Doing me! Sisters Working Together for a
Healthy Mind and Body:
Lessons Learned from a Community-Based
Participatory Weight Loss Intervention
with
ith Af
African
i
American
A
i
women
Angela Odoms-Young, PhD
Assistant Professor
U i
University
i off Illi
Illinois
i at Chi
Chicago
College of Applied Health Sciences
Department of Kinesiology and Nutrition
Overview
 Obesity and Overweight in African American
women.
 Weight
g Loss Interventions
 ORBIT
 Doing Me!
 Implications, Conclusions, Next Steps
Background: Obesity in America
 About 30% of Americans are classified as
obese, a body mass index (BMI) > 30 kg/m^2
 Obesity
y is associated with a varietyy of chronic
conditions:



Cardiovascular disease
Type 2 diabetes
Certain Cancers
 Racial/ethnic groups and other populations of
color are disproportionately affected
Source: Flegal, Carroll, Kit, & Ogden, 2012; Fitzgibbon et al., 2008;
Kumanyika et al., 2007
Doing me! Sisters Working Together for a
H l h Mind
Mi d andd Body
B d
Healthy
Purpose
 Use a community
community-based
based participatory
research approach to adapt an evidencebased intervention (ORBIT) for
implementation in a low-income African
American community
Background: Previous Research
 A recently
y conducted review of obesityy treatment
literature revealed more than 75% of the studies
either did not report an ethnic breakdown or did not
include a substantial number of black/AfricanAmerican participants

Even when studies had a substantial amount of
black/African-American p
participants,
p
, they
y were often
less successful at losing weight than white women
 Previous studies have shown that body image, family
roles,
beliefs, social-cultural
social cultural
roles spiritual and religious beliefs
history, identity, and food preference are important
factors to consider for weight loss and maintenance
Source: Fitzgibbon et al., 2008; Fitzgibbon et al., 2012
Background: The Need for Dissemination and
I l
i Science
S i
Implementation
 Health scientists have successfully developed and tested
a plethora of clinical and community interventions
demonstrated to treat and prevent medical and behavioral
illnesses.
 Leaders in research and clinical practice have noted,
there is still an enormous gap between what we know can
maximize the quality of health care and what is currently
being delivered in practice and community settings.
 More present than ever within the research community is
the belief that to optimize public health we must not only
understand how to create the best interventions, but how
to best ensure that they are effectively delivered within
clinical and community practice
practice.
Source: NIH, Office of Behavioral and Social Science Research
Interventions: Minimal Long-term
Impact
 Individual behavior change approaches have
shown minimal success in black women.
 Most interventions “Downstream” vs. “Upstream”.
Background: Cultural-Tailoring
Interventions
 Researchers suggest that cultural/community
targeting and tailoring intervention programs
could increase the success of weight-loss and
weight-maintenance
i ht
i t
in
i Af
African-American
i
A
i
women
 Understanding how to best tailor these
interventions is a challenge
 Surface Structure (languages, music, food,
etc.)
 Deep Structure (culture, social, historical
forces, etc.)
Source: Kreuter et al., 2003
Methods: ORBIT: The Obesity
Reduction Black Intervention Trial
 ORBIT is a randomized controlled trial designed
to assess the efficacy of a culturally proficient
weight loss and weight maintenance program for
black women.
 Outcomes included weight loss, diet, physical
activity
 Funded NCI (PI: Fitzgibbon-5 R01 CA105051)
Methods: ORBIT Study Design
Randomized=213
Intervention Group=107
Group 107
Control Group=106
Group 106
Weight Loss Intervention
(6 months)
th )
Control Newsletters
( months))
(6
6-month Assessment
6-month Assessment
Maintenance Intervention
Control Newsletters
18-Month Assessment
18-Month Assessment
Methods: Topics Covered in Six Month
Intervention and Control Newsletters
Methods: Baseline Characteristics
Characteristics
Intervention
(SD)(n=107)
Control (SD)
(n=106)
Age (years)
46.4 (8.4)
45.5 (8.4)
College Graduate/Professional
Degree (%)
39.3 (2.0)
49.1 (1.9)
42,500
42,500
Employed
p y Full time ((%))
72.0
71.7
Married/Living w/Partner
34.6
34.0
Children Under 18 Years
0.6 (0.9)
0.9 (1.3)
30-<35
33.6
25.5
35-<40
29.0
24.5
>40
37.4
50.0
Income (median)
BMI kg/m2 (%)
Methods: Class attendance for
intervention group participants
Months 1–6a
Months 7–18b
Percentage of classes
attended,
mean
53.0 (31.5)
27.1 (30.2)
Attended no. of
classes, no. (%)
9 (8%)
34 (32%)
Attended ≥25% of
classes,
l
no. (%)
79 (74%)
42 (39%)
Attended ≥50% of
classes, no. (%)
62 (58%)
32 (30%)
Attended ≥75% of
classes, no. (%)
34 (32%)
8 (7%)
aCohort
1 was offered 47 classes; cohort 2 was offered 46
46. bCohort 1 was
offered 66 classes; cohort 2 was offered 61.
BMI and Weight Change, Baseline to 6 Months,
B li to 18 Months,
M h andd 6-18
6 18 Months
M h
Baseline
Weight Loss at 6 months and 18
Months
Doing Me! Sisters Standing Together for a
Healthy Mind and Body
 4 month weight loss intervention in lowlow
income African American neighborhood in
Chicago
 Targets women 30-65 years of age
 Funded by
y American Cancer Society-Illinois
y
Division (PI: Odoms-Young)
 Adapts ORBIT to be implemented at the
community using CBPR
Vs ORBIT
Doing Me! Vs.
ORBIT
Doing Me!
Design
24 week weight loss + 1 year
maintenance intervention +
weekly MI during active
phase/monthly during
maintenance
16 week weight loss+ weekly
resource calls
Setting
University-based
Community-based
Cultural Adaptation
Culturally Targeted
Culturally-Community
Culturally
Community Targeted
Staff
African American Staff
African American and
Community Staff
Eligibility
y wide
City
g
((surrounding)
g)
Englewood
35-65 years of age
30-65 years of age
BMI 30-50
BMI 30-44 (plan to expand to
50)
Advisory Board
None
Professional/Community
Theory
Social Cognitive Theory
Social Cognitive Theory
Definition of CBPR
“ A Partnership approach to research that
equitably involves community members,
organizational
g
representatives
p
and researchers
in all aspects of the research process” Israel,
BA et al. (2001)
Comparison of Traditional Academic Research and Community-Based Research
Research Process
Traditional Research
CBPR
Goal of research
Advance knowledge
Betterment of community
Source of research
question
Theoretical work
CommunityCommunity-identified
problem
Designer of research
Trained researcher
Trained researcher &
community
R l off researcher
Role
h
O t id expertt
Outside
C ll b
Collaborator,
t
learner
l
Role of community
Subject of study
Collaborator, learner
Relationship of researcher
to participants
Short--term, taskShort
task-oriented,
detached
Long--term, multifaceted,
Long
connected
Value of research
Acceptance by peers (e.g.,
publication)
Contribution to community
change
Ownership of data
Academic researcher
Community
Means of dissemination
Academic conference,
journal
Any and all forums, media,
meetings, community
Strand K, et al. Community-Based Research and Higher Education: Principles and Practices.
San Francisco: Jossey-Bass & Co., 2003.
22
Setting: Englewood/West Englewood
Englewood: Social Context
 Among Chicago Community Areas with the
highest






