Group-Based, Culturally Sensitive Weight-Loss Program for Families Leads to Improvements in Children's Health-Related Behaviors and Declines in Body Mass Index

Problem Addressed

• A growing problem, especially for low-income children: Over the past three decades, the childhood obesity rate in the United States has more than doubled among preschool children (age 2 to 5 years) and more than tripled for children ages 6 to 11 years; approximately 9 million children older than 6 years of age are obese.² Ethnic minority populations (especially African Americans, Hispanics, and Native Americans) and children in low-socioeconomic status families tend to have higher rates of obesity than does the rest of the population. For example, up to 24 percent of African-American and Hispanic children are above the 95th percentile in terms of BMI, with Hispanic boys and African-American girls having the highest rates of overweight/obesity.² About 36 percent of primary care patients older than age 2 years at Children’s Mercy Hospitals and Clinics are overweight or obese; of these, 42 percent are African American, and 28 percent are Latino.³ 
• Devastating mental and physical health consequences: Young people are at risk of developing serious psychosocial burdens related to being obese. Because society stigmatizes this condition, obese children often feel shame, blame themselves, and suffer from low self-esteem that may impair academic and social functioning and carry into adulthood. Overweight/obesity also causes physical health problems. In a population-based sample, approximately 60 percent of obese children between the ages of 5 and 10 years had at least one cardiovascular disease (CVD) risk factor such as elevated total cholesterol, triglycerides, insulin, or blood pressure, while 25 percent had two or more risk CVD risk factors.²
• Limited physical activity, especially for children in low-income families: Leisure time that was once spent playing outdoors is now often spent watching television or playing computer and video games. Additionally, urban designs discourage walking and other physical activities. High-crime rates in inner-city areas also force parents and schools to limit children's outdoor activities (including walking or biking to and from school), whereas poorly equipped schools and neighborhoods (e.g., few if any nice playgrounds, playing fields, etc.) in these areas frequently limit opportunities for physical activity.
• Poor eating habits, especially among children in low-income families: Economic pressures to minimize food costs and limited available time for working parents to purchase and prepare nutritious food at home results in frequent consumption of convenience foods that are high in calories and fat. In low-income, urban neighborhoods, there is also limited access to grocery stores that sell healthy food, including fresh fruits and vegetables.
• Providers struggle to find effective interventions to reduce childhood obesity: Providers face many challenges related to providing services to overweight and obese children, including a lack of reimbursement for clinical care, lack of evaluation and outcomes data, limited resources, and increased demand for services. Addressing these needs is critical to promoting the health of children who are overweight, obese, or morbidly obese.⁴

