Running head: DECREASING OBESITY

Decreasing Obesity in African Americans in Baltimore Hollis Misiewicz NURS 674

DECREASING OBESITY Decreasing Obesity in African Americans in Baltimore Health Problem Obesity has become a nationwide epidemic in the United States increasing from 56% in 1988-1994 to 66% in 2004-2005 (Griffin, Wilson, Wilcox, Buck, & Ainsworth, 2008). Significant increases in costs secondary to obesity-related chronic illnesses is of concern to public health care, healthcare systems and policy makers (McCarthy, Yancey, Harrison, Leslie, & Siegel, 2007). Obesity has been linked to an increased incidence of heart disease, diabetes, hypertension, and cancer and is associated with increased mortality (Clark et al., 2001; Jen, Brogan, Washington, Flack, & Artinian, 2007; Parra-Medina et al., 2010). Health disparities and living conditions among low-income minorities contribute to the increased risk for obesity.

African Americans in particular tend to be more obese than the general population (Griffin et al., 2008; McCarthy et al., 2007; Parra-Medina et al., 2010; Van Duyn et al., 2007). A relationship has been shown to exist between the environment and factors leading to obesity. Two major obstacles to decreasing the incidence of obesity among low income African Americans in urban areas such as Baltimore are; (1) lack of suitable environment in which to increase physical activity and; (2) lack of the availability of healthy food sources (Haering & Franco, 2010; Griffin et al., 2008; Van Duyn et al., 2007). The purpose of this paper is to develop and describe an intervention program to increase the physical activity level of low income African Americans in Baltimore City and increase their access to healthy food in order to decrease the incidence of obesity. Review of the Literature Table 1 summarizes various interventions that have been tested to decrease the incidence of obesity within a particular population. Decreased physical activity is linked to an increase in

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obesity. Many research studies have attempted to explain why income low, minority populations tend to have low activity levels and what can be done to change this. Several studies that focused on promoters and barriers to physical activity found that programs that emphasized social support and involved important community organizations, such as churches, had a greater effect in increasing physical activity (Griffin et al., 2008; Van Duyn et al., 2007; Whitt-Glover, Hogan, Lang, & Heil, 2008). Volunteering in community schools was also found to be an effective means of increasing activity in older adults of the African American community (Tan, Xue, Li, Carlson, & Fried, 2006). A structured program for promotion of nutrition and physical activity based in a black-owned gym was successful in increasing consumption of fruits and vegetables and decreasing calories (McCarthy et al., 2007). A faith-based intervention aimed at increasing physical activity among African Americans was successful in increasing the number of people who became classified as active. This program focused on health as a way of taking care of Gods temple, the body (Whitt-Glover et al., 2008). Information about nutrition and physical activity given through phone counseling did not show any benefit over a control group without counseling (Parra-Medina et al., 2010). Physical improvements to parks in an urban area did not relate to an increase in use. Structured sports programs at these parks were linked to more people using the park and as these programs declined related to cuts in funding, park use declined as well (Cohen et al., 2009). One descriptive study examined factors related to increased obesity in African Americans in Baltimore. It was found that few African Americans use appropriate weight loss strategies such as increased physical activity and lower caloric intake to lose weight (Clark et al., 2001). A research study that was aimed at increasing activity and improving diet in low income African American children in Oakland consisted of a two week program at a YMCA that involved activities that focused on self-esteem and cultural pride in

