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A Community-Based Family Intervention Program to Improve Obesity in Hispanic Families 16 WMJ • DECEMBER 2012 programs. Publicity was primarily in the form of posters, announcements, and word of mouth. Families with schoolage children were encouraged to enroll. Families with children younger than school age were offered on-site childcare. The 8-week program included a 40-minute classroom component followed by a 40-minute physical activity session that concluded with a healthy family dinner to promote good eating habits. The classroom program was based upon the 3 crucial components used in the We Can! curriculum and became program objectives. Program objectives helped families: (1) improve food choices; (2) increase physical activity; and (3) reduce screen time. Screen time is the amount of time a person spends in front of a television, computer, or video game screen. Because many of the household decisions regarding television viewing, food preparation, and recreational activities are made by adults, the program was designed to present parallel messages to both the adults and children. The overall goal of the program was to encourage additional communication between parents and their children, leading to cooperative decisionmaking involving nutrition and physical activities for all family members. The educational component was divided into 2 groups, one consisting of adults and the other of school-age children. Adult educational programming was presented in Spanish by a bilingual health educator and a bilingual registered nurse. All written materials were made available in Spanish and English, with literacy level considerations. Children’s classes were presented in English. Bilingual staff included a registered nurse and exercise instructor from the HCHRC and a health educator from the Waukesha Public Health Division. Although the adults and children attended separate nutrition lessons, both discussed the importance of making healthy food choices and being active. A variety of activities and games were incorporated into the curriculum to strengthen the understanding of the lesson objectives (Table 1). All family members participated in the same exercise/physical activity session. The sessions were taught by the bilingual health promoter, a certified, bilingual exercise instructor. Physical activities proved to be a very popular component for all family members and strengthened the concept of being active together and enjoying physical activity. Participants had different levels of mobility and the exercises were selected with that in mind. The exercise sessions had 3 distinct dimensions: warm-up, exercise, and cool down. Physical activity included aerobic/cardiovascular (endurance), anaerobic (speed/strength), flexibility, and coordination exercises. The physical exercise equipment consisted of fun and inexpensive materials that many families already have at home, such as balls, jump ropes, hula hoops, lies in order to diminish health disparities such as those seen between the Hispanics and non-Hispanic whites in the areas of obesity. This article describes the study and specific individual and community outcomes. METHODS Where there are many lifestyle programs for children, few involve the full family unit and take the Hispanic culture into consideration. For example, the Fit Kids Program11 was structured with primarily the English-speaking child in mind and had a program fee. Given the high percentage of low-income Hispanic families in Waukesha, any program fee or language barrier could economically or socially exclude participation. The We Can! curriculum promotes awareness of healthy food choices and discusses the importance of physical activity with a particular focus on energy balance and family.10,12 It is available online at no cost, and the first 2 weeks of materials were already translated into Spanish. The curriculum is endorsed by the National Heart, Lung, and Blood Institute10,12 and strives to further the Healthiest Wisconsin 2020 focus areas and objectives regarding nutrition, healthy foods, and physical activity.13 It also addresses important overarching goals of Healthy People 2020 to reduce obesity and disparities.6,7 The Waukesha County Public Health Division collaborated with the Hispanic Community Health Resource Center to facilitate the We Can! curriculum in a series of nutrition and exercise classes. After translating the remaining curriculum into Spanish and including other culturally appropriate supplemental handouts, a family exercise component was added to each class. Community partnerships were sought to host activities, promote participation, and provide support for sustainability. Partners included White Rock Public Elementary School, La Casa de Esperanza (community center) and the local YMCA. Participants were recruited through convenience sampling using community outreach methods at local churches, medical clinics, schools, self-service laundries, and community Table 1. Nutrition Session Themes Week 1 Program Overview Week 2 Energy Balance Week 3 Body Mass Index and Portion Control Week 4 Energy In* and Reading Nutrition Labels *Energy In is the amount of calories consumed through dietary intake. Week 5 Energy In and Healthy Substitutions Week 6 Energy Out* and the Importance of Physical Activity in Energy Balance *Energy Out is the amount of calories burned through physical activities and normal daily functions. Week 7 Decreasing Screen Time Week 8 Program wrap-up with post-test, evaluation and program surveys VOLUME 111 • NO. 6 17 with the intent of measuring behaviors about healthy choices in nutrition and activity. Children also were asked true and false knowledge questions in a group setting, which included knowledge about nutrition labels, portions, physical activity, and general health. No biometric blood testing was done with children. Child participants were measured for height, weight, and body mass index (BMI) percentile pre-program and postprogram. RESULTS The program served 47 families: 57 adults and 54 children. The average age for adults was 32 years. Of the adults, 89% were women and 11% men. One 16-year-old participant was given a choice to participate in the adult or the children’s educational component. He chose to attend the adult class; however, a decision was made not to participate in biometric testing. The survey included assessment of families’ habits related to food choices, sweetened beverage consumption, physical activity, and screen time. Adult health risk assessments (HRAs) were performed