% living
g below p
poverty
y
% childhood poverty
% housing
g vacancies
% unemployment
% very low birthweight
Mortality rate for cancer, heart disease (WE),
diabetes (E), and stroke
Source: City of Chicago Department of Public Health Community
Health Inventory, 2006
Foundation of Doing Me!
 Follow up semi structured interviews with 10
ORBIT intervention group participants and 30
Control group participants
 Data from previous studies from CBPR
partnership
Interviews
 Atlas.ti
 Constant Comparative Analysis




Coding
Organizing codes into themes, categories,
sub-categories
g
Definitions
Using the text data to explain itself

Build middle-ranged theoretical frameworks that
explain the collected data and specify
relationships among concepts
Interview Summary
Risk and
Protective
Factor
Determinants
Body Image
Spiritual and
Religious
Beliefs
Cultural
Norms and
Values
Culture of
African
American
Women
Social and
Family
Expectations
and Contexts
Food
F d
Preference
Social-Cultural
History
Interview Results: Body Image
 Ideal Body Shape/Weight

Being comfortable, proportioned, and satisfied; emphasis of shape
over weight; perceived pressures from men; perceived pressures
from community;
y p
perceived disadvantages
g of being
g
overweight/obese; when weight becomes a problem
 Self-Esteem

Motivation;
M
ti ti
comparing
i selflf tto others,
th
perceived
i d
benefits, emphasis of clothing
“I was at my happiest when I was like 175 pounds. I mean I was
comfortable at that and that’s not necessarily skinny for my body type.
I was comfortable
f t bl and
d I didn’t
did ’t really
ll thi
thinkk off it even though
th
h my ideal
id l
weight for my height probably says I should be like 140.”
Results: Spiritual and Religious
Beliefs
 Positive Influence/Motivation

