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Childhood Obesity CoalitionDunn County

Wisconsin Rural Hospital Flexibility Program Page 1

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Family-based interventions to reduce childhood obesity in Dunn County

B. Executive SummaryA coalition to address childhood obesity through nutrition and physical activity was

organized three years ago. The coalition consists of faculty, students, physicians, nurses, other

health care personnel, and school administrators from UW-Stout, School District of the

Menomonie Area, Red Cedar Medical Center part of Mayo Health Systems, and Dunn County

Public Health Department. We recognize the need to address childhood obesity from a number

of perspectives including individual-, family-, school- and community-based interventions. This

proposal focuses on reducing childhood obesity through family-based interventions. Two

approaches are taken to reach the family unit. The first (objective 1), is to interact with the

family in their home, provide group classes to assist in developing personalized action plans, and

to support the family unit as they implement their action plan. The second approach (objective

2), has the capability of reaching all families in the county with fun activities promoting nutrition

education, strategies for healthier eating, and ways to increase physical activity in the home

environment. With other projects the coalition is working on and the completion of these

objectives, it is expected that childhood obesity in the county will decrease. Data is currently

being collected through a project supported by Wisconsin Dietetic Association which will

provide baseline data for this proposal.

C. Coalition InformationThe coalition is composed of Red Cedar Medical Center part of Mayo Health Systems

(RCMC), UW-Stout, and Dunn County Public Health Department (PHD) with close

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communication with the school district and city government. The coalition began in 2003 under

the name of obesity research team. At that time, faculty from a number of departments at UW-

Stout (Food and Nutrition, Biology, Psychology, Vocational Rehabilitation, etc), physicians and

other health care professionals met to discuss the importance of childhood obesity as a concern

in our community. This proposal

is only part of a comprehensive

scheme the group has developed

(see Figure 1). The large scheme

includes support and interventions

at many levels individuals,

families, schools, businesses, and

community-wide entities. An

initial focus on families was

identified in 2004 following a

review of the literature.

The lead partners in this

coalition have worked well

together on current and past

projects, and look forward to

working together to achieve the objectives of this proposal. Red Cedar Medical Center part of

Mayo Health Systems will sponsor the intervention program targeted to families with overweight

children or children at risk for being overweight. This program will draw on knowledge and

resources from existing partners as well as provide the opportunity to work with new members

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such as the Family Resource Center, the Menomonie Free-Clinic, and UW-Extension. The Dunn

County Public Health Department is currently conducting a community health assessment that

will help guide the content of the family-based intervention program. In a separate project, a

graduate student in Food and Nutritional Sciences, is collecting baseline dietary, physical

activity, attitudinal, and anthropometric data for children in grades 1, 3, and 5 and their families.

UW-Stout has diverse areas of expertise. In addition to sharing this expertise, this institution

will provide leadership on assessment and much needed student personnel (both hired and

volunteer). We envision a win/win scenario for the community, the university, and the students

educational experiences.

Meetings of the obesity research team were biweekly in 2003/04 and culminated in a grant

proposal to the American Diabetes Association in Nov. 2004. Although the grant was not

funded, the conceptual outline had been formulated research-based family intervention and

educational outreach. In fall 2004, an outreach program (called Fun, Food and Fitness) was

initiated with local elementary schools as part of the schools efforts to include families in the

school community. This program includes nutrition education, strategies for healthy eating, and

opportunities for physical activity designed for children and their families. The program has

been well received and has grown slowly. It is at the point where additional resources will make

it an integral part of community outreach and student learning (objective #2).

Through local funding, a pilot family camp was offered during summer 2005. This camp

allowed, first hand, for the obesity research team to see what a daunting challenge lays ahead in

overcoming childhood obesity. Evaluation of the camp was positive, however, it was

determined that a camp format was not the best way to reach the family unit. The knowledge

gained from the pilot project, current lack of funding, along with the observable need in our

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community, provides the impetus to further develop family-based interventions (objective #1).

The coalition has continued to work together, communicating primarily by email, on a number of

projects and has presented their work together at various meetings (Table 1).

Table 1. Projects and Presentations of the Coalition

Projects/Sponsored Events Presentations

Hosting Robert Sweetgall, national

motivational speaker Fun, Food and Fitness Summer, family-

based camp using the Shapedowncurriculum

Continual Fun, Food and Fitness schooloutreach events

Healthier You lifestyle change contest Walking programs (with pedometers)

Healthy Eating for Families on the Go

Lean and Delicious, healthy cooking series Submission of Wellness Policy to school

board Community health assessment

Weight management classes A book club

Action on Obesity (June 2005) American Association of Family and

Consumer Sciences (June 2005)

Action for Healthy Kids Conference(November 2005)

WI Association of Family and ConsumerSciences (March 2006)

Early Childhood Education Conference(April 2006)

Action on Obesity (June 2006)

Action for Healthy Kids Conference(requested to present November 2006)

D. Problem/Need Being AddressedThe health status of children in the United States has improved over the past three decades as

evidenced by lower rates of infant mortality (1) and declines in nutrient deficiency diseases (2).

