WHAT THE EXPERTS SAY

On a monthly basis, ACFN poses a question to its advisory board on the hottest topics of the day regarding obesity. Below are select answers to the question posed on November 3.

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One of the greatest lessons ACFN learned from the 2005 TRIUMPH series was the importance of cultural relevance in health and wellness programs. As the rates of overweight youth continue to increase, particularly in African-American and Hispanic communities, what are some successful methods you have seen communities, schools, churches, etc. use to tackle the obesity issue? What are some programs or methods that you would suggest?

Phil Lawler, Director of Outreach and Training, PE4Life Institute

“Pe4Life created a model in Naperville, where only 3% of the student population was overweight or obese. We are now opening new PE4Life models in two urban settings: Kansas City and Indianapolis. We anxiously await future results in those two settings.”

Phil Haberstro, Executive Director, National Association for Health and Fitness

“Among the critical components for creating health and reducing youth obesity are addressing public policy and the built environment.  In New York state, the state wide ‘Walk your children to School’ and ‘Safe routes to school’ campaigns have been effective in engaging students, faculty and parents to impact policy and the built environment around schools to encourage physical activity. For more information on statewide campaigns visit www.BeActiveNys.org.”

Lorena Drago, M.S., R.D., C.D.N., C.D.E., Hispanic-Latino Educator Specialist

“Engage each participant in an active learning process. When participants set their own goals and apply the learned skills, they will be more successful in attaining their goals.”

George Blackburn, M.D., Ph.D., Harvard Medical School

“The University of Massachusetts Extension Nutrition Education Program provides individuals, families and community members with the knowledge and skills to make informed choices about healthful diets. Another program is Boston Steps, a community mobilization effort to reduce the burden of diabetes, asthma and obesity for residents in seven Boston neighborhoods: Dorchester, Hyde Park, Jamaica Plain, Mattapan, Roxbury, South Boston and South End/Chinatown. The Boston Steps message focuses on 5-2-1-0 for better health and encourages children, adolescents and adults to make health lifestyle changes such as eating at least five servings of fruits and vegetables daily, limiting children’s TV viewing and video game playing to 2 hours, engaging in regular physical activity at least 1 hour a day, and no cigarettes.”

David Heber, M.D., Ph.D., F.A.D.A., F.A.C.N., University of California at Los Angeles Center for Human Nutrition

“A friend of mine started a very successful community garden next to a school where school kids are eager to participate, and have the opportunity to learn where many foods come from and how they are grown.”

Mary Lee Chin, M.S., R.D., Nutrition Edge Communications

“You need to be creative and work with the communities you’re targeting. In doing so, the Center for African-American Health at the Denver Black Church Initiative came up with a step competition called “Step’n For Life.” The program was culturally relevant and unique to their culture, and it was fun. Nobody wants to do any exercise, eating or any activity that is a chore. And because it had elements of music, fun and incorporation of all ages, it had a wide appeal. You can also be very creative with this program. It offers a lot of latitude for people to come up with their own dance routines, and it is something that doesn’t cost a huge amount of money. This makes the activity very replicable. There is no limit to using your imagination in taking this to other programs. You can create different music, different prizes and have competition between so many different groups. To see an example of this program please visit www.caahealth.org.”

Jan Dodds, Ed.D., R.D.; Representative, Society for Nutrition Education; Professor of Nutrition and Maternal and Child Health, University of North Carolina, Chapel Hill

“In any nutrition intervention it is important to listen to the audience to develop messages and appropriate activities.  In interventions with African-American school girls, including adolescents, it is important to include the mothers.  In one project where the girls were younger, the mothers were a welcome part of the activities.  In another, the focus groups revealed that the teens wished their mothers could cook more and the mothers did too.  However, they were working two jobs so the weekend was the only time the families had to enjoy their mom's or grandma's good cooking.  Good food at meals builds on the important strength that families are in many cultures.”