Participants’ spiritual and religious beliefs
motivated them to take care of their body
y and
to adopt healthy habits
 Negative Influence/Coping Mechanism

Participants’ spiritual and religious beliefs
were used to define their current body
weight/shape
“I guess at times I’m like well, God put everybody on the earth different
sizes.
i
S
So, it d
doesn’t
’t really
ll matter.”
tt ”
Results: Food Preference
 Time Barriers
 Participants’ mentioned their busy schedules and how they do not
have time to prepare meals, this lead them to buy more fast food
 Cultural Barriers
 Foods that are eaten; preparation of food; differences between
generations
 Social and Family Preference
 Influence from friends/co-workers and from family
 Cost
 Foods p
purchased
“Yes, the closest thing you will see won’t be the healthiest thing that
you can get your hands on. If you wanted to get yogurt or something
that has yogurt and fruit and stuff in it, well that’s $4.99 and the cup is
this big but you can have something, you can have that Egg McMuffin
or whatever it is and that is this. That’s only a buck. You can have
hash browns and this and that and it’s only a dollar.”
Social-Cultural
Results: Social
Cultural History
 Generation Differences

Participants’ mentioned how a shift from a
physically
y
y active lifestyle
y to a sedentaryy
lifestyle led to current weight status
“The
The kind of food that people eat
eat. I mean you go antebellum and
you’re eating hog guts and leftover this and throwaway that and frying
everything to make it be reasonable and decent and it adds a lot of
calories but we’re not picking cotton anymore. So you don’t have to
physically get rid of all those extra calories that you’re ingesting and
food is more plentiful. I mean this is one of the few countries on the
planet where poor people have an obesity problem. In most places the
rich people have the obesity problem
problem. So
So, I mean what we’re
we re eating is
not nutritious but it’s highly caloric.”
Results: Social and Family
Expectations and Contexts
 Conflicts between Roles and Stress
Participants’ mentioned the many roles that AfricanAmerican women have within society and their family and
how it leads to stress
 Family Influence
 Family members influenced a habit of eating large portions
and the p
portions of others
 Social/Family Support
 Participant’s mentioned the support they receive from their
husband/boyfriend and how it influences their weight status

“We face a lot of stress. You know going out and working and being a
g
and a lot of black women I see,, we don’t think about
caregiver
ourselves. We think about others. We help others.”
Results: Cultural Norms and
Values
 Self-Realized Differences in Body Images between Cultures
Participants’ believed that white women placed more importance on
weight loss and weight maintenance than African-American women
 Barriers Caused by Physical/Outward Appearance
 Participants’ mentioned how a need to maintain appearance is a barrier
to being physically active
 Lack of Healthy Education
 Participants’
P ti i
t ’ shared
h d th
thatt th
they were nott ttold
ld what
h t iis h
healthy
lth and
dh
how
important it is to maintain a healthy body weight
 Comparing Ideal Size/Shape to Other Priorities
 Participants
Participants’ shared their priorities and compared it to the importance of
reaching an ideal size/shape

“So, I have to find a balance between my hair and my exercise and
that’ss a big problem
that
problem. It is a big problem because it’s
it s like I want to
exercise and that was one thing that I didn’t want. I don’t want to get
my hair all sweaty out and then I have to go you know that’s more
maintenance and it’s more expensive”
Englewood Food Access Project
 Builds on university/community partnership (6
years)





Low availability
y of types
yp of food retail options
p
Low availability of healthy food options
Low p
perceived food access/security
y and
marketing options
High stress/hectic lifestyles
Strong community
organizations/leaders/organizers
Emergent Themes
 Price