However, despite the improvement in these areas, the number of children who are overweight

has increased alarmingly. Approximately 10% of children 2 to 5 years of age and 15% of

children 6 to 11 years of age are overweight (3). Dunn Countys poverty rate of 12.9% exceeds

the WI rate of 8.7% and this affects many dimensions of family living including nutrition and

physical activity (27). Thus, there is need for children to achieve healthy eating and physical

activity patterns that reduce the risk of chronic, long-term health problems (4).

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Type 2 diabetes has risen dramatically among children (5). Risk factors for heart disease,

such as high cholesterol and high blood pressure, occur with increased frequency in overweight

children compared to children with a healthy weight (6). Children who are overweight are more

likely than normal-weight children to become obese adults (7), which increases lifetime risk of

Type 2 diabetes, coronary heart disease, hypertension, gallbladder disease, and some cancers (8).

Multiple factors impact eating and sedentary behaviors in children. Interventions to improve

eating patterns in children have included individual, school-based and family-based

interventions. Eating is more than a response to a biological need, but rather, is a response to a

complex array of relationships a child has with food, their family unit, friends and their

environment. Parental influence on the development of a childs relationship with food later in

life is well documented (9, 10, 11, 12). For example each meal shared as a family reflects

increased grade point averages and fewer symptoms of depression or suicidal thoughts among

children. (13).

An individual is a member of a family and community system which is ecological in nature

(14). A childs food choices are thus influenced by the family, community, and the society.

Enlightened Eating (15) is the result of a person taking control of their food choices by

discovering why, when, and where they eat and with whom they eat. To take personal control,

the child needs to understand why they make decisions and who and what might be influencing

their decisions. A parent/guardian must also consider the childs choices through the eyes of

the child. These principles are critical components of a successful family-based intervention.

Objective #1 of this proposal will allow family members to explore their relationship with food

in their own ecosystems and to gain appropriate knowledge and understanding for incorporating

healthy lifestyle choices.

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Nutrition areas that appear problematic include excessive intakes of dietary fat, especially

saturated fat, and inadequate intakes of foods high in calcium and fiber. Approximately 68 to

75% of US children exceed the current dietary recommendations for intake of total or saturated

fats (16) which are associated with increased low-density lipoprotein (LDL) and increased risk of

cardiovascular disease. Failure to meet calcium requirements in combination with a sedentary

lifestyle in childhood can impede the achievement of maximal skeletal growth increasing the

diet-related risk of osteoporosis later in life (17). Low level of calcium intake also appears to be

related to childhood adiposity. Average dietary fiber intake among children ages 3 to 5 years and

6 to 11 years is 11 g/day and 13 g/day, respectively (18). The food choices of most US children

do not meet the recommended food group servings (19). For children 2 to 9 years of age, 63%

and 78% are not consuming the recommended number of servings of fruits and vegetables,

respectively. Average daily servings are 2.0 for fruits and 2.2 for vegetables (20). For children 6

to 11 years of age, average daily total grain intake was 6.5 servings, whereas daily whole grain

intake was 0.9 servings/day (21). The food intake data emphasize that intervention programs

must focus on increasing childrens consumption of grain, dairy, fruits, and vegetables. It is

extremely important that interventions also advocate that families promote physical activity to

replace sedentary behaviors in family routines (1, 2, 22, 23, 24, 25, 26). Objectives #1 and #2 of

this proposal will address these issues.

E. Work PlanThis proposal is part of several projects focused on the overall goal of lowering the incidence

of childhood obesity in Dunn County through best practices in diet and exercise. As Figure 1

indicates, there are many approaches necessary to reach this goal. They include, but are not

limited to, personal goals and motivation, school-based interventions, family-based

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interventions, and community-wide strategies. Funding from this award will be used to continue

to develop and implement family-based interventions. These family-based interventions will be

built upon successful strategies documented by the American Dietetic Association and by

preliminary work done in our community. Two objectives are identified.

Objective #1: Initiate a family-based intervention program with assessment, education, family-

specific action plan, and follow-up support.

