Preventive Medicine

Preventive Medicine 34, 289–297 (2002) doi:10.1006/pmed.2001.0977, available online at http://www.idealibrary.com on

A Community-Based Obesity Prevention Program for Minority Children: Rationale and Study Design for Hip-Hop to Health Jr.1 Marian L. Fitzgibbon, Ph.D.,2 Melinda R. Stolley, Ph.D., Alan R. Dyer, Ph.D., Linda VanHorn, Ph.D., and Katherine KauferChristoffel, M.D., M.P.H. Northwestern University Medical School, Evanston, Illinois 60208-1230

Background. The increasing prevalence of overweight among children in the United States presents a national health priority. Higher rates of overweight/ obesity among minority women place their children at increased risk. Although increased rates of overweight are observed in 4- to 5-year-old children, they are not observed in 2- to 3-year-old children. Therefore, early prevention efforts incorporating families are critical. Methods. The primary aim of Hip-Hop to Health Jr. is to alter the trajectory toward overweight/obesity among preschool African-American and Latino children. This 5-year randomized intervention is conducted in 24 Head Start programs, where each site is randomized to either a 14-week dietary/physical activity intervention or a general health intervention. Results. This paper presents the rationale and design of the study. Efficacy of the intervention will be determined by weight change for the children and parent/ caretaker. Secondary measures include reductions in dietary fat and increases in fiber, fruit/vegetable intake, and physical activity. Baseline data will be presented in future papers. Conclusions. The problem of overweight/obesity is epidemic in the United States. Behaviors related to diet and physical activity are established early in life and modeled by family members. Early intervention efforts addressing the child and family are needed to prevent obesity later in life. This paper describes a comprehensive, family-oriented obesity prevention program for minority preschool children. 䉷 2002 American Health Foundation and Elsevier Science (USA)

1 Supported by the National Heart Lung and Blood Institute Grant R01 HL58871 to Dr. Marian Fitzgibbon. 2 To whom correspondence and reprint requests should be addressed at Eating Disorders Research Program, 710 N. Lake Shore Dr., Suite 1200, Chicago, IL 60611. Fax: (312)908-5070. E-mail: [email protected].

Key Words: obesity; prevention; minorities; AfricanAmerican; Latino; child health. INTRODUCTION

Hip-Hop to Health Jr. is an obesity prevention program for preschool minority children funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health. The program is modeled after Hip-Hop to Health, a community-based cardiovascular risk reduction program that was conducted with 6- to 10-year-old African-American children and their families [1,2]. Hip-Hop to Health Jr. is also community-based and is conducted within Head Start programs in the Chicagoland area. The primary aim of Hip-Hop to Health Jr. is to alter the trajectory toward overweight/obesity in African-American and Latino preschool children. The 14-week intervention presents a developmentally, culturally, and linguistically appropriate integrated dietary/physical activity curriculum that targets preschoolers, while also including a parent component that addresses the dietary and physical activity patterns of the family. Although research has shown that eating and exercise patterns can be changed in individuals and families [3–8], little is known about the long-term effects of an early intervention program for preschool minority children. The critical question we address is, “Can we advance the science of obesity prevention by intervening early with an intensive program that will positively affect the weight status of a sample of preschool minority children?” Given that prevention is considered the best strategy for decreasing the rates of childhood obesity [9], the success of our intervention will be determined by the degree to which participants sustain changes over the longer term (i.e., at 12 and 24 months) and avoid obesity later in life. The current paper presents the rationale and design of the study.

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0091-7435/02 $35.00 䉷 2002 American Health Foundation and Elsevier Science (USA) All rights reserved.

