Quantitative and Qualitative Research in Clinical Settings

Audwin Fletcher, Janet R. Cooper, Pamela Helms, LaDonna Northington, and Karen Winters Stemming the Tide of Childhood Obesity in an Underserved Urban African American Population:

À Pilot Study Abstract: Recent data indicate that Americans are gaining weight at an alarming rate. It is estimated that over 12 million American children ages 2-19 years are overweight, with African American (AA) children comprising 20% of this cohort.

The problem of obesity appears to be more prominent in some southern states. According to a new report by the Trust for America's Health, Mississippi has the 7" highest rate of adult obesity and the 8''' highest rate of overweight youth ages 10-17 nationwide. The Kids for Healthy Eating and Exercising (KHEE) club was a model developed in the North Midtown area of Jackson, Mississippi.

The purpose of this project was to develop the first weight control program and model specifically designed for AA children in the North Midtown area ofthe city of Jackson. This program devised measures to effectively enhance the lifestyle changes of selected obese children representing the target population. Results of the pilot project revealed the following changes among all participants: a decrease in body mass index (BMI): a decrease in waist girth of greater than 4 inches: and positive behavioral changes as documented in the daily entries ofthe participants' food journal.

Key Words.- Obesity, Overweight, African American, Mississippi, Children, BMI T here has been a dramatic increase in obesity in the United States over the past 20 years. In fact, obesity has become a lifelong issue—one that is a major health problem and has reached an epidemic level (National Center for Health Statistics [NCHS] 1999; U. S. Department of Health and Human Services [USDHHS], 2001 ; CDC, 2004; Ogden et al., 2006). According to the National Institute of Health (NIH) (2007) if left unabated, the escalating rates of obesity in the U.S. will place a severe burden on the Nation's health and its healthcare system. Similarly, the increase in prevalence has made obesity a threat to public health in this country (Menifield, Doty, & Fletcher, 2008). Obesity has been directly linked to hypertension, type 2 diabetes, heart disease, stroke, cancer, and depression (McTigue, Garrett, & Barry, 2002; Rossner, 2002; NIH, 2007). Each year, over 300,000 adults in the U.S. will die from obesity related causes. As of 2004, the proportion of obese adults in the U.S. reached 32% ofthe total population.

The ABNF Journal Comparatively, among adolescents, obesity has increased to 17.1% ofthe population between the periods of 1999-2004 (Ogden et al., 2006). Additionally, approximately 33% of all children and adolescents ages 2-19 in the U.S are overweight or at risk of overweight. This trend of increasing obesity rates in children and adolescents continues despite the national campaigns of educating adults, adolescents and children regarding the untoward effects of obesity (NCHS, 1999).

Furthermore, the prevalence of overweight is higher in ethnic minority children and adolescents than white children (Davis, Arthur, Davis, Moll, & Davis, 2002; Chang & Lauderdale, 2005; Kumanyika & Grier, 2006; Ogden et al, 2006; Davis, Young, Davis, & Moil, 2008). As with adults, being overweight can create dramatic health consequences for youth such as increased risk for type 2 diabetes, hypertension and heart disease, as well as a myriad of other problems such as stress, sadness, and low self esteem (McTigue et al., 2002; Rossner, 2002; NIH, 2007).

This paper documents the findings ofthe pilot research study. Kids for Healthy Eating and Exercising (KHEE) club.

This publication was made possible by research funds from the Mississippi Institute for the Improvement of Geographic Minority Health Disparities (MIIGM) at the University of Mississippi Medical Center which is supported by OMH Grant NO.CPIMP061018-01-0I.

BACKGROUND/SIGNIFICANCE The problem of obesity appears to be more prominent in some southern states than in other states (Menifield et al., 2008).

According to a new report by the Trust for America's Health (TFA) (2008), Mississippi has the P' highest rate of adult obesity at 30.6 % and the 8* highest rate of overweight youth (ages 10-17) at 17.8% in the nation. Furthermore, the CDC (2004) contends that Mississippi leads the nation in cardiovascular disease (CVD) morbidity and mortality. While rates have declined over the past three decades in other states, Mississippi rates, particularly for African-Americans, continue to rise. African-Americans in Mississippi have CVD rates that are 50-70% higher than that of their white counterparts (Jones, Sempos, Thom, Harrington, Taylor, & Fletcher, 2000).

The age adjusted heart disease and stroke death rates for African-Americans are respectively, 29% and 40% higher when compared to White Americans (Saunders, Hertz, Kim, & McDonald, 2003). Lastly, African-Americans also experience higher prevalence rates of hypertension, heart attacks, and stroke.

