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THE BURDEN OF OBESITY |
Patricia B. Crawford is with the Center for Weight and Health, College of Natural Resources, and the Department of Nutritional Sciences and Toxicology, University of California, Berkeley. Wendi Gosliner is with the Center for Weight and Health, College of Natural Resources, University of California, Berkeley. Poppy Strode is with the California Department of Health Services WIC Branch, Sacramento. Sarah E. Samuels and Lisa Craypo are with Samuels and Associates, Oakland, Calif. At the time of this study, Claudia Burnett was with the California Department of Health Services WIC Branch, Sacramento. Antronette K. Yancey is with the School of Public Health, University of California, Los Angeles.
Correspondence: Requests for reprints should be sent to Patricia B. Crawford, DrPH, RD, Center for Weight and Health, College of Natural Resources, 9 Morgan Hall, Berkeley, CA 94720–3104 (e-mail: crawford{at}socrates.berkeley.edu).
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ABSTRACT |
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Six sites of the California Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participated in a staff wellness pilot intervention designed to improve staff self-efficacy in counseling WIC clients about childhood overweight.
A pre-post test design with intervention and control groups was used; outcome measures included staff perceptions of the intervention’s effects on the workplace environment, their personal habits and health beliefs, and their counseling self-efficacy.
Intervention site staff were more likely to report that the workplace environment supported their efforts to make healthy food choices (P < .001), be physically active (P < .01), make positive changes in counseling parents about their children’s weight (P < .01), and feel more comfortable in encouraging WIC clients to do physical activities with their children (P < .05).
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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It is not clear why young Latino children are at the greatest risk for being overweight.8 In the WIC setting, this phenomenon may be exacerbated by nutrition education techniques that are not well suited to Latino culture.9 Additionally, data from WIC have documented staff’s reluctance to talk to WIC mothers about their children’s weight.10 We postulate that 1 way to reduce staff reluctance to talk about weight issues is to engage staff in a health promotion program.
Traditionally, staff health promotion programs have not been instituted for the purpose of empowering health workers to better educate their clients.11 Rather, they have been designed to address the end point of employee health, specifically, to increase health awareness, to reduce health risk, and to produce positive health effects on the individual such as disease prevention.11 Further, staff wellness programs have been instituted to improve employee morale and reduce medical claims and absenteeism.12 Few worksite wellness programs have been conducted in community-based nonprofit settings. Both the content and the experience of participating in a staff wellness program provide workers with an opportunity for professional and personal development and may help empower them to make lifestyle changes. Additionally, these lifestyle changes may in turn enable staff who work with clients to be more effective counselors and role models.
The personal health habits of health workers have been found to be associated with their belief in the importance of the particular behavior for others. For example, Martin et al. found that 85% of dietetic professionals who exercised regularly rated exercise as a very important area of counseling versus only 48% of dietetic professionals who were nonexercisers.13 Physicians who exercised regularly were more likely to counsel their patients to exercise.14 Lewis and colleagues15 found significant associations between personal health habits and self-reported counseling practices in the areas of smoking, alcohol use, exercise, and weight control among physicians. Those with poorer health habits generally were not as likely to counsel patients about those habits, while those attempting to improve their own health habits counseled patients significantly more often than those who were not making such efforts. Even the act of disclosing one’s own health habits enhanced physicians’ ability to motivate patients to make healthy lifestyle changes.16
Self-efficacy or belief in one’s ability to perform determines whether behavior will be initiated, how much effort will be expended, and whether the effort will be sustained.17 In California, where most WIC staff are lay health workers rather than professionals, self-efficacy associated with the practice of healthy behaviors theoretically may exert influence on counseling practices. Use of lay health workers is believed to foster empathy and increased communication with clients.18 A high proportion of California WIC staff members are, like their clients, overweight. Modeling of behaviors from staff to client or peer to peer can be an effective way to facilitate the adoption of healthy behaviors. Further, the WIC environment offers a setting with only moderate sociodemographic distance between most staff and their clients and is thus an ideal setting for peer modeling influence.19 Sociodemographic similarities such as ethnicity and gender may enhance the opportunities for role modeling.20 Worksite health promotion programs are well suited to provide skill acquisition and demonstration as well as the social support that has been described by Marcus and colleagues as a primary predictor of sustained involvement.21
This article describes a pilot program instituted as part of the California Fit WIC project, which promoted healthy behaviors and a stronger sense of counseling self-efficacy among staff to improve their perceptions of their interactions with WIC clients. This 1-year staff health promotion program was designed to enable staff to counsel WIC clients more willingly and effectively with regard to prevention of childhood overweight. Outcome measures included staff perceptions of the intervention’s effects on the workplace environment, their personal habits and health beliefs, and their counseling self-efficacy.
