and linked chronic diseases such as type 2 diabetes mellitus and coronary heart disease. We seek to create clinically meaningful and cost-effective education tools to help treat such conditions in a manner that is both population specific and evidence based. Tulane University School of Medicine’s Goldring Center for Culinary Medicine (GCCM), a medical school-based teaching kitchen and research laboratory, utilized its novel collaboration of clinicians, registered dieticians, chefs, and culinary and medical students to create an open source international nutrition education resource comprised of region-specific recipes based upon the World Health Organization’s Nutrient Intake Goals. Using staple ingredients from three sample Millennium Development Goals regions, GCCM has developed sample recipes from three continents for proof-of-principle testing. The recipes include nutrition facts, interchangeable and optional ingredients, and salient nutrition education discussion points for students and medical professionals to use with a variety of patient conditions. Community-based participatory testing of the efficacy of this tool will allow for the refinement of the complete tool in the United States, followed by global expansion in coordination with physicians and students from Tulane University School of Public Health and Tropical Medicine in Kenya, Indonesia, and Colombia.

Appendices

Appendix 1: Sub-Saharan Africa: Goat & Root Vegetable Stew with Injera (4 Servings based on WHO nutrition guidelines)

Ingredients

For the stew:

22 mL:

Palm oil

227 gm:

Goat meat, medium cubes (optional)

2 each:

Tomato, large, chopped

1 large:

Yam, sweet potato, taro root, squash, or pumpkin, chopped

178 gm:

Black-eyed peas (increase to 357 gm if omitting goat)

1 L:

Water or stock (vegetable, chicken, beef, or other meat)

1 bunch:

Taro, baobab, pumpkin, or rosella leaves, or collard greens, rough chop or hand-torn (approx. 340 gm)

For the Injera:

*Begin at least 1 day early

22 mL:

Palm oil

187 gm:

Teff, flour (ground)

½ L:

Water

36 gm:

Salt

Preparation

• 1. One day ahead, mix teff flour with water in a large bowl; cover with a damp towel and let stand at room temperature at least overnight (up to 3 days ahead for a stronger flavor).

• 2. Heat a large pot with palm oil over high heat. Add goat cubes and brown on all sides (skip this step if no goat meat).

• 3. Remove meat from pot.

• 4. In same pot over medium heat, briefly brown tomato, yam, and peas

• 5. Add water to pot.

• 6. Add beef into pot.

• 7. Cook over low heat for about 30 min.

• 8. Add in taro leaves, and continue to cook for another 30 min, or until beef and vegetables are tender and sauce is thickened.

• 9. Stir salt into injera batter before cooking.

• 10. Heat a large pan with palm oil over medium–high heat. Pour in enough batter to cover bottom and move around until the bottom is evenly coated.

• 11. Remove flatbread when small holes appear in the top and edges lift away from pan.

• 12. Serve stew on top of injera.

Additional notes

• Use animal fat for vegetable oil, if easier.

• Stew may also be done in a kettle over an open fire, or in a pot on top of a grill, without changing method of preparation.

• Spices, if available, should be used. Turmeric, cumin, cinnamon, chili pepper, and curry are good ideas; they will add lots of flavor and some body to the final product.

• Tomato juice or paste will help flavor the water or stock and help thicken the stew.

• Using taro or cassava instead of yam will lower the vitamin A levels a lot.

Nutrition facts for meal with goat:

Serving Size:

453 g (16Oz)

Servings:

4

Calories:

600

Calories from fat:

130

Total Fat:

14 g

Saturated Fat:

6 g

Trans Fat:

0 g

Monounsaturated Fat:

4.5 g

Cholesterol:

45 mg

Sodium:

200 mg

Total Carbohydrates:

89 g

Dietary Fiber:

13 g

Sugars:

6 g

Protein:

32 g

Vitamin A:

50 %

Calcium:

6 %

Vitamin C:

80 %

Iron:

20 %

Nutrition facts for meal without goat (extra peas):

Serving size:

453 g (16Oz)

Servings:

4

Calories:

540

Calories from Fat:

110

Total Fat:

12 g

Saturated Fat:

5 g

Trans Fat:

0 g

Monounsaturated Fat:

4 g

Cholesterol:

0 mg

Sodium:

270 mg

Total carbohydrates:

95 g

Dietary fiber:

15 g

Sugars:

8 g

Protein:

18 g

Vitamin A:

50 %

Calcium:

6 %

Vitamin C:

80 %

Iron:

8 %

Nutritional value of individual ingredients:

Palm oil:

High in fats, increases uptake of vitamins D, E, A, K

Goat meat:

High in protein, iron, and vitamin B12

Tomatoes:

High in vitamin A and vitamin C

Yams:

High in dietary fiber, vitamin C, and vitamin B6

Black-eyed peas:

High in folate, protein

Taro:

High in vitamin A and vitamin B6

Appendix 2: Latin America and the Caribbean: Braised Pork Shoulder or bean cakes with vegetable rice (4 servings based on WHO nutrition guidelines)

Ingredients

For the pork shoulder:

30 mL:

Vegetable oil (preferably canola)

1 kg:

Lean pork roast

1 L:

Stock, vegetable or other (chicken, beef, fish, etc.)

OR

For the bean cakes:

453 gm:

Cooked black beans

1 each:

Egg

51 gm:

Masa harina or cornmeal

6 gm:

Salt

30 mL:

Vegetable oil

For the rice:

30 mL:

Vegetable oil

4 ea.:

Corn or maize, on cob, fresh

1 large:

Squash or sweet potato (calabza or similar), small cubes

½ ea.:

Onion, chopped small

2 large:

Tomatoes or tomatillos, chopped

391 gm:

Rice

1 L:

Water or stock

Preparation

For the Pork:

• 1. Preheat oven to 350 °F.