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Obesity has reached epidemic proportions [10] with nearly 54% of the U.S. adult population being overweight (BMI ⱖ 25 ⱕ 30 kg/m2) or obese (BMI ⱖ 30) [11]. Obesity is associated with increased mortality and morbidity and is a known risk factor for the development of a range of chronic diseases. These include coronary heart disease, hypertension, diabetes mellitus, gallbladder disease, arthritis, and certain cancers [12]. Once obesity is established in adulthood, the probability of achieving and maintaining an ideal body weight is often an unrealistic goal [13–15]. Few people are able to maintain modest weight losses over long periods of time [15] and data indicate that most individuals completely relapse after 3–5 years [16,17]. The etiology of obesity is complex and it is probable that a myriad of biological, psychological, and social factors lie at the root of its expression. With regard to the role of genetics in the onset of overweight/obesity, research suggests that between 5% and 25% of the variance in weight within a population can be attributed to genetic variability [9,18,19]. Familial aggregation is evident in humans [20], but it is difficult to assess the contribution of genetics over and above that of a shared environment/culture [9]. Nonetheless, the human genotype has not changed substantially enough over the past few decades to account for the dramatic rise in obesity [21]. Accordingly, it appears that the strongest contributors to the current epidemic are environmental influences. In fact, it has been estimated that the environment bears 30% of the responsibility for the development of overweight/obesity [18,19]. The environmental factor that seems to contribute the most to the rising rates of obesity is the continued decline in energy expenditure that is not offset by an equal reduction in energy intake [21]. This problem is most prominent in minority populations [9]. The prevalence of obesity is 37.4% among African-American women and 34.2% among MexicanAmerican women [10] compared with 22.4% among white women. Although no clear consensus exists on the definition of overweight for children, this paper defines overweight as weight for height above the 95th percentile of the National Center for Health Statistics weight for stature and length growth curves [22–25]. Using this definition, more than 10% of preschool children in the United States are overweight [26]. Similar to the profile for minority adults [10], the problem is greater for both African-American and Latino children and greatest among Mexican-American girls [23,27,28]. Specifically, among African-American 4 to 5 year olds, 8.5% of the boys and 11.2% of the girls are overweight and among Mexican-American 4 to 5 year olds, 12% of the boys and 13.2% of the girls are overweight [23]. In contrast to these rates, 2.7% of white 4 to 5 year old

boys and 9.0% of white 4 to 5 year old girls are overweight [23]. As with adults, the prevalence of overweight in 4- and 5-year-old children increased between the National Health and Nutritional Examination Survey II (NHANES II) and NHANES III. However, there was not a significant trend for increasing prevalence of overweight among 2- and 3-year-old children. These data underscore the potential benefits of early prevention efforts [29]. Unfortunately, excess body weight in childhood is associated with excess weight in adulthood [30]. Furthermore, the percentage of overweight children who grow into overweight adults increases with age [31]. For example, 26 to 41% of obese adults were obese in preschool, and 42 to 63% were obese in elementary school [30]. Excess weight gain is a function of energy intake that exceeds energy expenditure [32]. Explanations for the increase in overweight include an increase in dietary fat consumption, decreased fiber intake, and a reduction in physical activity [32–37]. Interestingly, according to dietary intake data from NHANES, the average total caloric intake has not changed significantly for preschool children in the past 20 years [38]. The current recommended fat intake for individuals over the age of 2 years is 30% or less of the total daily caloric intake [39]. Increased dietary fat intake can contribute proportionately more calories than other macronutrients, and an excess of dietary fat has been linked to obesity [40– 42]. Ethnic differences in dietary fat intake by the age of 6 parallel ethnic differences in weight, with AfricanAmerican and Mexican-American girls showing significantly higher percentages of energy from dietary fat. The percentage of energy from fat was also higher for African-American compared to white boys [43]. In a sample of 4- to 10-year-old African-American and white children, the average of two 24-h recalls showed that the percentage of energy from fat was 35.3 and 31.5%, respectively [44]. The potential for weight gain caused by high-fat diets may be particularly problematic among low-income communities because fried and high-fat foods are marketed more heavily and, from a cultural perspective, a diet high in fast food is often viewed positively [45]. Counteracting these influences by exposing young children to tasteful low-fat foods would be an important component of early prevention programs. Unlike dietary fat, dietary fiber has not traditionally been linked with obesity onset. However, recent data from the Coronary Artery Risk Development in Adults study reported that in 2,909 participants, dietary fiber predicted 10-year weight gain, insulin levels, blood pressure, and other CVD risk factors more than either total or saturated fat [46]. The authors concluded that high-fiber diets might protect against obesity and CVD by lowering insulin levels [46]. Additionally, foods high