approximately 1 week prior to the start of each program and 1 week following. HRA assessments included biometrics: total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, fasting glucose, height, weight, BMI percentile, waist circumference and blood pressure. The HCHRC hosted all screenings and offered a post-screening healthy breakfast. The biometric testing in the adults’ post-program intervention showed some improvements in reducing cardiac and diabetes risk factors (Table 2). This included improvements in systolic and diastolic blood pressure, glucose, weight, BMI, and waist circumference. Blood pressure data collection averaged a 3.5 mm Hg decrease systolically (P=.0132) and decreased 2.36 mm Hg diastolically (P=.0357). Blood glucose decreased by 3.08 points (P= .0253) comparing pre-program and postprogram collections. Weight decreased by 2.03 pounds overballoons, spoons and eggs, and foam pool toys. The participants were able to take home elastic bands to continue exercises taught. A family dinner encouraged participants to implement some of the strategies and decision-making skills covered in each week’s lesson. Demonstration and participation in snack and meal preparation encouraged participants to use healthy ingredients and substitutions. The participants practiced portion control and had many opportunities to experience new healthy foods. A closing ceremony anchored the last class, at which each participant’s accomplishments were recognized with a certificate of completion. Program incentives were awarded upon successful program completion and included YMCA memberships at a discounted rate. As an incentive for children, $50 was given toward the purchase of a bicycle to further promote physical activity. The program educators secured and fitted bicycle helmets for each child participant. Participants were encouraged to suggest any changes or to share any thoughts. Participants who completed the program were encouraged to register for other exercise classes and community health programs available at the HCHRC. For this study, data was collected before and at the conclusion of the 8-week program. Progress toward program objectives was measured through knowledge testing, lifestyle surveys, and biometric testing. Pre- and post-program lifestyle surveys, and knowledge and biometric testing for adults were facilitated. Testing and surveys were available in Spanish and English. In addition, adult test questions and response choices were read aloud at both pre- and post-assessments to ensure understanding. Children were given pre- and post-program survey questions that reflected the lifestyle behaviors of children participants. These were administered by a public health educator, Table 2. Biometric Results for Adults Program Year Unit of Measure Sample Size Pre-program Ave Post-program Ave Change P-valuea Systolic BP 2006-2010 mm Hg 50 108.34 104.84 decrease 3.5 0.0132a Diastolic BP 2006-2010 mm Hg 50 67.84 65.48 decrease 2.36 0.0357a Cholesterol 2006-2010 mg/dL 52 174.96 170.79 decrease 4.17 0.3616a HDL 2006-2010 mg/dL 52 44.94 46.52 increase 1.58 0.2663a LDL 2006-2010 mg/dL 48 104.71 97.44 decrease 7.27 0.1157a Triglycerides 2006-2010 mg/dL 50 145.92 154.36 increase 8.44 0.4678a Glucose 2006-2010 mg/dL 52 96.62 93.54 decrease 3.08 0.0253a Waist 2006-2010 in. 52 37.33 36.79 decrease 0.54 0.0345a Weight 2006-2009 lbs 37 156.97 154.95 decrease 2.03 0.0024a BMI 2006-2009 37 27.97 27.62 decrease 0.35 0.0103a Knowledge Test 2006-2010 % correct 57 38% 88% Increase of 50 0.0001b percentage points aStatistical significance tested using paired t test bStatistical significance tested using unpaired t test 18 WMJ • DECEMBER 2012 lack of motivation as a barrier to physical activity. For the third program objective, decreased screen time, lifestyle surveys for adults in 2008 showed that prior to program participation, 100% of participants reported watching more than 2 hours of television per day. Postprogram, that number dropped to 47%. In 2009, participants viewing more than 2 hours of television per day dropped by 34% by the program completion. Reportedly, in 2010, the number of participants watching more than 2 hours of television dropped by 65% at the end of the program. The children’s scores yielded similar findings. An overall goal of the study was to increase communication between parents and their children to facilitate cooperative decision-making involving nutrition and physical activities. Anecdotal evidence obtained through parent’s comments suggests that increased family communication of nutrition and physical activities had occurred. (Table 3) The HCHRC created a monthly support exercise group post program in response to participants’ comments. It reinforced nutrition and exercise concepts previously learned in the program and encouraged families to continue exercising together. Program participants led this exercise support group, which evolved into a monthly “Family Exercise Night” that is held during the winter months. In addition, a total of 16 walking sessions are offered as a counterpart during the summer months. Participants of all ages continue to walk together and numbers have surpassed 100 walkers. Other programmatic outcomes included a culturally appropriate We Can! curriculum translated into Spanish and available for use as well as pre-screening and post-screening HRA forms, Release of Information for HRA’s form, Release of Liability form, and a Photo Consent form, all translated into Spanish. COMMUNITY OUTCOMES The We Can! program served not only to improve the knowledge and individual behaviors of the participants, but it also facilitated a variety of systems changes in the community due to its collaborative nature. For example, the local YMCA provided gym memberships at a discounted rate, which were awarded all (P= .0024) and BMI decreased by 0.35 (P= .0103). Waist circumference decreases over the 4-year period averaged .54 inches (P=.0345). Each of the core evaluation measurements was linked to one of the program objectives in order to measure the program’s effectiveness. The first objective to improve food choices was measured through didactic testing of both adults and children. Comparisons of pre-program to post-program knowledge testing for adults revealed an average of a 50 percentage point increase over the span of the program. In 2008, there was a 50% decrease in soda consumption among adults. In 2009 and 2010, there was a 20% decrease of soda consumption among adults post program (Figure 1). For children, pre-program nutrition knowledge scores for children averaged 20%, while