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Working With Families to Prevent Obesity: A Community-Campus Partnership

Posted on: Sunday, 17 April 2005, 03:00 CDT

University faculty and community agencies collaborated to design and implement Healthy Weigh/El camino saludable, a family-focused obesity prevention and intervention program in a low-income, urban community at high risk for obesity and related chronic disease. Hispanic and African American families participated in 12 weekly sessions. Offered in English and Spanish, sessions included exercise classes, lessons based on Dietary Guidelines for Americans, and family meals with facilitated "table-talks" about how families were applying lesson content. Data were collected by interview and direct measurement. Participants demonstrated improved nutrition/exercise knowledge (p ≤ 0.01),dietary practices (92%), exercise patterns (54%), weight management (84%), and they attained individually determined goals (92%). Challenges, outcomes, and lessons learned in a community-campus partnership are described.

Overweight and obesity have increased steadily in the United States over the last two decades, with 34% of adults overweight and another 30% obese (Hedley et al., 2004). Overweight among children and adolescents has doubled with 30% now overweight or at-risk for overweight (Hedley et al., 2004; Ogden, Flegal, Carroll, & Johnson, 2002). Sparing no populations, obesity disproportionately affects minorities and individuals with lower educational and socioeconomic status (SES) (Flegal, Carroll, Ogden, & Johnson, 2002).

For all racial and ethnic groups, 24% of persons with less than a high school education are obese compared with 19% of those with high school diplomas, and women of lower SES are 50% more likely to be obese than those with higher incomes (Flegal et al., 2002). Additionally, the prevalence of overweight/ obesity is greater among African Americans and Hispanic Americans compared to White Americans (Flegal et al., 2002). Racial-ethnic disparities in overweight also exist among children, with more than 22% of African American and Hispanic American children overweight compared to 12% of White children (Hedley et al., 2004; Strauss & Pollack, 2001).

Minority groups also face higher risks for obesity-related chronic diseases (Keppel, Pearcy, & Wagener, 2002; Must et al., 1999). Diabetes prevalence in Hispanic Americans is nearly double that of White Americans and approximately 70% higher in African Americans. African Americans have higher rates and earlier onset of hypertension. Additionally, type 2 diabetes, elevated cholesterol, and hypertension-previously considered adult diseases-are seen more frequently in overweight youth (Dietz, 1998).

Although the causes of obesity are many and complex, research suggests the key contributor is a continued decline in daily exercise without a reduction in energy intake (Centers for Disease Control [CDC], 2004a, 2004b; Kahn et al., 2002; U.S. Department of Agriculture [USDA] & U.S. Department of Health and Human Services, 2005). Lowincome communities are particularly vulnerable because nutritious foods are expensive or difficult to find, and fewer healthy energy dense foods are readily accessible and affordable (Drewnowski & Spector, 2004). Poorer neighborhoods, often lacking well-maintained sidewalks and streets, safe outdoor spaces, or exercise facilities, may be less conducive to physical activity than higher income neighborhoods (Kahn et al., 2002). Cultural factors related to dietary choices, physical activity, and acceptance of excess weight may affect family behaviors and contribute to increasing overweight/obesity in high-risk communities (Kahn et al., 2002; Kant, 2004; Salinsky & Scott, 2003). Research confirms that families are critical in forming children's health behaviors. Overweight adolescents have a 70% greater chance of becoming overweight adults, and children with one obese parent face two times the risk of becoming obese adults (Whitaker, Wright, Pepe, Seidel, & Dietz, 1997).

PREVENTING OBESITY IN HIGH-RISK COMMUNITIES

U.S. health initiatives have increasingly focused on reducing overweight/obesity. Healthy People 2010 (HP2010) is the comprehensive set of national health objectives with two overarching goals: to increase quality and years of healthy life and eliminate health disparities. HP2010, the cornerstone of the nation's action plan for obesity prevention, includes objectives focusing on promoting health and reducing chronic disease associated with overweight/obesity by:

* Improving diet and weight management

* Increasing daily physical activity

* Providing quality, accessible, and effective health education in communities

Outreach strategies supporting healthy behaviors have increased awareness, resulting in beneficial changes for a variety of racial, ethnic, and socioeconomic populations in high-risk communities (CDC, 2005; Salinsky & Scott, 2003). Culturally appropriate and linguistically competent family-focused interventions may help children adopt behaviors that prevent obesity later in life and reduce chronic disease risk.

