<%BANNER%>

Evaluation of a Children's Medical Services Program for Overweight Children and Adolescents with Hyperinsulinemia and Ty...

Permanent Link: http://ufdc.ufl.edu/UFE0019961/00001

Material Information

Title: Evaluation of a Children's Medical Services Program for Overweight Children and Adolescents with Hyperinsulinemia and Type II Diabetes
Physical Description: 1 online resource (159 p.)
Language: english
Creator: Wall, Susan
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: bmi, body, children, diabetes, diet, exercise, hb, hyperinsulinemia, medical, overweight, program, services
Nursing -- Dissertations, Academic -- UF
Genre: Nursing Sciences thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The tripling of overweight rates among youths in the last 30 years has engendered a variety of public policy strategies. One such strategy is behavior intervention programs involving diet and exercise behavior modification. In 2002, Tallahassee Children's Medical Services (CMS) implemented a behavior intervention program. Youths, diagnosed with either hyperinsulinemia or type II diabetes, and their parents, were targeted. The purpose of this study was to evaluate the effectiveness of the CMS program by using a three-part, mixed method design. The evaluation included 1) a repeated measures retrospective chart review; 2) participant interviews; and 3) in-class observations. Convenience sampling was used. The chart review compared the body mass index (BMI) and the glycosylated hemoglobin (Hb A1c) of the youths at approximately three and six-months before program participation; the first day of the program; and approximately three and six -months after program participation. A qualitative component involved interviewing 11 youths and parents, and observing four class sessions. Youths ages ranged from 7 to 18 years (M = 13, SD = 2.68). A repeated measures ANOVA analysis revealed that BMI measures increased over time (df 4; F = 4.95; P < 0.05). The findings were then confirmed using a mixed general linear model. In addition, the mixed general linear model revealed that Hb A1c decreased over time (df 4; F = 2.80; P < 0.05). All youths and parents reported post-program nutrition and exercise behavioral changes. Five main themes emerged from the interview data and field notes. First, all youths and parents reported positive post-program nutrition and exercise behavior changes. Second, parents reported that the youths were reluctant to change post-program health behaviors. The last three themes revealed areas that the CMS program can use to improve curriculum methodology: 1) the presence of impediments to engaging youths; 2) the existence of program service deficiencies; and 3) additional parent concerns that went beyond the priorities of the program. While positive health outcomes are the goal of any behavior intervention program, health outcomes are not the sole measure of a success. Positive changes in behavior such as exercise and nutrition are necessary prerequisites to positive health outcomes and, therefore, a valid measure of success toward positive health outcomes. Qualitative findings in this study suggest that the CMS program achieved positive changes in exercise and nutrition that may potentially endure after the conclusion of the program. As the CMS program improves and is further validated, it may be revised and replicated in programs that target similar populations.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Susan Wall.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Krueger, Charlene.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0019961:00001

Permanent Link: http://ufdc.ufl.edu/UFE0019961/00001

Material Information

Title: Evaluation of a Children's Medical Services Program for Overweight Children and Adolescents with Hyperinsulinemia and Type II Diabetes
Physical Description: 1 online resource (159 p.)
Language: english
Creator: Wall, Susan
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: bmi, body, children, diabetes, diet, exercise, hb, hyperinsulinemia, medical, overweight, program, services
Nursing -- Dissertations, Academic -- UF
Genre: Nursing Sciences thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The tripling of overweight rates among youths in the last 30 years has engendered a variety of public policy strategies. One such strategy is behavior intervention programs involving diet and exercise behavior modification. In 2002, Tallahassee Children's Medical Services (CMS) implemented a behavior intervention program. Youths, diagnosed with either hyperinsulinemia or type II diabetes, and their parents, were targeted. The purpose of this study was to evaluate the effectiveness of the CMS program by using a three-part, mixed method design. The evaluation included 1) a repeated measures retrospective chart review; 2) participant interviews; and 3) in-class observations. Convenience sampling was used. The chart review compared the body mass index (BMI) and the glycosylated hemoglobin (Hb A1c) of the youths at approximately three and six-months before program participation; the first day of the program; and approximately three and six -months after program participation. A qualitative component involved interviewing 11 youths and parents, and observing four class sessions. Youths ages ranged from 7 to 18 years (M = 13, SD = 2.68). A repeated measures ANOVA analysis revealed that BMI measures increased over time (df 4; F = 4.95; P < 0.05). The findings were then confirmed using a mixed general linear model. In addition, the mixed general linear model revealed that Hb A1c decreased over time (df 4; F = 2.80; P < 0.05). All youths and parents reported post-program nutrition and exercise behavioral changes. Five main themes emerged from the interview data and field notes. First, all youths and parents reported positive post-program nutrition and exercise behavior changes. Second, parents reported that the youths were reluctant to change post-program health behaviors. The last three themes revealed areas that the CMS program can use to improve curriculum methodology: 1) the presence of impediments to engaging youths; 2) the existence of program service deficiencies; and 3) additional parent concerns that went beyond the priorities of the program. While positive health outcomes are the goal of any behavior intervention program, health outcomes are not the sole measure of a success. Positive changes in behavior such as exercise and nutrition are necessary prerequisites to positive health outcomes and, therefore, a valid measure of success toward positive health outcomes. Qualitative findings in this study suggest that the CMS program achieved positive changes in exercise and nutrition that may potentially endure after the conclusion of the program. As the CMS program improves and is further validated, it may be revised and replicated in programs that target similar populations.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Susan Wall.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Krueger, Charlene.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0019961:00001


This item has the following downloads:


Full Text





EVALUATION OF A CHILDREN' S MEDICAL SERVICES PROGRAM
FOR OVERWEIGHT CHILDREN AND ADOLESCENTS WITH HYPERINSULINEMIA
AND TYPE II DIABETES















By

SUSAN WALL


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2007




































0 Susan Wall 2007



































To Daniel Manry









ACKNOWLEDGEMENTS

I thank Daniel Manry and my family. I also thank my supervisory chair, Dr. Charlene

Krueger, and committee members (Dr. Sharleen Simpson, Dr. Allyson Hall and Dr. Kathleen

Wil son).












TABLE OF CONTENTS


page

ACKNOWLEDGEMENT S ........._._... ......... ...............4.....


LIST OF TABLES .........._.... ...............8.._.._ ......


LIST OF FIGURES .............. ...............9.....


AB S TRAC T ............._. .......... ..............._ 10...


CHAPTER


1 INTRODUCTION ................. ...............12.......... ......


Overweight Prevalence ................. ...............13.................
Definition of Overweight ................. ...............14........... ....
Risk Factors for Overweight ................. ...............15................
Environmental .............. ...............15....
B ehavi oral ................. ...............16........... ....
Personal .............. .. ..... ...............1
Overweight Costs and Implications ................. ...............17................
Public Health Policy and Program Interventions............... .............1
Children's Medical Services and Program ................. ...............21........... ...
Significance of the Study ................. ...............23................

2 LITERATURE REVIEW ................. ...............26................


Theoretical Perspective of CMS Program .............. ...............26....
Maj or Concepts of Social Cognitive Theory ................ ...............27........... ..
Reciprocal Determinism ................. ...............28........... ....
Behavioral Capability ................. ...............29.......... ......
Expectations .............. ...............30....
Self Efficacy ................. ...............3.. 1..............
Observational Learning .............. ...............32....
Reinforcem ent ................. ...............34.................
Summary ................. ...............44.................

3 M ETHOD .............. ...............61....


Study Aim s .............. ...............61....
Specific Aim #1 .............. ...............61....
Specify c Aim#2 ................. ...............61.................
Specify c Aim #3 .............. ...............62....
Sample and Sample Size............... ...............62..
Inclusion Criteria ................. ...............62.................
Exclusion Criteria............... ...............62












Recruitm ent .............. ...............63....
Procedure ................... .... ...... ...... ... .......6
Part #1: Repeated Measures Retrospective Chart Review ................. ......_.._.........64
Part #2: Post-Program Interviews .....___................. ...............64.....
Part #3: In-Class Observation............... ..............6
Hum an Subj ects ........._..... ........ ..... ...............65......
Confidentiality and Legal Minority ................. ....___ ....___ ............ 6
Possible Discomforts and Risks .............. ...............66....
Possible Benefits ................... ............ .... ........6
Description of Quantitative Analyses: Chart Review .....___................. ............... ....66
Descriptive Statistics .............. ...............66....
Repeated Measures ANOVA .............. ...............66....
General Linear Mixed Model ............... ..... ........... .... ..........6
Description of Qualitative Analyses: Interviews and In-Class Ob servations ................... ......70
Summary ................. ...............72.................


4 QUANTITATIVE RESULTS .............. ...............73....


Chart Review Findings .............. ...............73....
Descriptive Analyses ................. ...............73.................
Repeated Measures ANOVA .............. ...............74....
General Linear Mixed Model .............. ...............74....


5 QUALITATIVE RESULTS .............. ...............80....

Post-Program Interview Findings ................. ...............80........... ....
Why Did You Attend the Program? ............. ...............81.....
What Was the Prog~ram Like for You? .............. ...............82....
What Did You Like Most about the Program? ................ ...............83..............
What Did You Like Least About the Program? ............. ...............85.....
What Do You Suggest For Program Improvement? ............ ...............87.....
Would You Recommend the Program to Others? ................ .............................88
What Are Your Post-Program Behavioral Changes? ............. ...............89.....
What Are Your Post-Program Physical Changes? ............. ...............92.....
What Are the Challenges to Behavioral Changes? ................. ................ ......... .93
In-Class Observation Findings .............. ...............96....
Session Attendance............... ...............9
Exercise Activity .............. ...............97....
Snack Activity ................. ...............100......... ......
Educational Activity ............... ... ........ .... ...............102......
Theoretical Learning Concepts Used in the Program ................. .............................106
Reciprocal Determinism ................. ...............107......... ......
Behavioral Capability ................. ...............108......... ......
Expectations and Self-Efficacy .............. ...............109....
Observational Learning ................. ...............110......... ......
Reinforcement ................. ...............111.._.._.. ......
Sum m ary ................. ...............111........ ......












6 DI SCUS SSION ................. ................. 1......... 14....


Discussion of Quantitative Findings ................. ...............115...............
Discussion of Qualitative Findings ................. ...............119...............
Positive Post-Program Behavior Change ................. ...............119...............
Reluctance To Change Post-Program Behaviors .............. ...............120....
Impediments to Engaging Youths .............. ...............121....
Program Service Deficiencies .............. ...............123....
Additional Parent Concerns............... ... .. .... ..........12

Implications for Health Policy and Future Research ................. ............... ......... ...124
Sum m ary ................. ...............13. 1...............

APPENDIX


A CMS PROGRAM CURRICULUM .............. ...............133....


B INTERVIEW GUIDE............... ...............143.


C HIPAA IDENTIFYING FACTORS ................. ...............145...............


D CHART DATA COLLECTION FORM ................. ...............147........... ...


LIST OF REFERENCES ................. ...............148................


BIOGRAPHICAL SKETCH ................. ...............159......... ......










LIST OF TABLES


Table page

1-1 Prevalence of overweight among children and adolescents ages 6-19 years: For
selected years 1963-65 through 1999-2002. ............. ...............25.....

2-1 Maj or Learning Concepts in Social Cognitive Theory ........._.._.. ......._ ...............46

2-2 The Evaluation of Learning Concepts Social Cognitive Theory in Literature ..................47

2-3 Abbreviated Version Table: Outpatient Secondary- and Tertiary-Level Nutrition and
Exercise Programs .............. ...............48....

2-4 In-Depth Version Table: Outpatient Secondary- and Tertiary-Level Programs ................50

4-1 Repeated measures ANOVA for BMI using 26 subj ects: Within- and between-
subj ects effects ................. ...............77........... ....

4-2 General mixed linear model effects for BMI using 59 subjects. ............. ....................77

4-3 General linear model effects for Hb Alc using 59 subj ects. ................ ........___.......77










LIST OF FIGURES


Figure page

4-1 Chart Review: BMI (BMI1) measurements over 12 months. ............ .....................7

4-2 Chart Review: Hb Alc (Alcl) measurements over 12 months. ............ ....................79









Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

EVALUATION OF A CHILDREN' S MEDICAL SERVICES PROGRAM
FOR OVERWEIGHT CHILDREN AND ADOLESCENTS WITH HYPERINSULINEMIA OR
TYPE II DIABETES


By

Susan Wall

August 2007

Chair: Charlene Krueger
Major: Nursing Sciences

The tripling of overweight rates among youths in the last 30 years (National Center for

Health Statistics, 2005) has engendered a variety of public policy strategies. One such strategy is

behavior intervention programs involving diet and exercise behavior modification. In 2002,

Tallahassee Children's Medical Services (CMS) implemented a behavior intervention program.

Youths, diagnosed with either hyperinsulinemia or type II diabetes, and their parents, were

targeted. The purpose of this study was to evaluate the effectiveness of the CMS program by

using a three-part, mixed method design.

The evaluation included: 1) a repeated measures retrospective chart review; 2) participant

interviews; and 3) in-class observations. Convenience sampling was used. The chart review

compared the body mass index (BMI) and the glycosylated hemoglobin (Hb Alc) of the youths

at approximately three and six-months before program participation; the first day of the

program; and approximately three and six -months after program participation. A qualitative

component involved interviewing 11 youths and parents, and observing four class sessions.

Youths' ages ranged from 7 to 18 years (M~= 13, SD = 2.68). A repeated measures

ANOVA analysis revealed that BMI measures increased over time (df 4; F = 4.95; P<0.05). The









Endings were then confirmed using a mixed general linear model. In addition, the mixed general

linear model revealed that Hb Alc decreased over time (df 4; F = 2.80; P<0.05).

All youths and parents reported post-program nutrition and exercise behavioral changes.

Five main themes emerged from the interview data and Hield notes. First, all youths and parents

reported positive post-program nutrition and exercise behavior changes. Second, parents

reported that the youths were reluctant to change post-program health behaviors. The last three

themes revealed areas that the CMS program can use to improve curriculum methodology: 1) the

presence of impediments to engaging youths; 2) the existence of program service deficiencies;

and 3) additional parent concerns that went beyond the priorities of the program.

While positive health outcomes are the goal of any behavior intervention program, health

outcomes are not the sole measure of a success. Positive changes in behavior such as exercise

and nutrition are necessary prerequisites to positive health outcomes and, therefore, a valid

measure of success toward positive health outcomes. Qualitative findings in this study suggest

that the CMS program achieved positive changes in exercise and nutrition that may potentially

endure after the conclusion of the program. As the CMS program improves and is further

validated, it may be revised and replicated in programs that target similar populations.









CHAPTER 1
INTTRODUCTION

Today more children and adolescents are overweight and presenting with related medical

symptoms. National overweight rates among children and adolescents have tripled since 1980

(National Center for Health Statistics (NCHS), 2000).

Tallahassee Children's Medical Services (CMS) is a Florida Title V Program for children

with special health care needs. Children with special health care needs are those children under

age 21 whose serious or chronic physical, developmental, behavioral or emotional conditions

require extensive preventive and maintenance care beyond that required by typically healthy

children (Maternal and Child Health Bureau (MCHB), 2006).

In 2002, CMS implemented a nutrition and exercise behavior intervention plan for

overweight youths, ages 7 to 18 years old, with type II diabetes or hyperinsulinemia, a precursor

to type II diabetes. Nutrition and exercise behavior modification is based on learning concepts of

Social Cognitive Theory (Bandura, 1986). Behavior modification is directed at improving the

weight, body mass index (BMI), and glycosylated hemoglobin (Hb Alc) of CMS youths.

This study focused on evaluating a program (CMS) for children with special health care

needs that are attributable to being overweight or at-ri sk-for-overweight. The evaluation utilized

a mixed-method approach that included both a quantitative and qualitative analysis with three

specific aims.

The first aim was to carry out a repeated measures, retrospective chart review comparing

CMS program youths' biological measurements of BMI and Hb Alc at approximately three and

six-months before program participation; the first day of the program; and approximately three

and six-months after program participation. Statistical analysis of the data was intended to

reveal changes in BMI and Hb Alc over time.









The second aim was to carry out post-program interviews among youths and parents using

an interview guide. Thematic analysis of the data gathered aimed to elucidate salient strengths

and weaknesses of the program not measured by the quantitative data.

The third aim was to observe and take field notes during the in-class program sessions.

Thematic analysis was intended to enable me to take full account of the interactions between the

participants and their potential effects in the social setting of the program.

This chapter provides an overview of: 1) overweight prevalence; 2) a definition of

overweight; 3) risk factors for overweight; 4) overweight costs and implications; 5) public health

policy and program interventions; 6) CMS services and program; and 7) the significance of the

study .

Overweight Prevalence

According to the National Center for Health Statistics (NCHS, 2005), the incidence of

overweight in children and adolescents nearly tripled from 1980 to 2000. An estimated 16% of

children ages 6 to 12, and adolescents, ages 12 to 19, are overweightl (Table 1-1) (NCHS,

2005). Changes in weight are tracked as part of physical examinations given to a sample of the

non-institutionalized U.S. population in the National Health and Nutrition Examination Survey

(NHANES). The 1999-2000 NHANES estimates suggest that overweight in affected youth has

not leveled off or decreased but is increasing to even higher levels (NCHS, 2000).

The data for affected youths is significant for the general population. Children and

adolescents who are overweight are at greater risk of becoming overweight and obese adults (He

& Karlberg, 1999). Probability charts, based on childhood BMI, predict adult overweight or

obesity (He & Karlberg, 1999). About 50% of overweight adolescents with a BMI at or above


SFor youths younger than 20 years, overweight is defined as BMI at or above the 85th percentile, meaning that 85%
of the population weighs less. Obese is defined as BMI at or above the 95th percentile (NCHS, 2004).









the 95th percentile become obese adults (Dietz, 1998). Approximately 65% of U.S. adults are

now obese (NCHS, 2000).

Definition of Overweight

Definitions of "overweight" and "at-ri sk-for-overweight" (at risk) are based on body mass

index (BMI). BMI is a measure of body fat that is calculated by dividing an individual's weight

in kilograms by the square of his or her height in meters (National Institute of Health (NIH),

1998).

Ideally, BMI for youths is interpreted by reference to the Age- and Sex-Specific Growth

Charts for children ages two to 20 years published by the Centers for Disease Control (CDC,

2005). The CDC chart takes into account changes in percentages of body fat among children and

adolescents as they grow. For instance, such changes occur: 1) from ages four to six years,

during the occurrence of growth spurts; and 2) during adolescence, when BMI increases

secondary to pubertal development (Dietz, 1998). Based on the CDC chart, the proposed study

defines the term "overweight" for the study group as BMI at or above the 95th percentile and

defines the term at-risk-for-overweight" as BMI between the 85th and 95th percentiles (at risk)

(NCHS, 2000)The following examples elucidate the significance of using age- and gender-

specific growth charts. For example, as a boy grows, his BMI changes, yet he remains at the 95th

percentile BMI-for-age. At age 2, if his BMI is 19.3, he is at the 95th percentile. At age 4, if his

BMI is 17.8, he is still at the 95th percentile. At age 9 years, if his BMI is 21.0 he is at the 95th

percentile. At age 13, if his BMI is 25.1, he is at the 95th percentile. The boy's BMI declines

during his preschool years and increases as he gets older (medicinenet.com, 2007).

Additionally, gender differences in fat mass and fat distribution have been found to be

obvious in children ages 5 to 7 years of age (Mast, Koirtzinger, Koinig and Miidler, 1997). For

example, Mast et. al (1997) found boys to have increased body weights (P<0.05), body mass










indexes (BMI's) (P<0.001) and waist/hip ratios (WHRs) (P<0.001), and girls to have the % fat

mass (as assessed by anthropometric measures such as bioelectrical impedance analysis) (BIA)

(P<0.05), to be increased.

Risk Factors for Overweight

Excessive weight gain may begin at any age for a variety of reasons (Stark, Atkins, Wolff,

& Douglas, 1981). Overweight may be explained by several factors: 1) environmental 2)

behavioral, and 3) personal.

Environmental

Youths exposed to certain environmental factors are more likely to be overweight. For

example, youths are more likely to be overweight and at risk if they live in low-socioeconomic

households, (Alaimo, Olson, & Frongillo, 2001), have obese or sedentary parents, or experience

parental maltreatment (Johnson, Cohen, Kasen, & Brook, 2002).

Although children from low socioeconomic backgrounds have a greater incidence of

overweight, the prevalence of special health needs does not vary substantially based solely on

income. The percentage of children with special health needs is approximately 13.6% for

children living in poverty and for children living in families with family incomes four times the

poverty level or more. Poverty guidelines vary by family size. During 2001, the poverty

guideline for a family of four was $17,650 (MCHB, 2006).

Other environmental factors associated with being overweight and at risk include the heavy

marketing of fast-food outlets and micronutrient-poor foods and beverages (World Health

Organization (WHO), 2003). Another environmental factor, breastfeeding, is a probable

protective etiological factor for being overweight or at-risk-of-overweight (WHO, 2003).









Behavioral

Certain behaviors are also associated with being overweight. These behaviors include

watching television for more than two hours a day (Dowda, Ainsworth, Addy, Saunders, &

Riner, 2001), maintaining a sedentary lifestyle, consuming high intake of energy-dense,

micronutrient-poor foods, or exhibiting either depression or eating disorders (Barlow & Dietz,

1998).

Personal

Personal factors include having certain endocrine disorders that predispose an individual to

overweight (Dallas, & Foley, 1996; Leinung & Zimmerman, 1994). Genetics not associated

with syndromes may also relate to being overweight. For example, identical twins have similar

adiposity, irrespective of the environment in which they are raised (Loos & Bouchard, 2003).

Children with special health needs are vulnerable to factors that place other children at

nutritional risk, but also may be susceptible to a myriad of additional biological, environmental,

and psychosocial variables. These additional factors may further j eopardize their nutritional

status and pose barriers to their development.

A greater proportion of ethnic minority children experience special health needs, and

children with special health needs are at a greater risk of overweight. More children with special

health needs are Native American/Alaska Native children, multiracial, and non-Hispanic White

children. Approximately 14.2% of Hispanic White children, 13% of non-Hispanic Black

children, 8.6% of Hispanic children, and 4.4 percent of non-Hispanic Asian children have special

health needs (MCHB, 2006).

Whatever the contributing factors to overweight are, being overweight poses serious health

risks. Overweight-related health conditions significantly increase the need for health care and

the costs required for such care.









Overweight Costs and Implications

U.S. overweight-associated hospitalizations among children and adolescents have tripled

since 1979 (Wang & Dietz, 2002), and cost estimates for medical problems related to overweight

have reached 92.6 billion dollars (Finkelstein, Fiebelkorn, & Wang, 2003).

According to Dietz (1998 and 2004), immediate and long-range health complications of

being overweight include hyperinsulinemia and type II diabetes (Dietz, 1998), orthopedic

disorders (Dietz, Gross, & Kirkpatrick, 1982), sleep apnea (Silvestri et al., 1993), and

cardiovascular disease including hypertension and hyperlipidemia (Freedman, Dietz, Srinivasan,

& Berenson, 1999). Psychosocial consequences include discrimination, isolation, stigma, and

low self-esteem (Richardson, Goodman, Hastorf, & Dornbusch, 1961; Stunkard, & Burt, 1967;

Eisenberg, Neumark-Sztainer, & Story, 2003).

Type II diabetes may cause coronary and peripheral vascular disease, nephropathy,

retinopathy, and neuropathy (Hardy, Harrell, & Bell, 2004). Similar health risks are associated

with individuals who have hyperinsulinemia, or impaired glucose tolerance, a condition marked

by higher than normal plasma insulin and glucose levels that are too low to be considered

diagnostic for diabetes (Raskin et al., 1994).

While previous research findings suggest that Hb Alc values improve 11 ithr weight loss of

about 10 lb or five percent of body weight (Wing, Marcus, Epstein, & Salata, 1987), other

research findings suggest that elevated Hb Alc values may improve 11 ithmitn weight loss but from

increasing activity alone (American Diabetes Association (ADA), 2006).

Lifestyle modifications to improve diet and exercise continue to represent the cornerstone

of therapy for hyperinsulinemia and type II diabetes (ADA, 2006). Dietetic and exercise

programs often target Hb Alc values because Hb Alc values greater than 6.5 to 7.0 represents

poor glucose control and lead to poor health outcomes (Barclay and Vega, 2006).









Many federal health agencies and private organizations have issued public health

guidelines for reducing overweight and overweight health risks. The federal health and private

organizational guidelines focus primarily on environment and individual behavioral change

(Nestle & Jacobson, 2000).

Public Health Policy and Program Interventions

As early as 1952, the public health organization, the American Heart Association, began

identifying diet and exercise as a modifiable risk factor of cardiovascular disease. However,

when rising rates of overweight emerged in the 1980's and 1990s, the prevention of overweight

in individuals and among population groups became an explicit goal of national public health

policy (Nestle & Jacobson, 2000).

For example, Healthy People 2000, made the issue of overweight status and the need for

exercise a national priority. Their objective was to reduce overweight among adolescents to 15

percent, and to increase physical activity and fitness (U. S. Department of Heath and Human

Services (DHHS), 2000).

Currently, Healthy People 2010 seeks to reduce overweight among children and

adolescents to Hyve percent. Healthy People 2010 includes specific obesity-related objectives (U.

S. DHHS, 2000). The objectives include increased physical activity, consumption of more

healthful diets, increased use of nutrition labels, reduced sources of unnecessary calories,

increased nutrition and physical education in schools, and improved access to community

recreational facilities (U. S. DHHS, 2000).

Programmatic interventions and policies of local governments have focused primarily on

what researchers describe as a "toxic environment" that has evolved in public schools; an

environment that provides students with non-nutritious foods and minimal exercise (Ebbeling,

Pawlak, & Ludwig, 2002). About 60 % of the middle schools and high schools in the United









States sell soft drinks from vending machines (Fried & Nestle, 2002). Many meals prepared

under the National School Lunch Program include excessive amounts of saturated fats (Carter,

2002). Only 28 percent of high-school students participate in daily physical education (CDC,

2004).

Local governments are attempting to improve the public school environment. Efforts

include policies intended to reduce the availability of foods that are not nutritious and to increase

physical activity (National Conference of State Legislatures, 2006). New legislation restricts

competitive food sales, such as non-nutritious snacks and beverages that compete with school

lunch programs. The beverage industry has recently adopted guidelines designed to curtail

vending machine sales by 2010 (American Beverage Association, 2006). losed-campus policies

are intended to keep students at school for lunch so students will not be able to go to local stores

and restaurants and purchase non-nutritious foods.

However, since the federal government has not established minimum standards for

nutrition and exercise interventions in public schools, for most public schools, closed-campus

policies are a moot point. Additionally, the federal government has not promulgated any rules

regulating the sale of competitive foods in public schools (Institute of Medicine (IOM), 2005).

Prevention programs for affected youth seek to propagate future informed adults who can

advocate for healthful diets and exercise in health centers, communities, workplaces, schools,

and many other venues (IOM, 2005). Many of these venues are subj ect to federal and other

governmental regulations that can be modified to enhance healthful diet and exercise.

Higher education can be modified to require curricula for health care providers to include

the benefits of healthful diet and exercise patterns, the risks for obesity, counseling methods that

effectively modify behavior, efficacious health promotion campaigns for health care agencies,









research agenda focused on behavioral as well as metabolic determinants of weight gain and

maintenance, and the most cost-effective methods for promoting healthful diet and activity

patterns (Nestle & Jacobson (2000). Medicare and Medicaid reimbursement regulations can be

modified to adequately reimburse health care providers for nutrition and obesity counseling and

other interventions that meet specific standards of cost and effectiveness.

Healthy People 2010 addresses the role of healthcare providers. Appropriate clinical

practice includes preventive services nutrition screening and assessment, counseling, and

referrals to qualified nutrition professionals for nutrition assessment, education, counseling on

behavioral change, diet modification, and specialized nutrition therapies represents (U. S.

DHHS,2000). Many of these clinical practices are crucial elements of program interventions for

affected youth.

According to Gonzalez and Gilmer (2006), the most cost-effective method of approaching

the obesity epidemic is through education of health professionals. As part of an "Obesity

Prevention in Pediatrics" curriculum, postgraduate-year (PGY)-2 residents first observed and

then participated in the dietary evaluation and counseling of pediatric patients and their families.

Following participation in the curriculum, study residents' knowledge tended to improve, as did

their level of comfort in counseling obese and at-risk children, adolescents and their parents. The

"Obesity Prevention in Pediatrics" curriculum appeared to improve participants' knowledge base

as well as their skills and level of personal comfort in the recognition, evaluation and

management, including counseling, of both obese and at-risk pediatric patients and their

families.Additionally, nutrition counseling by registered dietitians is found to be cost effective

for patients with hyperlipidemia (McGehee et al., 1995) and type 2 diabetes mellitus (Franz et









al.,1995). This is because dietetic education promotes behavioral change in patients that, in

turn, prevents future costly health care for health complications.

Prevention programs for affected youth implement policies of pediatric health providers.

For example, pediatric health providers advocate the use of age- and sex-specific BMI for early

identification of weight gain, dietary and exercise interventions, and more advocacy and research

(American Academy of Pediatrics,2003).

The National Institute of Health (NIH) (2004) distinguishes primary, secondary, and

tertiary programs based on disease stage. The disease prevention model is not new. As early as

1957, the Commission on Chronic Illness used the disease prevention model to classify

prevention programs based on the stage of the disease process (Nestle & Jacobsen, 2000),

Primary programs aim to prevent inappropriate weight gain in youths currently at a healthy

weight (BMI less than the 85th percentile). Secondary programs aim to prevent further weight

gain in youths currently at risk of overweight (BMI greater than or equal to the 85th percentile to

less that the 95th percentile). Tertiary programs target interventions at youths already

overweight (BMI greater than or equal to the 95th percentile) (NIH, 2004).

Children's Medical Services and Program

The CMS program addresses dietetic and exercise behaviors of overweight youths ages 7

to 18 years old, diagnosed with type II diabetes or hyperinsulinemia, a precursor of type II

diabetes. It is categorized as a tertiary program because its interventions target youths already

overweight.

As previously mentioned, CMS is a Florida Title V Program for children with special

health needs. CMS implemented the intervention program for overweight members in 2002.

CMS is one of several programs funded by the Federal-State Title V Block Grant Partnership










Budget.2 The purpose of Title V is to improve the health of all mothers and children, including

children with special health needs (MCHB, 2006).

Nationally, about 963, 634 children and adolescents participate in services for children

with special health needs (12.8% of child and adolescent population). Services for children with

special health needs account for more than half of all child-related health care costs (Van Dyck,

Kogan, Merle, McPherson, Weissman, & Newacheck, 2004). Florida serves about 64, 992

children with special health needs, and 40.8 percent of the total 2006 Florida Title V budget is

allocated to health services for those children (MCHB, 2006).

The CMS program provides children with special health needs with a family- centered,

managed system of care. CMS provides a comprehensive continuum of medical and supporting

services to medically and financially eligible children and high-risk pregnant women. The

continuum of care includes prevention and early intervention programs, primary care, medical

and therapeutic specialty care and long-term care.

CMS is a program of the Florida Department of Health (DOH) and is directed by the

Deputy Secretary for CMS. The CMS Program is divided into two divisions: the Division of

CMS Network and Related Programs; and the Division of Prevention and Intervention. There are

22 CMS arranged in eight regional offices throughout the State of Florida (CMS, 2006).

CMS serves about 2,000 children in the northwest region of Florida comprised of 8

counties: Franklin, Leon, Jefferson, Liberty, Madison, Taylor, Wakulla, and Gadsden. Leon

County (Tallahassee) accounts for 50 percent of CMS clients; Gadsden County accounts for




SThe Title V includes Federal funds, State funds, local funds, and program income. Each year, States
report how their Title V budget is allocated among pregnant women, infants, children ages 1-22, children with
special health care needs, all others, and administration.









nearly 25 percent of CMS clients; the remaining outlying counties account for 25 percent of

CMS clients (CMS, 2006).

In 2002, the CMS initiated a nutrition and exercise program in response to increased

numbers of overweight children and adolescents presenting to the Diabetic and Endocrine

Clinics with type II diabetes or hyperinsulinemia. The program consists of four 1V2-hour sessions

for youths and parents, and emphasizes healthy dietetic and physical behaviors.

Research shows that overweight children and adolescents benefit from comprehensive

dietetic and exercise education (Dreimane et al., 2006; Eliakim, A. et al., 2002; Monzavi, R. et

al., 2006; Savoye et al., 2004; Speith, L. et al., 2000; & Taylor et al., 2005). CMS is in a position

to contribute to disease prevention strategies among overweight youths, offer information about

what occurs within a program, and to report progress on health outcomes.

Significance of the Study

Despite many efforts in health care, overweight prevalence rates continue to rise among

youths (NCHS, 2005). Being overweight poses serious health risks and significantly increases

the need for health care and the costs required for such care (Bandura, 2004).

By managing health habits, youths can have longer and healthier lives (Bandura, 2004).

Disease prevention programs can assist youths to consistently practice healthy lifestyle choices

through a variety of behavioral interventions.

In a time of guarded public health budgets, economic reality necessitates efficient resource

allocation. Intervention programs for affected youth that prevent or reduce the cost of disease

treatment appeal to health providers, the public, and policymakers (Frick, Milligan, White,

Serwint, & Pugh, 2005).

Prevention holds significant promise for overweight and overweight-related health

complications because prevention programs work (Dreimane et al., 2006; Eliakim, A. et al.,










2002; Monzavi, R. et al., 2006; Savoye et al., 2004; Speith, L. et al., 2000; Taylor, Mazzone, &

Wrotniak, 2005). Public behavioral intervention programs, such as the CMS program,

demonstrate a growing commitment toward the integration of research and practice in disease

prevention activities for vulnerable individuals and their families. Public health nurses comprise

an important component of this collective effort and play a unique role within public heath

programs that creatively utilize research to strengthen program practices, including those

involved in addressing the issues of overweight.

The findings of this study will be used to suggest ways to improve the CMS program and

develop further study of the program. In the future, agencies similar to the CMS may want to

replicate the program in order to improve the diet and activity behaviors of their patients because

improved health behaviors lead to improved health outcomes.











Table 1-1. Prevalence of overweight among children and adolescents ages 6-19 years: For
selected years 1963-65 through 1999-2002.


Age (years)


6-11
12-19


NHANES
1963-65
1966-703
4%
5%


NHANES NHANES NHANES
1971-74 1976-80 1988-1994


NHANES
1999-
2002
16%
16%


Fro
m
Cent
ers
for


11%
11%


Disease Control and Prevention (CDC), National Center for Health Statistics,
National Health Nutrition Examination Survey (NHANES) (2005).


3 Data for 1963-65 are for children 6-11 years of age; data for 1966-70 are for adolescents 12-17 years of age, not
12-19 years.









CHAPTER 2
LITERATURE REVIEW

The Children's Medical Services (CMS) program is based on Social Cognitive Theory

(Bandura, 1986) because the theory provides a basis for promoting healthy dietetic and exercise

behavior change among youths in intervention programs. Following the theory background for

this study, maj or health organization recommendations for overweight youths and out patient

intervention programs are reviewed.

Theoretical Perspective of CMS Program

By applying Social Cognitive Theory to intervention programs, how individuals acquire

and effectuate behavior, the process for changing behavior, and the effects on behavior caused by

external influences may be explained (National Institute of Health (NIH), 2003). Health is

influenced by lifestyle behaviors. By managing lifestyle behaviors, people can have longer and

healthier lives (Bandura, 2004).

Albert Bandura (1997) elucidates that behavior is influenced by the interplay of 1) personal

factors, 2) behavioral factors, and 3) environmental factors. This three-part interplay is identified

as triadic reciprocality or reciprocal determinism. Within the triad, cognition is critical for

individuals to construct reality, self-regulate, encode information, and perform behaviors

(Pajares, 2002). Social Cognitive Theory is often referred to as Social Learning Theory.

A personal-behavior interaction involves bi-directional influences between an individual's

thoughts, emotions, biological properties, and actions (Bandura, 1997). For example, an

individual's expectations and goals regarding their weight give shape to behavior. In turn, new

dietetic and exercise behaviors affect thoughts and emotions. Biological personal factors include

sex, ethnicity, temperament, and genetic predisposition and the influences they have on behavior.










An environmental-personal interaction involves bi-directional influences between an

individual's environment and personal characteristics (Bandura, 1997). An individual's

expectations and cognitive competencies regarding health are affected by social influences and

physical structures within the environment. For example, the home environment conveys

information and activates emotional reactions about nutrition and exercise through factors such

as persuasion, modeling and instruction (Bandura, 1986). An individual may receive different

reactions from her social environment depending on the individual's size, age, race, sex and

appearance.

A behavior-environmental interaction involves bi-directional influences between an

individual's thoughts, emotions, biological properties and their environment (Bandura, 1997).

Behavior influences environment, such as when a parent stops bringing high-calorie, low-

nutrient foods into the home for children and adolescents to consume. This new environment in

the home, may contribute to what forms of a child's behavior are developed and activated

(Bandura, 1989).

Beyond this three-part interplay of reciprocal determinism, there are other maj or concepts

of Social Cognitive Theory that explain how behavior may be influenced. This study used the

theoretical concepts of Bandura' s Social Cognitive Theory to observe and describe how the CMS

behavioral intervention program taught content and which learning behaviors were targeted.

The following elucidates those concepts.

Major Concepts of Social Cognitive Theory

Behavior may be influenced by the following: 1) reciprocal determinism; 2) behavioral

capability; 3) expectations; 4) self-efficacy; 5) observational learning; and 6) reinforcement

(NIH, 2003) (Table 2-1). For example, behavioral change results from an interaction between an

individual and the environment (reciprocal determinism), and knowledge and skills create the










precondition for change (behavioral capability). Individuals anticipate how their choices will

affect their health outcomes (expectations) and have the confidence to change their behavior

(self-efficacy). Individuals can learn healthy lifestyle choices by watching the appropriate

actions of others (observational learning), and by enjoying the benefit of positive reinforcement

from others in their endeavors (reinforcement) ((NIH, 2003; Bandura, 1997).

Using the theoretical concepts, teaching may be guided and learning behaviors may be

targeted. Social Cognitive Theory and its concepts are inherently linked to the measurement of

health behavior (Redding, Rossi, Rossi, Velicer, & Prochaska, 2000).

In this study, Social Cognitive Theory was used as a guide to observe and describe how the

CMS behavioral intervention program was teaching content and which learning behaviors were

targeted. Following this premise, if the CMS program utilized the theoretical concepts, youths

should expect positive behavioral changes, followed by improved BMI and Hb Alc

measurements.

The following is a description of the concepts. A review of health promotion literature is

also provided to elucidate how the utilization of a particular learning concept elicits behavioral

changes among the youths.

Reciprocal Determinism

Reciprocal determinism is the dynamic, reciprocal interaction between three key factors

identified as personal, environmental, and behavioral. These factors act as determinants of each

other. That is, a change in one of these factors impacts on the other two.

There is considerable research interest concerning how personal and environmental factors

interact to influence children's nutrition and exercise behavioral patterns. For example, schools

that provide lower fat content in their lunches and greater opportunities in physical exercise










improve the dietetic and exercise behaviors of children (Luepker et al., 1996; Rinderknecht &

Smith, 2004; Trevino et al., 1998).

Children's weekly television viewing hours significantly correlate with their requests for

purchases of food advertised on television (Taras, Sallis, Patterson, Nader, and Nelson, 1989).

When children are told that their mothers will be monitoring their food choices, children choose

fewer non-nutritious foods than they choose in the absence of that'threat' (Klesges, Stein, Eck,

Isbell, and Klesges (1991).

According to Bandura (1989), interactions between factors differ based on the individual,

the particular behavior being examined, and the specific situation in which the behavior occurs.

Research suggests that environmental factors may influence children's health behaviors more

than personal ones. For example, children less than age 9 are not worried about health outcomes,

and health is not a priority for them (Gochman, 1987). Thus, cognizance of the diet-disease

relationship may have less influence than environmental factors on healthy behavior in younger

children.

Behavioral Capability

The concept of behavioral capability is defined as having the knowledge and ability to

perform a behavior or sequence of behaviors. Most intervention programs improve an

individual's behavioral capability through instructional and skills training. Behavioral skill

training may be (ReCapp, 2006):

interpersonal, including communication, negotiation, and setting limits;

intrapersonal, such as values clarification, analyzing situations, and self-talk;

resource-related, focusing on locating information from adults, agencies, and the internet;
and

product-related, such as teaching use of condoms and contraceptives.









Parcel et al. (1989) reported that classroom health education and environmental changes in

school lunch and physical education were implemented to foster healthful diet and exercise

among elementary school children. Cognitive measures that included behavioral capability were

evaluated using self-reported diet and exercise behavior questionnaires at baseline and following

intervention. Statistically significant changes were observed for diet behavioral capability, self-

efficacy, and behavioral expectations, use of salt, and exercise behavioral capability (fourth

grade), self-efficacy (fourth grade) and frequency of participation in aerobic activity. The

program impacted learning outcomes and student behavior.

Individual behavior can have an important impact on disease prevention. However, it is

important to note that Social Cognitive Theory emphasizes that learning is influenced not only

cognitively in the learning of skills but within the complexity an individual's environment,

thoughts, emotions, and biological properties.

Expectations

An individual's expectations are defined as an individual's approximation that the

performance of certain behaviors will lead to attainment of a particular goal. For example, "If I

will eat a healthy diet and exercise regularly, I will lose weight." Factors that motivate an

individual's expectations as they go through the process of setting goals for themselves include

self-efficacy, feedback, and the anticipated time to goal attainment (Bandura, 1986; 1989).

First, if an individual feels s/he is capable of achieving the goal (self-efficacy), s/he is

likely to work hard and not give up. Second, if an individual is provided feedback, she is more

able to adjust her goals to be feasible and realistic. Feedback, in turn, improves self-efficacy.

Third, short-term goals are more effective than long-term goals because short-term goals are less

daunting for an individual to work toward than long-term goals (Stone, 1998).









In health promotion literature, expectations are frequently evaluated with self-efficacy by

comparing pre- and post-questionaires. For example, in Resnicow et al. (1997), the impact of a

self-administered, computer-based intervention on nutrition behavior, self-efficacy, and outcome

expectations among supermarket food shoppers was evaluated. The intervention, housed in

kiosks in supermarkets, used tailored information and self-regulation strategies delivered in 15

brief weekly segments. Treatment led to higher levels of nutrition-related self-efficacy, physical

outcome expectations, and social outcome expectations. Logistic regression analysis determined

that the treatment group was more likely than the control group to attain goals for reduced fat

and increased fiber and fruits and vegetables at post-test and to attain goals for reduced fat at

follow-up. Latent variable structural equation analysis revealed self-efficacy and physical

outcome expectations mediated intervention effects on nutrition. In addition, physical outcome

expectations mediated the effect of self-efficacy on nutrition outcomes.

Self Efficacy

According to Bandura (2004), self-efficacy is the most important concept that explains

behavioral change. Individuals with perceived self-efficacy set high personal goals for

themselves, expect favorable outcomes from their efforts, have an ability to recover from

setbacks, and are able to maintain the achieved habit (Bandura, 2004, Rinderknecht & Smith,

2004, Benight & Bandura, 2004 ).

Bandura (2006) has written a monograph entitled Guide for Constructing Self-Efficacy

Scales. The monograph deals with issues of domain specification, gradations of change, content

relevance, phrasing of items, response scale, item analysis, minimizing biases in responding,

assessing collective efficacy, and validation. A number of useful instruments are available

online, such as those from the National Institute of Nursing Research. For over 20 years,









researchers have been developing, adapting, and testing self-efficacy scales for research subjects

with chronic diseases (Bandura, 2006).

The concept of self-efficacy has guided program interventions for improving behaviors in

diet, physical exercise, and diabetic self-care (Allen, 2004). Dietary self-effcacy is the

perceived capability to choose more healthful foods and has been associated with improved

nutritional behavior among youth (Cusatis & Shannon, 1996) and adults (Van Duyn, Kristal, &

Dodd, 2001). Evidence underscores the importance of self-effcacy in metabolic control

(Ludlow & Gein, 1995), coping and problem solving (Anderson et al., 1995), diet adherence

(Miller, Edwards, Kissling, & Sanville, 2002), and maintaining healthy blood glucose (Skelley,

Marshall, Haughey, Davis, Dunford, 1995).

According to Bandura (2004), necessary components of a program to effectuate self-

effcacy include: 1) information regarding the desired behavior; 2) the development of social and

self-management skills; 3) building a resilient sense of effcacy such as supporting the exercise

of control in the face of dimfculties and setbacks in everyday life; and 4) enlisting and creating

social supports for desired personal change such as enlisting participants' caregivers in the effort.

In Margolis & McCabe (2004), additional strategies for improving self-efficacy for individuals

in programs include: 1) establishing small, incremetal goals for participants; 2) reinforcing effort

and persistence; 3) emphasizing modeling; and 4) providing feedback through record-keeping.

Observational Learning

Bandura (1977) wrote that learning would be exceedingly laborious, not to mention

hazardous, if people had to rely solely on the effects of their own actions to inform their choices.

Behavior can be learned observationally through modeling.

Modeling occurs when individuals observe others, form ideas regarding how the behaviors

are to be performed, and then act out the behaviors. Individuals are more likely to adopt a









modeled behavior if behavior change results in outcomes they value, and if the model is: 1)

similar to the observer, 2) has admired status, and 3) has functional value (Bandura, 1977).

Among children, observational learning often outweighs verbal instruction as an influence

on the internalization of standards (Bandura, 1989). Thus, dietetic and exercise programs are

encouraged to incorporate learning strategies that go beyond lectures, and include opportunities

to observe and model healthy behaviors, attitudes, and emotional reactions provided by program

instructors, parents/significant caretakers, and participant peers. Thus, experiential opportunities

used by the CMS program such as exercise sessions, grocery store tours, group food preparation

sessions, and sampling of healthy snacks may be beneficial.

A study by Carroll and Bandura (1987), examined the role of two forms of visual guidance

in facilitating the translation of cognitive representations into action. Subj ects matched a

modeled action pattern either concurrently with the model or after the modeled display. The

subj ects then either did or did not visually monitor their actions during tests of production

accuracy in the model's absence. Acquisition of the cognitive representation was assessed

periodically. Concurrent matching of modeled actions and visual monitoring of productions both

increased the level of observational learning. The more accurate the cognitive representation, the

more skilled were subsequent reproductions of the modeled actions. After acquiring proficiency

in converting cognition to action, subj ects maintained their level of performance accuracy even

though modeled and visual-monitoring guidance were withdrawn. These results are consistent

with the theory that cognitive representation mediates response production and that corrective

adjustments through visual guidance aid in the translation of conception into action.

In another study, researchers examined the effects of televised safety models on children's

willingness to take physical risks and their ability to identify injury hazards in common situations










(Potts & Swisher, 998). Exposure to the safety educational videotape decreased children's

willingness to take physical risks and increased their identification of injury hazards. Findings

are interpreted as evidence of observational learning related knowledge by the television stimuli

(Potts & Swisher, 1998).

Reinforcement

Reinforcement is said to occur when a reward, that is made contingent on an individual's

behavior, increases or decreases the chances of the individual repeating that behavior (Hendy,

Williams, & Camise, 2005). Reinforcement has been frequently used in health promotion

programs to improve behavioral outcomes.

In Hendy, Williams and Camise (2005), The "Kids Choice" school lunch program used

token reinforcement, food choice, and peer participation to increase children's fruit and vegetable

consumption. Rewards included jump ropes, water bottles, and graduation certificates.

Consumption increased for fruit and for vegetables and the increases lasted throughout

reinforcement conditions. Two weeks after the program, preference ratings showed increases for

fruit and for vegetables. Seven months later, fruit and vegetable preferences had returned to

baseline levels, suggesting the need for an ongoing intervention program to keep preferences

high.

In another study by DeVahl, King, and Williamson (2005), researchers sought to determine

whether a greater academic incentive would improve the effectiveness and adherence of

university students to a 12-week voluntary exercise program designed to decrease body fat. The

group with the greater reward structure showed better exercise adherence and lost more body fat

than those without the additional incentive. These findings suggest that an academic incentive

can increase overall student adherence to a voluntary exercise program and can boost the

effectiveness of the program in a university environment (DeVahl, King, & Williamson, 2005).









Robles et al. (2005) carried out an intervention that involved women living with their

children in a residential substance abuse treatment facility. The intervention consisted of

exposure to an educational video and a smoking cessation workbook, brief individual support

meetings, and an escalating schedule of youcher-based reinforcement of abstinence. Throughout

the study, three daily breath samples were collected Monday through Friday to determine carbon

monoxide (CO) concentration. In addition, urine cotinine (COT) was assessed weekly to monitor

weekend tobacco use. Participants received vouchers of escalating value for CO-negative breath

and COT-negative urine samples. Positive samples reset the voucher value. Significantly more

negative tests were submitted during the intervention than during baseline and follow-up. The

intensive behavioral intervention evaluated in this study produced a substantial reduction in

cigarette smoking, and 25 percent of participants remained abstinent two weeks after the

intervention was suspended. In this within-subjects repeated measures study, a one-week

baseline was followed by a four-week intervention and a two-week follow-up (same as the

baseline).

In Rowan-Szal, Joe, Chatham, & Simpson (1994), clients in a community-based

methadone treatment program earned stars for attending counseling sessions and for providing

clean urines. The stars were later redeemed for contingent rewards (food or gas coupons or bus

tokens) according to one of three randomly assigned reward schedules, including high reward

(eight stars per prize), low reward (four stars per prize), or delayed reward (those who had to

wait three-months to earn a prize). Those clients in the high-reward condition showed a pattern

of increasing the number of stars earned for group sessions and clean urines across the three-

month intervention. All clients, independent of reward condition, attended significantly more

group counseling sessions during the months that contingent reinforcers were available than in









the months prior to, and after, the intervention. Finally, urinalysis data indicated that, in the post

intervention period, high-reward clients had fewer dirty urines than did low-reward or delayed-

reward clients. This study suggests that a simple system of recognizing client progress with stars

and modest prizes for performing specific behaviors can be an effective tool in increasing clinic

attendance rates and reduced positive urines (Rowan-Szal, Joe, Chatham, & Simpson, 1994).

Recommendations for Overweight

Maj or health organizations such as the U. S. Department of Health and Human Services

(2004) address the potential health-pitfalls of overeating and under activity for children and

adolescents. Health recommendations include discouraging the consumption of energy-dense,

high sugar/high-fat foods, the amount of time spent on television, video games, and the Internet;

and encouraging the consumption of a healthy array of foods and more daily physical activity.

In Florida, the "Governor's Task Force on Obesity," has made recommendations to deal

with being overweight. Public health care providers are encouraged to promote lifelong nutrition

and physical activity by implementing programs that promote healthier lifestyles and disease

management for overweight-related illnesses such as diabetes and hyperinsulinemia (Florida

Department of Health, 2004).

