ADDRESSING OBESITY 1 Addressing Obesity in Hispanic Families Through a Family Centered Approach: An Educational Intervention for Providers Megan A. Munson Arizona State University ADDRESSING OBESITY 2 Abstract Current obesity statistics exceed national goals with Hispanics disproportionately affected. Evidence suggests a family centered methodology focusing on culture can positively improve weight loss, client satisfaction and participation. This project will evaluate use of culturally tailored resources for primary care providers to educate Hispanics on weight loss. Eight providers in a small practice in the Southwestern US were recruited to complete a pre- and postEBPAS tool after an educational session. A BMI form tracked provider use of the fotonovela intervention against preferred methods. Feedback on time spent educating and overall perception were collected. Four providers completed the pre-EBPAS, three completed the post-, one participated in the intervention, and six contributed project feedback. Descriptive statistics revealed an aggregate provider decrease of five-points post-educational session for attitude toward adopting EBP. The BMI documentation form demonstrated a 53% (n = 8) use of the fotonovela. However, there were five undocumented fotonovelas taken/given out postintervention. Key themes noted by providers included poor timing of the project, satisfaction with workflow and resources, and overall discontent for the fotonovela. Future implications include re-evaluating the project in a practice not undergoing significant changes with specific focus on timing of the intervention. Keywords: obesity, Hispanic, culture, primary care, family centered, health education, fotonovela ADDRESSING OBESITY 3 Addressing Obesity in Hispanic Families Through a Family Centered Approach: An Educational Intervention for Providers Obesity is a complex issue to address due to the many contributing factors that affect an individual’s weight. Genetics and behavioral aspects such as dietary patterns, physical activity, and culture play a large role (Centers for Disease Control and Prevention [CDC], 2016a). Health consequences in comparison to individuals with normal weight include shorter quantity of life and low quality of life related to cardiovascular disease, type-II diabetes, mental illness, physical pain and cancer (CDC, 2016a; Sung-Chan, Sung, Zhao, & Brownson, 2013; Thé, Suchindran, North, Popkin, & Gordon-Larsen, 2010). Family centered interventions have been recognized as superior models to weight management in families due to the unique blending of parental education and application of behavioral approaches to encourage lasting change for the entire family (Sung-Chan et al., 2012). This paper intends to illustrate the problem of obesity in Hispanic families, including the effects that culture plays in weight loss and an innovative strategy to address obesity in this population. Problem Statement Obesity in the United States (US) is a growing epidemic. Obesity in adults up to age 65 is described as a body mass index (BMI) of 30 kg/m2 or greater, with pediatric obesity occurring with a weight greater than the 95th percentile on CDC growth charts (CDC, 2015c; CDC, 2016c). While BMI does not directly measure body fat, it serves as a means of understanding the relationship between weight and health risks (Ogden, Carroll, Fryar, & Flegal, 2015). Nationally, approximately 36.5% of the adult US population and 17% of the pediatric population are considered obese, with a disproportionately larger percentage among Hispanics (CDC, 2015b; CDC, 2016b; Crespo & Arbesman, 2003; Ogden et al., 2015; Thé et al., 2010). Hispanics ADDRESSING OBESITY represent the second largest group of obese individuals in the US (CDC, 2015a). In 2015 alone, 73.9% of Hispanics in Arizona were classified as overweight, with 35.9% (95% CI [32.0, 39.8]) of those individuals classified as obese (CDC, 2015a). The prevalence of obesity for Arizonan Hispanic women is 45.7%, compared to 35.5% for their white counterparts. From 1999 through 2014, these obesity statistics have continued to rise (Ogden et al., 2015). Obesity is not just a problem for women. Research shows that obese parents typically raise obese children, with adolescents having a significantly higher probability of becoming severely obese (BMI greater than or equal to 40 kg/m2) in adulthood than their normal weight peers (Thé et al., 2010). There are many national initiatives focusing on a reduction in these obesity statistics. The Healthy People 2020 target is 30.5% or less of the population considered obese (Arizona Health Matters, 2012). With Hispanic women surpassing this benchmark, and 21.9% of their children qualifying as obese, these initiatives are falling short at addressing obesity in Arizona (CDC, 2016b). Due to this population’s high risk of adverse health outcomes and the plethora of modifiable risk factors, interventions with a focus on finding a leverage point need to be implemented (Terán, Belkic & Johnson, 2002). Psychosocial factors such as eating habits, level of activity, family values and acculturation play a key role in weight gain in Hispanics (Terán et al., 2002). Obesity is a multifaceted problem that requires a unique solution for lasting change. The impact of weight loss could have a profound effect on reducing chronic illness and contributing to quality of life in this target population. When it comes to weight loss, client outcomes, participation in care, and compliance all stem from the provider understanding the client’s culture and responding appropriately to these cultural values (Carteret, n.d.). Culturally, the family matriarch dictates these family values 4 ADDRESSING OBESITY 5 (Carteret, n.d.; Sorkin et al., 2014). When caring for a Hispanic client, the provider is in effect caring for the whole family. Because the Hispanic culture values family, a family centered intervention that focuses on mothers and their children needs to be implemented to address the health needs of the whole family. Family centered care focuses on the relationship between healthcare providers, patients and their families. This partnership allows for mutual decision making regarding planning, delivery and evaluation of healthcare, while appreciating the emotional, social and developmental needs of the family. Family centered care fosters empowerment in addressing the needs of the family as a whole while promoting wellness in a culturally relevant manner (Davidson, Lawson, & Coatsworth, 2012). Although Hispanic mothers may not be particularly motivated to make necessary changes to lose weight for themselves, if the family is encouraged to participate and cultural family values are included, it is probable that the client will be able to better achieve her weight loss goals and promote health prevention for her children, thus improving her overall health and the health of her family (Austin, Smith, Gianini, & Campos-Melady, 2013). Purpose and Rationale Treating obesity has been a challenge for the providers in a rural health clinic where 79% of the clients are Hispanic. The purpose of this paper is twofold. First, it will summarize available literature related to the treatment of obesity in Hispanic families and then discuss an intervention for providers that will guide efforts to focus on implementation of a family centered weight loss approach for their Hispanic clients. Background and Significance The idea of a family approach to weight loss is not novel. In a 1992 study, researchers set out to determine if a family intervention addressing weight loss in Hispanics had more of an ADDRESSING OBESITY 6 impact since evidence suggests that family centered lifestyle interventions are more culturally appropriate (Cousins et al., 1992; Sorkin et al., 2014). Results demonstrated a marginal change in weight loss with the family intervention group due to the Hispanic fathers’ refusal to participate in the group meetings. The men were cited as stating that health and nutrition are issues that concern the mothers (Cousins et al., 1992; Sorkin et al., 2014). While weight loss was low in the intervention group, the benefit of improving physiological measures such as fasting blood glucose and blood pressure could have a potentially large impact on overall health long term (Cousins et al., 1992). Many weight loss studies focus on support and behavior changes in dyads with spouses, but culturally, this has been recognized to be problematic as aforementioned (Sorkin et al., 2014). In another study that focused on a family intervention, mothers with diabetes and their overweight or obese adult daughters were paired together to encourage greater weight loss (Sorkin et al., 2014). This cross-generational study demonstrated that support from social networks that share similar health risk factors have the potential to promote significant changes in lifestyle behaviors (Sorkin et al., 2014). The authors discovered that one family member’s healthy lifestyle changes had the potential to catalyze similar effects in other family members (Sorkin et al., 2014). Most of the literature for family centered weight loss interventions are targeted at children, which remains the gold standard for addressing pediatric obesity (Bender, Clark, & Gahagan, 2014; Davidson et al., 2012; Kaplan, Arnold, Irby, Boles, & Skelton, 2014). Many of these interventions focus on the mother and child relationship. The notion is that with healthy behavior modification of one family member, others will follow suit (Kaplan et al., 2014). As is often the case with children, mothers are traditionally the individual who purchases and prepares ADDRESSING OBESITY 7 meals, making her a prime motivator and agent of change. While many pediatric obesity programs focus on the family, a meta-analytic review found that they were not family centered. Instead, the focus was placed on the individual in a group family setting, which limits the ability to assess family theory dynamics and how culture plays a role in health (Davidson et al., 2012). Family centered interventions are adaptive and allow for varying cultural needs and values (Davidson et al., 2012). Culture plays a large role in diet, activity, perceptions of weight and weight loss behaviors (Agne, Daubert, Munoz, Scarinci, & Cherrington, 2012; Lindberg & Stevens, 2011). In a qualitative study, focus groups of Hispanic women emphasized the importance of family and cultural foods to their quality of life. Common themes identified included children as motivators for weight loss, social isolation as a barrier to weight loss, and importance of tradition to health (Agne et al., 2012). The importance of family is emphasized in another study which found that Hispanic women cite commitment to family needs and family obligations as barriers that may impede personal weight loss efforts (Austin, Smith, Gianini, & Campos-Melady, 2013). The involvement of the Hispanic family in weight loss promotes not only adherence to weight loss programs, but improved outcomes (Agne et al., 2012; Austin et al., 2013; Bender et al., 2014). The importance of family in the Hispanic culture cannot be negated (Lindberg & Stevens, 2011). In addition, culture plays a role in what is viewed as healthy. While Hispanic women are not motivated by thinness, the importance of disease prevention and family health are viewed as essential (Agne et al., 2012; Lindberg & Stevens, 2011). Additionally, plump children are regarded as healthy (Agne et al., 2012). Culturally sensitive education and family centered interventions are necessary to promote health and wellness among Hispanic families. ADDRESSING OBESITY 8 There are sufficient studies to demonstrate that positive health behaviors in Hispanic women role model healthy habits for their children (Cousins et al., 1992; Klohe-Lehman et al., 2007; Sorkin et al., 2014). While the Cousins et al. (1992) study is older, it has shown promising results for family weight loss interventions if the limitations of the study (i.e, participation of the father) could be modified. Family centered interventions have also confirmed effectiveness for pediatric weight loss (Davidson et al., 2012; Kaplan et al., 2014; Klohe-Lehman et al., 2007). It is fair to conclude that by applying the same principles of a family centered intervention to Hispanic women and their children the outcomes would be similar. In a low-income rural primary care clinic in the Tucson area, interventions to address weight loss appear futile. Despite the time taken to deliver individualized diet and exercise counseling, little progress is made toward normalizing BMIs and weight percentiles. A large proportion of the clients seen in the clinic are low-income middle-aged Hispanic women with BMIs greater than 30 kg/m2. Providers are disheartened by the seemingly unchanged outcomes and clients are frustrated when it comes to weight loss education and interventions, but the issue lies deeper than cutting calories and increasing exercise. The Hispanic mother is the point of contact in the current clinic setting, and can function as the catalyst for change in the health of the entire family. Primary care providers are in a unique role to address health by focusing both on treatment of obesity in adults, and prevention for their children. This inquiry has led to the following clinically relevant PICO question: In a community health clinic, how does implementing an educational program for providers on family centered weight loss in Hispanic families affect patient education when compared to the current standard of care? Search Strategy ADDRESSING OBESITY 9 In order to understand the complex issue of obesity in Hispanic families, an extensive search of the literature was conducted. Initially, four databases were searched until articles began to reemerge. These databases included Web of Science, PubMed, Sage Premier, and PsychINFO for all available years to obtain seminal studies and encourage a wide knowledgebase on the topic. Inclusion criteria were studies that targeted overweight or obesity, family centered treatment, Hispanic population and original research. Exclusion criteria for each database included non-research articles, participants less than one year of age, and study focus other than overweight or obesity. A total of 10 articles were selected for inclusion for this literature review. Web of Science A search of Web of Science (Appendix