Spring 2009 Additionally, the youth behavioral surveillance survey from the American Obesity Association (2003) reported 15.7% of youth in Mississippi were overweight compared to 13.4% nationally. Ironically, 28% of the youth described themselves as being either slightly or very overweight. Childhood obesity is associated with substantial medical, psychological, and social morbidity (Robinson, 2004). For example, the risk factors for heart disease occur with increased frequency in obese children and adolescents when compared to children with a healthy weight. Type 2 diabetes, previously considered an adult disease, has increased dramatically in children and adolescents. The most immediate consequence of obesity [as perceived by children, themselves] is social discrimination.

Finally, overweight children and adolescents have a 70% chance of becoming obese adults. This increases to 80% if one or more parent is overweight or obese (American Obesity Association, 2003). The prevalence of obesity in the young varies by ethnicity and race. It is estimated that 5% to 7% of Caucasian and African-American children are obese while 12 % of Hispanic boys and 19 % Hispanic girls are obese (Keku, Kenney, Dawson, Gerard, & Hill, 2000; Davis, Davis, Northington, Moll, & Kolar, 2002; Speed, Meyer, Kolbo, Legget, & Penman, 2003). As indicated earlier, studies showed an alarming rise in obesity among children in the U.S. during the last twenty years. The prevalence of obesity increases with age among both males and females, and it is more likely that obese adolescents will become obese adults. Obesity presents numerous problems for the child. It takes a toll on physical health and psychosocial adjustment. Childhood obesity is the leading cause of pédiatrie hypertension and has been linked to risk factors for coronary heart disease. These staggering obesity figures, coupled with the morbidity factors associated with obesity dictate creative solutions.

Obesity can become a lifelong issue. Realizing that obesity is easier to prevent than to treat, this program's aim was to teach youth that obesity is not a normal phase of development, but rather, a result of an improper balance between food intake and exercise. Furthermore, proper nutrition does not need to be boring or difficult, and good exercise/activity does not have to be dull or isolating. Studies have indicated the reason most obese adolescents regain their lost pounds is that after they have reached the desired goal, improper eating patterns and the lack of a constant exercise regimen become less of a priority in an already full adolescent's schedule (Menifield et al, 2008). Hence, adolescents must learn to eat and enjoy healthy foods in moderate amounts and to exercise regularly to maintain the desired weight. Parents of an obese child can improve the self-esteem of the child by emphasizing their strengths and positive qualities. In addition, the program made nutrition and exercise a family affair by planning lower fat meals, nutritious snacks and providing for fun-family activities.

The elimination of disparities in health is one of the overarching goals of Healthy People 2010, and ensuring access to quality health services is one of the focus areas (USDHHS, 2001).

Research is needed which focuses on the excessive burden of CVD in African-Americans as well as the impact of CVD risk factors such as obesity, sedentary lifestyles, poor nutritional habits. Research that addresses these disparities has consisted primarily of epidemiological research which compares rates of disease and risk factors in African-Americans to those of white Americans (Mayberry, Mili, & Ofli, 2000).

Innovative approaches that extend beyond these comparisons to include interventions that effectively eliminate disparities in health and health care are needed. Neumark-Sztainer, Falkner, Story, Perry, Hannan, & Mulert, (2002) contended that nearly 80% of our children are overweight and physically not fit, yet just 20% of our nation's schools have mandated daily fitness classes. Despite the documented need, there are few weight control programs designed specifically for children and none specifically designed for African American children. Hence, the purpose of this pilot project was to develop the first weight control program and model specifically designed for African American children.

DEFINING OBESITY AND OVERWEIGHT The USDHHS (2001) and the CDC (2004) describe obesity and overweight as labels for ranges of weight that are greater than what is generally considered healthy for a given height. They also argue that the terms identify ranges of weight that have been shown to increase the likelihood of certain diseases and other health problems. Overweight refers to increased body weight in relation to height, when compared to some standard of acceptable or desirable weight. Overweight may or may not be due to increases in body fat or due to an increase in lean muscle. For example, professional athletes may be very lean and muscular, with very little body fat, yet may weigh more than others of the same height. While they [the athletes] may qualify as "overweight" due to their large muscle mass, they are not necessarily "over fat," regardless of BMI.

