articles
nature publishing group
Intervention and Prevention
Childhood Obesity Prevention: An Intervention Targeting Primary Caregivers of School Children Mozhdeh B. Bruss1, Timothy J. Michael2, Joseph R. Morris3, Brooks Applegate4, Linda Dannison5, Jackie A. Quitugua6, Rosa T. Palacios7 and David J. Klein8 Community-based participatory research (CBPR) was used to design and evaluate the effectiveness of a culturally relevant, science-based intervention for the prevention of childhood obesity in the Commonwealth of the Northern Mariana Islands (CNMI), a US Commonwealth in the western Pacific. This cognitive behavioral lifestyle intervention, Project Familia Giya Marianas (PFGM), was offered during the 2005–2007 school years in all CNMI public elementary schools over eight sessions to primary caregivers of 3rd grade children (N = 407). A crossover design was utilized with half of the schools offering the intervention in the Fall term, while the other half delivered the sessions in the Spring term. The primary outcome measure was change in BMI z-score. There was an intervention-dependent effect on BMI z-score, with program impact being a function of baseline BMI and the number of lessons attended. This effect was most apparent in students whose baseline BMI z-score was in healthy range (≥5 to 30 kg/m2 and 20% with T2DM (6). Childhood OW is also a growing concern with 34% of 2–11-year olds being ≥85th percentile BMI for age (7). When studying childhood obesity, differences in sociocultural values, beliefs, and practices among ethnic groups within a community must be considered (8). Community-based
participatory research (CBPR) is a method that engages community groups in development and evaluation of public health interventions. It forms academic–community partnerships to design, implement, and study interventions in a manner sensitive to the cultural diversity of its participants (9,10). To address the growing concern of childhood obesity, the CNMI Public School System, in partnership with public and private agencies and a multidisciplinary team of academic partners, designed and implemented a culturally relevant cognitive behavioral lifestyle intervention targeting primary caregivers (caregivers) of 3rd grade children (11). This study used CBPR to develop and evaluate the effectiveness of a culturally relevant adult caregiver–centered curriculum for the prevention of childhood obesity. The content of the curriculum was based on current scientific information and recommendations. As part of CBPR, careful attention was paid to a well-designed feedback loop, i.e., formative planning,
1 Department of Family and Consumer Sciences, Western Michigan University, Kalamazoo, Michigan, USA; 2Department of Health, Physical Education and Recreation, Western Michigan University, Kalamazoo, Michigan, USA; 3Department of Counselor Education and Counseling Psychology, Western Michigan University, Kalamazoo, Michigan, USA; 4Department of Evaluation, Measurement and Research, Western Michigan University, Kalamazoo, Michigan, USA; 5Department of Family and Consumer Sciences, Western Michigan University, Kalamazoo, Michigan, USA; 6Office of Curriculum, Instruction and Assessment, Commonwealth of the Northern Mariana Islands Public School System, Saipan, Northern Mariana Islands, USA; 7Health Educators, Hinemlo’ Network, Saipan, Northern Mariana Islands, Michigan, USA; 8Department of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA. Correspondence: Timothy J. Michael (
[email protected])
Received 12 June 2008; accepted 18 March 2009; published online 7 May 2009. doi:10.1038/oby.2009.111 obesity | VOLUME 18 NUMBER 1 | january 2010
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articles Intervention and Prevention training, evaluation, and reporting (12,13). Community members were engaged in all phases of the study, i.e., exploratory research, design and development of the intervention, and interventional research (14–16). The following were key elements of this CBPR study: (i) community–academic partnership built on trust and defined roles, (ii) research design and implementation, (iii) recruitment and retention, and (iv) interpretation of findings and strategic planning (9). The initial results of the implementation of the intervention are reported here. Methods and Procedures Intervention The intervention, entitled Project Familia Giya Marianas (PFGM), has been previously described (11). PFGM used a curriculum which was developed from (i) observational research findings on cultural practices of the caregivers related to diet, physical activity/inactivity, and weight normalcy; (ii) content and context expert input, review, and feedback; (iii) science-based recommendations for the prevention of childhood obesity; and (iv) evidenced-based strategies in delivering interventions to adult learners, i.e., facilitation and ROPES (a five-step lesson plan structuring described later) (17–21). The curriculum was divided into eight different 90-min sessions focused on the following topics: (i) promoting physical activity, (ii) recognizing and reducing sedentary activities, (iii) preserving self-esteem, (iv) weight normalcy and energy balance, (v) healthy eating environment, (vi) maintaining motivation, (vii) reading labels, and (viii) portion sizes. The intervention was delivered by school personnel (facilitators) in the elementary schools to primary caregivers of 3rd grade students. Each session focused on one of the eight topics and utilized the following ROPES format to engage primary caregivers:
Review: facilitators helped participants to establish where they are as learners in their understanding of childhood obesity concepts; Overview: facilitators helped participants to know the specific concept that would be covered in the session i.e., preserving self-esteem; Presentation: facilitators used a powerpoint presentation to discuss content related to each topic, i.e., reading food labels; Exercise: facilitators used cultural-based hands-on activities, discussion questions, role playing, and case studies to apply information gained in the presentation, i.e., highlight a behavior and engage participants to respond; and Summary: facilitators asked relevant questions and discussed takehome assignments related to the topic for family engagement, i.e., logging physical activity/inactivity. The curriculum focused on four key elements: (i) physiological and sociocultural, (ii) psychosocial, (iii) dietary, and (iv) activity and inactivity. Additionally, training of the facilitators, observations of the delivery of the sessions, and ongoing discussions between the community and academic partners were important aspects of this CBPR study. The adult caregiver–centered intervention was designed and evaluated to create and support a health promoting environment (12,13). Data collection and outcome measures Context relevant demographic, familial, and sociocultural variables discussed previously were identified for use in this study (8,22,23). These included maternal and paternal ethnicity of the child, caregiver and child’s age and gender, caregiver’s educational level, school lunch eligibility as indicated by the caregiver, household structure, history of prior participation in health education, and caregiver’s perception of child’s weight normalcy status. Physical measurements and calculations for both child and caregiver included height, weight, BMI, and percent body fat (%BF) and were obtained using SECA Height Roller S-206 and the Tanita TBF-310 (“foot-to-foot” bioelectrical impedance analysis), which has been validated and described previously (24). 100
The primary outcome measure of the study reported herein was the BMI z-score, with percentile categories computed from CDC 2000 reference data as utilized by other studies in this population (7,25). Current Centers for Disease Control and Prevention classification of childhood BMI status were used with underweight defined as