Recommendations for short-term program goals for overweight youths include the

maintenance of weight, or a decrease of weight by about 1 pound per month. A long-term goal is

to reduce BMI to below the 85th percentile (Barlow & Dietz, 1998 (current as of 2005). Over

time, the maintenance of weight leads to a BMI decline as height continues to increase.

Programs for overweight children and adolescents often evaluate both weight and BMI because

incremental weight loss may not impact BMI measurements. A subtle weight-loss of a few

pounds would not be revealed in a BMI calculation.










Recommendations for program goals for overweight youths with type II diabetes or

hyperinsulinemia include the reduction of Hb Alc. Glycosylated hemoglobin is a measure of

long-term glucose homeostasis (Goldstein, Parker & England, 1982), and is a way to monitor

long-term serum glucose regulation (Fajans, 1990). Increased Hb Alc measurements are

associated with being overweight (Plourde, 2002) and indicate the beginning or existence of

hyperinsulinemia (Hanna, & Howard, 1994). A healthful diet and regular exercise may prevent

the development of diabetes among persons who are overweight regardless of weight loss

(Sheaves et al, 1997; Manson et al., 1992). However, other research findings suggest that Hb

Alc values improve with weight loss of about 10 lb or five percent of body weight (Wing,

Marcus, Epstein, & Salata, 1987).

Previous agency programs for overweight children and adolescents at the primary,

secondary, and tertiary levels of the disease prevention model have been modestly successful in

maintaining or decreasing weight and in reducing other biological measures such BMI and Hb

Alc associated with overweight health complications (Saelens, et. al., 2002; Dietz, 1998; Dietz,

2004).

This chapter examines intervention programs aimed at secondary and tertiary levels of

disease. Research reveals that outpatient, healthcare-based, weight-intervention programs, that

use maj or health organization recommendations for diet and exercise, elicit weight-reduction

among children and adolescents (Saelens, Sallis, Wilfley, Patrick, Cella, & Buchta, 2002). The

prevention programs examined are primarily aimed toward improving diet and increasing

physical activity (Dreimane et al., 2006; Eliakim et al., 2002; Lazzer et al., 2005; Monzavi et al.,



SPrimary prevention programs commonly occur in schools and childcare settings than in health settings. Classroom
and physical education curricula, changes in school meals, vending machines, cafeterias, and after-school programs
may increase physical activity and improve dietary patterns (Daniels et al., 2005).










2006; Reinehr et al., 2003; Saelens et al., 2002; Savoye et al., 2004; Spieth et al., 2000; Taylor,

Mazzone, & Wrotniak, 2005; Woo et al., 2004). Many of the programs include behavioral

therapy and reduction in sedentary behavior.

Secondary-level prevention programs target youth at-ri sk-for-overweight, referred to

hereinafter as "early-disease." These programs are particularly interested in preventing the BMI

percentile from increasing (Jain, 2004).

Tertiary-level programs seek to limit illnesses associated with being overweight and to

rehabilitate those who are overweight (Murphy, 2004), hereinafter referred to as "late-disease."

Tertiary level illnesses include hyperinsulinemia, also known as impaired glucose tolerance

(IGT), a condition marked by higher than normal plasma insulin and glucose levels that are too

low to be considered diagnostic for type II diabetes.

Review of Programs

The following is a descriptive review of nine outpatient secondary and tertiary prevention

programs for affected youths (Tables 2-1 and 2-2). The review includes a description of: 1)

study size and ages of participants; 2) parental participation; 3) program frequency and duration;

4) outcomes; and 5) limitations. All nine programs were primarily aimed toward improving diet

and increasing physical activity. Diet and exercise together, rather than diet alone, are associated

with significantly improved health outcomes (Woo et al., 2004).

Study Size and Ages of Participants

Study sizes range from 25 to 264 participants, and ages range from 6-17 years. The studies

were conducted in clinical settings, and most of the studies were conducted in the United States.

The researchers of the programs were registered nurses, pediatricians, public health experts,

registered dieticians, and physical therapists.










Parental Participation

All studies included parents or legal guardians of the child or adolescent participants with

the exception of Saelens et al. (2002). According to Jain (2004), interventions that include the

parents or significant caretakers of the participants have greater effect on weight loss than those

that do not include parents or significant caretakers. In addition, children and adolescents do

better when treated in the same classroom rather than treated separately (Jain, 2004). Children

without parental overweight have significantly greater decreases in BMI compared to children

with obese parents (Eliakim et al., 2002).

Program Frequency and Duration

Programs ranged in duration from eight weeks to one year. Class sessions occurred as

infrequently as twice monthly and as frequently as five times a week. Program frequency and

duration was not necessarily associated with better weight and BMI outcomes. For example, in

Spieth et al. (2000), the program was about four months in duration, and included only one

primary session and four follow-up visits. Both weight and BMI significantly improved among

parti cipants.

However, in Reinehr et al. (2003), where the program was one year in duration and met at

least once weekly for exercise sessions, the BMI measures did not significantly improve among

participants.

Outcomes

Overall, the programs were modestly successful in maintaining or decreasing weight and

BMI. Six of the nine studies showed a statistically significant, short-term decrease in weight or

BMI (Dreimane et al., 2006; Eliakim, A. et al., 2002; Monzavi, R. et al., 2006; Savoye et al.,

2004; Spieth, L. et al., 2000; Taylor, Mazzone, & Wrotniak, 2005). Three of the nine studies did









not show statistically significant, short-term decrease in weight or BMI (Zador et al. (2006);

Woo et al. (2004); Saelens et al. (2002). However, the study of Zador et al. (2006) showed

significant short-term decreases in Hb Alc, and the study of Woo et al. (2004) showed

significant short-term decreases in lab values such as low-density lipoprotein (Tables 2-3 and 2-

4).

With the exceptions of Savoye et al. (2004) and Woo et al. (2004), program evaluations

were followed for less than one year. Savoye et al. (2004), a one-year-long program,

demonstrated significant decreases in BMI at the end of their program which was the end of

one year. However, those decreases in BMI were no longer significant (BMI from pre-program

baseline was primarily maintained) in the following year. At two-years post-program, the two

dietary approaches taught to participants during the program were compared. The group that had

been taught how to make better food choices, and not given a structured diet plan, further

improved BMI (P=.006), while the dieting group's BMI reverted back to pre-program baseline.

Monzavi et al. (2006), a 12-week-long program, also demonstrated significant

improvements in post-program BMI, systolic and diastolic blood pressures, lipids (total, low-

density lipoprotein cholesterol, and triglycerides), postprandial glucose, and leptin levels at the

end of the program (or three weeks after the end of the program). It is not known whether the

participants in Monzavi et al. (2006) enjoyed long-term positive outcomes.

Programs exhibited varied success at improving biological measures associated with

overweight-related illnesses. In Woo et al. (2004), children were randomly assigned to a dietary

modification program or a diet and exercise modification program. After 6 weeks, both groups

significantly decreased waist-hip ratio and cholesterol level and improved arterial endothelial










function. In Zador et al. (2006), Hb Alc was significantly improved by the completion of the

program.

In Eliakim et al. (2002), physical endurance significantly increased following the three-

month intervention. Affected youth that continued the program for another three-months,

further improved their endurance. Taylor, Mazzone, and Wrotniak (2005) evidenced significant

improvements beyond BMI. Waist and hip girth, blood pressure, resting heart rate, immediate

heart rate after exercise, and heart rate Hyve-minutes after exercise were significantly improved at

post-test.

Outcomes did not vary markedly between genders. According to Eliakim et al. (2002), in

their study of 177 participants, gender, pubertal status, and the degree of obesity had no

influence on BMI changes.

Reinehr et al. (2003) used multiple regression to relate factors to post-program weight loss.

Factors included the participant's willingness to change behavior (changes in weight status,

number of attempts at therapy, participation in exercise groups), somatic characteristics (BMI of

children and family members, gender, and age), socioeconomic status (level of education of the

children and their parents, working mother), exercise and dietary habits, and dietary intake, as

well as the quality of dietary records. The only significant difference between the children who

lost weight and the children who did not lose weight was that the children that lost weight had

previously taken part in regular exercise before the program began. Improvements in emotional

well-being and behavior correlated positively with weight loss (Dreimane et al., 2006).

Limitations

Identification of effective intervention methods utilized in various disease prevention

programs enables other health providers to replicate and improve successful intervention









methods and facilitates their generalization and application to broader population groups.

Alternatively, review of disease prevention programs may uncover intervention methods that are

successful for distinct population subsets even if those methods have limited utility for broader

populations.

Optimal design for evaluating a particular program minimizes potential bias and

maximizes general application to the extent permitted by practical limitations such as time

constraints, cost, ethics, and other limitations. Since it is evident that long-term program

adherence is difficult, further long-term evaluation of outcomes is necessary to identify which

program interventions result in positive outcomes that endure.

Evaluation results may be influenced by various factors. For example, youths may be

motivated just long enough to complete the program and revert back to their original lifestyles at

the completion of the program. Youths may be trying to please evaluators or to be overly eager,

making a program appear more effective than would normally be expected. Ideally, a study

should last for 6 months or longer.

In those programs that show no effect on weight or BMI, the results of the programs may

be disproportionate to their endeavors. However, because in most instances, pre-program

knowledge of patterns of weight gain is not obtained, program outcomes may be shown to be

more successful than they appear if they were compared to weight gain in previous years. Also,

the intervention effect may not occur until several weeks after the end of the program. In this

situation, a post-test at the end of the treatment would show no impact, but a post-test a month

later might show an impact.

Programs are costly, making the use of control groups and adequate sample sizes difficult.

If a control group is available, it may be ethically inappropriate not to offer an alternative










program. Because in most instances, small- to moderate- sized convenience samples are utilized,

there is the risk of the researcher making a Type II error (concluding the treatment caused no

change when it actually did cause a change).

Different study outcomes may be found among members of different ages, adversely

affecting the ability of the outcomes to be generalized to all ages. To control for this, a few of

the studies accounted for age in the statistical regression analyses.

It is not possible to know all the events, other than those planned in the program, that occur

during the course of the program, and such external events may affect study outcomes. It is

unknown whether successful biological outcomes occurred because of the programs, or because

of other environmental, personal, or behavioral factors. For example, some children and

adolescents may begin to be involved in physical education at school when they begin a

behavioral intervention program.

Some validity risks are inherent in any program evaluation. A test is reliable to the extent

that whatever is measured, is measured consistently. The program studies described their data

collection procedures well, including the assessment of their equipment such as weight scales.

However, there is always the potential for inconsistent performance during the collection of the

biological measurements and the fluctuation of measurements if taken at different times of the

day.

Overall, descriptions of the program evaluations were provided so that they could be

accurately replicated in other studies. In addition, nearly all the studies prevented a catalyst

effect by excluding participants who were participating in another program. Health professionals

implementing and participating in a program want the program to be effective.









Caution should be utilized in generalizing study findings either to broader population

groups or over time. Conditions for programs efficacy work change over time. In addition, the

external experiences of participants in different programs may vary. For example, some may

receive physical education class once a week at school, while others may receive it four times a

week at school.

Quantitative methods lose utility when the subj ect of the study is difficult to measure or

quantify. Each of the programs studied may have benefited from eclectic use of quantitative and

qualitative methods.

Program studies can potentially inform public policy and analysis in several ways.

Through these studies public policy may identify and classify interventions as either: successful

in the targeted populations; effective for broader populations or distinct population subsets; or

ineffective and not appropriate for further public expenditure.

Summary

Effective strategies to promote self-management of health habits are more important than

ever. Research shows that overweight children and adolescents benefit from comprehensive

dietetic and exercise education (Saelens, Sallis, Wilfley, Patrick, Cella, & Buchta, 2002).

The review of theses nine outpatient secondary and tertiary prevention programs for

overweight youth (Tables 2-1 and 2-2) revealed that diet and exercise together, rather than diet

alone, are associated with significantly improved health outcomes such as improved BMI and Hb

Alc values. Program studies suggest that weight-loss success is associated with interventions

that include the participants' parents (Jain, 2004), and the participant's willingness to change

behavior, somatic characteristics, socioeconomic status, exercise and dietary habits, and dietary

intake, as well as the quality of dietary records (Reinehr et al., 2003). Improvements in









emotional well-being and behavior also correlated positively with weight loss (Dreimane et al.,

2006).

Interventions that have a greater frequency and duration of program sessions were not

necessarily associated with better weight and BMI outcomes. According to Eliakim et al.

(2002), gender, pubertal status, and the degree of obesity had no influence on BMI changes.

Overall, the programs were modestly successful in maintaining or decreasing weight and

BMI. Six of the nine studies showed statistically significant, short-term decrease in weight or

BMI (Dreimane et al., 2006; Eliakim, A. et al., 2002; Monzavi, R. et al., 2006; Savoye et al.,

2004; Speith, L. et al., 2000; Taylor, Mazzone, & Wrotniak, 2005). Savoye et al. (2004) was the

one study that showed statistically significant, long-term outcomes. At two-years post-program,

the decrease in BMI from pre-program baseline was primarily maintained.

Program studies can potentially inform public policy and analysis in several ways.

Through these studies public policy may identify and classify interventions as either: successful

in the targeted populations; effective for broader populations or distinct population subsets; or

ineffective and not appropriate for further public expenditure.

CMS health providers are actively pursuing the integration of research and practice within

their agency. This program evaluation is in the position to contribute to the integration of

research and practice among overweight child and adolescents, offer information about what

occurs within the CMS program, and to report progress on health outcomes. Additionally,

knowledge gained through the use of Social Cognitive theory in behavior intervention programs

may be used to further educate individuals and their families how to manage, in part, their own

wellness and live healthier lives.











Table 2-1. Maj or Learning Concepts in Social Cognitive Theory
Concp Definition Application
Chneis bi-directional; behavior
Reciprocal Inolve the individual and relevant others; work to
cagsresult from interaction
Determinism change the environment, if warranted
btween person and environment
Behavioral Knwledge and skills to influence
Provide information and training about action
Capability bhavior
ncroae information about likely results of
Expectations Bliefs about likely results of action
acin in advice
Point out strengths: use persuasion and
Confidence in ability to take actionan
Self-Efficacy encouragement; approach behavior change in
ersist in action
salsteps
Observational Bliefs based on observing others like Point out others' experience, physical visible
Learning sland/or physical results changes; identify role models to emulate
Responses to a person's behavior that Poieincentives, rewards, praise: encourage
Reinforcement inraeor decrease the chances of sef-reward: decrease possibility of negative
reurnce rsoesthat deter positive changes
From U.S. National Institutes of Health (NIH): National Cancer Institute (2005). 'Theony at a Glance: A Guic e for
Health Promotion Practice' National Institutes of Health, National Cancer Institute. Retrieved Sept 24, 2005 at
/redirect. cgi?r-http://www. cancer. gov/cancerinformation/theory -at-a-glance











Table 2-2. The Evaluation of Learning. Concepts Social Cognitive Theory in Literature
Concept Examples of Concept Measurement in Literature
School environmental changes elicit dietetic and exercise behavioral changes (Luepker et al.,1996; Rinderknecht & Smith, 2004; Trevino
Reciprocal let al., 1998)
Determinism ~Home environmental changes elicit dietetic behavior changes (Taras et al., 1989; Klesges et al, 1991)

Behaviral Acommunity-based diabetes education program improves participants' behavioral capability in diet and diabetes as evidenced in pre- and
Capailit pos-knowledge tests (Chapman-Novakofski & Karduck, 2005)

Acomputer-based intervention on nutrition among supermarket food shoppers associated with improved outcome expectations (Resnicow
Expectations let al.1997)

Pr self-efficacy scales:
Sef-efficacy associated with more healthy foods choices in youth (Cusatis & Shannon, 1996) and adults (Van Duyn, Kristal, & Dodd,
2001)
Self-Efficacy
Sef-efficacy associated with improved metabolic control (Ludlow & Gein, 1995), quality of life (Rose, Fliege, Hildebrandt, Schirop, &
Klp,2002), coping and problem solving (Anderson et al., 1995), diet adherence (Miller, Edwards, Kissling, & Sanville, 2002), and
blood glucose testing (Skelley, Marshall, Haughey, Davis, Dunford, 1995)

Cognitive representation mediates response production and that corrective adjustments through visual guidance aid in the translation of
inception into action (Carroll and Bandura, 1987)
Observational
Teeffects of televised safety models decreased children's willingness to take physical risks and their ability to identify injury hazards in
Learning
cmmon situations (Potts & Swisher, 1998)


The "Kids Choice" school lunch program used token reinforcement and increases children's fruit and vegetable consumption (Hendy,
Williams and Camise (2005)
Academic incentives improve the effectiveness and student adherence to a 12-week voluntary exercise program designed to decrease
students' percentage of body fat (DeVahl, King, & Williamson, 2005).
A voucher-based reinforcement intervention improves smoking cessation among women in a residential substance abuse treatment
facility (Robles et al.,2005)
individualss in a community-based methadone treatment program who earn stars for attending counseling sessions as scheduled and for
providing clean urines have improved outcomes (Rowan-Szal, Joe, Chatham, & Simpson, 1994).


Reinforcement











Table 2-3. Abbreviated Version Table: Outpatient Secondary- and Tertiary-Level Nutrition and


Exercise Programs
AUTHOR PROGRAM


SUBJECTS


N Age
264 7-17y


177 6-16y


OUTCOME
IMPROVEMENTS :
Wt BMI Other
Perceived Health*


** Endurance Time*


Dreimane, D. et al.
(2006).

Eliakim, A. et al.
(2002).


Monzavi, R. et al.
(2006)


Reinehr, T. et al.
(2003)

Saelens, B. E. et al.
(2002)




Savoye, M. et al.



Speith, L. et al.
(2000)






Taylor, M. J. et al.
(2005)


Woo, K. S. et al


Duration: 8 or 12 weeks of 90-
minutes
Parental Involvement: Yes
Duration: 3- or 6-months (4 lectures,
dietician once/mos,
&exercise 1 hr twice weekly)
Parental Involvement: Yes
Duration: 12 weeks of 90-minutes
Parental Involvement: Yes


Duration: 1 year (exercise weekly,
other)
Parental Involvement: Yes
Duration: 4-months (computer
interaction, physician
counseling, & telephone/mail
counseling) vs. a single
physician counseling)
Parental Involvement: Yes
Duration: 1 year (two 30-minute
exercise/week; one
45-minute class each week)
Parental Involvement: Yes
Duration: About 4-months (one
primary session,
then about 4 follow-up visits); one
group on low-
glycemic diet & others on low fat
diet
Parental Involvement: Yes
Duration: 8 weeks of twice-weekly
60-minute
sessions
Parental Involvement: Yes
Duration: 1) 6 wks/diet & exercise
twice weekly
(1/2 of group diet modification, 1/2
of group diet &
exercise). 2) After 6 weeks to 1
year, 1/2 in diet &
exercise group attend weekly
exercise, & others
continue twice-monthly diet
monitoring program
Parental Involvement: Yes


Duration: 12 weeks of once-a-week
Parental Involvement: Yes


109 8-16y NS Systolic BP *
2-hr glucose *
TC & LDL *
TG & Leptin *
75 7-15y NS


44 12-16y NS NS Higher eating &
other skill than non-
program group*


* 1 yr: Body fat: *
Self-concept: *
2 year: Neither *

* *


25 13.3+
0.6y


107 10-14y


(low (both
-fat groups)
group)



41 10.5y Lower Waist & hip girth*
(mean) (*) SBP, DBP, &
RHR:*
HRfinish/5minHR*
82 9-12y NS NS 6 wks: TG (both)*
LDL (exercise)*
FG (exercise gr.)*
EDD (both gr.) *
1_y: Body fat*
IMT (both)*
LDL (exercise)*


Zador, I. et al.
(2006)


17 7-15.8y N/E NS Hb Alc: S
Hip-to-Waist: S












Note: This chart is an overview. Please see articles for extensive outcome results.* = Statistically significant;
5minHR = Heart rate 5 minutes after exercise; EDD = Endothelium-dependent dilation;
BMI = Body mass index; FG = Fasting glucose; gr. = Group; Hb Alc = Glycosylated hemoglobin;
HRfinish = Immediate post-exercise heart rate; Ht = Height; IMT = Intima-media thickness; LDL = Low density
lipoprotein; N = Number of subjects; NS = Not significant; RHR = Resting heart rate; NS: Not statistically
significant; TC = Total cholesterol; Wt = Weight











Table 2-4. In-Depth Version Table: Outpatient Secondary- and Tertiary-Level Programs
Publication Program Subjects Evaluation


Dreimane, D. et. Al (2006).
Feasibility of a hospital-based,
family-centered intervention to
reduce weight gain in overweight
and adolescents. Diabetes and
Research and Clinical Practice.


Name/Location: Kids N Fitness
in an out-patient setting
Description: Up to twelve 90-
minute sessions (8 week
program vs 12 week program);
interactive nutrition & exercise
sessions with behavior
modification
Personnel: Registered dieticians,
physical therapists, physicians,
other health professionals
Parental Involvement: Yes


Description: Overweight
N: 264
Gender: 127 boys & 137
girls
Age: 7-17 y (mean
11.5+2.1y)
Ethnicity: 73% Hispanic,
12% African American, 8%
Caucasian, & 7% Other
IC/EC: No physical
limitations, attendance >
50% of sessions,
undergoing rigorous
physical therapy,
overweight per CDC growth
chart, age 7-17y


Procedures :
*Wt, Ht, and BMI, & child health
questionnaire evaluated at pre- and post-
program. Subjects also recorded daily
dietary & exercise activity during the Irst,
4th, & 7th week of program. Outcomes of
participants in the 8-week vs. 12- week
program were compared.
Outcomes:
Wt: In whole study population, Wt velocity
decreased from 0.72610.980 to
0.193kg/month (p< 0.001)
Ht: Not evaluated
BMI: In whole study population BMI
velocity decreased from 0.22810.452 to -
0.06110.548kg/m2 (p <0.001); BMI z-score
rate (change in z-score per month)
improved from 0.01110.042 to -
0.001+0.003 z-score/month (p = 0.006)
Hb Alc: Not evaluated
*Other: Subjects in 12-week program
compared to those in 8-week program had
significantly reduced Wt gains and BMI
losses which did not correlate with age,
gender, or ethnicity. Females more likely to
attend more sessions. Significant
improvements in child's perceived health
and physical function in 8-week group.
Qualitative Component: No











Table 2-4. Continued.
Publication

Eliakim, A. et al. (2002). The
effect of a combined intervention
on body mass index and fitness in
obese children and adolescents a
clinical experience. Eur J Pediatr,
161, 449-454.


Program


Subjects


Evaluation


Name/Location: Child Health & Sports
Centre, Mier General Hospital, TelAviv
University
Description: All participated in the 3-
month program (4 evening lectures,
meet with the dietician once a month, &
weekly exercise for 1 hour twice a
week): 65 completed the 6-month
intervention
Personnel: Physicians, dieticians
Parental Involvement: Yes


Description: Obese
N: 177
Gender: 90 boys & 87
girls (3-month intervention
group): 10 boys & 15 girls
(control)
Age: 6-16y
Ethnicity: 128 Ashkenazi,
33 Sepharadic, 16 mixed
(3-month intervention)
IC/EC: Without organic
cause of obesity & not
taking medication that
would interfere with
growth or weight control


Procedures :
*Wt, BMI, & fitness were evaluated at
baseline, & after the 3 and 6 months
interventions. Also utilized a control
group of 25 subjects (had nutritional
counseling once every 3 months and
encouraged to exercise 3 times a
week)
Outcomes:
Wt: At 3 months, significant decrease
from 55.811.2 kg to 54.9 kg. In
contrast, a significant increase in wt
among the control group. At 6
months, significant decrease -
0.510.55 kg (mainly due to loss in
Irst 3 months).
Ht: Not evaluated
BMI: At 3-months, significant
decrease from 26.110.3 kg/m2 to
25.410.3 kg/m2. In contrast, a
significant increase in wt among the
control group. At 6 months,
significant decrease -1.0710.23 kg/
m2 (mainly due to loss in Irst 3
months).
Hb Alc: Not evaluated
Other: At 3 months, changes in wt &
BMI not significantly affected by
gender, pubertal status, degree of
obesity, & parental overweight
status. Endurance time increased
significantly.
Qualitative Component: No











Table 2-4. Continued.
Publication


Progrm


Subjects


Evaluation


Lazzer, S. et al. (2005).
Longitudinal changes in activity
patterns, plwsical capacities,
energy expenditure, and body
composition in severely obese
adolescents during a
multidisciplinary weight-reduction
program. International Journal of
Obesity, 29, 37-46.


Name/Location:
Pediatrics Department of
the Clermont-Ferrand
Hospital, France
Description: 5 days/week
for 9 months.
Consists of nutrition
education, endurance
resistance training, &
regular plwsical activity.
*Inpatient.
Personnel: Plwsicians,
plwsical trainers, research
assistant, dietician,
psychologist
Parental Involvement: Yes


Description: Severely
obese
N: 27
Gender: 13 boys & 14
girls
Age: 12-16y (mean 14y)
Ethnicitv/Race: Not
available
IC/EC: Ill health, in prior
wt program, taking regular
medications or
medications that influence
metabolism


Procedures:
*Comparison of pre- and post-program plwsical
characteristics (age, pubertal stage, wt, ht, BMI,
VO2) & body composition (FFM, FM, BMC, BMD
of total body; FFM & FM of arms, legs and trunk)
Outcomes*:
Wt: Loss of 18.4 kg and 15.7 kg, (s.e.m = 1.27 kg,
P<0.001) in boys & girls respectively
Ht: Increased 4.5 cm & 1.4 cm (s.e.m. = 0.24,
P<0.001) in boys & girls, respectively.
BMI: Decreased by 8.1 kg/m2 & 6.3 kg/m2 (s.e.m.
= 0.38 kg/m2, P<0.001) in boys & girls,
respectively.
Hb Alc: N/A
Other: Waist & hip circumferences decreased
significantly for boys & girls: FM also decreased
significantly for these groups. FFM decrease
significantly for girls but not for boys. BMC &
BMD increased significantly for both groups.
VO2max (1/min) did not vary significantly, but
strength & fitness were improved (P<0.001). Time
and EE spent at sedentary activities decreased
significantly (P<0.001) to the benefit of moderate
(recreational) activities and total plwsical activities
(P<0.001).
Qualitative Component: No











Table 2-4. Continued.
Publication

Monzavi, R. et al. (2006).
Improvement in risk factors for
metabolic syndrome and insulin
resistance in overweight youth
who are treated with lifestyle
intervention. Pediatrics,117(6),


Progrm


Subjects


Evaluation


Name/Location: Fun 'n
Fitness/Children's Hospital Los
Angeles
Description: 90 minutes per
week for 12 weeks. Consists of
nutrition and plwsical activity
modification activities
Personnel: Plwsicians,
dieticians, social work
Parental Involvement: Yes


Description: Overweight
N: 109 pre- program &
43 post-program
Gender: 60 boys & 49 girls
Age: 8-16y (11.5y)
Ethnicitv/Race: 85% Hispanic;
Other 15%
IC/EC: /History of diabetes,
inability to ambulate, medical
conditions or taking
medications (i.e.
glucocorticoids, insulin
sensitizers, or psychotropics),
no physician approval.


Procedures: Metabolic syndrome risk factors were
calculated at 3 weeks pre-program, & at or within 3
weeks after the end of the final session. Data
(factors) collected included: BMI, BMI SD, BP, TG,
FPG, serum insulin, c-peptide, total cholesterol,
HDL & LDL cholesterol, leptin, Hb Alc; repeat
sampling for FGP and serum insulin 2 hrs after
ingestion of 75g of Glucola.
Outcomes:
Wt: Before program mean 78.2313.69 kg:
after program mean 78.3113.64 kg: paired
t-test not significant: CI -0.72 to 0.54.
Ht: Before program 151.111.6 cm: after
program 152.211.6 cm; paired t-test <0.005;
CI -1.4 to -0.9.
BMI: Before program 33.6511.15 kg/nf:
after program 33.1911.12 kg/nf: p<0.005;
CI 0.2 to 0.7. BMI SDS before program
2.391 0.05; after program 2.341 0.06;
p<0.005; CI 0.016 to 0.076
Hb Alc: Not evaluated
*Other: Prior to the program, 49% of the
subjects had prevalence of risk factors for
metabolic syndrome. The overall prevalence
of risk factors for metabolic syndrome was
55% in Hispanic and 27% in black
participants. There were significant
changes (pre- and post-program) regarding
SBP, 2-hr glucose, cholesterol, LDL, TG,
and Leptin. See article for further results.
Qualitative Component: Informal telephone
surveys (8 questions) for 39 families that
didn't complete the program. Indicated
transportation, language barrier, and
program time requirements were main
reasons for droDming out.











Table 2-4. Continued.
Publication

Reinehr, T. et al. (2003).
Predictors to success in
outpatient training in obese
children and adolescents.
International Journal of Obesity,
27(9), 1087-1092.


Progrm


Subjects


Evaluation


Name/Location: "Obeldicks"
Description: 1 year & divided
into 3 phases: 1) Irst 3 months is
intensive phase (6
nutrition/eating sessions for 1.5
h each): 2) next 6 months is
establishing phase (individual
psychological family therapy
sessions); 3) last 3 month is
further individual care. Exercise
therapy is once weekly for one
year. Consists of nutrition &
exercise education, & behavior
therapy
Personnel: Pediatricians.
dieticians, psychologists, &
exercise psychologists
Parental Involvement: Yes


Description: Obese
N: 75 subjects
Sex: 39 boys & 36 girls
Age: 7-15y (mean y)
Ethnicitv/Race: Not addressed
IC/EC: Two-time presence in
the obesity ambulance & to
fill-in a questionnaire
according to exercise &
dietary habits: primary disease
excluded


Procedures:
Data collection included subjects'
willingness to change behavior (changes in
wt status, number of attempts at therapy,
participation in exercise), somatic
characteristics (BMI of children & family
members, children & their parents, working
mother), exercise & dietary habits, the
quality of dietary records. This data was r/t
the SDS-BMI using multiple regression.
Comparison of SDS-BMI occurred at 3-
months pre-program, at beginning of
program, and 3-months post-program.
Outcomes:
Wt: Not evaluated
Ht: Not evaluated
BMI: For 63% of subjects, there was a
median wt loss of 0.4 SDS-BMI (range -
0.2 to -1.1). 37% of subjects were
unsuccessful after treatment.
Hb Alc: Not evaluated
*Other: The only significant difference
(P<0.0001) between the successful &
unsuccessful ones was that they had taken
part in the exercise groups before the
program began.
Qualitative Component: No











Table 2-4. Continued.
Publication

Saelens, B. E. et al. (2002).
Behavioral weight control for
overweight adolescents initiated
in primary care. Obesity
Research, 10, 22-32.


Progrm


Subjects


Evaluation


Name/Location: Healthy Habits
(HH)/2 pediatric primary care
clinics in southern California
Description: 4-months: consists
nutrition of exercise instruction:
subjects randomly assigned to
either HH program (includes
computer interaction, plwsician
counseling & telephone-& mail-
based behavioral counseling) or
a single session of plwsician
weight counseling
Personnel: Plwsicians, those
with a degree in nutrition or
psychology
Parental Involvement: o
(subjects encouraged to
implement changes on own or
with the help of their families)


Description: Overweight
N: 44
Gender: 26 boys & 18 girls
Age: 12-16y (mean 14.2y)
Ethnicitv/Race:
IC/EC: 20 to 100% above the
median (50" percentile) for
BMI for sex & age; interested
in weight control: not
currently engaged in another
weight control program;
otherwise healthy as
determined by pediatrician


Procedures: Wt, ht, dietary intake, plwsical activity,
sedentary behavior, and problematic weight-related
and eating behaviors and beliefs were assessed
before and after the treatment, and at a 3-month
follow-up. Subject satisfaction & behavioral skills
use were measured
Outcomes:
Wt: No significant decrease for HH or TC
groups from baseline to post-treatment.
Ht: Not evaluated
BMI: Program led to modest decrease in
weight status for HH (about -0.05 in BMI z
score) & increase in weight status for TC
(about 0.06 BMI z score).
Hb Alc: Not evaluated
*Other: At post-treatment, HH reported
higher overall & eating behavioral skills
than TC group. (P<0.01). HH report greater
satisfaction for mailed materials versus
computer interaction (P<0.01).
Qualitative Component: No











Table 2-4. Continued.
Publication

Savoye, M. et al. (** *4).
Anthropometric and
psychosocial changes in obese
adolescents enrolled in a weight
management program. Journal
of the American Dietetic
Association, 105(3), 364-370.


Progrm


Subjects


Evaluation


Name/Location: Bright Bodies
Weight Management
Program/Yale New Haven
Hospital
Description: 1 year: each week
two 30-minute exercise sessions
and one 45-minute nutrition or
behavioral modification class.
Consists of nutrition, exercise,
and behavior modification: given
either a structured meal plan
(SMP) or taught to make better
food choices (BFC)
Personnel: Dieticians, social
workers, & exercise
physiologists
Parental Involvement: Yes


Description: Overweight
N: 25
Gender: 8 males & 17 females
Age: 13.310.6 (SMP): 13.6
+0.3 (BFC)
Ethnicitv/Race: 8 White
(SMP): 7 White, 7 Black, & 3
Hispanic (BFC)
IC/EC: Major health or
psychological condition,
medications for weight
management, or involved in a
concurrent weight control
program


Procedures:
BMI, body fat percent, and self -concept
were measured at 0, 1, and 2 years.
Outcomes were analyzed for the entire
group and by diet method groups.
Outcomes:
Wt: Not evaluated
Ht: Not evaluated
BMI: At 1 year, entire group had a decrease
in BMI z scores from 2.491 0.10 to 2.31
0.10(P=0.004) (i.e. a 7.7% decrease or a
decrease in absolute BMI from 40.10 to
37.7+2.08, P < or = .0001). At 2 years,
decrease in BMI from baseline was
maintained (2.291 0.10, P=.03), or an
absolute BMI decrease to 39.3+2.08, P .
When comparing dietary approaches, the
SMP group showed more favorable short-
term results for BMI (P=0.11), but by year
2, the BFC further improved BMI (P=.006),
while the dieting group reverted back to
baseline. See article for further results.
Hb Alc: Not evaluated
*Other: At 1 year body fat percent decreased
from 45.76% 1.65% to 40.799 1/66%
(P=0.002), & self-concept increased
(P<0.001). At 2 years body fat (P=0.15) &
self-concept (P=0.10) were not significantly
higher than baseline (P=0.10).
Qualitative Component: No











Table 2-4. Continued.
Publication

Spieth, L. et al. (2000). A low-
glycemic index diet in the
treatment of pediatric obesity.
Arch Pediatr Adolesc Med,
154(9), 947-951.


Progrm


Subjects


Evaluation


Name/Location: Optimal Weight
for Life Program; Children's
Hospital, Boston, Massachusetts
Description: About 4-
months/one primary session &
then about 4 follow-up visits.
Consists of a primary counseling
session that included dietary
instruction (assigned either low
glycemic index diet (low-GI)
instruction or low fat diet
instruction & plwsical activity
recommendations: follow-up
appointment once monthly for 4
months: some received problem-
focused behavior therapy with a
program psychologist
Personnel: Pediatrician,
dietician, pediatric nurse
practitioner, program
psychologist
Parental Involvement: Yes


Description: Obese
N: 107 (64 low-GI & 43 low
fat diet)
Gender: boys (30 low-GI & 19
low fat diet) & girls (34 low-
GI & 24 low fat diet)
Age: 10.6+4.0 y (low-GI) &
10.213.1 (low fat diet)
Ethnicitv/Race: 10
Black/Hispanic & 54 White
(low-GI) & 20 Black/Hispanic
& 23 White (low-fat diet)
IC/EC: Cushing's syndrome,
lwpotlwroidism,
lwpothalamic, diabetes, or
obesity-associated genetic
syndrome, or concurrent
energy diet


Procedures:
*Changes in BMI and wt from first to last
clinic visit were evaluated: the 2 groups
were compared. Outcomes:
Wt: -2.03 kg [95% confidence interval -3.19
to -0.88] in the low-glycemic index group
vs. +1.31 kg [ -0.11 to + 2.72], P<.001) in
the reduced fat group
Ht: Not evaluated
BMI: -1.53 kg/m2 [95% confidence interval,
-1.94 to -1.12] in the low-GI group vs. -0.06
kg/nr [-0.56 to + 0.44], P<.001) in the low
fat group. Significantly more patients in the
low-GI group experienced a decrease in
BMI of at least 3 kg/m2 (11 kg/m2 [17.2%]
vs. 1 kg/nr [2.3%], P =.03).
Hb Alc: Not evaluated
*Other: In multivariate models, these
differences remained significant (P<.01)
after adjustment for age, sex, ethnicity, BMI
or baseline weight, participation in
behavioral modification sessions, and
treatment duration
Qualitative Component: No











Table 2-4. Continued.
Publication

Taylor, M. J., Mazzone, M.,
Wrotniak, B. H. (2005).
Outcome of an exercise and
educational intervention
for children who are overweight.
Pediatric Plwsical
Therapy,17(3), 180-188.


Progrm


Subjects


Evaluation


Name/Location: Western New
York State
Description: Consecutive 8
weeks. Twice weekly for 60-
minute sessions; consists of
exercise and educational
components
Personnel: Plwsical therapists:
plwsicians, registered dieticians.
nutritionists, nurse clinicians, an
occupational therapist, & a
sports psychologist
Parental Involvement: Yes


Procedures:
*Data collection of 2 baseline, pretest
measures (separated by 1 week) & a single
posttest measure (1 week after program
completion). Data included BMI, waist &
hip girth, BP, resting heart rate (RHR),
immediate post-exercise heart rate
(HRfinish), five-minute recovery heart rate
(5minHR), & distance walked in six
minutes.
Outcomes:
Wt: Difference between pre- (mean 139 lbs)
& post-program (mean 140 lbs)
Ht: Difference between pre- (mean 57
inches) & post-program (mean 58 inches)
BMI: Significant difference between pre- &
post-program.
(p =0.0001). Mean BMI decreased by 0.4. 27%
of subjects decreased BMI by 1 point or more
(corresponds approximately to 4-pound weight
loss).
Hb Alc: Not evaluated
*Other: Significant difference between pre-
& post-program included waist girth
(p<0.000 1), hip girth (p<0.0001), SBP
(p=0.0006), DBP (p=0.0181), RHR
(p=0.0115), HRfinish (p=0.0298), &
5minHR (p=0.0255). No significant
difference across time for waist-to-lup ratio
or in the 6-minute walk. See article for
further and post hoc results.
Qualitative Component: No


Description: At-risk-for-
overweight or overweight
N: 41 (52 started excluded
d/t E.C.) sessions)
Gender: 18 boys: 23 girls
Age: (mean 10.5y)
Ethnicitv/Race: Not stated
I.C./E.C: Age between 8-15y,
BMI >'er 85%, stable vital
signs, adequate balance and
coordination to sit on a
therapy ball, sufficient
attention to follow instructions
in a group setting, and medical
consent to participate/missed
>'er 4 classes











Table 2-4. Continued.
Publication

Woo, K. S. et al. (I III4). Effects
of diet and exercise on obesity-
related vascular dysfunction in
children. Circulation, 109,
1981-1886.


Progrm


Subjects


Evaluation


Name/Location: Not available
(Recruited from 13 primary
schools)
Description: 1) 6 weeks/diet &
exercise twice weekly (1/2 of
group received diet modification
only; 1/2 of group received diet
& exercise). 2) After 6 weeks,
for 1 year, 1/2 of those in the
diet & exercise group continue
weekly exercise program for a
year, all of the others continue 2-
monthly diet monitoring
program.
Personnel: Trained
plwsiotherapists; dieticians.
others not stated
Parental Involvement: Yes


Description: Overweight or
obese
N: 82
Gender: 54 boys & 28 girls
Age: 9-12y
Ethnicitv/Race: Not available
IC/EC: No known medical
illnesses or alternative cause
for obesity, no family history
of premature cardiovascular
disease, no regular
medications or vitamins, &
have resting brachial artery
diameter >2.5 mm


Procedures:
*Plwsical assessment (BMI, hip-waist ratio,
body fat content), blood tests (cholesterol,
lipid profiles, glucose levels), and arterial
reactivity studies (ultrasound-derived
endothelial function (EDD) of brachial &
thickness of carotid artery) were compared
pre-program, & post-program at 6-weeks &
1-year. Also, multivariate analysis done.
Outcomes
Wt: Not evaluated
Ht: Not evaluated
BMI: No significant decrease at 6 weeks or
1 year post-program.
Hb Alc: Not evaluated
Other: After 6-week intervention, no
significant change in body fat content, fat-
free mass. A significant decrease in total
cholesterol in both groups & LDL in the
exercise group. Fasting glucose (P<0.002)
reduced in the exercise group. An
improvement in EDD but not NGT of
brachial artery after 6 weeks' intervention in
both groups, but significantly greater with
exercise (P=0.01). Exercise training
(13=0.54:P=0.02) & changes in LDL
(13=0.54;P=0.03). For other & 1 year
results see article.
Qualitative Component: No











Table 2-4. Continued
Publication

Zador, I. et al. (2006).
Hemoglobin Alc in obese
children and adolescents who
participated in a weight
management program. Acta
Paediatrica, 95(1), 105-107.


Progrm


Subjects


Evaluation


Name/Location: Marshfield
Clinic/North-Central Wisconsin
Description: Once-a-week for 12
weeks. Consists of nutrition,
exercise, and behavioral
component
Personnel: Exercise plwsiologist,
registered dietician, medical
social worker, & a nurse
practitioner
Parental Involvement: Yes


Description: Obese, non-
diabetic
N: 17
Gender: 10 boys & 7 girls
Age: 7-15.8y (mean 10.8y)
Ethnicitv/Race: All Caucasian
IC/EC: Not stated. Subjects
received a history, plwsical &
psychological exam prior to
program participation.


Procedures:
*Comparison of pre- and post-post Hb Alc
& BMI.
Outcomes:
Wt: Not evaluated
Ht: Not evaluated
BMI: At the outset of the weight
management program was 34.316.4 kg/m2
(mean+1 SD). BMI at the end of the
program was 3316.6 kg/nr (p<0.05). Mean
BMI in five patients (29%) actually
increased by the end of the program but
their HbA1, values decreased.
Hb Alc: At the beginning, Hb Alc was
5.310.3%. HbA1, at the end of the program
was 5+0.2% (p<0.05). There was no
significant difference in HbA1, change
between the prepubertal & pubertal
subgroups of children (p=0.59). No
significant correlation between changes in
BMI & changes in Hb Alc. No significant
correlation between changes in waist-to-hip
ratio and changes in Hb Alc.
Other: Waist-to-hip ratio at program
completion was 0.9610.09(mean +1SD).
Waist-to-hip ratio at program completion
was 0.9710.11 (p=0.411).
Qualitative Component: No


Note. ABMI = Adjusted Body Mass Index: ANOVA = Analysis of Variance: BMI = Body mass index: BM SDS = Body mass index standard deviation score:
BW = Body Weight; DABMI =Difference in Adjusted Body Mass Index: DXA = Dual-energy X-ray Absorption: EC = Exclusion Criteria; EE = Energy
Expenditures: FM = Fat Mass: FFM = Fat-free Mass: FPG = Fasting Plasma Glucose: Hemoglobin Glycosylated Hemoglobin = Hb Alc; HDL = High density
lipoprotein: Ht = Height: IC = Inclusion criteria; LDL = Low Density Lipoprotein: PE = Plwsical Exercise: SD = Standard Deviation: SDS-BMI = Standard
Duration Scores of Body Mass Index: s.e.m. = Least-squares means and standard errors: SPSS = Statistical Product and Service Solutions software: TG =
Triglycerides: VO2 max = Maximal Oxygen Uptake: VO2 170 = Oxygen Consumption at Heart Rate of 170 bpm; Wt = Weight









CHAPTER 3
METHOD

Using a mixed-methods approach, an evaluation of the Children' s Medical Services (CMS)

behavior intervention program, initiated in 2002, was carried out utilizing a repeated measures

retrospective chart review, interviews with youths and parents, and in-class observations. The

CMS program was comprised of four, 1.5 hour weekly sessions for children and adolescents

(herein referred to as "youths") and their parents. Although the program curricula (Appendix A)

remained constant throughout the program, it was implemented by a rotation of instructors that

included Registered Nurses, Registered Dieticians, and dietician students. The study evaluated

those youths' outcomes that attended the CMS program between October 1, 2002, and September

30, 2006.

Study Aims

Specific Aim #1

A repeated measures, retrospective chart review was used to compare CMS youths'

biological measurements of body mass index (BMI) and glycosylated hemoglobin (Hb Alc) at

approximately three and six-months before program participation; the first day of the program;

and approximately three and six-months after program participation.

Specific Aim#2

Post-program interviews were conducted with youths and parents using an interview guide

(Appendix B). Thematic analysis of the data gathered elucidates salient strengths and

weaknesses of the program.










Specific Aim #3

In-class sessions were observed. Field notes were recorded and analyzed for themes.

Thematic analysis enabled the researcher to take full account of the many interactions of youths

and parents and their potential effects in the social setting of the program.

Sample and Sample Size

A retrospective chart review, interviews, and in-class observations were obtained using

convenience sampling. Given a 0.75 effect size, as determined using the means and standard

deviation from Eliakim et al. (2002) (mean one: 26.1; mean two: 25.4; sd 0.6), a minimum

sample size of 44 will achieve 0.80 power (alpha 0.05) for repeated measures designs with five

levels (Maxwell & Delaney, 1990).

The sample consisted of: 1) 59 youths for the repeated measures, retrospective chart

review; 2) four youths and five parents for the interview portion of the study; and 3) six youths,

seven parents, and four program instructors for the in-class observations.

Inclusion Criteria

1. Met CMS eligibility requirements.
2. Client of the CMS Metabolic Clinic.
3. Age 7-18 years old.
4. Diagnosed as overweight.
5. Completed the CMS behavior intervention program in its entirety.

Exclusion Criteria

1. Youths that dropped-out of the CMS program.




lUnder age 21 with medical, behavioral, or other health conditions that have lasted or are expected to last at least 12
months. Economic requirements include Medicaid eligible (Title XIX) Children's State Health Care Network,
Florida KidCare State Children's Health Insurance Program (Title XXI) eligible with age up to 19 years with family
incomes up to 200% of the federal poverty level, Children' s State Health Care Network with family incomes over
200% of the federal poverty level through spend-down to Medicaid levels Children' s State Health Care Network as
defined in Title V of the Social Security Act, and high risk pregnant female eligible for Medicaid (CMS, 2006).









2. Diagnosed with a cognitive impairment that could affect the youth' s comprehension of the
CMS program intervention.

Recruitment

Part #1: Repeated measures, retrospective chart review. Institutional Review Board

(IRB) permission was granted to conduct statistical and scientific research of abstracted youth

information without the necessity of written consent from the patient pursuant to Section

456.057(5) (a), Florida Statutes (2006). The data collection procedure complied with relevant

requirements of the University of Florida and the Florida Department of Health IRBs by

redacting from the youth information provided to the PI all of the 18 HIPAA identifiers

(Appendix C). Fifty-nine youths were utilized for this portion of the study because that was the

number of youths that had completed the program when data collection began on October 1,

2006.

Part #2: Post-program interviews. Children' s Medical Services Registered Nurses or

Registered Dieticians informed CMS youths of the study by telephone or in person. The youths

called or emailed the researcher if they were interested in participating in study interviews. The

researcher arranged interviews at CMS or in the interviewee homes. Informed written consent

from the parents, and assent of the youths, were obtained. Four youths and five parents enrolled

for this portion of the study.

Part #3: In-class observations. The CMS nurse provided the researcher with a schedule

of the CMS program and the researcher attended a full program that consisted of four sessions.

At the beginning of each class, the researcher informed the class that she would observe the

program and collect non-identifiable data regarding the description of the room, the instructors,

and the participants, via note-taking. The University of Florida Institutional Review Board










(IRB) and the Florida Department of Health IRB granted a "Waiver of Documentation of

Informed Consent" for this portion of the study.

Procedure

Part #1: Repeated Measures Retrospective Chart Review

A CMS Licensed Practical Nurse (LPN) collected and recorded pertinent information from

59 CMS youths using the IRB-approved, attached data collection form (Appendix D). Pertinent

data included age, ethnicity, and gender. Data also included youths' BMI and Hb Alc values

across five data collection points. The points were approximately six- and three-months pre-

program, day of program, and approximately three- and six-months post-program.

Inter-rater reliability was assessed by having the LPN photocopy eight of the 59 CMS

youths' charts and having her to black out all 18 HIPAA identifiers. Then, the researcher

recollected the data. There was 100% inter-rater reliability between 18 items for eight subjects.

Part #2: Post-Program Interviews

The informal interviews were tape-recorded. The interviews occurred in the CMS agency

sitting room, with the exception of one interview that occurred at a parent' s home. Youths and

parents were interviewed separately. The researcher used an interview guide (Appendix B) and

encouraged youths and parents to talk about their perspectives.

The evening of the interview session, the researcher transcribed the tapes into typed

scripts. At a later date, the transcripts were entered into the Nvivo 2.0 program where they were

organized and eventually coded for themes.

Part #3: In-Class Observation

The researcher observed one, four-week program session that consisted of four, 1.5-hour

classes. After the researcher informed the class that she would observe the session, the










researcher sat apart from the participants usually in a chair against a wall at the side of the

room.

The researcher observed the entire setting which included a description of the room, the

activity, the time, the instructors, and the participants. The researcher observed and monitored

verbal and nonverbal cues, and used concrete, unambiguous, descriptive language during the

note-taking procedure. The data was collected in a manner that did not identify instructors or

parti cipants.

The evening of the session, the researcher typed the hand-written notes. At a later date, the

notes were entered into the Nvivo 2.0 software program (QSR International, 2002) where they

were organized and eventually coded for themes.

Human Subjects

Confidentiality and Legal Minority

To maintain confidentiality and anonymity of youths for the chart review, a code key was

developed for each youth by the CMS LPN. Only the youths' identification numbers appeared

on the chart review data collection tool that the researcher received back from the LPN.

Interview and in-class observation data was collected, stored, and locked in the researcher' s

office. After the interviews were transcribed without identifiable data, the audiotapes were

destroyed.

It is important to include youths in research. However, youths in research require special

considerations because of limitations on autonomous decision-making and requirements for

additional risk protections (they may not be able to protect themselves). Two ethical issues

relevant to youths involved in research include 1) autonomy, also known as the process of

informed consent assent, and 2) whether the proposed research involves minimal risk to the










subjects. For this study, the researcher obtained informed written consent from the parents and

assent from the youths.

Possible Discomforts and Risks

There was no risk to youths or parents (physical, psychological, social, or economic). The

interviews took about 30 to 45 minutes. The researcher met youths and parents at CMS or their

houses at their convenience.

Possible Benefits

A direct benefit to the youths and parents is that they each received a $15.00 gift certificate

to a department store for participation in the interviews. It is expected that the youths and

parents will eventually benefit from an improved program.