METHODOLOGY AND INTERVENTION

A Family Focus

Healthy Weigh/El camino saludable (HW) was a family-focused obesity prevention and intervention program offered in a high-risk, urban community of Fort Worth, Texas. Faculty consultants from Texas Christian University (TCU) (Nursing, Nutritional Sciences, Exercise Science, Kinesiology, and Social Work) created partnerships with Cornerstone Community Center (CCC), a local faith-based community center, Tarrant Area Food Bank, Fort Worth Public Health Department, and Texas Cooperative Extension to develop and implement this program. Table 1 identifies the program resources provided by each community agency. HW objectives included: (a) increasing community awareness about lifelong benefits of healthy eating and physical activity, (b) evaluating effectiveness of a community-campus partnership in a family-focused program, and (c) providing service- learning opportunities for university students. Program assessment was based on participant evaluation and outcome measures for improving nutrition and exercise knowledge; improving diet, exercise, and weight management patterns; and achieving individually- determined goals. Funding from United Way of Metropolitan Tarrant County and TCU's in-kind support made it possible to provide all services without charge to participants.

The Community

CCC serves a community with median household income of $20,000, 44.6% of families living below poverty, and 41.9% of persons over 25 years lacking high school diplomas (U.S. Census, 2005). Of 282 persons screened for HW, most participants were female (71.7%) and Hispanic (81.8%) or African American (11.7%). Families made up a large portion of participants, with 46.1% of participants younger than age 19, and 8.5% over age 60. Many participants had limited proficiency in English or Spanish.

Table I. Community Participation in Healthy Weigh/El camino saludable

Program Design

HW included two 12-week sessions, one each in summer and fall, 2003. Focus groups helped gain community participation in program planning and assisted in recruitment. Recruitment flyers were distributed through schools, CCC, and door-to-door. Participants chose to enroll in the English or Spanish language version of HW. Each evening session included exercise classes, family meals with facilitated "table-talks" about how families were applying nutrition and exercise content, nutrition and physical activity lessons, and child care for preschool children (Table 2). A university research team directed program implementation, which was coordinated by registered nurses, a registered dietitian, paid staff, community volunteers, and supervised students from Nursing, Nutritional Sciences, Kinesiology, Social Work, and Medicine. More than 100 undergraduate and graduate students from two universities served as educators, exercise leaders, coordinators of meal preparation and service, tabletalk leaders, child-care workers, health screeners, and research assistants.

The program design was research-based and adhered to national guidelines from HP2010; Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults; Recommendations to Increase Physical Activity in Communities; and Dietary Guidelines for Americans. All forms and educational materials (including the informed consent, approved by TCU's Committee on Safeguards in Human Research) were in English and Spanish and were developed at the 4th to 5th grade reading level.

Table 2. Healthy Weigh/El camino saludable Program

Data Collection and Measurements

All consenting participants were included in the study. Data were collected by interview and direct measurement. Participants completed comprehensive health screening before, immediately following, and 3 months after the 12week program. In addition to health profiles, health screening included assessment of body composition, dietary practices, physical activity patterns, and nutrition and exercise knowledge. Table 3 lists types of measurements and instruments used for data collection. Assessment of overweight/obesity in adults was based on standardized criteria, including Body Mass Index (BMI), waist circumference (WC), and waist- tohip ratio (WHR) \(Table 4). Total percent body fat was analyzed in adults by Bioelectrical Impedance Analysis (Spectrum II - RJL Systems). Assessment of overweight in adolescents and children was based on gender-specific BMI-for-Age percentiles that denote at- risk for overweight (85th to 95th percentile) and overweight (> 95th percentile) (U.S. Department of Health and Human Services, 2005). Participants who were age 5 or older set 1 or 2 goals related to diet, physical activity, or weight management.