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addition to physical activity and nutrition counseling. Parents were invited to attend educational sessions as well. Glucoregulation was measured with these children as diabetes is common in this population. After one year the children who attended the program had improved glucoregulation and decreased BMI (Ritchie et al., 2010). Studies that addressed barriers to increased physical activities found that safety was the most important determinant in predicting activity. High crime rates deterred people from leaving their homes and contributed to a low activity level. Non-safety factors such as lack of sidewalks or walking paths were viewed as less important (Griffin et al., 2008; Van Duyn et al., 2007). A second important factor linked to the increased incidence of obesity in low income neighborhoods is the lack of access to healthy foods. One study assessed the food environment in southwest Baltimore which is predominantly low income African Americans. It found that grocery stores with produce were not located close enough to walk to and to get to them involved complicated bus trips for those who did not have cars. Corner stores with processed foods and carryout restaurants were the closest places to obtain food. Recommendations were made to provide incentives to local stores to sell produce. Infrastructure support would be needed to enable to store owners to keep perishable foods. It was also deemed important to have a member of the community who could educate others about healthy eating (Haering & Franco, 2010). A study examining the relationship between the neighborhood environment and obesity determined that the availability of at least one store that offered healthy grocery options was linked to lower BMI. Walkability of neighborhoods was also related to lower BMI although increased density in lower income neighborhoods was linked to higher BMI (Zick et al., 2009). One other study assessed the availability of healthy food in urban St. Louis and conducted a survey of residents and their eating habits. From this information they launched the Garden of Eden which was a community run produce market in a

DECREASING OBESITY church that offered healthy food at reasonable prices. In addition, nutrition education was offered. This program was highly successful within that community (Baker et al., 2006). Physical activity and good nutrition are important for health and decreasing obesity. One theme which is apparent in all the aforementioned studies is that interventions need to be communitybased, utilizing social supports and be culturally acceptable to the population at which the intervention is aimed. Interventions Increasing physical activity and improving nutrition within the urban African American

population in Baltimore requires a multi-pronged approach. Targeting the children at the school level is important so that they grow up with physical activity as a normal part of their lifestyle and good nutrition as second nature. Physical education will be required in the schools with a minimum of 150 minutes per week in elementary school and 225 minutes per week in middle and high school. Schools will be required to offer only healthy food and beverages and smaller portion sizes will be available. Increased opportunities for physical activities need to be made available to communities. As physical activity has been shown to increase with structured activity, program funding would need to be obtained to support sports, dance and other suitable programs. Schools would allow use of their athletic facilities during non-school hours for community based programs. Area parks would also be used for these programs. Athletic leagues coached by members of the police force would provide an outlet for physical activity and help to bind the police force to the community. Addressing the safety concerns in many of these communities is the most difficult of all problems. Involving local jurisdictions to increase police presence in areas with high crime rates

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would be helpful. Activities that bind members of a neighborhood together also help to increase safety (Van Duyn et al., 2007) . Involvement of churches is known to be influential in changing behavior within the African American community (Griffin et al., 2008; Whitt-Glover et al., 2008). Increasing safety and providing structured programs promoting physical activity have been shown to be most influential in increasing the level of physical activity of residents of low income neighborhoods (Cohen et al., 2009; Griffin et al., 2008; McCarthy et al., 2007; Ritchie et al., 2010; Van Duyn et al., 2007)(Cohen et al., 2010)(Gallagher et al., 2010). Increasing the availability of healthy foods to the community is an important goal to improving health and decreasing obesity. The Garden of Eden project was a successful operation that worked with providers of produce and was able to obtain funding through grants. Healthy food was available at reasonable prices and the project also provided jobs for people in the community. It was based in a community church and this provided social cohesion for the operation within the neighborhood. Replication of this would be one intervention to improve access to healthy food within neighborhoods. Attracting grocery stores to low income neighborhoods can be difficult so it might be feasible to work with the stores that currently exist within the community. Local government could offer tax benefits, loans or loan guarantees to cover costs to improve the infrastructure, such as refrigeration, of existing stores so that perishable foods could be sold. Figure I illustrates how the above interventions lead to a decrease in obesity of a low income urban African American population. Conceptual Model The conceptual model was based on the KABB Change Theory developed by Donna Garske. In order for change to occur within a society knowledge is needed to make about how to make that change and why change is necessary. In the case of decreasing obesity, the African

DECREASING OBESITY American population of Baltimore needs to know how they can increase their activity, what constitutes healthy eating and how obesity contributes to poor health. This knowledge about activity is obtained as a child in school during physical education and passed on to parents.