post-program knowledge scores averaged 80%. There was a 33% decrease in soda consumption among children in year 2008. In 2009 and 2010, there was a 40% decrease in soda consumption among children. The second program objective was to increase physical activity. In an analysis of pre-program and post-program data, there was an average 60% drop in adult participants reporting Figure 1. Knowledge Testing Results for Adults by Program Year. 0 10 20 30 40 50 60 70 80 90 100 A verage Test Percentage Program Year Pre-program Post-Program Table 3. Participant Comments Participant 1 “I loved the program because it gave me the opportunity to be with my children. Also I learned that exercising as a family is fun.” Participant 2 “I am very pleased that there are programs like this because, aside from learning about good nutrition and health, we spent time as a family discussing what we want to do in the future.” Participant 3 “It seemed to be a great program, very complete for health. I loved that there are people concerned about the health of others. Thank you with all my heart. It also served to unite our family on what we should eat and how to exercise as a family.” VOLUME 111 • NO. 6 19 ability. A community approach was necessary to change both individual eating and exercise habits as well as to diminish environmental barriers to achieve a healthy and active lifestyle. Time for community conversations, strategic partnerships and grant writing became the first steps in developing community programs that address health disparities of minority populations. Collaboration between key community organizations and health institutions was essential in improving health in a social ecological approach. A strong collaboration between leadership at the Waukesha Public Health Division and management at Waukesha Memorial Hospital provided the framework to explore new ways to improve Hispanic health in Waukesha County. With hospital restructuring, health care reform, and state budget reductions, finding future funding for multiple year prevention programming may be challenging. The intent of this initiative was to provide a communitybased program to diminish the incidence of overweight and obesity in Hispanic families by promoting awareness of healthy food choices and the importance of physical activity in a culturally acceptable fashion with a particular focus on energy balance. Using the We Can! curriculum and intervening at an individual, family, and community level, program goals were achievable. The ability to replicate the program year after year has resulted in additional programmatic and system changes. Changes occurred in community systems, which positively affected the built environment with increased availability of and improved access to safe places for family physical activity. The results of this program evaluation are encouraging. This program has had a meaningful impact on the participating community members and the community at large. Funding/Support: This project was funded by a State of Wisconsin MCH Title V Services Block Grant from the Maternal and Child Health Bureau, Health Resource and Services Administration, US Department of Health and Human Services. Financial Disclosures: None declared. REFERENCES 1. CDC. Differences in prevalence of obesity among black, white, and Hispanic adults – United States, 2006-2008. MMWR Morb Mortal Wkly Rep. 2009; 58(27):740-7444. 2. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, MD: Office of the Surgeon General (US); 2001. http://www. surgeongeneral.gov/topics/obesity/calltoaction/CalltoAction.pdf. Accessed August 31, 2012. 3. Nestle M, Jacobson MF. Halting the obesity epidemic: a public health policy approach. Public Health Rep. 115(1):12-24. 4. Wisconsin Department of Health Services, Division of Public Health. Obesity, nutrition, and physical activity in Wisconsin. Executive summary. http://dhs.wisconsin. gov/health/physicalactivity/pdf_files/executivesummary.pdf. Accessed August 31, 2012. upon successful program completion. This encouraged families to maintain an active lifestyle post-program. Bilingual program staff interpreted and oriented one family to the gym equipment and activities at the YMCA. That family in turn oriented and interpreted for the remaining participants. Through this, the YMCA was made aware of the need for bilingual signage and staff. They have since hired 3 bilingual individuals to improve access for Spanish speakers. Meals were served by a local Hispanic café, which agreed to create some dishes especially for the program. The meals were so popular with program participants that the café added a healthy-options section to its menu, featuring many of the program entrées. System changes occurred in the built environment (community structures). After a report to the Waukesha Collaborative Hispanic Network, a community stakeholder group comprising 23 organizations, a call was made to city leaders to ask for improvements to a neighborhood intersection. The 5-way intersection was perceived by local residents as unsafe and created a barrier to a local park. Pedestrian-friendly lights were installed with audible cues. A partnership with a local elementary school and a wellknown water systems company resulted in the promotion and increased consumption of drinking water in schools. The Waukesha Public Health Department staff assisted the School District of Waukesha in their development of a school wellness policy. The HCHRC staff worked with County Parks and Recreation Department to assist with Spanish translation of their children’s program brochure. DISCUSSION The adapted We Can! curriculum, when combined with a physical activity and meal preparation component, showed some evidence in decreasing cardiac and diabetes risk factors in Hispanic families. Some biometric improvements were achieved, such as lowering BMI. Surveys pre- and post-program showed increased knowledge relating to energy balance and nutrition and revealed positive attitude changes regarding healthy behaviors. Limitations included the lack of a control group with which to compare the program’s effects, and the inability to control variables such as other sources of education from media or reading nutrition education materials that may have affected learning. There were no follow-up biometric measures planned beyond those of post-program. Collecting biometric measures at 6 months and 12 months post-program could yield additional evidence of long-term clinical impact. The community was involved in every step of the program, including program development, system changes and sustain-