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in soluble fiber affect the insulin response. Decreased serum levels of insulin could also affect satiety because insulin enhances appetite [47]. High-fiber foods have increased bulk compared to high-fat foods, thereby contributing to increased satiety on fewer calories [9]. Few people in the United States meet the recommended 20–30 g per day. Observations of fiber intake in minority diets reveal that the African-American diet is relatively high in green vegetables, but low in fruits [48]. Unfortunately, native cooking methods for vegetables tend to include added fats [49]. The consumption of orange and green vegetables and citrus juice among Latinos is lower when compared to that of non-Latino whites [50]. In a sample of 173 low-income Mexican-American children, the daily fruit and vegetable intake was half of what is recommended by national guidelines [51]. Specific dietary patterns also appear to differ as a function of time since migration to the United States and level of acculturation. Those less acculturated eat a more traditional, high-fiber diet that includes rice, beans, salsa, and tortillas [52]. Latinos who are more acculturated often adopt a more westernized diet that is lower in these high-fiber foods [53]. In reference to children’s fiber intake, data show that overall only 45% of 4 to 6 year olds consume adequate fiber [54]. Therefore, it is important to address fiber intake in obesity prevention programs, but in a manner that is sensitive to the cultural traditions of each ethnic group. Some researchers focus less on dietary intake and more on energy expenditure as an explanation for the increased prevalence of obesity [55–57]. Overall, minority adults in the United States are less active than white Americans and this is even more pronounced for women [58]. This trend appears to be true in children as well. According to NHANES III data, vigorous activity in children aged 8 through 16 years showed that white children were the most active, with 77% of girls and 88% of boys reporting vigorous activity three or more times per week [59]. This is compared to a rate of 69% for African-American girls, 73% for MexicanAmerican girls, 78% for African-American boys, and 80% for Mexican-American boys [59]. One contributing factor to the low levels of physical activity seen among adults and children is the large amount of time spent watching television [60]. Studies show that preschoolers watch as much as 17 h of TV per week [61], and school age children watch approximately 25–26 h per week [61,62]. These rates may be even higher when considering only minority children. Again, looking at data from NHANES III, Andersen et al. [59] reported that African-American children reported 4 or more hours a day of TV watching, which is the highest rate among children. The effects of television viewing are far-reaching. Klesges and colleagues [62] found that

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television viewing was associated with a lower metabolic rate among children. Similar results were seen in NHANES III, with children who watched 4 or more hours of TV per day exhibiting higher BMIs than children who watched less than 2 h per day [59] Moreover, studies show that less active preschoolers gain more subcutaneous fat than more active preschoolers by the time they reach elementary school [63]. Many researchers believe that family environment is a critical variable in the development of childhood obesity [64]. Parental dietary and activity patterns strongly influence the adoption of weight control behaviors in young children [41,65–69]. Furthermore, parents and caregivers influence the variety and frequency of foods served to children through purchasing decisions, food preparation, and control over food accessibility [66]. Oliveria and colleagues [69] concluded that the nutrient quality of the diets of 3- to 5-year-old children is dictated by the eating patterns of their parents. Similarities within families are documented in relation to exercise behavior [70], eating behavior [71,72], and body weight [73,74]. This clustering of family characteristics suggests the value of the family as a critical unit upon which prevention and intervention strategies can be developed. Research indicates that intensive interventions including a familial component result in dietary changes that can be maintained at least 1 year beyond completion of the interventions [75]. Early intervention is of critical importance for obesity prevention. The primary avenues to address the prevention of obesity in this study are a reduction in dietary fat, an increase in dietary fiber, an increase in physical activity, and inclusion of the family. These behavioral precursors of overweight/obesity and attention to the supporting environment are the tenets upon which the current intervention is based. THEORETICAL FRAMEWORK FOR THE INTERVENTION

Nutritional and activity interventions are likely to be more successful when factors that influence choice related to health behavior change are well understood. Furthermore, when families are the focus of the intervention, it is critical to consider the individual developmental needs of the participants. Our intervention is based on a combination of the principles of social learning theory (SCT) [76,77], self-determination theory [78,79] and the transtheoretical model that incorporates stages of change [80]. SCT not only emphasizes the importance of social and interpersonal influences in behavior change, but also incorporates cognitive processes that are mediators of behavior change [7]. For both nutrition and physical activity, SCT suggests that modeling will help children try new foods and engage in new activities. Research shows that children are more apt to eat new foods if they