Table 3. Pre and Post Program Data Collection and Measurements

Table 4. Classification of Overweight and Obesity by BMI, Waist Circumference, and Waist-to-Hip Ratio

Data Analyses

The Statistical Analysis System (Version 8.1) was used to examine participants' composite index score based on assessment of outcome objectives as primary hypotheses. Primary hypotheses were compared by two-tailed alternatives (paired-sample t-test and Wilcoxon signed rank test), and a Bonferroni correction was applied to ensure an overall alpha level of 0.05 (p ≤ 0.05).

OUTCOMES AND DISCUSSION

At baseline, more than 80% of adults were overweight or obese, and 50% of adolescents and children were overweight or at-risk for overweight. Participants reported having no regular physician (27%); using free medical clinics (22%); sedentary/light activity (44%); fair/poor health (43%); hypertension (35%), diabetes (24%), and cardiovascular disease (15%).

Participant Outcome Measures

Five outcome measures were based on selected HP2010 objectives, 2000 Dietary Guidelines for Americans, and recommendations emphasizing both diet and regular physical activity as important practices for lifetime health and weight management. Table 5 shows outcome measures and percentage of participants meeting each objective.

Outcome 1: Participants will demonstrate a statistically significant improvement in nutrition and exercise knowledge scores.

Participants demonstrated significant improvement between pre and post nutrition/physical activity knowledge, with mean pre-program scores at 51% (37%-66%) correct, and mean post-program scores at 60% (43%-77%) correct. Although children had lower scores than adults overall, monolingual Spanish-speaking children did not demonstrate improvements comparable to those of English-speaking children (Figure 1). As a group, participants demonstrated most improvement in questions related to daily servings of fruits/vegetables, sodium and sugar content in canned foods/beverages, recommended exercise, and healthy choices at fast food restaurants.

Outcome 2: 70% of participants 5 years or older will report dietary improvements over baseline to model components of the 2000 Dietary Guidelines for Americans.

Ninety-two percent of participants completing HW reported dietary improvements, and 78% made two or more improvements: balancing caloric intake with expenditure, increasing fruit/vegetable consumption, decreasing sodium or fat intake, or increasing fiber consumption. Of these, increased fiber and decreased sodium intake were the least improved dietary changes. Greatest improvements were in fruit/vegetable intake, which the HW curriculum emphasized. Free fruits/vegetables included in weekly food bags increased participants' exposure to a variety of fresh produce and reinforced healthy eating.

It is often difficult for low-income families to make healthy eating a priority when food budgets must be balanced with other critical living expenses (Drewnowski & Spector, 2004). In a pattern similar to that of other low-income populations, these families tended to substitute less expensive foods of lower nutritional value and quality for fresh produce, whole grains, fish, and lean meats (Kant, 2004; Leibtag & Kaufman, 2003). USDA's Healthy Eating Index shows lowincome populations do not consume recommended servings of fruit (77%), vegetables (96%), and grains (67%); and intake of sodium, saturated fat, and total fat is increased in twothirds of low-income households (Basiotis, Carlson, Gerrior, Juan, & Lino, 2002).

Table 5. Participant Outcome Measures

Outcome 3: 70% of participants iuill report an increase over self- reported baseline in frequency, intensity, or duration of exercise.

More than half of all participants demonstrated increased physical activity, falling short of the 70% objective. Adults were more likely to demonstrate improved physical activity (65%) than adolescents and children (39%).

Figure I. Total score on pre and post Nutrition and Physical Activity Knowledge Quiz in English- and Spanish-speaking adults and youths *(p < 0.05).

Despite proven benefits of physical activity, more than 60% of American adults get insufficient physical activity, and more than one-third of adolescents fail to regularly engage in physical activity vigorous enough to provide health benefits (CDC, 2003, 2004a; Grunbaum et al., 2004). Racial-ethnic disparities also exist, with no leisuretime physical activity higher among Hispanics (35.8%) and African Americans (33.2%) as compared to White non-Hispanics (22.9%) (CDC, 2004a). In addition, persons with lower income and education are least active in their leisure time.