Answer 1

A detailed precipitate for the article and benefits:

Explanation is man's appearance from his self-imposed childishness. Childishness is the incapability to use one's considerate without leadership from additional. This childishness is self-imposed when its reason dishonesties not in the absence of thoughtfulness, but in the absence of resolution and bravery to use it deprived of leadership from additional. Have bravery to use your individual considerate. Enlightenment means taking full accountability for your lifetime. Statement of Individuality in American Revolution covers the loveliness and power of the introduction, attainment back to farthest ancient times and onward so an unlimited upcoming, have raised the emotions of millions of men and will endure to do. These arguments are more volatile and revolutionary than whatever printed ever those are a repeated stimulus to the entire burdened persons around the world.

The entire consequence of the philosophy and manufacturing is one of anti-enlightenment that is the liberal procedural control of nature, develops mass dishonesty and is twisted into a means for binding awareness. It obstructs the growth of independent, self-governing persons who magistrate and choose deliberately for themselves. A permitted individual is the one who distinguish and differentiates his/her possible area e.g., set by his/her culture. The slave is not conscious of such restrictions. A free person is wise to identify what is underneath his/her control and what is not, and has the aptitude to receive the first and spread the second unique. We have heard that if there is a determination, then there must be a way. In detail the information should be in the conflicting order, i.e. if there is a way, then there might be a determination. It is right because the possible area might be unfilled, and one strength disregards one or some restraints, and then being in a big worry, e.g., keen outside ones' aptitude.

The impractical prospects of freedom and privileges to brand your own choices will abolish a person except it is documented that these principles are freedoms and not supplies and consequently they are attended by errands. Dread is not in the custom of language the certainty; when faultless genuineness is predictable, faultless freedom must be allowable. Nor does anybody who is appropriate to get annoyed when earshot the certainty should miracle why he does not catch it. For instance, when I requested a commercial boss what had made his group one of the best in his manufacturing, he piercing to his CIO and said Joe is a tycoon. He can leave any time. He speaks what he reasons is right!