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see an adult model eating the food [81,82]. Similarly, preschool children who observe other children choosing vegetables that they themselves did not like later exhibit an increase in the intake of those vegetables [83]. These data support the observation that models can have a substantial impact on food selection if the model is similar to the observer or if the model is seen as an authority, as in the case of a parent/caregiver [84]. The same effect appears to be true for physical activity [85]. Parents and other important figures in a child’s life appear to influence physical activity patterns. The influence can be either direct, by providing a supportive environment that encourages exercise, or indirect, through modeling of a physically active lifestyle [86]. Children whose parents report being physically active are nearly six times more likely to be active than children whose parents report being inactive [86]. Data suggest that in order to increase the strength of this potentially protective effect, it may be more important to provide modeling of this nature during early childhood rather than during adolescence [87]. The second theoretical premise upon which we base our intervention is self-determination theory [78]. Selfdetermination theory distinguishes between behaviors that an individual does freely and those that an individual feels coerced to do [88]. The concepts of choice and participation in behaviors that are intrinsically motivating are important in understanding this theory. As such, this theory purports that children are less likely to enjoy or choose things that are forced on them and more likely to enjoy or choose things that are not forced on them [89]. Accordingly, research shows that controlling food intake can have a negative impact on children’s food preferences, as well as their ability to regulate their food intake [90,91]. Repeated exposure to new foods in a noncoercive environment is more likely to increase consumption, especially if children are allowed to handle and taste the unfamiliar foods [92–94]. We developed our curriculum with attention to activities that would promote choices related to food and physical activity. We sought to avoid situations in which there could be coercion to eat or be physically active. In doing so, we hoped to enhance the children’s sense of control and thus encourage increased intrinsic motivation for trying new foods and physical activities. A high degree of parental control over the content and quantity of a child’s diet produces children who demonstrate less energy regulation and less self-control [95]. Consistent with the philosophy of Head Start and documented research, our goal is to facilitate the emergence and enhancement of the self-regulatory skills that children naturally possess [96,97]. We have further applied the Stages of Change model for the adults [80]. The Stages of Change model was conceptualized as a framework to study the processes

of behavior change [80]. This model has been used successfully with problems such as alcohol abuse [98] and weight loss [99] and has shown promise as a framework for dietary [100] and physical activity behavior change [101,102]. Although the model has not been used extensively with minority populations, a study of AfricanAmerican women supported the stage construct for dietary fat [103]. Another study of 556 rural AfricanAmerican smokers found that the predictors of stages of change were identical to those found in other nonminority populations [104]. Similarly, researchers found that the model was equally applicable within a population of 2,875 Mexican-American smokers [105]. METHODS

Study design. Hip-Hop to Health Jr. is a 5-year randomized intervention study that targets 3- to 5-yearold children enrolled in 24 Head Start programs administered through the Archdiocese of Chicago’s Catholic Charities. Twelve of the sites were randomly assigned to receive the intensive intervention and 12 were assigned to the general health intervention. During the first year of the active intervention we conducted the intervention in 12 sites that serviced primarily African-American communities. During the second year of the active intervention, we will conduct the intervention in the second 12 sites, which service primarily Latino communities. Follow-up data collection is planned for 1 and 2 years postbaseline. The primary outcome variables for the children are height and weight. Secondary outcome variables include nutrient data from a 24-h dietary recall, food frequency data, nutrition knowledge data, and assessment of physical activity. The primary outcome variables for the parent/ caregiver are height and weight. Secondary outcome variables include data from a 24-h dietary recall, food frequency data, nutrition knowledge data, assessment of physical activity, parental support for healthy eating and exercise, and stages of change measurement for physical activity, fruits and vegetables, and high-fat foods. The Institutional Review Board approved this study for research participants. To participate, a parent/caregiver must sign an informed consent for themselves and their children. INTERVENTIONS

Development of the intervention. The treatment intervention was modeled after the traffic light diet [106] and tailored to the developmental and cultural needs of minority preschool children. A 3-week pilot was conducted exploring the feasibility and acceptability of the parental and child components of the intervention. The child pilot consisted of three 40-minute classes for each of the 3 weeks. The classes were divided into two 20minute segments with the first half focusing on nutrition-related information and the second half engaged