Description of the Innovative Activity

• Initial screening to determine eligibility and interest in program: Children and parents are screened for the program to determine whether they are interested and eligible.
  • Qualifications: To be eligible for the program, a child must be age 9 years or older with a BMI that is equal to or greater than the 95th percentile for the child’s age and gender. Eligibility is not determined by income. To date, two-thirds of participating children are either African-American or Latino, and two-thirds are covered by Medicaid or qualify for financial assistance. The average age is 11 years, and 61 percent are female.  
  • Referral for initial screen: Most children are referred by a primary care or subspecialty physician affiliated with the hospital. 
  • Medical and psychosocial screening: Children and parents come in for a 2-hour initial evaluation with briefer follow up sessions by a physician or pediatric nurse practitioner, social worker, physical therapist, and dietician. During these sessions, the child is weighed and measured, and blood pressure, lipids, glucose, insulin, and liver enzymes are tested. The parent and child also talk to care team members about their quality of life and the barriers to weight loss that the family faces due to economic and other challenges. Common issues include the child being bullied at school, having no place safe to play outside, and eating to cope with troubles. The parent may face challenges as well, such as working two jobs, struggling to set limits around eating, and having to travel far from home on public transportation to purchase healthy foods. The family may also lack stable housing or electricity or may be living with a grandparent.
  • Referrals  to community-based organizations: After the screening, the family and child are referred to an appropriate community-based organization that can help. For example, the social worker may refer the family to a Big Brothers, Big Sisters program to support the child and/or to a program-based child psychologist to strengthen parenting skills. The social worker may call the school to address bullying problems. The dietician educates parents about key evidence-based nutrition and physical activity contributors to obesity. They review grocery store ads together to identify affordable healthy foods and/or refer the parent to the closest food bank. The physical therapist works with the patient to develop goals, which include reducing sedentary, screen time and increasing physical activity.
  • Enrollment in PHIT program: In addition to the referrals, the team screens the parents and child to see if they are motivated to develop healthier lifestyles. If they are interested and have demonstrated healthy behavior change, they are invited to join the PHIT Kids program. If they are not ready to commit, the family will continue to meet with their primary care provider or subspecialty physician until they are ready to participate in the program.
• PHIT program components: The PHIT program consists of 24 weekly classes followed by 18 monthly maintenance classes. There are two groups—one for 9 to 12 year olds and their parents and another for 13 to 18 year olds and their parents. In addition, program staff meet on a weekly basis to discuss specific families and cases. Key elements of the program curriculum are described below:
  • Weekly meetings: The weekly meetings are held during evening hours to accommodate working parents and last for 90 minutes. They are held in easily accessible locations in the community (including the hospital and a local YMCA). Up to 20 families attend each session. 
    • Daily log to document diet and activity: During the 24-week period, everyone is encouraged to keep a daily log to document his or her diet, physical activity, and television/computer “screen” time.
    • Class curriculum: On arrival, children and parents are weighed and measured, and then participate in 30 minutes of physical activity led by health educators, followed by 45 minutes of separate classes with health educators. With the children, the educators address nutrition and physical activity behaviors, plus behavior-related topics, including bullying, goal setting, self-esteem, and dealing with setbacks in age-appropriate manners. The parent group works on similar topics, including problem-solving such issues as unsafe neighborhoods, poor access to healthy food, and how to deal with other family members who do not support diet and nutrition change.
    • Setting measurable, realistic goals: The families reassemble to review what topics were addressed and to set goals for the next week. Typical weekly goals include achieving three to five servings of fruit and vegetables each day, eating at least four dinners at home that week with the family, and limiting fast food to once a week. Goals are designed to be specific, measurable, and achievable. For example, if a child sets a goal of drinking fewer sugary drinks, the health educator and child structure a way to track the goal. Goals are never weight-based; they focus on behaviors related to nutrition and physical activity.
  • Weekly staff brainstorming sessions: The program staff hold weekly team meetings among the program coordinator, health educators, psychologist, medical providers, social workers, physical therapist, and dietician. They discuss the families participating in the program, sharing perspectives, identifying barriers faced by families, and brainstorming solutions.
  • Monthly maintenance meetings: After the 24 weekly meetings conclude, parents and children meet for 18 consecutive monthly sessions that include clinic visits and a cooking class sponsored by a local food network that focuses on healthy, low-cost foods. The families are also given groceries at the end of the class to assist in healthy meal preparation. Organizers hold meetings at local YMCAs or recreation centers to link participants to recreation resources in their communities, including gyms, parks, pools, or organized sports leagues.
• Program principles that consider economic realities and integrate cultural practices: All aspects of the program are designed to recognize families' economic challenges and to understand and respect their cultural practices.
  • Recognition of the hierarchy of need and addressing economic issues first: Program staff recognize that, if they are not sensitive to families’ survival needs, then parents cannot devote more attention to their child’s weight and nutrition. The following are examples of issues that need to be addressed first, before weight loss can become a goal: housing and food insecurity, unemployment, lack of health insurance, immigration and deportation issues, transportation and communication barriers, neighborhood safety, limited access to grocery stores, and easy access to convenience stores and fast food.
  • Sensitivity to the characteristics and environments of participants: The program matches written materials and messages to the characteristics of the target population to enhance participant receptivity. The program also incorporates the cultural, social, historical, environmental, and psychological forces that influence the health behavior in the target population.
  • Incorporating cultures of participants: The program staff incorporate each target group's culture into their outreach, training styles, and materials.
    • Tailoring to Latino cultures: For Latino families, classes are available in Spanish and are led by Latino health educators. Some of the many Latino-specific issues that are addressed include the following: child-centered, paternalistic families; permissive parenting styles; meal patterns, including concerns that healthy meals are not tasty; the belief that being overweight is considered to be healthy; the belief that leaving uneaten food is impolite; and a reluctance to transition to lower fat or nonfat milk.
    • Tailoring to African-American culture: Sessions for African Americans are led by African-American educators. Some of the many African-American–specific issues that are addressed include the following: family-centered focus that involves all family members, collectivism and respect for elders (especially if the child and parent are living with grandparents or older extended family members), overcoming the belief that female caregivers are being selfish if they take time to be physically active, and discussing convenient hairstyles for physically active females.