ACFN learned from our TRIUMPH events that a number of local and state programs run by nonprofits, employers, schools and governments are helping people adopt healthier lifestyles. However, what is lacking is a consistent way to measure and evaluate their success. In your opinion, can the effectiveness of such programs be measured, and if so, how?

Tom Baranowski, Ph.D., Professor of Pediatrics and Leader of the Behavioral Nutrition Group, USDA-funded Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine

Of course aspects of success can be measured. There are many, many measurement tools. We have created a number of them for use with children. Which are best depends on what conceptual framework you want to impose on the program or the evaluation, and how much money you have to do it right. We have new measures that we are just analyzing now using the latest psychometric techniques.

Judith Young, Ph.D., Vice President for Programs, American Alliance for Health, Physical Education, Recreation and Dance

Certainly, long term we must depend on the national public health surveillance systems (Youth Risk Behavior Surveillance System, National Health and Nurtition Examination Survey, etc.) to assess changes in healthy behavior outcomes. However, I think programs can initiate some evaluation of specific process components such as rates of participation in programs, numbers of programs in various sectors (i.e. employers, local agencies, churches, local nonprofits), participant feedback and local focus groups, amount of local media attention or the establishment and use of citizen councils to help develop, implement and evaluate local efforts. We must take macro, research-based best practices and implement them at a micro level with whatever level of evaluation that can be incorporated cost effectively and efficiently. I think such assessment is preliminary to generating public or corporate support for local programs.

Kristine Clark, Ph.D., R.D., Director of Sports Nutrition and Assistant Professor of Nutrition, Center for Sports Medicine, Penn State

Yes, lifestyle changes can be measured. Once individuals identify WHAT they want to change (i.e. weight, physical activity frequency, number of times they eat home vs. in restaurants) goals or strategies for accomplishing the change should be concretely identified with dates for reaching the behavior goal. Follow-up is critical. I do this daily with clients (student athletes). They want to lose weight for example; we identify four strategies they are willing to employ to assist in achieving the weight loss. One strategy is writing down what they eat in food records. On the food records I'll be able to identify whether the food and beverage changes occurred. They'll record their physical activity on a log as well. Measuring behavior change is more important to focus on than the end result of efforts: weight loss. It's the new behavior that will ultimately manage the lost weight in the long run.

Phil Haberstro, Executive Director, National Association for Health and Fitness

I strongly believe that no program can be truly successful without a strategic commitment to changing health behavior and culture that spans the entire community. One way to measure a community's ability to foster health culture change is to assess the community's plan (or current actions if they do not have a plan) against the five health promotion action principles outlined in the World Health Organization's Ottawa Chapter for Health Promotion. This approach to measurement must also (in the action principle of "community capacity building") include an assessment of leadership in the community and the community's ability to work together (the National Civic League's “civic index” is a good start in assessing the health of a community's "civic infrastructure"). In summary, being a "healthy community" from a civic, environmental and economic perspective is critical to being able to improve community health and quality of life.

David Heber, M.D., Ph.D., Professor of Medicine and Public Health and Director, UCLA Center for Human Nutrition

It will be very difficult to evaluate. First, you have to evaluate the degree to which each program is being implemented and how it is affecting attitude, knowledge and behavior using questionnaire-type research. You can choose control community/school vs. the community where the program is being carried out. The biological results will be minimal as was found in studies by our group and by the late Dr. Ernst Wynder in his “Know Your Body” school program. There will be many testimonials from successes and this may be the best PR for the program.

Mary M. Austin, M.A., R.D., C.D.E., Immediate Past President, American Association of Diabetes Educators

On the individual local level, evaluating success depends on which "healthier lifestyle" the community program is trying to affect. For example, “increased exercise" as evidenced by "increased use of community nature trails," or "consumption of more fruits and vegetables" as evidenced by "more people attending community farmer's markets." I would think that a well-designed, pre-and post-program survey, specific to the program's goals and completed by the participants in that community, would provide useful information.