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in physical activity. The overarching theme of the nutrition lessons was the concept of “go and grow” foods with the emphasis placed on identifying and eating foods that will help you go and grow, while decreasing one’s intake of “slow” foods or foods that if you eat too much of them will make you slow. The pilot intervention emphasized hands-on learning and allowed children to learn concepts by seeing them, hearing them, and acting them out. The parental component of the pilot intervention included weekly 30-minute nutrition classes and twice weekly 30-minute aerobics classes. The content of the nutrition lessons paralleled the information offered in the children’s curriculum, but also covered feeding issues that are often of concern to parents of preschool children. For example, we covered topics such as how much preschool children need to eat, how to introduce new foods, and how to encourage fussy eaters to eat more fruits and vegetables. The pilot was quite successful, however; several important lessons were learned. First, although the children enjoyed the curriculum, the idea of different types of foods (go and grow vs slow) and food groups was difficult for the children to grasp. Therefore, we decided to create characters (in the form of puppets) that could serve as concrete representations of the food groups throughout the curriculum. Second, 40 minutes allowed little time for smooth transitions, so the class time was extended to 45 minutes. Third, we saw the need to dedicate more time to concepts related to the importance of physical activity in maintaining a healthy body, in particular, including activities that would challenge the high level of habitual television viewing. In terms of the parent pilot, the most critical observation was the poor attendance at the nutrition classes. Discussion in the postpilot focus groups provided important information on the mother’s preference to attain the information via a weekly newsletter that might also include “homework” reviewing the concepts presented. Mothers felt they could more easily accommodate this type of intervention into their schedules, as opposed to having to actually attend a class. This did not hold true for the aerobics classes, however. Uniformly, mothers reported wanting to have the opportunity to attend aerobics classes, assuming they were scheduled early in the morning or at the end of the workday. Using information learned in the pilot, we revised the child and parent components of the intensive intervention for the main study. Intensive intervention. The intensive intervention consists of a 45-minute class three times a week for 14 weeks. The classes begin with a group rhyme that serves to assemble the children and transition them from their Head Start activities to the Hip-Hop to

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Health activities. Following this, the children participate in a 20-minute activity related to healthy eating or exercise. These activities typically focus on one concept and emphasize interactive, hands-on learning. The goals of the activities are to emphasize the importance of healthy eating and exercise, to encourage the exploration of new foods, and to support the relationship among nutritious foods, consistent activity, and healthy bodies. Although the curriculum does present the idea that foods with too much fat or sugar in them can make children “slow,” at no time are foods ever identified as “bad” or “forbidden.” For example, the first class introduces go and grow foods vs slow foods using hand puppets representing characters from each of the food groups in the food pyramid (Miss Grain, Miss Fruit, Mr. Vegetable, Mr. Protein, Miss Dairy, Mr. Fat, and Miss Sugar). In this lesson, children learn that foods that have too much Mr. Fat or Miss Sugar are slow foods, whereas foods that are nutritious and don’t have too much Mr. Fat or Miss Sugar are go and grow foods. To reinforce the concepts learned, the children go on a picture food find. Pictures of various go and grow foods and slow foods are hidden around the classroom. Each child is asked to find one picture. The children then sit in a circle and take turns presenting their food picture. As a class they decide whether the picture is of a go and grow food or a slow food. The child then pastes his/ her go and grow food onto a large, green circle, or if it’s a slow food, they paste it onto a large, yellow triangle. All concepts are delivered in a developmentally and culturally appropriate manner and often incorporate use of the hand puppets. The last 20 minutes of each class are spent in aerobic activity. Keeping these young children moving for 20 minutes is a challenge and requires music and creativity. One of the favorite activities is “Going to the Zoo,” where children act out various motions of zoo animals. The parent component of the intervention consists of a weekly newsletter, homework assignments, and twice weekly aerobics classes. The newsletter follows the themes of the children’s classes, but also contains a homework assignment that reinforces concepts presented in the newsletter. For example, one newsletter presents information on the different types of milk, highlighting the similarities in vitamin and calcium content and underscoring the differences in fat content. A strong, easily understood rationale is presented for choosing 1% milk for themselves and their children. The homework is to purchase 1% milk (with the coupon included) and rate their own and their children’s responses. When the parents complete the homework and return it to the Hip-Hop to Health teacher, they are compensated $5. In addition to the newsletters and homework assignments, we also offer twice weekly 30minute low-impact aerobics classes at the children’s Head Starts. Class times are chosen based on polls