References/Related Articles

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Results

• Reduced BMI: PHIT Kids participants began with an average BMI that put them at the 98.36 percentile (i.e., on average, 98.36 percent of children had lower BMIs than did program participants). By the end of the program, this figure had fallen to 97.72. (Analysis of a similar 12-week class for children ages 5 to 8 years found that the average BMI percentile for the seven participants fell from 96.43 at the beginning of the program to 94.4 at the end of the program.) 
• Reduced triglycerides: Healthy triglyceride levels in children should be under 150 mg per dl. Triglyceride levels for PHIT Kids participants fell from 130.2 at the start of the program to 99.17 at week 24.
• Higher good cholesterol: Ideal high-density lipoprotein levels are greater than 45 mg/dl, with levels less than 35 mg posing a risk of heart disease. Participants had levels of 42.5 at the start of the program and 46.67 at 24 weeks.
• Reduced consumption of sugary beverages: Children reduced their consumption of sugary beverages by an average of 3.1 servings per week (from 5.1 to 2.0).
• Increased physical activity: The children significantly increased time spent being physically active, to almost 2 (1.91) hours per day by the end of the program.
• More meals eaten at home: By the end of the program, the children ate an average of 2.4 additional meals with their families at home each week. 
• High levels of parent and child satisfaction: About 93 percent of parents reported that the program was the right length (or not long enough, implying that participants wanted to continue receiving program services), and 94 percent strongly recommended the program. About 88 percent of child participants thought the program was the right length or not long enough, and 73 percent strongly recommended the program.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Creation of referral system: The hospital created a referral system so that CMH primary care providers could refer children if their BMI percentile was above 95 percent and they and their families were motivated for family-based lifestyle changes.
• Development of culturally appropriate program materials and staffing: Materials were developed, written, and translated for the targeted clientele. African-American and Latino health educators were hired to lead the evening sessions.
• Applying for grant funding: Program staff recognized that economic, transportation, and other culturally specific barriers had to be addressed. In response, program developers applied to local foundations and Blue Cross Blue Shield of Kansas City for grants to craft a culturally sensitive program that provided psychosocial and community assistance to stabilize families in crisis.
• Adaptations to cultural and socioeconomic realities of the target population: The program's impact was continually monitored, with refinements being made in response to the cultural and socioeconomic realities of the families being served. For example, it was known that working parents could not attend the sessions unless they were held in the evenings, so evening sessions were added. Another refinement was made after an outreach program aimed at parents of younger children proved to be difficult, primarily because parents wanted to have their children accompany them to the sessions. As a result, daycare services were made available during the sessions, and age-appropriate physical activities were added to the program curriculum.
• Negotiating reimbursement from insurers: Although insurers had generally been willing to cover the families' visits to the PHIT KIDS clinic, they were initially not willing to cover the evening, health education and physical activity classes because they were not considered clinical in nature. Children's Mercy Family Health Partners, a Medicaid managed care company, agreed to pay a per member per month (PMPM) amount for members to attend the program.