G. Ken Goodrick, Ph.D., Associate Professor of Family and Community Medicine, Baylor College of Medicine

The RE-AIM (Reach Efficacy/Effectiveness-Adoption Implementation Maintenance) evaluation method should be used (RE-AIM.org). For effectiveness, identify all those who were targeted by an intervention. At least one year later, randomly select a sample and assess changes in exercise and eating behavior, weight and fitness, and also collect opinions about intervention effectiveness and ease of implementation.

Jim Hill, Ph.D., Director, Health Sciences Center, Center for Human Nutrition, University of Colorado

It is difficult to evaluate such programs because they are "real world" studies without the controlled conditions used in most of the research we do. Additionally, these programs often have little or no resources for evaluation and do not have personnel experienced in research evaluation. However, I do think it is possible to evaluate the extent to which these programs engage the target audience and to evaluate some process and behavioral outcomes. I do not believe that easy ways to do this exist, but they could be developed.

George Blackburn, M.D., Ph.D., Associate Director of Nutrition, Beth Israel Deaconess Medical Center

We need to bridge the intention-behavior gap enabling people to act on their motivations. This is a high priority in the National Institute of Health “Look Ahead” clinical trial to study the effect of weight loss in management of cardiovascular disease. After a group meeting or during a class, we use worksheets that enable the participants to get down on paper what actions they will take to make the specific behavior changes requested of them. This catches them while they are experiencing a high level of motivation (group setting with interventionists present) and a high level of accountability. As it stands now, patients are generally highly motivated after leaving their doctor’s office with high hopes of making changes. Somewhere between that visit and the referral to the registered dietitian (R.D.), we are losing that momentum. Interactive worksheets or a funnel directly to the R.D. within the office may help to start bridging that gap.

With regard to measuring outcome, the technology required is quite complex. Rather than trying to measure something that would be inadequate, I would go with your belief system and intuition.

Lorena Drago, R.D., Multi-Cultural Nutrition & Diabetes Educator

Yes by collectively creating a valid and reliable evaluation tool for all programs.

Sharon Cox, M.S., R.D., CDE, Parkland Health & Hospital System, Bluitt Flowers Health Center

Outcome measured by: weight checks/record and biochemical - lipids/glucose levels.

Below are select answers to the question posed on August 11.

As children return to school this fall, many parents face a continued trend toward decreased recess and physical education time for their kids. What word of advice would you offer parents who want to arm their children to make wise choices?

Phil Haberstro, Executive Director, National Association for Health and Fitness

It is my understanding that the federal No Child Left Behind Act is requiring school districts to have wellness committees by June 2006 - I would encourage parents to find out where their district is on this action and see if they can serve on the wellness committee. A second action they could take is to partner with the local media in completing the CDC’s School Health Index each year and track their school’s progress toward becoming a health-enabling school.

Lisa Mosing, M.S., R.D., F.A.D.A., President, NutriTalk Inc.

Under this scenario, parents can help their children lead active lives by taking this opportunity as a neighborhood, community or civic group to create new alternatives to P.E. Perhaps there is a parent, a retired neighbor or someone with a home-based business that can supervise active play experiences. Activities like raking leaves, hiking and biking can be fun and healthy.

Lorena Drago, Multicultural Nutrition & Diabetes Educator

Take advantage of your computer and help your child move while having fun. Visit www.kidnetic.com and engage your child in a scavenger hunt.

G. Ken Goodrick, Ph.D., Associate Professor of Family Community Medicine, Baylor College of Medicine

Physical education that teaches enjoyable lifestyle exercise should be taught by public schools and parents. Until the renewal of school P.E., parents should work with neighborhood organizations or worship centers to provide after-school opportunities for exercise. It is also critical that children be raised with positive fitness values parents should act as models if able. However, in the lower socioeconomic strata, peer, media and passive entertainment influences, family disorganization and lack of community resources can be barriers.

Maureen Storey, Director, Center for Food and Nutrition Policy at Virginia Tech

Parents might try, "Will you play with me? Let's go for a walk, run, swim, dance, skip, jump, bike-ride with me!”