The family-based intervention program will require selection of three main groups of

individuals an in-home evaluation team, an education team, and a physical activity team. A

program coordinator will be hired to screen applicants and organize appropriate training and

back-ground checks. The program coordinator will gain IRB approval for all protocols and

recruit families. Children between the ages of 8-10 who are overweight or at risk of becoming

overweight will be sought. Referrals from RCMC, Menomonie Free Clinic, other local clinics,

Public Health Department, and councilors will be requested. An important outcome of this

selection process is that the families in most need of the intervention will have the opportunity to

participate and benefit. Families will be selected without regard to socioeconomic status,

ethnicity or religious beliefs. Following informed consent, in-home evaluators will spend time in

the homes of selected families, observing the family dynamics during meal preparation, while

the meal is eaten, and following the meal. Special attention will be given to available utensils

and equipment, the physical environment, and interpersonal interactions. This information will

be used when assisting the family in developing an action plan towards healthier eating. The

program coordinator will design ten sessions where all participating families come together.

The sessions will include a curriculum such as Shapedown (RCMC currently owns a license for

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this curricula), family-specific action plans, a time for physical activity, food preparation and

guest speakers. Physical activity will be led, not surprisingly, by the physical activity team

consisting of certified fitness trainers. Children will receive a pedometer and instructions on

using them. A weekly log will be kept. Families will also learn techniques for preparing more

nutritious meals. During the in-home visits recipes used by the family will be collected (or

recorded if no written recipe is available). When the families attend the group sessions they will

receive suggestions on how to improve the nutritional quality of the recipe and then get to

practice preparing the modified recipe and sampling the outcome. Utensils and equipment

observed in the home will be used by the family at the sessions. Cooking sessions will occur in

teaching kitchens available at UW-Stout, the high school, or the middle school. Guest speakers

will present a wide range of topics related to family dynamics, the eating relationship, portion

sizes, body image, and food choices. An atmosphere that fosters support within the family unit

and between family units will be fostered using team building activities. After the organized

sessions, families will be invited to follow-up events which will combine socializing with

continuing education. In addition, families will receive a quarterly newsletter that contains

items of interest to the whole family. A student enrolled in technical communications or

graphics communications UW-Stout will design and edit the newsletter. A spring introductory

newsletter and a mid summer newsletter will be funded from this proposal. Follow-up in-home

visits will be provided. These visits will assist families in implementing their action plans and

answer questions as they are encountered.

The program coordinator will take steps towards developing this into a sustainable program.

An estimated cost per family will be determined. The next time the program is offered

(hopefully fall 2007 or spring 2008) each family will be assessed this rate with opportunities for

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financial assistance through the free clinic, grants obtained by the Dunn County Health

Department or through the Menomonie Community Health Foundation.

Objective #2: Strengthen an existing outreach program focused on families with elementary-

aged children and create a mechanism for sustainability.

The current outreach program is in its third year. This objective will build the infrastructure

needed to ensure that the program (called Fun, Food and Fitness: Outreach) is ongoing.

Statements of commitment between outreach providers (the hospital and clinic, the university,

and county extension) and local schools will be sought. The outreach coordinator will schedule

events with priority given to events in which children and their families attend together (family

night or math day). Examples of family-based events in the community include Safe Kids Day,

Freedom Fest, and the county fair. Other events such as kindergarten vaccinations or sports

physicals offered through the schools, the free clinic and Dunn County Health Department can

be utilized to connect with families. Outreach will be extended to organizations such as Boy or

Girl Scouts, church youth groups, 4-H clubs, etc. This resource can also be used for smaller

outreach events such as classroom presentations or in-service classes for teachers. The win/win

design allows university students to gain valuable professional skills while having minimal drain

on hospital and university resources. Another winning component is that recipients will receive

age-appropriate, research-based materials and education.

The inventory of outreach materials will be strengthened. Fun, Food and Fitness: Outreach

currently has a limited supply of materials, most of which has been hand-made by students and

are, unfortunately, not very durable. Fifteen modules in nutrition education, healthier eating

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behaviors and increasing physical activities will be developed and tested. An additional 6-8

activity stations will be created. Figure 1 provides a guide of possible modules and activities.

This grant provides the means to purchase quality educational materials that can be displayed

professionally. A professional look requires items such as table-top displays, table skirts and

room partitions. When Fun, Food and Fitness: Outreach is heading to an event a small utility

trailer with custom decals will be used to transport materials. The trailer, while necessary, will

also be a symbol of our commitment to better health and highlight the coalition partners.

F. Evaluation PlanThe overall goal within this proposal is to use family-based interventions to reduce childhood

obesity in Dunn County as determined by a change in either BMI or percent body fat (Note:

funding for these assessments are not part of this proposals budget because these funds have

been received through other sources). Body mass index will be determined from growth charts

using the childs height, weight, age and gender. This data will begin to be collected in Oct.

2006.

