Countless campaigns have been launched to steer schoolchildren toward healthy habits, and yet rates of childhood obesity and diabetes continue to soar. Celebrity endorsements, catchy catchphrases, and food pyramid redesigns have struggled to combat the allure of fast food and television in the battle for child health in the United States. But with childhood obesity rates tripling in the last 30 years and type 2 diabetes showing up earlier in life, there’s an urgent need for more effective programs to promote nutrition and exercise in kids. One strategy is to create more relevant programs, locally focused and tailored to the culture of the children the program is trying to help.
That approach inspired not one but two child diabetes prevention programs created by Medical Center researchers and tested with our neighbors on Chicago’s South Side. The two programs – called Reach-Out and Power-Up – are siblings, with similar designs, goals, and measures, but in slightly different populations and venues. The pilot studies, both published in recent months, demonstrate the challenges faced by researchers in creating effective, reproducible programs with a local focus…and also offer hope that a successful intervention is possible.
Before the programs could be designed, the first step was to listen. The research team, led by Deborah Burnet, professor of medicine and pediatrics, organized focus groups with overweight children and their parents to learn about their specific obstacles to improving health and gather ideas about the types of physical activity and classes that would appeal to them. For example, the African-American children said they would like to try martial arts and yoga, so instructors for those activities were recruited. The conversations laid the groundwork for programs that would take the unique circumstances of families on the South Side of Chicago into account.
“Nutrition and exercise are both behaviors we do in a social context; in a place, in a neighborhood, in the context of certain social mores and expectations and cultural factors,” Burnet said. “Food, especially – who cooks, where we learn how to cook, how do our tastes get shaped in what we like to eat – those occur in social and cultural contexts.”
While both programs were designed to improve the health and behavior of children, the targets were both the kids and their parents. In Reach-Out, families gathered at a local YMCA for 14 weeks, splitting into separate parent and child groups for the first part of each session and then reconvening for a combined activity. Sessions included grocery store tours, exercise training, cooking classes, and even a family basketball game. Scavenger hunts, relay races, and Family Feud-style review quizzes were used to keep the kids and their parents engaged. But addressing the family’s cooking and eating habits could also be a sensitive topic.
“Feeding is all bound up with caring and love, so it’s very complicated – if you tell grandma she’s not cooking for her grandchildren right, her feelings get hurt,” Burnet said. “So how do you do that in a constructive way so that grandma is valued, but also moves in this healthy direction?”
At the end of the Reach-Out pilot study, published in the Journal of the National Medical Association, the program earned glowing reviews from participants, who said that it helped reduce food intake, steered them toward new fruits and vegetables, and encouraged increased physical activity. However, the clinical improvements were modest, including slight dips in BMI z-score (which scales the measure to child age) and glucose-to-insulin ratio. The incremental changes might mean that very heavy kids need more help to get back to healthy habits, Burnet said: “Kids who are this big probably need a more intensive treatment and intervention than a weekly community-based program.”
Another place for improvement in Reach-Out may have been the artificial method of gathering the subjects – families were recruited from doctor’s recommendations, magazine advertisements, and flyers, and didn’t know each other before the class began. For Power-Up, Burnet’s group used a pre-existing, ready-made group: children in an after-school program at Woodlawn Community School. Though other health programs have been tested nationally in a school setting, Burnet thought that setting Power-Up after hours and away from academic pressures would be an advantage.
Once again, the researchers took community suggestions to help shape the program before it was launched. At Woodlawn, where students are taught about their African heritage, teachers suggested activities such as African drumming and dance that were already part of the curriculum. The program also needed to be adapted for a wider age range of children – from the 9-to-12 year-olds of Reach-Out to the kindergarten through sixth grade range of the school.
“They were a good partner, they really liked working with us, and they felt a sense of ownership,” Burnet said. “We didn’t just plunk it in there, they worked with us to think about how it would work in their setting.”
In the pilot study [pdf], Power-Up produced a larger drop in BMI z-score than Reach-Out. However, most of the improvement was seen in the kids who were overweight rather than the obese children, adding more evidence that very heavy kids need more than an educational program to produce dramatic improvement. Researchers also found it harder to include parents in the Power-Up program despite setting aside discussion time when the kids were picked up from the program. The next wave of Power-Up, starting up this fall, will include text messaging to parents with lessons and tips from the day’s session, Burnet said, to improve engagement with parents and try a cost-effective way to individualize programs even further.
“It’s a risk and a benefit; you want to tailor it enough to make it attractive to people but it becomes complicated the more and more you do,” Burnet said. “The ultimate degree of that would be personalized therapy, which would be very expensive with nutrition and exercise or personal diabetes goals care. Or is it? There may be ways to use technology to help us personalize things and that’s where these programs are going.”
Burnet DL, Plaut AJ, Wolf SA, Huo D, Solomon MC, Dekayie G, Quinn MT, Lipton R, & Chin MH (2011). Reach-out: a family-based diabetes prevention program for African American youth. Journal of the National Medical Association, 103 (3), 269-77 PMID: 21671531