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taken at the baseline interviews. The concepts for the 14 weeks of the intervention are as follows. Week 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Concept Introduction to and go grow foods Food pyramid Portions Grains Fruits Vegetables A to Z Milk: Making the switch to 1% Protein Heart healthy exercise—Fitness part I Instead of TV, I could…Fitness part II Grooving moving—Fitness part III Healthy snacks Healthy me—Part I Healthy me—Part 2

The curriculum accommodates both Spanish and English speakers and is therefore written in both languages. At the Latino sites, two teachers present the curriculum, one teaching in English and one teaching in Spanish. This technique mirrors the method bilingual Head Start sites use in their own curriculum. In translating the curriculum materials, we used a back translation approach with decentering that was acceptable to the developers of the original English version [107]. General health intervention. The General Health Intervention consists of a 20-minute class, once a week for 14 weeks. All 20 minutes are spent on a general health activity. As with the Healthy Eating and Exercise curriculum, the GHI activities also emphasize hands-on active learning. Examples include learning to brush teeth correctly on egg carton teeth, demonstrating distracting techniques to cope with getting an immunization shot, and practicing the use of 911 in an emergency. The parent component of the intervention includes a weekly newsletter that parallels the information offered in the children’s curriculum. Examples of topics for this curriculum include dental health, using 911, immunizations, and reading readiness. Culturally specific intervention. Through developing this and other health promotion interventions for minority families, we have identified components that seem to improve the experience of the participants and the efficacy of the intervention. These components include: (a) easy and safe access to program; (b) fostering identification between interventionists and participants; (c) addressing cognitive (knowledge and attitudes) and environmental (social support, cultural attitudes, unsafe neighborhoods, conflicting responsibilities) barriers to exercise and adoption of a low-fat, high-fiber diet that includes more fruits and vegetables; (d) emphasis on behavioral demonstrations to facilitate

lifestyle changes; and (e) consideration for all levels of literacy. CONCLUSIONS

Hip Hop to Health Jr. is a randomized controlled intervention that will assess the effectiveness of an intensive obesity prevention intervention to alter the trajectory toward obesity in preschool minority children. Twenty-four Head Start sites administered through the Archdiocese of Chicago’s Catholic Charities are randomized to either an intensive intervention or a general health control intervention. Twelve of the sites serve primarily African-American families and 12 serve primarily Latino families. The children in the intensive intervention receive 45-minute sessions three times per week for 14 weeks. This curriculum combines social learning theory and self-determination theory to emphasize healthy eating and physical activity. These behaviors are highlighted through developmentally and culturally appropriate material that incorporates modeling, social support, and positive lifestyle choices. Parents receive weekly newsletters that introduce that week’s concept and that are written to underscore the importance of parental involvement and modeling in the eating and physical activity patterns of their child. These newsletters include homework assignments that reinforce material presented to the children. In addition, twice weekly aerobics classes are made available for parents at the intervention sites. Data support the increasing prevalence of overweight among 4- to 5-year-old children and emphasize the need for early prevention efforts. The goals of Hip-Hop to Health Jr. are consistent with the guidelines in “Dietary Guidelines for Americans,” recommending increased physical activity, increased daily fruit and vegetable intake with a goal of five servings per day, and decreased dietary fat with a goal of no more than 30% of daily energy intake [108]. ACKNOWLEDGMENTS We gratefully acknowledge the technical assistance of Jamie Gayle and the helpful comments of Lisa Blackman and Anita Wells in the preparation of this manuscript. REFERENCES 1. Fitzgibbon ML, Prewitt TE, Blackman LR, Simon P, Luke A, Keys LC, et al. Quantitative assessment of recruitment efforts for prevention trials in two diverse black populations. Prev Med 1998;27:838–45. 2. Stolley MR, Fitzgibbon ML, Blackman LR. Incidence of CVD risk in inner city Black youth. In: Society of Behavioral Medicine Annual Meeting; 1998. New Orleans, (LA); 1998. 3. Epstein LH, Valoski A, Wing RR, McCurley J. Ten-year outcomes of behavioral family-based treatment for childhood obesity [see comments]. Health Psychol 1994;13(5):373–83.

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