The primary outcome of the family-based intervention program will be families who are

better able to understand factors behind lifestyle choices and to explore ways to incorporate

healthier choices and activities into the familys lifestyle. The previous section describes the

activities. Assessment of these activities is important. Pre- and post- surveys of families

participating in the multi-week intervention program will include questions related to nutrition

education, dietary habits, lifestyle habits related to physical activity, attitude, ability to

incorporate healthy lifestyles into the family structure, and understanding of the eating

relationship. Families (as a family unit or as individuals) will be given the opportunity to

provide feed back in the form of a survey on each component of the intervention including the

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in-home visit, curricula, recipe adaptation and meal preparation, guest speakers, fitness trainers,

and the newsletter. The assessment tool for the in-home visits will include the professionalism

of the evaluator, the incorporation of information into the sessions, and the overall effectiveness

of home-visits. The number of participating families will be an indicator of our referral method

and marketing strategies. Demographic information about families will be correlated to the

interventions outcomes.

The Fun, Food and Fitness: Outreach program will provide a social and family experience.

To determine if it has become a recognized component of the communitys commitment to

health the program will be assessed by evaluation tools and attendance as well as the number of

requests to participate in family-based community events. The funds requested will provide 15

modules and 6-8 activity stations. All modules and activities created will be peer-reviewed and

field-tested prior to public outreach. Outreach participants will be able to provide evaluations of

the modules and activities. Participants will also be asked to answer short surveys (pre- and

post-) about knowledge, perception of foods and physical activities, and attitude about

incorporating healthier food choices and more physical activities into their familys lifestyle.

When the outreach program is part of another event such as Safe Kids Day or Freedom Fest,

event sponsors will be encouraged to provide feedback.

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G. Budget (Corrections received 11/20/2006 from Ann Parsons)(1) Expenses Requested From Grant

(a) Salaries

Family-based intervention coordinator $--

In-home evaluators $--Event educators $--

Newsletter developer/editor $--

Outreach developer $--

Grant assessor $--

Subtotal $--

(b) Fringe Benefits

-- % of salary (total salary = $--) $--

-- % of salary (total salaries = $--) $--

Subtotal $--(c) Travel ($.x/mi)

In-home evaluators ($--/mi * 500 miles) $--

State and regional conferences $--

Subtotal $--

(d) Equipment

no equipment over $5000 requested Subtotal $0.00

(e) Supplies

Materials and back ground checks for in-home eval. $--

Photocopying $--Postage $--

Curriculuar materials (workbooks, pedometers, food) $--

Incentives $--

Outreach materials (educational, motivational) $--Outreach: professional supplies (displays, table skirts,dividers) $--

Outreach: partability (trailer, decals, small cart) $--

Misc. $--

Subtotal $--

(f) Stipends

Event assistants $--

Guest speakers $--

Subtotal $--

(g) Other Costs $0.00

Total $--

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(2) Expenses Paid by Matching/In-Kind Funds

(a) Salaries

RCMC (Pejsa and staff) $--

MacDougall, Dunn County PHD $--

Parsons, UW-Stout $--

Barnhart, UW-Stout $--

Subtotal $--

(b) Fringe Benefits

--% of salary $--

Subtotal $--

(c) Travel

Subtotal $--

(d) Equipment

Room usage (RCMC, School District, UW-Stout) --Anthropometric Assessment equipment --

Subtotal $--

(e) Supplies

Photocopying $--

UW-Stout student research awards $--

Subtotal $--

(f) Stipends

Subtotal $0.00

(g) Other

Wisconsin Dietetic Association grant (UW-Stout) $--

Total $--

Personnel are needed to coordinate the family-based intervention program and the outreach

efforts. Additional support personnel will form the specialized teams for in-home visits,

curricula educators, and physical training. The family-based coordinator will determine the

curricula, establish and oversee training of personnel, coordinate sessions, and recruit families.

Minimum qualifications include a bachelors degree with credits towards a masters degree.

Background checks on all in-home evaluators will be conducted. Travel throughout the county

is expected. The space, including teaching kitchens, for sessions with families will be provided

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by a coalition partner. Anthropometric measurements will be provided by the clinic, PHD or

UW-Stout.

Photocopying and mailing costs of educational materials, assessment forms and newsletters

are included in the budget with the participating partners contributing additional dollars. An

assessment coordinator(s) will develop assessment tools, oversee their administration and

analyze the information. The coordinators will need to work together. Incentives for families to

participate will be provided at the end of the family-based program and during outreach

activities. These include, but are not limited to, frisbee, dance CD, fruit, balls, jump ropes,

recipe books, etc. Diverse education materials and activities will be purchased. The goal is to

establish 15 educational modules for the outreach team as well as 6-8 activity stations. When the

Fun, Food and Fitness: Outreach is heading to an event a small utility trailer with custom decals

will be used to transport materials. The trailer will be a symbol of our commitment to better

health and highlight the coalition partners.

References1. MMWR Guidelines for school and community health programs to promote lifelong physical

activity among young people. MMWR. 1997; 46:1-36.

Etc.

Appendix

A. Letters of Support:

B. Short bios of key staff

C. Short resumes of key staff

D. References

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