A) using the terms Hispanic mothers and obesity was conducted for all years. Initial yields produced 272 articles. The search was refined using the years 2011-2017 resulting in 176 articles. This was further refined with the addition of the term family intervention, resulting in 32 articles. Of these, one was selected for further review. PubMed The search strategy in PubMed (Appendix B) included two sets of search terms. The first strategy utilized Boolean connectors and the terms Hispanic mother AND obesity AND family AND weight loss. This search resulted in 13 yields. The search strategy was adjusted to encourage a broader range of articles. This second search in PubMed utilized the terms Hispanic woman OR Hispanic women AND weight loss AND family. This search resulted in 39 yields. Four were selected for further review. One of these articles was also retrieved in the preliminary search of PubMed. Sage Premier ADDRESSING OBESITY 10 Sage Premier (Appendix C) was searched using the search terms family based AND weight loss AND obesity AND Hispanic with Boolean connectors. The search was limited to research articles between the years 2011-2017. A total of 453 articles were retrieved. Of these, two were selected for further review. PsychINFO A search of PsychINFO (Appendix D) was conducted using Boolean connectors and the terms obesity AND family intervention. The initial yield produced 1,082 articles. The search was refined to include English only peer reviewed articles that included participants in the following categories: childhood, preschool age, school age, adolescence, and adulthood. This search resulted in 55 articles, of which two were selected. Critical Appraisal and Synthesis The studies included in this literature review were analyzed using Melnyk & FineoutOverholt’s (2015) rapid critical appraisal checklists and placed in an evaluation table (Appendix E). Due to the multifaceted elements addressed in the clinical practice inquiry, the PICO question is best answered using a variety of study designs. Levels of evidence were evaluated using grades I-VI (Melnyk & Fineout-Overholt, 2015). Of the 10 studies, one was a randomized controlled trial (level II) and one was a systematic review (level I). The remaining study designs included lower levels of evidence (five level IVs and three level VIs). The studies conducted by Agne et al. (2012) and Lindberg & Stevens (2011) were well adept to address the cultural and social components of the PICO, while Austin et al. (2013); Kramer, Cepak, Venditti, Semler, & Kriska (2013); Li et al. (2015); Parra-Medina, Liang, Yin, Esparza, & Lopez (2015); and Siwik, Kutob, Ritenbaugh, Aickin, & Gordon (2012) addressed the feasibility of a family centered ADDRESSING OBESITY 11 model. Bender et al. (2014) uniquely designed a study to evaluate both the effects of culture and a family centered model on weight loss. Although many of the evidence levels for these studies are considered lower levels, validity and reliability of measurement tools were high and many findings demonstrated statistical significance. Common measurement tools included questionnaires for demographics or health status, and anthropomorphic measures of BMI and weight (Appendix F). Validity for these tools were underreported. However, one study demonstrated questionnaire validity with Cronbach’s alpha pre- and post-intervention. Scores ranged from 0.84-0.93 (Sorkin et al., 2014). BMI for Hispanic women when compared to body fat percentage is deemed valid with a Cronbach’s alpha of 0.94, and is 100% sensitive and 93.33% specific (Ocker & Melrose, 2008). Validity for weight measured by scales were not reported. No bias was noted among studies. Despite some missing information, the studies included had sufficient methodological rigor to inform practice. The conceptual frameworks utilized in the studies focused mainly on the Health Belief Model, Family Systems Theory, and Social Cognitive Learning Theory, revealing homogeneity, which can be seen in the synthesis table (Appendix F). Design methods, however, demonstrate heterogeneity. Three studies used focus groups or descriptive statistics to obtain qualitative data related to perceptions of obesity and factors that affect weight loss. Other study designs included quasi-experimental, sequential mixed methods, prospective pilot study, correlational, systematic review and a randomized controlled trial. Despite the differing methods, these studies all addressed a component of family centered or group based intervention effectiveness on weight outcomes. This diversity lends well to the various perspectives of the PICO. ADDRESSING OBESITY 12 All studies either exclusively or predominantly focus on the Hispanic population. Most study participants are women who are considered obese, with an ample number being overweight. A common theme among studies includes low socioeconomic status and low healthrelated education levels. Measurements demonstrate some homogeneity with a focus on a variety of questionnaires, BMI, food or physical activity logs, and weight. Two studies also included waist circumference. While one study did not report waist circumference values, the other study demonstrated a decreased measurement in adult participants; children demonstrated no change. Qualitative variables validate common themes of both barriers (health-related education and social isolation) and values (traditional foods, family involvement and health status). The quantitative variables of BMI, study attendance, calorie goal, physical activity goal, study related satisfaction, and waist circumference demonstrate some heterogeneity in scope, but homogeneity in focusing on overall weight loss, cultural factors affecting weight and satisfaction with family centered approaches to weight loss. Physical activity demonstrated neutral impact on weight, while two studies reported increased satisfaction and attendance. Four studies relate a family centered program to improved BMI, while also positively correlating with program attendance, program satisfaction and weight loss. Qualitative data suggests that by addressing both barriers and incorporating values into weight loss interventions, weight loss education would be more comprehensive and suitable for Hispanic families. Overall, the selected studies reveal both qualitative and quantitative factors that positively impact weight loss in Hispanic families. Conclusions The selected study demographics mirror the anecdotal demographics from the current clinic setting. Current obesity treatment in the clinical setting lacks a family focus. Evidence suggests that family centered care increases attendance in weight loss programs, improves ADDRESSING OBESITY 13 overall satisfaction, and increases the amount of weight lost. The Hispanic population values family and culturally tailored programs that include traditional foods and understanding of cultural norms. It is recognized that the Hispanic population is largely disadvantaged when it comes to health-related education level and socioeconomic status. It can be concluded that these factors affect BMI and must be considered when designing a weight loss program in this population. Given this evidence, it would be appropriate to include a family focus to weight loss interventions in the clinic setting. Programs should include elements of healthy traditional food options and physical activity that are culturally tailored to families, affordable and presented in an understandable manner. Contribution of Theoretical Model to Utility of the Evidence Given the emerging theme of cultural impact on weight, a theoretical model that addresses cultural competence is essential to guide implementation of an evidence based practice (EBP) intervention. The Purnell Model of Cultural Competence (Appendix G) is an organizational framework that addresses the themes of family, nutrition, activity, family roles, barriers and beliefs (Purnell, 2005). These themes were central in the review of the literature among this population. The model addresses 12 cultural domains in a figure that depicts interaction between the associated concepts. These cultural domains will be applied in the implementation of an educational intervention for providers to impact a clinical practice change that addresses obesity in Hispanic families utilizing culturally appropriate methods that address weight from the perspective of the person, the family, the community and society (Purnell, 2005). Evidence Based Practice Model to Guide Project Development ADDRESSING OBESITY 14 The Stetler Model (Appendix H) was developed for individual practitioners to design safe and effective practice improvements based on step-by-step processes for research utilization, application and evaluation (Stetler, 2001). The model is based off of six assumptions: a formal organization may or may not be involved; research utilization may be instrumental, conceptual and/or symbolic; other forms of evidence such as non-research related information may be utilized in decision making; internal and external factors can influence the use of evidence; data and evaluation provide probabilistic information; and poor understanding of research utilization and EBP can limit the usefulness of the project (Stetler, 2001, p. 274). Unique to this model is the allowance for theoretical and experiential data supplementation to the research. There are five phases that guide the process: preparation; validation; evaluation and decision making; translation and application; and evaluation (Stetler, 2001). Identification and confirmation of the clinical problem has been discussed with key practice stakeholders and measurable outcomes have been linked to national initiatives, namely Healthy People 2020. The best available evidence has been reviewed and evaluated for quality and clinical application. Key findings have been synthesized and documented for translation to the clinically relevant practice question. Given the lower level of evidence, the information renders a change at the practitioner level. In phase IV, an EBP plan was developed with the contribution and participation of key practice stakeholders. Stakeholder interest and project effectiveness determined that the practice change would be best received at the practice level. Project related materials were developed and evaluation tools obtained for use. Phase V concludes the process with an evaluation of the project as well as collecting evidence to support routine use in clinical practice or inform the need to revise the project to promote positive outcomes. ADDRESSING OBESITY 15 Project Methods Permission to conduct the EBP improvement project was granted by the Arizona State University Institutional Review Board for one year beginning August 8, 2017 (Appendix I). All eight providers at the clinic were recruited for participation in the project. Provider attendance at the educational session, participation in the intervention, and completion of the surveys were considered consent to participate. Setting and Organizational Culture The practice improvement project took place in a rural community health clinic that cares for low-income families in South Tucson. Until mid 2017, the facility has been privately owned and had little funding for EBP changes. The site sees many clients daily that live with one or more chronic illnesses, leading to complex care regimens and allows for ample opportunity to implement an EBP intervention. The clinic population served is made up of 78.9% of Hispanic clients, with 73.2% of all clients receiving state or federal assisted medical insurance coverage. Optum acquired the clinic site in 2017 with the goal of providing the healthcare providers and clients at the clinic resources to encourage healthier lifestyles and partnerships across the healthcare system (Optum, 2018). Optum prides themselves in utilizing technology, data and human capital in creating a positive healthcare experience for their clients (Optum, 2018). To date, the change in the organization has had little impact on the structure or mission of the rural community health clinic. Fotonovela A creative alliance was formed with HolaDoctor and a license for use of the selected fotonovela was granted during the project period (Appendix J). HolaDoctor is a Spanish language health and wellness digital network that connects the Hispanic community with ADDRESSING OBESITY 16 information related to health insurance, access to care, healthy living, health screening and chronic illness management (HolaDoctor, 2018). Fotonovelas are short story telling booklets that share health related information in an understandable, relatable and engaging manner (Hernandez & Organista, 2013; Hinojsa, Hinojsa, Nelson & Delgado, 2010). They are culturally adapted to the Hispanic culture and have been shown to improve Healthcare Effectiveness Data and Information Set measures and health literacy in Latinas (Hernandez & Organista, 2013; Hinojsa, Hinojsa, Nelson & Delgado, 2010). The selected fotonovela, You Only Live Once, was developed with the web designer at HolaDoctor to include additional resources for patient education and documentation. Inside the cover is a BMI sheet for the patient to document their current BMI, goal weight, reason for wanting to lose weight and a support person to assist in reaching the goal. The back cover includes local free and low cost resources for physical activity, nutrition services, activity tracking and medical management. These resources were translated to Spanish to be included in the Spanish fotonovela. Participants To be eligible to participate in the practice improvement project, participants needed to be 18 years of age or older, a licensed provider in the state of Arizona, and at least a part time employee of the chosen rural health clinic. Due to the small sample size, provider demographics were not collected to ensure privacy and blinded data collection. Provider educational demographics include three Nurse Practitioners, one Physician Assistant, two Medical Doctors and two Doctors of Osteopathy. Procedure ADDRESSING OBESITY 17 The practice improvement project occurred over a four-week period, beginning November 3, 2017 and ending December 1, 2017. Prior to the start of the project, providers were asked to fill out a pre-Evidence Based Practice Attitude Scale (EBPAS) to determine their overall attitude toward applying EBP in the clinic