Participants' reasons for not increasing exercise were similar to those of other studies: lack of time, access to convenient facilities, or safe environments (Kahn et al., 2002). This low- income population also lacked appropriate footwear for exercise, frequently worked in physically demanding jobs such as construction or housekeeping, faced extreme seasonal heat, and did not perceive exercise as important to health.

Outcome 4: 50% of adolescent and adult participants who are overweight at baseline will show an improvement in weight management.

Due to established patterns of sedentary activity and overweight/ obesity, making changes in daily lifestyle practices was difficult for this population during a 12-week period. Although improvements in weight management varied among participants, all improvements, whether large or small, were regarded as successful. Eighty-four percent of adults and adolescents, overweight at baseline, improved in one or more areas of weight management. Greatest improvements among adults were shown in WC (70%), WHR (48%), body fat percentage (46%), and BMI (40%). Experts agree that the best approach to weight management combines diet and physical activity, yet only 20% follow this advice to manage their weight (ADA, 2002; USDA, 2005). Losing weight is challenging and often temporary unless healthy eating and activity are part of daily lifestyles. The inability to make necessary lifestyle changes is reported as the primary underlying reason for ineffective weight management (ADA, 2002).

Outcome 5: 70% of adolescent and adult participants completing the program will achieve their individually determined nutrition or activity objective.

Goal-setting helps people recognize a need for changes in health behaviors and identify directed activities for achieving goals (Cullen, Baranowski, & Smith, 2001). Participants' primary goals were to improve dietary practices (43%), physical activity patterns (28.5%), and/or weight management (28.5%). Participants self-rated their goal achievement as "fully met,""partially met," or "not met," with 92 % at least partially meeting their goals. Overall, participants set realistic and attainable goals such as "eat more fruits and vegetables,""switch from whole to low-fat milk," or "be physically active more times per week. " In contrast, weight management goals were often unrealistic, with expectations such as losing 5 pounds in 1 week. Participants seemed to be unfamiliar with goal-setting and needed instruction on realistic and attainable goal- setting strategies. Goal-setting inherently requires a future orientation to time, knowing that something done in the present can alter a future state. Although individuals vary greatly in their predominant orientation to time, people from Hispanic American and African American cultures, and people from lower income communities often have a present orientation to time (Galanti, 2004).

Program Challenges and Evaluation

Implementing an obesity prevention and intervention program in a low-income community proved to be both challenging and rewarding. Organizational challenges involved ongoing coordination of day-to- day tasks among community agencies and members, university faculty and staff, students, and volunteers. Program challenges included cultural differences, language barriers and limited literacy, and retention of participants. Using focus groups to gain community input was important for participant recruitment/retention, and contributed to key strategies such as weekly family meals and physical activity classes, lessons provided in English and Spanish, free weekly food bags, taxi-assisted transportation, child care, and weekly reminder calls to participants.

Effectiveness of HW was based on outcome measures and participants' program evaluations. At completion of the 12-week intervention, participants rated program components as "very good,""could have been better," or "I did not like this at all." Most participants (89%) rated HW "very good." Community-wide benefits from HW included community planning experience for focus group members, job skill development for project staff from the neighborhood, and initiation of a Health Action Group (HAG). The purpose of the HAG is to empower community members in addressing obesity prevention beyond the grant period. Additional United Way funding for Phase 2 of HW will support ongoing weekly classes for families, and help community members continue to find solutions for reducing obesity and chronic disease in their community.