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METHODS |
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Three California WIC agencies were selected to participate in Fit WIC from a pool of agencies that volunteered. Interested agencies were screened for their capacity to conduct the project, their ability to represent the variety of WIC programs throughout the state, and the degree to which they reflected the ethnic diversity of California WIC participants (70% of whom are Latino). After selection, intervention and control sites were assigned randomly. Intervention sites included a semi-urban area of Sacramento, a rural area of Ventura County, and an urban area of Los Angeles. All staff at each intervention site participated in all aspects of the Fit WIC program.
Intervention
California Fit WIC developed a multilevel intervention to prevent pediatric overweight, including staff training sessions on a variety of topics, the addition of new classes for WIC clients, and the organization of communitywide coalitions to address the issue.
The staff wellness intervention programs at the 3 sites were developed by local WIC managers with the support of the Fit WIC project staff. To initiate the staff wellness activities, each site received 1 half-day interactive training session conducted by 1 of the authors (A. K. Y.), an expert on wellness programs. While the training provided information on the "obesogenic" (or obesity-encouraging) environment of modern culture, especially in communities of color,22–24 it focused primarily on beneficial behaviors rather than weight loss and motivated staff members to eat more healthfully and to be more physically active.
A particular focus of the training session was to assist staff in identifying opportunities for making changes in organizational practices during the workday that might support their behavior change efforts. Examples of organizational change included offering healthy choices (e.g., fresh fruit or vegetables) when refreshments were served in meetings or celebratory occasions and integrating 10-minute exercise breaks into regular staff meetings or at certain times of the workday (on "company time"). Each staff person received workplace wellness English- and Spanish-language audio- and videotapes and other simple exercise materials. The wellness training also covered the importance of taking 10 000 steps a day.25 Pedometers were provided for all staff members.
Wellness programs implemented at the intervention sites included "brown bag lunches" in which staff members were encouraged to bring a healthy lunch from home, healthy food potlucks (in which staff members shared meals and recipes), "water drinking challenges" (staff were encouraged to increase daily consumption of water), lunchtime walking groups, "step challenges" (staff members encouraged one another to meet the 10 000 steps a day challenge), and the addition of on-site exercise equipment. Staff members were provided relatively low-cost incentive items such as lunch bags to encourage healthy lunches from home, water bottles to reinforce water consumption, and tote bags for purchase of produce at farmers’ markets. While the incentive items were consistent across sites, the actual programs varied slightly by site.
Data Collection
Staff completed self-administered questionnaires before and after the intervention. Pretested survey instruments were administered by a project staff member who was not a WIC employee. All pre-post questions were the same; however, baseline surveys included a limited number of questions designed only to assist in developing the Fit WIC intervention program, and final surveys included some program evaluation questions designed only to assess Fit WIC intervention activities and their impact on staff. Intervention site staff completed an extra exit survey that included a number of questions specifically evaluating the Fit WIC program.
Data Analysis
We compared answers from intervention and control groups using 
2 techniques to evaluate the categorical variables. For comparison of the dichotomous pre- versus post-intervention outcomes, we examined the number of persons who made positive changes and the number of persons who made negative changes for intervention and control groups and performed 2 tests to determine whether the proportions were different for treatment and control groups.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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). Most of the staff surveyed (69%) were WIC paraprofessionals. Site supervisors were registered dietitians. Most of the WIC staff were women (88% at intervention sites and 92% at control sites). Just over half of the staff members in each group self-identified as Hispanic, with approximately 18% Asian and 24% White. No staff members in either group were African American or American Indian. Staff at the intervention sites were on average older (75% were aged older than 35 years) than those at control sites (46% were aged older than 35 years). Intervention sites had more staff with a lower level of education (high school or less) than the control sites (25% vs 8%). Intervention site staff were more likely to report being overweight or obese than control site staff (61% vs 40%).