Nutrition information is taught in classes given at the church in conjunction with the communitybased produce market. This market is supported by funding through government programs or private organizations. Produce is provided by local farmers. The church also teaches that by staying healthy one is taking care of Gods temple. Positive changes in attitudes toward health are developed. Changed attitudes about health influence the belief that physical activity and nutritious food do, in fact, promote health. Changes in beliefs lead to changes in behavior. In order for the behavior to occur, however, the environment must be suitable. In addition to the produce market at the church, other healthy food sources should be available such as the local corner store. Local jurisdictions can provide incentive or aid to help these local stores build an infrastructure that supports keeping and supplying perishable healthy food. The environment must also be safe to encourage increased physical activity. In high crime areas an increased presence of police can help with this. A cohesive community group that works together and participates in activities together also increases the perceived safety of a neighborhood. If healthy food is available and neighborhoods are safe then the people in that neighborhood will continue their changed behavior of increased physical activity and eating healthy food. This behavior will lead to a decrease in obesity. As obesity decreases feedback is provided to reinforce the belief that physical activity and healthy eating do promote health. Conclusion Obesity is linked to many chronic health problems such as diabetes, hypertension, heart

DECREASING OBESITY disease and cancer (Clark et al., 2001; Jen et al., 2007; Parra-Medina et al., 2010). In the low

income African American population of Baltimore obesity is increasing. Intervention to promote increased physical activity and healthy eating has been shown to lead to decreases in obesity (Ritchie et al., 2010). An intervention which starts at childhood and incorporates adults as well to provide knowledge about exercise and nutritious foods will help change attitudes about health. Involving community organizations such as the church lends strength to the intervention. Increasing available food sources by working with existing stores and developing markets at local churches encourages people to choose healthy foods. Structured programs at available facilities supported by a safe environment provide opportunities for increased physical activity. These combined interventions lead to changes in beliefs and behaviors and result in a decreased incidence of obesity and a healthier community.

DECREASING OBESITY Table 1 Review of Interventions Addressing Obesity

Author Ritchie et al., 2010 Intervention Controlled non-randomized trial. Two weeks at YMCA. Experimental group had activities focusing on improving diet, increased activity, self-esteem, cultural pride, behavioral competence. Parents received mailings and invited to nine 1-2 hr educational sessions. Control group at another YMCA and just allowed use of facility without additional programs. Population Children with at least one AA parent. BMI at or above 85%ile, 9-10 yrs old Results/Findings Glucoregulation improved after 1 year, more in boys than girls. More children in experimental group decreased their BMI than in control group.

Haering & Franco, 2010

Operation Reachout Southwest 2006-2007 Community Food Assessment. Led by residents and community stakeholders. Food store survey. Survey of residents re: eating habits and food access

Residents of southwest Baltimore, mostly AA with high rates of obesity, HTN, diabetes

Baker et al., 2006

Assessed availability of produce and healthy food at area stores in various areas both white and AA. Interviews with residents about institutions that were important within the community

AA in low income areas in St. Louis

Cohen et al., 2009

ParraMedina et al., 2010

Clark et al., 2001

Assess effect of improving parks on increasing physical activity. Of 10 urban parks in CA, 5 were improved and 5 were not. Improvements: improve or build new gym, new picnic areas, upgrade walking paths, enhance playground. Sports programs. Interviewed residents and counted # of people in parks Randomized, controlled trial compare standard intervention to comprehensive care (std care and phone counseling and reading material over 12 months) on changes in physical activity and dietary fat intake at 6 and 12 months Described factors that are related to obesity and approaches to weight

Residents around 10 urban parks in predominantly AA and Latino lowincome neighborhoods Low income AA women older than 35. Most obese with chronic health problems Inner city AAs in Baltimore

Rely on corner stores with processed foods, carryout restaurants and supermarkets that are not close by. Recommendations: Corner stores to stock healthy foods. Provide infrastructure improvement incentives to enable store owners to keep perishable foods. Improve relations btw residents and store owners. Educate about healthy food and preparation. Identify local champion. Citywide campaign to increase demand for healthy food. More difficult to get produce at stores in AA areas. Churches found to be important and trusted institution. Garden of Eden started: developed community run produce market in a church, transportation provided from church and senior citizens. Identified foods that communities favored (ie greens, sweet potatoes). Produce inexpensive, provide part time jobs > minimum wage, education on healthy eating. Community members own the project. Next project physical activity Park use declined in intervention and control parks. Funding for programs dropped and this influenced decrease in use of parks. Improved perception of safety in parks did not increase use. Programs and staffing seemed related to increased use.