setting (Appendix K). All documentation was identifiable only with a provider created identification number, known only to the provider. All project related documents were left in a secure, central area in the practice for data collection. On November 3, 2017, a 30-minute educational session was conducted for providers and medical assistants (Appendix L). The educational session included information on current regional and national obesity statistics, a summary of the literature search guiding the project, and a description of family centered weight loss education for Hispanic patients (Appendix M). Providers and their medical assistants were introduced to the fotonovela, and encouraged to use this tool with their overweight or obese Hispanic clients. Both English (Appendix N) and Spanish (Appendix O) versions were made available in each clinic room. Medical assistants were encouraged to assist providers in documentation of client weight loss education using the BMI Documentation Form and instructed on making de-identified copies for data collection using a physical barrier (Appendix P). Following the educational session, providers were asked to complete a second EBPAS form to measure provider attitudes toward implementing EBP interventions after full understanding of the project and current literature. The post-EBPAS was requested within one week following the educational session. At the end of the four-week project period, all remaining fotonovelas were collected and inventoried. Providers were asked to complete an anonymous Provider Feedback Form to assess the use of the fotonovela in their practice and their overall feelings about the project and process ADDRESSING OBESITY 18 (Appendix Q). All documents and project related materials were collected on the final day of the project period. Budget The proposed project budget included staff incentives, photocopying of tools, presentation supplies and handouts, and travel to the clinical site for a total estimated cost of $685 (Appendix R). Total project costs came in under budget for a total of $515. Clinic staff declined a formal meal during the planned Lunch and Learn, which accounted for coming in under budget. Instead, staff incentives accounted for $95 of total project costs. Other costs included the photocopying of the fotonovela for $300, $85 in presentation supplies and handouts, and $35 for travel to the site. The clinic site chose to absorb the minimal cost related to copies of the BMI Documentation Form, as this modified form was a current standard of practice in the clinic. No funding was received to implement this project. Outcome Measures The EBPAS is a 15-item survey with a Likert scale ranging from zero, or Not at All, to five, or To A Very Great Extent (Aarons, 2004). Four domains are assessed in this tool: appeal (⍺=.74), requirements (⍺=.93), openness (⍺=.81) and divergence (⍺=.66). Face validity was determined by researchers and mental health providers. Construct validity was confirmed with a third study. The total reliability of the tool is ⍺=.79 (Aarons, et al., 2010). The BMI Documentation Form was used for data collection to measure the frequency of use of weight loss interventions. The clinic site was previously using a version of this form apart from the check box options for weight loss interventions and the addition of the fotonovela. The documentation form included the client’s exact BMI and BMI category based on age as outlined by the CDC (CDC, 2015c, 2016c). Interventions were listed with check boxes and included ADDRESSING OBESITY 19 common educational methods that were currently used by providers as well as the intervention of interest, the fotonovela. Providers could document as many interventions as were appropriate for the client visit. The Provider Feedback Form assessed provider understanding, time commitment, effectiveness and overall acceptance of the project in an eight-item tool. Provider understanding, time commitment and effectiveness were assessed using a five point Likert scale ranging from one, Strongly Agree, to five, Strongly Disagree. The remaining three questions were open-ended to assess provider acceptance of the project and allow for qualitative feedback. Providers were given the opportunity to state what they would change about the project to lend insight into their rationale for scoring. Data Collection and Analysis Outcome data of interest collected included attitudes related to implementing EBP into current workflow, patterns of use for family centered educational materials, and overall satisfaction with the project. Provider understanding and willingness to implement EBP findings into practice were measured comparing the EBPAS scores pre- and post-educational intervention. The post-intervention evaluation was collected using the Provider Feedback Tool four weeks following the educational intervention was put in place to measure the level of change in provider willingness to use the materials during the project period. A total of 80 English and 20 Spanish fotonovelas were printed and each exam room was stocked with copies of each for use by providers during the intervention period. Copies of the BMI documentation form were placed in each room as well, to assist providers in documenting each patient’s BMI and the interventions used during the visit, as appropriate. The sum of each intervention was calculated, with interest paid to the fotonovela. The remaining fotonovelas at ADDRESSING OBESITY 20 the end of the project period were collected and inventoried to compare to the number that were documented by providers. The Provider Feedback Form was collected on the final day of the project. The form used five Likert scale questions and three open ended questions to allow for adequate project feedback. Descriptive statistics were used to evaluate the effectiveness of the pre- and postEBPAS scores, measure the frequency of interventions from the BMI Documentation Form, and analyze the feedback from the Provider Feedback Form. Project Results A total of six of the eight providers participated in at least one aspect of the project, for a total of 75% provider participation. As aforementioned, demographics were not collected on providers to ensure that providers were unidentifiable from the data. However, each provider met inclusion criteria to be eligible to participate in the project. EBPAS The difference in scores from the pre-EBPAS tool (N = 4) and the post-EBPAS tool (N = 3) demonstrate an aggregate five-point decrease in provider attitude toward adopting EBP posteducational session (Appendix S). A closer look at the paired subscales indicate that there was a decrease in overall divergence pre- to post-, despite the unchanged median (Mdn = 2, 95% CI [2.50, 7.83] LL 1, UL 5 and Mdn = 2, 95% CI [-.48, 4.48], LL 1, UL 3, respectively) (Appendix T). The appeal subscale demonstrated a median drop of one point, however distributions remained unchanged pre- to post- (Mdn = 15, 95% CI [2.17, 23.83], LL 8, UL 16, and Mdn = 14, 95% CI [2.34, 23.01], LL 8, UL 16, respectively) (Appendix U). The requirement subscale had a slightly larger decrease in the median, however the distribution was similar, with slightly reduced variability (Mdn = 10, 95% CI [-3.41, 20.07], LL 3, UL 12, and Mdn = 8, 95% CI [- ADDRESSING OBESITY 21 1.06, 16.39], LL 4, UL 12, respectively) (Appendix V). The openness subscale demonstrated no change with a slightly larger distribution in the post-assessment (Mdn = 13, 95% CI [3.68, 19.65], LL 8, UL 14, and Mdn = 13, 95% CI [1.32, 22.01], LL 7, UL 15, respectively) (Appendix W). BMI Documentation Form One provider participated in documenting weight related client intervention documentation using the BMI Documentation Forms (N = 15) (Appendix X). Of the collected forms, the mean documented BMI categories were as follows: pediatric, overweight (n = 1); adult, obese (n = 13); and elderly, overweight (n = 1). The majority of clients received education on MyPlate (M = .73), followed by education on not skipping meals/eating three meals a day (M = .60), and the fotonovela (M = .53). There were eight documented fotonovelas; however, when inventoried, there were nine English and four Spanish fotonovelas that appeared to be handed out to clients (N = 13). Provider Feedback Form The Provider Feedback Form (N = 6) identified four key themes (Appendix Y). The first theme that evolved was that providers enjoyed the BMI Documentation Sheets. Providers stated that these forms maximized workflow when documenting client interventions and BMI for reimbursement purposes. The second theme that was strongly emphasized was that providers identified that the project implementation timing was poor. One provider stated, “It was bad timing with the new EHR [electronic health record]” (Provider one). Another theme that emerged was related to time spent implementing the project. When queried if the use of the fotonovela increased time spent education clients, 50% of participants (N = 3) stated that it did not increase time, and 50% stated that it did. However, one provider noted, “It provided useful ADDRESSING OBESITY 22 information in a practical way that patients could understand” (Provider four). Finally, 50% of the providers noted that they did not like the fotonovela. One provider stated, “They are embarrassing” and commented that “One patient said ‘no thanks’ and handed it back” (Provider one). Discussion In analyzing the pre-post EBPAS tool, provider one and three each had a one point increase; provider two had a seven-point decrease. It can be assumed that provider two was less likely to apply the intervention due to the decrease in appeal of the project. Providers also indicated they were less likely to implement a tool if it were a requirement and if they felt the tool was not as clinically relevant as their own experience. Two of the four providers felt that EBP was not clinically useful and less important than clinical experience after the educational session and introduction of the fotonovela. The providers were slightly less likely to implement EBP after the educational session based on a decrease in overall appeal of the tools. The requirements subscale demonstrated a slight decrease in post-educational intervention scores and variability, however, the scores clinically remained the same. Overall, the difference in scores indicated that providers were more likely to participate in the project prior to the educational session. This may have been due to the timing of the project or discontent for the fotonovela. Provider feedback offered insight into the acceptance and reception of the project. Despite significant attempts to obtain 100% participation on the Provider Feedback Form, 25% of providers did not participate in this portion or any portion of the project. Half of the providers who completed the Provider Feedback Form indicated that the fotonovela did increase the time spent educating clients, however, only one provider documented use of the tool. It can be assumed that at least two other providers have a perceived notion that the fotonovela increased ADDRESSING OBESITY 23 time spent on education, or participated in the intervention but did not document education on the BMI Documentation Form. With this missing data, it could also be assumed that clients may have been interested in the fotonovelas and obtained copies for themselves. Despite poor use of the interventional tool, providers enjoyed the BMI Documentation Form for their own use, despite their participation in the practice improvement project. Project Limitations Due to the small sample size, obtaining clinically significant data was not feasible. Consequently, even if all the providers had participated in the project as designed, drawing significant conclusions would have been difficult. The timing of the project coincided with a large EHR roll out. Prior to that, the site had previously been using paper charting. This transition caused significant stress for all clinic staff. The short duration of the project also played a role in the amount of data that was obtained. A longer project period might have resulted in more data and more significant results. In addition, only one provider completed the entire project, making it difficult to draw conclusion about the project as a whole. Implications for Future Practice Given the limitations of the study, repeating the project in a larger practice not undergoing significant changes may result in a larger data set. It was evident that timing was key, and having provider buy-in was necessary for project success. It is expected that repeat implementation of this project in a different clinical setting could have a potentially large impact on both the practice and clients. It would be anticipated that providers would see a steady increase in weight loss at each client visit with gradual improvement of physiologic indicators of health over time. Clients would be expected to report increased satisfaction with weight loss education, increased perception of control over health outcomes, healthier habits and overall ADDRESSING OBESITY 24 weight loss. In addition to physical changes, long-term implications include a decrease in the number of clients seen in the clinic that are categorized as obese and improved overall health indicators such as a decrease in glycosylated hemoglobin, blood pressure, pain and depressive symptoms. While these outcomes were not measured in this brief timeframe, it is expected that providers would continue to see positive changes after the end of this project period. Conclusion Primary care providers can positively impact weight loss efforts in Hispanic clients through addressing cultural values and limiting barriers. The evidence suggests that family centered programs increase participation, satisfaction and overall weight loss. Common barriers noted for this population include low health-related education levels and low income, which potentially lead to poor treatment adherence. There are key groups of stakeholders who will influence and be affected by an EBP change: primary care providers, their Hispanic clients, clinic management, and medical assistants. In order for a practice improvement project to be effective, providers and medical assistants must be active in providing culturally tailored education, clients must be willing to participate, and clinic management must be supportive of the