Description of Quantitative Analyses: Chart Review

Descriptive Statistics

As a preliminary step, summary statistics of the group's age, gender, ethnicity and

physiological measurements were computed. These statistics included means, ranges, and

standard deviations.

Repeated Measures ANOVA

The next step in evaluation of the data involved an exploratory analysis using a repeated

measures analysis of variance (ANOVA) to compare group means on a dependent variable

across repeated measures of time (Krueger and Tian, 2004). Time is often referred to as the

with-in subj ects factor, whereas a Eixed or non-changing variable (i.e. ethnicity) is referred to as

the between-subjects factor (Huck, Cormier, & Bounds, 1974). In this study, one-way repeated

measures ANOVA was used to compare differences in BMI and Hb Alc (dependent variable)

across time (within-subj ects factor) by gender and ethnicity (between-subj ects factors).









Since the data was on the same variables over time, they were considered to be dependent

observations. Thus, in this case, standard ANOVA was not appropriate because it fails to take

into account the correlation between the repeated measures and the assumption of independence

in ANOVA would have been violated (Davis, 2002; Kuehl, 2000).

Repeated measures ANOVA analyses are a special case of "randomized block" designs

that account for the correlation in measurements (Davis, 2002; Kuehl, 2000). The purpose of

"blocking" is to isolate variation due to a particular grouping variable Davis 2002, Kuehl, 2000).

Generally, the null hypothesis of no block effect (no subj ect differences between the two blocks)

is rej ected. Blocking also reduces mean sum of squares of error (MSE), so that the effects of a

treatment may be better detected such as changes over time. For the purpose of this exploratory

analysis, each subj ect was treated as a block. This controlled for the variation between different

subj ects so that the trend over time was the main focus (Davis, 2002; Kuehl, 2000).

The assumptions of repeated measures ANOVA include: 1) independence of observations;

2) multivariate normality; and 3) sphericity. To meet the assumption of sphericity, it is required

that correlations across all pairs of time periods are constant (Kuehl, 2000). In this study, there

were missing Hb Alc data points, and the repeated measures ANOVA dropped 54 of the 59

subjects for Hb Alc analysis. Data collection points were approximately every three months

over the course of one year. If a youth was missing BMI and Hb Alc measures at just one of the

data collection points, the ANOVA dropped that youth' s entire data set. If there had been a

complete data analysis set, the repeated measures ANOVA would have accurately reported

whether or not the assumptions held (Kuehl, 2000). Thus, the general linear mixed model was

used as the final step in evaluating the data.









General Linear Mixed Model

The final step in analyzing data was the use of the general linear mixed model because of

its ability to handle multiple missing data points (Cary, 1989; Dilorio, 1991). In addition, the

general linear mixed model can be used to describe nonlinear relationships across time in a

longitudinal database with multiple missing data points (Krueger and Tian, 2004).

The general linear mixed model models for group means as fixed effects while

simultaneously modeling for individual subject variables as random effects (Krueger and Tian,

2004). One of the advantages of using the general linear mixed model is it can accommodate

missing, random data because the modeling of the individual subject variables allows for the

accommodation (Little et al., 1995; Edwards, 2000).

The usual linear model y= X ??+ ???? usually assumes that ?? is Normal (0 ,?21

(Edwards, 2000). For example, the errors are independent Normal with zero means and constant

variances ?2. The mixed model is an extension of the general linear model. It gives us more

flexibility while specifying the covariance matrix of epsilon (Edwards, 2000). This allows the

researcher to include both correlation and heterogeneous variances while assuming normality

(Edwards, 2000).

The mixed model is written as y= X ??+ Z???+ ? where ?? and ?? are normally

distributed with E[ ?] = 0 E[ ?] = ? ; while the ?'s have a covariance matrix G and the ?'s have

a covariance matrix which is given by R (Little, 1995). In SAS, the PROC MIXED implements

two likelihood-based methods to estimate the model parameters (?, ???G, R) (Little, 1995). The

PROC MIXED uses maximum likelihood (ML) and restricted/residual maximum likelihood

(REML) estimation methods (Little, 1995). A favorable theoretical property of ML and REML is

that they accommodate data that are missing at random (Little, 1995).










For models with fixed-effects involving class variables, such as gender and ethnicity, there

are more design columns in X constructed than there are degrees of freedom for the effect. Thus,

there are linear dependencies among the columns of X. In this event, all of the parameters are not

estimable (Little 1995).

There are an infinite number of solutions to the mixed model equations. The PROC

MIXED uses a generalized (g2) inverse to obtain values for the estimates (Searle, 1971). The

PROC MIXED handles missing level combinations of classification variables by deleting fixed-

effects parameters corresponding to missing levels in order to preserve estimability. However,

the PROC MIXED does not delete missing level combinations for random-effects parameters

because linear combinations of the random-effects parameters are always estimable (Searle,

1971). In this study's data set, there were only missing values on the repeated measures of BMI

and Hb Alc and not on the classification variables of gender and race. So all the effects were

estimable.

A variety of within-subj ect covariance matrix structures like Compound Symmetry, Auto-

Regressive Heterogeneous (ARH (1)), Unstructured, and others, are allowed in the mixed model.

It uses restricted maximum likelihood to estimate the parameters of the covariates (Little, 1995).

For the purposes of this study, the researcher tried to fit the same model under different

assumptions, otherwise called Model Selection. For the BMI values, the researcher fit the models

under Compound Symmetry (which was not violated). Although it was determined that it was

appropriate to use Compound Symmetry, the researcher also assessed whether other assumptions

would do better. The Model Selection assisted the researcher to pick the best model in terms of

both the model fit as well as how parsimoniousness of the model. Between the three models, it

was determined that the Unstructured Covariance Matrix was the best fit.









In the same way as within-subj ects can be specified, the between subj ects covariance

matrix structure may also be specified. For example, if we assume for Eu Compound Symmetry,

ARH(1), Unstructured, and others, then under the above model the E (BMI, )= ? + ?1 TIME, +

?2 Male j + ?3 Whitej is the population averaged model (Little et al., 1994). In order to decide

which covariance structure to use, models can be fitted under different covariance assumptions

and then selected using some model selection criteria like BMI and Hb Alc.

The mixed model also allows the effect of time and the intercept to vary between subj ects

and includes them as random effects in the model (Little, 1995). The mixed model is capable of

treating time as either a continuous variable or a categorical variable or both (Krueger and Tian,

2004). The analysis was performed treating time as a continuous variable using the Random

statement.

Description of Qualitative Analyses: Interviews and In-Class Observations

The researcher interviewed participants and observed in-class sessions in order to go

beyond what the chart review data would allow; to have a deeper understanding of the CMS

program. According to Weinreich (2005), qualitative methods immerse the researcher in the

situation, enable the researcher to interact with study subj ects, and thereby generate a rich

context for understanding health behavior, the meaning people assign to phenomena, and the

mental processes underlying their behavior.

The researcher used the method of ethnography by seeking to answer central questions

concerning the ways of life of the program participants. Ethnographic questions are generally

concerned with the link between culture and behavior and/or how cultural processes develop

over time (Hall, 2007). Ethnographies are usually extensive descriptions of the details of social

life or cultural phenomena in a small number of cases (Hall, 2007). For the purpose of this










study, the interview questions and in-class observations provided a wide range descriptive data

concerning participants' program experiences. The researcher spent a considerable amount of

time interviewing participants and observing program classes. The researcher sought to gain

what is called an "emic" perspective; that is to say the program participants' perspectives.

Initially, using the Nvivo 2.0 program software, the transcribed interview data was coded

according to the interview guide questions in order to facilitate the grouping of answers from the

participants. For example, "Why did you attend the CMS program?" was an initial code. The in-

class observation field notes was coded according to the sequence of activities that occurred in

the program snack, exercise, or lecture activity. Those preliminary codes are presented in

chapter five.

Lastly, the entire text of chapter five was hand-coded into five maj or themes as discussed

in chapter six. Themes are described as the conceptual linking of expressions (Ryan & Bemard,

2003). The researcher knew that she had found a theme from the organized data when she was

able to answer the question, "What is this expression an example of" (Ryan & Bemard, 2003)?

Thus, scrutiny of the interview and in-class observation data occurred when the interview

tapes were transcribed and in-class notes read and reread. Examination of the data continued

after the transcribed text was entered into the Nvivo 2.0 program for organization and coding

analysis. The entire process facilitated analysis of the transcripts for emerging themes.

In 1945, anthropologist Morris Opler (Ryan & Bernard, 2003) defined themes as dynamic

affirmations that control behavior or stimulate activity. Themes come from the data (an

inductive approach) and from the investigators prior theoretical understanding of the

phenomenon under study (a priori approach) (Ryan and Bernard, 2003). The researcher









identified themes mostly by recognizing topics that reoccurred in the program setting, activities,

and among the participants.

Summary

The CMS program was comprised of a four, 1.5 hour weekly sessions for overweight

youths ages 7 to 18 years. The mixed-method design included three parts: 1) a repeated

measures, retrospective chart review of 59 CMS youths' BMI and Hb Alc measures from six

months before the program to six months after the program; 2) nine post-program interviews

among youths and parents; and 3) in class observation of the program.

Statistical analyses for the chart review included summary statistics and a preliminary

analysis using repeated measures ANOVA. The repeated measures ANOVA, which requires a

complete array of data, could not accommodate (dropped any subj ect that was missing as few as

one data point) for the missing Hb Alc data points in the study. Therefore, the general linear

mixed model was utilized because the mixed model can accommodate a dataset with a large

portion missing (Krueger and Tian, 2004).

Qualitative interview and observation data was collected to supplement and interpret the

quantitative component of the study. Thematic analysis of the interview data gathered aimed to

elucidate salient strengths and weaknesses of the program. Class observation data was collected

to describe the program setting, activities, and participants.









CHAPTER 4
QUANTITATIVE RESULTS

This chapter provides the quantitative results of the chart review. The quantitative findings

include the use of descriptive statistics, repeated measures ANOVA for preliminary analysis, and

the general linear mixed model.

Chart Review Findings

Descriptive Analyses

The 59 youths' ages ranged from 7 to 18 years (M~= 13, SD = 2.68). The percentage of

female participants (69.5%) was greater than that of male participants (30.5%). The ethnicities

of the members were as follows: African American (64.4%); Caucasian (22%); and Unknown

ethnicity (13.6%).

At each of three-month data collection intervals across 12 months, BMI measures were as

follows: six-months pre-program ranged from 22.8 to 50.9 (M~= 34.9, SD = 6.64); three-months

pre-program ranged from 22.6 to 58.0 (M~= 36.8, SD = 8.56); day of program ranged from 22.4

to 59.8 (M~= 37.4, SD = 8.83); three-months post-program ranged from 21.9 to 60.6 (M~ = 36.4,

SD = 8.43); and six-months post-program ranged from 22.2 to 62.2 (M~= 37.0, SD = 9. 15)

(Figure 4-1).

At each of the three-month data collection intervals across 12 months, Hb Alc measures

were as follows: six-months pre-program ranged from 4.5% to 13.5% (M~= 5.67%, SD = 1.8);

three-months pre-program ranged from 4.7% to 12.4% (M~= 5.8%, SD = 1.57); day of program

ranged from 4.2% to 13.9% (M~= 5.5, SD = 1.5); three-months post-program ranged from 4.4%

to 11.9% (M~ = 5.69, SD = 1.26); and six-months post-program ranged from 4.4% to 7.9% (M~=

5.35, SD = 0.65) (Figure 4-2).









Repeated Measures ANOVA

Repeated measures ANOVA analysis requires a complete set of data; therefore, the

repeated measures ANOVA was performed as a preliminary analysis for only the BMI datasets

and not the Hb Alc datasets. As formerly mentioned in Chapter three, the incomplete Hb Alc

datasets led to the use of the general linear mixed model in order to accommodate for the

multiple missing data points. Only five of the 59 Hb Alc datasets were complete, therefore, the

repeated measures ANOVA for Hb Alc was not included in results.

The total number of BMI datasets used in this repeated measures ANOVA analysis was

26 as compared to 59 BMI datasets used for the general linear mixed model analyses. This was

because 33 BMI datasets were incomplete. This analysis revealed a significant increase in BMI

measurements for the group over time (df 1; F = 4.7; P<0.05) (Table 4-1). No significant

within-subj ect effects were noted for BMI or changes across time (Table 4-1).

General Linear Mixed Model

The purpose of the general linear mixed model analysis was to describe changes in BMI

and Hb Alc. The BMI dataset was previously analysed using a preliminary analysis using

repeated measures ANOVA. Since both the Hb Alc and BMI datasets were incomplete, the

researcher decided to use the mixed model to analyze both BMI and Hb Alc datasets. The

general linear mixed model analysis accommodated for 59 BMI datasets and 59 Hb Alc datasets.

The primary fixed effects in the model were gender, ethnicity, and time. The mixed model

analysis allowed the researcher to model for higher order, nonlinear changes in the dependent

measures (BMI and Hb Alc) across time. As previously explained in chapter three, the

Unstructured Covariance Model yielded the best model for both BMI and Hb Alc.

The effect of time on BMI was significant (df 4; F = 4.95; P<0.05) (See Table 4-2). This

finding was the same as the preliminary repeated measures ANOVA finding for BMI; that










youths' BMI measures increased rather than decreased over time. The effects of gender and

ethnicity on BMI measurements were not significant (Table 4-2).

The effect of time on Hb Alc was significant (df 4; F = 2.80; P<0.05) (See Table 4-3); that

youths' Hb Alc measures decreased over time. The effects of gender and ethnicity on Hb Alc

measurements were not significant (Table 4-3).

Summary

For the chart review, 59 youths' ages ranged from 7 to 18 years (M~= 13, SD = 2.68).

Since the repeated measures ANOVA required a complete set of data, the repeated measures

ANOVA was performed for only 26 of the 59 BMI datasets. It was not performed on the the Hb

Alc datasets. This analysis revealed a significant increase in BMI measurements for the group

over time (df 1; F = 4.7; P<0.05) (Table 4-1). No significant within-subj ect effects were noted

for BMI or changes across time (Table 4-1).

The researcher used the mixed model to analyze both BMI and Hb Alc datasets. The

mixed method accommodated for 59 BMI datasets and 59 Hb Alc datasets. The primary fixed

effects in this model were gender, ethnicity, and time. The effects of gender and ethnicity on

BMI measurements were not significant (Table 4-2). The effect of time on BMI was significant

(df4; F = 4.95; P<0.05) (Table 4-2). This finding is the same as the repeated measures ANOVA

finding for BMI; that members' BMI measures increased rather than decreased over time. The

effects of gender and ethnicity on Hb Alc measurements were not significant (Table 4-3). The

effect of time on Hb Alc was significant (df 4; F = 2.80; P<0.05) (Table 4-3); that youths' Hb

Alc measures decreased over time.

The quantitative data provided a general understanding of how the program was affecting

youths' biological measures such as BMI and Hb Alc. The following chapter will add content to









the statistical results by exploring youths' and parents' views and program experiences more in

depth (Ivankova, Creswell, & Stick, 2006). Qualitative results are especially useful when

unexpected findings, such as youths' higher post-program BMI values and lower post-program

Hb Alc values, arise from quantitative findings (Invankova, Creswell, & Stick, 2006).










Table 4-1. Repeated measures ANOVA for BMI using 26 subj ects: Within- and between-
subjects effects.
Sum Mean
Source df Square Square F;

Within
BMI 1 0047.50 47.50 4.730*
BMI x gender 1 0002.62 02.62 0.260
BMI x ethnicity 8 0024.50 03.06 0.762
Error (BMI) 24 0241.00 10.00

Between
Gender 1 0573.00 573.00 0.186
Ethnicity 2 0015.40 007.71 0.776
Error 24 7415.00 309.00
*p<0.05
ANOVA = Analysis of Variance
BMI = Body Mass Index




Table 4-2. General mixed linear model effects for BMI using 59 subjects.
Effect df F
Time 4 4.95 *
Gender 1 0.02
Race 2 0.15
*p<0.05
BMI = Body Mass Index





Table 4-3. General linear model effects for Hb Alc using 59 subj ects.
Effect df F
Time 4 2.80 *
Gender 1 0.64
Race 2 0.85
*p<0.05
Hb Alc = Glycosylated hemoglobin































60 2



50 -e



Fiue401 Chr -iw M BI)maueet vr1 ots h aacleto












Figuren 4-1 CartReilew BIs (BMI1 mleasurmeein tse ovder1 monthoserain. The 5u daacolcion
pins are 3 miton ths mapar. IData colletion points 1 trog 3s arwe e pre-programpu



is the poiretion of the mkean Inat thatha outliers. h dors skewe the mean gets pulled
















12.5






















25-




1 2 3 4 5
tirre



Figure 4-2: Chart Review: Hb Alc (Alcl) measurements over 12 months. The 5 data collection
points are 3 months apart. Data collection points 1 through 3 are pre-program
measurements, and data collection points 4 and 5 are post-program measurements.
BOX PLOT: The two major lines are the minimum and maximum values. The three
lines that make up the main box are the three quartiles. Quartiles divide the data into
4 equal parts in terms of the number of observations you have (not the magnitude) the
second quartile is also called the median (the middle most observation). The plus sign
is the position of the mean. In data that has outliers or is skewed the mean gets pulled
in the direction of the skew or the outliers. The dots are the outlying points.









CHAPTER 5
QUALITATIVE RESULTS

This chapter provides the qualitative results of the interviews and in-class observations .

In this chapter, the transcribed interview data were organized according to the interview guide

questions in order to facilitate the grouping of answers from the youths and parents. The in-class

observation field notes were organized according to the sequence of activities that occurred in

the program. Using the Nvivo 2.0 software program, the data was then coded for the grouping of

answers and observations. Later, the organized data was categorized into five main themes by

hand (as discussed in chapter six).

Post-Program Interview Findings

Three of the four youths were female, and three were African American. The male youth

(M-1) was the sole graduating member of the program that I observed for this study. The ages of

the four youths ranged from 12 to 16. Each youth had at least one sibling living at home.

The five parents were female, and four were African American. The ages of the parents

ranged from 33 to 55. The highest education level was two years of college.

I organized the interview findings using the format of the interview guide. This allowed

the findings to be organized so that they could be later analyzed for themes. The maj or data

groupings that I identified from the post-program interview questions were: 1) the program is

mandatory (for CMS Endocrine Clinic youths); 2) parents were fonder of the program than

youths; 3) youths enjoyed exercise and snack activities the most; 4) the parents enjoyed the

camaraderie of fellow parents; 5) youths were challenged with the skill-level required for


SThis chapter is presented in "first person." First person is acceptable for qualitative work because the researcher in
qualitative is the tool and needs to take responsibility directly for the work.










aerobics and uncomfortable by parental presence; 6) youths want more games; 7) parents want a

greater variety snacks and want to be as accountable to the CMS program as the youths (To

paraphrase a parent, "Take my BMI and Hb Alc too."); 8) youths and parents had positive post-

program physical changes; 9) youths and parents have made positive diet and exercise changes;

10) there are many challenges to healthy behavior change; and 11) youths and parents would

recommend the program to others (Table 5-1). The grouped data was later organized into nine

main themes.

Why Did You Attend the Program?

When asked why they attended the program, youths and parents responded that program

participation was mandatory and that the CMS endocrinologist referred them to the program

because of they were overweight and had elevated Hb Alc levels. One youth stated he was

referred to the program by his pediatrician but was scheduled to see a CMS endocrinologist. All

parents interviewed appeared to be overweight. Many of the parents stated that they too have

type II diabetes.

Parent statement:

I attended because it was mandatory for my daughter to attend. She, like myself, is very
much overweight. Struggles with overeating. Struggles with food addiction. Mainly, our
food choices .junk food, sugar. So it was mandatory. And for her, her sake, we agreed
to go because we want what' s best for her.

Overall, parents were positive about the program and appreciated the support. Parents saw

it as a resource for both the youths and their families.

Parent statement: The endocrine specialist here at CMS, referred us to the .. program as
a way to implement some better and healthier changes .. To see if it would help my
daughter lower her bad cholesterol, and get her Hb Alcs down .. And just as a resource
for our whole family, so we can transition together. And not just leave her out in no man' s
land with this blood level stuff and no way to help her diet and you know, no education
about what she could do to help herself basically.










What Was the Program Like for You?


Parents had fond recollections of the program. Parents expressed enthusiasm when they

talked about the program.

Parent statements:

I thought that was great. I thought the whole program was very upbeat. There is nothing
at all negative about it. Nothing at all boring about it. You could tell the people were well
prepared .. they did their homework.

Enjoyed everything about it!

I liked it. I hated when it was done.

So we came and we had a good time. .

.. When I talked to Ms. RD [Referring to the dietician], I said, "You all want us to do it
again? I want to do it again!" I enjoyed it and wanted to keep going. I want to go back.

Well .. for one I enjoyed myself because I love exercise [Laugh].

Youths' feedback was more difficult to elicit. The youths generally expressed disinterest

in the program. Their responses as to whether or not they enjoyed the program ranged from "no"

to "it was ok."

Parents also had difficultly eliciting feedback from youths. When asked whether their

children enjoyed the program, parents did not know what to say.

Parent statements:

A: She didn't say. I enjoyed it. [Laugh]

Q: You enjoyed it but you're not sure she did.

A: I can't say.

I don't remember her saying anything positive. But I don't remember her saying anything
negative either. Maybe she said something like she didn't need it. Because like I said,
we've always tried to be healthy. But again, it was reinforcement for me. And it was great
that my husband was there because he learned a lot.

In two instances, parents mistakenly said their children enjoyed the program.










Parent statement:

PI: How did your child like the program?

Mother: Well, she loved it.

Youth statement:

PI: Do you think the program was fun?

Daughter: It was ok.

PI: Was it something you looked forward to coming to?

Daughter: No, not really.

Q: Ok. So, it was ok, it wasn't really fun, you didn't really look forward to coming to it ..

Daughter: I had to come.

Parent statement:

Mother: I think that she did enj oy it and she loves to dance. That was a big thing for her.
Oh it was wonderful for us .. it was a lot of fun because the parents and the kids got to
participate.

Youth statement:

PI: Would you say the program was fun?

Daughter: No.

What Did You Like Most about the Program?

With the exception of one youth, exercise and snacks were the youths' favorites.


Youth statements:

I like the exercising that we did. We danced every time we came .. Just the dancing.

The individual, against-the-wall, exercises .. we put our backs against the wall and tried
to see how long we can stay on our backs. And then we had to switch and hold the cans of
peaches or pears like that. [Demonstrates]

The hula-hoops. That's it.

Parent statement:










Um, she liked making, um, pizzas.


The exception was the youth whose favorite program activity was the food pyramid

exercise. The youths were given a copy of the food pyramid and asked to identify how many

servings of each food group they should consume each day.

Youth statement:

The part I liked the most was when we were in the back room and started talking. Then
she gave us like a photo, and asked us how many servings we should have .. and I
guessed the most right.

What parents liked about the program was that it was family-based and not just youth-

specific.

Parent statements:

Well, I liked the fact that I was allowed to include my family and not just _[Referring
to daughter]. I think that is so important, especially when you're dealing with a child that
is in the CMS program for whatever reason. They are already marked because of whatever
disability or chronic illness of whatever they have. So, the ability to include the family in
this part of her j ourney is important to me.

What I really liked about it was it incorporated the whole family and it gave my husband a
chance to learn about healthy eating. He's never had a weight problem and between just
[Refers to daughter participant] and I trying to lose weight, it was always hard
because he would always have all this junk food. And what I really liked about it was that
it brought the whole family together .. that is what I liked about it. That my husband was
able to come and we were able to work on the problem as a couple. Not just me trying to
feed this guy brown rice and wheat bread. You know, I had a lot of years that he fought
me on that you know [Laugh]. That' s what I really enjoyed about it. That is was a family
affair.

Other parental favorites included: 1) the variety of snacks; 2) the live aerobic exercising; 3)

the camaraderie with other parents; the 4) peer support for their children; and 5) the end-of-

program graduation certificates.

Parent statements:

I thought it was wonderful the way they offered the children there a variety of new kinds of
snacks.

We'd have our workout clothes on and exercise and get a snack here that was nutritious.










I like the fact that they made the exercise fun and the snacks that they put out for us were .
.. there where choices and you could make it the way that you wanted to make it .. the
way you like. And it wasn't just, you know, a pre-made thing that you had to try. You
could do it this way or that way. So there was a choice. Umm, which I think is also
important with children.

We had a FSU student that would come and she taught us dances and you know, steps as
part of physical activity and that was our exercise for the day. It was a lot of fun because
the parents and the kids got to participate. And my other two children were allowed to
participate as well so it was really good for us.

It was the exercising. It wasn't way they did this one .. she brought in some, you know,
the updated music and I guess, the fitness instructor. You know, they taught us a dance
step and to go along with it.

Just to listen to other parents talk about their struggles .. they go, this is how I did it ..
so you sort of form a friendship .. you just hated it ending.

She was with her peers. And so, I guess it kind of is not like Charlie Brown's teacher,
"Wha wha wha wha ." It' s not what they hear. They actually can know that other
people are doing it too that are their age and it is ok.

And I like the fact that there was a reward [a graduation certificate] for participating
because I think that shows the children that their time is valued.

Parents appreciated convenient program schedules.

Parent statements:

The times were ok .. We're in a church and on Wednesdays .. you know with me
coming with her .. we got out .. she met friends ..

It worked out that, because D [Referring to daughter] is in middle school, she gets
out...she has a late release time. So I would pick-up my younger children from school
after two o'clock, get them a snack, get some homework done, and then pick D [Referring
to daughter] up and come to CMS. The program was on Wednesday. I attend church on
Wednesday evening. So, it got over just in time for us to leave and go to church. So, it
worked out really good for us.

What Did You Like Least About the Program?

Youths and parents did not openly share what they liked the least about the program.

Youth statements:

I can't think of anything.

Q: Is there anything about the program that you didn't like as much?










A: No.


Q: Were there any parts of the program that you didn't like?

A: No.

Parent statements:

But to think about anything I disliked, I maybe can't remember.

Nothing I didn't like.

One female youth spoke of an experience with an aerobics instructor. She shared that the

instructor was impatient and demanding.

Youth statement:

Q: Were there any parts of the program that you really didn't enj oy?

A: Well, the aerobics .. because she was like kinda getting frustrated with us. I'm a hard
learner. I'm a really hard learner and you have to like, sit down, and be a little more
patient with me. So, she couldn't get me to get it and she got frustrated with me. That
could have been better. Plus, she kept messing up on the aerobics so I couldn't follow her.

Parents shared that their children were embarrassed when performing the exercises and

were also embarrassed to be with their parents.

Parent statements:

Well I guess I was the class clown. The dancing thing .we got very .. you know when
we had to introduce ourselves. You know, she wasn't motivated at first but I guess you
know kids don't like to be embarrassed. She was like, you stay in the back or whatever.
You know, at first the exercising was kind of challenging to her and you know, being a
teenager but .. I told her, if you get out there and just show that .. even if you don't like
it .just do it. So I think, by the time we completed .. learned the dance she started to
like it. But at first, it was just like, oh my god exercise. I think being heavy and you
know, overweight, she thought, "I gotta move?"

They put us in groups and we had to do the whole dance thing with the group so she didn't
want to be in my group. She wanted to show that her group was better. But that was
probably the only thing that I perceived that she didn't like.

One parent shared her daughter' s dissatisfaction with the journal-writing activity that

requires members' to record their dietary consumption during the day.










Parent statement:


Dislike is a strong word but .[one] thing that she didn't like .. the journal writing.
Writing down what she ate. It was, you know, to somebody who is a preteen, it is
pointless. "Why would I write it down?" "Well, because this is a way for you, and the
doctors, and nurses, to see what you're putting in your body so that they can help you
maintain this." But you know, I think her thing was, on top of all the writing you have to
do you still have to do your homework. And it was a weekly thing you know. So I think
for her all that writing and remembering you know, and trying to keep up at that age you
don't want to be so anal about .. you don't really care.

One parent shared that her daughter was tired from school at the end of the day, making

attendance at the program stressful.

Parent statement:

.. You know coming straight from school and having your brain picked all day was
probably...and a lot of the kids, including D [Referring to daughter] would drag. It' s just
that time of day where they are tired and worn-out ..

What Do You Suggest For Program Improvement?

Only one youth had a suggestion to improve the program. She shared that it could be more

interesting if the program includes games.

Youth statement:

I would put more games into the program. Games that would make it more fun and where
you could do exercise at the same time. Or if games so you just wouldn't have to just sit in
a room.

The parents' suggestions ranged from "no suggestions" and "keep it the way you had it" to

1) have a greater variety of snacks, especially regarding vegetable choices; 2) make the parents

as accountable as the members in the program.

Parent statements:

I think they need to keep it the way they had it. I thought everything was great. thought it
was an excellent .. it's an awesome program. I don't know where they could make any
changes.

I would say to really go out of the norm of what people think they wouldn't like. The
carrots and the broccoli .. try something different. Because I know there's a restaurant, I
can't think of the name of the restaurant right now, but they have a salad that I go there and










they have the fresh squash and zucchini cut up and it' s not cooked but in the salad. So you
know, just integrate something like that .. I don't know what they've done lately. But
that would be really good. But other than that they had some very nutritious snacks.

But in fact, there is nothing wrong with all of us making the changes to eat the food
pyramid the way that it' s designed. And so, if there was a way to keep parents on that
same accountability level, I think that would be a big way to ensure more success for more
people.

Would You Recommend the Program to Others?

Youths and parents unanimously articulated that they would recommend the program to

other members and their parents (if they needed it).

Youth statements:

Yes. But I don't think I have any friends like me. But if I did, I would.

Q: Do you think your friends would like the program?

A:Yes.

Q: So you would recommend this program to other kids if they needed it?

A: If they needed it, yes.

Parent statements:

Oh yes, definitely. Definitely. I've even had some friends, you know that their children
are now looking at D [Referring to daughter] and saying, "What has she done?" Well, she
was recommended by the doctor .. if you're concerned about your child's health or
weight, they can .. refer you to it .because that is how we got to it by referral .. I
would definitely recommend it.

Q: Would you recommend this program?

A: Absolutely.

Q: Would you recommend this program to other parents or children?

A: Sure.

Q: Would you recommend the program to other parents and children?

A: Yes. Yes. Absolutely.










What Are Your Post-Program Behavioral Changes?

Youths shared that they were eating more fruits and vegetables, and exercising more since

participating in the program.

Youth statements:

Well, eating more salads. Eating more fruits and vegetables.

At my school, I do PE as much as possible .. And I do aerobics at home. I turn on the
music and I just dance to the music.

And I do crunches and sit-ups. I dance for 30 minutes and do jumping j acks when I turn on
the CD. We have this channel called "Fit TV." They do aerobics, exercises, it's all
day...you can do it all day if you want to. I do it until I get tired. [Laugh]

Q: Umm .. do you exercise every day?

A: I try to but .. [Unintelligible]

Q: So how long every day do you exercise?

A: Umm .. at school it's like 55 minutes?

Q: Do you have PE every day at school?

A: Yeah. It's the only time we get exercise .. softball .. baseball .. football ..
basketball .. and we have warm-up where we do lunges and things like that.

Parents talked about changes they made after the program regarding: 1) grocery shopping;

2) beverages; 3) junk food; 4) portion sizes; 5) salt, sugar, and fat intake; 6) cooking methods; 7)

fruit and vegetable consumption; 8) whole grains; 9) reading food labels; and 10) exercise.

Grocery shopping changes. I shop now with a list versus, you know, at least that way if I
have a list I don't have to go down every isle. And I try to stop first at the fruits and
vegetables so that I don't fill my buggy up with all the other stuff and then...where am I
going to put these, you know, the fruits and vegetables.

Beverage changes. For one, cokes, I don't buy cokes.

Our biggest problem was soft drinks.

We don't do soft drinks any more. We love, I know I'm advertising, Crystal Light.










We do water more than anything. If we do soft drinks...trying to get used to the diets. It' s
hard to get used to the diets because my body is a Pepsi person. But I mean, it' s just if we
do get a regular drink, that's you know not a diet, we portion what we drink. We only
drink just a serving.

[After the interview the mom had continued talking and said they were drinking a lot of
mint tea now .. ]

She opts for water over soda a lot of the time .. and fat-free milk.

The nurse stressed that if [she] would just get off the sugar sodas and just drink water and
diet soda .. that within weeks [she] would lose weight. And she did. She lost 7 lbs in 2
weeks. And that' s all she did different.

Cutting out junk food. We don't bring as much of the junk food in the house.

She's very, very disciplined about the food choices that she makes. She watches the carbs
that she puts into her body. She' s very .. if we eat out, she will choose a vegetable over
the French fries.

Practicing portion control. We watch our portions. They talked a lot about portions,
portion sizes. It just really helped me in my portion control .. and like food wasn't really
bad if you could just watch your portion control. You can have some candy. But you
know, try the small, bite-sized candy bars and not the biggies. Or not a bag of butter
fingers. Get small. You don't have to deprive yourself. You still can have what you want
as long as you check portion control. So the portion control issue helped me because I'm
you know ..

And I say, you can't have that today. But I tell them, when they're hungry when they get
home .. you can have A sandwich, not a Dagwood piled up with meat. You can have A
sandwich. [Unintelligible] I tell them just because your not full doesn't mean there is
nothing in there.

But I don't want to deny them. I give the candy, the cookies, all the temptations and stuff,
um; they do it so they are in little containers. And he knows that, one container a day. If
you eat it during school, don't ask for it after school.

For me it was to learn how to portion food. You can eat what you want but it just comes in
portions.

Now, we're eating better, but it' s portions of what they're eating .. I'm not going to say it
wasn't hard. But once you get into that habit .. and we've kept it. And I think it' s been
more than a year.

Decreasing salt and sugar intake. You know .. I put a lot of salt in my food and I don't
do that now for one. I say well, what I am doing to her I am doing to myself. And so I
say, I didn't say a thing, but put less sugar in tea, kool-aid, and other stuff like that so .. I
say we do this together.










Decreasing fat intake. We have transitioned as a family to .. fat-free milk.

I switched from whole milk to 2% milk.

And I tell her .. I bought the light mayonnaise, you know. I hadn't done that a lot, you
know, earlier. But I tell her she can have some of the mayonnaise, but just use a little bit.
I told her, and tell her often, just use a little bit. Don't use a lot. If you want mayonnaise,
just use a little bit.

I get chips now and then. But there again I go for the baked chips and I go low fat
everything as much as I can.

Improving cooking methods. If you season them right you could never tell they were
vegetables, you would think it was a meat. Because I've got my children on ."Oh, what
kind of meat is this? Oh, it's chicken."

Increasing fruit and vegetable consumption. And to say that canned foods are the very
last thing that you use...We've totally changed things a lot now. We're totally eating fresh
vegetables. Totally straight from a garden .. tomatoes, the cucumbers, the zucchini, the
butter squash, just everything, I mean even the spinach.

But you know I stopped buying all the snacks, although, I buy fruits and vegetables. I still
give them the chips and cookies and stuff but I do more fruits and vegetable and stuff than
I was, and they eat them. Apples, oranges, bananas .. And they eat them. They love
grapes.

Changing to whole grains. We have transitioned as a family to whole grain and whole
wheat as opposed to white breads and pastas.

Reading food labels. And I think the one thing that she came away from it with was
learning how to read the labels.

Increasing exercise. And I have bicycle at home and sometime, uh, I say, you and I can
do this together. What else do we do? We walk together sometime...we don't do it all the
time. Sometime we do it together.

She's been doing more exercising. We walk on Fridays. She's made her own exercise
gym. [Unintelligible] She's found a fitness program on television that she keeps up with.
She' s went down, I want to say, I think it' s 2 sizes in her clothes.

She is very self disciplined how she does things. Every evening she does a certain amount
of crunches on the AB machine at home that she uses. She's on the dance team at school
so that provides 3 days a week a level of physical activity for her in the afternoons.

Even if you are folding-up clothes or walking up stairs, you're losing the calories and
everything.

Youth statement:










A: I really used to never exercise but now every night I do some type of physical activity.

Q: .. What types of exercise do you do?

A: Dance.

Q: And you do dancing how many times a week?

A: Two times a week and then the rest of the nights I jog a mile with my dad.

Well, I love to walk .. Once I started coming here, we started to walk.

A family affair. Parents also discussed how the program has prompted them to include

the entire family in dietetic and exercise behavioral changes.

Parent statement:

I think it' s important that parents support their children in any way possible and just .. the
whole family. We needed a whole family change .. To get her to see it and then the
whole family got involved. Even though her brothers didn't need to lose weight they do it
along with her. .And also, I like the fact that my children hold each other accountable. I
don't have to do that because what they learned they took with them. They can point out
to each other what they are eating and how many carbs that is and that kind of thing. They
take the knowledge they have and apply it to their relationship.

What Are Your Post-Program Physical Changes?

Youths and parents stated that weight for the youths had: 1) decreased; 2) maintained from

pre-program levels; or 3) most noticeably resulted in smaller dress sizes.

Parent statements:

She's lost more weight than anyone from the class.

So, and gradually we're just seeing it. And I was telling her that she will lose the inches
before you start seeing everything .. so she gotten some clothes packed because I said she
can't get back in these. She's even gotten into some of my clothes.

Youth statements:

I've maintained my weight.

I lost weight .. About 12 pounds? It fluctuates though.

A youth shared that her Hb Alc has decreased since the program.










Youth statement:

I'm borderline [Referring to diabetes]. They said it [Referring to Hb Alc] was lower but
still borderline.

A parent mentioned that she has lost 4 dress sizes since participating in the program with

her daughter a year ago.

Parent statement.

I had, you know, when we started this program I was a size 20 .. now I'm a size 12.

What Are the Challenges to Behavioral Changes?

Parents talked about the challenges the youths face in order to initiate and sustain dietetic

and nutritional behavioral changes. Challenges included: 1) apathy for exercising; 2) dislike of

certain healthier foods; 3) aversion to following the food pyramid for daily food allowances; 4)

practicing different habits when they are away from home; and 5) asserting their identity.

Parent statements:

But every now and then, my daughter, we call her. It's time to walk. She gets mad but
she'll go do it.

She gripes a lot about us not having a lot of good stuff in the house. But ah, she' s eating
better. So that's kind of incorporating what we learned.

He likes, ranch. I tried that low fat stuff, that fat-free ranch. And that' s my other problem.
I taste it, it' s not good me, I just can't make any of my kids eat it. I know that if it is bad
for me it 's going to be bad to them.

And I don't want to make any of them you know .. you don't want that salad, well, sit
there and choke it down any kind of way. I don't want them to tell me they're hungry.

And we're not bringing so much junk food into the house so of course she has to eat better.
She doesn't like it though.

I know the one thing, I'm still trying him (to get him) to eat salads. Over the summer, my
uncle would say he would eat salads. Now, it' s like when I say come to dinner for salad,
he's like, "What?" So I stopped forcing him. He gags .. he doesn't chew. So I have to
actually tell him, slow down.

I asked her to do that food chart several times but she wouldn't do it.










.. And I can't control what she does outside.

Q: Why didn't she want to attend the program?

A: It wasn't that she didn't want to. At the time she was very rebellious and acting out.
She was staying away from home and she was going to do what she wanted to do.

Two youths talked about the lack of Physical Education (P.E.) available to them at school.

Youth statements:

Q: You were in 6th grade when you were in the program and they didn't have P.E.? A:
They didn't have PE class.

I would take P.E. but they didn't give it to me. They made some changes .. When I
registered for classes I got confused.

According to one parent, her child was on medication to treat a medical condition. The

medication was causing her son to gain weight irrespective of his behaviors.

Parent statement:

What happened was, I was looking at pictures of him. When he was younger he wasn't
that big. But when he got diagnosed with epilepsy, he got on the medicine, he just blew
up.

Another challenge is that parents are in the same position as their children; overweight

with type II diabetes. Thus, the parents are not following the types of behavioral changes they

are advocating for their children.

Parent statements:

Q: Have you changed any ways in exercising?

A: I make him do it.

.. I'm a diabetic myself and I'm supposed to be going to diabetic classes .. I learned
about things I should have done by now. Like foods. [Laughs]

I had that bicycle for over 3 years. And that bicycle sat there for over a year before I even
got on it. [Laugh]

Q [ To parent]: Ok. So you have increased your exercise.










A: I have, but then um .. stopped. To be honest I stopped. And I haven't did it for a little
over a week.

.. My husband had recently been diagnosed with Type II Diabetes as well.

She, like myself, is very much overweight. Struggles with overeating. Struggles with food
addiction. Mainly, our food choices .junk food, sugar.

The following quote by a parent elucidates the need for both parents and members to

practice healthy dietetic and exercise behaviors.

Parent statement:

I think one of the things that I would like to see is .. for the parent as you do for the child.
And then, you know, take my Alc at the start of the class and hold me accountable as a
parent on the same level that you are holding my child accountable. Because, that way I
believe you would get more of a response and maybe more success. Because I think a lot
of times, and this is a cultural-type thing or an environmental thing but, you have people
that show up and do the class and they know their child is at risk for or already has
diabetes. One of the other issues is they are here because their child has to be here and
needs to be eating this way.

Parents had priorities that superceded the goals of the CMS program. Parents shared a

variety of concerns other than that of their children' weight and type II diabetes.

Parent statement:

I am a survivor of sexual molestation in my childhood that has affected every area of my
life. I love the Lord Jesus Christ with all my heart. If it were not for him I would be in the
bars, Chattahoochee, and I thank God for my salvation and what he saved me from.

A different parent, after the interview recorder was turned off, cried while she shared that

she was so tired from raising 4 children and working full-time.

A 12-year-old talked about the importance of individual responsibility to change.

Youth statement:

Push yourself. You're not going to do it all at one time. If you want to go a distance you
can't just sit there and expect yourself to change. If this happened to me it can happen to
you.










In-Class Observation Findings

For the purpose of organizing the in-class observation analyses, I have provided attendance

information for each of the four classes (Table 5-2). Additionally, I categorized the program's

class activities into three major segments. The first segment was an exercise activity, the second

segment was a snack, and the third segment was an educational segment. This allowed the data

to be organized and grouped. Later, the data was categorized into nine main themes.

The grouped data revealed that: 1) the attendance rate declined with each consecutive

class; 2) the aerobic exercise venue was confined; 3) youths were challenged with the skill-level

required for aerobics and uncomfortable by parental presence; 4) the snack portions appeared to

be too small (two out of four times); 5) parents interacted a lot among themselves; 6) the

activities were frequently not engaging youths; 7) youths were not utilizing take-home

equipment; and 8) the CMS instructors utilized comprehensive learning strategies, however, they

may not have been age-appropriate (Table 5-1).

Session Attendance

The four-day program included 13 youths and parents (Table 5-2). Attendance declined

with each consecutive class. Six participants were youths and seven were parents. The six

youths ranged in age from 12 to 16. Two youths were male (Ml and M2) and four were female

(Fl1-F4).

Session one. The attendance rate for session one was 93.3% percent. Five youths and

seven parents attended. The parents of F-4 attended without her.

Session two. The attendance rate for session two dropped to 69.2%. F-4 attended this

session for the only time, but four other participants did not attend. M-2 and F-2 and the mother

of each were absent from session two.










Session three. The attendance rate for sessions three and four decreased to 46.2%. Only

six youths and parents attended sessions three and four.

Session four. Thirty-one percent of youths and parents attended all four sessions or the

"complete" program. M-1, his mother, and F-4's parents attended all four sessions. F-1 attended

three of the four sessions. The remaining youths missed two or more sessions.

Exercise Activity

Just prior to each exercise session, youths and parents met in a first floor, CMS conference

room. They signed in and seated themselves at one of two, long tables. On the first session day,

CMS staff first led individual youths to a clinic room and recorded each youth's weight, height,

and glycosylated hemoglobin measurements. This established biological measures for the day-

of-the-program. Youths then rej oined parents in the conference room and waited for the exercise

activity to begin.

Sessions one and two. The exercise segments in the first two sessions consisted of

aerobic exercise to videos. The exercise segments in the first two sessions took place in the

CMS lobby. The RN instructed youths and parents to find a place between chairs and to follow

the televised aerobic instruction. The following is a narrative of the exercise segment in session

two.

The exercise video "African Grace" begins. The video instructor is middle-aged and she
wears colorful, African attire. Her head is wrapped in cloth to match her attire. The music
is rhythmic. There are multiple drums beating in the background.

During in-class observation, I observed at that at times, the youths appeared self-conscious

during the video sessions. This was evident when youths refused to participate or barely

participated, laughed and looked around, or rolled their eyes.

Except for F4, the participants follow in participation. F4 smiles, rolls her eyes, and
watches the other participants. The other participants are laughing and frequently misstep
while they move. They occasionally bump into each other or the chairs.










RN1 approaches F-4, stands beside her, and prompts her. "Come on. Do what I'm
doing. RN1 moves her own feet side to side. F4 smiles and remains stationary. Both of
her parents move to the video, albeit, in a hesitant and unrhythmic manner.

One parent is overweight and mobility-impaired. While seated in a chair, the parent
follows the video instructor by swaying her upper body, bending her arms, and stomping
her feet. The parent smiles and encourages her daughter to follow aboug~. but the daughter
just shakes her head, "No".

I observed that the aerobic exercise venue was not conducive to youths and parents fully

and accurately engaging in the exercise. Staff instructed youths and parents to find a place

between chairs and to follow the televised aerobic instruction. Some of the youths and parents

could not find enough room between the chairs and kept bumping into each other.

Closer to the television, another member and her mother move to the video slowly, and
keep missteping. They laugh together. The member and her mother occasionally bump
into each other and the chairs.

The exercise videos exceeded the ability of youths and parents. They frequently

misstepped. Additionally, youths may have been uncomfortable by the presence of their parents

and CMS patients who came in and out of the lobby but were not involved in the program.

The video instruction is demanding. Some of the moves require hip thrusts that the make
the participants laugh. About 2 minutes into the video, the male member becomes
immobile. He laughs and looks around.

During the session, a dietician informed me that the program continues to review exercise

videos for the purpose of finding the best one. She states that she'd like to find an exercise video

that:

Is good for those participants that are greater than 300 pounds, has non-weight-bearing
exercises, and is arthritis-friendly.

Some youths and parents did not wear the appropriate attire for exercise. One youth's

pants fell down when he moved. Youths and parents exercised in their socks, in Birkenstocks,

and in loafers.










One mother exercises in loafers. Another mother and her daughter exercise in
Birckenstocks, and a third mother exercises in her socks. Every participant wears street
clothes.

Whenever a certain member makes a minor move in response to the video, his low-riding
pants fall down, causing him to stop moving. The RN walks over to the male member and
verbally prompts him to move. He moves very little. Whenever he does move, his pants
fall down and he has to pull them back up.

After 15 minutes, the RN stops the video leads the participants through two minutes of
deep breathing and side stretching. She then states, Get some water and we'll meet back
in the conference room." The participants take turns at the water fountain that is located
there in the lobby.

Once everyone is seated in the conference room, the RN asks, "What video do you like
better...the one we did last week or the one we just did?" The mother of Ml states, "The
walking one." [Referring to the video in session one.] The parents of F4 nod their heads in
agreement. The RN states, "This video is a little complex."

The exercise segments in sessions three and four did not exhibit the same problems

observed during the exercise segments in sessions one and two. The exercise in each segment

occurred in an appropriate venue (spacious exercise areas), did not require advanced ability, and

did not require special attire or equipment.

Session three. The exercise segment in session three involved a hula-hoop activity for

youths and parents. The exercise occurred in a spacious, staff lounge, away from in-coming

CMS patients. The parents and youths both appeared to enj oy themselves during this activity.

Session four. On the last day of the program, the exercise segment involved walking

outdoors, around the spacious, CMS parking lot located in picturesque surroundings punctuated

by large, maj estic oak trees and rolling grass fields. The RN walked at a steady pace with the

two youths in attendance, while the parents walked slowly, several yards behind.










Snack Activity

The snack segment followed the completion of each exercise activity. CMS staff directed

youths and parents to the water fountain in the lobby, and many did drink from the fountain. All

of youths ate their snacks in the staff lounge.

During sessions one and two, dietetic instruction occurred while youths ate their snacks.

The parents were also provided snacks during their dietetic instruction while in the conference

room. Snack portions appeared to be small (two of the four sessions) under the circumstances.

Session one. The snack provided to youths and parents after the exercise session was a

cup of fruit that included 15 grapes, a half of an apple, and a half of a banana. Cups of water

were also provided to the them.

Youths are separated from the parents and go with the dieticians to the staff lounge. Cup
of fruit are distributed to the participants. A dietician brings cups of fruit to the parents
who are in the conference room.

While seated in armchairs and sofas that are placed in a circle, the participants eat from
their fruit cups. The dietician introduces herself and states, "What we are going to do will
be fun .. learning about nutrition .. snacks .and weight." In less than 5 minutes, all
the fruit in the cups is consumed except for one members' half of a banana.

Session two. At session two, youths and parents were provided with a bowls of popcorn.

Cups of water were also provided to the participants.

The dietician instructs the youths to follow her to the staff lounge for snacks. On one of
the tables in the lounge are small plates of popcorn and cups of ice water. The youths each
take their serving, and proceed to sit down in a corner of the lounge where there is a
carpeted area with sofas and armchairs. The dietician sits with the youths and asks them
about daily exercise. The bowls of popcorn are consumed very quickly.

During sessions three and four, snacks were either unavailable or not offered to parents.

Most parents sat and watched the youths eat snacks. The one Caucasian mother was assertive at

snack time. The mother asked if she could have a snack and if she could have a second portion.

The other parents would not ask for snacks.









Session three. Vegetables plates at session three appeared to precipitate the most

disappointment among youths. They ate mostly the carrots and the dip. They pushed the

vegetables around in their plates, and the dieticians stood over them and prompted them by

saying, "Try it." When the plates were put away, a hungry youth went over to the dip bowl and

began dipping her carrots into the bowl. She was not offered more to eat and was instructed to

join the dietician for nutrition instruction.

The children are nibbling at their vegetables. [The plates remain full of broccoli and
cauliflower]. One nibbles at her carrots. As the children sit at the table, the dieticians
encourage the children to at least try the vegetables. The parents are seated down the table
from the members and are not offered a snack.

Session four. Snack portions were small. Youths each received a half of an English

muffin, spaghetti sauce, and miscellaneous toppings. One parent also made a pizza. The

beverage was a cup of ice water.

The RN invites the children to sit down at one end of a long table. Each child is provided
with one half of an English muffin and a cup of ice water. Multiple small bowls set out in
front of them. Each bowl contains a different ingredient to build a pizza. The ingredients
include Ragu spaghetti sauce, 2 percent mozzarella cheese, mushrooms, green peppers,
onions, and pineapple.

The snack segment in session four was an opportunity for youths to engage in an

associative activity independent of CMS staff. However, RN and dieticians managed the

activity by directing youths' activities and hovered over the two youths during pizza-making.

The RN and dieticians stand over the children and the food. The parents of the participants
eye the food and sit at the other end of the long table. After the children make their pizzas,
the dieticians place the pizzas in a broiler oven (temperature 425 degrees F) for 10 minutes
while the children sit at the table and wait.