Obesity is defined as an excessively high amount of body fat or adipose tissue in relation to lean body mass or as BMI for age > 95"' percentile. The amount of body fat (or adiposity) includes concern for both the distribution of fat throughout the body and the size of the adipose tissue deposits. Body fat distribution can be estimated by skin fold measures, waist- to-hip circumference ratios, or techniques such as ultrasound, computed tomography, or magnetic resonance imaging.

PROJECT DESIGN AND METHODOLOGY Data were collected via a descriptive, developmental study. Pre- and post-tests, BMI assessment, surveys, participant and faculty satisfaction questionnaires, and anthropometries [weight loss total, BMI, waist girth, and total inches lost] were used to collect data. The statistical analyses were paired t-test and anthropometries/weight loss records.

The project involved reducing childhood obesity to improve overall health in African-American children by teaching the proper balance between food intake and exercise.

The KHEE Club consisted of a ten-month daily or weekly pilot program. The program convened during the regular school semesters [Fall, August through December; Spring, January through May] from 3:00 pm - 5:00 pm. All children selected for the program were eligible for Mississippi Children Health Insurance Program (CHIP) or Medicaid and were identified upon regularly scheduled Medicaid screenings at the UNACARE Health Center. Parental consent was obtained at the time of screenings. The conceptual model was based on a three-level approach to preventing and/or treating childhood , obesity. Level I consisted of baseline BMI screening of all children in the 39212 zip code between the ages of 13-19.

Level II consisted of initiating early interventions for children with BMI measurements of greater than 25 but less than 30.

Early interventions consisted of creating services and supports that addressed risk factors of obesity. Level III consisted of coordinated, comprehensive, intensive, and sustained child- and family-focused services and supports (Appendix A). Each participant was individually assessed for nutrition and physical activity intervention. Each person was given a plan based on individual needs and stage of change.

Caloric intakes were determined and meal plans developed. The group participated in group and individual interventions. The group was assessed on pre- and post-knowledge in several key nutritional areas.

Topics completed during the project included: Basic Meal Plan and Meal Planning, Know Your Label, Portion Distortion, Healthy Snacking and Carbohydrate Counting, and Healthy Eating during the Holidays. Activity included sixty minutes of cardiovascular activities and thirty minutes toning exercises The ABNF Journal Spring 2009 Table 1: Program Phases and Activities Phase Intervention Graduation Summer Retreat Level 1 - Screening All children Level II - Early Intervention Children with BMl >25 and <30 Level lit - Intensive Intervention Children with BMl >30 Activities Recruitment during the months of June and July, preceding the fall semester • Screening physicals for all potential participants including preliminary lab work (CBC, Urinalysis, and EKG), and a calculated baseline BMl.

• Selection of the participants based on the criteria • KHEE Club program meetings one day per week • Exercise program implemented Nutritional classes implemented Chaperoned field trips for participants and parents KHEE Club program activities daily • Exercise program implemented Nutritional classes implemented • Chaperoned field trips for participants and parents End of Spring Semester Demonstration of knowledge gained through role play exercises Parental participation from knowledge gained • Measurements of changed cumulative BMl Active recruitment of 2™* year participants Ail graduated participants would now serve as ambassadors for the KHEE Club using weight resistance in group settings twice a week. The program consisted of five phases (Tabie 1).

During the KHEE club sessions, mutually developed individual goals based on the BMI were set for each child.

Structured nutritional sessions for participants included instructions on the basic food groups, fad diets, choosing healthy foods, and preparing healthy foods. Chaperoned field trips were designed to give "hands-on" experience with shopping for nutritional foods, dining at local restaurants, and choosing healthy foods from menus.

Study Population The target population for the project was a microcosm of the minority population of Mississippi. It was characterized by a high rate of unemployment, low literacy, little or no health insurance and high rates of heart disease, asthma, diabetes, and stroke. Access [lack thereof!

to affordable quality health care is thought to be a causative factor contributing to poor health status.

The federal government has designated North Midtown, where UNACARE is located, as a medically underserved area.

Demographics of the area as follows:

Total population, 8,830 Youth between ages often and nineteen, 1,188 White, 44% Black, 52% Median Household income, $24, 935 Average Family size, 3.16 Eamilies living below poverty level, 404 Individuals living below poverty level, 2,578 Program Eligibility criteria consisted of the following:

39212 Jackson, Mississippi zip code address 13-19 years of age BMI >25 Willingness to participate Informed parental consent to participate Twelve students participated in the study (Table 2). The ages of the participated ranged from 13-17. Ninety-two percent of the participants were female and in high school (9"' grade or higher). All participants had BMI >25.

RESULTS The following results were included at the conclusion for the KHEE club.