proposed changes. ADDRESSING OBESITY 25 References Aarons, G. A. (2004). Mental health provider attitudes toward adoption of evidencebased practice: The evidence-based practice attitude scale. Mental Health Services Research, 6(2), 61-74. Aarons, G.A., Glisson, C., Hoagwood, K., Kelleher, K., Lanksverk, J., & Cafri, G. (2010). Psychometric properties and u.s. national norms of the evidence-based practice attitude scale (ebpas). Psychological Assessment, 22(2), 356-365. DOI: 10.1037.a0019188 Agne, A. A., Daubert, R., Munoz, M. L., Scarinci, I., & Cherrington, A. L. (2012). The cultural context of obesity: Exploring perceptions of obesity and weight loss among latina immigrants. Journal of Immigrant and Minority Health, 14(6), 1063-1070. doi:10.1007/s10903-011-9557-3 Arizona Health Matters. (2012). All data: Health/exercise, nutrition, & weight. Retrieved from http://www.arizonahealthmatters.org/index.php?module=Indicators&controller=index&a ction=dashboard&alias=alldata&localeId=158. Austin, J. L., Smith, J. E., Gianini, L., & Campos-Melady, M. (2013). Attitudinal familism predicts weight management adherence in mexican-american women. Journal of Behavioral Medicine, 36(3), 259-269. doi:10.1007/s10865-012-9420-6 Bender, M. S., Clark, M. J., & Gahagan, S. (2014). Community engagement approach: Developing a culturally appropriate intervention for hispanic mother-child dyads. Journal of Transcultural Nursing, 25(4), 373-382. doi:10.1177/1043659614523473 ADDRESSING OBESITY 26 Carteret, M. (n.d.). Cultural values of latino patients and families. Retrieved from http://www.dimensionsofculture.com/2011/03/cultural-values-of-latino-patients-andfamilies/. Centers for Disease Control and Prevention. (2015a). BRFFS prevalence & trends data. Retrieved from https://www.cdc.gov.brfss/brfssprevalence/. Centers for Disease Control and Prevention. (2015b). Overweight & obesity: Adult obesity prevalence maps. Retrieved from http://www.cdc.gov/obesity/data/prevalencemaps.html. Centers for Disease Control and Prevention. (2015c). Overweight & obesity: Defining childhood obesity. Retrieved from https://www.cdc.gov/obesity/childhood/defining.html. Centers for Disease Control and Prevention. (2016a). Overweight & obesity: Adult obesity causes & consequences. Retrieved from http://www.cdc.gov/obesity/adult/causes.html. Centers for Disease Control and Prevention. (2016b). Overweight & obesity: Childhood obesity facts. Retrieved from https://www.cdc.gov/obesity/data/childhood.html. Centers for Disease Control and Prevention (CDC). (2016c). Overweight & obesity: Defining adult overweight and obesity. Retrieved from http://www.cdc.gov/obesity/adult/defining.html. Cousins, J. H., Rubovits, D. S., Dunn, J. K., Reeves, R. S., Ramirez, A. G., & Foreyt, J. P. (1992). Family versus individually oriented intervention for weight loss in mexican american women. Public Health Reports (Washington, D.C.: 1974), 107(5), 549-555. Crespo, C. J., & Arbesman, J. (2003). Obesity in the united states: A worrisome epidemic. Physician & Sportsmedicine, 31(11), 23-28. ADDRESSING OBESITY 27 Davidson, K.K., Lawson, H.A., & Coatsworth, J.D. (2012). The family-centered action model of intervention layout and implementation (famili): The example of childhood obesity. Health Promotion Practice 13(4), 454-461. doi: 10.1177/1524839910377966 Hernandez, M. Y., & Organista, K.C. (2013). Entertainment-education? a fotonovela? a new strategy to improve depression literacy and help-seeking behaviors in at-risk immigrant latinas. American Journal of Community Psychology, 52, 224-235. DOI 10.1007/s10464013-9587-1 Hinojosa, M.S., Hinojosa, R., Nelson, D.A., & Delgado, A. (2010). Salud de la mujer: Using fotonovelas to increase health literacy among latinas. Progress in Community Health Partnerships: Research, Education, and Action, 4(1), 25-30. DOI: 10.1353/cpr.0.0106 HolaDoctor. (2018). About us. Retrieved from http://holadoctor.net/about-us. Kaplan, S.G., Arnold, E.M., Irby, M.B., Boles, K.A., & Skelton, J.A. (2014). Family systems theory and obesity treatment: Applications for clinicians. ICAN: Infant, Child, & Adolescent Nutrition, 6(1), 24-29. Klohe-Lehman, D. M., Freeland-Graves, J., Clarke, K. K., Cai, G., Voruganti, V. S., Milani, T. J., . . . Bohman, T. M. (2007). Low-income, overweight and obese mothers as agents of change to improve food choices, fat habits, and physical activity in their 1-to-3-year-old children. Journal of the American College of Nutrition, 26(3), 196-208. doi:26/3/196 Kramer, M. K., Cepak, Y. P., Venditti, E. M., Semler, L. N., & Kriska, A. M. (2013). Evaluation of the group lifestyle balance programme for diabetes prevention in a hispanic women, infants and children (WIC) programme population in the USA. Diversity & Equality in Health & Care, 10(2), 73-82. ADDRESSING OBESITY 28 Li, R., Raber, M., Mejia, L., Domenech, M., Brewster, A., Swartz, M. C., . . . Chandra, J. (2015). Development and feasibility of a culturally sensitive cooking and physical activity program designed for obese hispanic families. ICAN: Infant, Child, & Adolescent Nutrition, 7(2), 86-93. doi:10.1177/1941406414568563 Lindberg, N. M., & Stevens, V. J. (2011). Immigration and weight gain: Mexican-american women's perspectives. Journal of Immigrant and Minority Health, 13(1), 155-160. doi:10.1007/s10903-009-9298-8 Melnyk, B.M., & Fineout-Overholt, E. (2015). Evidence-based Practice in Nursing and Healthcare: A Guide to Best Practice (3rd ed.). Lippincott, Williams & Wilkins. ISBN-13: 978-1451190946 National Association of School Nurses. (2013). Purnell model for cultural competence by larry Purnell. Retrieved from https://www.nasn.org/ToolsResources/CulturalCompetency/ PurnellModelforCulturalCompetence. Ocker, L.B., & Melrose, D.R. (2008). Examining the validity of the body mass index cut-off score for obesity of different ethnicities. Journal of Multicultural, Gender and Minority Studies, 2(1), 1-7. Ogden, C.L., Carroll, M.D., Fryar, C.D., & Flegal, K.M. (2015). Prevalence of obesity among adults and youth: United states, 2011-2014. NCHS Data Brief, 219, 1-8. Optum. (2018). About us. Retrieved from https://www.optum.com/about.html. Parra-Medina, D., Liang, Y., Yin, Z., Esparza, L., & Lopez, L. (2015). Weight outcomes of latino adults and children participating in the Y living program, a family-focused lifestyle intervention, san antonio, 2012-2013. Preventing Chronic Disease, 12, E219. doi:10.5888/pcd12.150219 ADDRESSING OBESITY 29 Purnell, L. (2005). The Purnell model for cultural competence. Journal of Multicultural Nursing & Health, 11(2), 7-15. Siwik, V.P., Kutob, R.M., Ritenbaugh, C., Aickin, M., & Gordon, J.S. (2012). Families united/familias unidas development and implementation of a family-based group office visit model for the primary prevention of type 2 diabetes. The Diabetes Educator, 38(6), 811-821. doi:10.1177/0145721712461533 Sorkin, D. H., Mavandadi, S., Rook, K. S., Biegler, K. A., Kilgore, D., Dow, E., & Ngo-Metzger, Q. (2014). Dyadic collaboration in shared health behavior change: The effects of a randomized trial to test a lifestyle intervention for high-risk latinas. Health Psychology: Official Journal of the Division of Health Psychology, American Psychological Association, 33(6), 566-575. doi:10.1037/hea0000063 Stetler, C.B. (2001). Updating the stetler model of research utilization to facilitate evidencebased practice. Nursing Outlook, 49(6), 272-279. doi:10.1067/mno.2001.120517 Sung-Chan, P., Sung, Y.W., Zhao, X. & Brownson R.C. (2012). Family-based models for childhood-obesity intervention: A systematic review of randomized controlled trials. Obesity Reviews, 14, 265-278. doi:10.1111/obr.12000 Terán, L. M., Belkic, K. L., & Johnson, C. A. (2002). An exploration of psychosocial determinants of obesity among hispanic women. Hispanic Journal of Behavioral Sciences, 24(1), 92-103 Thé, N. S., Suchindran, C., North, K. E., Popkin, B. M., & Gordon-Larsen, P. (2010). Association of adolescent obesity with risk of severe obesity in adulthood. JAMA: Journal of the American Medical Association, 304(18), 2042-2047. doi:10.1001/jama.2010.1635 ADDRESSING OBESITY 30 Appendix A Database Search Strategy Web of Science ADDRESSING OBESITY 31 Appendix B Database Search Strategy PubMed ADDRESSING OBESITY 32 Appendix C Database Search Strategy Sage Premier ADDRESSING OBESITY 33 Appendix D Database Search Strategy PsychINFO ADDRESSING OBESITY 34 Appendix E Table 1 Evaluation Table Citation Agne et al. (2012) The Cultural Context of Obesity: Exploring Perceptions of Obesity and Weight Loss Among Latina Immigrants Country: USA Funding: RWJF Physician Faculty Scholars program and NIH Bias: none noted Theory/ Conceptual Framework HBM Design/ Method Sample/Setting Method: focus groups conducted until saturation Purpose: to examine perceptions of obesity and weight manageme nt among Latina immigrant women in Alabama. n: 25 Demographics: MA: 38 (22-65) Education: >9th grade 92%; high school 16%; not reported 12% USA X̅ years: 7 BMI: 25-29.9 (48%), >30 (52%) Setting: community based Exclusion: not listed Inclusion: foreign born Latinas, >/=19yo, BMI>25, non-pregnant, nondiabetic Attrition: 0 Major Variables & Definitions IV: moderator’s guide (HBM construct) DV1: perceptions regarding obesity DV2: contributors to weight gain DV3: prior weight loss attempts DV4: motivators/ program needs Measurement/ Instrumentation Data Analysis Findings/ Results Bilingual/bicult ural moderator/notetaker, added nonverbal behavior; audiotapes with translated transcripts verbatim Descriptive statistics: qualitative analyses were coded using inductive/deduc tive analysis; developed codebook until thematic saturation DV1: health risks, aesthetics, symptoms DV2: social isolation, marriage, pregnancy, changes in diet and PA, depression, stress DV3: crash diets, supplements, diet pills, and exercise DV4: include traditional foods, family, and PA; C as motivators Demographic questionnaires Short Acculturation Scale for Hispanics (reliability 0.92; validity 0.520.76) Quality/LOE; Decision/Application for practice LOE: VI Strengths: strong design; culturally tailored; sample 100% Mexican F with ­ BMI; qualitative allowing for themes to emerge to saturation Weaknesses: low level of evidence Conclusions: good for use in practice to understand cultural perception and barriers; generalizable to Mexican women 22-65 yo Likert scale of acculturation Key: A: adult; APA: American Psychological Association; BI: behavioral intervention; BMI: body mass index; c: control; C: child(ren); CA: cancer; CBT: Cognitive Behavioral Theory; DM: Diabetes Mellitus; DV: dependent variable; F: female; FND: foundation; FST: Family Systems Theory; FQHC: Federally Qualified Health Center; HBM: Health Belief Model; HM: Hispanic mother(s); HPM: Health Promotion Model; HTN: hypertension; i: intervention; IV: independent variable; LOE: level of evidence; MA: mean age; N: number of studies; n: number of participants; NIH: National Institutes of Health; p: alpha value; PA: physical activity; PS: pilot study; PV: predictor variable; RCT: Randomized Controlled Trial; RWJF: Robert Wood Johnson Foundation; SCLT: Social Cognitive Learning Theory; SD: standard deviation; SR: Systematic Review; SS: Spanish Speaking; SSB: sugar sweetened beverages; SMM: sequential mixed methods; SW: Southwester; T1: pre-test; T2: post-test; U: university; USA: United States of America; WIC: Women, Infants and Children; x̅ : mean; YO: year(s) old ADDRESSING OBESITY Citation Austin (2013) Attitudinal Familism Predicts Weight Management Adherence in MexicanAmerican Women Country: USA Funding: APA Minority Fellowship Dissertation Grant; U of New Mexico Graduate Research and Development Grant; U of New Mexico RWJF Center for Health Policy Dissertation Fellowship Bias: none noted Theory/ Conceptual Framework Inferred to be FST 35 Design/ Method Sample/Setting Design: Quasiexperiment al Purpose: whether attitudinal familism predicted poorer adherence to a behavioral weight manageme nt program in Mexican– American women n: 100 F Demographics: MA: 45.07 X̅ years education: 15.05 C total: 1.97 C in home: 0.96 X̅ BMI: 33.04 Waist to hip ratio: 0.86 X̅ family income: $44,000 Setting: community Exclusion: pregnant/planning in 6 months; moving >50 miles from the study area; lack of English proficiency Inclusion: 18–65 yo; BMI >/= 25 and /=30:63% Gestational DM: 29.6% Parent/Sibling with DM: 26% Setting: 2 urban WIC sites Exclusion: attend <75%; pregnant/given birth in last 6 weeks; no medical clearance Inclusion: SS, Dallas WIC relative; 18 yo/>; BMI >/= 26; read Spanish; non-DM Attrition: 37%, transportation Major Variables & Definitions IV: effectiveness of Spanish translation of Group Lifestyle Balance Program DV1: BMI DV2: DM risk factors DV3: weekly selfmonitoring habits DV4: session attendance DV5: weight loss DV6: met PA goal of 150min/week DV7: satisfaction with program Measurement/ Instrumentation Data Analysis Findings/ Results Scale; stadiometer; BMI (validity in Hispanic women = 0.94) Paired Student’s t-tests DV1: 3 or > sessions X̅ = 0.94 (2.9% change), p=<0.001; 50% sessions X̅ = -1.2 (4%), p=0.001 DV2: X̅ = 6.1 (1-11) DV3: weighing self once/week (14.8%), recording food intake at least once/week (7.4%), recoding PA once/week (26%) DV4: attended 3 or > sessions (67%); average rate of attendance 7.1/12; attended at least 50% (44%) DV5: 3 or > sessions X̅ = 4.5 pounds (2.7% change), p=<0.001; 50% sessions X̅ = -6.8 pounds (3.9%), p=0.001 DV6: 41.2% DV7: satisfaction with leader and environment, better understanding of preDM risk factors: 100%; program length appropriate (82.4%), too short (6%) Demographic data with a brief selfcompleted questionnaire CDC Prediabetes Screening Test Questionnaire to assess understanding of and satisfaction with program, confidence about sustainability of program and barriers to longterm maintenance of PA and healthy eating habits Chi square tests Pearson’s or Spearman’s r PASW Statistics 18 by SPSS P=.05 Confidence interval = 95% Quality/LOE; Decision/Application for practice LOE: IV Strengths: Demographics representative of other such studies; Weaknesses: Does not address cultural adaptation of program; High attrition; Survey on understanding and satisfaction not validated. Conclusions: Cultural adaptation appears to affect retention but not attendance; Spanish materials and program feedback very positive; lack of attendance related to finding a new