One parent walks over to the pizza-making area and asks the dieticians if she can make a
pizza. The other parents stay seated and quiet. [This activity seems slow to the PI.] As
the youth eat their pizzas the dieticians talk among themselves.

After the youths ate their pizza, they appeared disappointed and hungry. The Caucasian

father of the adopted daughter observed this and told one of the youth to make himself another










pizza. The young boy looked to the RN and dieticians, but they did not confirm the father' s

suggestion. The boy sat sullen.

One participant finishes his pizza first, in about 3 bites. He eyes the food. The parent of
another youth notices the boy eyeing the food. The parent states to the youth, "Have
another one there." The boy looks to the instructors and the instructors don't say anything.
The dieticians pack-up the pizza-making ingredients. Both children are quiet.

Educational Activity

Sessions one through four. At the completion of snack-time, youths and parents

separated into different rooms for three of the four education segments. The educational

curriculum included a variety of subj ects (Appendix A).

Youths met with program instructors in the staff lounge where there were comfortable,

upholstered seats. The parents met with program instructors in the CMS conference room

equivalently as comfortable as the staff lounge. Youths and parents met jointly with CMS staff

during the educational segment for session three.

I observed that during the youths' educational sessions, the youths conversationally-

engaged with the program instructors but not with each other. There did not seem to be a time

when the youths visited with each other.

Session Two

RD3 pulls out a colorful copy of a food pyramid. She points to the pyramid's
grain/rice/pasta/popcorn section. She then points to the veggies/fruits, dairy/meats, and
fat/sweets sections. She quizzes the youths re: how many servings, from each section, they
need to eat every day. Fl and F4 answer most of the questions. RD3 laughs and tells the
group how well they are doing.

Next, RD3 asks, "How much is a serving of fruit." She continues asking them about
portion sizes for all the 4 food groups. Fl primarily answers all of the questions.

There were a few instances when youths appeared to be disengaged from the educational

session. In one instance, a dietician had to direct a male youth to put down a newspaper he was

reading during the educational segment.










Session One

Ml is quiet and is looking at his feet. [May be a bit bored.] M2 is slouching in chair but
continues to interact. The dietician informs the group, When you eat fried chicken, you
can peel off the skin .. "Try not to eat fried foods too much .. it you're having it a lot,
try to have it just one time a week." She continues, "Baked or broiled is better" and "Fat
stays a fat."

Session Two

During the discussion, Ml picks up a newspaper from a table and begin to leaf through it.
RD3 asks him politely to "Please put that away."

The food journal was not a methodology that was favored by the youths. CMS staff

provided each youth with a journal, instructed the youth to record his or her food intake during

the week, and told each of them to bring the j journal back to the program the following week.

Compliance was low. Over the course of the program, approximately three youths returned their

respective food j ournals to the dieticians for review.

Session Two

The dietician reminds the class to remember to bring their food diaries next week. Also,
she wants them to bring in one food label. She asks, "Who did your food diary last week?"
Ml and F2 raise their hands. The dietician exclaims, "Good job."

The dietician leads the participants back to the conference room where the parents are
meeting .. RD3 informs me after the class that she has tried everything to get the youth to
bring in their food diaries and that "Nothing works."

I observed that parents were engaged in their educational sessions. They engaged in

associative activities by sharing ideas and tips with each other about cooking and grocery

shopping. Parents seemed to bond over recipes and their common interest in properly parenting

an overweight child. At the end of session three, parents actually stayed late, interacting among

themselves and the dieticians regarding where to buy canned fruits, turnips, and collard greens.

Session Three

[The 3 RDs continue to share advice with a group of congregated parents]

"Try one new thing a week or another way to eat it."










"Plan out your meals what you are doing."


"Lean meats are less expensive than fatty ones .. cook lean meats for a longer time to get
them tender. For example, in the oven, slow cook the roast with carrots and celery .. keep
adding water .. worstershire .. round steak will get really tender." "Roasts and
meatloafs are better left over."

"Instant oatmeal has more sodium than regular oatmeal."

"Take off the chicken' s skin before you eat it .. what you can do is season under the skin,
leave the skin on while you cook it, and then take the skin off before you eat it."

"I like using my crock-pot or pressure cooker."

"Make a list, be prepared, and be on a budget."

1732: [The advice continues.]

"Fresh fruit is more expensive .. so buy it in season. Get canned or frozen if fruit out of
season."

[Parents interact with among selves and with dieticians re: where to buy canned fruit and
greens.]

For session three, youths and parents were together for the educational session. The topics

were reading food labels and grocery shopping tips. Both youths and parents appeared to really

enj oy themselves at that particular session.

Session Three

The dietician informs the group that "We're going on a grocery store tour today."

With assistance of other dieticians, various types of empty bread bags, cereal boxes, and
snack containers are distributed to the youth and parents. A dietician states that nutrition
facts are on most food products, however, "Miniature pieces of food don't have it."

A dietician tells the group to Stay less than 300mg/day of cholesterol a day." She stresses
the importance of a diet low in saturated fat. "Some fruits and nuts such as avocados and
nuts have mono-unsaturated fat .. but be careful because they are high in calories." RD2
states that cholesterol is "Only in animal sources and products .. not in natural
vegetables." "Cholesterol is made in the liver .. so it can only come from a source that
has a liver." The participants laugh.

A dietician instructs the group to shop "on the parameter" in grocery stores. "The foods on
the parameter have less fat, sugar, and calories." These foods include dairy, produce, deli,










and bakery." "Aromas attract you point to point. The bakery operates to draw people in ..
.the longer that you are in there, the more money you spend."

"The cereals are in the middle and are placed at children' s eye level." "Half of the cost of
most food is the packaging." "Produce is scattered to be inconvenient to get people to buy
more. It' s conveniently inconvenient. "Also, you'll never find the things together like
mayonnaise and mustard. This keeps you in the store longer."

[I think that the content is more engaging for the participants and parents than the previous
two sessions. The group is laughing a lot.]

I observed that youths were not utilizing the take-home tools that they were provided with

in class. During session one, each family was provided with a set of measuring cups that they

are supposed to use to manage food portions. By session four, the youths were still not using the

cups.

Session Four

The youth are asked whether they are using their measuring cups. [A set of measuring cups
were provided to each family in session 1 of the program.] Both members respond that
they haven't used the cups yet. RD2 encourages them to use the cups and states, "Get
them out and do something with them. Start using them twice a day and then next week
use them 3 times a day."

Additionally, the youths were given the hula-hoop that s/he used during the exercise

activity in session three. When asked the following week whether the hula-hoop is being used, a

youth replied that it was still in the car.

Session Three

The instructor asks the group if they have been using their hoola-hoops. [Hula hoops were
given to participants in session 3 of the program.] M1 states, "It' s too hard. My hoop is
still in the car." Fl states that she missed last week' s session and didn't get a hula-hoop.
The instructor tells her that she will get one when she attends the missed session next time
around.

By the end of the program, the youth and parents appeared to have learned a lot about

nutrition and physical activity. The concept of behavioral capability is defined as having the










knowledge and ability to perform a behavior or sequence of behaviors. When two youths were

asked about what they learned in the program, the youth had ample replies.

Session Four

The instructor asks the two members what they have learned by participating in the
program. Fl states, "As you get older it is not easier to lose the extra weight." Ml states,
"Trying different foods is good and exercise is better." The instructor asks what new food
they each want to try. Ml replies, "Peppers" and FI replies, "Strawberries."

The instructor asks what else they have learned from the program. Fl states, "That there is
no good food and no bad food. Every food does something different for the body." Ml
states, That exercise isn't bad .. that it can be fun. And that you can have 3 cups of fruit
a day and umm .. that' s it."

RD tells them that you need to have milk for calcium and that it plays a role to lower blood
pressure. The instructor asks Ml what fruit and vegetables do for the body. He states,
"They make you healthier." RD2 asks Fl what carbohydrates do for the body. She
responds, "They give you energy for your body." RD2 states that the purpose of protein is
to heal the body. The instructor states, "Hair and skin are made out of protein. Remember,
whole grains are better because they contain more vitamins and minerals."

The instructor asks the children what they are going to change in their health habits. Fl
replies, "I'll eat more vegetables and fruit instead of candy." Ml responds, "I'll eat less
sugar and more vegetables and fruit."

Session four ended with M-1 and F4's parents receiving graduation certificates (F4 only

attended one session). The dietician informed M-1 that he will return to the clinic in three

months and six months for follow-up. CMS staff provided youths with extra, blank copies of the

food journal. Class was dismissed.

Theoretical Learning Concepts Used in the Program

I observed that the CMS instructors provided comprehensive learning strategies in the

behavioral intervention program in order to effectuate behavioral change among the youths and

the parents. The CMS instructors utilized the following learning concepts (as defined below): 1)

reciprocal determinism; 2) behavioral capability; 3) expectations and self-efficacy; 5)

observational learning; and 6) reinforcement of leaming concepts utilized in the program. They










provided youths and parents with pertinent dietetic and exercise information, taught social and

self-management skills, and ensured parental support in order to elicit positive behavior

modification.

According to Bandura (1989; 1991), youths may learn more from observational learning

than verbal instruction as an influence on the internalization of standards (Bandura, 1989; 1991).

The CMS program incorporated learning strategies that went beyond lectures to include

opportunities to observe and model healthy behaviors, attitudes, and emotional reactions

provided by program instructors, parents, and participant peers. The instructors used token

reinforcement by providing hula-hoops to youths for attendance and graduation certificates.

Additionally, youths and parents were provided with experiential opportunities in the program

such as exercise sessions and food label activities.

Reciprocal Determinism

I observed that CMS program focused on how to effect change in the home in order to

change nutritional and exercise behaviors, and vice versa. For example, the parents were

instructed to purchase healthy groceries, cook in healthy ways such as lowering sodium and fat,

monitor their own and their children's portion sizes and food choices, exercise as a family and

singly, and to decrease sedentary activities such a television viewing.

In-class observations:

The dietician is talking (to the parents) about watching sodium and fat content in food. She
suggests a particular brand of light wheat bread for the parents to purchase (for the home).

The dietician states (to the parents) that to make fruit interesting for the children, the fruit
can be coated in a sugar-free glaze sweetened with Splenda. She states that most fruits can
be coated in a sugar-free glaze.

The dietician instructs the parents to shop "on the parameter" in grocery stores. "The foods
on the parameter have less fat, sugar, and calories." These foods include dairy, produce,
deli, and bakery." "Aromas attract you point to point. The bakery operates to draw people
in...the longer that you are in there, the more money you spend."










The dietician discusses how grocery stores have what' s referred to as "turbulence."
"Turbulence is things like noise, distraction, and tables of things to get you stay in the store
longer." Shop with a list, don't shop if you're hungry, and get a basket...not a cart."
You'll also notice that stores will have the pharmacy at the back, no clock, and pleasant
music." "Did you know that grocery stores actually lose a lot of money on produce and
bakery goods?" "I saw health bars in 3 different places in a store .. they are not
necessarily a snack but like a candy bar."

"Try one new thing a week or find another way to eat it."

"Plan out your meals .. what you are doing."

"Lean meats are less expensive than fatty ones...cook lean meats for a longer time to get
them tender. For example, in the oven, slow cook the roast with carrots and celery. Keep
adding water and worstershire .. round steak will get really tender." "Roasts and
meatloafs are better left over."

"Instant oatmeal has more sodium than regular oatmeal."

"Take off the chicken' s skin before you eat it .. what you can do is season under the skin,
leave the skin on while you cook it, and then take the skin off before you eat it."

"Make a list, be prepared, and be on a budget."

"Fresh fruit is more expensive...so buy it in season. Get canned or frozen if fruit out of
season."

Behavioral Capability

I also observed that the CMS program provided ample knowledge and skills necessary for

youths to meet the recommended nutrition and exercise standards set out by maj or health

organizations. In particular, the training was 1) resource-related, providing information from

maj or health organizations; and 4) product-related, providing samples of Splenda and health

journals; and practice related providing "hands-on" exercises, snacks, food pyramid practice,

food label reading, and food diary activities.

In-class observations:

The dietician states, "You need about 20 grams of fiber a day. The average American gets
between 10-13 grams of fiber per day." She tells the group that it is preferable to get fiber
from foods such as fruits and vegetables .. "Natural sugars are better too ."










The dietician addresses the topic of food labels. "Look to see if one of the first ingredients
is sugar." "Milk, eggs, peanuts, wheat, oats, fish, and rye will be marked in bold on the
label because of food allergies." "The new labels will tell you information about a single
serving or the whole serving."

The dietician states, "Read the label, whole wheat is not always whole wheat."
"Pumpernickle bread has molasses in it to make it dark in appearance."

The dietician collects the tests (pre-program tests not evaluated in this study) and proceeds
to give each child a colorful copy of the Food Pyramid. She states, We want bright
colors .. if it looks good then we'll want to eat it." She asks the Fl, How many
vegetables should you eat per day?" Fl replies, "5." The dietician retorts, "Good. How
many servings of fruits should you eat per day?" Fl replies, "4." The dietician states, "We
can have up to 9 servings of fruit and vegetables per day. We want everyone to have at
least 5 a day so a fruit or vegetable can be eaten for each meal and snack."

Expectations and Self-Efficacy

During the process of class observations I noticed that CMS instructors motivated the

youths by encouraging them during the exercise and lecture activities. However, expectations

can go beyond feedback and include the anticipated time to goal attainment which was not

apparent in the program. The program did collect the height, weight, and Hb Alc measures of

the youths; however, I did not observe that youths were specifically told what they could expect

by participating the program.

In-class observations:

Upon arrival (on the first day of program), the RN leads individual participants to clinic
room where the dietician measures and records their weight, height, and glycosylated
hemoglobin measurements.

87: M2 smiles and looks around. Appears embarrassed. When M2 begins to move with the
video, his low-riding pants fall lower. He stops moving. The RN walks over him and
begins to encourage him to move. He moves very little. Another RN approaches M2 and
both RNs encourage M2 from either side of him.

The dietician asks, "Who did your food diary last week?" Ml and F2 raise their hands. She
exclaims, "Good job."

If youths feel they are capable of achieving the goal (self-efficacy), they are likely to work

hard and not give up. Second, if youths are provided feedback, they are more able to develop










feasible and realistic goals. Feedback, in turn, improves self-efficacy. Third, short-term goals

are more effective than long-term goals (Stone, 1998). The instructors did provide short-term

goals for the youths and parents.

In-class observations:

The dietician reviews the food pyramid and discusses exercise. She states,

Increase your exercise 1 to 5 minutes each week. Do something in addition to what
you're doing now." The dietician provides the parents with examples of "incremental
steps" such as walking around a circular driveway. She also encourage to park further
away from the building that they need to be.

322: "Try one new thing a week or another way to eat it."

Both children respond that they haven't used their measuring cups yet. The dietician
encourages them to use the cups and states, "Get them out and do something with them.
Start using them twice a day and then next week use them 3 times a day."

Observational Learning

Among youths, observational learning often outweighs verbal instruction as an influence

on the internalization of standards (Bandura, 1989; 1991). The CMS program incorporated

learning strategies that went beyond lectures that included opportunities to observe and model

healthy behaviors of the program instructors, parents, and participant peers.

In-class observations:

The RN, who is exercising while she walks about the room, encourages them (youths and
parents) to follow the video.

In one instance, a parent modeled unhealthy behavior to her son. When it was time to walk

for the exercise activity, the parent did not want to go. However, the parent did eventually walk

a little bit.

In-class observation:

M1's mother states, "I can't walk today." She coughs and points to Ml and states, "You'll
walk."









Reinforcement

Reinforcement is a response to an individual's behavior that increases or decreases the

chances of the individual repeating that behavior. The CMS instructors used token

reinforcement. They provided hula-hoops and graduation certificates to participants.

In-class observation:

Ml and F4's parents are awarded graduation certificates by the RDs. (M1's mother did
not get one although she attended all 4 sessions with Mi). RD1 informs the participants
that they will return to the clinic in 3 months and 6 months for follow-up.

Summary

The 11 interviews among youths and parents, and the in-class program observations,

enabled me to go beyond the pre- and post-program correlations of BMI and Hb Alc and to

focus on the experience of the program for the youths and parents.

Of the five youths that started the program, just one completed it. In one instance, parents

attended all four sessions of the program when their daughter attended one session. I learned

from the in-class observations that youths were not utilizing their take-home equipment, and that

the CMS instructors were using comprehensive learning strategies.

In organizing the data, I identified that data from the post-program interviews reoccurred

during my in-class observations. Reoccurring data included: 1) youths were challenged with the

skill-level required for aerobics and uncomfortable by parental presence; 2) snack portions

appeared to be conservative; 3) parents interacted more among themselves than youths interacted

among themselves; and 4) activities were frequently not engaging youths.

Analysis of the grouped interview and in-class observation data revealed five main themes.

First, youths and parents all reported positive post-program nutrition and exercise behavior

changes. Second, the parents reported that the youths were reluctant to change post-program

health behaviors. The last three themes revealed areas that the CMS program could use to









improve curriculum methodology: 1) the presence of impediments to engaging youths; 2) the

existence of program service deficiencies; and 3) additional parent concerns that went beyond

the priorities of the program. These themes are discussed in the following chapter.










Table 5-1. In-class observations: Program attendance.


Week 1



Ml
M2
Fl
F2
F3




M1's MO
M2's MO
Fl's MO
F2's MO
F3's MO
F4's MO & FA


Week 2



Ml


Week 3



Ml


Week 4



Ml

Fl


Youth


F3
F4


M1's MO


Others


M1's MO & BR


M1's MO & FA


Fl's MO & FR

Fl's MO
F4's MO & FA


M1's MO


F3's MO
F4's MO & FA


F4's MO & FA


M = Male; F = Female; MO


Mother; FA = Father; FR = Friend; BR


Brother









CHAPTER 6
DISCUSSION

The concept of mixed-method research is not new to primary care (Creswell, Fetters, and

Ivankova, 2004). Almost 15 years ago, Blake (1989) and Stange and Zyzanski (1989), integrated

quantitative and qualitative research in their studies. Quantitative and qualitative methods can be

mixed, such as in collecting qualitative data before quantitative data where variables are

unknown, or as in the case of this study, using qualitative methods to expand quantitative results

in order to advance study aims (Creswell et al., 2004). For example, in this study, quantitative

methods were utilized to analyze changes in youths' post-program biological measures.

Qualitative methods expanded upon this by elucidating the rationale behind the youths'

behaviors that influence the quantitative changes in biological measures.

Overall, programs have demonstrated modest success in maintaining or decreasing weight

and body mass index (BMI) (Dreimane et al., 2006; Eliakim et al., 2002; Monzavi et al., 2006;

Savoye et al., 2004; Speith et al., 2000; Taylor, Mazzone, Wrotniak, 2005) and in success at

improving other biological measures associated with overweight-related illnesses (Monzavi et

al., 2006; Taylor, Mazzone, & Wrotniak, 2005).

For example, in Eliakim, et al. (2002), the study used for this study's sample size

calculation, youths demonstrated a significant decrease (P<0.05) in BMI at 3-months post-

program a decrease from 26.110.3 kg/m2 to 25.410.3 kg/m2. In this study, youths experienced

a significant decrease in Hb Alc values by time interaction from six-months pre-program to six-

months post-program (P<0.05) a decrease from 5.6711.8% to 5.351 0.65%, whereas their BMI

measurements significantly increased (P<0.05) over the same time an increase from

34.916.64kg/m2 to 37.019.15 kg/m2










Program success is contingent on many factors beyond the control of program managers.

These factors include youths': 1) willingness to change behavior (changes in weight status,

number of attempts at therapy, participation in exercise groups), 2) somatic characteristics (BMI

of children and family members, gender, and age), 3) socioeconomic status (level of education of

the children and their parents, working mother), 4) exercise and dietary habits, and dietary

intake, as well as, 5) the quality of dietary records (Bandura, 2004).

Since there are so many challenges to program success, Bandura (2004) encourages

programs to have comprehensive frameworks in order to be efficacious. The CMS used several

learning strategies implicit in Social Cognitive Theory to guide program teaching and target

youths' learning behaviors. This study did not measure whether or not the CMS program's use

of Bandura's learning concepts were effective. The researcher merely observed whether the

CMS program appeared to use the learning concepts to guide program teaching and target

youths' learning behaviors.

Program evaluation offers the potential to inform public policy in several ways. Public

policy may identify and classify interventions as either: successful in the targeted populations;

effective for broader populations or distinct population subsets; or ineffective and not appropriate

for further public expenditure.

This chapter provides an integration of the quantitative and the qualitative findings and

discusses the theoretical learning concepts used in the CMS program. The chapter concludes

with a discussion of the implications for health policy and future research.

Discussion of Quantitative Findings

Although CMS program youths experienced a significant decrease in their pre- and post-

program Hb Alc values (P<0.05), their BMI values significantly increased over the same time










(P<0.05). The goal of the CMS program is for the youth to decrease both BMI and Hb Al c

measures.

These findings cannot be easily explained. While previous research findings suggest that

Hb Alc values improve 11ithr weight loss of about 10 lb or five percent of body weight (Wing,

Marcus, Epstein, & Salata, 1987), other research findings suggest that elevated Hb Alc values

may improve 11 ithmitn weight loss but from increasing activity alone (American Diabetes

Association (ADA), 2006).

Program youths' Hb Alc measures at six-months pre-program ranged from 4.5% to 13.5%

(M~= 5.67, SD = 1.8) and six-months post-program Hb Alc measures ranged from 4.4% to 7.9%

(M~= 5.35, SD = 0.65). Unfortunately, there is not enough research available to elucidate

whether different Hb Alc values have different susceptibilities to diet and exercise, or not. For

example, would a Hb Alc of 5.5% be more sensitive to diet and exercise, without weight loss,

than a Hb Alc of 6.5%?

There was a wide range in Hb Alc values. The wide range of Hb Alc measurements

among youths is suggestive of "outlier" values. However, the mixed general linear model used

to analyze the data, the Unstructured Covariance Matrix, was valid because the assumptions

were satisfied.

Other possible limitations of Hb Alc findings may include: 1) laboratory results can differ

depending on the analytical technique; and 2) biological variation between individuals can be up

to one percentage point. For example, two individuals with the same average blood sugar can

have Hb Alc values that differ by up to one percentage point (Rohlfing, Wiedmeyer, & Little,

2002).









With regard to the BMI Eindings, an important note to make is that youths' BMI values

were not calculated using the recommended age- and gender-specific growth charts for youth.

Since the IRB process prohibited the researcher from collecting members' date of birth a

necessary component for calculating age- and gender-specific BMI percentiles, youths' BMI

values were calculated using the BMI formula for adults. Thus, the BMI findings in this study

are appropriate to reveal only a general trend of the youths' BMI values and do not accurately

depict their true BMI measurements. The six-months pre-program BMI measures ranged from

22.8 to 50.9 (M~= 34.9, SD = 6.64) and six-months post-program BMI measures ranged from

22.2 to 62.2 (M~= 37.0, SD = 9. 15).

According to the NIH (2006) definitions, a healthy adult weight is a BMI of 18.5-24.9;

overweight is 25-29.9; and obese is 30 or higher. While the BMI for adults is a simple,

inexpensive method of screening for weight categories, it does not take into account age, gender,

or muscle mass. Nor does it distinguish between lean body mass and fat mass. As a result, some

people, such as heavily muscled athletes, may have a high BMI even though they don't have a

high percentage of body fat. In others, such as elderly people, BMI may appear normal even

though muscle has been lost with aging (IOM, 2005).

Although the adult BMI is not as accurate for youths, it was useful in that it demonstrated

the general trend in the youths' BMI measures. Essentially, BMI is a simple mathematical

formula based on height and weight that is used to measure fatness. The researcher did evaluate

weight independent of BMI values in this study and weight significantly increased over time

(P<.05). However, youths' heights also increased significantly over time (P<0.05). These

findings are attributable to the fact the youths were growing.










Thus, the increase in BMI measures may be partly explained by recalling that BMI does

not distinguish between lean body mass and fat mass. According to the post-program interview

Endings, youths' improvement in diet and exercise may have increased the participants' lean

body mass.

Additionally, fatness and BMI have been found to be closely correlated with maturation

stage (or development age) among girls (Kaplowitz, Slora, Wasserman, Pedlow, & Herman-

Giddens, 2001). For example, early maturing girls are almost twice as likely to be overweight

than average-maturing girls (Adair and Gordon-Larsen, 2001). There is limited research on the

correlation between boys. According to Wang (2002), early sexual maturation is associated with

overweight in girls but not in boys. The rising BMI Eindings in this study do not take into

account the maturational development of the youths. The use of the age- and sex-specific BMI

percentiles would have compensated for the maturational changes among youths more than using

the adult BMI calculations.

There were no significant differences between gender or ethnic groups for BMI or Hb Alc

Endings. In another program, gender also had no influence on BMI changes, nor did pubertal

status or the degree of participants' obesity (Eliakim et. al., 2002).

Previous programs demonstrate that youths whose parents are not overweight have

significantly greater decreases in BMI compared to youths of obese parents (Eliakim et al.,

2002). In the CMS program, parents were frequently overweight and diagnosed with type II

diabetes. Additionally, programs that include parents or significant caretakers have greater effect

on weight loss than those that do not include parents or significant caretakers (Jain, 2004).

The CMS youths' BMI and Hb Alc measures were evaluated over a short period of time.

By following the youths' biological measures over a longer period of time, significant










improvement in BMI values may also occur; similar to the significant improvement in the Hb

Alc values. It takes time for behavioral changes to improve BMI measures.

The following qualitative Eindings elucidate the post-program improvements that the

youths and parents reported they made to their diet and exercise regimes. Additionally, the

qualitative findings illuminate areas the CMS program may improve.

Discussion of Qualitative Findings

Five main themes emerged from the interview data and Hield notes. First, all youths and

parents reported positive post-program nutrition and exercise behavior changes. Second, parents

reported that youths were reluctant to change post-program health behaviors. The last three

themes revealed areas that the CMS program could use to improve curriculum methodology: 1)

the presence of impediments to engaging youths; 2) the existence of program service

deficiencies; and 3) additional parent concerns that went beyond the priorities of the program

(that may have affected their ability to participate).

Positive Post-Program Behavior Change

Youths and parents reported positive post-program improvement in diet and exercise

behavior. During the interviews, youths and parents stated that they consume more fruits,

vegetables, and whole grains; and less sugary beverages, junk food, as well as less salt, sugar,

and fat. They also stated that they watch portion sizes, read food labels, and exercise more.

This finding is consistent with the quantitative data Eindings that that Hb Alc values for

the youths significantly improved post-program. With regard to the youths' BMI values, it may

be that the full effect of the CMS program on those values may not fully emerge until some time

beyond the last post-program data collection period. Despite youths' reported changes in diet

and exercise, the BMI findings may be partly explained by recalling that BMI does not









distinguish between lean body mass and fat mass or especially, adjustment related to potential

hormone-related growth velocity changes that often occur during the pubertal phase.

Reluctance To Change Post-Program Behaviors

Although all youths and parents reported positive post-program diet and exercise changes,

parents stated that those changes did not come easy for the youths. According to parents, youths

were frequently reluctant to make healthful changes. Examples of the reluctance among youths

to change included: (1) apathy for exercising; 2) dislike of certain healthier foods; 3) aversion to

following the food pyramid for daily food allowances; 4) practicing different habits when away

from home; 5) asserting their identity; and 6) not using measuring cups at home.

The greater reluctance to changes in diet and exercise among youths may be related to

differences in age, experience, and perspective, as well as differences in experience during

program participation. Although the presence of parents during program participation adversely

affected the participation of youths in the program, the presence of parents appears to positively

affects post-program behaviors of youths. Thus, CMS should devise ways to enhance the

experience of parents in during program participation. One parent stated that the program may

want to consider recording and monitoring BMI and Hb Alc measurements for the parents. One

parent shared that she has lost 4 dress sizes after attending the program with her child. BMI data

may be more appropriate for adults than for youths and may provide parents with obj ective

standards, in addition to dress sizes, by which parents can measure post-program progress and

compliance.

The CMS program is in a unique position to introduce youths to types of exercise and

foods that are appealing. Rather than providing water as the beverage of choice in the program,

the youths could be given a choice of low-calorie beverages. A further recommendation would

be to instruct parents how to pack the youths' lunches so that they are appealing.










Impediments to Engaging Youths

Snack and exercise methodologies fostered "solitary" and "parallel" (side-by-side) play

among the youth. Solitary and parallel play activities are more appropriate for younger children.

School-age children and adolescents require activities that foster "associative play" among

members of the group. Associative play begins among the preschool age (London, Ladewig,

Ball, & Bindler, 2006) when children begin to interact with each other during play. School age

child and adolescents continue this type of interaction: bonding over games, competitions, and

proj ects. Youths in the CMS program did not appear to have a meaningful opportunity to get to

interact with each other during play.

Unlike youths, parents articulated that they looked forward to attending each session.

Parents bonded by sharing recipes and cooking tips and looked forward to experiencing the

feeling of camaraderie each week.

The program is in a position to create opportunities for communication that fosters

friendship and support among youths. In turn, youths would look forward to coming to weekly

sessions, rather than attending "because they have to" or not attending at all, as attested to by the

dismal attendance and graduation rates. One suggestion is that the CMS instructors may want to

ask the youths, prior to the beginning of the program, what games and sports that they enj oy

playing with their friends. The CMS instructors could then offer those activities to the youths.

Class observations and interviews indicated that parents may be enjoying the CMS

program more than youths. That could be because parental presence during the snack and

exercise segments impedes the ability of youths to get to know one another. A parent shared that

she embarrassed her daughter because the parent was the "class clown" during exercise (drawing

unwanted attention to the daughter).










Unlike their parents, youths did not express feelings of camaraderie with their peers. A

variety of factors may influence the relatively diminished bonding among youths. It may be that

youths are shy due to age or other causes. However, because the youth and parents participate

together for exercise- and snack-activities, the presence of the parents may impede the ability of

youths to get to know one another. The CMS program may want to consider separating youths

and parents for some activities and j oining them for group discussions of their separate activities.

Since research demonstrates that parental involvement in programs is vital for positive program

outcomes, it is very important that parents are as involved in a program as youths.

The CMS program was mandatory for the youths and parents. A significant decline in

attendance was observed with each consecutive class; only one of the five enrolled youths

completed all four classes.

Adolescents frequently experience boredom, time stress, and lack of choice (lack of

control) in their daily lives. In Shaw, Caldwell, and Kleiber (1995), adolescents reported high

levels of time stress and boredom related not only to lack of options, but also to participation in

adult-structured activities. In addition, adolescents, at times, participated in activities to please

others rather than to please themselves.

Since the CMS program is mandatory, it places time stress on the participants. This

challenge may not be readily resolved. It may be necessary for CMS instructors to acknowledge

that they are aware of the "loss of control" that the youths may be feeling and then have the

youths talk about it as part of the program. The instructors should continue to improve on

program dynamics; provide an atmosphere that is engaging to the youth to keep them interested.

Additionally, within the program, youths should be given choices whenever possible. For

example, rather than having the program instructors provide the snacks, the program could










provide each youth with a gift certificate to purchase his or her snacks in accordance with food

label requirements for nutrition. This would bring more variety to the snack activity, diminish

the sense of loss of control, enhance participation, enhance associative play among youths, and

improve attendance (as the youths would know that others are relying on them).

Program Service Deficiencies

The aerobic exercise was impeded by the location of the activity. The activity was

implemented in the front lobby of the CMS agency. The youths and the parents had to find a

place to workout between the chairs. It also appeared that youths were self-conscious when

CMS patients arrived for their scheduled appointments (as the activity occurred while the CMS

office was open for daily business).

The location issue could be remedied with an appropriate change in venue. The exercise

activity could occur in the spacious staff lounge or in some other CMS room. Also, some youth

participants did not dress appropriately for exercise this factor hindered their movement

abilities. CMS instructions for exercise attire should be modified to avoid this issue in the future.

The youths and the parents were challenged with the skill-level necessary for the video

aerobic activity; they frequently missteped. This may be remedied by the use of age- and skill-

appropriate aerobic video activities. The CMS instructors may want to invite youths to discuss

the types of activities that they enj oy playing with their friends.

The researcher also observed that snack portions appeared to be small under the

circumstances. The youths and their parents may have been hungry at that time of day,

especially after the unaccustomed exercise that they had just completed. The small servings risk

creating a negative association in the minds of the participants that a healthful diet means

deprivation.










Vegetable plates at session three appeared to precipitate the most disappointment among

the youths. They ate mostly the carrots and the dip. Program instructors may want to include a

greater variety and a greater portion of appealing vegetables to the youths and the parents.

One parent suggested that instructors may want to go "out of the norm of what people

think they wouldn't like" at the snack activity. The parent suggested that instructors serve

vegetables other than the typical carrots and broccoli. In addition, larger, more satisfying

portions may reinforce the perception that snacks are nutritious and satisfying.

Additional Parent Concerns

During and after the post-program interviews, two parents shared personal concerns that

went beyond the expertise of the program; one having had been sexually abused as a child, and

the other feeling overwhelmed by life generally. Since improvements in emotional well-being

and behavior are positively correlated with weight loss (Dreimane et al., 2006), the CMS

program may want to consider the feasibility of providing social or psychological counseling to

the youths and the parents.

The interviews and in-class observation findings suggest that the CMS program is eliciting

dietetic and exercise behavioral changes among youths and parents. The Eindings also clarified

some areas in need of improving the CMS program: 1) engaging the youth to get to know each

other; 2) engaging the youth with activities that they enj oy and look forward to participating in;

and 3) separating the parents for some activities.

Implications for Health Policy and Future Research

The next step for the CMS behavioral intervention program is to have the youths followed

long-term, such as one to two years post-program, to see whether their BMI and Hb Alc

measures are improving or not improving. The long-term study could also include pre- and post-

program age- and sex-specific BMI percentiles. In doing so, the research would address a









limitation in this study that the researcher did not include age-and sex-specific BMI percentiles.

In the meantime, the CMS program instructors could continue to work to improve the program

by including feasible suggestions from this study.

The program instructors may want to think about ways to get the youths and parents "to

buy into the program." They may want to consider following parents' biological measures of

BMI and Hb Alc.

Another way for the program instructors to get the youths and parents "to buy into the

program" would be to create clear expectations for the youths and parents from the onset. For

example, youths and parents could be told to expect to a change in their clothing size within

three months if they follow program guidelines. Since the youths' and parents' outcome

priorities may be different than those of the program instructor' s priorities, it may also be helpful

to address expectations on an individual basis with the input of the participants. Rather than

graduation certificates, the program may want to consider store gift cards.

Additionally, the program may want to separate the youths according to age groups

because their ages ranged from 7 to 18 years. Parents and youths could be separated for all of

the activities as well.

The identification of effective teaching methods utilized in the CMS program and other

programs enables health providers to replicate and improve successful intervention methods.

Behavior may be influenced by the following: 1) reciprocal determinism; 2) behavioral

capability; 3) expectations; 4) self-efficacy; 5) observational learning; and 6) reinforcement

(NIH, 2003) (Table 2-1).

Behavioral change results from an interaction between an individual and three key factors

identified as personal, environmental, and behavioral (reciprocal determinism). Research










suggests that environmental factors may influence children's health behaviors more than personal

ones because children are not so worried about their health (Gochman, 1987). The involvement

of parents in the CMS program is crucial is because parents control much of the home

environment. A possible way to improve youths' compliance with the "food diary" activity

would be to have the parents responsible to monitor the activity at home. In addition, the parents

could also participate in the activity (observational learning). Individuals are more likely to

adopt a modeled behavior if behavior change results in outcomes they value, and if the model is:

1) similar to the observer, 2) has admired status, and 3) has functional value (Bandura, 1977).

The CMS program provides behavioral skills training to youths and parents in the way of

nutrition and exercise lectures, and snack and exercise activities. However, the learning of skills

just begins in the CMS classroom, and ends within the complexity of the external environment -

such as home and school. Thus, the CMS program may want to creatively engage youths and

parents during "after hours." For example, the youths' could be responsible for shopping for the

weekly program snacks using food labels.

The learning concepts of expectation and self-efficacy were less utilized by the CMS

program. There were not explicit explanations for youths or parents as to how their nutrition and

exercise choices would affect their health outcomes (expectations) in a measurable way, or

obvious tactics to build the youths' and parents' confidence so that they would feel that that

could change their behavior (self-efficacy).

Factors that motivate an individual's expectations as they go through the process of setting

goals for themselves include self-efficacy, feedback, and the anticipated time to goal attainment

(Bandura, 1986; 1989). If the youths and parents felt that they were capable of achieving the

goal (self-efficacy), they would be likely to work hard and not give up.










The youths and parents could be given one-on-one individual weekly feedback using their

weekly food diaries, and they would be more able to adjust their goals to be feasible and

realistic. Feedback, in turn, improves self-efficacy. Also, short-term goals are more effective

than long-term goals. Weekly incremental goals for reduced fat and increased fiber and fruits

and vegetables, and physical outcome expectations could be included in the curriculum.

According to Margolis and McCabe (2004), strategies for improving self-efficacy may include:

1) establishing small, incremetal goals for participants; 2) reinforcing effort and persistence; 3)

emphasizing modeling; and 4) providing feedback through record-keeping (Margolis & McCabe

2004).

According to Bandura (2004), an effective program includes similar components to

effectuate self-efficacy. The components include 1) information regarding the desired behavior;

2) the development of social and self-management skills; 3) building a resilient sense of efficacy

such as supporting the exercise of control in the face of difficulties and setbacks in everyday life;

and 4) enlisting and creating social supports for desired personal change such as enlisting

participants' caregivers in the effort.

Future research can go beyond observation and description of the theoretical concepts, and

measure whether the utilization of a particular learning concept in the CMS program actually

elicits behavioral changes among the youths. For example, this study revealed that the CMS is

utilizing "reinforcement" methods, such as giving out program graduation certificates. However,

this reinforcement method does not appear to work. There are a variety of reinforcement

rewards that have been utilized in other programs that have been shown to improve program

outcomes including stars, modest prizes, jump ropes, and water bottles. As aforementioned, store

gift cards may be more effective to improve attendance and outcomes.









With regard to thematic coding procedures in this study, in the future it will be important

for the researcher to choose another researcher to assist in cross-coding the interview and in-class

observation transcripts in order to validate the thematic Eindings. In this study, the researcher

identified themes in the transcripts without the assistance of another researcher.

It would be interesting to include the input of the program instructors in the study

methodology. For example, after the qualitative data is thematically coded by two researchers,

one or both of the researchers could then meet with the program instructors to elicit feedback and

suggestions regarding their Eindings. The program instructors could also be interviewed after the

program. This would allow the researcher to gain insight of the instructors' perception of the

CMS program.

Future research offers the opportunity to reduce or eliminate some limitations unique to

this study design. In the interviews, youths and parents may have shared only what they thought

the researcher wanted to hear that they have made positive changes to their lifestyle. It is

difficult to know whether youths and parents accurately reported their behavioral changes. In the

future, behavioral change data may be more accurately collected if youths and parents would

bring their recorded daily diet and exercise regimes to the interview. In-home observation by the

researcher might also be helpful.

Ideally, a control group would strengthen the validity of the study findings. Youths that

participate in the program could be compared to youths that do not participate in the program

(and receive only routine in-office educational sessions).

Other opportunities for study design improvement include the opportunity to reduce or

eliminate some other limitations unique to this study, including sample size, time-span, and

external environmental influence. For example, by replicating the study in other programs, the










aggregate results effectively enlarge the sample size to statistically significant proportions of

affected youth.

Analysis of larger sample sizes may be able to tease out time-spans and environmental

influences that, in concert with intervention programs, correlate with desired behavior

modification. For example, 100 future studies of similar intervention programs would enlarge

the sample size to 6,000 youth. The larger aggregate study population, more likely than not, may

confirm that BMI and Hb Alc are inappropriate measures of efficacy for children and

adolescents. However, the larger study may be able to demonstrate, through qualitative analysis,

the efficacy of certain intervention methodologies up to some period, such as 24 months after the

conclusion of the program, without subsequent intervention but declining efficacy thereafter

without renewed intervention.

Future research may also target external environmental events that precipitate undesired

dietetic and exercise behavior with a view toward eliminating those events. For example, peer

group influence may be shown to have more proportional influence on positive or negative

outcomes than does parental influence. That is, graduates of intervention programs may be

influenced more by peers than by the parents of the graduates. It may be possible to evaluate the

interplay between school intervention programs, peers, and parents, and the net effect on youths

who graduate from intervention programs.

There is not enough qualitative research concerning program evaluation. Only one of nine

the programs in the literature review used qualitative research. This study demonstrates the

usefulness of a mixed-method design to illuminate biological measures findings and to enhance

program effectiveness.









The CMS program is fulfilling obj ectives of national and state public health policies.

Currently, Healthy People 2010 seeks to reduce overweight among youths to five percent. In

Florida, the "Governor's Task Force on Obesity" has recommended that health care providers

promote lifelong nutrition and physical activity by implementing programs that promote

healthier lifestyles and disease management for overweight-related illnesses such as diabetes and

hyperinsulinemia (Florida Department of Health, 2004).

With the initiation of the CMS program, health care providers at Tallahassee CMS have

demonstrated a commitment to go beyond typical in-office nutrition and exercise education.

They are dedicated to improve the CMS program despite the challenges. As previously

mentioned, separating youths and parents during the program (while keeping it as a family

intervention), and creating clear program expectations of youths and parents, emerged as areas

requiring improvement.

The CMS program is propagating future informed adults who can advocate for healthful

diets and exercise. The take-home message for policy makers is that program evaluation informs

public policy, with either qualitative or quantitative data or both, and is aimed toward providing

information that helps policy makers decide how a certain program may be understood in terms

of better or worse social outcomes. Strategies and methodologies that are identified as

successful for distinct population group subsets may be replicated in behavior intervention

programs that target similar populations.

Potentially, the CMS program may be implemented by other CMS agencies, and

eventually, by outpatient health clinics generally. Future research may compare other CMS

programs or programs similar to this CMS program public and private intervention programs,

their methodologies, and their relative efficacy.









Summary

A design that includes both quantitative and qualitative methods of evaluation offers the

potential for gathering complete, accurate, contextualized evidence needed to evaluate the

effectiveness of a health intervention program (Creswell, Fetters, and Ivankova, 2004). This

mixed-method is particularly appropriate when biological outcomes, that are dependent on diet

and exercise behavioral changes, are being followed for only a short-term following the program

intervention. For example, the CMS program appeared to have successfully motivated behavioral

changes relative to diet and exercise behaviors. However those behavioral changes may be more

evident in BMI outcomes if members were followed for a longer period of time. Overall,

programs have demonstrated modest success in maintaining or decreasing weight and BMI

(Dreimane et al., 2006; Eliakim et al., 2002; Monzavi et al., 2006; Savoye et al., 2004; Speith et

al., 2000; Taylor, Mazzone, Wrotniak, 2005) and in success at improving other biological

measures associated with overweight-related illnesses (Monzavi et al., 2006; Taylor, Mazzone,

& Wrotniak, 2005).

For example, in Eliakim, et al. (2002), the study used for this study's sample size

calculation, youths demonstrated a significant decrease (P<0.05) in BMI at 3-months post-

program a decrease from 26.110.3 kg/m2 to 25.410.3 kg/m2. In this study, youths experienced

a significant decrease in Hb Alc values by time interaction from six-months pre-program to six-

months post-program (P<0.05) a decrease from 5.6711.8% to 5.351 0.65%, whereas their BMI

measurements significantly increased (P<0.05) over the same time an increase from

34.916.64kg/m2 to 37.019.15 kg/m2

There were no significant differences between gender or ethnic groups for BMI or Hb Alc

Endings. The decrease in Hb Alc measures and increase in BMI measures may be partly

explained by recalling that BMI does not distinguish between lean body mass and fat mass or










especially, adjustment related to potential hormone-related growth velocity changes that often

occur during the pubertal phase. According to the post-program interview findings, the youths

were increasing their exercise levels and improving their dietary intake.

Although the youths' BMI values were not calculated using the recommended age- and

gender-specific growth charts for youth, it was useful in that it demonstrated the general trend in

the youths' BMI measures. Essentially, BMI is a simple mathematical formula, based on height

and weight that is used to measure adiposity.

The qualitative analyses elucidated several areas of program implementation as factors that

may adversely influence the ability of youths and parents to internalize CMS principles for

healthier living. The most obvious factor is the absence of a methodology for ensuring

attendance. Other factors include, incompatible exercise skill levels, exercise venue and

equipment, and the absence of implementation methods that foster associative interaction among

youths.

Future research offers the opportunity to reduce or eliminate some limitations unique to

this study, including sample size, span, and external environmental influence. Identification of

effective intervention methods utilized in various disease prevention programs enables other

health providers to replicate and improve successful intervention methods and facilitates the

generalization of successful methods to broader populations.










APPENDIX A
CMS PROGRAM CURRICULUM

Week 1
General Overview and Introduction Outline

L. Pre-preparation

A. Health/diet history participant's form
1. Ensure that all participants have received/completed these forms:
a. Participant form
b. Guardian form

2. NOTE: These forms sent out minimum one week prior to class

B. Assessment
1. Review participant's records
a. If no A1C value is noted in previous four weeks, this data will be
assessed/collected first class
b. If A1C are noted in patient chart a month or less prior to first day of
class, no A1C is necessary on first day

C. Flow sheet
1. A flow sheet, which includes height, weight, and A1C data for each
participant will be used
2. Data will be entered by the end of first class for each participant

D. Food: Fruit (apples, oranges, bananas) and flavored water (Fruit20)

E. Prizes: (for example, paddleballs)

II. Introduction
A. Overview of goals of the clinic
1. Emphasize healthy lifestyle, not weight loss

2. Review layout of class
a. begin with exercise session each class
b. either participants remain with parent/guardian or are separated
c. review topics to be covered

3. Provide snacks
a. sliced fruit
b. water

III. Class begins
A. Exercise session
1. Parents/Guardians and children all participant in this activity










2. This takes place in the lounge room


B. (Return to conference room)
Distribute pre-test for
1. Participants
2. Parents/Guardians

C. Food Guide Pyramid and Eating Smart: Keeping Your Eating Under Rap
1. Distribute handouts
2. Identify categories
3. Discuss total servings for each group/category
4. Review appropriate portion sizes utilizing food models and Eating Smart
handout

D. What does a calorie look like?
1. Display various foods demonstrating what 20, 60, and 120 kcals look like
a. 20 calories demonstrated with appropriate servings of
i. air popped popcorn
ii. cookie
iii. cracker
iv. pretzel

b. 60 calories
i. small apple
ii. small banana
iii. 4 oz juice
iv. 2 Hershey's kisses

c. 150 calories
i. 12 ounces of cola
ii. 9 ounces of juice
iii. 8 ounces of whole milk

E. Exercise
1. Review "Hey Couch Potatoes" on Eating Smart handout to emphasize the
benefits of exercise
2. Distribute Lean Routines for exercise journal

F. Distribute Food Journals
1. Emphasize the need to document what and HOW MUCH was consumed
every day until the next class
a. offer incentives for completion
b. emphasize need to include beverages

2. Discuss the need to familiarize with portion sizes











G. Closing
1. Distribute prizes
2. Address questions

Week 2
Focus: Diabetes Prevention Outline

I. Pre-Preparation
A. Obtain copies of handouts, as appropriate
B. Food: popcorn and flavored water
C. Obtain prizes
D. Obtain food/beverage samples for children's discussion (colas, diet colas, juice, etc)

II. Exercise
A. Class will be led by Dr. A. Mobley (or other provider)
B. Once again, both children and parents/guardians are to participate

III. Snack offered: Popcorn and water

IV. Review
A. Brief discussion and review concerning previous class on portion sizes and serving
sizes
B. Discuss journal entries
1. Food journals
a. What patterns emerged?
b. What types of beverages consumed?
c. How are portion sizes?

V. Discussions
A. Parents/Guardians in Conference Room for discussion led by Roberta Stevens, M.S.,
R.D., C.D.E.
1. What is Type II Diabetes?
a. the disease
b. the risks
c. the health effects
d. how to prevent or manage

2. How does diet play a role?
a. beverage choices
b. Food labels handout (what do I look for?) (additional handouts may be
provided by Roberta Stevens)
c. Fast food/best choices
i. Calorie books for fast foods obtained from Lily via Suzanne Laws
ii. Discover Nutrition Anytime Anywhere: Menu Makeovers handout










B. Children in Lounge area for discussion
1. What does Type II diabetes mean for you?
a. what is happening to your body?
b. what are the risks?
c. what are the health effects?
d. what can you do?

2. How does your diet play a role? (emphasizing "sugars" and excessive calories)
a. review beverage options (juice, milk, water, soda)
b. incorporate label reading introduction into this
c. taste test of regular vs. diet sodas

3. Fast Food options
a. excessive portion sizes
b. "healthier" fast food choices (offering a calorie count comparison)

4. Incorporate a :Jeopardy-like" format, dividing group into teams to guess calories
of vari ous fast foods or "what-i s-the-b etter-opti on" in a fast food setting

VI. Closing
A. Children and parents/guardians all gather in Conference Room
B. Review and encourage continued journal entries (food and exercise)
C. Address questions
D. Distribute "prizes"

Week 3
Focus: Virtual Supermarket Tour Outline

I. Pre-preparation
A. Virtual Tour
B. Handout: Discover Nutrition Anytime Do-It-Yourself Supermarket Tour
C. Bring a measuring cup (1 c, V/2 C for solids) to use for demonstration purposes
highlighting portion sizes

II. Exercise session

III. Virtual Tour-in general, encourage them to begin at produce and end at meats (from
both a health and food safety perspective)
A. Produce
1. Ask: How many fruit/vegetable servings per day? For review (5d)
2. What do we get from fruit/vegetable?
a. lots of vitamins (A, C) and minerals
b. plant chemicals, known as phytochemicals, which may have a role in
preventing many diseases such as cancer
c. GOAL is to get as many "colors" in your diet everyday
3. Ask: What are your favorite fruits and vegetables?










4. Highlight different fruit such as kiwi, star fruit, mango, etc, and different
vegetables, broccosprouts, broccoflower, etc.
5. Highlight fruit and vegetables as great snacks
a. apple and cheese
b. banana and peanut butter
c. mini carrots with V2Sandwich
d. dried fruit (raisins, apricots, etc.)
e. prepared vegetables make it really easy!!i

B. Snack Chips
1. focus on high amount of fat, calories, sodium
2. while occasionally fine, can displace more nutrient dense snacks
3. ACTIVITY:
Have everyone pick up a bag of chips and look at the labels
a. how many calories?
b. what is considered a serving size?