APPLICATIONS

Obesity is a serious and complex public health problem. Universities are in a unique position to partner with community members and agencies to share expertise and resources. HW is an example of a successful community-campus partnership \designed to address obesity in a lowincome community. Community members, agencies, the university, students, and funding partners learned from each other. Effective solutions for reducing obesity in high- risk populations include community partnerships using multiple strategies to help families adopt the health behaviors needed for lifetime prevention of obesity and chronic disease. L.Dart@tcu.edu Note: Healthy Weigh could not have been successful without the dedication of all its partners. Cornerstone Community Center and its Director, Jesse Vasquez, provided space, entre to the community, grassroots expertise, and support for HW. Tarrant Area Food Bank provided access to food, particularly free fruit and vegetables. United Way of Metropolitan Tarrant County and Texas Christian University provided financial support. Students from Texas Christian University and University of North Texas Health Science Center donated numerous hours as critical staff. The real heroes were the program participants who shared their stories and time, made life changes, exercised, helped themselves, and changed their community.

Although the causes of obesity are many and complex, research suggests the key contributor is a continued decline in daily exercise without a reduction in energy intake.

REFERENCES

American Dietetic Association. (2002). Position of the American Dietetic Association: Weight management. Journal of the American Dietetic Association, 102(8), 1145-1155.

Basiotis, P. P., Carlson, A., Gerrior, S. A., Juan, W. Y., & Lino, M. (2002). The healthy eating index: 7999-2000. U.S. Department of Agriculture (USDA), Center for Nutrition Policy and Promotion. CNPP-12. Washington, DC: U.S. Government Printing Office.

Centers for Disease Control and Prevention. (August 15, 2003). Prevalence of physical activity, including lifestyle activities among adults - United States, 2000-2001. Morbidity and Mortality Weekly Report, 52(32), 764-769.

Centers for Disease Control and Prevention. (February 6, 2004a). Prevalence of no leisure-time physical activity 35 States and the District of Columbia, 1988-2002. Morbidity and Mortality Weekly Report, 53(4), 82-86.

Centers for Disease Control and Prevention. (February 6, 2004b). Trends in intake of energy and macronutrients United States, 1971- 2000. Morbidity and Mortality Weekly Report, 53(4), 80-82.

Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. (2005). Racial and ethnic approaches to community health (REACH 2010): Addressing, disparities in health. Retrieved January 9, 2005, from http:// www.cdc.gov/ nccdphp/ aag/aag_reach .htm.

Cullen, K. W, Baranowski, T., & Smith, S. P. (2001). Using goal setting as a strategy for dietary behavior change. Journal of the American Dietetic Association, 101(5), 562-565.

Dietz, W. H. (1998). Health consequences of obesity in youth: Childhood predictors of adult disease. Pediatrics, 10 !(3 Pt 2), 518- 525.

Drewnowski, A., & Spector, S. E. (2004). Poverty and obesity: The role of energy density and energy costs. American Journal of Clinical Nutrition, 79(1), 6-16.

Flegal, K. M., Carroll, M. D., Ogclen, C. L., & Johnson, C. L. (2002). Prevalence and trends in obesity among US adults, 1999- 2000. Journal υ/ the American Medical Association, 288(IA), 1723-1727.

Galanti, G. (2004). Caring for patients from different cultures. 3^sup rd^ ed. Philadelphia: University of Pennsylvania Press.

Grunbaum, J. A., Kann, L., Kinchen, S., Ross, J., Hawkins, J., Lowry, R. et al. (May 21, 2004). Youth risk behavior surveillance - United States, 2003. Morbidity and Mortality Weekly Report Surveillance Summary, 53(SS02), 1-96.

Hedley, A. A., Ogden, C. L., Johnson, C. L., Carroll, M. D., Curtin, L. R., & Flegal, K. M. (2004). Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. Journal of the American Medical Association, 291(21), 2847-2850.

Kahn, E. B., Ramsey, L. T., Brownson, R. C., Heath, G. W., Howze, E. H., Povvell, K. E., et al. (2002). The effectiveness of interventions to increase physical activity. A systematic review. American Journal of Preventive Medicine, 22(4S), 73-107.

Kant, A. K. (2004). Dietary patterns and health outcomes. Journal of the American Dietetic Association, 104(4), 615-635.

Keppel, K. G., Pearcy, J. N., & Wagener, D. K. (2002). Trends in racial and ethnic-specific rates for the health status indicators: United Stales, 1990-98. Healthy people statistical notes, No. 23. Hyattsville, Maryland: National Center for Health Statistics.