Plays a Role in Purchasing and Eating
Decisions




Value/Specials/Sales
Purchased Store Brands
Availability of Resources (Cash/Food Assistance)
No Waste (“If I buy it, you better eat it”)
Doing Me! Adaptation *new
new
1.
Introduction
Tools for Effective
Weight Loss
Dietary and physical activity
Guidelines, food diaries, MyPlate
1. Learn how to
self-monitor
2. learn how to
reduce calories
Setting
How to put self first, time
1. learn how to
Priorities/Readiness to management/stress, getting enough manage stress
Change/Sleep*
Change/Sleep
sleep Mindful Eating (element of
sleep,
2 learn how the
2.
mindfulness-based stress
amount of sleep you
reduction)
get affects weight
gain/loss
3. learn how to be
aware when you are
eating
Meal Planning
Planning a well-balanced meal for 1. learn how to plan
self, family, and holidays
a well-balanced
meal for self
2. learn how to
substitute favorite
foods for healthier
foods
3 llearn h
3.
how tto use
MyPlate for healthy
4. learn how plan
before you shop
Self-monitoring
Motivation, culture
Food preparation,
calorie intake,
labeling,
labeling My Plate,
Plate
culture
Doing Me! Adaptation *new
new
1.
Introduction
How to make smarter
1. learn how to make healthy
choices and stretch your decisions on a limited budget
produce
dollar
2. learn how to choose p
Portion Control
Portions, Food Labels 1. learn what a serving size is
2. observe what a typical
portion is and what it should be
3. learn how to read a food
label for macronutrients
4. learn what an appropriate
portion is
5. learn why portions matters
6. identify methods/tools for
measuring/estimating portions
Physical Activity-What’s Role of physical activity 1. learn physical activity’s role
Enough/Exercise
in weight loss, lifestyle in weight loss
Myths*
activities versus
2. learn the difference between
exercise,
exercise Guidelines
lifestyle activities versus
exercise
3. understand how much
exercise is needed for weight
loss
4 teach
4.
t
h the
th diff
difference b
between
t
frequency and duration
5. learn how to find target heart
rate
Grocery Store/Food
Labels(Lab)
Shopping, labeling
Self-monitoring,
labeling, food
preparation, My
Plate, food groups
Benefits of physical
activity, barriers to
physical activity,
culture
Doing Me! Adaptation
1.
Introduction
Hair*
Goal Setting/Checkin/Rate your diet and
exercise patterns
How to set realistic goals, review
weight loss and behavior change
progress to date
Stress management, using
Coping with adverse
meditation/spirituality
childhood
trauma/Coping
/C
in crisis//
dealing with
discrimination*
Cancer
Screening and guidelines
Motivation, culture
1. how to set
realistic weight-loss
and nutrition goals
2. Review progress
t date
to
d t
Self-monitoring,
motivation, culture
Self-monitoring
1 learn about
screening resources
2. learn what
screenings to
receive and how
frequently
Doing Me! Adaptation
1.
Introduction
Dealing with emotional Stress management, using
issues which trigger old meditation/spirituality/mantras to
behavior problems
stay on track
1. learn how to use
different stress
management
activities to assist
with weight loss
2.
1 learn how to
1.
make a favorite
meal healthier
Self-monitoring,
motivation,, culture
Extreme meal make
over (Lab)*
Healthy substitutes
Fast Food, Fast Fat
Identify pros and cons of fast food. 1. increase
Self-monitoring,
Making better choices when eating awareness of
shopping, calorie
on the run
intake, labeling
fat/calories in fast
food items
2.
2 identify lower fat
and caloric fast food
options
Overflow
Shopping, cooking,
Shopping
cooking
calorie intake,
culture
Doing Me! Adaptation
 Chicago Park District


Membership: Weight Room, Fitness Classes,
Child Programs
g
Case Resource Manager: Weekly calls to
address resource barriers (food security,
t
transportation,
t ti
housing,
h
i
gas/lights,
/li ht cargiving)
i i )
Doing Me!: Measures
 Anthropometrics (Weight, Height, WHR)
 Diet (24 hour recall)
 Physical Activity (Accelerometer)
 Blood Pressure
 Environmental (Shopping Behaviors
Behaviors, NEWS
NEWS,
Perceived Food Environment, Home Food
a ab ty, US
ood Secu
ty)
Availability,
USDA Food
Security)
 Psychosocial Measures (Black Superwomen,
Mindfulness,, CRYSIS,, Unfair Treatment,,
Perceived Stress, Spirituality)
Preliminary Data: Demographics
Characteristics
% (n=66)
Education
< High
g School
34
<Some/College
66
Income
<$40,000
56
>$40,000
44
Insurance
None
25
Public
36
Private
39
Preliminary Data: Demographics
Characteristics
% (n=66)
Children in House None
52
1 or more
48
Adult in House
None 38
1 or more
62
Assistance
Yes
53
No
47
Preliminary Data: Demographics
Characteristics
% (n=66)
Marital
Single
g
39
Married
22
Wid/sep/div
39
Occupation
Employed 59
Unemployed
41
CRYSIS Scale
Item
Did your income increase by a lot?
Did your income decrease by a lot?
Did you miss an appointment or have to change your
Did you miss an appointment or have to change your plans because you had no transportation to get there?
Did you look for a job?
Did f i d di ?
Did a friend die?
Were you a victim of a crime while in your own home?
Did you hear violence outside your home?
Did anything happen in your neighborhood or home that made you feel unsafe?
%
9.4
37.5
23.4
46.9
31 8
31.8
6.4
58.1
42.8
Implications, Conclusions, Next
Steps
 Interventions in Black women show limited
success
 Need for community-based,
y
, culturallyy
appropriate interventions
 Test efficacy
y of communityy adaptation
p
of
evidence-based intervention