job, children’s health or transportation. Key: A: adult; APA: American Psychological Association; BI: behavioral intervention; BMI: body mass index; c: control; C: child(ren); CA: cancer; CBT: Cognitive Behavioral Theory; DM: Diabetes Mellitus; DV: dependent variable; F: female; FND: foundation; FST: Family Systems Theory; FQHC: Federally Qualified Health Center; HBM: Health Belief Model; HM: Hispanic mother(s); HPM: Health Promotion Model; HTN: hypertension; i: intervention; IV: independent variable; LOE: level of evidence; MA: mean age; N: number of studies; n: number of participants; NIH: National Institutes of Health; p: alpha value; PA: physical activity; PS: pilot study; PV: predictor variable; RCT: Randomized Controlled Trial; RWJF: Robert Wood Johnson Foundation; SCLT: Social Cognitive Learning Theory; SD: standard deviation; SR: Systematic Review; SS: Spanish Speaking; SSB: sugar sweetened beverages; SMM: sequential mixed methods; SW: Southwester; T1: pre-test; T2: post-test; U: university; USA: United States of America; WIC: Women, Infants and Children; x̅ : mean; YO: year(s) old ADDRESSING OBESITY Citation Theory/ Conceptual Framework Inferred to be Socioecolo gical Model Design/ Method 38 Sample/Setting Major Variables & Definitions IV: program feasibility DV1: food frequency questionnaire (C) DV2: fruit and vegetable parenting practice questionnaire (parents) DV3: BMI (C) DV4: waist circumferenc e (C) Measurement/ Instrumentation Data Analysis Findings/ Results Quality/LOE; Decision/Application for practice LOE: VI Strengths: Parental report of social support and greater self-efficacy; information on healthier eating with convenient strategies not in literature. Weaknesses: Difficulty in collecting diet recall materials from participants; small study sample; difficult recruitment; no control group; not all data reported. Conclusions: Limited applicability. Demonstrates feasibility of such study, but needs larger recruitment. Demonstrates areas not to focus for weight loss intervention due to no weight change with studied variables. Li et al. Design: n: 4 families BMI (validity Nutrition Data DV1: 77 % meet calorie (2015) descriptive Demographics: in Hispanic System for needs, 17% exceed (fat) 0% Development Purpose: Hispanic: 100% women = 0.94) Research met fiber goal, X̅ = 15.4 and to C age: 6-12 software g/day (25-35 g/day) Feasibility of determine HM age: 28-42 Waist (version 2013) DV2: C and parent change a Culturally whether a Income <$60,000: circumference in fruit and vegetable intake Sensitive 10 week 100% (0%) Cooking and cooking Setting: SW USA Children food DV3: no change PA Program and PA primary care frequency DV4: not reported Designed for pilot Exclusion: medical questionnaire Obese interventio issues related to Hispanic n could be obesity (DM, Adult fruit and Families delivered HTN); medications vegetable Country: in a health affecting weight; parenting USA care setting history of practice Funding: psychological questionnaire Luci Baines disorders Johnson, Inclusion: 6-11 yo Food logs Racing for with BMI >/= 85 CA, Archer, percentile, but <99th Gerber, percentile with Farrah willing parent Fawcett FDN, participant Children Art Attrition: 0 Project, Santa’s Elves Fundraiser, David Herr & Family, MD Anderson CA Center, Duncan Family Key: A: adult; APA: American Psychological Association; BI: behavioral intervention; BMI: body mass index; c: control; C: child(ren); CA: cancer; CBT: Cognitive Behavioral Theory; DM: Diabetes Mellitus; DV: dependent variable; F: female; FND: foundation; FST: Family Systems Theory; FQHC: Federally Qualified Health Center; HBM: Health Belief Model; HM: Hispanic mother(s); HPM: Health Promotion Model; HTN: hypertension; i: intervention; IV: independent variable; LOE: level of evidence; MA: mean age; N: number of studies; n: number of participants; NIH: National Institutes of Health; p: alpha value; PA: physical activity; PS: pilot study; PV: predictor variable; RCT: Randomized Controlled Trial; RWJF: Robert Wood Johnson Foundation; SCLT: Social Cognitive Learning Theory; SD: standard deviation; SR: Systematic Review; SS: Spanish Speaking; SSB: sugar sweetened beverages; SMM: sequential mixed methods; SW: Southwester; T1: pre-test; T2: post-test; U: university; USA: United States of America; WIC: Women, Infants and Children; x̅ : mean; YO: year(s) old ADDRESSING OBESITY Institute, National CA Institute Bias: none noted Citation Lindberg et al. (2011) Immigration and Weight Gain: MexicanAmerican Women’s Perspectives Country: USA Funding: Grant U01 HL06867603S1 from the National Heart, Lung, and Blood Institute Bias: none noted Theory/ Conceptual Framework Phenomeno logy 39 Design/ Method Sample/Setting Method: focus groups Purpose: to examine the experience s, concerns, and beliefs regarding diet, weight and weight loss in MexicanAmerican immigrant women n: 25 Demographics: MA: 36yo Mexican born:100% Emigrate: rural 76%, urban: 24% X̅ length of residence in USA: 7.5years X̅ schooling: 8 years Work: domestic service 72%, retail 28% Setting: Mexican community in Portland, Oregon Exclusion: not stated Inclusion: Mexican-American women >18yo, provide written consent Attrition: 0 Major Variables & Definitions IV: development of culturally sensitive weight loss interventions DV1: adapting to American Society DV2: experiences with weightloss attempts and need for nutritional information DV3: importance of family Measurement/ Instrumentation Data Analysis Findings/ Results Group sessions facilitated by bilingual Mexican clinical psychologists in Spanish Transcripts analyzed to find recurring themes using Morgan’s principles of qualitative research: words, context, internal consistency, specificity of responses, tone and nonverbal communication assessed DV1: weight gain common when moving to USA; puzzled by weight gain; more processed foods; more variety of foods; eating “the American ‘way”; difference in body type; role of food in culture DV2: frustration with inability to lose weight/maintain; modified diet and non-traditional methods; spotty methods of dieting; nutrition information confusing; not being understood DV3: role of family in food choices; changes have effects on rest of family Notes Audiotapes Quality/LOE; Decision/Application for practice LOE: VI Strengths: first-hand experience/beliefs demonstrated through study design; wide ranges of demographics of Hispanic F Weaknesses: May not be generalized to all Mexican-Americans or other Hispanic subgroups. Conclusions: Provide guidance to inform weight-loss and dietary-change interventions for Hispanic F. Key: A: adult; APA: American Psychological Association; BI: behavioral intervention; BMI: body mass index; c: control; C: child(ren); CA: cancer; CBT: Cognitive Behavioral Theory; DM: Diabetes Mellitus; DV: dependent variable; F: female; FND: foundation; FST: Family Systems Theory; FQHC: Federally Qualified Health Center; HBM: Health Belief Model; HM: Hispanic mother(s); HPM: Health Promotion Model; HTN: hypertension; i: intervention; IV: independent variable; LOE: level of evidence; MA: mean age; N: number of studies; n: number of participants; NIH: National Institutes of Health; p: alpha value; PA: physical activity; PS: pilot study; PV: predictor variable; RCT: Randomized Controlled Trial; RWJF: Robert Wood Johnson Foundation; SCLT: Social Cognitive Learning Theory; SD: standard deviation; SR: Systematic Review; SS: Spanish Speaking; SSB: sugar sweetened beverages; SMM: sequential mixed methods; SW: Southwester; T1: pre-test; T2: post-test; U: university; USA: United States of America; WIC: Women, Infants and Children; x̅ : mean; YO: year(s) old ADDRESSING OBESITY Citation Parra-Medina et al. (2015) Weight Outcomes of Latino Adults and Children Participating in the Y living Program, a FamilyFocused Lifestyle Intervention, San Antonio 2012-2013 Country: USA Funding: the CA Prevention and Research Institute of Texas Bias: potential selection bias due to voluntary participation Theory/ Conceptual Framework SCLT 40 Design/ Method Sample/Setting Design: Quasiexperiment al Purpose: to prevent excess weight gain by increasing adoption of healthpromoting PA and dietary behaviors n: 106 C, 242 A Demographics: Gender: AF 80.6%, A male 19.4%, CF 49.1%, C male 50.9%; Latino: A 70.6%, C 77.3%; Weight: A BMI <25: 8.4%, BMI 2530: 18%, BMI >/= 30: 73.6%; C BMI <85th percentile: 35%, BMI 85-95th percentile: 16.5%, BMI >/= 95th percentile: 48.5% Setting: urban city >65% obese residents Exclusion: not listed Inclusion: commitment to 12-week program in English, entire family 2/week group activity, PA at least 3/week, >/= 7 yo Attrition: A 25.6%, C 32.1% Major Variables & Definitions IV: impact of 12-week Y Living Program DV1: BMI DV2: Waist circumferenc e DV3: body fat percentage DV4: Weight Measurement/ Instrumentation Data Analysis Findings/ Results Pretest-posttest of: Descriptive statistics for demographics DV1: A = 34.9 (29.6-41.3), change -.02 (-1.0-0.3), p<.001; C = 94.2% (65.098.8), change 0.4 (-0.033.5), p= .001 DV2: A= 41.0 inches (36.546.5), change -1.0 (-2.5-0), p <.001; C = 30.8 inches (26.1-36.4), change 0 (-1.01.0), p= .69 DV3: A= 42.7% (35.848.0), change -0.6 (-1.80.7), p <.001; C= 31.0% (20.6-38.7), change 0.6 (1.1-2.7), p= .03 DV4: A=200.2 (163.6237.3), change -1.6 (-5.5-12), p <.001; C= 125.8 (90.0157.8), change 2.6 (0-5), p <.001 Waist circumference with MyoTape Body Tape measure Wilcoxon signed rank test Fisher exact test Height with standiometer Mann-Whitney U Bioelectrical impedance analysis machine for body fat percentage, body weight, and BMI (validity in Hispanic women = 0.94) Strata SE version 13 BMI percentile with CDC BMI-for-age growth chart Paired, p= .05 Confidence interval = 95% Quality/LOE; Decision/Application for practice LOE: IV Strengths: Diverse family structure; participants made up mainly of mothers and their children. Weaknesses: No control group; higher drop out among young adults and families with children; potential selection bias due to voluntary enrollment in a free program for lowincome community residents. Conclusions: Weight loss measures improved in adults, and increased in children as expected. Program demonstrated utility in a largely Hispanic population. Family based intervention effective for many participants; materials may not have been suited for all families. Key: A: adult; APA: American Psychological Association; BI: behavioral intervention; BMI: body mass index; c: control; C: child(ren); CA: cancer; CBT: Cognitive Behavioral Theory; DM: Diabetes Mellitus; DV: dependent variable; F: female; FND: foundation; FST: Family Systems Theory; FQHC: Federally Qualified Health Center; HBM: Health Belief Model; HM: Hispanic mother(s); HPM: Health Promotion Model; HTN: hypertension; i: intervention; IV: independent variable; LOE: level of evidence; MA: mean age; N: number of studies; n: number of participants; NIH: National Institutes of Health; p: alpha value; PA: physical activity; PS: pilot study; PV: predictor variable; RCT: Randomized Controlled Trial; RWJF: Robert Wood Johnson Foundation; SCLT: Social Cognitive Learning Theory; SD: standard deviation; SR: Systematic Review; SS: Spanish Speaking; SSB: sugar sweetened beverages; SMM: sequential mixed methods; SW: Southwester; T1: pre-test; T2: post-test; U: university; USA: United States of America; WIC: Women, Infants and Children; x̅ : mean; YO: year(s) old ADDRESSING OBESITY Citation Siwik et al. (2012) Families United/ Familias Unidas: Development and Implementati on of a Family-Based Group Office Visit Model for the Primary Prevention of Type 2 Diabetes Country: USA Funding: American Diabetes Association grant (1-CR09-33 Bias: none noted Theory/ Conceptual Framework CBT 41 Design/ Method Sample/Setting Design: correlation al Purpose: describe the developme nt and implement ation of a new diabetes prevention interventio n that combines the benefits of family support with the group office model n: 45 Demographics: Participants: MA 45; F 74%; White 56.9%, Hispanic 37.9% Support person: MA: 45; F 79.3%; white 58.6%, Hispanic 37.9% Setting: group outpatient Exclusion: pregnancy, inability to attend regularly or participate in group activities Inclusion: A 18-70 yo with any DM risk factor; no DM; a support person aged 14-70 yo Attrition: 11% Major Variables & Definitions PV: effectiveness of a group outpatient DM prevention model DV1: participation DV2: retention DV3: attendance DV4: billing and sustainability Measurement/ Instrumentation Data Analysis Findings/ Results Pedometer and pedometer log Descriptive statistics for demographics and DVs DV1: 53% learned about from family/friend, 15% healthcare professional, 14% letter, 10% brochure/poster in clinic, 5% brochure/poster in library/gym, 0% newspaper; DV2: n=14 (7 pairs); significantly younger than those who attended at least 1 session (37.0 +/- 7.9yrs vs. 47.9 +/- 12.2 years, p= .001); more likely to have lower education (p= 0.46), be on Medicaid (p= .002); 35% completed were Hispanic/Latino, 64.2% were Mexican American DV3: 72% (8.3-100%) DV4: 2.6 patients/hour Scale Quality/LOE; Decision/Application for practice LOE: IV Strengths: All Hispanic participants completed the program demonstrating a program fit; aim to enroll more Hispanic participants met. Weaknesses: Recruitment of more than one support person not successful; C not included which may have aided in participation; Less than 1/5 were on Medicaid; Those who did not complete had highest risk factors. Conclusions: Model effective for Hispanic population; targeting those with obesity or family history of DM effective recruitment; time spent in clinic similar to family medicine; Group visits a sustainable model for DM prevention. Key: A: adult; APA: American Psychological Association; BI: behavioral intervention; BMI: body mass index; c: control; C: child(ren); CA: cancer; CBT: Cognitive Behavioral Theory; DM: Diabetes Mellitus; DV: dependent variable; F: female; FND: foundation; FST: Family Systems Theory; FQHC: Federally Qualified Health Center; HBM: Health Belief Model; HM: Hispanic mother(s); HPM: Health Promotion Model; HTN: hypertension; i: intervention; IV: independent variable; LOE: level of evidence; MA: mean age; N: number of studies; n: number of participants; NIH: National Institutes of Health; p: alpha value; PA: physical activity; PS: pilot study; PV: predictor variable; RCT: Randomized Controlled Trial; RWJF: Robert Wood Johnson Foundation; SCLT: Social Cognitive Learning Theory; SD: standard deviation; SR: Systematic Review; SS: Spanish Speaking; SSB: sugar sweetened beverages; SMM: sequential mixed methods; SW: Southwester; T1: pre-test; T2: post-test; U: university; USA: United States of America; WIC: Women, Infants and Children; x̅ : mean; YO: year(s) old ADDRESSING OBESITY Citation Theory/ Conceptual Framework ActorPartner Interdepen dence Models Design/ Method 42 Sample/Setting Major Variables & Definitions IV: feasibility of Unidads program DV1: social support DV2: social control – persuasion DV3: social control pressure DV4: undermining DV5: weight DV6: average grams glycemic load DV7: grams saturated fat DV8: fruit, cup equivalent DV9: vegetable, cup equivalent Measurement/ Instrumentation Data Analysis Findings/ Results Quality/LOE; Decision/Application for practice Sorkin et al. Design: n: 178 Self-report Paired sample t IV on DV5: -1.61, p= .003 LOE: II (2014) RCT Intervention: 53 questionnaire: tests IV on DV6: -7.67, p<.001 Strengths: Effective Dyadic Purpose: HM, 53 C demographics, IV on DV7: -1.30, p= .004 program for low Collaboration to conduct Control: 36 HM, 36 health status, chi-square IV on DV8: -.12, p= .09 income individuals in Shared a pilot test C social support analyses IV on DV9: 0.10, p= .12 with unique needs and Health of a theory- Demographics: (Cronbach’s DV1: HM i: T1 3.8 (SD barriers; dyadic Behavior driven, <$30,000/year: 94% alpha: T1 0.91, ANOVA 1.7), T2 4.8 (SD1.5); HM c approach Change: The culturally HM: MA 52.7; < T2 0.93), T1 3.7 (SD 1.9), T2 3.9 (SD demonstrated to have Effects of a responsive, high school persuasion p<.05 1.4); C i: T13.7 (SD 1.4), significantly lower Randomized behavioral education 83% (Cronbach’s Confidence T2 4.8 (SD 1.2); c T1 3.5 weight, lower Trial to Test lifestyle Daughters: alpha T1 0.93, Interval = 95% (SD 1.7), T2 3.4 (SD 1.6) glycemic load and and Lifestyle interventio MA 27.8; < high T2 0.92) DV2: HM i: T1 4.0 (SD saturated fat when Intervention n designed school 25%; lived pressure 1.9), T2 4.9 (SD 1.5); HM c compared to c. for High-Risk to promote with HM 75% (Cronbach’s T1 3.7 (SD 1.5), T2 3.8 (SD Weaknesses: Low Latinas weight loss Setting: community alpha T1 0.89, 1.8); C i: T1 3.7 (SD 1.5), response rate to study Country: and Exclusion: T2 0.85); T2 4.8 (SD 1.1); c T1 3.4 participation; No USA improve pregnancy, dietary intake (SD 1.6), T2 3.6 (SD 1.6) significant findings Funding: dietary contraindications to DV3: HM i: T1 2.9 (SD related to diet-related National behavior weight loss, Sabotage 1.6), T2 2.8 (SD1.6); HM c support, control and Center for among incompetent to sign subscale of the T1 2.4 (SD 1.6), T2 3.3 (SD undermining by Research high-risk consent Family and 1.5); C i: T1 3.0 (SD 1.7), participants; Follow up Resources Mexican Inclusion: Latina Friends Support T2 3.0 (SD 1.7); c T1 2.7 not more extensive and the American age >/= 18yo, MH for Heart (SD 1.6), T2 2.9 (SD 1.6) due to nature of study National women residence /= 25 alpha T1 0.88, T2 1.0 (SD 1.1); c T1 1.9 individual approach. NIH through Attrition: 3.9% T2 0.87) (SD 1.3), T2 1.7 (SD 1.2) Conclusions: Grants DV5: HM i: T1 176.2 (SD Lifestyle changes of UL1 Block “Alive” 37.6), T2 172.6 (SD 36.4); one family member TR000153, Screener HM c T1 179.4 (SD 38.8), may influence other R34DK08350 (validated for T2 180.7 (SD 41.1); C i: T1 family members. Key: A: adult; APA: American Psychological Association; BI: behavioral intervention; BMI: body mass index; c: control; C: child(ren); CA: cancer; CBT: Cognitive Behavioral Theory; DM: Diabetes Mellitus; DV: dependent variable; F: female; FND: foundation; FST: Family Systems Theory; FQHC: Federally Qualified Health Center; HBM: Health Belief Model; HM: Hispanic mother(s); HPM: Health Promotion Model; HTN: hypertension; i: intervention; IV: independent variable; LOE: level of evidence; MA: mean age; N: number of studies; n: number of participants; NIH: National Institutes of Health; p: alpha value; PA: physical activity; PS: pilot study; PV: predictor variable; RCT: Randomized Controlled Trial; RWJF: Robert Wood Johnson Foundation; SCLT: Social Cognitive Learning Theory; SD: standard deviation; SR: Systematic Review; SS: Spanish Speaking; SSB: sugar sweetened beverages; SMM: sequential mixed methods; SW: Southwester; T1: pre-test; T2: post-test; U: university; USA: United States of America; WIC: Women, Infants and Children; x̅ : mean; YO: year(s) old ADDRESSING OBESITY 0, and K01DK07893 9. Bias: none noted 43 Hispanic populations) SECA 882 portable scale for weight 186.0 (SD 32.7), T2 181.4 (SD 30.7); c T1 188.2 (SD 41.5), T2 186.6 (SD 42.5) DV6: HM i: T1 46.3 (SD 27.4), T2 32.3 (SD 19.1); HM c T1 42.2 (SD 20.9), T2 50.4 (SD 13.6); C i: T1 52.0 (SD 40.3), T2 36.2 (SD 23.3); c T1 73.8 (SD 43.3), T2 52.9 (SD 28.0) DV7: HM i: T1 9.6 (SD 5.4), T2 7.2 (SD 4.0); HM c T1 9.2 (SD 4.4), T2 10.6 (SD 5.7); C i: T1 12.0 (SD 5.9), T2 8.6 (SD 5.5); c T1 16.7 (SD 10.2), T2 12.6 (SD 7.3) DV8: HM i: T1 1.3 (SD 1.2), T2 0.9 (SD 0.6); HM c T1 1.3 (SD 1.0), T2 1.6 (SD 1.0); C i: T1 1.1 (SD 1.0), T2 1.2 (SD 1.0); C c T1 1.4 (SD 1.1), T2 1.2 (SD0.9) DV9: HM i: T1 1.1 (SD 0.8), T2 1.4 (SD 1.0); HM c T1 1.2 (SD 1.0), T2 1.5 (SD 0.8); C i: T1 0.8 (SD 0.5), T2 1.3 (SD 1.0); c T1 1.0 (SD 0.8), T2 0.7 (SD 0.5) Key: A: adult; APA: American Psychological Association; BI: behavioral intervention; BMI: body mass index; c: control; C: child(ren); CA: cancer; CBT: Cognitive Behavioral Theory; DM: Diabetes Mellitus; DV: dependent variable; F: female; FND: foundation; FST: Family Systems Theory; FQHC: Federally Qualified Health Center; HBM: Health Belief Model; HM: Hispanic mother(s); HPM: Health Promotion Model; HTN: hypertension; i: intervention; IV: independent variable; LOE: level of evidence; MA: mean age; N: number of studies; n: number of participants; NIH: National Institutes of Health; p: alpha value; PA: physical activity; PS: pilot study; PV: predictor variable; RCT: Randomized Controlled Trial; RWJF: Robert Wood Johnson Foundation; SCLT: Social Cognitive Learning Theory; SD: standard deviation; SR: Systematic Review; SS: Spanish Speaking; SSB: sugar sweetened beverages; SMM: sequential mixed methods; SW: Southwester; T1: pre-test; T2: post-test; U: university; USA: United States of America; WIC: Women, Infants and Children; x̅ : mean; YO: year(s) old ADDRESSING OBESITY Citation Theory/ Conceptual Framework Behavior Modificatio n Theory, Behavioral Change Theory, SCLT, FST Design/ Method 44 Sample/Setting Major Variables & Definitions IV1: methodologic al rigor IV2: effectiveness of treatment DV1: BI to family-based lifestyle intervention (N=8) DV2: BI to family-based lifestyle intervention and parent education (N= 5) DV3: family therapy (N= 1) DV4: family therapy and behavioral psychoeducation (N= 1) Measurement/ Instrumentation Data Analysis Findings/ Results Quality/LOE; Decision/Application for practice LOE: I Strengths: BI and family based model demonstrate consistently positive results related to effectiveness when compared to methodological rigor. Weaknesses: Studies did not address culture, family resilience, or family dynamics. Gender not evaluated in all studies. Conclusions: Family based model effective for weight loss in children; Family plays important role in weight loss; Behavioral approach to a family based intervention consistently achieve better outcomes. N: 15 Adapted Inferred to be IV1 on DV1: X̅ = 7.5; FST Demographics: Methodological correlational X̅ = 9.5 (N= 2), treatment MA: 10.1yo Quality Rating effect = 2.5; behavior theory N, no control: 14 Scales (0-14 X̅ = 7.7 (N=13), treatment N with BI: 53% points) effect = 3.2 N with BI and IV1 on DV2: X̅ = 8 education: 33% IV1 on DV3: X̅ = 11 N with family IV1 on DV4: X̅ = 8; all therapy: 7% studies demonstrate N with BI and substantial change at end of family therapy: 7% study (score=3), and 4 Average rigor score: demonstrate significant 8 (6-12) changes at follow up Setting: not (score= 4) specified IV2 on DV1: X̅ = 3.5 Exclusion: not IV2 on DV2: X̅ = 2.6 listed IV2 on DV3: score= 4 Inclusion: 1975IV2 on DV4: score= 1 2012 articles in Cumulative Index to Nursing and Allied Health Literature, Family & Society Studies Worldwide, PsycINFO, PubMed, Social Work Abstracts, and SocINDEX; RCTs from familybased lifestyle interventions or weight loss and weight control in Key: A: adult; APA: American Psychological Association; BI: behavioral intervention; BMI: body mass index; c: control; C: child(ren); CA: cancer; CBT: Cognitive Behavioral Theory; DM: Diabetes Mellitus; DV: dependent variable; F: female; FND: foundation; FST: Family Systems Theory; FQHC: Federally Qualified Health Center; HBM: Health Belief Model; HM: Hispanic mother(s); HPM: Health Promotion Model; HTN: hypertension; i: intervention; IV: independent variable; LOE: level of evidence; MA: mean age; N: number of studies; n: number of participants; NIH: National Institutes of Health; p: alpha value; PA: physical activity; PS: pilot study; PV: predictor variable; RCT: Randomized Controlled Trial; RWJF: Robert Wood Johnson Foundation; SCLT: Social Cognitive Learning Theory; SD: standard deviation; SR: Systematic Review; SS: Spanish Speaking; SSB: sugar sweetened beverages; SMM: sequential mixed methods; SW: Southwester; T1: pre-test; T2: post-test; U: university; USA: United States of America; WIC: Women, Infants and Children; x̅ : mean; YO: year(s) old Sung-Chan et al. (2013) Family-Based models for childhoodobesity intervention: A Systematic Review of Randomized Controlled Trials Country: China (N=1) USA (N=14) Funding: Hong Kong Research Grant Council and the Fulbright Research Grant (201112) Bias: none noted Design: SR Purpose: to examine the advanceme nt in the familybased approach to childhood obesity through studying the methodolo gical rigor of family based interventio ns ADDRESSING OBESITY 45 children and adolescents ages 219yo Attrition: not applicable Key: A: adult; APA: American Psychological Association; BI: behavioral intervention; BMI: body mass index; c: control; C: child(ren); CA: cancer; CBT: Cognitive Behavioral Theory; DM: Diabetes Mellitus; DV: dependent variable; F: female; FND: foundation; FST: Family Systems Theory; FQHC: Federally Qualified Health Center; HBM: Health Belief Model; HM: Hispanic mother(s); HPM: Health Promotion Model; HTN: hypertension; i: intervention; IV: independent variable; LOE: level of evidence; MA: mean age; N: number of studies; n: number of participants; NIH: National Institutes of Health; p: alpha value; PA: physical activity; PS: pilot study; PV: predictor variable; RCT: Randomized Controlled Trial; RWJF: Robert Wood Johnson Foundation; SCLT: Social Cognitive Learning Theory; SD: standard deviation; SR: Systematic Review; SS: Spanish Speaking; SSB: sugar sweetened beverages; SMM: sequential mixed methods; SW: Southwester; T1: pre-test; T2: post-test; U: university; USA: United States of America; WIC: Women, Infants and Children; x̅ : mean; YO: year(s) old ADDRESSING OBESITY Appendix F Table 2 Synthesis Table Study Characteristics Author Agne Austin Bender Kramer Li Lindberg Year Design Level of Evidence 2012 FG VI 2013 QE IV 2014 PS, SMM IV 2013 NR, PPS IV 2015 D VI 2011 FG VI ParraMedina 2015 QE IV Siwik Sorkin Sung-Chan 2012 COR IV 2014 RCT II 2013 SR I Sample Demographics N 15 n 25 100 Maternal Age, mean 38 45.07 C Age, mean A 43, C 43 27 27 4F 25 32.7 28-42yrs 36 3.6 % Hispanic 100 % Female 100 100 100 74 Overweight 48 20 37 Obese 52 80 63 Low SES % College graduate/some college % HS grad./some HS/GED/trade % <8th grade 88 16 grad. 92 some 100 100 100 48 11.1 52 22.2 grad. 14.8 some 51.9 76 45 45 6-12yrs A 100, C 22 C 24% % Male A 242, C 106 A 70.6, C 77.3 A 80.6, C 49.1 A 19.4, C 50.9 A 18, C 16.5 A 73.6, C 48.5 Ai 53, c 36; Ci 53, c 36 52.7 C 982 27.8 10.1 P 37.9, SP 37.9 P 74, SP 79.3 94 100 A 83, C 25 Key: *: statistically significant finding; A: adult; BI: behavioral intervention; BMI: body mass index; C: child(ren); c: control; COR: correlational; D: descriptive; F: families; FG focus group; FT: family therapy; GED: general education diploma; GL: glycemic load; grad: graduate; HS: high school; i: intervention; N: number of studies; n: number of participants; NR: non-randomized; P: participant; PA: physical activity; PS: pilot study; PPS: prospective pilot study; QE: quasi-experimental; RCT: randomized controlled trial; SMM: sequential mixed methods; SP: support person; SR: systematic review; SES: socioeconomic status; yrs: years ADDRESSING OBESITY Measurements Audiotapes/notes X Questionnaires X PA scales BMI Food/PA log Waist circumference Weight X X X X X X X X X X X X X X X X X X X ¯* ¯* Qualitative Variables of Interest Barriers: Health-related education Social isolation, depression, stress X X X X X X X X X X Values: Traditional Foods Family Involvement Health>appearance Quantitative Variables of Interest Effect of family or group on following: BMI Attendance Calorie goal PA goal Satisfaction Waist circumference Weight loss ¯* ­* neutral ­ neutral ­ neutral ¯ neutral ­ ¯ BI neutral FT ¯*GL ¯*fat ­vegetable ¯fruit neutral ­ Not reported ¯* A¯* C neutral ¯* Key: *: statistically significant finding; A: adult; BI: behavioral intervention; BMI: body mass index; C: child(ren); c: control; COR: correlational; D: descriptive; F: families; FG focus group; FT: family therapy; GED: general education diploma; GL: glycemic load; grad: graduate; HS: high school; i: intervention; N: number of studies; n: number of participants; NR: non-randomized; P: participant; PA: physical activity; PS: pilot study; PPS: prospective pilot study; QE: quasi-experimental; RCT: randomized controlled trial; SMM: sequential mixed methods; SP: support person; SR: systematic review; SES: socioeconomic status; yrs: years ADDRESSING OBESITY 48 Appendix G Figure 1. The Purnell Model for Cultural Competence comprised of the 12 culture domains (National Association for School Nurses. 