Resources Used and Skills Needed

• Staffing: The program has a part-time child psychologist, medical director, nurse practitioner, dietitian, social worker, physical therapist, health educators who have college degrees, and a full-time program coordinator. PHIT Kids also relies on CMH volunteers to help health educators during the evening sessions. Because program services are not covered by all health insurers, it is difficult for CMH to use paid staff after normal working hours. 
• Costs: The 2008 budget for the program is $367,000, which consists primarily of salary and benefits for paid program staff.

Funding Sources

Children’s Mercy Hospitals and Clinics; HealthCare Foundation of Greater Kansas City; Blue Cross Blue Shield of Kansas City

Tools and Other Resources

The National Initiative for Children's Healthcare Quality (NICHQ) is an action-oriented organization dedicated to improving the quality of health care provided to children, including preventing and reducing on of childhood obesity. Available at: http://www.nichq.org/index.html

National Initiative for Children's Healthcare Quality’s Childhood Obesity Action Network. Available at: http://www.nichq.org/register_coan.html?returnpage=/online_communities/coan/index.html

Getting Started with This Innovation

• Solicit hospital or health system participation: Due to high startup costs and the need for in-house expertise and a source of ready referrals, this program likely requires the active participation of a hospital, large outpatient clinic, or integrated health care system.
• Build partnerships within the health care system: Establish connections with pediatric practices and other health care providers who may be able to refer clients or donate funds or expertise to support the program. 
• Build partnerships within the community: Tap organizations that share an interest in healthy living, children's safety, and reducing childhood obesity. Potential partners include public and private recreation and fitness programs, public safety programs, YMCAs or YWCAs, grocery store chains, health food stores, and other enterprises. Also approach schools and other organizations that might be willing to host evening group meetings.
• Work with health insurers and local Medicaid administrators: Work with insurers and managed care organizations to raise startup funds and to secure insurance coverage for program services.
• Assemble and train a weight loss team: To the extent possible, leverage existing staff, including dieticians, social workers, and health educators, to provide program services. Make sure that social workers and health educators know about existing community resources and are aware of the appropriate processes for making referrals to emergency shelters, food banks, local welfare offices, domestic violence shelters, and other agencies as needed.
• Customize the program for the clientele: Be sensitive to the ethnic and cultural makeup of the target population, including ensuring that educational materials and staff reflect the culture of the patient base.
• Establish metrics and collect baseline data: Decide what metrics will be measured, and collect baseline data from participants on these metrics. Potential metrics include BMI; measures of physical activity and diet (e.g., hours engaged in physical activity, number of meals eaten at home, consumption of sugary beverages, consumption of fruits and vegetables); biometric indicators, such as cholesterol and triglyceride levels; and psychosocial indicators, such as weight-related quality of life and self-esteem.

Sustaining This Innovation

• Partner with community organizations: Given the paucity of insurance coverage for this type of weight-loss program, it is important to recruit financial contributions or in-kind services from local community organizations. For example, YMCA and other providers of recreational activities may be willing to provide free memberships to participants.
• Secure long-term funding from insurers: A lack of Medicaid or private insurance reimbursement for weight-loss services, especially behavioral groups, is a major barrier to sustaining these kinds of programs. Program sponsors should approach local insurers and Medicaid agencies in an effort to convince them to provide reimbursement. In the interim, however, PHIT Kids and other similar programs must rely on local grants and support from sponsor organizations. 
• Expand referral sources: The program needs referrals from a wide variety of sources to ensure that as many overweight and obese children are identified and treated as possible. One potential referral source is local pediatricians who are not affiliated with the sponsoring organization; these physicians should be approached and educated about the program, including how to refer appropriate patients. 
• Use hospital volunteers during evening programs: As noted, as a way to reduce costs, PHIT Kids relies heavily on hospital volunteers to assist health educators during the evening sessions.
• Monitor program impact: Continually monitor the key patient metrics over time to assess the program's impact.