For weight loss, working together is often the best approach (Fall, 2010)

November 29, 2010

The Active Living by Design grantee in Columbia, Mo., has worked hard to mobilize the community to bike more often. Here, several families enjoy a crisp fall morning. Photo courtesy of Active Living By Design.

The prescription for losing excess weight and avoiding heart disease and diabetes sounds simple – eat less in general, eat more fruits and vegetables, and move more. The hard part is helping real people fit those changes into their lives.

Researchers at UNC Gillings School of Global Public Health have found that, for many, community support helps make those behaviors stick. The School has a long history of creating, testing and implementing programs designed to engage groups of people to work together to improve their health.

One long-running effort based at the UNC Center for Health Promotion and Disease Prevention and led by a School researcher – HOPE (Health, Opportunities, Partnerships, Empowerment) Works – brought together low-income women in several rural counties in eastern North Carolina to form “Hope Circles” to support each other in healthier habits. Researchers reported that women who participated in the circles for six months lost an average of 4.5 pounds and also increased their physical activity significantly. Women in control groups didn’t lose weight.

UNC nutrition professor Marci Campbell, PhD, who led the effort, now studies the same intervention over a longer time period. Campbell’s project, Seeds of HOPE, centers the support circles around churches or other formal groups, as her initial study found these settings more effective than informal meetings in private homes. Findings by Campbell and colleagues appear in Journal of Women’s Health (October 2007).

Feedback from the communities involved in HOPE Works has led researchers to focus on improving economic as well as physical health.

“People were saying you can’t tackle obesity if women don’t have jobs or education, because they don’t have hope for the future. People will improve their health as part of an effort to improve their lives,” Campbell says.

The Threads of Hope organic cotton bags were sold last year at The Regulator Bookshop in Durham, N.C. Photo by Salli Benedict.

She and colleagues helped launch a model business, Threads of HOPE NC Inc., in Salemburg, a small town in Sampson County, N.C. The business provides women with management experience and draws on the sewing skills some had developed when the textile industry was vital in the eastern part of the state. Participants make custom tote bags from organic cotton and have filled orders for clients including the 2009 National Conference on Chronic Disease Prevention and Control.

Input from HOPE Works participants also led to HOPE Accounts, which combines HOPE circles with a matched savings program to help women meet a goal such as going back to school or starting a small business. That project is funded by a grant from the American Recovery and Reinvestment Act.

Listening to people in communities we serve is crucial if we are to solve complex health problems such as obesity, says Leah Devlin, DDS, MPH, former North Carolina state health director and a Gillings Visiting Professor of health policy and management at the School.

“The problems we face in North Carolina are complex and multifactorial, and they require creative solutions that engage all types of expertise that we have in the public health school. But those solutions also must include the will and desires of the community,” Devlin says. “We have to listen to communities to understand what they see as priorities and what ideas they have for solutions that will help us be more successful together.”

Campbell and Marlyn Allicock, PhD, research assistant professor of nutrition, also are applying strategies proven to help people eat more fruits and vegetables to an intervention in which military veterans are trained to counsel each other. They use motivational interviewing, which focuses on reflective listening and positive affirmations rather than on persuasion or advice giving. Those strategies were shown to help veterans eat more fruits and vegetables than did the standard Veterans Affairs weight-management program, in a pilot study published in the May-June 2010 issue of Preventive Medicine.

“We found that, due to other clinical responsibilities and time constraints, nurses are not necessarily the best people to do the counseling,” Allicock says. So she, Campbell and colleagues developed manuals and DVDs that train veterans to conduct the motivational interviewing for other veterans. The researchers currently are evaluating that intervention.

The School also collaborates with towns and communities to develop programs for healthy living.

Active Living By Design (ALBD), founded in 2001 by the Robert Wood Johnson Foundation, works with communities to build environments for active living and healthy eating. (See related story.)

ALBD staff members provide technical assistance to towns that have received grants from “Fit Community,” an initiative of the N.C. Health and Wellness Trust Fund.

“The problems we face in North Carolina are complex and multifactorial, and they require creative solutions that engage all types of expertise that we have in the public health school. But those solutions also must include the will and desires of the community.”

“Our role is to help communities identify those resources that are going to help make their project successful, not just over the course of the grant period, but beyond,” says Joanne Lee, a program officer with Active Living By Design.

For example, Lee worked with a community in Black Mountain, N.C., which planted gardens connected by walking trails. “They were able to get a permanent position established that included in its duties managing the gardens,” Lee says. “We also worked with the community to help establish a nonprofit coalition to generate funding.”

Another community intervention is led by Carmen Samuel-Hodge, PhD, research assistant professor of nutrition. Samuel-Hodge is testing a modified group weight-loss intervention to determine whether it is effective for low-income women when administered by county health department staff members rather than research team staff members. For example, to accommodate some women’s low literacy skills, she had them break into groups and choose a designated person to do any required writing. A preliminary analysis of her ongoing study in six North Carolina counties found that 40 percent of the women lost 5 percent or more of their body weight, a clinically significant amount.

“This was a better result than other studies targeting low-income populations have gotten,” Samuel-Hodge says. “A key element was the women helping each other,” she says. “A lot of the sessions were about problem solving, and the women solved their own problems. These were not teaching sessions. If the interventionist did more than 50 percent of the talking in a session, it was considered ineffective. The goal is for interventionists to guide the discussion. A lot of times the women are learning from each other. One person will come in and say, ‘I had a wonderful week, and here’s what I did.'”

Finding ways that people in communities can work together to get healthy is becoming ever more important as public health officials try to fight obesity with fewer resources. For example, Samuel-Hodge points outs that in July 2011, the North Carolina State Health Plan, through its Comprehensive Wellness Initiative, will begin requiring members with a body mass index above 40 to enroll in weight-loss programs or pay higher insurance co-pays. But how many state employees can afford the hundreds of dollars that private weight-loss programs may cost? Can communities provide other options that cost less but are still effective?

“We are finding that they can,” Samuel-Hodge says.

– Angela Spivey

Carolina Public Health is a publication of the University of North Carolina at Chapel Hill Gillings School of Global Public Health. To view previous issues, please visit www.sph.unc.edu/cph.