No significant difference noted in dietary fat intake or amount of physical activity between groups.

Few AAs used recommended weight loss strategies of increased activity and lower caloric intake to try to lose weight. Study did not attempt to explain why. Some normal wt. individuals were trying to gain weight. Many felt they could not get the professional help they needed even if had insurance and seen a physician within the last year.

DECREASING OBESITY Table 1 Review of Interventions Addressing Obesity

Author McCarthy et al., 2007 Intervention Study of an 8 week intervention of promotion of nutrition and physical activity conducted at a black-owned gym. Intervention was skills training in regular exercise and nutrition education, integration of PA into lifestyle . Control group with sessions on womens issues. Evaluated a community based program to increase activity level of older adults by placing them as volunteers in elementary schools in roles to improve academics of children and increase activity level of adults. > 15 hours/week. Control group was placed on waiting list. Followed for 4-8 months. Descriptive study to determine the influence of safety and environment on physical activity in low income, high crime areas. Community residents participated in 3 meetings. Discussed what would assist them in increasing physical activity Population Obese, health AA women Results/Findings Intervention group had increased intake of fruits and vegetables at 12 month follow-up. Calories consumed decreased in both groups. Did not evaluate physical activity.

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Tan et al., 2006

Lower income older AA adults in Baltimore

Experimental group had increase in physical activity with 110% increase in those who reported low level of activity at baseline. Increase in minutes of activity per week from 220 to 270 in experimental group. Control group had decrease in activity. Importance of community being connected and close knit. Need for increased and visible law enforcement to decrease crime and curtail drug trafficking. Need for structured programs addressing physical activity programs. Safety issues related to crime was greatest concern vs nonsafety barriers to exercise (lack of walking paths, sidewalks etc.). Recommended social support through community leaders or church, neighborhood events and programs within the neighborhood. Participants increased number of steps by 28% after 12 weeks. Decrease in number of individuals who had been classified as sedentary or somewhat active. Increase in number of individuals classified as active.

Griffin et al., 2008

Low income AAs in suburban southeastern commumity

WhittGlover et al., 2008

Van Duyn et al., 2007

Pre and post intervention study of 3 month faith based intervention for increasing physical activity such as walking and moderate to vigorous activity. No control group. Intervention was eight weekly sessions focusing on behavior strategies to increase PA. Fitness instructor conducted 30 min fitness session. Opened and ended with a prayer and focused on perspective of personal health as a way of protecting the body as Gods temple. Kept weekly logs and used pedometers. Conducted focus groups to discuss the benefits of physical activity, proposed strategies to increase activity and barriers to interventions

AAs in suburban community in North Carolina, mostly women

Zick et al., 2009

Analysis to determine neighbothood factors related to increased BMI of residents. Data from the Utah Population Database was analyzed to determine linkages between food source availability and physical characteristics of neighborhoods to increased BMI.

Low income African American, Hispanics, Hmong, Native Hawaiians in Texas, Mississippi, California and Hawaii Neighborhoods in Salt Lake County

Better response to interventions that increase social support and improve areas where physical activity can take place. All groups supported activities that took into account cultural heritage. Health messages delivered by peers better received. African Americans motivated by church support.. Safety concerns seen as significant barrier (high crime rate, poor sidewalks, lighting) Access to at least one food source offering healthy food linked to lower BMI. No relationship noted between fast food outlets and BMI. Walkable neighborhoods and more people who walk to work linked to lower BMI in low income neighborhoods.

DECREASING OBESITY Figure 1

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DECREASING OBESITY References

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Baker, E. A., Kelly, C., Barnidge, E., Strayhorn, J., Schootman, M., Struthers, J., & Griffith, D. (2006). The Garden of Eden: Acknowledging the impact of race and class in efforts to decrease obesity rates. American Journal of Public Health, 96(7), 1170-1174. doi:10.2105/AJPH.2004.049502

Clark, J. M., Bone, L. R., Stallings, R., Gelber, A. C., Barker, A., Zeger, S., . . . Levine, D. M. (2001). Obesity and approaches to weight in an urban African-American community. Ethnicity & Disease, 11(4), 676-686.