4. Compare pretzels to chips
a. look at labels
b. Ask: are you really saving anything in calories
c. Suggest pretzels dipped in mustard as a snack, add a piece of fruit and you
are doing great!!i

5. ACTIVITY with popcorn:
a. have everyone pick up microwavable popcorn
b. tour guide can use popcorn kernels (for air-popped popcorn as "gold
standard")
c. Ask: What are the serving sizes and calories for each?
d. Is there a "best one"? Let them decide...
e. Great high fiber and (can be) low calorie snack if chosen wisely
f. add some yogurt cheese, fruit, or nuts for higher satiety

C. Bread/Cereal
1. Lower calorie breads typically mean thinner slices
2. Look for high fiber breads (Nature' s Own White Wheat, or 100% Whole Wheat)
Key here is that the first ingredient says "WHOLE" wheat"
3. Cereals
a. look for higher fiber cereal >5 g/serving)
b. granola cereals can be very high calorie
c. watch serving sizes on cereal (have them look at the serving sizes)
d. cereals can make a great snack
e. may consider mixing a high fiber cereal (like All-Bran) with a high sugar/low
fiber cereal (Frosted Flakes)

D. Juice
1. Calcium fortified orange juice for those who aren't getting enough calcium










2. NO MORE THAN 8 ounces per day of ANY juice
3. Review class discussion about juice
a. briefly look at labels for calories per serving
b. highlight 100% fruit juices (Juicy Juice, Mott's)

E. Milk/Yogurt/Cheese
1. aim for 3 servings/d (this includes high calcium foods such as cheese, yogurt,
etc.)
2. look at the huge variety of yogurts (drinkable, whipped, regular, with added
crunch/granola, etc.)
3. calcium fortified cottage cheese
4. cheese sticks for snacks, etc...

F. Frozen foods section: Meat alternatives
1. Boca Burgers
2. Harvest Burger recipe crumbles
3. Veggie hot dogs (e.g. Yves Good Dogs)

G. Meat
1. Key here is FAT (therefore calories) and saturated fat
2. Leaner is better
3. Meat can AB SOLUTELY be a part of a healthy diet
4. Still, limit red meat when possible
5. Seek >90% lean meats
WARNING: "ground turkey" may not be saving you anything in fat and calories
(since it may have skin, dark meat, etc, ground in there...be sure to read the
labels!!!

6. Advantages/di advantages to cooking poultry with/without skin
a. cook with skin for flavor
b. remove before eating

7. Beef
a. >90% lean
b. key words are "top round", "eye round", "loin", or "London broil"
c. when frying, may consider draining the fat and then rinsing with hot water to
remove more fat

H. Pork
Tenderloins can be a wonderful option

I. Fish/Shellfish
1. limit frying
2. aim for one serving/week

J. Miscellaneous










1. Soups can be a great snack that fills you up
a. Campbell's Healthy Request, Healthy Choice soups, etc.)

2. Beans-great fiber, protein, vitamins, and minerals
a. rice and beans make a great meal
b. also try bean burritos, etc

3. Nuts also make a great snack
a. watch portion sizes
b. awesome protein and minerals
c. high satiety value

TAKE HOME MESSAGE: Aim for a majority of your foods from grains, fruits, and vegetables,,
...fair amount of lean meats, poultry, low fat dairy, and least amount of fats, oils, and sweets.

Week 4
Focus: Healthy Meals, Healthy Snacks Outline

I. Pre-Preparation -4 weeks ahead
A. Seek student volunteers from FSU Student Dietetic Association (at least 2)

II. Preparation
A. Make copies of the Post-test for participants
B. Make copies of the post test for parents
C. Make copies of handouts to be included in the end-of-class book
D. Make copies of the feedback form
E. Obtain food for pizzas (student activity)
1. Utensils
a. toaster oven/conventional oven
b. knives to prepare condiments for pizza
c. spoons/forks to serve condiments
d. can opener

2. Plates
a. large platter or individual paper plates and/or bowls for "buffet line" of
toppmngs
b. serving (paper) plates

3. Napkins

4. Food
a. English muffins
b. Tomato sauce
c. Shredded mozzarella cheese
d. Pepperoni
e. Pineapple










f. Onions
g. Green pepper
h. Tomatoes
i. Mushrooms

F. Have paper/pens available for parent activity

G. Pens are also needed for post-test for participants and parents

II. Exercise
Dr. Mobley (or other providers)

III. Parents: healthy Meals, Healthy Living
A. Review health risks of obesity
B. Include in discussion
1. (review of) what is hyperinsulemia-risks
2. (review of) what is diabetes-risks, prevention, management
3. (review of) how managing their weight will be a lifetime challenge
4. (review of) how it will be much more difficult for your children to first tackle
this as adults. They are much more impressionable now and, therefore, we
want to take advantage of that impressionability ...

C. The importance of nutrition and exercise in managing hyperinsulemia and/or
Diabetes (i.e. the role of diet and lifestyle)

D. EXTREMELY important and invaluable position you have as a ROLE MODEL for
them in terms of both diet AND exercise
a. they watch what you do
b. they learn from what you do
c. they count on you to make available, prepare, and/or serve healthful snacks
and meals
d. however, empowering them with the same knowledge and abilities to choose,
prepare, obtain, and/or serve for themselves (either at home or away from
home) is the MOST important thing that you can do for them (because the
impression you have made on them should be one that influences them and
stays with them even if you are not around at the time they have to make the
healthful decisions for themselves...)

E. What you bring into the house matters (recap supermarket tour)

F. While all foods can fit, you want to encourage the healthful ones and find ways to
incorporate those into their daily meal plans
1. involve your children in meal planning
2. take them to the grocery store with you

G. Parent Activity: Meeting the Challenges









Description: Divide the parents into two groups (if enough are present; in the event
that there is not a minimum of two in each group, combine the activity)

1. Group I:
a. identify/list the challenges you face in offering and/or preparing healthy
snacks (allow about three minutes for this)

b. List how you can meet that challenge (problem-solve!)
(allow about Hyve minutes for this). Also include a list of some healthy snacks that
would work well with your children...

2. Group II
a. Identify/List the challenges you face in offering and/or preparing healthy
meals (including lunch for school) (allow three minutes for this)
b. List how you can meet that challenge (allow Hyve minutes to problem-solve)
and give examples of some healthy meals (even something that you haven't
tried before!)

3. Discussion of the above... incorporating the following:
1. all foods can fit into a healthy meal plan
2. planning for all meals (including lunches and/or snacks) when grocery
shopping is imperative
3. Being a positive role model for your children is invaluable
4. Look for some other ideas in your take-home packet (lean meat choices,
healthy lunch makeovers, supermarket tour list, etc.)

4. Post-test questionnaire
5. Feedback questionnaire

IV. Participants
A. Review health risks of obesity
B. Include in discussion
1. (review of) what is hyperinsulemia-risks
2. (review of) what is diabetes-risks, prevention, management
3. (review of) how managing their weight will be a lifetime challenge
4. (review of) how it will be much more difficult for them to Birst tackle this
as adults. (pre/post-test question)

C. The importance of nutrition and exercise in managing hyperinsulinemia and/or
Diabetes (i.e. the role of diet and lifestyle)

D. RE1VE1VBERING THAT ALL FOODS CAN FIT!!i

E. Activity
The children are to be divided into two groups:
This will allow one FSU student volunteer to manage/oversee the food activity









while another FSU student volunteer oversees the paper activity


1. Group A: meeting the challenge
Have participants list the types of snacks they have typically eaten that may or
may not fit well into a healthy meal plan
What are some ideas they have for healthy snacks? Let's see which group can
come up with the most ideas that fit include a variety of foods from the FGP

2. Group B: Food Activity first
a. discuss all of the food groups represented in the pizza snack (can they tell
you what groups fit where?)
b. discuss the low fat mozzarella, the leaner pepperoni, and all of the different
vegetable (and fruit!) toppings that can be included

3. Each group will then switch

4. Post-test quiz

V. End-of-clinic
A. Distribute certificates
B. Distribute packets
C. Discuss follow-up clinic sessions

Food Guide Pyramid: Guide to Daily Food Choices
A Food Diary Example
Eating Smart: Keep Your Eating Under Rap
Snack A attack
Nutrition Fact .1heetl~ 7 Steps to Being More Active
Nutrition Fact .1heetl~ Straight Facts about Beverage Choices
Handout: Recommended Reading & Websites
Splenda information 0I ithr Sample
Positive Diabetes Journal, September 2006
Diabetes Health Journal, September 2006









APPENDIX B
INTTERVIEW GUIDE

Youth Questions

1. Tell me a little bit about yourself.

2. Tell me how you happened to go to the program.

3. Tell me about the program. What kinds of things did you do in the program?

4. What kinds of things did you learn about how you eat and exercise?

5. Since the program, do you eat healthier food? Do you exercise more than you did
before the program? If so, in what kind of ways?

6. Was the program fun? Did you like it? If so, tell me what was fun about it?

7. Were there any parts of the program that were not fun or that you didn't like? If so,
which parts?

8. Do you think your friends would like the program? Why or why not?

Parent Questions

1. Tell me a little bit about yourself.

2. Why did you attend the program?

3. What was the program like for you?

4. What kinds of things did you learn?

5. Did it motivate you to improve nutrition and exercise routines for your
child/family?

6. Since the program, have you changed how you do things at home (example: grocery
purchases, cooking, exercise)? How?

7. Do you think your child learned anything new? Did your child want to change (diet
and exercise routines)? Does your child do anything differently after the program?

8. Can you tell me about what you liked about the program? Were there any aspects
of the program that you didn't like?

9. Did your child want to attend the program? Did you? Why or why not?









10. Did you think your child liked the program? What things did he/she like or not like?

1 1. If you were giving advice to the program organizers to the program, what would you
say?

12. Would you recommend the program to other parents or children? Why or why not?









APPENDIX C
HIPAA IDENTIFYING FACTORS

1. Names;

2. All geographical subdivisions smaller than a state, including street address, city, county,

precinct, ZIP code, and their equivalent geocodes, except for the initial three digits of a ZIP

code, if according to the current publicly available data from the Bureau of the Census: (1)

The geographic unit formed by combining all ZIP codes with the same three initial digits

contains more than 20,000 people; and (2) The initial three digits of a ZIP code for all such

geographic units containing 20,000 or fewer people is changed to 000;

3. All elements of dates (except year) for dates directly related to an individual, including

birth date, admission date, discharge date, date of death; and all ages over 89 and all

elements of dates (including year) indicative of such age, except that such ages and

elements may be aggregated into a single category of age 90 or older;

4. Phone numbers;

5. Fax numbers;

6. Electronic mail addresses;

7. Social Security numbers;

8. Medical record numbers;

9. Health plan beneficiary numbers;

10. Account numbers;

11. Certificate/license numbers;

12. Vehicle identifiers and serial numbers, including license plate numbers;

13. Device identifiers and serial numbers;

14. Web Universal Resource Locators (URLs);









15. Internet Protocol (IP) address numbers;

16. Biometric identifiers, including finger and voiceprints;

17. Full face photographic images and any comparable images; and

18. Any other unique identifying number, characteristic, or code (note this does not mean the

unique code assigned by the investigator to code the data).









APPENDIX D
CHART DATA COLLECTION FORM

Data Collection Form

Physician/Clinic Name/

Demographics
Calculations/Comments
Subj ect Identification Number
Age
Gender (1. Male 2. Female)
Race

Medical Diagnosis(es)


Medication(s)


12 to 6 Month Pre-Test Measurements
/ / ate (Month/Day/Year)
Weight (in kg)
Height (in meters)
BMI
Hb Alc
M>. visits 12 ninibsllr pre-programn

Day-of-Program Measurements
/ / ate (Month/Day/Year)
Weight (in kg)
Height (in meters)
BMI
Hb Alc

3-Month Post-Program Measurements
/ / ate (Month/Day/Year)
Weight (in kg)
Height (in meters)
BMI
Hb Alc


6-Month Post-Program Measurements
/ / ate (Month/Day/Year)
Weight (in kg)
Height (in meters)
BMI
Hb Alc
M>. visits 6 ninibsllr post- program










LIST OF REFERENCES


Adair, L. S., & Gordon-Larsen, P. (2001). Maturational timing and overweight prevalence in US
adolescent girls. Am JPublic Health, 91(4), 642-644.

Alaimo, K., Olson, C. M., & Frongillo, E.A. (2001). Low family income and food
insufficiency in relation to overweight in US children [Electronic version]. Archives of
Pediatrics & Adolescent M~edicine, 155(10), 1161-1167.

Allen, N. A. (2004). Social cognitive theory in diabetes exercise research: An
Integrative literature review. The Diabetes Educator, 30(5), 805-819.

American Academy of Pediatrics (2003). Prevention of pediatric overweight and obesity:
Committee on nutrition. Pediatrics, 112(2), 424-430.

American Beverage Association (2006). School beverage guidelines Q andA [On-line].
Retrieved January 12, 2007 from: http://www.ameribev. org/school s/GuidelineQandA. asp

American Diabetes Association (2006) [On-line]. Obesity and children. Retrieved January 12,
2007 from: http://www.di ab etes.org/home.j sp

Anderson, R. M., Funnell, M. M., Butler, P. M., Arnold, M. S., Fitgerald, J., T., & Feste,
C. C. (1995). Patient empowerment: Results of a randomized controlled trial. Diabetes Care,
18, 943-949.

Bandura, A. (2006). Guide for constructing self-efficacy scales. In Pajares, F., and
Urden, T., self-efficacy beliefs of adolescents. Greenwich, CT: Information Age Publishing.

Bandura, A. (2004). Health promotion by social cognitive means. Health Education and
Behavior, 31(2), 143-164.

Bandura, A. (1997). Self-efficacy: The exercise of control. New York: Freeman.

Bandura, A. (1989). Bandura, A. (1989).Human agency in social cognitive theory.
American Psychologist, 44, 1175-1184.

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory.
Englewood Cliffs, NJ: Prentice Hall.

Bandura, A. (1977). Social learning theory (1rst ed.). Pearson.

Barclay, L. & Vega, C. (2006). New guidelines for management of hyperglycemia of type II
diabetes. M~edscape Nurses. Retrieved February 23, 2006 from
http://www.medscape. com/vi ewarti cl e/5 41 95 3

Barlow, S. E., & Dietz, W. H. (1998). Obesity evaluation and treatment: Expert
committee recommendations. Pediatrics, 102(3), e29.











Benight, C. C., & Bandura, A. (2004). Social cognitive theory of a posttraumatic recovery: The
role of perceived self-efficacy. Behavior Research and Theory, 42(10), 1129-1 148.

Blake, R. L. (1989). Integrating quantitative and qualitative methods in family research. Fant
Syst Med, 7, 411-427.

Carter, R. C. (2002). The impact of public schools on childhood obesity. JAM4A, 2180-
2180.

Carroll, W. R., & Bandura, A (1987). Translating cognition into action: the role of visual
guidance in learning. J~ot Behav, 19(3), 385-98.

Cary, N. C. (1989). SAS STA Tuser 's guide, version 6 (4th ed.). SAS Institute Inc.

Centers for Disease Control and Prevention (2004). Youth Risk Behavioral Surveillance
Survey: Youth online comprehensive results. MMWR Morb Mortal Wkly Report, 53(24), 536.

Centers for Disease Control and Prevention (CDC), National Center for Health Statistics,
National Health Nutrition Examination Survey (NHANES) (2005). Prevalence
of overweight among children and adolescents ages 6-19 years, for selected years
1963-65 through 1999-2002. Retrieved July 13, 2004 from
http://www. cdc.gov/nch s/products/pub s/pub d/he stats/overwght9 9 .htm

Chapman-Novakofski, K. and J. Karduck. (2005) Improvement in knowledge, social cognitive
theory variables, and movement through stages of change after a community-based diabetes
education program. J. Anzer. Dietetic Assoc. 105(10): 1613-1616.

Children's Medical Service Program (2006) [Online]. CM~Snetwork. Available at:
http://www. cm s-ki ds. com/CM SNTally .htm

Creswell, J. W., Fetters, M. D., & Ivankova, N. V. (2004). Designing a mixed methods study in
primary care. Annals ofFantily M~edicine, 2, 7-12.

Cusatis, D. C., & Shannon, B. M. (1996). Influences on adolescent eating behavior. J
Adolesc Health, 18, 227-34.

Dallas, J.S., & Foley, T. P. (1996). Hypothyroidism. In: Lifeshitz F. ed. Pediatric
endocrinology. New York, NY: Springer-Verlag.


Daniels, S. R., Arnett, D. K., Eckel, R. H., Gidding, S. S., Hayman, L. L., Kumanyika, S.,
Robinson, T. N., Scott, B. J., St. Jeor, S., & Williams, C. L. (2005). Overweight in children and
adolescents: Pathophysiology, consequences, prevention, and treatment. Circulation, 111, 1999-
2012.










Davis, C. S. (2002). Statistical methods for the analysis of repeated nea;surentents. New York:
Springer Verlag.

DeVahl, J., King, R., & Williamson, J. W. (2005). Academic incentives for students can
increase participation in and effectiveness of a physical activity program.
JAnzCollHealth, 53(6),295-298.

Dietz, W. H. (1998). Health consequences of obesity in youth: Childhood predictors of
adult disease. Pediatrics, 101(3 Pt 2), 518-525.

Dietz, W. H. (2004). Overweight in childhood and adolescence [Electronic version]. The
New Englan2dJournal of2~edicine, 350(9), 855-857.

Dietz, W. H., Gross, W.L., Kirkpatrick, J.A. (1982). Blount disease (tibia vara): another skeletal
disorder associated with childhood obesity. JPediatr, 101:735-737.

Dilorio, F. C. (1991). SAS applications and progrananing: A gentle introduction. Belmont, CA:
Duxbury Press.

Dowda, M., Ainsworth, B. E., Addy, C. L., Saunders, R., & Riner, W. (2001).
Environmental influences, physical activity, and weight status in 8- to 16-year-olds [Electronic
version]. Archives of Pediatrics & Adolescent M~edicine, 155(6), 711-717.

Dreimane, D., Safani, D., MacKenzie, M., Halvorson, M., Braun, S., Conrad, B., & Kaufman, F.
(2006). Feasibility of a hospital-based, family-centered intervention
to reduce weight gain in overweight and adolescents. Diabetes and Research and
Clinical Practice.

Ebbeling, C. B., Pawlak, D. B. & Ludwig, D. S. (2002). Childhood obesity: Pulic-health
crisis, common sense cure. Lancet, 360, 473-482.

Edwards, L. (2000). Modern statistical techniques for the analysis of longitudinal data in
biomedical research. Pediatr Pulnzonol, 30(4), 330-344.

Eisenberg, M. E., Neumark-Sztainer, D., & Story, M. (2003). Associations of weight-
based teasing and emotional well being among adolescents [Electronic version]. Archives of
Pediatrics and Adolescent M~edicine, 157(8), 733-73 8.

Eliakim, Kaven, Berger, Friedlant, Wolack, & Namet (2002). The effect of a combined
intervention on body mass index and fitness in obese children and adolescents a clinical
experience. Eur JPediatr, 161, 449-454.

Fajans, S. S. (1990). Classification and diagnosis of diabetes. In Rifkin, H., & Porte, D.,
editors. Diabetes mellitus theory and practice (4th ed.). New York: Elsevier.

Finkelstein, E. A., Fiebelkorn, I. C., & Wang, G. (2003). National medical spending










attributable to overweight and obesity: How much, and who's paying [Electronic version]? The
Policy Journal of the Health Sphere, W3, 2 19-226.

Florida Department of Health (2004). Obesity in Florida: Report of the Governor's task
force on the obesity epidemic. Retrieved Sept. 4, 2005 from
http://www.doh. state.fl .us/Family/GTFOE/report.pdf

Florida Statutes (2006). Section 456.057(5)(a) 4.

Franz, M. J., Splett, P. L., Monk, A., Barry, B., McClain, K., Weaver, T., Upham, P., Bergenstal,
R., & Mazze, R. S. (1995). Cost-effectiveness of medical nutrition
therapy provided by dieticians for persons with non-insulin dependent diabetes
mellitus. Journal of the American Dietetic Association, 95(9), 1018-1024.

Freedman, D. S., Dietz, W. H., Srinivasnet, S. R., Berenson, G. S. (1999). The relation of
overweight to cardiovascular risk factors among children and adolescents: The bogalusa heart
study. Pediatrics, 103(6), 1175-1182.

Frick, K. D., Milligan, R. A., White, K., Serwint, J. R., & Pugh, L. C. (2005). Nurse-
supported breastfeeding promotion: A framework for economic development. Nursing
Economics, 23(4), 165-172.

Fried, E. J. & Nestle, M (2002). The growing political movement against soft drinks in
schools. JAM~A, 288, 2181-2181.

Gochman, D. S. (1987) Youngsters' health cognitions: cross-sectional and longitudinal
analyses. Health Behavior Systems, Louisville, KY.

Goldestein, D. E., Parker, K. M., England, J. D. (1982). Clinical application of
glycosolated Hemoglobin measurements. Diabetes, 31(supp), 70-78.

Gonzalez, J. L., & Gilmer, L. (2006). Obesity prevention in pediatrics: A pilot pediatric resident
curriculum intervention on nutrition and obesity education and counseling. JNat2~edAssoc.,
98(9), 1483-1488.

Hall, B. (2007) [On-line]. What is ethnography? Retrieved May 1, 2007 from:
http://www. sas.upenn.edu/anthro/CPIA/METHODS/Ethnogrpyhm

Hanna, J. S., & Howard, B. V. (1994). Dietary fats, insulin resistance and diabetes.
J Cardiovasc Risk, 1, 3 1-37.


Hardy, L. R., Harrell, J. S., & Bell, R. A. (2004). Overweight in children: Definitions,
measurements, confounding factors, & health consequences. Journal of Pediatric
Nursing










He, Q, & Karlberg, J (1999). Prediction of adult overweight during the pediatric years.
Pediatr Res, 46, 697-703.

Hendy, H. M., Williams, K. E., & Camise, T. S. (2005). "Kids Choice" school lunch
program increases children's fruit and vegetable acceptance. Appetite, 45(3),
250-63.

Huck, S., Cormier, W., & Bounds, W. (1974). Reading statistics and research. New York:
HarperCollins, 103-31.

Institute of Medicine (2005). Nutrition standar~ds for foodsdd~~d~~dd in school [ On-line].
Available at http://www.iom. edu/proj ect. asp?id=3 01 81.

Ivankova, N. V., Creswell, J. W., & Stick, S. L. (2006). Using mixed-methods sequential
explanatory design. Field2~ethods, 18(1), 3-20.

Jain, A. (2004). What works for obesity: A sunmanay of research behind obesity interventions.
London, UK: BMJ Publishing Group.

Johnson, J. G., Cohen, P., Kasen, S., & Brook, J. S. (2002). Childhood adversities
associated with risk for eating disorders or weight problems during adolescence or early
adulthood. American Journal ofPsychiatry, 159, 394-400.

Kaplowitz, P. B., Slora, E. J. Wasserman, R. C., Pedlow, S. E., Herman-Giddens, M. E. (2001).
Earlier onset of puberty in girls: Relation to increased body mass index and race. Pediatrics,
108(2), 347-353.

Klesges, R. C., Stein, R. J., Eck, L. H., Isbell, T. R. and Klesges, L. M. (1991) Parental
influence on food selection in young children and its relationships to childhood
obesity. American Journal of Clinical Nutrition, 53, 859-864.

Krueger, C., and Tian, L. (2004). A comparison of the general linear mixed model and repeated
measures ANOVA using a dataset with multiple missing data points. Biol Res Nurs, 6(151).

Kuehl, R. O. (2000). Design of experiments: Statisticl principles of research design and analysis
(2nd ed.). Duxbury Press.

Lazzer, S., Meyer, M., Derumeaux, H., Boirie, Y., & Vermorel, M. (2005). Longitudinal changes
in activity patterns, physical capacities, energy expenditure, and body composition in severely
obese adolescents during a multidisciplinary weight-reduction program. hIternational Journal of
Obesity, 29, 37-46.

Leinung, M.C, & Zimmerman, D. (1994). Cushing's disease in children. Endocrinol
Metab Clin North Am., 23, 629-639.










Little, R. J. A. (1995). Modeling the drop-out mechanism in longitudinal studies. Journal of the
American Statistical Association, 90, 1112-1121.

London, M. L., Ladewig, P. W., Ball, J. W. & Bindler, R. C. (2006). Maternal & Child Nursing
Care (2nd ed.). London: Prentice Hall.

Loos, R. J., & Bouchard, C. (2003). Obesity---is it a genetic disorder? Jlntern M~ed,
254(5), 401-424.

Ludlow, A. P., & Gein, L. (1995). Relationships among self-care, self-efficacy and Hb
Alc levels in individuals with non-insulin dependent diabetes mellitus (NIDDM).
Ca JDiabetes Care, 19, 10-15.

Luepker, R., Perry, C., McKinlay, S., Nader, P., Parcel, G., Stone, E., Webber, L., Elder,
J., Feldman, H., Johnson, C., Kelder, S., and Wu, M. (1996). Outcomes of a field trial to
improve children's dietary patterns and physical activity: The child and adolescent trial for
cardiovascular health (CATCH). JamJJJJJJJJ~~~~~~~~~a, 275, 768-776.

Manson, J. E., Nathan, D. M., Krolewski, A. S., Willett, W. C., & Hennekens, C. H. (1992). A
prospective study of exercise and incidence of diabetes
among US male physicians. JAM~A, 268(1).

Mast, M., Koirtzinger, I., Koinig, E., and Miidler, M. J. (1997). Gender differences in fat mass of
5 to 7 year-old children. Journal ofObesity, 22(9), 878-884.Maternal and Child Health Bureau
(MCHB) (2006). The national survey of children with special health care needs [Online].
Available at: ureau.http://mchb .hrsa.gov/chson/pages/prevalence.htm#incom

Maxwell, S. E., & Delaney, H. D. (1990). Designing experiments and analyzing data. Belmont,
CA: Wadsworth.

McGehee, M. M., Johnson, E. Q., Rasmussen, H. M., Sahyoun, N., Lynch, M. M., & Carey, M.
(1995). Benefits and costs of medical nutrition therapy by registered dieticians for patients with
hyperinsulinemia. Journal of the American Dietetic Association, 95, 1 041 1043 .

Margolis, H. & McCabe, P. P. (2004). Self-efficacy: A key to improving the motivation
of struggling learners. The Clearing House, 77, 241.

Medicine.net (2007). Body mass index (BMI) for children and teens. Retrieved July 09, 2007
from http://www.medi cinenet. com/script/main/art. asp?articlekey=412 84

Miller, C. K., Edwards, L., Kissling, G., & Sanville, L. (2002). Nutrition education
improves metabolic outcomes among older adults with diabetes mellitus: Results from a
randomized control group. Prev Med, 34, 252-259.

Monzavi, R., Dreimane, D., Geffner, M. E., Braun, S., Conrad, B., Klier, M. & Kaufman, F. R.
(2006). Improvement in risk factors for metabolic syndrome and









insulin resistance in overweight youth who are treated with lifestyle intervention.
Pediatrics, 117(6), ellll-elll8.

National Center for Health Statistics (NCHS) (2000). 2000 CDC gi/ 1,n th charts: thrited
States. Retrieved August 20, 2004 from http://www. cdc/gov/growthcharts/

National Center for Health Statistics (NCHS ) (2005). Prevalence of overweight among
children and adolescents: thrited States, 1999-2002. Retrieved January 1, 2005 from
http://www. cdc.gov/nch s/products/pub s/pub d/he stats/overweight9 9 .htm

National Conference of State Legislatures. Health promotion program state legislation
and statute database: Obesity, obesity-childhood, physical activity and nutrition. (Accessed May
25, 2006, at http:/www.ncsl .org/programs/health/phdatabase.htm)

National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI)
(1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and
obesity in adults. HHS, Public Health Service (PHS),xxiii.
Retrieved March 8, 2005 from:
http:.//www.nhlbi .nih.gov/guidelines/obesity/ob~home.htm

National Institutes of Health (NIH) (2003). Theory at a Glance: A guide for health promotion
practice. National Cancer Institute. Retrieved Sept 24, 2005 at
/redirect. cgi?r-http://www. cancer. gov/cancerinformation/theory-at-a-glance

Nestle, M. & Jacobson, M. F. (2000). Halting the obesity epidemic: A public health
policy approach. Public Health Reports, 115, 12-24.

QSR International (2002). N~ivo 2. 0. Doncaster, Victoria, Australia. Retrieved July 11, 2007 at
www. qsrinternational. com

Parcel, G. S., Simons-Morton, B., O-Hara, N. M., Baranowski, T., & Wilson, B. (1989).
School promotion of healthful diet and physical activity: impact on learning
outcomes and self-reported behavior. Health Educ Q. 16(2), 181-99.

Parjares (2002). Overview of social cognitive theory and ofself-efficacy. Retrieved Sept.
26, 2005 from http://www.emor. edu/EDUCATION/mfp/eff. html

Plourde, G. (2002). Impact of obesity on glucose and lipid profiles in adolescent
different age groups in relation to adulthood [Electronic version]. BM~C Family
Practice, 3. Retrieved online March 8, 2005 from
http://www.pubmedcentral.nih.gov/articlernefcitopumdub dd=
2379160

Potts, R. & Swisher, L (1998). Effects of televised safety models on children's risk
taking and hazard identification. JPediatr Psychol, 23(3), 157-63.










Raskin, P. et al ((1994). Medical management of non-insulin dependent (Type II)
diabetes (3rd ed.). Alexandria, Va: American Diabetes Association.

ReCapp (2006). Theories and' approaches: How can I use Social Learning Theory in my
setting? Retrieved online March 18, 2006 from
http://www. etr. org/recapp/theori es/slt/HowtoUse.htm

Redding, C. A., Rossi, J. S., Rossi, S. R., Velicer, W. F., & Prochaska, J. O. (2000).
Health behavior models. The International Electronic Journal of Health
Education, 3 (Special Issue), 180-193.

Reinehr, T., Brylak, K., Alexy, U., Kersting, M., & Andler, W. (2003). Predictors to success in
outpatient training in obese children and adolescents. International Journal of Obesity, 27(9),
1087-1092.

Resnicow, K., Davis-Hearn, M., Smith, M., Baranowski, T., Lin, L. S., Baranowski, J., Doyle,
C., & Wang, D. T. (1997). Social-cognitive predictors of fruit and vegetable intake in children.
Health Psychology, 16(3), 272-276.

Richardson, S. A., Goodman, N., Hastorf, A. H., & Dornbusch, S. M. (1961). Cultural
uniformity in reaction to physical disabilities. Am Soc Rev, 26( ), 241-247.

Rinderknecht, K., & Smith, C. (2004). Social cognitive theory in an after-school
nutrition intervention for urban Native American youth. Journal of Nutrition and Education
Behavior, 36(6), 298-304.

Robles, E., Crone, C. C., Whiteside-Mansell, L., Conners, N. A., Bokony, P. A., Worley,
L. L. & McMillian, D. E. (2005). Voucher-based incentives for cigarette smoking reduction in a
women's residential treatment program. Nicotine Tob Res, 7(1), 111-117.
Rohlfing C, Wiedmeyer H.M., & Little R. (2002). Biological variation of glycohemoglobin. Clin.
Chem. 48 (7): 1116-8.

Rose, M., Fliege, H., Hildebrandt, M., Schirop, T., & Klapp, B. F. (2002). The network
of psychological variables in patients with diabetes and their importance for quality of life and
metabolic control. Diabetes Care, 25, 35-42.

Rowan-Sazal, G., Joe, G. W., Chatham, L. R. & Simpson, D. D. (1994). A simple
reinforcement system for methadone clients in a community-based treatment program. JSubst
Abuse Treat, 11(3), 217-223.

Ryan, G. W. & Bernard, H. R. (2003). Techniques to identify themes. Field2~ethods, 15(1), 85-
109.

Saelens, B. E., Sallis, J. F., Wilfley, D. E., Patrick, K., Cella, J. A., & Buchta, R. (2002).
Behavioral weight control for overweight adolescents initiated in primary care.
Obesity Research, 10, 22-32.











Savoye, M., Berry, D., Dziura, J., Shaw, M., Serrecchia, J. B., Barbetta, G., Rose, P., Lavietes,
S., & Caprio, S. et al. (2004). Anthropometric and psychosocial changes in obese adolescents
enrolled in a weight management program. Journal of the American Dietetic Association,
105(3), 364-370.

Searle, S. R. (1971). Linear models. Wiley, New York.

Shaw, S. M., Kleiber, D. A., & Caldwell, L. L. (1995). Leisure and identity formation in male
and female adolescents: A preliminary examination. Journal of Leisure Research, 27(3), 245-
263.

Sheaves, R., Jenkins, P., Wass, J., & Thorner, M. (1997). Clinical endocrine oncology. Oxford:
Blackwell.

Silvestri, J. M., Weese-Mayer, D.E., Bass, M.T., Kenny, A.S., Hauptman, S.A., Pearsall, S.M.
(1993). Polysomnography in obese children with a history of sleep-associated breathing
disorders Pediatr Pulmonol, 16, 124-129.

Skelley, A. H., Marshall, J. R., Haughey, B. P., Davis, P. J., & Dunford, R. J. (1995).
Self-efficacy and confidence in outcomes as determinates of self-care practices in inner-city,
African-American women with non-insulin-dependent-diabetes. Diabetes Educator, 21, 38-46.

Spieth, L., Harnish, J. D., Lenders, C. M., Raezer, L. B., Pereira, M. A., Hangen, S. J., Ludwig,
D. S. (2000). A low-glycemic index diet in the treatment of pediatric obesity.
Arch Pediatr Adolesc M~ed, 154(9), 947-951.

Stange, K. C., & Zyzanski, S. J. (1989). Integrating qualitative and quantitative research
methods. FFFFFFFFFFFFFFFFFFam Prac M~ed, 21, 448-451.

Stark, O., Atkins, E., Wolff, O. H., & Douglas, J. W. B. (1981). Longitudinal study of
obesity in the National Survey of Health and Development. British M~edicalJournal, 283, 13-17.


Stone, D. (1998). University of Florida department of community and family health:
Social cognitive theory. Retrieved March 17, 2005 from
http ://hsc. usf edu/~kmb rown/ Soci al_C ognitive_Theory_Overvi ew. htm

Stunkard, A., Burt, V. (1967). Obesity and body image II. Age at onset of disturbance in
body image. Am JPsychiatry, 123(11), 1443-1447.

Taras, H. L., Sallis, J. F., Paterson, T.L., Nader, P.R. & Nelson, J. A. (1989). Television's
influence on children's diet and physical activity. JDev Behav Pediatr, 10, 176-180.

Taylor, M. J., Mazzone, M., Wrotniak, B. H. (2005). Outcome of an exercise and educational
intervention for children who are overweight. Pediatric Physical 7hzerapy, 17(3), 180-188.











Trevino, R., Pugh, J., Hernandez, A., Menchaca, V., Ramirez, R., & Mendoza, M (1998).
Bienstar: A diabetes risk-factor prevention program. Journal of School Health,
68(2), 62-7.

Van Duyn, M. A. S., Kristal, A. R., Dodd, K. (2001). Association of awareness, intrapersonal
and interpersonal factors, and stage of dietary change with fruit and vegetable consumption: A
national survey. Am JHealth Pronat, 16, 69-79.

Van Dyck, P. C., Kogan, M. D., McPherson, M. G., Weissman, G. R. & Newacheck, P. W.
(2004). Prevalence and characteristics of children with special health care needs. Arch Pediatr
Adolesc 2ed, 158, 884-890.

U. S. Department of Health and Human Services (2004). Nutrition and your health:
Dietary guidelines for Americans [Electronic version]. Retrieved December 30, 2004 from
http ://www.health.gov/dietaryguidelines/

U. S. Department of Health and Human Services (2001). The Surgeon General's call to
action to prevent and decrease overweight and obesity: M~easuring overweight
and obesity. [Electronic version]. Retrieved January 2, 2005 from
http://www. surgeongeneral .gov/topi cs/ob esity/calltoacti on/1_1 .htm

U. S. Department of Health and Human Services (2000). Healthy People 2010: Thiderstanding
and improving health. Conference edition. Washington: Government Printing Office.

U. S. Department of Health and Human Services (1990). Healthy People 2000: National health
promotion and disease prevention objectives. Conference edition. Washington: Government
Printing Office.

Wang, Y. (2002). Is obesity associated with early sexual maturation? A comparison of the
association in American boys versus girls. Pediatrics, 110(5), 903-910.

Wang, G. & Dietz, W. H. (2002). Economic burden of obesity in youths aged 6 to 17 years:
1979-1999. Pediatrics, 109(e81).

Weinreich, N. K. (2005). Integrating quantitative and qualitative methods in social
marketing research. Retrieved on Nov. 17, 2005 from http://www.social-
marketing. com/research. html

Wing, R.R., Marcus, M. D., Epstein, L.H., & Salata, R. (1987). Type II diabetic subjects lose
less weight than their overweight non-diabetic spouses. Diabetes Care, 10, 563-566.

Woo, K. S., Chook, P., Yu, C. W., Sung, R. Y., Qiao, M., Leung, S. S., Lam, C. W., Metreweli,
C., & Celermajer, D. S. (2004). Effects of diet and exercise on obesity-related vascular
dysfunction in children. Circulation, 109, 1981-1886.










WHO (2003). Diet, nutrition and the prevention of chronic diseases. World Health
Organ Tech Rep Ser, 916, 1-149.

Zador, I., Meyer, L. J., Scheets, D. R., Wittstruck, T. M., Timmler, T., & Switaj, D. M. (2006).
Hemoglobin Alc in obese children and adolescents who
participated in a weight management program. Acta Paediatrica, 95(1), 105-107.









BIOGRAPHICAL SKETCH

Susan Wall is currently working as an Assistant Professor at Florida State University

College of Nursing. Her educational background includes a Registered Nurse Diploma from

Fanshawe College in Ontario, Canada, and a Bachelor and Master of Science of Nursing from

the University of Florida. She is a Certified Nurse Midwife.





PAGE 1

1 EVALUATION OF A CHILDRENS MEDICAL SERVICES PROGRAM FOR OVERWEIGHT CHILDREN AND ADOLESCENTS WITH HYPERINSULINEMIA AND TYPE II DIABETES By SUSAN WALL A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORI DA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2007

PAGE 2

2 Susan Wall 2007

PAGE 3

3 To Daniel Manry

PAGE 4

4 ACKNOWLEDGEMENTS I thank Daniel Manry and my family. I also thank my supervisory chair, Dr. Charlene Krueger, and committee members (Dr. Sharleen Simpson, Dr. Allyson Hall and Dr. Kathleen Wilson).

PAGE 5

5 TABLE OF CONTENTS page ACKNOWLEDGEMENTS.............................................................................................................4 LIST OF TABLES................................................................................................................. ..........8 LIST OF FIGURES................................................................................................................ .........9 ABSTRACT....................................................................................................................... ............10 CHAPTER 1 INTRODUCTION..................................................................................................................12 Overweight Prevalence.......................................................................................................... .13 Definition of Overweight....................................................................................................... .14 Risk Factors for Overweight...................................................................................................15 Environmental.................................................................................................................15 Behavioral..................................................................................................................... ...16 Personal....................................................................................................................... ....16 Overweight Costs and Implications........................................................................................17 Public Health Policy and Program Interventions....................................................................18 Children's Medical Services and Program..............................................................................21 Significance of the Study...................................................................................................... ..23 2 LITERATURE REVIEW.......................................................................................................26 Theoretical Perspective of CMS Program..............................................................................26 Major Concepts of Social Cognitive Theory..........................................................................27 Reciprocal Determinism..................................................................................................28 Behavioral Capability......................................................................................................29 Expectations................................................................................................................... .30 Self Efficacy.................................................................................................................. ..31 Observational Learning......................................................................................................... .32 Reinforcement.................................................................................................................. .......34 Summary........................................................................................................................ .........44 3 METHOD......................................................................................................................... ......61 Study Aims..................................................................................................................... ........61 Specific Aim #1...............................................................................................................61 Specific Aim#2................................................................................................................61 Specific Aim #3...............................................................................................................62 Sample and Sample Size.........................................................................................................62 Inclusion Criteria.............................................................................................................62 Exclusion Criteria............................................................................................................62

PAGE 6

6 Recruitment.................................................................................................................... .63 Procedure...................................................................................................................... ..........64 Part #1: Repeated Measures Retrospective Chart Review..............................................64 Part #2: Post-Program Interviews....................................................................................64 Part #3: In-Class Observation..........................................................................................64 Human Subjects................................................................................................................. .....65 Confidentiality and Legal Minority.................................................................................65 Possible Discomforts and Risks......................................................................................66 Possible Benefits.............................................................................................................66 Description of Quantitative Analyses: Chart Review.............................................................66 Descriptive Statistics.......................................................................................................66 Repeated Measures ANOVA..........................................................................................66 General Linear Mixed Model..........................................................................................68 Description of Qualitative Analyses: Interviews and In-Class Observations.........................70 Summary........................................................................................................................ .........72 4 QUANTITATIVE RESULTS................................................................................................73 Chart Review Findings.......................................................................................................... .73 Descriptive Analyses.......................................................................................................73 Repeated Measures ANOVA..........................................................................................74 General Linear Mixed Model..........................................................................................74 5 QUALITATIVE RESULTS...................................................................................................80 Post-Program Interview Findings...........................................................................................80 Why Did You Attend the Program?................................................................................81 What Was the Program Like for You?............................................................................82 What Did You Like Most about the Program?................................................................83 What Did You Like Least About the Program?..............................................................85 What Do You Suggest For Program Improvement?.......................................................87 Would You Recommend the Program to Others?...........................................................88 What Are Your Post-Progr am Behavioral Changes?......................................................89 What Are Your Post-Program Physical Changes?..........................................................92 What Are the Challenges to Behavioral Changes?..........................................................93 In-Class Observation Findings...............................................................................................96 Session Attendance..........................................................................................................96 Exercise Activity.............................................................................................................97 Snack Activity...............................................................................................................100 Educational Activity......................................................................................................102 Theoretical Learning Concepts Used in the Program...........................................................106 Reciprocal Determinism................................................................................................107 Behavioral Capability....................................................................................................108 Expectations and Self-Efficacy.....................................................................................109 Observational Learning.................................................................................................110 Reinforcement...............................................................................................................111 Summary........................................................................................................................ .......111

PAGE 7

7 6 DISCUSSION..................................................................................................................... ..114 Discussion of Quantitative Findings.....................................................................................115 Discussion of Qualitative Findings.......................................................................................119 Positive Post-Program Behavior Change......................................................................119 Reluctance To Change Po st-Program Behaviors..........................................................120 Impediments to Engaging Youths.................................................................................121 Program Service Deficiencies.......................................................................................123 Additional Parent Concerns...........................................................................................124 Implications for Health Policy and Future Research............................................................124 Summary........................................................................................................................ .......131 APPENDIX A CMS PROGRAM CURRICULUM.....................................................................................133 B INTERVIEW GUIDE...........................................................................................................143 C HIPAA IDENTIFYING FACTORS.....................................................................................145 D CHART DATA COLLECTION FORM..............................................................................147 LIST OF REFERENCES.............................................................................................................148 BIOGRAPHICAL SKETCH.......................................................................................................159

PAGE 8

8 LIST OF TABLES Table page 1-1 Prevalence of overweight among children and adolescents ages 6-19 years: For selected years 1963-65 through 1999-2002.......................................................................25 2-1 Major Learning Concepts in Social Cognitive Theory......................................................46 2-2 The Evaluation of Learning Concepts Social Cognitive Theory in Literature..................47 2-3 Abbreviated Version Table: Outpatient Secondaryand Tertiary-Level Nutrition and Exercise Programs.............................................................................................................48 2-4 In-Depth Version Table: Outpatient Secondaryand Tertiary-Level Programs................50 4-1 Repeated measures ANOVA for BMI us ing 26 subjects: W ithinand betweensubjects effects............................................................................................................... ....77 4-2 General mixed linear model effects for BMI using 59 subjects.......................................77 4-3 General linear model effects for Hb A1c using 59 subjects..............................................77

PAGE 9

9 LIST OF FIGURES Figure page 4-1 Chart Review: BMI (BMI1) m easurements over 12 months. ..........................................78 4-2 Chart Review: Hb A1c (A1c1) measurements over 12 months. ......................................79

PAGE 10

10 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy EVALUATION OF A CHILDRENS MEDICAL SERVICES PROGRAM FOR OVERWEIGHT CHILDREN AND ADOLES CENTS WITH HYPERINSULINEMIA OR TYPE II DIABETES By Susan Wall August 2007 Chair: Charlene Krueger Major: Nursing Sciences The tripling of overweight rate s among youths in the last 30 years (National Center for Health Statistics, 2005) has engendered a variety of public policy strategies. One such strategy is behavior intervention programs involving diet and exercise be havior modification. In 2002, Tallahassee Childrens Medical Services (CMS) im plemented a behavior intervention program. Youths, diagnosed with either hyperinsulinemia or type II diabetes, and their parents, were targeted. The purpose of this study was to evaluate the effectiveness of the CMS program by using a three-part, mixed method design. The evaluation included: 1) a repeated measures retrospective chart re view; 2) participant interviews; and 3) in-class observations. Convenience sampling was used. The chart review compared the body mass index (BMI) and the glyc osylated hemoglobin (Hb A1c) of the youths at approximately th ree and six-month s before program participation ; the first day of the program ; and approximately three and six -month s after program partic ipation. A qualitative component involved interviewing 11 youths and pa rents, and observing four class sessions. Youths ages ranged from 7 to 18 years ( M = 13, SD = 2.68). A repeated measures ANOVA analysis revealed that BM I measures increased over time ( df 4; F = 4.95; P<0.05). The

PAGE 11

11 findings were then confirmed using a mixed genera l linear model. In addition, the mixed general linear model revealed that Hb A1c decreased over time ( df 4; F = 2.80; P<0.05). All youths and parents reported post-program nutri tion and exercise beha vioral changes. Five main themes emerged from the interview data and field notes. First, all youths and parents reported positive post-program nutrition and exer cise behavior changes. Second, parents reported that the youths were reluctant to change post-program health behaviors. The last three themes revealed areas that the CMS program can use to improve curriculum methodology: 1) the presence of impediments to engaging youths; 2) the existence of program service deficiencies; and 3) additional parent concerns that went beyond the prioritie s of the program. While positive health outcomes are the goal of any behavior intervention program, health outcomes are not the sole measure of a success. Positive changes in behavior such as exercise and nutrition are necessary prerequisites to posit ive health outcomes and, therefore, a valid measure of success toward positive health outcomes. Qualitative fi ndings in this study suggest that the CMS program achieved positive changes in exercise and nutrition that may potentially endure after the conclusi on of the program. As the CMS program improves and is further validated, it may be revised and replicated in programs that ta rget similar populations.

PAGE 12

12 CHAPTER 1 INTRODUCTION Today more children and adolescents are overw eight and presenting with related medical symptoms. National overweight rates among ch ildren and adolescents have tripled since 1980 (National Center for Health Statistics (NCHS), 2000). Tallahassee Children's Medical Services (CMS) is a Florida Title V Program for children with special health care needs. Children with sp ecial health care need s are those children under age 21 whose serious or chronic physical, developmenta l, behavioral or emotional conditions require extensive preventive a nd maintenance care beyond that re quired by typically healthy children (Maternal and Child H ealth Bureau (MCHB), 2006). In 2002, CMS implemented a nutrition and ex ercise behavior intervention plan for overweight youths, ages 7 to 18 y ears old, with type II diabetes or hyperinsulinemia, a precursor to type II diabetes Nutrition and exercise beha vior modification is base d on learning concepts of Social Cognitive Theory (Bandura, 1986). Behavi or modification is directed at improving the weight, body mass index (BMI), and glycosylated hemoglobin (Hb A1c) of CMS youths. This study focused on evaluating a program (CMS ) for children with special health care needs that are attributable to being overweight or at-risk-for-overweight. The evaluation utilized a mixed-method approach that included both a quan titative and qualitative analysis with three specific aims. The first aim was to carry out a repeated m easures, retrospective chart review comparing CMS program youths biological measurements of BMI and Hb A1c at approximately three and six-month s before program participation ; the first day of the program ; and approximately three and six-month s after program participation. Statistical analysis of the data was intended to reveal changes in BMI and Hb A1c over time.

PAGE 13

13 The second aim was to carry out post-program interviews among youths and parents using an interview guide. Thematic analysis of the da ta gathered aimed to elucidate salient strengths and weaknesses of the program not measured by the quantitative data. The third aim was to observe and take fiel d notes during the in-class program sessions. Thematic analysis was intended to enable me to take full account of the interactions between the participants and their pot ential effects in the soci al setting of the program. This chapter provides an overview of: 1) overweight prevalence; 2) a definition of overweight; 3) risk factors for overweight; 4) overw eight costs and implications; 5) public health policy and program interventions; 6) CMS servic es and program; and 7) the significance of the study. Overweight Prevalence According to the National Center for Health Statistics (NCHS, 2005), the incidence of overweight in children and adolescents nearly tr ipled from 1980 to 2000. An estimated 16% of children ages 6 to 12, and adolesce nts, ages 12 to 19, are overweight1 (Table 1-1) (NCHS, 2005). Changes in weight are tracked as part of physical examinations given to a sample of the non-institutionalized U.S. populatio n in the National Health and Nutrition Examination Survey (NHANES). The 1999-2000 NHANES estimates suggest that overweight in affected youth has not leveled off or decreased but is increasing to even hi gher levels (NCHS, 2000). The data for affected youths is significant for the general population. Children and adolescents who are overweight ar e at greater risk of becoming overweight and obese adults (He & Karlberg, 1999). Probability charts, based on childhood BMI, predict adult overweight or obesity (He & Karlberg, 1999). About 50% of ove rweight adolescents with a BMI at or above 1 For youths younger than 20 years, overweight is defined as BMI at or above the 85th percentile, meaning that 85% of the population weighs less. Obese is defined as BMI at or above the 95th percentile (NCHS, 2004).