2013). The outer rim represents global society; the second rim represents community; the third rim represents family; the inner rim represents person; the interior depicts 12 domains; and the center is empty, representing what is not yet know about culture. Adapted from “Purnell Model for Cultural Competence” by Larry Purnell, 2005, The Journal of Multicultural Nursing & Health, 11:2, p. 11 ADDRESSING OBESITY 49 Appendix H Figure 2. The Stetler Model. Adapted from “Updating the Stetler Model of Research Utilization to Facilitate Evidence-Based Practice,” by Cheryl B. Stetler, 2001, Nursing Outlook, 49(6), p. 27 ADDRESSING OBESITY 50 Appendix I Arizona State University Institutional Review Board Approval APPROVAL: EXPEDITED REVIEW Sarah Bay CONHI - DNP Sarah.Ambrose@asu.edu Dear Sarah Bay: On 8/8/2017 the ASU IRB reviewed the following protocol: Type of Review: Initial Study Title: Addressing Obesity in Hispanic Families Through a Family Centered Approach: An Educational Intervention for Providers Investigator: Sarah Bay IRB ID: STUDY00006618 Category of review: (5) Data, documents, records, or specimens, (7)(a) Behavioral research Funding: None Grant Title: None Grant ID: None Documents Reviewed: • Acknowledgment of Privacy Practives , Category: Other (to reflect anything not captured above); • Fotonovela Letter of Support, Category: Other (to reflect anything not captured above); • Provider Education Session Outline, Category: Other (to reflect anything not captured above); • Munson_HRP-503a, Category: IRB Protocol; • Fotonovela, Category: Participant materials (specific directions for them); • Cover Letter, Category: Recruitment Materials; • Midvale HIPAA Document, Category: Other (to reflect anything not captured above); • EBPAS Letter of Permission , Category: Other (to reflect anything not captured above); • EBPAS tool, Category: Measures (Survey questions/Interview questions /interview guides/focus ADDRESSING OBESITY 51 group questions); • BMI Form, Category: Screening forms; • CITI Training Certificate , Category: Other (to reflect anything not captured above); • Provider Feedback Form, Category: Measures (Survey questions/Interview questions /interview guides/focus group questions); • Cover Letter, Category: Consent Form; • DNP Project Proposal Worksheet, Category: Other (to reflect anything not captured above); • Privacy Practices Form, Category: Other (to reflect anything not captured above); • Clinical Site Letter of Support, Category: Other (to reflect anything not captured above); The IRB approved the protocol from 8/8/2017 to 8/7/2018 inclusive. Three weeks before 8/7/2018 you are to submit a completed Continuing Review application and required attachments to request continuing approval or closure. If continuing review approval is not granted before the expiration date of 8/7/2018 approval of this protocol expires on that date. When consent is appropriate, you must use final, watermarked versions available under the “Documents” tab in ERA-IRB. In conducting this protocol you are required to follow the requirements listed in the INVESTIGATOR MANUAL (HRP-103). Sincerely, IRB Administrator cc: Megan Munson Megan Munson Johannah Uriri-Glover Sarah Bay Daniel Crawford ADDRESSING OBESITY 52 Appendix J License For Use of Fotonovela ADDRESSING OBESITY 53 Appendix K Evidence Based Practice Attitudes Scale ADDRESSING OBESITY 54 Appendix L Logic Model for a Provider Educational Module Goal: To provide culturally relevant weight loss education to Hispanic families in a small rural health care clinic in Tucson, Arizona. INPUTS Staff § Providers § Medical Assistants § Office manager § DNP student Time § Education § Intervention Training Tools § Client education tools § Evidence Based Practice Attitudes Scale (EBPAS) § Fotonovela § Educational presentation § Space Funding § Copies § Staff incentives OUTPUTS Activities A Population Develop resources § Client education § Provider documentation tool Educational Intervention for providers Deliver client weight education services Instruction on data collection process to Medical Assistants Target Providers Hispanic Families Other stakeholders (i.e, decision makers, community members) Short Short Change in attitude toward EBP, and knowledge to make changes Change in motivation to lose weight, and awareness and knowledge of best practices interventions Change in awareness of best practice interventions for weight loss OUTCOMES Medium Medium IMPACTS Long Long Change in behavior regarding weight loss education Continue culturally relevant weight loss education and monitor client outcomes Improved satisfaction with weight loss education Change in weight loss behaviors Change in clinical site policies and social action at community level Change in economic spending at practice and community level Improved weight loss outcomes for Hispanic families Change in health and overall social wellbeing Decrease obesity rates in Hispanic families to less than Healthy People 2020 goal Assumptions: 1. Providers want their patients to meet their weight loss goals. 2. Data collection needed for this project is the same process as the current standard of care. 3. The evidence suggests that family centered weight loss interventions are culturally relevant and best practice (Davidson, Lawson, & Coatsworth, 2012; SungChan, Sung, Zhao, & Brownson, 2012). Key: Red text areas to monitor if not meeting targets; Red arrows depict areas to improve; Dark blue text is goal. ADDRESSING OBESITY 55 Appendix M Provider Education Session Learning Objectives: By the end of this session participants will: 1. discuss 2-3 reasons why treating overweight and obesity in Hispanic clients is important to their overall health outcomes. 2. demonstrate how to use the BMI Tracking Form to monitor client BMI and interventions discussed at each appointment. 3. list 1-2 reasons why using family centered education with Hispanic clients for treatment of overweight and obesity is most effective. Overweight & Obesity in Hispanic Families Megan Munson, MSN/Ed, RN DNP Candidate Overweight & Obesity Education National and Local Statistics National Obesity Statistics Hispanics in Arizona 45 40 Obese 35 Underweight 2% 35% 30 Normal Weight 30% 25 20 15 Overweight 33% 10 5 0 Adults Children Hispanic Caucasian (CDC, 2016c; CDC, 2017) Underweight Normal Weight Overweight Obese (CDC, 2016) ØWeight disparity between Hispanics and Caucasians Impact ØHealth risks Ø Shorter quantity of life and lower quality of life r/t CV disease, DM II, mental illness, physical pain and cancer (CDC, 2016; SungChan, Sung, Zhao, & Brownson, 2013; Thé, Suchindran, North, Popkin, & Gordon-Larsen, 2010) Ø WHO estimates that 44% DM II burden, 23% of ischemic heart disease burden, and between 7-41% of certain cancer burdens are attributed to weight (Arizona Department of Health Services, 2016) Ø Research shows that obese parents typically raise obese children (Thé et al., 2010) ØGoals Ø Healthy People 2020: 30.5% or less of population considered obese (Arizona Health Matters, 2012) Ø 5% decrease in obesity rates (Arizona Department of Health Services, 2016) ØFinancial Burden Ø $190 billion/year (20.6%) of US healthcare expenditure attributed to obesity Ø US per capita spending is 42% greater than normal weight peers Ø Worldwide, direct medicals costs are approximately 30% greater than normal weight peers Ø If trends continue, by 2030 86.3% of adults will be overweight, 51.1% obese Ø Projected healthcare costs to double every decade over $860 billion (FOJP, 2012) Family Centered Education for Weight Loss ØCulture ØMother prime candidate to make healthy changes for family ØNeeds of family over own cited as common barrier to weight loss (Austin, Smith, Gianini, & Campos-Melady, 2013) ØPartnership with provider ØMutual decision making, planning and evaluation of goals ØRole modeling for the family ØChange in one family member can be catalyst for change in others (Sorkin et al., 2014) ØLiterature search results ØFamily centered education: most culturally appropriate method of weight loss education (Davidson, Lawson, & Coatsworth, 2012) ØHispanic women not motivated by thinness; plump children seen as healthy (Agnes, Daubert, Munoz, Scarinci, & Cherrington, 2012; Lindberg & Stevens, 2011) ØCommon themes: Ø Barriers: health-related, social isolation Ø Values: traditional foods, family involvement, health > weight 1 ADDRESSING OBESITY 56 ADDRESSING OBESITY 57 ADDRESSING OBESITY 58 Appendix N Fotonovela – English 4 STEPS TO GOOD HEALTH FREE LIFE STORIES PRESENTS WE CAN’T GO ON LIKE THIS! YOU ONLY LIVE ONCE IN THIS ISSUE! IN GRANDMA’S KITCHEN THE FOOD IS DELICIOUS. BUT IS IT HEALTHY? HE WORRIES ABOUT HIS GRANDSON’S HEALTH, BUT WHAT ABOUT HIS BAD HABIT? FIND OUT! Donated by Holadoctor & Megan Munson, MSN-Ed, RN DNP Candidate ADDRESSING OBESITY 59 BMI (BODY MASS INDEX) TODAY’S DATE GOAL DATE MY WEIGHT MY GOAL WEIGHT MY BMI (BODY MASS INDEX) MY SUPPORT PERSON IS HAZ UN CÍRCULO ALREDEDOR DE TU CLASIFICACIÓN DE IMC SEGÚN TU EDAD MY PLAN TO REACH MY GOAL WEIGHT: BMI (AGES 0-19 YEARS) <5 PERCENTILE UNDERWEIGHT 5 - <85 PERCENTILE NORMAL WEIGHT 85 - <95 PERCENTILE OVERWEIGHT >/= 95 PERCENTILE OBESE BMI (AGES 20-64 YEARS) <18.5 UNDERWEIGHT 18.5-24.9 NORMAL WEIGHT 25-29.9 OVERWEIGHT 30-39.9 OBESE 40+ MORBIDLY OBESE BMI (AGES 65+) <22.9 UNDERWEIGHT 23-29.9 NORMAL WEIGHT 30-39.9 OVERWEIGHT 40+ MORBIDLY OBESE WHY I WANT TO LOSE WEIGHT: ADDRESSING OBESITY 60 LIFE STORIES PRESENTS YOU ONLY LIVE ONCE ACTORS Juan Cristóbal Castillo is an actor, director, composer, and playwright. He has worked in the film Post tenebras lux by Carlos Reygadas, which won Best Director in Cannes. GRANDPA Adriana Laffan, actress, has worked in 25 soap operas, including the greatly successful El amor manda, 30 plays, and six films. GRANDMA Paulina Sabugal is a graduate of the Escuela Nacional de Arte Teatral of the Instituto Nacional de Bellas Artes in Mexico. She has acted in many theatrical productions. DAUGHTER Ana Maria Meza Escalante is an actress who studied in Mexico and Vancouver. She is currently participating in plays at Casa azul which are sponsored by Argos, one of the most important soap opera production companies in Mexico. FRIEND Diego Fernandez Rodriguez in his acting debut. GRANDSON PRODUCTION EXECUTIVE PRODUCER Angelica Lopez Antúnez has been a producer for over 25 years. She was nominated for the Pantalla de Cristal award—the Oscar of Mexico—for Best Casting Director for the film El principio de la espiral. SCRIPTWRITERS Gloria López Villaseñor held the position of Strategic Planner and Creative Director at JW Thomspon for 20 years. She’s won numerous advertising awards in London and New York and was a finalist at Cannes. CASTING DIRECTOR Teresa Coria Bedolla has selected actors for more than 500 projects in both the United States and Mexico. MAKEUP ARTIST Raquel Chavira has participated in both film and advertising projects. She worked in movies such as Apocalypto directed by Mel Gibson, Frida starring Salma Hayek, and The far side of the world starring Russell Crowe. Héctor Estrada, Senior Writer, has worked in multinational agencies for many renowned North American brands. FOTONOVELA DESIGN Andrés Felipe Prieto is the Vice President of Design & Usability for HolaDoctor. DIRECTOR OF PHOTOGRAPHY Guadalupe Szymanski graduated from the Instituto de Estudios Fotográficos de Cataluña in Spain. She was a photographer for the Grupo Expansión in México. LIFE STORIES PRESENTS Published & Copyright © 2017 by HolaDoctor, Inc. All rights reserved. ADDRESSING OBESITY 61 PATY AND HER FRIEND LUZ GO ON THEIR USUAL MORNING RUN. WHAT A WORKOUT! I CAN’T THANK YOU ENOUGH FOR CONVINCING ME TO GO RUNNING WITH YOU. I FEEL SO MUCH BETTER, AND I’VE ALREADY LOST WEIGHT! I KNOW, I CAN TELL! AND I’M SURE EVERYONE ELSE CAN, TOO, SO GET READY TO FEND OFF THE BOYS… UGH, I CAN ONLY HOPE! OF COURSE—I FEEL GREAT! YOU’LL SEE! BUT YOU HAVE TO STICK TO WORKING OUT AND HEALTHY EATING. 4 | VISIT HOLADOCTOR.COM ADDRESSING OBESITY 62 I WISH MY MOM UNDERSTOOD HOW IMPORTANT THIS IS TO LEADING A BETTER LIFE. I KEEP TRYING TO GET HER TO CHANGE HER HABITS… I’LL SEE YOU TOMORROW. SOONER OR LATER SHE’LL REALIZE IT, TRUST ME. PHYSICAL ACTIVITY IS ESSENTIAL TO MAINTAINING A HEALTHY LIFESTYLE. IT HELPS YOU LOSE WEIGHT AND DEVELOP STRONG BONES, MUSCLES, AND JOINTS, AS WELL AS IMPROVING YOUR SELF-ESTEEM AND COGNITIVE SKILLS. CHANGING YOUR HABITS? ALWAYS A POSSIBILITY! Stress, a sedentary lifestyle, and an inadequate diet are the main factors contributing to heart disease, diabetes, high blood pressure, and obesity. START LIVING WELL PRACTICE YOUR PASSIONS Hereditary predisposition to certain illnesses is something we can battle, but we have to start by changing our way of life Every day, dedicate some time to do what you love. If you feel like you're too busy, start by limiting time spent in front of your computer screen And above all... CUT SUGAR & SALT CONSUMPTION This will help you lose weight. Say goodbye to your saltshaker for good, and rinse canned goods in order to eliminate or limit sodium content HUG IT OUT! TAKE A WALK Going for a walk with your family will help you lose weight and strengthen family bonds MODERATION Hug your friends and family members, and ask them to hug you-- it's by far one of the most therapeutic activities yet. Start by drinking a little less alcohol, and cut down portion sizes gradually FUENTE: www.holadoctor.com |5 ADDRESSING OBESITY 63 IN THE EVENING AT PATY’S HOUSE, HER MOTHER AURORA PREPARES DINNER. SAUSAGE, BACON, POTATOES… AND I EVEN MADE THAT PIE MY GRANDSON IS CRAZY ABOUT! MOM…DO YOU HAVE ANY IDEA HOW MANY CALORIES AND HOW MUCH FAT IS IN ALL THIS? 6 | VISIT HOLADOCTOR.COM IF YOU DON’T WANT ANY, THERE’S VEGGIES AND FRUITS IN THE FRIDGE FOR YOU. ADDRESSING OBESITY 64 MOM, I JUST WANT YOU TO SEE THAT EATING THIS WAY AND DOING ZERO PHYSICAL ACTIVITY COULD SERIOUSLY AFFECT YOUR HEALTH. BUT I’M FINE… NO, YOU AREN’T. YOUR BLOOD PRESSURE IS ALWAYS SOARING, YOU TAKE TWO STEPS AND YOU’RE OUT OF BREATH. SO IF YOU WANT TO ENJOY YOUR GRANDSON, YOU NEED TO START EATING BETTER AND LOSE SOME WEIGHT. EATING HABITS ARE FUNDAMENTAL IN LEADING A HEALTHY LIFESTYLE AND HELP TO AVOID BECOMING OVERWEIGHT OR OBESE. YOU SHOULD INCLUDE VEGETABLES, FRUITS, WHOLE GRAINS, AND LOWFAT DAIRY PRODUCTS IN YOUR DIET. DON’T FRY FOOD--TRY GRILLING OR BAKING IT. LIMIT YOUR CONSUMPTION OF FOODS THAT ARE HIGH IN CHOLESTEROL, SODIUM, AND ADDED SUGARS. |7 ADDRESSING OBESITY 65 LATER, THE FAMILY SITS DOWN FOR DINNER. WANT SOME MORE PIE, SWEETIE? YES GRANDMA... SOMEONE’S GETTING ROUNDER! HE’S A GOOD EATER, AND LIKE MY MOM SAID: CHUBBY EQUALS HEALTHY! BUT HE’S GROWING, HE NEEDS TO BE WELL FED! BUT NOT OVERFED. MOM, THOSE ARE MYTHS… PATY’S RIGHT, HONEY. “CHUBBY” RUNS IN OUR FAMILY, AND EVERYONE HAS ENCOUNTERED SOME KIND OF WEIGHT-RELATED PROBLEM. SO…DO WE AGREE THAT IT’S TIME TO MAKE A CHANGE? CHILDHOOD OBESITY CAN BE THE CAUSE OF TYPE 2 DIABETES, HIGH BLOOD PRESSURE AND HIGH CHOLESTEROL. CONTROL YOUR AND YOUR FAMILY’S WEIGHT WITH A BALANCED DIET AND REGULAR PHYSICAL ACTIVITY. 