Families and Community Partners Learning Together to Prevent Obesity

Obesity in Disadvantaged Populations

Obesity is a complex and increasingly prevalent public health issue (Hedley et al., 2004). Experts agree the continued decline in daily exercise and an increase in caloric intake are the key contributors (Centers for Disease Control and Prevention [CDC], 2004a; CDC, 2004b; Kahn et al., 2002; U.S. Department of Agriculture [USDA]; U.S. Department of Health and Human Services [USDHHS], 2000, 2005). People with limited resources, food-insecure families, and racial-ethnic minorities have increased risk for obesity and related chronic disease (Townsend, Peerson, Love, Achterberg, & Murphy, 2001; USDHHS, 2000; USDHHS, 2006). Low-income populations are particularly vulnerable, because they combine limited leisure-time physical activity with consumption of less expensive, energy-dense foods (CDC, 2004a; Drewnowski & Spector, 2004; Kahn et al., 2002; Leibtag & Kaufman, 2003).

Texas rates of poverty, food insecurity, overweight, and obesity are particularly high. In Texas, 16.5% live in poverty (DeNavas-Walt, Proctor, & Lee, 2006), 16.4% reside in food-insecure households (Nord, Andrews, & Carlson, 2005), and more than 35% of African-American and 30% of Hispanic adults are obese (Texas Department of State Health Services [TDSHS], 2005).

Preventing Obesity in High-Risk Communities

U.S. health initiatives increasingly focus on promoting health and reducing chronic disease associated with excess weight (USDA & USDHHS, 2000, 2005; USDHHS, 2000). Collaborative, interdisciplinary partnerships with community members can help (1) identify effective strategies that support behavioral change among racial, ethnic, and socioeconomic populations in high-risk communities (Kahn et al., 2002; TDSHS, 2005; USDHHS, 2006); and (2) implement sustainable program outcomes for "healthy, well-nourished children, youth and families" (Cooperative State Research, Education, and Extension Service [CSREES], 2006; Expanded Food and Nutrition Education Program [EFNEP], 2006).

Community-Campus Program for Families

Healthy Weigh/El camino saludable (HW) was a multi-component initiative that helped low-income families adopt healthy eating and physical activity patterns. Responding to United Way's obesity prevention initiative (United Way of Metropolitan Tarrant County, 2002), Texas Christian University (TCU) faculty (Nursing, Nutritional Sciences, Exercise Science, Kinesiology, and Social Work) partnered with community members and agencies to implement HW in a community at high risk for obesity and related chronic disease.

The geographic target community was predominantly African-American (35%) and Hispanic (26.4%), living below poverty (44.6%), overweight or obese (37%), and lacking high school diplomas (41.9%) (Fort Worth Public Health Department, 1998; U.S. Census Bureau, 2000). HW program objectives included (1) increasing community awareness about lifelong benefits of healthy eating and physical activity, (2) evaluating effectiveness of community-campus partnerships in a family-focused program, and (3) providing service-learning opportunities for university students.

Community involvement was integral to HW's success. HW's design incorporated multiple community partners, including Texas Cooperative Extension, committed to finding effective solutions for sustainable healthy lifestyle changes (Table 1). Collaboration among HW partners created a working relationship reflecting community-based participatory research principles (Israel, Schulz, Parker, & Becker, 1998):

• Build on community strengths and resources


• Integrate knowledge and action for mutual benefits


• Promote co-learning and empowerment processes, and


• Disseminate findings and knowledge gained.

Data collection, program components, and evaluation strategies were evidence-based. Comprehensive baseline and post-program participant health screenings assessed health profiles, body composition, dietary practices, physical activity patterns, and knowledge (nutrition, exercise, and weight management). The program design integrated evidence from Healthy People 2010 (USDHHS, 2000); Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (National Heart, Lung, and Blood Institute, 1998); Recommendations to Increase Physical Activity in Communities (Task Force on Community Preventive Services, 2002); and Dietary Guidelines for Americans (USDA & USDHHS, 2000; 2005). Program evaluation was based on participant feedback and outcome measures for (1) increasing nutrition and exercise knowledge, (2) improving diet, exercise, and weight management patterns, and (3) achieving individually-determined goals. TCU's Human Subjects Institutional Review Board approved the program design.

Families and Community Learning Together

HW Phase 1 (12-week program) and Phase 2 (8-week program) were successful community-campus partnerships that met program objectives. Innovative program features that contributed to the success of HW included family participation and design considerations integrating developmentally appropriate and culturally acceptable components for all ages. Weekly sessions in both phases consisted of physical activity classes, family meals with facilitated table talks that helped families apply nutrition and activity content, nutrition and physical activity lessons, and child care for preschool children (Table 2). Qualified Spanish language interpreters assisted in offering program components in English and Spanish.

Age- and ability-appropriate physical activity classes included community walking. Nutrition and physical activity lessons focused on Dietary Guidelines for Americans. Family meals emphasized healthy eating and dietary/cooking practices, reinforcing weekly nutrition lessons. Meals provided foods from each food group for children and adults, and used recipes that were affordable and easy to prepare at home within limited time. Concurrent, structured child care for preschool children included physical activity and age-appropriate nutrition lessons. Other key retention strategies were telephone reminders and mailings to each family, weekly transportation as needed, and family food bags with fresh produce and healthy food items from Tarrant Area Food Bank.

A university research team implemented the program, which was coordinated by registered nurses, a registered dietitian, and volunteer and paid staff that included community members and supervised university students from nursing, nutrition/dietetics, social work, kinesiology, and medicine. Service learning was an important feature, with baccalaureate students involved in selected aspects of designing, implementing, and evaluating the program. Trained students helped facilitate health screening, physical activity classes, walking groups, meal preparation, nutrition classes, table talks, and child care.

Community Challenges and Future Outreach

Finding ways to prevent and slow rising obesity among disadvantaged populations challenges community health professionals, educators, and researchers. The most difficult challenge is how best to facilitate sustainable changes and influence family values in low-income communities, whose priorities are more concerned with daily financial struggles than with adopting healthy lifestyle practices. In HW, community partners learned to work together to find solutions for reducing obesity, family members learned about their role in guiding and evaluating the intervention, and students learned to work with low-income families with limited literacy and English.

Reducing adult and childhood obesity is a shared community responsibility (CSREES, 2006). Outreach programs that integrate community-based research, education, and collaboration among committed partners hold promise for finding effective strategies to sustain health-related community changes (CSREES, 2006; EFNEP, 2006; TDSHS, 2005; USDHHS, 2006). With their history of community commitment and successful program implementation among low-income and underserved populations, Extension educators are in a key position to work with multiple community partners and initiate such outreach programs.

Acknowledgments

Healthy Weigh/El camino saludable had successful program outcomes because of the ongoing dedication of all its partners. United Way of Metropolitan Tarrant County and supplemental funds from the Alma Moreton Research Grant provided financial support for Phase 1 and Phase 2. Texas Christian University provided in-kind support. The Cornerstone Community Center shared its facilities and knowledge of the community. Healthy Weigh planning and coordination of ongoing program tasks would not have been possible without the multiple talents and numerous hours donated by community members and agencies, university faculty and staff, and student volunteers--each a contributing partner committed to finding effective solutions for sustainable change.

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