Cohen, D. A., Golinelli, D., Williamson, S., Sehgal, A., Marsh, T., & McKenzie, T. L. (2009). Effects of park improvements on park use and physical activity: Policy and programming implications. American Journal of Preventive Medicine, 37(6), 475-480. doi:10.1016/j.amepre.2009.07.017

Cohen, D. A., Marsh, T., Williamson, S., Derose, K. P., Martinez, H., Setodji, C., & McKenzie, T. L. (2010). Parks and physical activity: Why are some parks used more than others? Preventive Medicine, 50 Suppl 1, S9-12. doi:10.1016/j.ypmed.2009.08.020

Gallagher, N. A., Gretebeck, K. A., Robinson, J. C., Torres, E. R., Murphy, S. L., & Martyn, K. K. (2010). Neighborhood factors relevant for walking in older, urban, African American adults. Journal of Aging and Physical Activity, 18(1), 99-115.

Griffin, S. F., Wilson, D. K., Wilcox, S., Buck, J., & Ainsworth, B. E. (2008). Physical activity influences in a disadvantaged African American community and the communities' proposed solutions. Health Promotion Practice, 9(2), 180-190. doi:10.1177/1524839906296011

DECREASING OBESITY Haering, S.A., & Franco, M. (Eds.). (2010). The Baltimore city food environment. Johns Hopkins Center for a Livable Future. Retrieved from: http://www.jhsph.edu/clf/PDF_Files/BaltimoreCityFoodEnvironment.pdf

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Jen, K. L., Brogan, K., Washington, O. G., Flack, J. M., & Artinian, N. T. (2007). Poor nutrient intake and high obese rate in an urban African American population with hypertension. Journal of the American College of Nutrition, 26(1), 57-65.

McCarthy, W. J., Yancey, A. K., Harrison, G. G., Leslie, J., & Siegel, J. M. (2007). Fighting cancer with fitness: Dietary outcomes of a randomized, controlled lifestyle change intervention in healthy African-American women. Preventive Medicine, 44(3), 246-253. doi:10.1016/j.ypmed.2006.08.019

Parra-Medina, D., Wilcox, S., Wilson, D. K., Addy, C. L., Felton, G., & Poston, M. B. (2010). Heart healthy and ethnically relevant (HHER) lifestyle trial for improving diet and physical activity in underserved African American women. Contemporary Clinical Trials, 31(1), 92104. doi:10.1016/j.cct.2009.09.006

Ritchie, L. D., Sharma, S., Ikeda, J. P., Mitchell, R. A., Raman, A., Green, B. S., . . . Fleming, S. E. (2010). Taking action together: A YMCA-based protocol to prevent type-2 diabetes in high-BMI inner-city African American children. Trials, 11, 60. doi:10.1186/1745-6215-1160

Tan, E. J., Xue, Q. L., Li, T., Carlson, M. C., & Fried, L. P. (2006). Volunteering: A physical activity intervention for older adults--the experience corps program in Baltimore. Journal of

DECREASING OBESITY Urban Health : Bulletin of the New York Academy of Medicine, 83(5), 954-969. doi:10.1007/s11524-006-9060-7

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Van Duyn, M. A., McCrae, T., Wingrove, B. K., Henderson, K. M., Boyd, J. K., Kagawa-Singer, M., . . . Maibach, E. W. (2007). Adapting evidence-based strategies to increase physical activity among African Americans, Hispanics, Hmong, and native Hawaiians: A social marketing approach. Preventing Chronic Disease, 4(4), A102.

Whitt-Glover, M. C., Hogan, P. E., Lang, W., & Heil, D. P. (2008). Pilot study of a faith-based physical activity program among sedentary blacks. Preventing Chronic Disease, 5(2), A51.

Zick, C. D., Smith, K. R., Fan, J. X., Brown, B. B., Yamada, I., & Kowaleski-Jones, L. (2009). Running to the store? the relationship between neighborhood environments and the risk of obesity. Social Science & Medicine (1982), 69(10), 1493-1500. doi:10.1016/j.socscimed.2009.08.032