PAGE 14

14 the 95th percentile become obese adults (Dietz 1998). Approximately 65% of U.S. adults are now obese (NCHS, 2000). Definition of Overweight Definitions of overweight and at-risk-for-overweight (at risk) are based on body mass index (BMI). BMI is a measure of body fat that is calculated by dividing an individual's weight in kilograms by the square of his or her height in meters (National Institute of Health (NIH), 1998). Ideally, BMI for youths is inte rpreted by reference to the Ag eand Sex-Specific Growth Charts for children ages two to 20 years publis hed by the Centers for Disease Control (CDC, 2005). The CDC chart takes into account changes in percentages of body fat among children and adolescents as they grow. For instance, such ch anges occur: 1) from ages four to six years, during the occurrence of growth spurts; and 2) during adoles cence, when BMI increases secondary to pubertal development (Dietz, 1998) Based on the CDC chart, the proposed study defines the term "overweight" for the study grou p as BMI at or above the 95th percentile and defines the term "at-risk-for-overweight" as BMI between the 85th and 95th percentiles (at risk) (NCHS, 2000)The following examples elucidate the significance of us ing ageand genderspecific growth charts. For example, as a boy grow s, his BMI changes, yet he remains at the 95th percentile BMI-for-age. At age 2, if his BMI is 19.3, he is at the 95th percentile. At age 4, if his BMI is 17.8, he is still at the 95th percentile. At age 9 years, if his BMI is 21.0 he is at the 95th percentile. At age 13, if hi s BMI is 25.1, he is at the 95th percentile. The boy's BMI declines during his preschool years and increases as he gets older (medicinenet.com, 2007). Additionally, gender differences in fat mass a nd fat distribution have been found to be obvious in children ages 5 to 7 years of age (M ast, Krtzinger, Knig and Mller, 1997). For example, Mast et. al (1997) found boys to have increased body weights ( P <0.05), body mass

PAGE 15

15 indexes (BMI's) ( P <0.001) and waist hip ratios (WHRs) ( P <0.001), and girls to have the % fat mass (as assessed by anthropometric measures such as bioelectrical impe dance analysis) (BIA) ( P <0.05), to be increased. Risk Factors for Overweight Excessive weight gain may begin at any age fo r a variety of reasons (Stark, Atkins, Wolff, & Douglas, 1981). Overweight ma y be explained by several fact ors: 1) environmental 2) behavioral, and 3) personal. Environmental Youths exposed to certain environmental fact ors are more likely to be overweight. For example, youths are more likely to be overweight and at risk if they liv e in low-socioeconomic households, (Alaimo, Olson, & Frongillo, 2001), have obese or sedentary parents, or experience parental maltreatment (Johnson, Cohen, Kasen, & Brook, 2002). Although children from low socioeconomic b ackgrounds have a greater incidence of overweight, the prevalence of special health need s does not vary substantially based solely on income. The percentage of ch ildren with special h ealth needs is appr oximately 13.6% for children living in poverty and for children living in families with family incomes four times the poverty level or more. Poverty guidelines va ry by family size. During 2001, the poverty guideline for a family of four was $17,650 (MCHB, 2006). Other environmental factors asso ciated with being overweight a nd at risk include the heavy marketing of fast-food outlets and micronutrie nt-poor foods and beverages (World Health Organization (WHO), 2003). Anot her environmental factor, breastfeeding, is a probable protective etiological factor for being overwei ght or at-risk-of-ove rweight (WHO, 2003).

PAGE 16

16 Behavioral Certain behaviors are also a ssociated with being overwei ght. These behaviors include watching television for more than two hours a day (Dowda, Ainsworth, Addy, Saunders, & Riner, 2001), maintaining a sede ntary lifestyle, consuming hi gh intake of energy-dense, micronutrient-poor foods, or exhi biting either depression or eati ng disorders (Barlow & Dietz, 1998). Personal Personal factors include having ce rtain endocrine disorders that predispose an individual to overweight (Dallas, & Foley, 1996; Leinung & Zimmerman, 1994). Genetics not associated with syndromes may also relate to being overweight For example identical twins have similar adiposity, irrespective of the environment in which they are raised (Loos & Bouchard, 2003). Children with special health needs are vulnerabl e to factors that pla ce other children at nutritional risk, but also may be susceptible to a myriad of additional biological, environmental, and psychosocial variables. These additional factors may further jeopardize their nutritional status and pose barriers to their development. A greater proportion of ethnic minority child ren experience special health needs, and children with special health needs are at a greater risk of overweight. More children with special health needs are Native American/Alaska Nati ve children, multiracial, and non-Hispanic White children. Approximately 14.2% of Hispanic White children, 13% of non-Hispanic Black children, 8.6% of Hispanic childr en, and 4.4 percent of non-Hispanic Asian children have special health needs (MCHB, 2006). Whatever the contributing factor s to overweight are, being over weight poses serious health risks. Overweight-related heal th conditions significantly increase the need for health care and the costs required for such care.

PAGE 17

17 Overweight Costs and Implications U.S. overweight-associated hospi talizations among children a nd adolescents have tripled since 1979 (Wang & Dietz, 2002), and cost es timates for medical problems related to overweight have reached 92.6 billion dollars (F inkelstein, Fiebelkorn, & Wang, 2003). According to Dietz (1998 and 2004), immediat e and long-range health complications of being overweight include hyperinsulinemia and type II diabetes (Dietz, 1998), orthopedic disorders (Dietz, Gross, & Kirkpatrick, 1982) sleep apnea (Silvestri et al., 1993), and cardiovascular disease including hypertension and hyperl ipidemia (Freedman, Dietz, Srinivasan, & Berenson, 1999). Psychosocial consequences include discrimination, isolation, stigma, and low self-esteem (Richardson, Goodman, Hastor f, & Dornbusch, 1961; Stunkard, & Burt, 1967; Eisenberg, Neumark-Szta iner, & Story, 2003). Type II diabetes may cause coronary and pe ripheral vascular disease, nephropathy, retinopathy, and neuropathy (Hardy, Ha rrell, & Bell, 2004). Similar health risks are associated with individuals who have hyperinsulinemia or impaired glucose tole rance, a condition marked by higher than normal plasma insulin and gl ucose levels that are too low to be considered diagnostic for diabetes (Raskin et al., 1994). While previous research findings su ggest that Hb A1c values improve with weight loss of about 10 lb or five percent of body weight (Wing, Marcus, Epstein, & Salata, 1987), other research findings suggest that elevated Hb A1c values may improve without weight loss but from increasing activity alone (American Di abetes Association (ADA), 2006). Lifestyle modifications to improve diet and ex ercise continue to represent the cornerstone of therapy for hyperinsulinemia and type II di abetes (ADA, 2006). Dietetic and exercise programs often target Hb A1c values because Hb A1c values greater than 6.5 to 7.0 represents poor glucose control and lead to poor health outcomes (Barclay and Vega, 2006).

PAGE 18

18 Many federal health agencies and private organizations have issued public health guidelines for reducing overweight and overweight health risks. The federal health and private organizational guidelines focus primarily on environment and individual behavioral change (Nestle & Jacobson, 2000). Public Health Policy and Program Interventions As early as 1952, the public health organiza tion, the American Heart Association, began identifying diet and exercise as a modifiable risk factor of car diovascular disease. However, when rising rates of overweight emerged in the 1980's and 1990s, the prevention of overweight in individuals and among populat ion groups became an explicit goal of national public health policy (Nestle & Jacobson, 2000). For example, Healthy People 2000, made the issu e of overweight status and the need for exercise a national priority. Their objective was to reduce overweight among adolescents to 15 percent, and to increase physical activity and f itness (U. S. Department of Heath and Human Services (DHHS), 2000). Currently, Healthy People 2010 seeks to reduce overweight among children and adolescents to five percent. Healthy People 2010 incl udes specific obesity-rela ted objectives (U. S. DHHS, 2000). The objectives include increased physical ac tivity, consumption of more healthful diets, increased use of nutrition la bels, reduced sources of unnecessary calories, increased nutrition and phys ical education in schools and improved access to community recreational facilities (U. S. DHHS, 2000). Programmatic interventions and policies of local governments have focused primarily on what researchers describe as a "toxic environment" that has evolved in public schools; an environment that provides students with non-nutr itious foods and minimal exercise (Ebbeling, Pawlak, & Ludwig, 2002). About 60 % of the middle schools and high schools in the United

PAGE 19

19 States sell soft drinks from vending machines (Fried & Nestle, 2002). Many meals prepared under the National School Lunch Program include excessive amounts of saturated fats (Carter, 2002). Only 28 percent of high-school students participate in daily physical education (CDC, 2004). Local governments are attempting to im prove the public school environment. Efforts include policies intended to re duce the availability of foods that are not nutritious and to increase physical activity (National Conference of St ate Legislatures, 2006). New legislation restricts competitive food sales, such as non-nutritious sn acks and beverages that compete with school lunch programs. The beverage industry has recently adopted guidelines designed to curtail vending machine sales by 2010 (American Beverage A ssociation, 2006). losed-campus policies are intended to keep students at school for lunch so students will not be able to go to local stores and restaurants and purchas e non-nutritious foods. However, since the federal government ha s not established minimum standards for nutrition and exercise interventi ons in public schools, for most public schools, closed-campus policies are a moot point. Additionally, th e federal government has not promulgated any rules regulating the sale of competitive foods in public schools (Institute of Medicine (IOM), 2005). Prevention programs for affected youth seek to propagate future informed adults who can advocate for healthful diets and exercise in health centers, communities, workplaces, schools, and many other venues (IOM, 2005). Many of these venues are subject to federal and other governmental regulations that can be modified to enhance he althful diet and exercise. Higher education can be modified to require curricula for health care providers to include the benefits of healthful diet a nd exercise patterns, the risks fo r obesity, counseling methods that effectively modify behavior efficacious health promotion campaigns for health care agencies,

PAGE 20

20 research agenda focused on behavioral as well as metabolic determinants of weight gain and maintenance, and the most cost-effective met hods for promoting healthful diet and activity patterns (Nestle & Jacobson (2000). Medicare an d Medicaid reimbursement regulations can be modified to adequately reimburse health care providers for nutr ition and obesity counseling and other interventions that meet specific standards of cost and effectiveness. Healthy People 2010 addresses the role of h ealthcare providers. A ppropriate clinical practice includes preventive services nutrition screen ing and assessment, counseling, and referrals to qualified nutrition professionals fo r nutrition assessment, education, counseling on behavioral change, diet modification, and specialized nutri tion therapies represents (U. S. DHHS,2000). Many of these clinical practices are crucial element s of program interventions for affected youth. According to Gonzalez and Gilmer (2006), the most cost-effective method of approaching the obesity epidemic is through education of heal th professionals. As part of an "Obesity Prevention in Pediatrics" curriculum, postgradua te-year (PGY)-2 residents first observed and then participated in the dietary evaluation and couns eling of pediatric patients and their families. Following participation in the curriculum, study re sidents' knowledge tended to improve, as did their level of comfort in counseling obese and at-r isk children, adolescents and their parents. The "Obesity Prevention in Pediatri cs" curriculum appeared to impr ove participants' knowledge base as well as their skills and level of personal comfort in the recognition, evaluation and management, including counseling, of both obese and at-risk pediatri c patients and their families.Additionally, nutrition counseling by register ed dietitians is found to be cost effective for patients with hyperlipidemia (McGehee et al ., 1995) and type 2 diabetes mellitus (Franz et

PAGE 21

21 al.,1995). This is because dietetic education prom otes behavioural change in patients that, in turn, prevents future costly heal th care for health complications. Prevention programs for affected youth implemen t policies of pediatric health providers. For example, pediatric health providers advocate the use of ageand sex-specific BMI for early identification of weight gain, dietary and exercise interventions, and more advocacy and research (American Academy of Pediatrics,2003). The National Institute of H ealth (NIH) (2004) distinguish es primary, secondary, and tertiary programs based on di sease stage. The disease prevention model is not new As early as 1957, the Commission on Chronic Illness used th e disease prevention model to classify prevention programs based on the stage of the disease process (Nestle & Jacobsen, 2000), Primary programs aim to prevent inappropriate we ight gain in youths currently at a healthy weight (BMI less than the 85th percentile). Secondary programs aim to prevent further weight gain in youths currently at risk of overweight (BMI greater than or equal to the 85th percentile to less that the 95th percentile). Tert iary programs target interventions at youths already overweight (BMI greater than or equal to the 95th percentile) (NIH, 2004). Children's Medical Services and Program The CMS program addresses dietetic and exer cise behaviors of overweight youths ages 7 to 18 years old, diagnosed with type II diabetes or hyperins ulinemia, a precursor of type II diabetes It is categorized as a tert iary program because its interv entions target youths already overweight. As previously mentioned, CMS is a Florida Title V Program for children with special health needs. CMS implemented the interv ention program for overw eight members in 2002. CMS is one of several programs funded by the Federal-State Title V Block Grant Partnership

PAGE 22

22 Budget.2 The purpose of Title V is to improve the health of all mothers and children, including children with special health needs (MCHB, 2006). Nationally, about 963, 634 childre n and adolescents participat e in services for children with special health needs (12.8% of child and adolescent population). Services for children with special health needs account for more than half of all child-related health care costs (Van Dyck, Kogan, Merle, McPherson, Weissman, & New acheck, 2004). Florida serves about 64, 992 children with special health needs, and 40.8 perc ent of the total 2006 Florida Title V budget is allocated to health services for those children (MCHB, 2006). The CMS program provides children with spec ial health needs with a familycentered, managed system of care. CMS provides a comp rehensive continuum of medical and supporting services to medically and financially eligible children and high-risk pregnant women. The continuum of care includes prev ention and early inte rvention programs, primary care, medical and therapeutic specialty care and long-term care. CMS is a program of the Florida Departme nt of Health (DOH) and is directed by the Deputy Secretary for CMS. The CMS Program is divided into two divisions: the Division of CMS Network and Related Programs; and the Divi sion of Prevention and In tervention. There are 22 CMS arranged in eight regional offices thr oughout the State of Fl orida (CMS, 2006). CMS serves about 2,000 children in the northwe st region of Florida comprised of 8 counties: Franklin, Leon, Jefferson, Liberty, Madison, Taylor, Wakulla, and Gadsden. Leon County (Tallahassee) accounts for 50 percent of CMS clients; Gadsden County accounts for 2 The Title V includes Federal funds, State funds, local funds, and program income. Each year, States report how their Title V budget is allocated among pregnant women, infant s, children ages 1-22, children with special health care needs, all others, and administration.

PAGE 23

23 nearly 25 percent of CMS clients; the remain ing outlying counties acc ount for 25 percent of CMS clients (CMS, 2006). In 2002, the CMS initiated a nutrition and ex ercise program in response to increased numbers of overweight children and adolescents presenting to the Diabetic and Endocrine Clinics with type II diabetes or hyperinsulinemia The program consists of four 1-hour sessions for youths and parents, and emphasizes heal thy dietetic and physical behaviors. Research shows that overwei ght children and adolescents benefit from comprehensive dietetic and exercise education (Dreimane et al., 2006; Eliakim, A. et al., 2002; Monzavi, R. et al., 2006; Savoye et al., 2004; Speith, L. et al., 2000; & Taylor et al., 2005). CMS is in a position to contribute to disease prevention strategies among overweight youths, offer information about what occurs within a program, and to report progress on health outcomes. Significance of the Study Despite many efforts in health care, overwei ght prevalence rates continue to rise among youths (NCHS, 2005). Being overweight poses seri ous health risks and significantly increases the need for health care and the costs required for such care (Bandura, 2004). By managing health habits, youths can have l onger and healthier lives (Bandura, 2004). Disease prevention programs can assist youths to consistently practice h ealthy lifestyle choices through a variety of behavioral interventions. In a time of guarded public health budgets, economic reality necessitates efficient resource allocation. Intervention programs fo r affected youth that prevent or reduce the cost of disease treatment appeal to health providers, the publ ic, and policymakers (Frick, Milligan, White, Serwint, & Pugh, 2005). Prevention holds significant promise for overweight and overweight-related health complications because prevention programs work (Dreimane et al., 2006; Eliakim, A. et al.,

PAGE 24

24 2002; Monzavi, R. et al., 2006; Savoye et al., 20 04; Speith, L. et al., 2000; Taylor, Mazzone, & Wrotniak, 2005). Public behavioral interven tion programs, such as the CMS program, demonstrate a growing commitment toward the integration of re search and practice in disease prevention activities for vulnerable individuals and their families. P ublic health nurses comprise an important component of this collective effort and play a unique role within public heath programs that creatively utilize research to strengthen program prac tices, including those involved in addressing the issues of overweight. The findings of this study will be used to suggest ways to improve the CMS program and develop further study of the program. In the futu re, agencies similar to the CMS may want to replicate the program in order to improve the diet and activity behaviors of their patients because improved health behaviors lead to improved health outcomes.

PAGE 25

25 Table 1-1. Prevalence of overweight among child ren and adolescents ages 6-19 years: For selected years 1963-65 through 1999-2002. Fro m Cent ers for Disease Control and Prevention (CDC), Na tional Center for Health Statistics, National Health Nutrition Examination Survey (NHANES) (2005). 3 Data for 1963-65 are for children 6-11 years of age; data for 1966-70 are for adolescents 12-17 years of age, not 12-19 years. Age (years) NHANES 1963-65 1966-703 NHANES 1971-74 NHANES 1976-80 NHANES 1988-1994 NHANES 19992002 6-11 4% 4% 7% 11% 16% 12-19 5% 6% 5% 11% 16%

PAGE 26

26 CHAPTER 2 LITERATURE REVIEW The Childrens Medical Services (CMS) progr am is based on Social Cognitive Theory (Bandura, 1986) because the theory provides a basi s for promoting healthy dietetic and exercise behavior change among youths in intervention programs. Following the theory background for this study, major health organization recommenda tions for overweight youths and out patient intervention programs are reviewed. Theoretical Perspective of CMS Program By applying Social Cognitive Theory to in tervention programs, how individuals acquire and effectuate behavior, the process for changi ng behavior, and the effe cts on behavior caused by external influences may be explained (National Institute of Health (N IH), 2003). Health is influenced by lifestyle behaviors. By managing lifestyle behaviors, people can have longer and healthier lives (B andura, 2004). Albert Bandura (1997) eluc idates that behavior is influen ced by the interplay of 1) personal factors, 2) behavioral factors, a nd 3) environmental factors. This three-part interplay is identified as triadic reciprocality or reci procal determinism. Within the triad, cognition is critical for individuals to construct realit y, self-regulate, encode info rmation, and perform behaviors (Pajares, 2002). Social Cognitive Theory is often referred to as Social Learning Theory. A personal-behavior interaction involves bi-d irectional influences between an individual's thoughts, emotions, biological properties, and actions (Bandura, 1997). For example, an individual's expectations and goals regarding their weight give sh ape to behavior. In turn, new dietetic and exercise behavior s affect thoughts and emotions. Bi ological personal factors include sex, ethnicity, temperament, and genetic predispos ition and the influences th ey have on behavior.

PAGE 27

27 An environmental-personal interaction invol ves bi-directional influences between an individual's environment and personal charact eristics (Bandura, 1997). An individual's expectations and cognitive competencies regarding health are affected by social influences and physical structures within th e environment. For example, the home environment conveys information and activates emotional reactions ab out nutrition and exerci se through factors such as persuasion, modeling and inst ruction (Bandura, 1986). An indi vidual may receive different reactions from her social environment dependi ng on the individuals size, age, race, sex and appearance. A behavior-environmental interaction involve s bi-directional influences between an individual's thoughts, emotions, biological properties and thei r environment (Bandura, 1997). Behavior influences environment, such as when a parent stops br inging high-calorie, lownutrient foods into the home for children and adolescents to cons ume. This new environment in the home, may contribute to what forms of a child's behavior are developed and activated (Bandura, 1989). Beyond this three-part interplay of reciprocal determinism, th ere are other major concepts of Social Cognitive Theory that explain how be havior may be influenced. This study used the theoretical concepts of Banduras Social Cognitive Theory to obs erve and describe how the CMS behavioral intervention program taught content and which learning behaviors were targeted. The following elucidates those concepts. Major Concepts of Social Cognitive Theory Behavior may be influenced by the following: 1) reciprocal determin ism; 2) behavioral capability; 3) expectations; 4) self-efficacy; 5) observational learning; and 6) reinforcement (NIH, 2003) (Table 2-1). For example, behavioral change results from an interaction between an individual and the environment (reciprocal dete rminism), and knowledge and skills create the

PAGE 28

28 precondition for change (behavioral capability). Individuals anticipate how their choices will affect their health outcomes (expectations) and have the confidence to change their behavior (self-efficacy). Individuals can learn healthy lifestyle choice s by watching the appropriate actions of others (observational learning), and by enjoying the benefit of positive reinforcement from others in their endeavors (reinf orcement) ((NIH, 2003; Bandura, 1997). Using the theoretical concepts, teaching ma y be guided and learning behaviors may be targeted. Social Cognitive Theory and its concep ts are inherently linked to the measurement of health behavior (Redding, Rossi, Rossi, Velicer, & Prochaska, 2000). In this study, Social Cognitive Theory was used as a guide to observe and describe how the CMS behavioral intervention program was teachi ng content and which learning behaviors were targeted. Following this premise, if the CMS program utilized the theoretical concepts, youths should expect positive behavioral change s, followed by improved BMI and Hb A1c measurements. The following is a description of the concepts. A review of health promotion literature is also provided to elucidate how the utilization of a particular le arning concept elicits behavioral changes among the youths. Reciprocal Determinism Reciprocal determinism is the dynamic, recipr ocal interaction betw een three key factors identified as personal, environmental, and behavi oral. These factors act as determinants of each other. That is, a change in one of these factors impacts on the other two. There is considerable research interest conc erning how personal and environmental factors interact to influence children's nutrition and exer cise behavioral patter ns. For example, schools that provide lower fat content in their lunches and greater opp ortunities in physical exercise

PAGE 29

29 improve the dietetic and exercise behaviors of children (Luepk er et al., 1996; Rinderknecht & Smith, 2004; Trevino et al., 1998). Children's weekly television view ing hours significantly correlate with their requests for purchases of food advertised on television (Taras, Sallis, Patt erson, Nader, and Nelson, 1989). When children are told that their mothers will be monitoring their food choices, children choose fewer non-nutritious foods than they choose in the absence of that `threat' (Klesges, Stein, Eck, Isbell, and Klesges (1991). According to Bandura (1989), interactions betw een factors differ based on the individual, the particular behavior being examined, and the sp ecific situation in which the behavior occurs. Research suggests that environmental factors ma y influence children's health behaviors more than personal ones. For example, children less th an age 9 are not worried about health outcomes, and health is not a priority for them (Gochm an, 1987). Thus, cognizance of the diet-disease relationship may have less influence than envi ronmental factors on healthy behavior in younger children. Behavioral Capability The concept of behavioral capability is de fined as having the knowledge and ability to perform a behavior or sequence of behavior s. Most intervention programs improve an individual's behavioral capability through inst ructional and skills trai ning. Behavioral skill training may be (ReCapp, 2006): interpersonal, including communica tion, negotiation, and setting limits; intrapersonal, such as values clarific ation, analyzing situat ions, and self-talk; resource-related, focusing on locating informa tion from adults, agencies, and the internet; and product-related, such as teaching us e of condoms and contraceptives.

PAGE 30

30 Parcel et al. (1989) re ported that classroom health edu cation and environmental changes in school lunch and physical education were implemen ted to foster healthful diet and exercise among elementary school children. Cognitive measur es that included behavioral capability were evaluated using self-reported diet and exercise behavior questionnaires at baseline and following intervention. Statistically signi ficant changes were observed for di et behavioral capability, selfefficacy, and behavioral expectations, use of sa lt, and exercise behavioral capability (fourth grade), self-efficacy (fourth grade) and frequenc y of participation in aerobic activity. The program impacted learning out comes and student behavior. Individual behavior can have an important impact on di sease prevention. However, it is important to note that Social C ognitive Theory emphasizes that learning is influenced not only cognitively in the learning of skills but within the complexity an individuals environment, thoughts, emotions, and biologi cal properties. Expectations An individual's expectations are defined as an individual's approximation that the performance of certain behaviors will lead to atta inment of a particular goal. For example, "If I will eat a healthy diet and exercise regularly, I will lose weight." Factors that motivate an individual's expectations as they go through the process of setting goals for themselves include self-efficacy, feedback, and the anticipated time to goal attainment (Bandura, 1986; 1989). First, if an individual feels s/ he is capable of achieving the goal (self-efficacy), s/he is likely to work hard and not give up. Second, if an individual is provided feedback, she is more able to adjust her goals to be feasible and rea listic. Feedback, in tur n, improves self-efficacy. Third, short-term goals are more effective than long-term goals because short-term goals are less daunting for an individual to work towa rd than long-term goals (Stone, 1998).

PAGE 31

31 In health promotion literature, expectations are frequently evaluated with self-efficacy by comparing preand post-questionaires. For exampl e, in Resnicow et al. (1997), the impact of a self-administered, computer-based intervention on nutrition behavior, se lf-efficacy, and outcome expectations among supermarket food shoppers was evaluated. The intervention, housed in kiosks in supermarkets, used ta ilored information and self-regulat ion strategies delivered in 15 brief weekly segments. Treatment led to higher levels of nutrition-rela ted self-efficacy, physical outcome expectations, and social outcome expecta tions. Logistic regressi on analysis determined that the treatment group was more likely than th e control group to attain goals for reduced fat and increased fiber and fruits and vegetables at post-test and to attain goals for reduced fat at follow-up. Latent variable struct ural equation analysis reveal ed self-efficacy and physical outcome expectations mediated intervention e ffects on nutrition. In a ddition, physical outcome expectations mediated the effect of self-efficacy on nutrition outcomes. Self Efficacy According to Bandura (2004), self-efficacy is th e most important concept that explains behavioral change. Individuals with perc eived self-efficacy set high personal goals for themselves, expect favorable outcomes from thei r efforts, have an ability to recover from setbacks, and are able to maintain the achieved habit (Bandura, 2004, Rinderknecht & Smith, 2004, Benight & Bandura, 2004 ). Bandura (2006) has written a monograph entitled Guide for Constructing Self-Efficacy Scales. The monograph deals with issues of domain sp ecification, gradations of change, content relevance, phrasing of items, response scale, item analysis, minimizing biases in responding, assessing collective efficacy, and validation. A number of useful instruments are available online, such as those from the National Instit ute of Nursing Research. For over 20 years,

PAGE 32

32 researchers have been developing, adapting, an d testing self-efficacy scales for research subjects with chronic diseases (Bandura, 2006). The concept of self-efficacy has guided program interventions for improving behaviors in diet, physical exercise, and diab etic self-care (Allen, 2004). Dietary self-efficacy is the perceived capability to choose more healthful foods and has been associated with improved nutritional behavior among youth (Cusatis & Shannon, 1996) and adults (Van Duyn, Kristal, & Dodd, 2001). Evidence underscores the importan ce of self-efficacy in metabolic control (Ludlow & Gein, 1995), coping a nd problem solving (Anderson et al., 1995), diet adherence (Miller, Edwards, Kissling, & Sanville, 2002), a nd maintaining healthy blood glucose (Skelley, Marshall, Haughey, Davis, Dunford, 1995). According to Bandura (2004), necessary compon ents of a program to effectuate selfefficacy include: 1) information regarding the desi red behavior; 2) the development of social and self-management skills; 3) building a resilient se nse of efficacy such as supporting the exercise of control in the face of difficulties and setbacks in everyday life; and 4) enlisting and creating social supports for desired personal change such as enlisting particip ants' caregivers in the effort. In Margolis & McCabe (2004), additional strategi es for improving self-efficacy for individuals in programs include: 1) establishing small, incremet al goals for participants; 2) reinforcing effort and persistence; 3) emphasizing modeling; and 4) providing feedback through record-keeping. Observational Learning Bandura (1977) wrote that learning would be exceedingly laborious, not to mention hazardous, if people had to rely sole ly on the effects of their own actions to inform their choices. Behavior can be learned obser vationally through modeling. Modeling occurs when individuals observe othe rs, form ideas regarding how the behaviors are to be performed, and then act out the behavi ors. Individuals are more likely to adopt a

PAGE 33

33 modeled behavior if behavior ch ange results in outcomes they value, and if the model is: 1) similar to the observer, 2) has admired status and 3) has functional value (Bandura, 1977). Among children, observational learning often outwei ghs verbal instruction as an influence on the internalization of standards (Bandura, 1989). Thus, di etetic and exercise programs are encouraged to incorporate lear ning strategies that go beyond lect ures, and include opportunities to observe and model healthy behaviors, attitude s, and emotional reactions provided by program instructors, parents/significant ca retakers, and participant peers. Thus, experien tial opportunities used by the CMS program such as exercise sess ions, grocery store tour s, group food preparation sessions, and sampling of healt hy snacks may be beneficial. A study by Carroll and Bandura (1987), examined the role of two form s of visual guidance in facilitating the tran slation of cognitive representations into action. Subjects matched a modeled action pattern either concurrently with the model or after the modeled display. The subjects then either did or did not visually monitor their actions during tests of production accuracy in the model's absence. Acquisition of the cognitive representation was assessed periodically. Concurrent matchi ng of modeled actions and visual monitoring of productions both increased the level of observational learning. Th e more accurate the cognitive representation, the more skilled were subsequent reproductions of the modeled actions. After acquiring proficiency in converting cognition to action, subjects maintain ed their level of performance accuracy even though modeled and visual-monitoring guidance were withdrawn. These results are consistent with the theory that cognitive representation me diates response production and that corrective adjustments through visual guidance aid in the translation of conception into action. In another study, researchers examined the eff ects of televised safety models on children's willingness to take physical risks and their ability to identify injury hazards in common situations

PAGE 34

34 (Potts & Swisher, 998). Exposure to the safe ty educational videotap e decreased children's willingness to take physical risks and increased th eir identification of injury hazards. Findings are interpreted as evidence of observational lear ning related knowledge by the television stimuli (Potts & Swisher, 1998). Reinforcement Reinforcement is said to occur when a reward, that is made contingent on an individual's behavior, increases or decreases the chances of the individual repeati ng that behavior (Hendy, Williams, & Camise, 2005). Reinforcement has b een frequently used in health promotion programs to improve behavioral outcomes. In Hendy, Williams and Camise (2005), The "Kids Choice" school lunch program used token reinforcement, food choice, and peer partic ipation to increase children's fruit and vegetable consumption. Rewards included jump ropes, wa ter bottles, and gradua tion certificates. Consumption increased for fruit and for vege tables and the increas es lasted throughout reinforcement conditions. Two weeks after the pr ogram, preference ratings showed increases for fruit and for vegetables. Seven months later, fr uit and vegetable prefer ences had returned to baseline levels, suggesting the need for an ongoing intervention program to keep preferences high. In another study by DeVahl, King, and Williams on (2005), researchers sought to determine whether a greater academic incentive would im prove the effectiveness and adherence of university students to a 12-week voluntary exerci se program designed to decrease body fat. The group with the greater reward structure showed better exercise adherence and lost more body fat than those without the additional incentive. Th ese findings suggest that an academic incentive can increase overall student adherence to a voluntary exercise program and can boost the effectiveness of the program in a universit y environment (DeVahl, King, & Williamson, 2005).

PAGE 35

35 Robles et al. (2005) carried out an interven tion that involved wo men living with their children in a residential substance abuse treatm ent facility. The intervention consisted of exposure to an educational video and a sm oking cessation workbook, brief individual support meetings, and an escalating schedule of voucherbased reinforcement of abstinence. Throughout the study, three daily breath samples were coll ected Monday through Friday to determine carbon monoxide (CO) concentration. In addition, urine cotinine (COT) was assessed weekly to monitor weekend tobacco use. Participants received vouche rs of escalating value for CO-negative breath and COT-negative urine samples. Positive sample s reset the voucher value. Significantly more negative tests were submitted during the intervention than du ring baseline and follow-up. The intensive behavioral interventi on evaluated in this study produ ced a substantial reduction in cigarette smoking, and 25 percent of participan ts remained abstinen t two weeks after the intervention was suspended. In this within -subjects repeated m easures study, a one-week baseline was followed by a four-week interven tion and a two-week follow-up (same as the baseline). In Rowan-Szal, Joe, Chatham, & Simps on (1994), clients in a community-based methadone treatment program earned stars for attending counseling sessions and for providing clean urines. The stars were later redeemed fo r contingent rewards (food or gas coupons or bus tokens) according to on e of three randomly assigned rewa rd schedules, including high reward (eight stars per prize), low rewa rd (four stars per prize), or de layed reward (those who had to wait three-months to earn a prize). Those clie nts in the high-reward condition showed a pattern of increasing the number of stars earned for gr oup sessions and clean urines across the threemonth intervention. All clients, independent of reward condition, attended significantly more group counseling sessions during the months that c ontingent reinforcers were available than in

PAGE 36

36 the months prior to, and after, the intervention. Fi nally, urinalysis data indicated that, in the post intervention period, high-reward cl ients had fewer dirty urines th an did low-reward or delayedreward clients. This study suggests that a simple system of recognizing client progress with stars and modest prizes for performing specific behaviors can be an eff ective tool in increasing clinic attendance rates and reduced positive urines (Rowan-Szal, Joe, Chatham, & Simpson, 1994). Recommendations for Overweight Major health organizations such as the U. S. Department of Health and Human Services (2004) address the potential h ealth-pitfalls of overeating an d under activity for children and adolescents. Health recommendations include discouraging the consumption of energy-dense, high sugar/high-fat foods, the amount of time spen t on television, video games, and the Internet; and encouraging the consumption of a healthy a rray of foods and more daily physical activity. In Florida, the "Governor's Task Force on Ob esity," has made recommendations to deal with being overweight. Public health care providers are encour aged to promote lifelong nutrition and physical activity by implementing programs th at promote healthier lifestyles and disease management for overweight-related illnesses such as diabetes and hyperinsulinemia (Florida Department of Health, 2004). Recommendations for short-term program goals for overweight youths include the maintenance of weight, or a decrease of wei ght by about 1 pound per month. A long-term goal is to reduce BMI to below the 85th percentile (Bar low & Dietz, 1998 (current as of 2005). Over time, the maintenance of weight leads to a BM I decline as height c ontinues to increase. Programs for overweight children and adolescents often evaluate both weight and BMI because incremental weight loss may not impact BMI m easurements. A subtle weight-loss of a few pounds would not be revealed in a BMI calculation.

PAGE 37

37 Recommendations for program goals for overw eight youths with type II diabetes or hyperinsulinemia include the reduction of Hb A1c. Glycosylated hemoglobin is a measure of long-term glucose homeostasis (Goldstein, Park er & England, 1982), and is a way to monitor long-term serum glucose regulation (Fajans, 1990). Increased Hb A1c measurements are associated with being overwei ght (Plourde, 2002) and indicate the beginning or existence of hyperinsulinemia (Hanna, & Howard, 1994). A hea lthful diet and regular exercise may prevent the development of diabetes among persons wh o are overweight regardless of weight loss (Sheaves et al, 1997; Manson et al ., 1992). However, other research findings suggest that Hb A1c values improve with weight loss of about 10 lb or fi ve percent of body weight (Wing, Marcus, Epstein, & Salata, 1987). Previous agency programs for overweight ch ildren and adolescents at the primary, secondary, and tertiary levels of the disease prevention model have been modestly successful in maintaining or decreasing weight and in reducing other biological measures such BMI and Hb A1c associated with overweight health complicati ons (Saelens, et. al., 2002; Dietz, 1998; Dietz, 2004). This chapter examines intervention programs ai med at secondary and tertiary levels of disease.1 Research reveals that outpatient, health care-based, weight-interve ntion programs, that use major health organization recommendations for diet and exercise, elicit weight-reduction among children and adolescents (Saelens, Sallis, Wilfley, Patrick, Cella, & Buchta, 2002). The prevention programs examined are primarily aimed toward improving diet and increasing physical activity (Dreimane et al., 2006; Eliakim et al., 2002; Lazzer et al., 2005; Monzavi et al., 1 Primary prevention programs commonly occur in schools and childcare settings than in health settings. Classroom and physical education curricula, changes in school meals, vending machines, cafeterias, and after-school programs may increase physical ac tivity and improve dietary patterns (Daniels et al., 2005).

PAGE 38

38 2006; Reinehr et al., 2003; Saelens et al., 2002; Savoye et al., 2004; Spieth et al., 2000; Taylor, Mazzone, & Wrotniak, 2005; W oo et al., 2004). Many of the programs include behavioral therapy and reduction in sedentary behavior. Secondary-level prevention programs target youth at-risk-for-overweight, referred to hereinafter as "early-disease." These programs are particularly in terested in preventing the BMI percentile from increas ing (Jain, 2004). Tertiary-level programs seek to limit illnesses associated with being overweight and to rehabilitate those who are overweight (Murphy, 2004), hereinafter referr ed to as "late-disease." Tertiary level illnesses include hyperinsulinemia, also known as impaired glucose tolerance (IGT), a condition marked by higher than normal plasma insulin and glucose levels that are too low to be considered diagnostic fo r type II diabetes. Review of Programs The following is a descriptive review of nine outpatient secondary and tertiary prevention programs for affected youths (Tables 2-1 and 22). The review include s a description of: 1) study size and ages of participan ts; 2) parental participation; 3) program frequency and duration; 4) outcomes; and 5) limitations. All nine progr ams were primarily aimed toward improving diet and increasing physical activity. Diet and ex ercise together, rather than diet alone are associated with significantly improved health outcomes (Woo et al., 2004). Study Size and Ages of Participants Study sizes range from 25 to 264 participants and ages range from 6-17 years. The studies were conducted in clinical settings and most of the studies were conducted in the United States. The researchers of the programs were registered nurses, pediatricians, pu blic health experts, registered dieticians, and physical therapists.

PAGE 39

39 Parental Participation All studies included parents or legal guardians of the child or adolescent participants with the exception of Saelens et al. (2002). According to Jain (200 4), interventions that include the parents or significant caretakers of the participants have greater effect on weight loss than those that do not include parents or significant careta kers. In addition, children and adolescents do better when treated in the same classroom rather than treated separately (Jain, 2004). Children without parental overweight have significantly greater decrease s in BMI compared to children with obese parents (Eliakim et al., 2002). Program Frequency and Duration Programs ranged in duration from eight weeks to one year. Class sessions occurred as infrequently as twice monthly and as frequently as five times a week. Program frequency and duration was not necessarily associated with bett er weight and BMI outcomes. For example, in Spieth et al. (2000), the program was about four months in duration, and included only one primary session and four follow-up visits. Bo th weight and BMI significantly improved among participants. However, in Reinehr et al. (2003), where the program was one year in duration and met at least once weekly for exercise sessions, the BMI measures did not significantly improve among participants. Outcomes Overall, the programs were modestly successful in maintaining or decreasing weight and BMI. Six of the nine studies show ed a statistically significant, shor t-term decrease in weight or BMI (Dreimane et al., 2006; Eliakim, A. et al., 2002; Monzavi, R. et al., 2006; Savoye et al., 2004; Spieth, L. et al., 2000; Tayl or, Mazzone, & Wrotniak, 2005). Three of the nine studies did

PAGE 40

40 not show statistically significant, short-term decrease in weight or BMI (Zador et al. (2006); Woo et al. (2004); Saelens et al. (2002). Howe ver, the study of Zador et al. (2006) showed significant short-term decreases in Hb A1c, and the study of Woo et al. (2004) showed significant short-term decreases in lab values such as low-dens ity lipoprotein (Tables 2-3 and 24). With the exceptions of Savoye et al. (2004) and Woo et al. (2004), program evaluations were followed for less than one year. Sa voye et al. (2004), a one-year-long program, demonstrated significant decreases in BMI at th e end of their program which was the end of one year. However, those decreases in BMI we re no longer significant (B MI from pre-program baseline was primarily maintained) in the followi ng year. At two-years post-program, the two dietary approaches taught to pa rticipants during the program were compared. The group that had been taught how to make better food choices, and not given a st ructured diet plan, further improved BMI (P=.006), while the dieting group's BM I reverted back to pre-program baseline. Monzavi et al. (2006), a 12-week-long pr ogram, also demonstrated significant improvements in post-program BMI, systolic an d diastolic blood pressure s, lipids (total, lowdensity lipoprotein cholesterol, and triglycerides) postprandial glucose, and leptin levels at the end of the program (or three weeks after the end of the program). It is not known whether the participants in Monzavi et al. (2006) enjoyed long-t erm positive outcomes. Programs exhibited varied success at improving biologi cal measures associated with overweight-related illnesses. In Woo et al. (2004), children we re randomly assigned to a dietary modification program or a diet and exercise modification progra m. After 6 weeks, both groups significantly decreased waist-hip ratio and cholesterol level and improved arterial endothelial

PAGE 41

41 function. In Zador et al. (2006), Hb A1c was significantly improved by the completion of the program. In Eliakim et al. (2002), physical enduran ce significantly increased following the threemonth intervention. Affected youth that con tinued the program for another three-months, further improved their endurance. Taylor, Mazz one, and Wrotniak (2005) evidenced significant improvements beyond BMI. Waist and hip girth, blood pressure, resti ng heart rate, immediate heart rate after exercise, and hear t rate five-minutes after exercise were significantly improved at post-test. Outcomes did not vary markedly between gende rs. According to Eliakim et al. (2002), in their study of 177 participants, gender, pubertal status, and the degree of obesity had no influence on BMI changes. Reinehr et al. (2003) used multiple regression to relate factors to post-program weight loss. Factors included the par ticipant's willingness to change beha vior (changes in weight status, number of attempts at therapy, participation in exercise groups), somatic characteristics (BMI of children and family members, gender, and age), so cioeconomic status (level of education of the children and their parents, working mother), exer cise and dietary habits, and dietary intake, as well as the quality of dietary re cords. The only significant difference between the children who lost weight and the children who did not lose wei ght was that the children that lost weight had previously taken part in regular exercise before the program began. Improvements in emotional well-being and behavior correlated positively w ith weight loss (Dreimane et al., 2006). Limitations Identification of effective in tervention methods utilized in various disease prevention programs enables other health providers to replicate and improve successful intervention

PAGE 42

42 methods and facilitates their generalization and application to broader population groups. Alternatively, review of disease prevention progr ams may uncover intervention methods that are successful for distinct population subsets even if those methods ha ve limited utility for broader populations. Optimal design for evaluating a particular program minimizes potential bias and maximizes general application to the extent pe rmitted by practical limitations such as time constraints, cost, ethics, and ot her limitations. Since it is evident that long-term program adherence is difficult, further long-term evaluation of outcomes is necessary to identify which program interventions result in positive outcomes that endure. Evaluation results may be influenced by vari ous factors. For example, youths may be motivated just long enough to comple te the program and revert back to their original lifestyles at the completion of the program. Youths may be trying to please evaluators or to be overly eager, making a program appear more effective than would normally be expected. Ideally, a study should last for 6 months or longer. In those programs that show no effect on wei ght or BMI, the results of the programs may be disproportionate to their endeavors. Howe ver, because in most instances, pre-program knowledge of patterns of weight gain is not ob tained, program outcomes may be shown to be more successful than they appear if they were co mpared to weight gain in previous years. Also, the intervention effect may not occur until several weeks after the end of the program. In this situation, a post-test at the end of the treatmen t would show no impact, but a post-test a month later might show an impact. Programs are costly, making the use of control groups and adequate sample sizes difficult. If a control group is available, it may be ethically inappropriate not to offer an alternative

PAGE 43

43 program. Because in most instances, smallto moderatesized convenience samples are utilized, there is the risk of the researcher making a Type II error (concluding the treatment caused no change when it actually did cause a change). Different study outcomes may be found am ong members of different ages, adversely affecting the ability of the outcomes to be generali zed to all ages. To control for this, a few of the studies accounted for age in the statistical regression analyses. It is not possible to know all th e events, other than those plan ned in the program, that occur during the course of the program, and such external events may affect study outcomes. It is unknown whether successful biolog ical outcomes occurred because of the programs, or because of other environmental, personal, or behavioral fa ctors. For example, some children and adolescents may begin to be involved in physic al education at school when they begin a behavioral intervention program. Some validity risks are inherent in any program evaluation. A test is reliable to the extent that whatever is measured, is measured consiste ntly. The program studies described their data collection procedures well, includi ng the assessment of th eir equipment such as weight scales. However, there is always the potential for inc onsistent performance during the collection of the biological measurements and the fl uctuation of measurem ents if taken at different times of the day. Overall, descriptions of the program evalua tions were provided so that they could be accurately replicated in other st udies. In addition, nearly all the studies prevented a catalyst effect by excluding participants who were particip ating in another program. Health professionals implementing and participating in a program want the program to be effective.

PAGE 44

44 Caution should be utilized in generalizing study findings ei ther to broader population groups or over time. Conditions for programs efficacy wo rk change over time. In addition, the external experiences of participants in different programs may vary For example, some may receive physical education class once a week at school, while othe rs may receive it four times a week at school. Quantitative methods lose utility when the subj ect of the study is difficult to measure or quantify. Each of the programs studied may have benefited from eclectic use of quantitative and qualitative methods. Program studies can potentially inform pub lic policy and analysis in several ways. Through these studies public policy may identify a nd classify interventions as either: successful in the targeted populations; effec tive for broader populations or di stinct population subsets; or ineffective and not appropriate for further public expenditure. Summary Effective strategies to promote self-managemen t of health habits are more important than ever. Research shows that overweight childr en and adolescents benefit from comprehensive dietetic and exercise educati on (Saelens, Sallis, Wilfley, Patr ick, Cella, & Buchta, 2002). The review of theses nine outpatient sec ondary and tertiary prevention programs for overweight youth (Tables 2-1 and 2-2) revealed that diet and exerci se together, rather than diet alone are associated with significantly improved h ealth outcomes such as improved BMI and Hb A1c values. Program studies suggest that weight -loss success is associated with interventions that include the participants parents (Jain, 2004), a nd the participant's w illingness to change behavior, somatic characteristics, socioeconomic status, exercise and diet ary habits, and dietary intake, as well as the quality of dietary r ecords (Reinehr et al., 2003). Improvements in

PAGE 45

45 emotional well-being and behavior also correlat ed positively with weight loss (Dreimane et al., 2006). Interventions that have a greater frequenc y and duration of program sessions were not necessarily associated with be tter weight and BMI outcomes. According to Eliakim et al. (2002), gender, pubertal status, and the degree of obesity had no influence on BMI changes. Overall, the programs were modestly successful in maintaining or decreasing weight and BMI. Six of the nine studies showed statistically significant, short-term decrease in weight or BMI (Dreimane et al., 2006; Eliakim, A. et al., 2002; Monzavi, R. et al., 2006; Savoye et al., 2004; Speith, L. et al., 2000; Ta ylor, Mazzone, & Wrotniak, 2005). Savoye et al. (2004) was the one study that showed sta tistically significant, lo ng-term outcomes. At two-years post-program, the decrease in BMI from pre-program ba seline was primarily maintained. Program studies can potentially inform public policy and analysis in several ways. Through these studies public policy may identify a nd classify interventions as either: successful in the targeted populations; effec tive for broader populations or di stinct population subsets; or ineffective and not appropriate fo r further public expenditure. CMS health providers are activel y pursuing the integr ation of research and practice within their agency. This program evaluation is in th e position to contribute to the integration of research and practice among overweight child and adolescents, offer information about what occurs within the CMS program, and to report progress on health outcomes. Additionally, knowledge gained through the use of Social Cogn itive theory in behavior intervention programs may be used to further educate individuals and their families how to mana ge, in part, their own wellness and live healthier lives.

PAGE 46

46 Table 2-1. Major Learning Concepts in Social Cognitive Theory Concept Definition Application Reciprocal Determinism Change is bi-directional; behavior changes result from interaction between person and environment Involve the individual and relevant others; work to change the environment, if warranted Behavioral Capability Knowledge and skills to influence behavior Provide information and training about action Expectations Beliefs about likely results of action Incorporate information about likely results of action in advice Self-Efficacy Confidence in ability to take action and persist in action Point out strengths; use persuasion and encouragement; approach behavior change in small steps Observational Learning Beliefs based on observing others like self and/or physical results Point out others' experience, physical visible changes; identify role models to emulate Reinforcement Responses to a person's behavior that increase or decrease the chances of recurrence Provide incentives, rewa rds, praise; encourage self-reward; decrease possibility of negative responses that deter positive changes From U.S. National Institutes of Health (NIH): National Cancer Institute (2005). 'Theory at a Glance: A Guide for Health Promotion Practice' National Institutes of Health, National Cancer Institute. Retrieved Sept 24, 2005 at /redirect.cgi?r=http://www.cancer.gov/ cancerinformation/theory-at-a-glance

PAGE 47

47Table 2-2. The Evaluation of Learning Concepts Social Cognitive Theory in Literature Concept Examples of Concept Measurement in Literature Reciprocal Determinism School environmental changes elicit dietetic and exercise behavioral changes (Luepker et al.,1996; Rinderknecht & Smith, 2004; Trevino et al., 1998) Home environmental changes elicit dietetic behavior changes (Taras et al., 1989; Klesges et al,1991) Behavioral Capability A community-based diabetes education program improves participants' behavioral capability in diet and diabetes as evidenced in preand post-knowledge tests (Chapman-Novakofski & Karduck, 2005) Expectations A computer-based intervention on nutrition among supermarket food sh oppers associated with improv ed outcome expectations (Resni cow et al.1997) Self-Efficacy Per self-efficacy scales: Self-efficacy associated with more healthy foods choices in youth (Cusatis & Shannon, 1996) and adults (Van Duyn, Kristal, & Do dd, 2001) Self-efficacy associated with improved meta bolic control (Ludlow & Gein, 1995), quality of life (Rose, Fliege, Hildebrandt, Sch irop, & Klapp, 2002), coping and problem solving (Anderson et al., 1995) diet adherence (Miller, Edwards, Kissling, & Sanville, 2002), and blood glucose testing (Skelley, Marsha ll, Haughey, Davis, Dunford, 1995) Observational Learning Cognitive representation mediates response production and that co rrective adjustments through visual guidance aid in the transl ation of conception into action (Carroll and Bandura,1987) The effects of televised safety models decreased children's willingness to take physical risks and their ability to identify in jury hazards in common situations (Potts & Swisher, 1998) Reinforcement The "Kids Choice" school lunch program used token reinforcement and increases children's fruit andvegetable consumption (Hendy, Williams and Camise (2005) Academic incentives improv e the effectiveness and student adherence to a 12-we ek voluntary exercise program designed to decreas e students' percentage of body fat (D eVahl, King, & Williamson, 2005). A voucherb ased reinforcement intervention improves smoking cessation among women in a residential substance abuse treatment facility (Robles et al.,2005) Individuals in a community-based methadone treatment program who earn stars for attending counseling sessions as scheduled and for providing clean urines have improved outcomes (Rowan-Szal, Joe, Chatham, & Simpson, 1994).