BMI —all participants [n=12] showed decrease in BMI. Although, all participants showed greater than 10% Table 2: Profile of Study Participants, N=12 Variable Age 13 14 15 16 17 BMl 25-29 30-34 35-39 >40 Gender Female Male Grade Level ßth gth 10* 11"^ N 1 2 6 2 1 6 4 1 1 11 1 1 9 1 1 % .08 .17 .50 .17 .08 .50 .34 .08 .08 .92 .08 .08 .76 .08 .08 - The ABNF Journal Spring 2009 weight loss, one student showed status change from obese to overweight. NOTE: BMI does not note difference between muscle mass and fat. Waist Girth—all participates [n=12] had deceased waist girth of greater than four (4) inches. Behavioral changes—the participants [n=12] found the use of the food journals beneficial. Fifty percent reported daily documentation of intake, while 33.3% and 16.7% stated use of journal as "sometime" and "only for review", respectively. Eighty percent of sample increased their intakes of fruits and vegetable to the recommended intake of 5 servings per day (with at least two servings of vegetables per day). All [n-12] participants consumed at least 3 servings of calcium-rich foods. All [n=12] participants stated the use of broiled, grilled or baked cooking method when purchasing or preparing foods. All [n=12] participants stated reading labels and the use of label reading in the decision making process. All [n=12] participants had either deleted carbonated beverages or changed to a diet variety. The triceps skin folds showed a significant decrease (p<.05) for all participants. All [n=12] participants stated feeling a difference in physical endurance. All [n=12] participants stated having changed to a 3-4 days per week activity schedule, with two of the participants [16.6%], including a 5 days per week activity schedule. All [n=12] participants preferred muscle toning over cardiovascular. Twenty-five percent of the participants stated the intent of limiting cardiovascular to 3 days/ week; while, 75% of the participants stated the intent of continuing cardiovascular activities at >3 days per week. All [n=12] participants voiced the hope of continuing with a trainer to reach final weight goals. When asked "wliat was your favorite aspect to the program", 83.3% said, "Ms. Johnson's tough love approach in helping them to achieve their goals" while the other 16.7% stated learning nutrition and the role of eating more properly had in fighting disease. When asked how they felt about the program—83.3% said they loved it and wish it could continue; and, 16.7% said they liked the program but didn't like the time. When asked their commitment to continue with changes in lifestyle—100% said yes. However, 50% said they didn't know where they would workout. And, 25% said they knew where they could go but did not know how they would get there.

DISCUSSION It is evident that the KHEE Club has successfully changed the lifestyles of its participants. With the increased incidence of hypertension and type II diabetes in teens, it is rewarding to see the efforts these students have made.

Each KHEE club member has been encouraged to share the behaviors with friends and family members. It is believed that with the changes in the teens' lifestyles that positive changes will also be found in the remaining members of the household.

The findings from this pilot project are important for two reasons. One, the project allows us to critically analyze the results of our efforts to improve the health of the participants with emphasis on weight control and reduction. Secondly, the analytic results allow us to disseminate the information gleaned to the larger academic audience. Ultimately, we hope to make significant contributions in the reduction of adverse health outcomes in African American children. For this project, the participants have:

• gained knowledge, skills and confidence to make healthy lifestyle choices • improved their level of physical fitness • gained an understanding of the impact [short- and long- term] of the benefit of physical activity • gained the understanding of the connection between mental health and physical health • learned that fitness can be fun while being healthy, and The ABNF Journal • learned lifelong healthy behaviors that could reduce the risk for weight related diseases through healthy lifestyle choices and increased physical activity.

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Appendix A Audwin Fletcher, is a Professor of Nursing in the School of Nursing at the University of Mississippi Medical Center, located in Jackson, MS. Dr. Fletcher may be reached at:

[email protected]. Janet R. Cooper, Assistant Professor of Nursing, Pamela Helms, Assistant Professor of Nursing, LaDonna Northington, Associate Professor of Nursing, and Karen Winters, Assistant Professor of Nursing, all teach at the School of Nursing, University of Mississippi Medical Center located in Jackson, MS.

A Three-Level Approach to Childhood Obesity Provide Intensive Interventions For a Few Children Intervene Early Some Children BMI >25 but Screen All Children Screen all children' Screen all children in 39212 zip area between the ages of 13-19 Intervene Early Create services and supports that address risk factors of obesity for children with BMI>25 but <30 Intensive Interventions Provide coordinated, com- prehensive, intensive, sustained, child-and-family focused services and support for children with BMI >30 The ABNF Journal Spring 2009