Leibtag, E. S., & Kaufman, P. R. (2003). Exploring food purchase behavior of low-income households. Current Issues in Economies of Food Markets, Agriculture Information Bulletin No. 747-07, 1-7.

Must, A., Spadano, J., Coakley, E. H., Field, A. E., Colditz, G., & Dietz, W. H. (1999). The disease burden associated with overweight and obesity. Journal of the American Medical Association, 282(16), 1523-1529.

North American Association for the Study of Obesity (NAASO) and the National Heart, Lung, and Blood Institute (NHLBI). (2000). Practical guide: Identification, evaluation, and treatment of overweight and obesity in adults. Retrieved January 9, 2005, from http:// www.nhlbi.nih.gov/guidelines/obesity/prctgd_b.pdf.

Ogden, C. L., Flegal, K. M., Carroll, M. D., & Johnson, C. L. (2002). Prevalence and trends in overweight among US children and adolescents, 1999-2000. Journal of the American Medical Association, 288(14), 1728-1732.

Salinsky, E. & Scott, W. (July, 2003). Obesity in America: A growing threat. National Health Policy Forum Background Paper, 1- 31. Washington, DC: National Health Policy Forum,

Strauss, R. S., & Pollack, H. A. (2001). Epidemic increase in childhood overweight, 1986-1998. Journal of the American Medical Association, 286(22), 2845-2848.

U.S. Census Bureau (2005). Census 2000. Retrieved January 9, 2005, using detailed tables from www.census.gov.

U.S. Department of Agriculture & U.S. Department of Health and Human Services. (2005). Nutrition and your health: Dietary guidelines for Americans. 5'1' ed. [Electronic version]. Home and Garden Bulletin No. 232. Washington, DC. Retrieved January 9, 2005, from http://www.usda. gov/cnpp/DietGd.pdf.

U.S. Department of Health and Human Services. (2005). 2000 CDC growth charts: United States. Retrieved January 9, 2005, from http:/ /urww.cdc.gov/growthcharts.

Whitaker, R. C, Wright, J. ?., Pepe, M. S., Seidel, K. D., & Dietz, W. H. (1997). Predicting obesity in young adulthood from childhood and parental obesity. New England Journal of Medicine, 337(13), 869.

ADDITIONAL RESOURCES

Marcus, B. H., & Lewis, B. A. (March, 2003). Physical activity and the stages of motivational readiness for change model. [Electronic version]. President's Council on Physical fitness and Sports Research Digest, 4, No.l. Retrieved January 9, 2005, from http://fitness.gov/Reading_Room/ Digests/march2003digest.pdf.

National Heart, Lung, and Blood Institute (NHLBI). (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. [Electronic version]. NIH Publication No. 98-4083. Retrieved January 9, 2005, from http:// www.nhlbi.nih.gov/guidelines/ obesity/ob_gdlns.pdf

Task Force on Community Preventive Services. (2002). Recommendations to increase physical activity in communities. [Electronic version]. American Journal of Preventive Medicine, 22(4S), 67-72. Retrieved January 9, 2005, from http:// www.thecommunityguide.org/pa/pa-ajpm-recs.pdf.

U.S. Department of Health and Human Services. (2005). Healthy People 2010 2^sup nd^ ed. [Electronic version]. Retrieved January 9, 2005, from http://www.healthypeople.gov/ document/ tableofcontents.htm.

Lyn Dart, PhD, RD, LD

Assistant Professor

Texas Christian University

Pamela Jean Frable, ND, RN

Assistant Professor

Texas Christian University

Patricia J. Bradley, DNS, RN

Associate Professor

Texas Christian University

Sejong Bae, PhD

Assistant Professor

University of North Texas Health Science Center

Karan Singh, PhD

Professor and Chair

University of North Texas Health Science Center

Copyright American Association of Family & Consumer Sciences Apr 2005

Source: Journal of Family and Consumer Sciences

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