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). Intervention sites implemented more changes in the workplace environment than control sites. Staff at intervention sites were nearly twice as likely to feel that their workplace supported their efforts to be physically active (96% vs 58%, P < .01) and were nearly 3 times as likely to feel the workplace supported their efforts to make healthy food choices (84% vs 28%, P < .001). Nearly 3 times as many intervention site staff reported a change in the types of foods served during staff meetings and snacks over the past year (72% vs 24%, P < .01). Further, a significant number of intervention site staff members felt that physical activity had become a higher priority at their worksite during the past year (96% vs 71%, P < .05).
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). Greater increases in healthful behaviors were consistently reported for intervention site staff, although there were no statistically significant differences. While not significant, more intervention site staff reported feeling their health habits set an example for WIC participants (92% vs 73%, P = .076).
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). Staff differences were not statistically significant with regard to change in comfort in talking about weight issues, in helping children maintain a healthy weight, or in feeling that they had success in helping parents with their overweight children. Significantly more staff at the intervention sites reported making changes during the last year in the way in which they talked with parents about weight (92% vs 58%, P < .01).
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• "We are more active and we started to eat healthy."
• "We set the example for clients."
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Since prevention is the goal of programs to curb childhood overweight, information about healthful physical activity is profitably provided to all families, not just those with overweight children. This is particularly the case with Latino WIC parents, who frequently do not acknowledge that their child is overweight.9,26 WIC staff who are themselves sedentary may be hesitant to discuss healthy physical activity patterns with parents. We found that staff who undertook and enjoyed changes in workplace eating and physical activity were motivated to encourage physical activity with their clients. Even if weight isn’t explicitly discussed, the impact of the counseling on weight is potentially positive.
Relatively simple measures can be implemented in the workplace to enhance WIC staff members’ confidence in counseling WIC families. Increasing staff members’ sense of self-efficacy may facilitate counseling on sensitive subjects, while at the same time staff who themselves become committed to healthy behaviors serve as role models for their clientele. A supportive social context in which a role model initiates and performs physical activities with a group using an interactive style has been associated with greater enjoyment of physical activity and increased probability of subsequent engagement in the activity.27 Social support such as that available in a WIC work setting is a crucial ingredient to lifestyle changes for WIC’s nutrition educators and may set the stage for WIC to effectively offer physical activity opportunities for WIC clients.
To date, most worksite interventions promoting physical activity have disproportionately recruited White males of higher socioeconomic status,28 and the magnitude of effect in other populations has been small.29 Commitment of on-site organizational leaders, as manifested in role modeling of physical activity by participation in group activities,30,31 and conducting activities on paid time32,33 are factors associated with feasibility in these intervention efforts. These factors shift some of the responsibility and "cost" for healthy lifestyle change and maintenance from the individual to the societal level. Data from our study suggest that worksite staff wellness programs may benefit the clientele served in addition to the staff members themselves. This should be captured in cost-effectiveness analyses of these societal investments.
Staff overwhelmingly reported that participating in Fit WIC had positively affected their lives. By participating in a wellness program, staff became enthusiastic supporters of sharing health messages and felt more comfortable talking with parents about their own efforts. In a study of nurses as role models for patients, Connolly et al. likened their job to the sale of health.34 The best salespeople are genuinely committed to their product and model its benefits. The California Fit WIC staff became committed to a message of the value of healthy eating and physical activity.
WIC staff are well suited to serve as role models for WIC participants, as they share many demographic characteristics and understand many of the constraints faced by WIC participants: insufficient time for buying and preparing healthy foods or being physically active, limited resources for food or physical activity, and lack of access to healthy food and physical activity opportunities in their community.
Limitations
Our conclusions are limited by several factors. Only 1 component of a complex intervention project has been described here, the staff wellness component. Owing to the complex nature of the intervention project conducted, it was not possible to determine the degree to which staff wellness activities were specifically responsible for some of the reported results. However, staff reported being most affected by becoming healthier themselves. Some staff reported weight loss as a result of recent behavioral changes. Future studies might measure long-term staff weight changes as a result of participating in the program.
Although our results show promise for the success of staff wellness programs in this type of setting, any attempts to replicate our study should consider (1) increasing the sample size to permit more sophisticated statistical testing, (2) increasing the follow-up time, and (3) objectively validating self-reported data. Further, while we feel that using the empowerment model to justify the development of the staff wellness programs at the local level contributed to the degree of success they achieved, this model made it difficult to comprehensively evaluate the effort. It is important to note that staff wellness activities have been sustained in the year beyond the intervention period, which may also be attributable to positive staff changes and local ownership of the program.