8 | VISIT HOLADOCTOR.COM ADDRESSING OBESITY 66 LATER, SAMUEL AND PEPE WATCH A MOVIE TOGETHER. GRANDPA, WHY DO YOU SMOKE? BECAUSE I LIKE IT. BUT…ISN’T IT BAD FOR YOU? SO, WHY DO YOU DO IT THEN? I SUPPOSE IT IS… BUT…MY MOM SAYS THAT THE SMOKE COULD MAKE YOU SICK, AND I REALLY DON’T WANT ANYTHING TO HAPPEN TO YOU…PLEASE DON’T SMOKE, GRANDPA… WELL MY BOY, I JUST CAN’T QUIT. THERE’S A LOT OF WAYS TO STOP SMOKING. IF YOU’VE ALREADY DECIDED TO QUIT, REACH OUT TO YOUR DOCTOR OR MEDICAL PROVIDER TO DISCUSS TREATMENT AND MEDICATION OPTIONS THAT WILL HELP YOU SUCCEED. |9 ADDRESSING OBESITY 67 SIX MONTHS LATER… WE HAVE A LOT TO CELEBRATE TODAY. I’VE ALREADY LOST 20 POUNDS, AND I LEARNED TO EAT HEALTHILY. I EVEN ENJOY SALADS! AND I REALLY ENJOY MY DAILY WALKS. TODAY, IT HAS BEEN FIVE MONTHS SINCE I QUIT SMOKING. AND I FEEL 10 YEARS YOUNGER. GRANDPA! BET YOU CAN’T CATCH UP WITH ME! 10 | VISIT HOLADOCTOR.COM TO LEAD A HEALTHY LIFE: EXERCISE. IMPROVE YOUR EATING HABITS. CONTROL YOUR WEIGHT AND QUIT SMOKING. THE END. AND I AM SO PROUD OF BOTH OF YOU… ADDRESSING OBESITY 68 RESOURCES WEBSITES MYPLATE: https://www.choosemyplate.gov/MyPlate SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP): https://www.fns.usda.gov/snap UNDERSTANDING NUTRITION FACTS LABEL: https://www.fda.gov/food/ingredientspackaginglabeling SUPER TRACKER: MY FOODS. MY FITNESS. MY HEALTH: https://www.supertracker.usda.gov CALIFORNIA DEPARTMENT OF PUBLIC HEALTH - RECIPES: https://archive.cdph.ca.gov/HealthInfo/healthyliving/nutrition/recipes FREE APPLICATIONS FOR IPHONE AND ANDROID MYFITNESSPAL: Whether you want to lose weight, tone up, get healthy, change your habits, or start a new diet, you’ll love MyFitnessPal. RUNKEEPER: Everyone. Ever run. Join the community that helps people get out the door and stick with running forever! Track exercise, set goals, sweat, and see progress along the way. PACER: Download the free app that will help you get active, lose weight, live longer, and feel better. LOCAL RESOURCES BOUNTIFUL BASKETS FOOD COOP: www.bountifulbaskets.org MARKET ON THE MOVE: http://the3000club.org/wordpress/marketonthemove/ COMMUNITY FOOD BANK: https://www.communityfoodbank.org DIET OF HOPE: Referral needed for HMO, Tricare and AHCCCS. Ask your provider! www.dietofhope.org | Phone: 520.696.3438 ADDRESSING OBESITY 69 Appendix O Fotonovela - Spanish 4 PASOS PARA UNA BUENA SALUD HISTORIAS de VIDA PRESENTA ¡NO PODEMOS SEGUIR ASÍ! SOLO SE VIVE UNA VEZ ¡EN ESTA EDICIÓN! EN LA COCINA DE LA ABUELA SE COCINA MUY RICO. ¡RICO EN GRASA Y CALORÍAS! EL ABUELO SE PREOCUPA POR LA SALUD DE SU NIETO. ¿PERO Y QUÉ PASA CON LA SALUD DE ÉL? Donated by Holadoctor & Megan Munson, MSN-Ed, RN DNP Candidate ADDRESSING OBESITY 70 IMC (ÍNDICE DE MASA CORPORAL) EL DÍA DE HOY MI FECHA META MI PESO ES MI PESO META MI IMC (ÍNDICE DE MASA CORPORAL) MI PERSONA DE APOYO ES HAZ UN CÍRCULO ALREDEDOR DE TU CLASIFICACIÓN DE IMC SEGÚN TU EDAD MI PLAN PARA ALCANZAR MI PESO META: IMC (EDADES 0-19 AÑOS) PERCENTIL <5 BAJO PESO PERCENTIL 5 - <85 PESO NORMAL PERCENTIL 85 - <95 EXCESO DE PESO PERCENTIL >/= 95 OBESO IMC (EDADES 20-64 AÑOS) <18.5 BAJO PESO 18.5-24.9 PESO NORMAL 25-29.9 EXCESO DE PESO 30-39.9 OBESO 40+ OBESIDAD MÓRBIDA IMC (EDAD 65+) <22.9 BAJO PESO 23-29.9 PESO NORMAL 30-39.9 EXCESO DE PESO 40+ OBESIDAD MÓRBIDA POR QUÉ QUIERO BAJAR DE PESO: ADDRESSING OBESITY 71 HISTORIAS DE VIDA PRESENTA SOLO SE VIVE UNA VEZ ACTORES Juan Cristóbal Castillo es actor, director, compositor y dramaturgo. En cine trabajó en Post tenebras lux de Carlos Reygadas, película que ganó mejor dirección en Cannes. ABUELO Adriana Laffan, actriz, trabajó en 25 telenovelas, tales como la exitosa El amor manda, 30 obras de teatro y 6 películas. ABUELA Paulina Sabugal, graduada de la Escuela Nacional de Arte Teatral del Instituto Nacional de Bellas Artes, ha trabajado como actriz en varias obras de teatro. HIJA Ana Maria Meza Escalante, actriz formada en México y Vancouver, actualmente se presenta en obras montadas en Casa Azul bajo el auspicio de Argos, una de las mayores productoras de telenovelas en México. AMIGA Diego Fernandez Rodriguez, debut. NIETO PRODUCCIÓN PRODUCTORA EJECUTIVA Angélica López Antúnez, productora durante más de 25 años. Nominada para recibir un Pantalla de Cristal – equivalente al Óscar de México –como mejor directora de casting por la película El principio de la espiral GUIONISTAS Gloria López Villaseñor, directora Estratégica y Creativa por 20 años en JW Thompson. Ganadora en festivales publicitarios de Londres, Nueva York y finalista en Cannes. Héctor Estrada, redactor senior, ha trabajado en agencias multinacionales para muchas de las más grandes marcas norteamericanas. DIRECTORA DE FOTOGRAFÍA Guadalupe Szymanski, graduada del Instituto de Estudios Fotográficos de Cataluña, España, y fotógrafa de Grupo Expansión de México. DIRECTORA DE CASTING Teresa Coria Bedolla ha trabajado en la selección de actores para más de 500 proyectos, tanto en Estados Unidos como en México. MAQUILLISTA Raquel Chavira trabajó en proyectos de cine y publicidad, como la película Apocalypto de Mel Gibson y Frida con Salma Hayek, al igual que en The far side of the world con Russell Crowe. DISEÑO DE FOTONOVELA Andrés Felipe Prieto es Vicepresidente de Diseño y Usabilidad para HolaDoctor. LIFE STORIES PRESENTA Publicado y Derechos de Autor © 2017 por HolaDoctor, Inc. Reservados todos los derechos. ADDRESSING OBESITY 72 COMO TODAS LAS MAÑANAS, PATY Y SU AMIGA LUZ SE EJERCITAN... UFF..ESTUVO BUENO EL EJERCICIO… SÍ AMIGA, NO SABES CUÁNTO TE AGRADEZCO QUE ME HAYAS CONVENCIDO DE VENIR A CORRER CONTIGO, ME SIENTO MUY BIEN Y YA BAJÉ DE PESO… SE TE NOTA, ASÍ QUE PREPÁRATE PORQUE LOS GALANES TE VAN A SOBRAR… YA VERÁS, PERO NO DEJES DE HACER EJERCICIO Y DE COMER SANAMENTE ¿EH? 4 | VISITA HOLADOCTOR.COM DIOS TE OIGA, AMIGA… CLARO QUE NO, ME GUSTA SENTIRME Y VERME ASÍ.. ADDRESSING OBESITY 73 OJALA MI MAMÁ ENTENDIERA LO IMPORTANTE QUE ES ESTO PARA VIVIR MEJOR, PERO YO SIGO INTENTANDO QUE CAMBIE SUS HÁBITOS. NOS VEMOS MAÑANA.. LE VA A CAER EL VEINTE, YA VERÁS. LA ACTIVIDAD FÍSICA ES LA BASE PARA TENER UNA VIDA SALUDABLE, AYUDA A CONTROLAR EL PESO. AYUDA A DESARROLLAR HUESOS, MÚSCULOS Y ARTICULACIONES SALUDABLES. MEJORA LA AUTOESTIMA Y CAPACIDAD DE APRENDIZAJE. EL CAMBIO DE HÁBITOS SIEMPRE ES POSIBLE El estrés, el sedentarismo, la mala alimentación son los mayores contribuyentes al desarrollo de enfermedades como las cardiopatías, la diabetes, la presión alta y la obesidad COMIENZA A VIVIR BIEN PRACTICA TUS PASIONES Si queremos neutralizar la carga hereditaria de nuestras enfermedades, empecemos por cambiar nuestra forma de vida Tómate un tiempo cada día para hacer lo que te gusta y si crees que estás muy ocupado comienza por alejarte de la computadora Y sobre todo CORTA EL AZÚCAR Y LA SAL Esto te ayudará a bajar de peso. Dile adiós al salero, lava los alimentos enlatados para sacarles el sodio ¡ABRAZA! CAMINA Salir a caminar con tu familia ayuda a bajar de peso y mejora las relaciones con la familia MODERACIÓN Y pide que te abracen en familia y entre amigos. Es una de las mejores terapias para el alma que haya existido. Comienza a beber cada día menos y reduce las porciones de a poco FUENTE: www.holadoctor.com |5 ADDRESSING OBESITY 74 POR LA NOCHE EN LA CASA DE PATY. AURORA, SU MAMÁ, PREPARA LA CENA. SALCHICHAS FRITAS, TOCINO , PAPAS… Y TAMBIÉN HICE EL PASTEL QUE LE GUSTA A MI NIETO. MAMÁ..¿SABES LA CANTIDAD DE GRASA Y CALORÍAS QUE TIENE ESTO? 6 | VISITA HOLADOCTOR.COM SI NO LO QUIERES, EN EL REFRIGERADOR HAY VEGETALES Y FRUTAS PARA TI. ADDRESSING OBESITY 75 MAMÁ, LO QUE QUIERO ES QUE ENTIENDAS QUE COMER ASÍ Y NO HACER NINGUNA ACTIVIDAD FÍSICA PUEDE AFECTAR SERIAMENTE TU SALUD… YO ESTOY BIEN... NO LO ESTÁS, SE TE SUBE LA PRESIÓN SEGUIDO, DAS DOS PASOS Y TE CANSAS, ASÍ QUE SI QUIERES DISFRUTAR A TU NIETO DEBES COMER SANAMENTE Y BAJAR DE PESO. LA ALIMENTACIÓN ES CLAVE PARA TENER UNA VIDA SALUDABLE Y EVITAR EL SOBREPESO Y LA OBESIDAD. INCLUYE EN TU DIETA VEGETALES, FRUTAS, GRANOS INTEGRALES Y PRODUCTOS LÁCTEOS BAJOS EN GRASA. NO FRIAS LOS ALIMENTOS, CONSÚMELOS A LA PARRILLA O AL HORNO. LIMITA EL CONSUMO DE ALIMENTOS ALTOS EN COLESTEROL, SODIO Y AZÚCAR AGREGADA. |7 ADDRESSING OBESITY 76 MÁS TARDE LA FAMILIA SE REUNE A CENAR. ¿QUIERES MÁS PASTEL, MI HIJO? SI ABUE… TE ESTÁS PONIENDO CACHETÓN… ESTÁ BIEN ALIMENTADO, COMO DECÍA MI MAMÁ: NIÑO GORDITO, NIÑO SANITO… ESO SON MITOS MAMÁ… PERO ESTÁ CRECIENDO, HAY QUE ALIMENTARLO… ALIMENTARLO NO ES ENGORDARLO MAMÁ… PATY TIENE RAZÓN VIEJA, EN NUESTRA FAMILIA HAY MUCHO GORDITO Y TODOS HAN TENIDO PROBLEMAS DE SALUD POR EL PESO. ENTONCES.. ¿NO CREEN QUE YA ES HORA DE CAMBIAR NUESTROS HÁBITOS? LA OBESIDAD INFANTIL PUEDE OCASIONAR AFECCIONES COMO LA DIABETES TIPO 2, ALTO NIVEL DE COLESTEROL EN LA SANGRE E HIPERTENSIÓN ARTERIAL. CONTROLA TU PESO Y EL DE TU FAMILIA CON UNA DIETA BALANCEADA Y ACTIVIDAD FÍSICA DIARIA. 8 | VISITA HOLADOCTOR.COM ADDRESSING OBESITY 77 MÁS TARDE, SAMUEL Y PEPE VEN UNA PELÍCULA. ¿POR QUÉ FUMAS ABUELITO? PORQUE ME GUSTA PERO ES MALO..¿NO? ENTONCES…¿POR QUÉ LO HACES? BUENO..SI.. PERO MI MAMÁ DICE QUE EL HUMO PUEDE HACER QUE TE ENFERMES Y YO NO QUIERO QUE TE PASE NADA.. NO FUMES ABUE… AY HIJO, ES QUE NO PUEDO DEJARLO.. HAY MUCHOS MÉTODOS PARA DEJAR DE FUMAR. SI YA DECIDISTE HACERLO, HABLA CON TU MÉDICO O PROOVEDOR DE ATENCIÓN MÉDICA PARA QUE TE ASESORE SOBRE LOS TRATAMIENTOS Y MEDICAMENTOS QUE TE AYUDARÁN A LOGRARLO. |9 ADDRESSING OBESITY 78 MÁS TARDE, SAMUEL Y PEPE VEN UNA PELÍCULA. ¿POR QUÉ FUMAS ABUELITO? PORQUE ME GUSTA PERO ES MALO..¿NO? ENTONCES…¿POR QUÉ LO HACES? BUENO..SI.. PERO MI MAMÁ DICE QUE EL HUMO PUEDE HACER QUE TE ENFERMES Y YO NO QUIERO QUE TE PASE NADA.. NO FUMES ABUE… AY HIJO, ES QUE NO PUEDO DEJARLO.. HAY MUCHOS MÉTODOS PARA DEJAR DE FUMAR. SI YA DECIDISTE HACERLO, HABLA CON TU MÉDICO O PROOVEDOR DE ATENCIÓN MÉDICA PARA QUE TE ASESORE SOBRE LOS TRATAMIENTOS Y MEDICAMENTOS QUE TE AYUDARÁN A LOGRARLO. |9 ADDRESSING OBESITY 79 RECURSOS DIRECCIÓNES WEB MIPLATO: https://www.choosemyplate.gov/multilanguage-spanish MIDIETA: http://midieta.com PROGRAMA DE SNAP: https://www.fns.usda.gov/es/snap/programa-de-snap LA ETIQUETA DE INFORMACIÓN NUTRICIONAL: https://www.fda.gov/Food/IngredientsPackagingLabeling/LabelingNutrition/ucm268173.htm DEPARTAMENTO DE SALÚD PUBLICA DE CALIFORNIA – RECETAS: https://archive.cdph.ca.gov/HealthInfo/healthyliving/nutrition/recipes APLICACIONES GRATUITAS PARA IPHONE Y ANDROID MYFITNESSPAL: Si desea perder peso, tonificar, mantenerse sano, cambiar sus hábitos o comenzar una nueva dieta, le encantará MyFitnessPal. RUNKEEPER: Todo el mundo. Siempre corre. Únete a la comunidad que ayuda a las personas a salir por la puerta y seguir con la ejecución para siempre! Seguimiento de ejercicio, establecer metas, sudor, y ver el progreso en el camino. PACER: Descargue la aplicación gratuita que le ayudará a mantenerse activo, perder peso, vivir más tiempo y sentirse mejor. MIDIETA: Menú semanal personalizado para bajar de peso, con recetas simples y deliciosas, y monitoreo diario de tu peso! RECURSOS LOCALES BOUNTIFUL BASKETS FOOD COOP: www.bountifulbaskets.org MARKET ON THE MOVE: http://the3000club.org/wordpress/marketonthemove/ COMMUNITY FOOD BANK: https://www.communityfoodbank.org DIET OF HOPE: Referencia para HMO, Tricare y AHCCCS. ¡Pregúntele a su proveedor! www.dietofhope.org | Teléfono: 520.696.3438 ADDRESSING OBESITY 80 Appendix P BMI Documentation Form ADDRESSING OBESITY 81 Appendix Q Provider Feedback Form ADDRESSING OBESITY 82 Appendix R Projected Implementation Costs Projected Costs Lunch and Learn meal for providers and staff Copying supplies (paper, coping costs) Cost for copies of BMI sheet at facility for data collection Cost of using selected copyrighted tools Travel to site for meetings, implementation, evaluation Student time for preparing presentations and creating forms; ordering and obtaining copies; presenting project Student time for obtaining culturally relevant resources in English and Spanish (when available) Provider, MA and Office staff time $200-300 $200-300 $50 Free $35 Approximately 10 hours Approximately 5 hours 1 hour during lunch and minimal for implementation Approximate total: $685 ADDRESSING OBESITY 83 Appendix S Global Attitude Toward Adopting Evidence Based Practice 45 40 35 30 25 20 15 10 5 0 Pre-EBPAS Post-EBPAS Figure 1. Overall provider attitude toward adopting evidence based practice comparing pre- to post- scores. ADDRESSING OBESITY 84 Appendix T Pre- to Post-EBPAS Divergence Scores Figure 1. Total pre-divergence scores. Figure 2. Total post-divergence scores. ADDRESSING OBESITY 85 Appendix U Pre- to Post-EBPAS Appeal Scores Figure 1. Total pre-appeal scores. Figure 2. Total post-appeal scores. ADDRESSING OBESITY 86 Appendix V Pre- to Post-EBPAS Requirement Scores Figure 1. Total pre-requirement scores. Figure 2. Total post-requirement scores. ADDRESSING OBESITY 87 Appendix W Pre- to Post-EBPAS Openness Scores Figure 1. Total pre-openness scores. Figure 2. Total post-openness scores. ADDRESSING OBESITY 88 Appendix X BMI Documentation Form Frequencies Descriptive Statistics BMI Pediatric_BMI Adult_BMI Elderly_BMI MyPlate Increased_aerobic_activity Skipping_meals_eat_3_meals_per_day Calorie_counts MyFitnessPal Avoid_sugar_drinks Increase_fiber Increase_protein Increase_fruits_vegetables Decrease_fat Decreae_sweets_deserts DASH_diet Low_carb_diabetic_diet Fotnovela Null_normal_weight Valid N (listwise) N Minimum Maximum Mean 15 26.78 46.78 36.0580 1 2.00 2.00 2.0000 13 2.00 4.00 3.0769 1 2.00 2.00 2.0000 15 .00 1.00 .7333 15 .00 1.00 .4000 15 .00 1.00 .6000 15 .00 .00 .0000 15 .00 1.00 .2000 15 .00 1.00 .4000 15 .00 1.00 .0667 15 .00 1.00 .1333 15 .00 1.00 .3333 15 .00 1.00 .2667 15 .00 1.00 .2000 15 .00 .00 .0000 15 .00 1.00 .0667 15 .00 1.00 .5333 0 0 Std. Deviation 6.29804 . .75955 . .45774 .50709 .50709 .00000 .41404 .50709 .25820 .35187 .48795 .45774 .41404 .00000 .25820 .51640 ADDRESSING OBESITY 89 Appendix Y Provider Feedback Form Quantitative Data Descriptive Statistics N Minimum Maximum Mean Std. Deviation Q1_purpose Q2_resources Q3_time 6 6 1.00 1.00 2.00 2.00 1.3333 1.5000 .51640 .54772 6 1.00 4.00 2.8333 1.47196 Q4_positively Q5_use_in_future Valid N (listwise) 6 6 6 3.00 1.00 4.00 5.00 3.3333 2.6667 .51640 1.50555