• 2. Heat oil in a large pot over high heat.

• 3. Brown pork on all sides; add in stock.

• 4. Place pot in oven and slowly boil for about 2 h, or until meat is tender and easily pulls away from bone.

OR

For the bean cakes:

• 1. In a bowl, mix together beans, egg, masa or cornmeal, and salt, taking care to break up the beans, until mixture holds together well.

• 2. Form bean mix into four patties of equal size, and set aside.

• 3. Heat oil in a pan over medium–high heat.

• 4. Cook each patty in the pan, about 5 min a side.

*These cakes may also be baked for 15 min in a medium-heat oven.

For the rice:

• 1. Brush corn with ½ ounce of oil; roast over open flame or on grill until corn is a little brown.

• 2. With a knife, remove corn kernels and set aside. Throw away cob.

• 3. In a pot, heat oil in a large saucepot over medium heat.

• 4. Add onions and cook until soft.

• 5. Add squash and cook for about 3 min.

• 6. Add rice and tomatoes and cook for 2 min, until tomatoes begin to soften.

• 7. Add water or stock; bring to a boil, then turn down heat until almost boiling. Let cook, slowly, until water is absorbed and rice is tender.

• 8. In pot, stir corn into finished rice.

Additional notes:

• Use animal fat for vegetable oil, if easier.

• Both pork and rice may also be done in a kettle over an open fire, or in a pot on top of a grill, without changing method of preparation.

• Spices, if available, should be used in all of the dishes. Chili powder (ancho, dark, cayenne, etc.), cumin, and cinnamon are good ideas; they will add lots of flavor and some body to the rice and final product.

• Tomato juice or paste will help flavor the pork and thicken the liquid.

• If easy to find, adding greens will help increase vitamins.

Nutrition facts for meal with pork shoulder:

Serving size:

396 g (14Oz)

Servings:

4

Calories:

610

Calories from Fat:

120

Total Fat:

13 g

Saturated Fat:

2 g

Trans Fat:

0 g

Monounsaturated fat:

6 g

Cholesterol:

50 mg

Sodium:

270 mg

Total carbohydrates:

94 g

Dietary fiber:

8 g

Sugars:

5 g

Protein:

31 g

Vitamin A:

20 %

Calcium:

6 %

Vitamin C:

35 %

Iron:

20 %

Nutrition facts for meal with bean cakes:

Serving size:

425 g (15Oz)

Servings:

4

Calories:

540

Calories from Fat:

90

Total fat:

10 g

Saturated fat:

1.5 g

Trans fat:

0 g

Monounsaturated fat:

4 g

Cholesterol:

45 mg

Sodium:

170 mg

Total carbohydrates:

95 g

Dietary fiber:

18 g

Sugars:

5 g

Protein:

23 g

Vitamin A:

25 %

Calcium:

8 %

Vitamin C:

35 %

Iron:

30 %

Nutritional value of individual ingredients:

Vegetable oil:

High in fat, increases uptake of vitamins D, E, A, K

Pork:

High in protein, iron, vitamin B12 and vitamin B6

Black beans:

High in protein, iron, calcium, vitamin B6

Egg:

High in protein, vitamin D

Masa Harina:

High in protein, vitamin B6

Maize:

High in protein, iron, vitamin B6

Squash:

High in vitamin C

Onion:

Low nutritional content

Tomatoes:

High in vitamin A and vitamin C

Appendix 3: Eastern Asia: Brown Rice Stir Fry with Bok Choy, Mushrooms, Eggplant, and Tofu (4 Servings based on WHO nutrition guidelines)

Ingredients

44 mL:

Sesame oil

340 gm:

Tofu, extra firm, 1″ dice

10 gm:

Garlic, chopped small

½ head:

Bok choy, chopped

100 gm:

Shiitake (or other) mushrooms, cleaned

1 each:

Eggplant, large, cubed

30 mL:

Soy sauce

870 gm:

Brown rice, cooked

Preparation

• 1. Gather all ingredients and equipment.

• 2. Heat sesame and vegetable oil in a wok or pot over high heat.

• 3. Add tofu to hot pan and brown on both sides.

• 4. Add in garlic, bok choy, mushrooms, eggplant, and soy sauce and stir constantly until vegetables are tender.

• 5. Stir in rice to warm, and serve.

Additional notes:

• Use animal fat for vegetable oil, if easier.

• Stir-fry may also be done in any sort of pan or kettle over an open fire or grill without changing method of preparation.

• Spices, if available, should be used, especially ginger, red pepper, and lemongrass.

• Any easy-to-find mushroom can be used instead of shiitakes.

• Noodles can be used instead of rice; Buckwheat soba or rice noodles are good alternatives.

Nutrition facts for meal:

Serving size:

368 g (13Oz)

Servings:

4

Calories:

610

Calories from Fat:

160

Total fat:

18 g

Saturated fat:

2 g

Trans fat:

0 g

Monounsaturated fat:

7 g

Cholesterol:

0 mg

Sodium:

530 mg

Total carbohydrates:

93 g

Dietary fiber:

8 g

Sugars:

5 g

Protein:

21 g

Vitamin A:

35 %

Calcium:

8 %

Vitamin C:

20 %

Iron:

15 %

Nutritional value of individual ingredients:

Sesame oil:

High in fat, increases uptake of vitamins D, E, A, K

Tofu:

High in protein, iron, and calcium

Garlic:

Low nutritional content

Bok choy:

High in vitamin A and vitamin C

Shiitake mushroom:

Low nutritional content

Eggplant:

Low nutritional content