This project took place during a time in which childhood overweight was getting a great deal of media attention. Many WIC sites were trying to address the childhood overweight problem during the Fit WIC project period. Accordingly, there was positive change reported at the control sites as well as at the intervention sites for a number of our outcomes. While staff reported feeling greater self-efficacy in counseling, this pilot study was not able to measure whether their counseling had changed or whether clients responded differently to their counseling.
Implications and Applications
More than 60% of the adult US population is currently overweight or obese.35 In this context, there is a high likelihood that a significant number of health care and social service providers, both professional and paraprofessional, are themselves overweight. This was found to be the case in WIC and is no doubt true for other agencies dealing with children as well as with adults. As we seek ways to slow the spread of the obesity epidemic or even reverse it, we must consider more upstream approaches that intervene within existing organizational structures. One such approach is to train providers and facilitate their adoption of healthy behaviors to increase the amount and effectiveness of their counseling. This approach has been proven to be effective with smoking.15 Enhancing health workers’ self-efficacy, a key construct of social cognitive theory, provides a theoretical underpinning for such an approach to effect behavior change.
The Fit WIC experience illustrates that supporting staff in achieving their own healthy eating and physical activity goals significantly increases staff commitment and enthusiasm for addressing healthful behavior patterns with clients in the WIC setting. Staff participating in Fit WIC achieved a high degree of personal satisfaction and felt more skilled in communicating about nutrition and physical activity with WIC clients.
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Acknowledgments |
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The authors thank the 6 participating California WIC sites, their staff, and participants. Special thanks to Gauri Rao, MS, RD, Marcie Hughes, RD, Margie Rose, MPH, RD, Melinda Pendleton, RD, Kim Frinzell, RD, and Laurie Green, MS, RD. Thanks also to Nancie Hughes and Sheila Stern for editorial assistance.
Note. The contents of this publication do not necessarily reflect the views or policies of the US Department of Agriculture, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government.
Human Participant Protection
Institutional review board approval was obtained from the University of California at Berkeley’s committee for the protection of human subjects. All subjects gave informed consent before participating in the program.
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Footnotes |
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Accepted for publication November 6, 2003.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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2. Mei Z, Scanlon KS, Grummer-Strawn LM, Freedman DS, Yip R, Trowbridge FL. Increasing prevalence of overweight among US low-income preschool children: The Centers for Disease Control and Prevention Pediatric Nutrition Surveillance, 1983 to 1995. Pediatrics. 1998;101:1–6.
3. Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. Pediatrics. 1999;103:1175–1182.
4. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337:869–873.
5. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med. 1993;22:167–177.[ISI][Medline]
6. Pediatric Nutrition Surveillance System Annual Report. Atlanta, Ga: Maternal and Child Health Branch, Division of Nutrition, Centers for Disease and Prevention; 1998.
7. Cole N. The Prevalence of Overweight Among WIC Children. Alexandria, Va: US Dept of Agriculture; 2001. Available at: http://www.fns.usda.gov/oane/MENU/Published/WIC/FILES/overwgt.pdf. Accessed April 7, 2003.
8. Crawford PB, Story M, Wang MC, Ritchie LD, Sabry ZI. Ethnic issues in the epidemiology of childhood obesity. Pediatr Clin North Am. 2001;48:855–878.[ISI][Medline]
9. Crawford PB, Gosliner W, Anderson C, et al. Counseling Latina mothers of preschool children about weight issues: suggestions for a new framework. J Am Diet Assoc. 2004;104:387–394.[ISI][Medline]
10. Chamberlin LA, Sherman SN, Jain A, Powers SW, Whitaker RC. The challenge of preventing and treating obesity in low-income, preschool children: perceptions of WIC health care professionals. Arch Pediatr Adolesc Med. 2002;156:662–668.