PAGE 48

48 Table 2-3. Abbreviated Version Table: Outpatient Secondaryand Tertiary-Level Nutrition and Exercise Programs AUTHOR PROGRAM SUBJECTS N Age OUTCOME IMPROVEMENTS: Wt BMI Other Dreimane, D. et al. (2006). Duration: 8 or 12 weeks of 90minutes Parental Involvement: Yes 264 7-17y Perceived Health* Eliakim, A. et al. (2002). Duration: 3or 6-months (4 lectures, dietician once/mos, &exercise 1 hr twice weekly) Parental Involvement: Yes 177 6-16y Endurance Time* Monzavi, R. et al. (2006) Duration: 12 weeks of 90-minutes Parental Involvement: Yes 109 8-16y NS Systolic BP 2-hr glucose TC & LDL TG & Leptin Reinehr, T. et al. (2003) Duration: 1 year (exercise weekly, other) Parental Involvement: Yes 75 7-15y NS Saelens, B. E. et al. (2002) Duration: 4-months (computer interaction, physician counseling, & telephone/mail counseling) vs. a single physician counseling) Parental Involvement: Yes 44 12-16y N S NS Higher eating & other skill than nonprogram group* Savoye, M. et al. (2004) Duration: 1 year (two 30-minute exercise/week; one 45-minute class each week) Parental Involvement: Yes 25 13.3 0.6y 1 yr: Body fat: Self-concept: 2 year: Neither Speith, L. et al. (2000) Duration: About 4-months (one primary session, then about 4 follow-up visits); one group on lowglycemic diet & others on low fat diet Parental Involvement: Yes 107 10-14y *. (low (both -fat groups) group) Taylor, M. J. et al. (2005) Duration: 8 weeks of twice-weekly 60-minute sessions Parental Involvement: Yes 41 10.5y (mean) Lower Waist & hip girth* (*) SBP, DBP, & RHR:* HRfinish/5minHR* Woo, K. S. et al (2004) Duration: 1) 6 wks/diet & exercise twice weekly (1/2 of group diet modification, 1/2 of group diet & exercise). 2) After 6 weeks to 1 year, 1/2 in diet & exercise group attend weekly exercise, & others continue twice-monthly diet monitoring program Parental Involvement: Yes 82 9-12y NS NS 6 wks: TG (both)* LDL (exercise)* FG (exercise gr.)* EDD (both gr.) 1 y : Body fat* IMT (both)* LDL (exercise)* Zador, I. et al. (2006) Duration: 12 weeks of once-a-week Parental Involvement: Yes 17 7-15.8y N/E NS Hb A1c: S Hip-to-Waist: S

PAGE 49

49 Note: This chart is an overview. Pl ease see articles for extensive outcome results.* = Statistically significant; 5minHR = Heart rate 5 minutes after exercise; EDD = Endothelium-dependent dilation; BMI = Body mass index; FG = Fasting glucose; gr. = Group; Hb A1c = Glycosylated hemoglobin; HRfinish = Immediate post-exercise heart rate; Ht = Height; IMT = Intima-media thickness; LDL = Low density lipoprotein; N = Number of subjects; NS = Not signifi cant; RHR = Resting heart rate; NS: Not statisitically significant; TC = Total cholesterol; Wt = Weight

PAGE 50

50Table 2-4. In-Depth Version Ta ble: Outpatient Secondarya nd Tertiary-Level Programs Publication Program Subjects Evaluation Dreimane, D. et. Al (2006). Feasibility of a hospital-based, family-centered intervention to reduce weight gain in overweight and adolescents. Diabetes and Research and Clinical Practice. Name/Location: Kids N Fitness in an out-patient setting Description: Up to twelve 90minute sessions (8 week program vs 12 week program); interactive nutrition & exercise sessions with behavior modification Personnel: Registered dieticians, physical therapists, physicians, other health professionals Parental Involvement: Yes Description: Overweight N: 264 Gender: 127 boys & 137 girls Age: 7-17 y (mean 11.52.1y) Ethnicity: 73% Hispanic, 12% African American, 8% Caucasian, & 7% Other IC/EC: No physical limitations, attendance > 50% of sessions, undergoing rigorous physical therapy, overweight per CDC growth chart, age 7-17y Procedures: Wt, Ht, and BMI, & child health questionnaire evaluated at preand postprogram. Subjects also recorded daily dietary & exercise activity during the 1rst, 4th, & 7th week of program. Outcomes of articipants in the 8-week vs. 12week program were compared. Outcomes: Wt: In whole study population, Wt velocity decreased from 0.7260.980 to 0.193kg/month (p< 0.001) Ht: Not evaluated BMI: In whole study population BMI velocity decreased from 0.2280.452 to 0.0610.548kg/m (p <0.001); BMI z-score rate (change in z-score per month) improved from 0.0110.042 to 0.0010.003 z-score/month (p = 0.006) Hb A1c: Not evaluated Other: Subjects in 12-week program compared to those in 8-week program had significantly reduced Wt gains and BMI losses which did not correlate with age, gender, or ethnicity. Females more likely to attend more sessions. Significant improvements in child's perceived health and physical function in 8-week group. Qualitative Component: No

PAGE 51

51Table 2-4. Continued. Publication Program Subjects Evaluation Eliakim, A. et al. (2002). The effect of a combined intervention on body mass index and fitness in obese children and adolescents a clinical experience. Eur J Pediatr, 161, 449-454. Name/Location: Child Health & Sports Centre, Mier General Hospital, TelAviv University Description: All participated in the 3month program (4 evening lectures, meet with the dietician once a month, & weekly exercise for 1 hour twice a week); 65 completed the 6-month intervention Personnel: Physicians, dieticians Parental Involvement: Yes Description: Obese N: 177 Gender: 90 boys & 87 girls (3-month intervention group); 10 boys & 15 girls (control) Age: 6-16y Ethnicity: 128 Ashkenazi, 33 Sepharadic, 16 mixed (3-month intervention) IC/EC: Without organic cause of obesity & not taking medication that would interfere with growth or weight control Procedures: Wt, BMI, & fitness were evaluated at baseline, & after the 3 and 6 months interventions. Also utilized a control group of 25 subjects (had nutritional counseling once every 3 months and encouraged to exercise 3 times a week) Outcomes: Wt: At 3 months, significant decrease from 55.81.2 kg to 54.9 kg. In contrast, a significant increase in wt among the control group. At 6 months, significant decrease 0.50.55 kg (mainly due to loss in 1rst 3 months). Ht: Not evaluated BMI: At 3-months, significant decrease from 26.10.3 kg/m to 25.40.3 kg/m. In contrast, a significant increase in wt among the control group. At 6 months, significant decrease -1.070.23 kg/ m (mainly due to loss in 1rst 3 months). Hb A1c: Not evaluated Other: At 3 months, changes in wt & BMI not significantly affected by gender, pubertal status, degree of obesity, & parental overweight status. Endurance time increased significantly. Qualitative Component: No

PAGE 52

52Table 2-4. Continued. Publication Program Subjects Evaluation Lazzer, S. et al. (2005). Longitudinal changes in activity patterns, physical capacities, energy expenditure, and body composition in severely obese adolescents during a multidisciplinary weight-reduction program. International Journal of Obesity, 29, 37-46. Name/Location: Pediatrics Department of the Clermont-Ferrand Hospital, France Description: 5 days/week for 9 months. Consists of nutrition education, endurance resistance training, & regular physical activity. *Inpatient. Personnel: Physicians, physical trainers, research assistant, dietician, psychologist Parental Involvement: Yes Description: Severely obese N: 27 Gender: 13 boys & 14 girls Age: 12-16y (mean 14y) Ethnicity/Race: Not available IC/EC: Ill health, in prior wt program, taking regular medications or medications that influence metabolism Procedures: Comparison of preand post-program physical characteristics (age, pubertal stage, wt, ht, BMI, VO2) & body composition (FFM, FM, BMC, BMD of total body; FFM & FM of arms, legs and trunk) Outcomes*: Wt: Loss of 18.4 kg and 15.7 kg, (s.e.m = 1.27 kg, P<0.001) in boys & girls respectively Ht: Increased 4.5 cm & 1.4 cm (s.e.m. = 0.24, P<0.001) in boys & girls, respectively. BMI: Decreased by 8.1 kg/m & 6.3 kg/m (s.e.m. = 0.38 kg/m, P<0.001) in boys & girls, respectively. Hb A1c: N/A Other: Waist & hip circumferences decreased significantly for boys & girls; FM also decreased significantly for these groups. FFM decrease significantly for girls but not for boys. BMC & BMD increased significantly for both groups. VO2max (l/min) did not vary significantly, but strength & fitness were improved (P<0.001). Time and EE spent at sedentary activities decreased significantly (P<0.001) to the benefit of moderate (recreational) activities and total physical activities (P<0.001). Qualitative Component: No

PAGE 53

53Table 2-4. Continued. Publication Program Subjects Evaluation Monzavi, R. et al. (2006). Improvement in risk factors for metabolic syndrome and insulin resistance in overweight youth who are treated with lifestyle intervention. Pediatrics,117(6), e1111-e1118. Name/Location: Fun 'n Fitness/Children's Hospital Los Angeles Description: 90 minutes per week for 12 weeks. Consists of nutrition and physical activity modification activities Personnel: Physicians, dieticians, social work Parental Involvement: Yes Description: Overweight N: 109 preprogram & 43 post-program Gender: 60 boys & 49 girls Age: 8-16y (11.5y) Ethnicity/Race: 85% Hispanic; Other 15% IC/EC: /History of diabetes, inability to ambulate, medical conditions or taking medications (i.e. glucocorticoids, insulin sensitizers, or psychotropics), no physician approval. Procedures: Metabolic syndrome risk factors were calculated at 3 weeks pre-pr ogram, & at or within 3 weeks after the end of the final session. Data (factors) collected included: BMI, BMI SD, BP, TG, FPG, serum insulin, c-peptide, total cholesterol, HDL & LDL cholesterol, le ptin, Hb A1c; repeat sampling for FGP and serum insulin 2 hrs after ingestion of 75g of Glucola. Outcomes: Wt: Before program mean 78.23.69 kg; after program mean 78.31.64 kg; paired t-test not significant; CI -0.72 to 0.54. Ht: Before program 151.11.6 cm; after program 152.21.6 cm; paired t-test <0.005; CI -1.4 to -0.9. BMI: Before program 33.65.15 kg/m ; after program 33.191.12 kg/m ; p<0.005; CI 0.2 to 0.7. BMI SDS before program 2.39 0.05; after program 2.34 0.06; p<0.005; CI 0.016 to 0.076 Hb A1c: Not evaluated Other: Prior to the program, 49% of the subjects had prevalence of risk factors for metabolic syndrome. The overall prevalence of risk factors for metabolic syndrome was 55% in Hispanic and 27% in black participants. There were significant changes (preand post-program) regarding SBP, 2-hr glucose, cholesterol, LDL, TG, and Leptin. See article for further results. Qualitative Component: Informal telephone surveys (8 questions) for 39 families that didn't complete the program. Indicated transportation, language barrier, and program time requirements were main reasons for dropping out.

PAGE 54

54Table 2-4. Continued. Publication Program Subjects Evaluation Reinehr, T. et al. (2003). Predictors to success in outpatient training in obese children and adolescents. International Journal of Obesity, 27(9), 1087-1092. Name/Location: Obeldicks Description: 1 year & divided into 3 phases: 1) 1rst 3 months is intensive phase (6 nutrition/eating sessions for 1.5 h each); 2) next 6 months is establishing phase (individual psychological family therapy sessions); 3) last 3 month is further individual care. Exercise therapy is once weekly for one year. Consists of nutrition & exercise education, & behavior therapy Personnel: Pediatricians, dieticians, psychologists, & exercise psychologists Parental Involvement: Yes Description: Obese N: 75 subjects Sex: 39 boys & 36 girls Age: 7-15y (mean y) Ethnicity/Race: Not addressed IC/EC: Two-time presence in the obesity ambulance & to fill-in a questionnaire according to exercise & dietary habits; primary disease excluded Procedures: Data collection included subjects willingness to change behavior (changes in wt status, number of attempts at therapy, participation in exercise), somatic characteristics (BMI of children & family members, children & their parents, working mother), exercise & dietary habits, the quality of dietary records. This data was r/t the SDS-BMI using multiple regression. Comparison of SDS-BMI occurred at 3months pre-program, at beginning of program, and 3-months post-program. Outcomes: Wt: Not evaluated Ht: Not evaluated BMI: For 63% of subjects, there was a median wt loss of 0.4 SDS-BMI (range 0.2 to .1). 37% of subjects were unsuccessful after treatment. Hb A1c: Not evaluated Other: The only significant difference (P<0.0001) between the successful & unsuccessful ones was that they had taken part in the exercise groups before the program began. Qualitative Component: No

PAGE 55

55Table 2-4. Continued. Publication Program Subjects Evaluation Saelens, B. E. et al. (2002). Behavioral weight control for overweight adolescents initiated in primary care. Obesity Research, 10, 22-32. Name/Location: Healthy Habits (HH)/2 pediatric primary care clinics in southern California Description: 4-months; consists nutrition of exercise instruction; subjects randomly assigned to either HH program (includes computer interaction, physician counseling & telephone-& mailbased behavioral counseling) or a single session of physician weight counseling Personnel: Physicians, those with a degree in nutrition or psychology Parental Involvement: No (subjects encouraged to implement changes on own or with the help of their families) Description: Overweight N: 44 Gender: 26 boys & 18 girls Age: 12-16y (mean 14.2y) Ethnicity/Race: IC/EC: 20 to 100% above the median (50th percentile) for BMI for sex & age; interested in weight control; not currently engaged in another weight control program; otherwise healthy as determined by pediatrician Procedures: Wt, ht, dietary intake, physical activity, sedentary behavior, and problematic weight-related and eating behaviors and beliefs were assessed before and after the treatment, and at a 3-month follow-up. Subject satisfaction & behavioral skills use were measured Outcomes: Wt: No significant decrease for HH or TC groups from baseline to post-treatment. Ht: Not evaluated BMI: Program led to modest decrease in weight status for HH (about .05 in BMI z score) & increase in weight status for TC (about 0.06 BMI z score). Hb A1c: Not evaluated Other: At post-tr eatment, HH reported higher overall & eating behavioral skills than TC group. (P<0.01). HH report greater satisfaction for mailed materials versus computer interaction (P<0.01). Qualitative Component: No

PAGE 56

56Table 2-4. Continued. Publication Program Subjects Evaluation Savoye, M. et al. (2004). Anthropometric and psychosocial changes in obese adolescents enrolled in a weight management program. Journal of the American Dietetic Association, 105(3), 364-370. Name/Location: Bright Bodies Weight Management Program/Yale New Haven Hospital Description: 1 year; each week two 30-minute exercise sessions and one 45-minute nutrition or behavioral modification class. Consists of nutrition, exercise, and behavior modification; given either a structured meal plan (SMP) or taught to make better food choices (BFC) Personnel: Dieticians, social workers, & exercise physiologists Parental Involvement: Yes Description: Overweight N: 25 Gender: 8 males & 17 females Age: 13.3.6 (SMP); 13.6 .3 (BFC) Ethnicity/Race: 8 White (SMP); 7 White, 7 Black, & 3 Hispanic (BFC) IC/EC: Major health or psychological condition, medications for weight management, or involved in a concurrent weight control program Procedures: BMI, body fat percent, and self concept were measured at 0, 1, and 2 years. Outcomes were analyzed for the entire group and by diet method groups. Outcomes: Wt: Not evaluated Ht: Not evaluated BMI: At 1 year, entire group had a decrease in BMI z scores from 2.49 0.10 to 2.3 0.10(P=0.004) (i.e. a 7.7% decrease or a decrease in absolute BMI from 40.10 to 37.7.08, P < or = .0001). At 2 years, decrease in BMI from baseline was maintained (2.29 0.10, P=.03), or an absolute BMI decrease to 39.3.08, P When comparing dietary approaches, the SMP group showed more favorable shortterm results for BMI (P=0.11), but by year 2, the BFC further improved BMI (P=.006), while the dieting group reverted back to baseline. See article for further results. Hb A1c: Not evaluated Other: At 1 year body fat percent decreased from 45.76% 1.65% to 40.79% 1/66% (P=0.002), & self-concept increased (P<0.001). At 2 years body fat (P=0.15) & self-concept (P=0.10) were not significantly higher than baseline (P=0.10). Qualitative Component: No

PAGE 57

57Table 2-4. Continued. Publication Program Subjects Evaluation Spieth, L. et al. (2000). A lowglycemic index diet in the treatment of pediatric obesity. Arch Pediatr Adolesc Med, 154(9), 947-951. Name/Location: Optimal Weight for Life Program; Childrens Hospital, Boston, Massachusetts Description: About 4months/one primary session & then about 4 follow-up visits. Consists of a primary counseling session that included dietary instruction (assigned either low glycemic index diet (low-GI) instruction or low fat diet instruction & physical activity recommendations; follow-up appointment once monthly for 4 months; some received problemfocused behavior therapy with a program psychologist Personnel: Pediatrician, dietician, pediatric nurse practitioner, program psychologist Parental Involvement: Yes Description: Obese N: 107 (64 low-GI & 43 low fat diet) Gender: boys (30 low-GI & 19 low fat diet) & girls (34 lowGI & 24 low fat diet) Age: 10.64.0 y (low-GI) & 10.23.1 (low fat diet) Ethnicity/Race: 10 Black/Hispanic & 54 White (low-GI) & 20 Black/Hispanic & 23 White (low-fat diet) IC/EC: Cushing's syndrome, hypothyroidism, hypothalamic, diabetes, or obesity-associated genetic syndrome, or concurrent energy diet Procedures: Changes in BMI and wt from first to last clinic visit were evaluated; the 2 groups were compared. Outcomes: Wt: -2.03 kg [95% confidence interval -3.19 to -0.88] in the low-glycemic index group vs. +1.31 kg [ -0.11 to + 2.72], P<.001) in the reduced fat group Ht: Not evaluated BMI: -1.53 kg/m2 [95% confidence interval, -1.94 to -1.12] in the low-GI group vs. -0.06 kg/m2 [-0.56 to + 0.44], P<.001) in the low fat group. Significantly more patients in the low-GI group experienced a decrease in BMI of at least 3 kg/m2 (11 kg/m2 [17.2%] vs. 1 kg/m2 [2.3%], P = .03). Hb A1c: Not evaluated Other: In multivariate models, these differences remained significant (P<.01) after adjustment for age, sex, ethnicity, BMI or baseline weight, participation in behavioral modification sessions, and treatment duration Qualitative Component: No

PAGE 58

58Table 2-4. Continued. Publication Program Subjects Evaluation Taylor, M. J., Mazzone, M., Wrotniak, B. H. (2005). Outcome of an exercise and educational intervention for children who are overweight. Pediatric Physical Therapy,17(3), 180-188. Name/Location: Western New York State Description: Consecutive 8 weeks. Twice weekly for 60minute sessions; consists of exercise and educational components Personnel: Physical therapists; physicians, registered dieticians, nutritionists, nurse clinicians, an occupational therapist, & a sports psychologist Parental Involvement: Yes Description: At-risk-foroverweight or overweight N: 41 (52 started excluded d/t E.C.) sessions) Gender: 18 boys; 23 girls Age: (mean 10.5y) Ethnicity/Race: Not stated I.C./E.C: Age between 8-15y, BMI >er 85%, stable vital signs, adequate balance and coordination to sit on a therapy ball, sufficient attention to follow instructions in a group setting, and medical consent to participate/missed >er 4 classes Procedures: Data collection of 2 baseline, pretest measures (separated by 1 week) & a single posttest measure (1 week after program completion). Data included BMI, waist & hip girth, BP, resting heart rate (RHR), immediate post-exercise heart rate (HRfinish), five-minute recovery heart rate (5minHR), & distance walked in six minutes. Outcomes: Wt: Difference between pre(mean 139 lbs) & post-program (mean 140 lbs) Ht: Difference between pre(mean 57 inches) & post-program (mean 58 inches) BMI: Significant difference between pre& post-program. (p =0.0001). Mean BMI decreased by 0.4. 27% of subjects decreased BMI by 1 point or more (corresponds approximately to 4-pound weight loss). Hb A1c: Not evaluated Other: Significant difference between pre& post-program included waist girth (p<0.0001), hip girth (p<0.0001), SBP (p=0.0006), DBP (p=0.0181), RHR (p=0.0115), HRfinish (p=0.0298), & 5minHR (p=0.0255). No significant difference across time for waist-to-hip ratio or in the 6-minute walk. See article for further and post hoc results. Qualitative Component: No

PAGE 59

59Table 2-4. Continued. Publication Program Subjects Evaluation Woo, K. S. et al. (2004). Effects of diet and exercise on obesityrelated vascular dysfunction in children. Circulation, 109, 1981-1886. Name/Location: Not available (Recruited from 13 primary schools) Description: 1) 6 weeks/diet & exercise twice weekly (1/2 of group received diet modification only; 1/2 of grou p received diet & exercise). 2) After 6 weeks, for 1 year, 1/2 of those in the diet & exercise group continue weekly exercise program for a year, all of the others continue 2monthly diet monitoring program. Personnel: Trained physiotherapists; dieticians, others not stated Parental Involvement: Yes Description: Overweight or obese N: 82 Gender: 54 boys & 28 girls Age: 9-12y Ethnicity/Race: Not available IC/EC: No known medical illnesses or alternative cause for obesity, no family history of premature cardiovascular disease, no regular medications or vitamins, & have resting brachial artery diameter >2.5 mm Procedures: Physical assessment (BMI, hip-waist ratio, body fat content), blood tests (cholesterol, lipid profiles, glucose levels), and arterial reactivity studies (ultrasound-derived endothelial function (EDD) of brachial & thickness of carotid artery) were compared pre-program, & post-program at 6-weeks & 1-year. Also, multivar iate analysis done. Outcomes Wt: Not evaluated Ht: Not evaluated BMI: No significant decrease at 6 weeks or 1 year post-program. Hb A1c: Not evaluated Other: After 6-week intervention, no significant change in body fat content, fatfree mass. A significant decrease in total cholesterol in both groups & LDL in the exercise group. Fasting glucose (P<0.002) reduced in the ex ercise group. An improvement in EDD but not NGT of brachial artery after 6 weeks' intervention in both groups, but significantly greater with exercise (P=0.01). Exercise training ( =0.54;P=0.02) & changes in LDL ( =0.54; P=0.03). For other & 1 year results see article. Qualitative Component: No

PAGE 60

60Table 2-4. Continued Publication Program Subjects Evaluation Zador, I. et al. (2006). Hemoglobin A1c in obese children and adolescents who participated in a weight management program. Acta Paediatrica, 95(1), 105-107. Name/Location: Marshfield Clinic/North-Central Wisconsin Description: Once-a-week for 12 weeks. Consists of nutrition, exercise, and behavioral component Personnel: Exercise physiologist, registered dietician, medical social worker, & a nurse practitioner Parental Involvement: Yes Description: Obese, nondiabetic N: 17 Gender: 10 boys & 7 girls Age: 7-15.8y (mean 10.8y) Ethnicity/Race: All Caucasian IC/EC: Not stated. Subjects received a history, physical & psychological exam prior to program participation. Procedures: Comparison of preand post-post Hb A1c & BMI. Outcomes: Wt: Not evaluated Ht: Not evaluated BMI: At the outset of the weight management program was 34.36.4 kg/m2 (mean SD). BMI at the end of the program was 33.6 kg/m2 (p<0.05). Mean BMI in five patients (29%) actually increased by the end of the program but their HbA1c values decreased. Hb AIc: At the beginning, Hb A1c was 5.30.3%. HbA1c at the end of the program was 50.2% (p<0.05). There was no significant difference in HbA1c change between the prepubertal & pubertal subgroups of children (p=0.59). No significant correlation between changes in BMI & changes in Hb A1c. No significant correlation between changes in waist-to-hip ratio and changes in Hb A1c. Other: Waist-to-hip ratio at program completion was 0.960.09(mean SD). Waist-to-hip ratio at program completion was 0.970.11 (p=0.411). Qualitative Component: No Note. ABMI = Adjusted Body Mass Index; ANOVA = Analysis of Variance; BMI = Body mass index; BM SDS = Body mass index standard d eviation score; BW = Body Weight; DABMI =Difference in Adjusted Body Mass In dex; DXA = Dual-energy X-ray Absorption; EC = Exclusion Criteria; EE = Energy Expenditures; FM = Fat Mass; FFM = Fat-free Mass; FPG = Fasting Plasma Glucose; Hemoglobin Glycosylated Hemoglobin = Hb A1c; HD L = High density lipoprotein; Ht = Height; IC = Inclusion criteria; LDL = Low Density Lipoprotein; PE = Physical Ex ercise; SD = Standard Deviati on; SDS-BMI = Standard Duration Scores of Body Mass I ndex; s.e.m. = Least-squares means and standard errors; SPSS = Statistical Product and Service So lutions software; TG = Triglycerides; VO2 max = Maximal Oxygen Uptake; V02 170 = Oxygen Consumption at Heart Rate of 170 bpm; Wt = Weight

PAGE 61

61 CHAPTER 3 METHOD Using a mixed-methods approach, an evaluati on of the Childrens Medical Services (CMS) behavior intervention program, initiated in 2002, wa s carried out utilizing a repeated measures retrospective chart review, inte rviews with youths and parents, and in-class observations. The CMS program was comprised of four, 1.5 hour w eekly sessions for children and adolescents (herein referred to as youths) and their pare nts. Although the program curricula (Appendix A) remained constant throughout the program, it was implemented by a rotation of instructors that included Registered Nurses, Registered Dieticia ns, and dietician student s. The study evaluated those youths' outcomes that attended the CMS program between October 1, 2002, and September 30, 2006. Study Aims Specific Aim #1 A repeated measures, retrospective chart review was used to compare CMS youths' biological measurements of body mass index (BM I) and glycosylated hemoglobin (Hb A1c) at approximately three and six-month s before program participation ; the first day of the program ; and approximately three and six-month s after program participation. Specific Aim#2 Post-program interviews were conducted with youths and parents usi ng an interview guide (Appendix B). Thematic analysis of the data gathered elucidates salient strengths and weaknesses of the program.

PAGE 62

62 Specific Aim #3 In-class sessions were observed. Field notes were recorded and analyzed for themes. Thematic analysis enabled the researcher to ta ke full account of the many interactions of youths and parents and their poten tial effects in the social setting of the program. Sample and Sample Size A retrospective chart review, interviews, and in-class observations were obtained using convenience sampling. Given a 0.75 effect size, as determined using the means and standard deviation from Eliakim et al (2002) (mean one: 26.1; mean two: 25.4; sd 0.6), a minimum sample size of 44 will achieve 0.80 power (alpha 0.05) for repeated measures designs with five levels (Maxwell & Delaney, 1990). The sample consisted of: 1) 59 youths for th e repeated measures, retrospective chart review; 2) four youths and five parents for the interview portion of the study; and 3) six youths, seven parents, and four program instru ctors for the in-cla ss observations. Inclusion Criteria 1. Met CMS eligibility requirements.1 2. Client of the CMS Metabolic Clinic. 3. Age 7-18 years old. 4. Diagnosed as overweight. 5. Completed the CMS behavior inte rvention program in its entirety. Exclusion Criteria 1. Youths that dropped-out of the CMS program. 1Under age 21 with medical, behavioral, or other health conditions that have lasted or are expected to last at least 12 months. Economic requirements include Medicaid eligible (Title XIX) Childrens State Health Care Network, Florida KidCare State Childrens Health Insurance Program (Title XXI) eligible with age up to 19 years with family incomes up to 200% of the federal poverty level, Childre ns State Health Care Network with family incomes over 200% of the federal poverty level through spend-down to Medicaid levels Childrens State Health Care Network as defined in Title V of the Social Security Act, and high risk pregnant female eligible for Medicaid (CMS, 2006).

PAGE 63

63 2. Diagnosed with a cognitive impairment that could affect the youths comprehension of the CMS program intervention. Recruitment Part #1: Repeated measures retrospective chart review. Institutional Review Board (IRB) permission was granted to conduct statistica l and scientific resear ch of abstracted youth information without the necessity of written consent from the patient pursuant to Section 456.057(5) (a), Florida Statutes (2006). The data collection procedure complied with relevant requirements of the University of Florida a nd the Florida Department of Health IRBs by redacting from the youth information provided to the PI all of the 18 HIPAA identifiers (Appendix C). Fifty-nine youths we re utilized for this portion of the study because that was the number of youths that had completed the pr ogram when data collection began on October 1, 2006. Part #2: Post-program interviews. Childrens Medical Servi ces Registered Nurses or Registered Dieticians informed CMS youths of the study by tele phone or in person. The youths called or emailed the researcher if they were interested in participating in study interviews. The researcher arranged interviews at CMS or in the interviewee homes. Informed written consent from the parents, and assent of the youths, were obtained. Four youths and five parents enrolled for this portion of the study. Part #3: In-class observations. The CMS nurse provided the researcher with a schedule of the CMS program and the researcher attended a full program that consisted of four sessions. At the beginning of each class, the researcher informed the class that she would observe the program and collect non-identifiable data regardi ng the description of the room, the instructors, and the participants, via note-taking. The Univ ersity of Florida Inst itutional Review Board

PAGE 64

64 (IRB) and the Florida Department of Health IRB granted a Waiver of Documentation of Informed Consent for this portion of the study. Procedure Part #1: Repeated Measures Retrospective Chart Review A CMS Licensed Practical Nurse (LPN) collected and recorded pertinent information from 59 CMS youths using the IRB-approv ed, attached data collection fo rm (Appendix D). Pertinent data included age, ethnicity, and gender. Data also included youths BMI and Hb A1c values across five data collection point s. The points were approximate ly sixand three-months preprogram, day of program, and approximately threeand six-m onths post-program. Inter-rater reliability was assessed by having the LPN photocopy eight of the 59 CMS youths charts and having her to black out al l 18 HIPAA identifiers. Then, the researcher recollected the data. There was 100% inter-rater re liability between 18 items for eight subjects. Part #2: Post-Program Interviews The informal interviews were tape-recorded. The interviews occurred in the CMS agency sitting room, with the exception of one interview th at occurred at a parents home. Youths and parents were interviewed separate ly. The researcher used an interview guide (Appendix B) and encouraged youths and parents to talk about their perspectives. The evening of the interview session, the researcher transcribed the tapes into typed scripts. At a later date, the tr anscripts were entered into the Nvivo 2.0 program where they were organized and eventually coded for themes. Part #3: In-Class Observation The researcher observed one, four-week progr am session that consis ted of four, 1.5-hour classes. After the re searcher informed the class that she would observe the session, the

PAGE 65

65 researcher sat apart from the participants usua lly in a chair against a wall at the side of the room. The researcher observed the entire setting wh ich included a descrip tion of the room, the activity, the time, the instructors, and the partic ipants. The researcher observed and monitored verbal and nonverbal cues, and used concre te, unambiguous, descrip tive language during the note-taking procedure. The data was collected in a manner that did not identify instructors or participants. The evening of the session, the researcher typed the hand-written notes. At a later date, the notes were entered into the Nvivo 2.0 software program (QSR International, 2002) where they were organized and eventually coded for themes. Human Subjects Confidentiality and Legal Minority To maintain confidentiality a nd anonymity of youths for the chart review, a code key was developed for each youth by the CMS LPN. Only the youths identification numbers appeared on the chart review data collection tool that th e researcher received back from the LPN. Interview and in-class observation data was coll ected, stored, and locked in the researchers office. After the interviews were transcribed without identifiable data the audiotapes were destroyed. It is important to include youths in research. However, youths in research require special considerations because of limitations on autonomous decision-making and requirements for additional risk protections (they may not be able to protect themselves). Two ethical issues relevant to youths involved in research include 1) autonom y, also known as the process of informed consent/assent and 2) whether the proposed research involves minimal risk to the

PAGE 66

66 subjects. For this study, the researcher obtaine d informed written consent from the parents and assent from the youths. Possible Discomforts and Risks There was no risk to youths or parents (physic al, psychological, social, or economic). The interviews took about 30 to 45 minutes. The re searcher met youths and parents at CMS or their houses at their convenience. Possible Benefits A direct benefit to the youths and parents is that they each received a $15.00 gift certificate to a department store for partic ipation in the interviews. It is expected that the youths and parents will eventually benefit from an improved program. Description of Quantitative Analyses: Chart Review Descriptive Statistics As a preliminary step, summary statistics of the groups age, gender, ethnicity and physiological measurements were computed. Th ese statistics included means, ranges, and standard deviations. Repeated Measures ANOVA The next step in evaluation of the data invol ved an exploratory anal ysis using a repeated measures analysis of variance (ANOVA) to compare group means on a dependent variable across repeated measures of time (Krueger and Tian, 2004). Time is often referred to as the with-in subjects factor, whereas a fixed or non-changing variable (i.e ethnicity) is referred to as the between-subjects factor (Huck, Cormier, & Bounds, 1974). In this study, one-way repeated measures ANOVA was used to compare differen ces in BMI and Hb A1c (dependent variable) across time (within-subjects factor) by gender an d ethnicity (between-s ubjects factors).

PAGE 67

67 Since the data was on the same variables over time, they were considered to be dependent observations. Thus, in this case, standard ANOVA was not appropriate because it fails to take into account the correlation between the repeat ed measures and the assumption of independence in ANOVA would have been violated (Davis, 2002; Kuehl, 2000). Repeated measures ANOVA analyses are a spec ial case of randomized block designs that account for the correlation in measuremen ts (Davis, 2002; Kuehl, 2000). The purpose of blocking is to isolate variation due to a pa rticular grouping variable Davis 2002, Kuehl, 2000). Generally, the null hypothesis of no block effect (no subject differences between the two blocks) is rejected. Blocking also reduces mean sum of s quares of error (MSE), so that the effects of a treatment may be better detected such as change s over time. For the purpose of this exploratory analysis, each subject was treated as a block. This controlled for the variation between different subjects so that the trend over time was the main focus (Davis, 2002; Kuehl, 2000). The assumptions of repeated measures ANOV A include: 1) independe nce of observations; 2) multivariate normality; and 3) sphericity. To m eet the assumption of sphericity, it is required that correlations across all pairs of time periods are constant (K uehl, 2000). In this study, there were missing Hb A1c data points, and the repeated measures ANOVA dropped 54 of the 59 subjects for Hb A1c analysis. Data collection points were approximately every three months over the course of one year. If a youth was missi ng BMI and Hb A1c measures at just one of the data collection points, the ANOVA dropped that youths entire data set. If there had been a complete data analysis set, the repeated measures ANOVA would have accurately reported whether or not the assumptions held (Kuehl, 2000). Thus, the general linear mixed model was used as the final step in evaluating the data.

PAGE 68

68 General Linear Mixed Model The final step in analyzing data was the use of the general linear mixed model because of its ability to handle multiple missing data point s (Cary, 1989; Dilorio, 1991). In addition, the general linear mixed model can be used to de scribe nonlinear relationships across time in a longitudinal database with multiple missing data points (Krueger and Tian, 2004). The general linear mixed model models for group means as fixed effects while simultaneously modeling for individual subject va riables as random effects (Krueger and Tian, 2004). One of the advantages of using the gene ral linear mixed model is it can accommodate missing, random data because the modeling of the individual subject variables allows for the accommodation (Little et al., 1995; Edwards, 2000). The usual linear model y= X + usually assumes that is Normal (0 2I) (Edwards, 2000). For example, the errors are in dependent Normal with zero means and constant variances 2. The mixed model is an extension of th e general linear model. It gives us more flexibility while specifying the covariance matrix of epsilon (Edwards, 2000). This allows the researcher to include both correlation and heterogeneous variances while assuming normality (Edwards, 2000). The mixed model is written as y= X + Z + where and are normally distributed with E[ ] = 0 E[ ] = ; while the 's have a covariance matrix G and the 's have a covariance matrix which is given by R (Litt le, 1995). In SAS, the PROC MIXED implements two likelihood-based methods to es timate the model parameters ( G, R) (Little, 1995). The PROC MIXED uses maximum likelihood (ML) and restricted/residual maximum likelihood (REML) estimation methods (Little, 1995). A favorable theoretical property of ML and REML is that they accommodate data that are missing at random (Little, 1995).

PAGE 69

69 For models with fixed-effects involving class va riables, such as gende r and ethnicity, there are more design columns in X constructed than th ere are degrees of freedom for the effect. Thus, there are linear dependencies among th e columns of X. In this event, all of the parameters are not estimable (Little 1995). There are an infinite number of solutions to the mixed model equations. The PROC MIXED uses a generalized (g2) inverse to obtain values for the estimates (Searle, 1971). The PROC MIXED handles missing level combinations of classification variables by deleting fixedeffects parameters corresponding to missing levels in order to preserve estimability. However, the PROC MIXED does not delete missing level combinations for random-effects parameters because linear combinations of the random-eff ects parameters are always estimable (Searle, 1971). In this studys data set, there were only missing values on the repeated measures of BMI and Hb A1c and not on the classification variable s of gender and race. So all the effects were estimable. A variety of within-subject covariance matrix structur es like Compound Symmetry, AutoRegressive Heterogeneous (ARH (1 )), Unstructured, and others, are allowed in the mixed model. It uses restricted maximum likelihood to estimate the parameters of the co variates (Little, 1995). For the purposes of this study, the researcher trie d to fit the same model under different assumptions, otherwise called Model Selection. For the BMI values, the researcher fit the models under Compound Symmetry (which was not violated). Although it was determined that it was appropriate to use Comp ound Symmetry, the researcher also a ssessed whether other assumptions would do better. The Model Selection assisted the researcher to pick the best model in terms of both the model fit as well as how parsimoniousness of the model. Betwee n the three models, it was determined that the Unstructured Covariance Matrix was the best fit.

PAGE 70

70 In the same way as within-subjects can be specified, the between subjects covariance matrix structure may also be specifi ed. For example, if we assume for u Compound Symmetry, ARH(1), Unstructured, a nd others, then under the above model the E (BMI ij )= + 1 TIME ij + 2 Male j + 3 White j is the population averaged model (Little et al., 1994) In order to decide which covariance structure to use, models can be fitted under different covariance assumptions and then selected using so me model selection criteria like BMI and Hb A1c. The mixed model also allows th e effect of time and the intercept to vary between subjects and includes them as random effects in the mode l (Little, 1995). The mixed model is capable of treating time as either a continuous variable or a categorical variab le or both (Krueger and Tian, 2004). The analysis was performed treating time as a continuous vari able using the Random statement. Description of Qualitative Analyses: Interviews and In-Class Observations The researcher interviewed participants and observed in-class sessions in order to go beyond what the chart review da ta would allow; to have a deeper understanding of the CMS program. According to Weinre ich (2005), qualitative methods im merse the researcher in the situation, enable the researcher to interact with study subjects and thereby generate a rich context for understanding health behavior, the meaning people assign to phenomena, and the mental processes underlying their behavior. The researcher used the method of ethnography by seeking to answer central questions concerning the ways of life of the program par ticipants. Ethnographic qu estions are generally concerned with the link between culture and be havior and/or how cultu ral processes develop over time (Hall, 2007). Ethnographies are usually ex tensive descriptions of the details of social life or cultural phenomena in a small number of cases (Hall, 2007). Fo r the purpose of this

PAGE 71

71 study, the interview questions and in-class observations provided a wide range descriptive data concerning participants program experiences. The researcher sp ent a considerable amount of time interviewing participants and observing prog ram classes. The rese archer sought to gain what is called an emic perspective; that is to say the program particip ants perspectives. Initially, using the Nvivo 2.0 program software the transcribed interview data was coded according to the interview guide questions in order to facilitate the grouping of answers from the participants. For example, Why did you attend the CMS program? was an initial code. The inclass observation field notes was coded according to the sequence of activities that occurred in the program snack, exercise, or lecture activit y. Those preliminary codes are presented in chapter five. Lastly, the entire text of chapter five was ha nd-coded into five major themes as discussed in chapter six. Themes are described as the conceptual linking of expressions (Ryan & Bernard, 2003). The researcher knew that she had found a theme from the organized data when she was able to answer the question, W hat is this expression an example of (Ryan & Bernard, 2003)? Thus, scrutiny of the interview and in-class observation data occurred when the interview tapes were transcribed and in-class notes read a nd reread. Examination of the data continued after the transcribed text was entered into the Nvivo 2.0 program for organization and coding analysis. The entire process faci litated analysis of the transc ripts for emerging themes. In 1945, anthropologist Morris Opler (Ryan & Bernard, 2003) defined themes as dynamic affirmations that control be havior or stimulate activity Themes come from the data (an inductive approach) and from the investigat ors prior theoretical understanding of the phenomenon under study (a prio ri approach) (Ryan and Bern ard, 2003). The researcher

PAGE 72

72 identified themes mostly by recognizing topics th at reoccurred in the program setting, activities, and among the participants. Summary The CMS program was comprised of a four 1.5 hour weekly sessions for overweight youths ages 7 to 18 years. The mixed-method design included three parts: 1) a repeated measures, retrospective chart review of 59 CMS youths' BMI a nd Hb A1c measures from six months before the program to six months afte r the program; 2) nine post-program interviews among youths and parents; and 3) in class observation of the program. Statistical analyses for the chart review in cluded summary statistics and a preliminary analysis using repeated measures ANOVA. The repeated measures ANOVA, which requires a complete array of data, could not accommodate (d ropped any subject that was missing as few as one data point) for the missing Hb A1c data poin ts in the study. Theref ore, the general linear mixed model was utilized because the mixed mo del can accommodate a dataset with a large portion missing (Krueger and Tian, 2004). Qualitative interview and observation data wa s collected to supplement and interpret the quantitative component of the study. Thematic anal ysis of the interview da ta gathered aimed to elucidate salient strengths and weaknesses of the program. Cla ss observation data was collected to describe the program setti ng, activities, and participants.

PAGE 73

73 CHAPTER 4 QUANTITATIVE RESULTS This chapter provides the quantitative results of the chart review. The quantitative findings include the use of descriptive st atistics, repeated measures ANOV A for preliminary analysis, and the general linear mixed model. Chart Review Findings Descriptive Analyses The 59 youths ages ranged from 7 to 18 years ( M = 13, SD = 2.68). The percentage of female participants (69.5%) was greater than that of male participants (3 0.5%). The ethnicities of the members were as follows: African Am erican (64.4%); Caucasian (22%); and Unknown ethnicity (13.6%). At each of three-month data collection interv als across 12 months, BMI measures were as follows: six-months pre-program ranged from 22.8 to 50.9 ( M = 34.9, SD = 6.64); three-months pre-program ranged from 22.6 to 58.0 ( M = 36.8, SD = 8.56); day of program ranged from 22.4 to 59.8 ( M = 37.4, SD = 8.83); three-months post-program ranged from 21.9 to 60.6 ( M = 36.4, SD = 8.43); and six-months post-program ranged from 22.2 to 62.2 ( M = 37.0, SD = 9.15) (Figure 4-1). At each of the three-month da ta collection intervals across 12 months, Hb A1c measures were as follows: six-months pre-program ranged from 4.5% to 13.5% ( M = 5.67%, SD = 1.8); three-months pre-program ranged from 4.7% to 12.4% ( M = 5.8%, SD = 1.57); day of program ranged from 4.2% to 13.9% ( M = 5.5, SD = 1.5); three-months post-program ranged from 4.4% to 11.9% ( M = 5.69, SD = 1.26); and six-months post-program ranged from 4.4% to 7.9% ( M = 5.35, SD = 0.65) (Figure 4-2).

PAGE 74

74 Repeated Measures ANOVA Repeated measures ANOVA analysis requires a complete set of data; therefore, the repeated measures ANOVA was performed as a preliminary analysis for only the BMI datasets and not the Hb A1c datasets. As formerly men tioned in Chapter three, the incomplete Hb A1c datasets led to the use of th e general linear mixed model in order to accommodate for the multiple missing data points. Only five of the 59 Hb A1c datasets were complete, therefore, the repeated measures ANOVA for Hb A1c was not included in results. The total number of BMI datasets used in this repeated measures ANOVA analysis was 26 as compared to 59 BMI datasets used for the general linear mixed model analyses. This was because 33 BMI datasets were incomplete. This an alysis revealed a significant increase in BMI measurements for the group over time ( df 1 ; F = 4.7 ; P<0.05) (Table 4-1). No significant within-subject effects were noted for BM I or changes across time (Table 4-1). General Linear Mixed Model The purpose of the general linear mixed model analysis was to describe changes in BMI and Hb A1c. The BMI dataset was previously analysed using a prelim inary analysis using repeated measures ANOVA. Since both the Hb A1c and BMI datasets were incomplete, the researcher decided to use the mixed model to analyze both BMI and Hb A1c datasets. The general linear mixed model analysis accommodated for 59 BMI datasets and 59 Hb A1c datasets. The primary fixed effects in the model were ge nder, ethnicity, and tim e. The mixed model analysis allowed the researcher to model for hi gher order, nonlinear ch anges in the dependent measures (BMI and Hb A1c) across time. As previously explained in chapter three, the Unstructured Covariance Model yielded the be st model for both BMI and Hb A1c. The effect of time on BMI was significant ( df 4; F = 4.95; P<0.05) (See Table 4-2). This finding was the same as the preliminary rep eated measures ANOVA finding for BMI; that

PAGE 75

75 youths BMI measures increased rather than decreased over time. The effects of gender and ethnicity on BMI measurements were not significant (Table 4-2). The effect of time on Hb A1c was significant ( df 4; F = 2.80; P<0.05) (See Table 4-3); that youths Hb A1c measures decreased over time. The effects of ge nder and ethnicity on Hb A1c measurements were not significant (Table 4-3). Summary For the chart review, 59 youths ages ranged from 7 to 18 years ( M = 13, SD = 2.68). Since the repeated measures ANOVA required a co mplete set of data, the repeated measures ANOVA was performed for only 26 of the 59 BMI data sets. It was not performed on the the Hb A1c datasets. This analysis re vealed a significant increase in BMI measurements for the group over time ( df 1 ; F = 4.7 ; P<0.05) (Table 4-1). No significant within-subject effects were noted for BMI or changes across time (Table 4-1). The researcher used the mixed model to an alyze both BMI and Hb A1c datasets. The mixed method accommodated for 59 BMI datasets and 59 Hb A1c datasets. The primary fixed effects in this model were gender, ethnicity, a nd time. The effects of gender and ethnicity on BMI measurements were not significant (Table 4-2). The effect of time on BMI was significant ( df 4; F = 4.95; P<0.05) (Table 4-2) This finding is the same as the repeated measures ANOVA finding for BMI; that members BMI measures increased rather than decreased over time. The effects of gender and ethnicity on Hb A1c measurem ents were not significant (Table 4-3). The effect of time on Hb A1c was significant ( df 4; F = 2.80; P<0.05) (Table 4-3); that youths Hb A1c measures decreased over time. The quantitative data provided a general unde rstanding of how the program was affecting youths biological measures such as BMI and Hb A1c. The following chap ter will add content to

PAGE 76

76 the statistical results by explori ng youths and parents views a nd program experiences more in depth (Ivankova, Creswell, & Stick, 2006). Qual itative results are esp ecially useful when unexpected findings, such as youths higher postprogram BMI values and lower post-program Hb A1c values, arise from quantitative findings (Invankova, Creswell, & Stick, 2006).

PAGE 77

77 Table 4-1. Repeated measures ANOVA for BM I using 26 subjects: Withinand betweensubjects effects. Sum Mean Source df Square Square F Within BMI 1 0047.50 47.50 4.730 BMI x gender 1 0002.62 02.62 0.260 BMI x ethnicity 8 0024.50 03.06 0.762 Error (BMI) 24 0241.00 10.00 Between Gender 1 0573.00 573.00 0.186 Ethnicity 2 0015.40 007.71 0.776 Error 24 7415.00 309.00 *p<0.05 ANOVA = Analysis of Variance BMI = Body Mass Index Table 4-2. General mixed linear mode l effects for BMI using 59 subjects. Effect df F Time 4 4.95 Gender 1 0.02 Race 2 0.15 *p<0.05 BMI = Body Mass Index Table 4-3. General linear model eff ects for Hb A1c using 59 subjects. Effect df F Time 4 2.80 Gender 1 0.64 Race 2 0.85 *p<0.05 Hb A1c = Glycosylated hemoglobin

PAGE 78

78 Figure 4-1: Chart Review: BMI (BMI1) measur ements over 12 months. The 5 data collection points are 3 months apart. Data colle ction points 1 thr ough 3 are pre-program measurements, and data collection points 4 and 5 are post-program measurements. BOX PLOT: The two major lines are the minimum and maximum values. The three lines that make up the main box are the three quartiles. Quartiles divide the data into 4 equal parts in terms of the number of obs ervations you have (not the magnitude) the second quartile is also called the median (t he middle most observation). The plus sign is the position of the mean. In data that has outliers or is skewed the mean gets pulled in the direction of the skew or the outli ers. The dots are the outlying points.

PAGE 79

79 Figure 4-2: Chart Review: Hb A1c (A1c1) measur ements over 12 months. The 5 data collection points are 3 months apart. Data colle ction points 1 thr ough 3 are pre-program measurements, and data collection points 4 and 5 are post-program measurements. BOX PLOT: The two major lines are the minimum and maximum values. The three lines that make up the main box are the three quartiles. Quartiles divide the data into 4 equal parts in terms of the number of obs ervations you have (not the magnitude) the second quartile is also called the median (t he middle most observation). The plus sign is the position of the mean. In data that has outliers or is skewed the mean gets pulled in the direction of the skew or the outli ers. The dots are the outlying points.

PAGE 80

80 CHAPTER 5 QUALITATIVE RESULTS This chapter provides the qualitative result s of the interviews and in-class observations1. In this chapter, the transcribed interview data were organized according to the interview guide questions in order to facilitate the grouping of answers from the youths and parents. The in-class observation field notes were organized according to the sequence of activities that occurred in the program. Using the Nvivo 2.0 software progra m, the data was then coded for the grouping of answers and observations. Later, the organized data was categori zed into five main themes by hand (as discussed in chapter six). Post-Program Interview Findings Three of the four youths were female, and th ree were African American. The male youth (M-1) was the sole graduating memb er of the program that I observe d for this study. The ages of the four youths ranged from 12 to 16. Each youth had at least one sibling living at home. The five parents were female, and four were African American. The ages of the parents ranged from 33 to 55. The highest educa tion level was two years of college. I organized the interview findings using the fo rmat of the interview guide. This allowed the findings to be organized so that they could be later analyzed for themes. The major data groupings that I identified from the post-progra m interview questions were: 1) the program is mandatory (for CMS Endocrine Clinic youths); 2) parents were fonder of the program than youths; 3) youths enjoyed exercise and snack ac tivities the most; 4) the parents enjoyed the camaraderie of fellow parents; 5) youths were challenged with the skill-level required for 1 This chapter is presented in first person. First person is acceptable for qualitative work because the researcher in qualitative is the tool and needs to take responsibility directly for the work

PAGE 81

81 aerobics and uncomfortable by parent al presence; 6) youths want mo re games; 7) parents want a greater variety snacks and want to be as acc ountable to the CMS progr am as the youths (To paraphrase a parent, Take my BMI and Hb A1c too.); 8) youths and parents had positive postprogram physical changes; 9) youths and parents ha ve made positive diet and exercise changes; 10) there are many challenges to healthy behavi or change; and 11) youths and parents would recommend the program to others (Table 5-1). The grouped data was later organized into nine main themes. Why Did You Attend the Program? When asked why they attended the program, youths and parents responded that program participation was mandatory and that the CMS e ndocrinologist referred them to the program because of they were overweight and had elev ated Hb A1c levels. One youth stated he was referred to the program by his pediatrician but wa s scheduled to see a CMS endocrinologist. All parents interviewed appeared to be overweight. Many of the pare nts stated that they too have type II diabetes. Parent statement: I attended because it was mandatory for my dau ghter to attend. She, like myself, is very much overweight. Struggles with overeating. Struggles with food addiction. Mainly, our food choices junk food, sugar. So it was ma ndatory. And for her, her sake, we agreed to go because we want whats best for her. Overall, parents were positive about the program and appreciated the support. Parents saw it as a resource for both the youths and their families. Parent statement: The endocrine specialist here at CMS, referred us to the program as a way to implement some better and healthier changes To see if it would help my daughter lower her bad cholestero l, and get her Hb A1cs down And just as a resource for our whole family, so we can transition toge ther. And not just leave her out in no mans land with this blood level stuff and no way to help her diet and you know, no education about what she could do to help herself basically.