Attention is what your brain does deliberately. Our attentions achieve a sequence of info dispensation in order to form plans wanted to live our daily exists. This procedure is recognized as choice creation. Though, sideways from creating choices, since of many types of doubts we also face a problematic called decidophobia, which is the terror of creation the wrong choices joint with anxious anxiety. Furthermore, fear of ruling by others is a sure trail to sadness which is a state of attention. Choices are at the heart of achievement, and at periods there are dangerous instants when they can be problematic, confusing, and nerve racking. This delivers help and leadership for creation of well-organized and real choices by hitting to use a well-structured technique and well-focused procedure recognized as the demonstrating or paradigm procedure. The term paradigm originates from the Greek expression paradeigma, connotation "prototypical" or "design." A prototypical characterizes a way of observing at the world, a communal set of expectations that allow us to understand or forecast behavior. Copies have a powerful result on peoples and on civilization since our view of the world is determined by our set of casts about it. To put it extra way, our daydream is often ostentatious by what we hope about the biosphere; our politics usually regulator the info that we appreciate.

Choice manufacture is about fronting a inquiry, such as, "To remain or not to remain?” i.e., to be the one you want to be or not to be? That is a choice. Humankind has continuously existed in the shadow of doubts. Yet nearly nonentity was known near fear pending Freud started the education of uncommon phobias. A little advanced, some psychologists optional that one fear is shared to all manhood: the fear of death. Choices, decisions and more choices! The terror of creation serious choices is a novel kind of fear, called decidophobia. The terror of creation the incorrect choices is well recognized to any accountable manager. As said that one can gain asset, bravery, and sureness by every knowledge in which you actually halt to look terror in the expression. Anywhere you see a fruitful commercial, somebody once complete a brave choice. There has not ever yet been a being in the past of manhood who ran a life of comfort whose designation is worth retention. The trouble in life is the excellent.

An actual and proven choice process has been industrialized over the previous 70 ages and is recognized as Processes Investigation/Organization Discipline/Result Discipline/Success Discipline. In the thoughtful conclusions that mold the forthcoming of your commercial, liberty becomes touchable; thoughtful conclusions are matters of life-threatening terror. Serious occupational conclusions that eventually shape, leader, and straight our upcoming are very fearful to commercial bosses. These choices comprise standards, values, and the contrast and excellent of goalmouths. Knowledge the organized, well-focused method to the decision creation procedure diminishes decidophobia. The jewel of Practical Organization Discipline is that it goes the old saying that commercial bosses are instinctive, not complete into fable. If one can chief organization discipline requests, then no problematic is also big nor any choice too irresistible. The goalmouth of organization science specialists is to wipe out decidophobia.

The primary obligatory for accomplishment science is the aptitude to apply your bodily and cerebral dynamisms to one choice problematic/chance nonstop without rising tired. Just the existence concerned about creation thoughtful choices is like sedentary on an astounding chair, it gives you somewhat to do but doesn't get you wherever. Consequently perturbing about manufacture a choice is a left-over of time. A choice is somewhat you have the competence of shifting. Whatever different is a detail of life. The primary belief in manufacture good choice is that you necessity not fool by hand, and you are the calmest being to fool. Furthermore, creation a choice and applying one are two dissimilar belongings. Here is a query for you: Five frogs are sedentary on a record. Four choose to hurdle off. How many are missing? A long-drawn-out choice is only unique share of the procedure of selecting since it absences the promise to tool the choice. There is a large change amid creation a choice and applying it. The amount of achievement is not whether you have a threatening choice to contract with, but whether it's the same choice you had beforehand. Choose like a gentleman of deed; tool like a man of supposed. It does not gross much forte to choose what to do, but it necessitates great forte to do clothes.

Different deterministic replicas, the consequence of some choices be contingent on the additional party, as is the circumstance in any publicity campaign planned choices in a modest marketplace. Consequently, one of the physiognomies of choice examination glitches is that decent choice creation does not unavoidably bring about good consequences.

A choice typically includes three steps:

1. A credit of a essential: A displeasure within oneself a annulled or essential;
2. A choice to alteration to stop the annulled or necessity;
3. A mindful commitment to device the choice.

So sidewise from that, we see that creation the precise choices is not lone what we need to do, but contains what we consume to do. The fool who recurrences again and over: I am certain, I am bound, ruins in captivity. The dread of creation the wrong result is what shoves and directors us to manufacture a conclusion by applying a scientific method. This is what Organization Discipline is all around.