11. O’Donnell MP. Health Promotion in the Workplace. 3rd ed. New York, NY: Delmar Learning; 2002:64.
12. Stein AD, Shakour SK, Zuidema RA. Financial incentives, participation in employer-sponsored health promotion, and changes in employee health and productivity: Healthplus Health Quotient Program. J Occup Environ Med. 2000;42:1148–1155.[Medline]
13. Martin JB, Holcomb JD, Mullen PD. Health promotion and disease prevention beliefs and behaviors of dietetic practitioners. J Am Diet Assoc. 1987;87:609–614.[Medline]
14. Abramson S, Stein J, Schaufele M, Frates E, Rogan S. Personal exercise habits and counseling practices of primary care physicians: a national survey. Clin J Sport Med. 2000;10:40–48.[ISI][Medline]
15. Lewis CE, Wells KB, Ware J. A model for predicting the counseling practices of physicians. J Gen Intern Med. 1986;1:14–19.[ISI][Medline]
16. Frank E, Breyan J, Elon L. Physician disclosure of healthy personal behaviors improves credibility and ability to motivate. Arch Fam Med. 2000;9:287–290.
17. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84:191–215.[ISI][Medline]
18. Hainsworth J, Barlow J. Volunteers’ experiences of becoming arthritis self-management lay leaders: "It’s almost as if I’ve stopped aging and started to get younger!" Arthritis Rheum. 2001;45:378–383.[Medline]
19. Ramos IN, May M, Ramos KS. Environmental health training of promotoras in colonias along the Texas–Mexico border. Am J Public Health. 2001;91:568–570.[Abstract]
20. Yancey A, Seigel J, McDaniel K. Ethnic identity, role models, risk and health behaviors in urban adolescents. Arch Pediatr Adolesc Med. 2002;156:55–61.
21. Marcus B, Forsyth L, Stone E, et al. Physical activity behavior change: issues in adoption and maintenance. Health Psychol. 2000;19(suppl 1):32–41.[ISI][Medline]
22. Kumanyika SK. Minisymposium on obesity: overview and some strategic considerations. Annu Rev Public Health. 2001;22:293–308.[ISI][Medline]
23. Kumanyika S. Obesity treatment in minorities. In: Wadden T, Stunkard A, eds. Obesity Theory and Therapy. 3rd ed. New York, NY: Guilford Publications Inc; 2002.
24. Swinburn B, Egger, G, Raza F. Dissecting obesogenic environments: the development and application of a framework for identifying and prioritizing environmental interventions for obesity. Prev Med. 1999;29:563–570.[ISI][Medline]
25. Croteau KA. A preliminary study on the impact of a pedometer-based intervention on daily steps. Am J Health Promot. 2004;18:217–220.[Medline]
26. Myers S, Vargas Z. Parental perceptions of the preschool obese child. Pediatr Nurs. 2000;26:23–30.[Medline]
27. Fox LD, Rejeski WJ, Gauvin L. Effects of leadership style and group dynamics on enjoyment of physical activity. Am J Health Promot. 2000;14:277–283.[ISI][Medline]
28. Emmons KM, Linnan L, Abrams D, Lovell HJ. Women who work in manufacturing settings: factors influencing their participation in worksite health promotion programs. Womens Health Issues. 1996;6:74–81.[ISI][Medline]
29. Dishman R, Oldenburg B, O’Neal H, Shephard R. Worksite physical activity interventions. Am J Prev Med. 1998;15:344–361.[ISI][Medline]
30. Hammond SL, Leonard B, Fridinger F. The Centers for Disease Control and Prevention director’s physical activity challenge: an evaluation of a worksite health promotion intervention. Am J Health Promot. 2000;15:17–20.[Medline]
31. Yancey A, Miles O, Jordan A. Organizational characteristics facilitating initiation and institutionalization of physical activity programs in a multi-ethnic urban community. J Health Educ. 1999;30:S44–S52.
32. Pohjonen T, Ranta R. Effects of a worksite physical exercise intervention on physical fitness, perceived health status, and work ability among home care workers: five-year follow-up. Prev Med. 2001;32:465–75.[Medline]
33. Yancey AK, Raines AM, McCarthy WJ, Gewa C, Weber MC, Fielding JE. The Los Angeles Lift Off: a sociocultural environmental change intervention to increase physical activity in the workplace. Prev Med. 2004;38:848–856.[ISI][Medline]
34. Connolly MA, Gulanick M, Keough V, Holm K. Health practices of critical care nurses: are these nurses good role models for patients? Am J Crit Care. 1997;6:261–266.
35. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999–2000. JAMA. 2002;288:1723–1727.
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