PAGE 82

82 What Was the Program Like for You? Parents had fond recollections of the program. Parents expressed enthusiasm when they talked about the program. Parent statements: I thought that was great. I thought the whole program was ve ry upbeat. There is nothing at all negative about it. Noth ing at all boring about it. Y ou could tell the people were well prepared they did their homework. Enjoyed everything about it! I liked it. I hated when it was done. So we came and we had a good time. . When I talked to Ms. RD [Referring to th e dietician], I said, You all want us to do it again? I want to do it again! I enjoyed it a nd wanted to keep going. I want to go back. Well for one I enjoyed myself because I love exercise [Laugh]. Youths feedback was more difficult to elicit The youths generally expressed disinterest in the program. Their responses as to whether or not they enjoyed the program ranged from no to it was ok. Parents also had difficultly eliciting feedb ack from youths. When asked whether their children enjoyed the program, parents did not know what to say. Parent statements: A: She didnt say. I enjoyed it. [Laugh] Q: You enjoyed it but you re not sure she did. A: I cant say. I dont remember her saying anything positive. But I dont remember her saying anything negative either. Maybe she said something lik e she didnt need it. Because like I said, weve always tried to be healthy. But again, it was reinforcement for me. And it was great that my husband was there because he learned a lot. In two instances, parents mistakenly said their children enjoyed the program.

PAGE 83

83 Parent statement: PI: How did your child like the program? Mother: Well, she loved it. Youth statement: PI: Do you think the program was fun? Daughter: It was ok. PI: Was it something you looked forward to coming to? Daughter: No, not really. Q: Ok. So, it was ok, it wasnt really fun, you didnt really look forward to coming to it Daughter: I had to come. Parent statement: Mother: I think that she did enj oy it and she loves to dance. That was a big thing for her. Oh it was wonderful for us it was a lot of fun because the parents and the kids got to participate. Youth statement: PI: Would you say the program was fun? Daughter: No. What Did You Like Most about the Program? With the exception of one youth, exercise and snacks were th e youths favorites. Youth statements: I like the exercising that we did. We danced every time we came Just the dancing. The individual, against-the-wall exercises we put our b acks against the wall and tried to see how long we can stay on our backs. A nd then we had to switch and hold the cans of peaches or pears like that. [Demonstrates] The hula-hoops. Thats it. Parent statement:

PAGE 84

84 Um, she liked making, um, pizzas. The exception was the youth whose favorite program activity was the food pyramid exercise. The youths were given a copy of th e food pyramid and asked to identify how many servings of each food group they should consume each day. Youth statement: The part I liked the most was when we were in the back room and started talking. Then she gave us like a photo, and asked us how many servings we should have and I guessed the most right. What parents liked about the program was th at it was family-based and not just youthspecific. Parent statements: Well, I liked the fact that I was allowed to include my family and not just ____ [Referring to daughter]. I think that is so important, especially when yo ure dealing with a child that is in the CMS program for whatever reason. Th ey are already marked because of whatever disability or chronic illness of whatever they have. So, the ability to include the family in this part of her journey is important to me. What I really liked about it was it incorporat ed the whole family and it gave my husband a chance to learn about healthy eating. Hes never had a weight problem and between just ____ [Refers to daughter participant] and I tr ying to lose weight, it was always hard because he would always have all this junk food. And what I really liked about it was that it brought the whole family together that is what I liked about it. That my husband was able to come and we were able to work on the problem as a couple. Not just me trying to feed this guy brown rice and wheat bread. Y ou know, I had a lot of y ears that he fought me on that you know [Laugh]. Thats what I real ly enjoyed about it. That is was a family affair. Other parental favorites included: 1) the variety of snacks; 2) the live aerobic exercising; 3) the camaraderie with other parents; the 4) peer support for thei r children; and 5) the end-ofprogram graduation certificates. Parent statements: I thought it was wonderful the way they offered the children there a variety of new kinds of snacks. Wed have our workout clothes on and exercise and get a snack here that was nutritious.

PAGE 85

85 I like the fact that they made the exercise fun and the snacks that they put out for us were there where choices and you could make it th e way that you wanted to make it the way you like. And it wasnt just, you know, a pre-made thing that you had to try. You could do it this way or that way. So there was a choice. Umm, which I think is also important with children. We had a FSU student that would come and she taught us dances and you know, steps as part of physical activity and that was our exercise for the day. It was a lot of fun because the parents and the kids got to participate. And my other two children were allowed to participate as well so it was really good for us. It was the exercising. It wasn t way they did this one she brought in some, you know, the updated music and I guess, the fitness inst ructor. You know, they taught us a dance step and to go along with it. Just to listen to other parents talk about their struggles they go, this is how I did it so you sort of form a friendship you just hated it ending. She was with her peers. And so, I guess it ki nd of is not like Charlie Browns teacher, Wha wha wha wha . Its not what th ey hear. They actually can know that other people are doing it too that are their age and it is ok. And I like the fact that there was a reward [a graduation certificate] for participating because I think that shows the childre n that their time is valued. Parents appreciated convenient program schedules. Parent statements: The times were ok Were in a church and on Wednesdays you know with me coming with her we got out she met friends It worked out that, because D [Referring to daughter] is in middle school, she gets outshe has a late release time. So I w ould pick-up my younger children from school after two oclock, get them a snack, get some homework done, and then pick D [Referring to daughter] up and come to CMS. The pr ogram was on Wednesday. I attend church on Wednesday evening. So, it got over just in tim e for us to leave and go to church. So, it worked out really good for us. What Did You Like Least About the Program? Youths and parents did not ope nly share what they liked th e least about the program. Youth statements: I cant think of anything. Q: Is there anything about the pr ogram that you didnt like as much?

PAGE 86

86 A: No. Q: Were there any parts of th e program that you didnt like? A: No. Parent statements: But to think about anything I disliked, I maybe cant remember. Nothing I didnt like. One female youth spoke of an experience with an aerobics instructor. She shared that the instructor was impatient and demanding. Youth statement: Q: Were there any parts of the progr am that you really didnt enjoy? A: Well, the aerobics because she was like kinda getting frustrated with us. Im a hard learner. Im a really hard learner and you ha ve to like, sit down, and be a little more patient with me. So, she couldnt get me to get it and she got frustrated with me. That could have been better. Plus, she kept messi ng up on the aerobics so I couldnt follow her. Parents shared that their children were em barrassed when performing the exercises and were also embarrassed to be with their parents. Parent statements: Well I guess I was the class clown. The dancin g thing .we got very you know when we had to introduce ourselves. You know, she wasnt motivated at first but I guess you know kids dont like to be embarrassed. She wa s like, you stay in the back or whatever. You know, at first the exercising was kind of challenging to her and you know, being a teenager but I told her, if you get out ther e and just show that even if you dont like it just do it. So I think, by the time we completed learned the dance she started to like it. But at first, it was just like, oh my god exercise. I think being heavy and you know, overweight, she thought, I gotta move? They put us in groups and we had to do the whole dance thing with the group so she didnt want to be in my group. She wanted to s how that her group was better. But that was probably the only thing that I perc eived that she didnt like. One parent shared her daughters dissatisfac tion with the journalwriting activity that requires members to record their dietary consumption during the day.

PAGE 87

87 Parent statement: Dislike is a strong word but .[one] thing that she didnt lik e the journal writing. Writing down what she ate. It was, you know, to somebody who is a preteen, it is pointless. Why would I write it down? We ll, because this is a way for you, and the doctors, and nurses, to see what youre putti ng in your body so that they can help you maintain this. But you know, I think her thing was, on top of all the writing you have to do you still have to do your homework. And it was a weekly thing you know. So I think for her all that writing and remembering you know and trying to keep up at that age you dont want to be so anal about you dont really care. One parent shared that her daughter was tired from school at the end of the day, making attendance at the program stressful. Parent statement: You know coming straight from school and having your brain picked all day was probablyand a lot of the kids, including D [Ref erring to daughter] woul d drag. Its just that time of day where they ar e tired and worn-out What Do You Suggest For Program Improvement? Only one youth had a suggestion to improve the pr ogram. She shared that it could be more interesting if the progr am includes games. Youth statement: I would put more games into the program. Games that would make it more fun and where you could do exercise at the same time. Or if games so you just wouldnt have to just sit in a room. The parents suggestions ranged from no sugge stions and keep it the way you had it" to 1) have a greater variety of snacks, especially regarding vegetable choices; 2) make the parents as accountable as the members in the program. Parent statements: I think they need to keep it the way they had it. I thought everything was great. thought it was an excellent its an awesome progr am. I dont know where they could make any changes. I would say to really go out of the norm of what people think they wouldnt like. The carrots and the broccoli try something diffe rent. Because I know th eres a restaurant, I cant think of the name of the restaurant right now, but they have a sa lad that I go there and

PAGE 88

88 they have the fresh squash a nd zucchini cut up and its not c ooked but in the salad. So you know, just integrate something like that I dont know what theyv e done lately. But that would be really good. But other than th at they had some very nutritious snacks. But in fact, there is nothing wrong with al l of us making the changes to eat the food pyramid the way that its designed. And so, if there was a way to keep parents on that same accountability level, I think that would be a big way to ensure more success for more people. Would You Recommend the Program to Others? Youths and parents unanimously articulated that they would recommend the program to other members and their parents (if they needed it). Youth statements: Yes. But I dont think I have any fr iends like me. But if I did, I would. Q: Do you think your friends would like the program? A:Yes. Q: So you would recommend this program to other kids if they needed it? A: If they needed it, yes. Parent statements: Oh yes, definitely. Definitely. Ive even had some friends, you know that their children are now looking at D [Referring to daughter ] and saying, What has she done? Well, she was recommended by the doctor if youre concerned about your childs health or weight, they can refer you to it .because that is how we got to it by referral I would definitely recommend it. Q: Would you recommend this program? A: Absolutely. Q: Would you recommend this progra m to other parents or children? A: Sure. Q: Would you recommend the program to other parents and children? A: Yes. Yes. Absolutely.

PAGE 89

89 What Are Your Post-Program Behavioral Changes? Youths shared that they were eating more fr uits and vegetables, and exercising more since participating in the program. Youth statements: Well, eating more salads. Eating mo re fruits and vegetables. At my school, I do PE as much as possible And I do aerobics at home. I turn on the music and I just dance to the music. And I do crunches and sit-ups. I dance for 30 minutes and do jumping jacks when I turn on the CD. We have this cha nnel called Fit TV. They do aer obics, exercises, its all dayyou can do it all day if you want t o. I do it until I get tired. [Laugh] Q: Umm do you exercise every day? A: I try to but [Unintelligible] Q: So how long every day do you exercise? A: Umm at school its like 55 minutes? Q: Do you have PE every day at school? A: Yeah. Its the only time we get exercise softball baseball football basketball and we have warm-up wh ere we do lunges and things like that. Parents talked about changes they made after the program regarding: 1) grocery shopping; 2) beverages; 3) junk food; 4) portion sizes; 5) sa lt, sugar, and fat intake; 6) cooking methods; 7) fruit and vegetable consumption; 8) whole grai ns; 9) reading food labels; and 10) exercise. Grocery shopping changes. I shop now with a list versus, y ou know, at least that way if I have a list I dont have to go down every isle. And I try to stop first at the fruits and vegetables so that I dont fill my buggy up with all the other stuff and thenwhere am I going to put these, you know, the fruits and vegetables. Beverage changes. For one, cokes, I dont buy cokes. Our biggest problem was soft drinks. We dont do soft drinks any more. We love I know Im advertising, Crystal Light.

PAGE 90

90 We do water more than anything. If we do soft dr inkstrying to get used to the diets. Its hard to get used to the diets because my body is a Pepsi person. But I me an, its just if we do get a regular drink, thats you know not a diet, we portion what we drink. We only drink just a serving. [After the interview the mom had continued talking and said they were drinking a lot of mint tea now ] She opts for water over soda a lot of the time and fat-free milk. The nurse stressed that if [she] would just ge t off the sugar sodas and just drink water and diet soda that within weeks [she] would lo se weight. And she did. She lost 7 lbs in 2 weeks. And thats all she did different. Cutting out junk food. We dont bring as much of the junk food in the house. Shes very, very disciplined about the food choi ces that she makes. She watches the carbs that she puts into her body. Shes very if we eat out, she will choose a vegetable over the French fries. Practicing portion control. We watch our portions. They talked a lot about portions, portion sizes. It just really helped me in my portion control and like food wasnt really bad if you could just watch your portion control. You can have some candy. But you know, try the small, bite-sized candy bars and not the biggi es. Or not a bag of butter fingers. Get small. You dont have to depriv e yourself. You still can have what you want as long as you check portion control. So th e portion control issue he lped me because Im you know And I say, you cant have that today. But I tell them, when theyre hungry when they get home you can have A sandwich, not a Dagw ood piled up with meat. You can have A sandwich. [Unintelligible] I tell them just because your not full doesnt mean there is nothing in there. But I dont want to deny them. I give the ca ndy, the cookies, all the temptations and stuff, um; they do it so they are in l ittle containers. And he knows that, one container a day. If you eat it during school, dont ask for it after school. For me it was to learn how to portion food. Y ou can eat what you want but it just comes in portions. Now, were eating better, but its portions of what theyre eating Im not going to say it wasnt hard. But once you get into that habit and weve kept it. And I think its been more than a year. Decreasing salt and sugar intake. You know I put a lot of salt in my food and I dont do that now for one. I say well, what I am doing to her I am doing to myself. And so I say, I didnt say a thing, but put less sugar in tea, kool-aid, and ot her stuff like that so I say we do this together.

PAGE 91

91 Decreasing fat intake. We have transitioned as a family to fat-free milk. I switched from whole milk to 2% milk. And I tell her I bought the light mayonnaise, you know. I hadnt done that a lot, you know, earlier. But I tell her she can have some of the mayonnaise, but ju st use a little bit. I told her, and tell her often, ju st use a little bit. Dont use a lot. If you want mayonnaise, just use a little bit. I get chips now and then. But there agai n I go for the baked chips and I go low fat everything as much as I can. Improving cooking methods. If you season them right you c ould never tell they were vegetables, you would think it wa s a meat. Because Ive got my children on .Oh, what kind of meat is this? Oh, its chicken. Increasing fruit and vegetable consumption. And to say that canned foods are the very last thing that you useWeve to tally changed things a lot now. Were totally eating fresh vegetables. Totally straight fr om a garden tomatoes, the cucumbers, the zucchini, the butter squash, just everything, I mean even the spinach. But you know I stopped buying all the snacks, alt hough, I buy fruits and vegetables. I still give them the chips and cookies and stuff but I do more fruits and vegetable and stuff than I was, and they eat them. Apples, oranges, bananas And they eat them. They love grapes. Changing to whole grains. We have transitioned as a family to whole grain and whole wheat as opposed to white breads and pastas. Reading food labels. And I think the one thing that sh e came away from it with was learning how to read the labels. Increasing exercise. And I have bicycle at home and sometime, uh, I say, you and I can do this together. What else do we do? We walk together sometimewe dont do it all the time. Sometime we do it together. Shes been doing more exercising. We walk on Fridays. Shes made her own exercise gym. [Unintelligible] Shes found a fitness pr ogram on television that she keeps up with. Shes went down, I want to say, I thi nk its 2 sizes in her clothes. She is very self disciplined how she does th ings. Every evening she does a certain amount of crunches on the AB machine at home that she uses. Shes on the dance team at school so that provides 3 days a week a level of physical activity for her in the afternoons. Even if you are folding-up clothes or walki ng up stairs, youre losing the calories and everything. Youth statement:

PAGE 92

92 A: I really used to never exercise but now ever y night I do some type of physical activity. Q: What types of exercise do you do? A: Dance. Q: And you do dancing how many times a week? A: Two times a week and then the rest of the nights I jog a mile with my dad. Well, I love to walk Once I starte d coming here, we started to walk. A family affair. Parents also discussed how the program has prompted them to include the entire family in dietetic a nd exercise behavioral changes. Parent statement: I think its important that pare nts support their children in any way possible and just the whole family. We needed a whole family cha nge To get her to see it and then the whole family got involved. Even though her brot hers didnt need to lose weight they do it along with her. .And also, I like the fact that my childre n hold each other accountable. I dont have to do that because what they learne d they took with them. They can point out to each other what they are eati ng and how many carbs that is and that kind of thing. They take the knowledge they have a nd apply it to their relationship. What Are Your Post-Program Physical Changes? Youths and parents stated that weight for the youths had: 1) decreased; 2) maintained from pre-program levels; or 3) most noticea bly resulted in smaller dress sizes. Parent statements: Shes lost more weight than anyone from the class. So, and gradually were just seeing it. And I was telling her that she will lose the inches before you start seeing everything so she got ten some clothes packed because I said she cant get back in these. Shes even gotten into some of my clothes. Youth statements: Ive maintained my weight. I lost weight About 12 pounds? It fluctuates though. A youth shared that her Hb A1c has decreased since the program.

PAGE 93

93 Youth statement: Im borderline [Referring to diabetes]. They said it [Referring to Hb A1c] was lower but still borderline. A parent mentioned that she ha s lost 4 dress sizes since part icipating in the program with her daughter a year ago. Parent statement. I had, you know, when we starte d this program I was a size 20 now Im a size 12. What Are the Challenges to Behavioral Changes? Parents talked about the challenges the youths f ace in order to initiate and sustain dietetic and nutritional behavioral changes. Challenges in cluded: 1) apathy for exercising; 2) dislike of certain healthier foods; 3) aversion to following the food pyramid for daily food allowances; 4) practicing different habits when they are away from home; and 5) a sserting their identity. Parent statements: But every now and then, my daughter, we call her. Its time to walk. She gets mad but shell go do it. She gripes a lot about us not having a lot of good stuff in the house. But ah, shes eating better. So thats kind of incorporating what we learned. He likes, ranch. I tried that low fat stuff, that fat-free ranch. And that s my other problem. I taste it, its not good me, I just cant make any of my kids eat it. I know that if it is bad for me it s going to be bad to them. And I dont want to make any of them you know you dont want th at salad, well, sit there and choke it down any kind of way. I dont want them to tell me theyre hungry. And were not bringing so much junk food into th e house so of course sh e has to eat better. She doesnt like it though. I know the one thing, Im still trying him (to get him) to eat salads. Over the summer, my uncle would say he would eat salads. Now, it s like when I say come to dinner for salad, hes like, What? So I stopped fo rcing him. He gags he doesnt chew. So I have to actually tell him, slow down. I asked her to do that food chart several times but she wouldnt do it.

PAGE 94

94 And I cant control what she does outside. Q: Why didnt she want to attend the program? A: It wasnt that she didnt want to. At the time she was very rebellious and acting out. She was staying away from home and she was going to do what she wanted to do. Two youths talked about the lack of Physical Ed ucation (P.E.) available to them at school. Youth statements: Q: You were in 6th grade when you were in th e program and they didn t have P.E.? A: They didnt have PE class. I would take P.E. but they didnt give it to me. They made some changes When I registered for classes I got confused. According to one parent, her child was on medication to treat a medical condition. The medication was causing her son to gain weight irrespective of his behaviors. Parent statement: What happened was, I was looking at pictures of him. When he was younger he wasnt that big. But when he got diagnosed with ep ilepsy, he got on the medicine, he just blew up. Another challenge is that pa rents are in the same position as their children; overweight with type II diabetes. Thus, the parents are no t following the types of behavioral changes they are advocating for their children. Parent statements: Q: Have you changed any ways in exercising? A: I make him do it. Im a diabetic myself and Im supposed to be going to diabetic cl asses I learned about things I should have done by now. Like foods. [Laughs] I had that bicycle for over 3 years. And that bicycle sat there for over a year before I even got on it. [Laugh] Q [ To parent]: Ok. So you have increased your exercise.

PAGE 95

95 A: I have, but then um stopped. To be honest I stopped. And I havent did it for a little over a week. My husband had recently been diagnosed with Type II Diabetes as well. She, like myself, is very much overweight. St ruggles with overeating. Struggles with food addiction. Mainly, our food c hoices junk food, sugar. The following quote by a parent elucidates th e need for both parents and members to practice healthy dietetic a nd exercise behaviors. Parent statement: I think one of the things that I would like to see is for th e parent as you do for the child. And then, you know, take my A1c at the start of the class and hold me accountable as a parent on the same level that you are holding my child accountable. Because, that way I believe you would get more of a response and maybe more success. Because I think a lot of times, and this is a cultural-type thing or an environmental thing but, you have people that show up and do the class and they know their child is at risk for or already has diabetes. One of the other issues is they ar e here because their child has to be here and needs to be eating this way. Parents had priorities that superceded the goals of the CMS program. Parents shared a variety of concerns other than that of thei r children weight and type II diabetes. Parent statement: I am a survivor of sexual molestation in my childhood that has affected every area of my life. I love the Lord Jesus Christ with all my heart. If it were not for him I would be in the bars, Chattahoochee, and I th ank God for my salvation and what he saved me from. A different parent, after the inte rview recorder was turned off, cried while she shared that she was so tired from raising 4 children and working full-time. A 12-year-old talked about the importance of individua l responsibility to change. Youth statement: Push yourself. Youre not going to do it all at one time. If you want to go a distance you cant just sit there and expect yourself to change. If this happened to me it can happen to you.

PAGE 96

96 In-Class Observation Findings For the purpose of organizing the in-class obs ervation analyses, I have provided attendance information for each of the four classes (Table 5-2). Additionally, I cat egorized the programs class activities into three major segments. The first segment was an exercise activity, the second segment was a snack, and the third segment was an educational segment. This allowed the data to be organized and grouped. Later, the data was categorized into nine main themes. The grouped data revealed that: 1) the atte ndance rate declined with each consecutive class; 2) the aerobic exercise ve nue was confined; 3) youths were challenged with the skill-level required for aerobics and uncomfortable by parental presence; 4) the snac k portions appeared to be too small (two out of four times); 5) pa rents interacted a lot among themselves; 6) the activities were frequently not engaging youths ; 7) youths were not utilizing take-home equipment; and 8) the CMS instructors utilized co mprehensive learning strategies, however, they may not have been age-appropr iate (Table 5-1). Session Attendance The four-day program included 13 youths and pa rents (Table 5-2). Attendance declined with each consecutive class. Six participants were youths and seven were parents. The six youths ranged in age from 12 to 16. Two youths were male (M1 and M2) and four were female (F1-F4). Session one. The attendance rate for session one was 93.3% percent. Five youths and seven parents attended. The parents of F-4 attended without her. Session two. The attendance rate for session two dr opped to 69.2%. F-4 attended this session for the only time, but four other participan ts did not attend. M-2 and F-2 and the mother of each were absent from session two.

PAGE 97

97 Session three. The attendance rate for sessions three and four decreased to 46.2%. Only six youths and parents attended sessions three and four. Session four. Thirty-one per cent of youths and parents atte nded all four sessions or the complete program. M-1, his mother, and F-4s pa rents attended all four sessions. F-1 attended three of the four sessions. The rema ining youths missed two or more sessions. Exercise Activity Just prior to each exercise session, youths a nd parents met in a first floor, CMS conference room. They signed in and seated themselves at one of two, long tables. On the first session day, CMS staff first led individual youths to a clinic room and recorded each youth's weight, height, and glycosylated hemoglobin measurements. This established biological measures for the dayof-the-program. Youths then re joined parents in the conference room and waited for the exercise activity to begin. Sessions one and two. The exercise segments in the first two sessions consisted of aerobic exercise to videos. The exercise segmen ts in the first two sessions took place in the CMS lobby. The RN instructed youths and parents to find a place between chairs and to follow the televised aerobic instruction. The following is a narrative of the exercise segment in session two. The exercise video African Grace begins. Th e video instructor is middle-aged and she wears colorful, African attire. He r head is wrapped in cloth to match her attire. The music is rhythmic. There are multiple drums beating in the background. During in-class observation, I observed at that at times, the youths appeared self-conscious during the video sessions. This was evident wh en youths refused to participate or barely participated, laughed and looked ar ound, or rolled their eyes. Except for F4, the participants follow in par ticipation. F4 smiles, rolls her eyes, and watches the other participants. The other participants are la ughing and frequently misstep while they move. They occasionally bump into each other or the chairs.

PAGE 98

98 RN1 approaches F-4, stands beside her, and prompts her. Come on. Do what Im doing. RN1 moves her own feet side to side. F4 smiles and remains stationary. Both of her parents move to the video, albeit, in a hesitant and unrhythmic manner. One parent is overweight and mobility-impaire d. While seated in a chair, the parent follows the video instructor by swayin g her upper body, bending her arms, and stomping her feet. The parent smiles and encourages he r daughter to follow along, but the daughter just shakes her head, "No". I observed that the aerobic exercise venue was not conducive to youths and parents fully and accurately engaging in the exercise. Staff instructed youths and parents to find a place between chairs and to follow th e televised aerobic instruction. Some of the youths and parents could not find enough room between the chairs and kept bumping into each other. Closer to the television, anot her member and her mother mo ve to the video slowly, and keep missteping. They laugh together. The member and her mother occasionally bump into each other and the chairs. The exercise videos exceeded the ability of youths and parents. They frequently misstepped. Additionally, youths may have been unc omfortable by the presen ce of their parents and CMS patients who came in and out of the lo bby but were not involved in the program. The video instruction is demandi ng. Some of the moves require hip thrusts that the make the participants laugh. About 2 minutes into the video, the male member becomes immobile. He laugh s and look s around. During the session, a dietician informed me that the program continues to review exercise videos for the purpose of finding the best one. She st ates that shed like to find an exercise video that: Is good for those participants that are gr eater than 300 pounds, has non-weight-bearing exercises, and is arthritis-friendly. Some youths and parents did not wear the a ppropriate attire for exercise. One youths pants fell down when he moved. Youths and pare nts exercised in their socks, in Birkenstocks, and in loafers.

PAGE 99

99 One mother exercises in loafers. Anot her mother and her daughter exercise in Birckenstocks, and a third mother exercises in her socks. Every participant wears street clothes. Whenever a certain member makes a minor m ove in response to the video, his low-riding pants fall down, causing him to stop moving. Th e RN walks over to the male member and verbally prompts him to move. He moves very little. Whenever he does move, his pants fall down and he has to pull them back up. After 15 minutes, the RN stops the video leads the particip ants through two minutes of deep breathing and side stretching. She then st ates, Get some water and well meet back in the conference room. The participants take turns at the water f ountain that is located there in the lobby. Once everyone is seated in the conferen ce room, the RN asks, What video do you like betterthe one we did last week or the one we just did? The mother of M1 states, The walking one. [Referring to the video in sessi on one.] The parents of F4 nod their heads in agreement. The RN states, Thi s video is a little complex. The exercise segments in sessions three a nd four did not exhibit the same problems observed during the exercise segments in sessions one and two. The exercise in each segment occurred in an appropriate venue (spacious exercise areas), did not require advanced ability, and did not require special at tire or equipment. Session three. The exercise segment in session three involved a hula-hoop activity for youths and parents. The exercise occurred in a spacious, staff lounge, away from in-coming CMS patients. The parents and youths both appear ed to enjoy themselves during this activity. Session four. On the last day of the program, the exercise segment involved walking outdoors, around the spacious, CMS parking lot lo cated in picturesque surroundings punctuated by large, majestic oak trees and rolling grass fi elds. The RN walked at a steady pace with the two youths in attendance, while the pare nts walked slowly, several yards behind.

PAGE 100

100 Snack Activity The snack segment followed the completion of each exercise activity. CMS staff directed youths and parents to the water fountain in the lobby, and many did drink from the fountain. All of youths ate their snacks in the staff lounge. During sessions one and two, diet etic instruction occurred wh ile youths ate their snacks. The parents were also provided sn acks during their dietetic inst ruction while in the conference room. Snack portions appeared to be small (two of th e four sessions) under the circumstances. Session one. The snack provided to youths and pare nts after the exercise session was a cup of fruit that included 15 grapes, a half of an apple, and a half of a banana. Cups of water were also provided to the them. Youths are separated from the parents and go wi th the dieticians to the staff lounge. Cup of fruit are distributed to the participants. A dietician brings cups of fruit to the parents who are in the conference room. While seated in armchairs and sofas that are pl aced in a circle, the participants eat from their fruit cups. The dietician introduces herself and states, What we are going to do will be fun learning about nutrition snacks .and weight. In less than 5 minutes, all the fruit in the cups is consumed excep t for one members half of a banana. Session two. At session two, youths and parents were provided with a bowls of popcorn. Cups of water were also pr ovided to the participants. The dietician instructs the youths to follow her to the staff lounge for snacks. On one of the tables in the lounge are small plates of popcorn and cups of ice water. The youths each take their serving, and proceed to sit down in a corner of the lounge where there is a carpeted area with sofas and armchairs. The di etician sits with the youths and asks them about daily exercise. The bowls of popcorn are consumed very quickly. During sessions three and four, snacks were either unavailable or not offered to parents. Most parents sat and watched the youths eat snacks. The one Cau casian mother was assertive at snack time. The mother asked if she could have a snack and if she could have a second portion. The other parents would not ask for snacks.

PAGE 101

101 Session three. Vegetables plates at session three appeared to precipitate the most disappointment among youths. They ate mostly the carrots and the dip. They pushed the vegetables around in their plates, and the die ticians stood over them and prompted them by saying, Try it. When the plates were put aw ay, a hungry youth went ov er to the dip bowl and began dipping her carrots into the bowl. She was not offered more to eat and was instructed to join the dietician for nutr ition instruction. The children are nibbling at their vegetables [The plates remain full of broccoli and cauliflower]. One nibbles at her carrots. As the children sit at the table, the dieticians encourage the children to at least try the vege tables. The parents are seated down the table from the members and are not offered a snack. Session four. Snack portions were small. Youths each received a half of an English muffin, spaghetti sauce, and miscellaneous toppi ngs. One parent also made a pizza. The beverage was a cup of ice water. The RN invites the children to sit down at one end of a long table. Each child is provided with one half of an English muffin and a cup of ice water. Multiple small bowls set out in front of them. Each bowl contai ns a different ingredient to build a pizza. The ingredients include Ragu spaghetti sauce, 2 percent mo zzarella cheese, mushrooms, green peppers, onions, and pineapple. The snack segment in session four was an opportunity for youths to engage in an associative activity independent of CMS staff. However, RN and dieticians managed the activity by directing youths act ivities and hovered over the two youths during pizza-making. The RN and dieticians stand ove r the children and the food. The parents of the participants eye the food and sit at the othe r end of the long table. After the children make their pizzas, the dieticians place the pizzas in a broiler oven (temperature 425 degrees F) for 10 minutes while the children sit at the table and wait. One parent walks over to the pizza-making area and asks the dieticians if she can make a pizza. The other parents stay seated and quiet [This activity seems slow to the PI.] As the youth eat their pizzas the dietic ians talk among themselves. After the youths ate their pi zza, they appeared disappointed and hungry. The Caucasian father of the adopted daughter observed this and told one of th e youth to make himself another

PAGE 102

102 pizza. The young boy looked to the RN and dieticia ns, but they did not confirm the fathers suggestion. The boy sat sullen. One participant finishes his pizza first, in a bout 3 bites. He eyes the food. The parent of another youth notices the boy eyeing the food. The parent states to the youth, Have another one there. The boy looks to the instructors and the in structors dont say anything. The dieticians pack-up the pizza-making ingredients. Both children are quiet. Educational Activity Sessions one through four. At the completion of snack-time, youths and parents separated into different rooms for three of th e four education segments. The educational curriculum included a variety of subjects (Appendix A). Youths met with program instructors in the staff lounge where there were comfortable, upholstered seats. The parents met with prog ram instructors in th e CMS conference room equivalently as comfortable as the staff lounge. Youths and pare nts met jointly with CMS staff during the educational se gment for session three. I observed that during the youths educatio nal sessions, the yout hs conversationallyengaged with the program instructors but not with each other. There did not seem to be a time when the youths visited with each other. Session Two RD3 pulls out a colorful copy of a fo od pyramid. She points to the pyramids grain/rice/pasta/popcorn secti on. She then points to the veggies/fruits, dairy/meats, and fat/sweets sections. She quizzes the youths re: how many servings, from each section, they need to eat every day. F1 and F4 answer mo st of the questions. RD3 laughs and tells the group how well they are doing. Next, RD3 asks, How much is a serving of fruit. She continues asking them about portion sizes for all the 4 food groups. F1 pr imarily answers all of the questions. There were a few instances when youths appear ed to be disengaged from the educational session. In one instance, a dietic ian had to direct a male youth to put down a newspaper he was reading during the educational segment.

PAGE 103

103 Session One M1 is quiet and is looking at his feet. [May be a bit bored.] M2 is slouching in chair but continues to interact. The dietician inform s the group, When you eat fried chicken, you can peel off the skin Try not to eat fr ied foods too much it youre having it a lot, try to have it just one time a week. She contin ues, Baked or broiled is better and Fat stays a fat. Session Two During the discussion, M1 picks up a newspaper fr om a table and begin to leaf through it. RD3 asks him politely to Please put that away. The food journal was not a methodology that was favored by the youths. CMS staff provided each youth with a journal, instructed th e youth to record his or her food intake during the week, and told each of them to bring the journal back to the program the following week. Compliance was low. Over the course of the pr ogram, approximately three youths returned their respective food journals to the dieticians for review. Session Two The dietician reminds the class to remember to bring their food diaries next week. Also, she wants them to bring in one food label. She asks, "Who did your food diary last week?" M1 and F2 raise their hands. The dietician exclaims, "Good job." The dietician leads the participants back to the conference room where the parents are meeting RD3 informs me after the class that she has tried everything to get the youth to bring in their food diaries and that "Nothing works." I observed that parents were engaged in th eir educational sessions. They engaged in associative activities by sharing ideas and tip s with each other about cooking and grocery shopping. Parents seemed to bond over recipes a nd their common interest in properly parenting an overweight child. At the end of session three, parents actually stayed late, interacting among themselves and the dieticians regarding where to buy canned fruits, turnips, and collard greens. Session Three [The 3 RDs continue to share advice with a group of congregated parents] Try one new thing a week or another way to eat it.

PAGE 104

104 Plan out your meals what you are doing. Lean meats are less expensive than fatty ones cook lean meats for a longer time to get them tender. For example, in the oven, slow c ook the roast with carrots and celery keep adding water worstershire round steak will get really tender. Roasts and meatloafs are better left over. Instant oatmeal has more sodi um than regular oatmeal. Take off the chickens skin before you eat it what you can do is season under the skin, leave the skin on while you cook it, and then take the skin off before you eat it. I like using my crockpot or pressure cooker. Make a list, be prepared, and be on a budget. 1732: [The advice continues.] Fresh fruit is more expensive so buy it in season. Get canned or frozen if fruit out of season. [Parents interact with among se lves and with dieticians re : where to buy canned fruit and greens.] For session three, youths and pare nts were together for the ed ucational session. The topics were reading food labels and grocery shopping tips. Both youths and parents appeared to really enjoy themselves at that particular session. Session Three The dietician informs the group that "We' re going on a grocery store tour today." With assistance of other dieticians, various types of empty bread ba gs, cereal boxes, and snack containers are distributed to the youth and parents. A di etician states that nutrition facts are on most food products, however, "Min iature pieces of food don't have it." A dietician tells the group to "Stay less than 300mg/day of cholesterol a day." She stresses the importance of a diet low in saturated fat. "Some fruits and nuts such as avocados and nuts have mono-unsaturated fat but be care ful because they are high in calories." RD2 states that cholesterol is "Only in animal sources and products not in natural vegetables." "Cholesterol is made in the live r so it can only come from a source that has a liver." The participants laugh. A dietician instructs the group to shop on the parameter in grocery stores. The foods on the parameter have less fat, sugar, and calor ies. These foods include dairy, produce, deli,

PAGE 105

105 and bakery. Aromas attract you point to point The bakery operates to draw people in .the longer that you are in ther e, the more money you spend. The cereals are in the middle and are placed at childrens eye level. Half of the cost of most food is the packaging. P roduce is scattered to be in convenient to get people to buy more. Its conveniently inconvenient. Also, youll never find the th ings together like mayonnaise and mustard. This keeps you in the store longer. [I think that the content is more engaging for the participants and pare nts than the previous two sessions. The group is laughing a lot.] I observed that youths were not utilizing the ta ke-home tools that they were provided with in class. During session one, each family was pr ovided with a set of measuring cups that they are supposed to use to manage food portions. By session four, the youths we re still not using the cups. Session Four The youth are asked whether they are using thei r measuring cups. [A set of measuring cups were provided to each family in session 1 of the program.] Both members respond that they havent used the cups yet. RD2 encour ages them to use the cups and states, Get them out and do something with them. Start us ing them twice a day and then next week use them 3 times a day. Additionally, the youths were given the hulahoop that s/he used during the exercise activity in session three. When asked the following week whether the hula-hoop is being used, a youth replied that it wa s still in the car. Session Three The instructor asks the group if they have been using their hoola-hoops. [Hula hoops were given to participants in session 3 of the pr ogram.] M1 states, Its too hard. My hoop is still in the car. F1 states that she missed last weeks session and didnt get a hula-hoop. The instructor tells her that she will get one when she attends the missed session next time around. By the end of the program, the youth and pare nts appeared to have learned a lot about nutrition and physical activity. Th e concept of behavioral capabi lity is defined as having the

PAGE 106

106 knowledge and ability to perform a behavior or sequence of behaviors. When two youths were asked about what they learned in th e program, the youth had ample replies. Session Four The instructor asks the two members what they have learned by participating in the program. F1 states, As you get older it is not easier to lose the extr a weight. M1 states, Trying different foods is good and exercise is better. The instructor asks what new food they each want to try. M1 replies, Pe ppers and FI replies, Strawberries. The instructor asks what else they have lear ned from the program. F1 states, That there is no good food and no bad food. Every food does something different for the body. M1 states, That exercise isnt bad that it can be fun. And th at you can have 3 cups of fruit a day and umm thats it. RD tells them that you need to have milk for calcium and that it plays a role to lower blood pressure. The instructor asks M1 what fru it and vegetables do for the body. He states, They make you healthier. RD2 asks F1 what carbohydrates do for the body. She responds, They give you energy for your body. RD 2 states that the purpose of protein is to heal the body. The instruct or states, Hair and skin are made out of protein. Remember, whole grains are better b ecause they contain more vitamins and minerals. The instructor asks the children what they are going to change in their health habits. F1 replies, Ill eat more vegetables and fruit instead of candy. M1 re sponds, Ill eat less sugar and more vegetables and fruit. Session four ended with M-1 and F4s parents receiving graduation certificates (F4 only attended one session). The diet ician informed M-1 that he will return to the clinic in three months and six months for follow-up. CMS staff provided youths with extr a, blank copies of the food journal. Class was dismissed. Theoretical Learning Concepts Used in the Program I observed that the CMS instructors provided comprehensive learning strategies in the behavioral intervention program in order to e ffectuate behavioral ch ange among the youths and the parents. The CMS instructors utilized the fo llowing learning concepts (as defined below): 1) reciprocal determinism; 2) behavioral capab ility; 3) expectations and self-efficacy; 5) observational learning; and 6) rein forcement of learning concepts ut ilized in the program. They

PAGE 107

107 provided youths and parents with pertinent dietet ic and exercise information, taught social and self-management skills, and ensured parental su pport in order to elicit positive behavior modification. According to Bandura (1989; 1991), youths may learn more from observational learning than verbal instruction as an influence on the internalization of sta ndards (Bandura, 1989; 1991). The CMS program incorporated learning strate gies that went beyond lectures to include opportunities to observe and mode l healthy behaviors, attitude s, and emotional reactions provided by program instructors, parents, and pa rticipant peers. The instructors used token reinforcement by providing hula-hoops to youths for attendance and graduation certificates. Additionally, youths and parents were provided with experientia l opportunities in the program such as exercise sessions and food label activities. Reciprocal Determinism I observed that CMS program focused on how to effect change in the home in order to change nutritional and exercise behaviors, and vice versa. For example, the parents were instructed to purchase healthy gr oceries, cook in healthy ways such as lowering sodium and fat, monitor their own and th eir childrens portion size s and food choices, exercise as a family and singly, and to decrease sedentary act ivities such a television viewing. In-class observations: The dietician is talking (to th e parents) about watching sodium and fat content in food. She suggests a particular brand of li ght wheat bread for the parents to purchase (for the home). The dietician states (to the parents) that to make fruit interesting for the children, the fruit can be coated in a sugar-free glaze sweetened with Splenda. She states that most fruits can be coated in a sugar-free glaze. The dietician instructs the pare nts to shop on the parameter in grocery stores. The foods on the parameter have less fat, sugar, and ca lories. These foods include dairy, produce, deli, and bakery. Aromas attract you point to point. The bakery operates to draw people inthe longer that you are in th ere, the more money you spend.

PAGE 108

108 The dietician discusses how gr ocery stores have whats re ferred to as turbulence. Turbulence is things like noise, distraction, and tables of things to get you stay in the store longer. Shop with a list, dont shop if youre hungry, and get a basketnot a cart. Youll also notice that stores will have the pharmacy at the back, no clock, and pleasant music. Did you know that grocery stores act ually lose a lot of money on produce and bakery goods? I saw health bars in 3 diffe rent places in a store they are not necessarily a snack but like a candy bar. Try one new thing a week or find another way to eat it. Plan out your meals what you are doing. Lean meats are less expensive than fatty ones cook lean meats for a longer time to get them tender. For example, in the oven, slow cook the roast with carro ts and celery. Keep adding water and worstershire round st eak will get really tender. Roasts and meatloafs are better left over. Instant oatmeal has more sodi um than regular oatmeal. Take off the chickens skin before you eat it what you can do is season under the skin, leave the skin on while you cook it, and then take the skin off before you eat it. Make a list, be prepared, and be on a budget. Fresh fruit is more expensiveso buy it in season. Get canned or frozen if fruit out of season. Behavioral Capability I also observed that the CMS program provide d ample knowledge and sk ills necessary for youths to meet the recommended nutrition and exercise standards set out by major health organizations. In particular, the training was 1) resource-rela ted, providing information from major health organizations; and 4) product-rela ted, providing samples of Splenda and health journals; and practice related pr oviding hands-on exercises, snacks, food pyramid practice, food label reading, and food diary activities. In-class observations: The dietician states, You need about 20 grams of fiber a day. The average American gets between 10-13 grams of fiber per day." She tells the group that it is preferable to get fiber from foods such as fruits and vegetables Natural sugars ar e better too .

PAGE 109

109 The dietician addresses the topic of food labels Look to see if one of the first ingredients is sugar. Milk, eggs, peanuts, wheat, oats, fish, and rye will be marked in bold on the label because of food allergies. The new labels will tell you information about a single serving or the whole serving. The dietician states, Read the label, w hole wheat is not always whole wheat. Pumpernickle bread has molasses in it to make it dark in appearance. The dietician collects the tests (pre-program te sts not evaluated in this study) and proceeds to give each child a colorful copy of the F ood Pyramid. She states, We want bright colors if it looks good then well wa nt to eat it. She asks the F1, How many vegetables should you eat per day? F1 replies, The dietician retorts, Good. How many servings of fruits should you eat per day? F1 replies, The dietician states, We can have up to 9 servings of fruit and vegetabl es per day. We want everyone to have at least 5 a day so a fruit or vegetable can be eaten for each meal and snack. Expectations and Self-Efficacy During the process of class observations I not iced that CMS instructors motivated the youths by encouraging them during the exercise a nd lecture activities. However, expectations can go beyond feedback and include the anticipa ted time to goal attainment which was not apparent in the program. The program did collect the height, weight, a nd Hb A1c measures of the youths; however, I did not observe that youths we re specifically told wh at they could expect by participating the program. In-class observations: Upon arrival (on the first day of program), the RN leads individual participants to clinic room where the dietician meas ures and records their weight height, and glycosylated hemoglobin measurements. 87: M2 smiles and looks around. Appears embarrassed. When M2 begins to move with the video, his low-riding pants fall lower. He stops moving. The RN walks over him and begins to encourage him to move. He moves very little. Another RN approaches M2 and both RNs encourage M2 from either side of him. The dietician asks, "Who did your food diary last week?" M1 and F2 raise their hands. She exclaims, "Good job." If youths feel they are capable of achieving the goal (self-efficacy), they are likely to work hard and not give up. Second, if youths are provid ed feedback, they are more able to develop

PAGE 110

110 feasible and realistic goals. F eedback, in turn, improves self-efficacy. Third, short-term goals are more effective than long-term goals (Stone, 1998). The instructors did provide short-term goals for the youths and parents. In-class observations: The dietician reviews the food pyramid and discusses exercise. She states, Increase your exercise 1 to 5 minutes each week. Do something in addition to what youre doing now. The dietician provides the parents with examples of incremental steps such as walking around a circular driveway. She also encourage to park further away from the building that they need to be. 322: Try one new thing a week or another way to eat it. Both children respond that they havent used their measuring cups yet. The dietician encourages them to use the cups and states Get them out and do something with them. Start using them twice a day and then next week use them 3 times a day. Observational Learning Among youths, observational learning often outwei ghs verbal instructi on as an influence on the internalization of standards (Bandura, 1989; 1991). The CMS program incorporated learning strategies that went beyond lectures th at included opportunities to observe and model healthy behaviors of the program instructor s, parents, and participant peers. In-class observations: The RN, who is exercising while she walks a bout the room, encourages them (youths and parents) to follow the video. In one instance, a parent modeled unhealthy beha vior to her son. When it was time to walk for the exercise activity, the parent did not want to go. However, the parent did eventually walk a little bit. In-class observation: M1s mother states, I cant walk today. She coughs and points to M1 and states, Youll walk.

PAGE 111

111 Reinforcement Reinforcement is a response to an individual' s behavior that increases or decreases the chances of the individual repeating that be havior. The CMS instructors used token reinforcement. They provided hula-hoops and graduation certificates to participants. In-class observation: M1 and F4s parents are awar ded graduation certificates by the RDs. (M1s mother did not get one although she attended all 4 sessions with M1). RD1 informs the participants that they will return to the clinic in 3 months and 6 months for follow-up. Summary The 11 interviews among youths and parent s, and the in-class program observations, enabled me to go beyond the preand post-prog ram correlations of BMI and Hb A1c and to focus on the experience of the progr am for the youths and parents. Of the five youths that started the program, ju st one completed it. In one instance, parents attended all four sessi ons of the program when their daugh ter attended one session. I learned from the in-class observations that youths were no t utilizing their take-home equipment, and that the CMS instructors were using co mprehensive learning strategies. In organizing the data, I identified that data from the post-program interviews reoccurred during my in-class observations. Reoccurring data included: 1) youths were challenged with the skill-level required for aerobics and uncomfortable by parental presence; 2) snack portions appeared to be conservative; 3) parents interacted more among th emselves than youths interacted among themselves; and 4) activities were frequently not engaging youths. Analysis of the grouped interview and in-class ob servation data revealed five main themes. First, youths and parents all reported positive post-program nutrition and exercise behavior changes. Second, the parents re ported that the youths were re luctant to change post-program health behaviors. The last three themes rev ealed areas that the CMS program could use to

PAGE 112

112 improve curriculum methodology: 1) the presence of impediments to engaging youths; 2) the existence of program service deficiencies; and 3) additional parent c oncerns that went beyond the priorities of the program. These themes are discussed in the following chapter.

PAGE 113

113 Table 5-1. In-class observati ons: Program attendance.______________________ Week 1 Week 2 Week 3 Week 4 Youth M1 M1 M1 M1 M2 F1 F1 F1 F2 F3 F3 F3 F4 Others M1s MO M1s MO M1s MO & BR M1s MO & FA M2s MO F1s MO F1s MO & FR M1s MO F2s MO F3s MO F1s MO F3s MO F4s MO & FA F4s MO & FA F4s MO & FA F4s MO & FA M = Male; F = Female; MO = Mother; FA = Father; FR = Friend; BR = Brother

PAGE 114

114 CHAPTER 6 DISCUSSION The concept of mixed-method research is not new to primary care (Creswell, Fetters, and Ivankova, 2004). Almost 15 years ago, Blake (1989) and Stange and Zyzanski (1989), integrated quantitative and qualitative research in their studies. Quantitativ e and qualitative methods can be mixed, such as in collecting quali tative data before quantitative data where variables are unknown, or as in the case of this study, using qualitative methods to expand quantitative results in order to advance study aims (Creswell et al., 2004). For exam ple, in this study, quantitative methods were utilized to anal yze changes in youths post-program biological measures. Qualitative methods expanded upon this by eluc idating the rationale behind the youths behaviors that influence th e quantitative changes in bi ological measures. Overall, programs have demonstrated modest success in maintaining or decreasing weight and body mass index (BMI) (Dreimane et al., 2006; Eliakim et al., 2002; Monzavi et al., 2006; Savoye et al., 2004; Speith et al., 2000; Taylor Mazzone, Wrotniak, 2005) and in success at improving other biological measures associated with overweight-related illnesses (Monzavi et al., 2006; Taylor, Mazzone, & Wrotniak, 2005). For example, in Eliakim, et al. (2002), the study used for this studys sample size calculation, youths demonstrated a significant decrease (P<0.05) in BMI at 3-months postprogram a decrease from 26.1.3 kg/m to 25.4 0.3 kg/m. In this study, youths experienced a significant decrease in Hb A1c values by time interaction from six-months pre-program to sixmonths post-program (P<0.05) a decrease from 5.67.8% to 5.35 0.65%, whereas their BMI measurements significantly in creased (P<0.05) over the same time an increase from 34.9.64kg/m to 37.0.15 kg/m.

PAGE 115

115 Program success is contingent on many factor s beyond the control of program managers. These factors include youths: 1) willingness to change behavi or (changes in weight status, number of attempts at therapy, participation in exercise groups), 2) soma tic characteristics (BMI of children and family members, gender, and age), 3) socioeconomic status (level of education of the children and their parents, working mother), 4) exercise and diet ary habits, and dietary intake, as well as, 5) the quality of di etary records (Bandura, 2004). Since there are so many challenges to pr ogram success, Bandura (2004) encourages programs to have comprehensive frameworks in orde r to be efficacious. The CMS used several learning strategies implicit in Social Cognitive Theory to guide program teaching and target youths learning behaviors. This study did not measure whether or not the CMS programs use of Banduras learning concepts we re effective. The researcher merely observed whether the CMS program appeared to use the learning conc epts to guide program teaching and target youths learning behaviors. Program evaluation offers the potential to in form public policy in several ways. Public policy may identify and classify interventions as either: successful in th e targeted populations; effective for broader populations or distinct population subsets; or ineffective and not appropriate for further public expenditure. This chapter provides an integration of the quantitative and the qualitative findings and discusses the theoretical learning concepts used in the CMS program. The chapter concludes with a discussion of the im plications for health policy and future research. Discussion of Quantitative Findings Although CMS program youths experienced a sign ificant decrease in their preand postprogram Hb A1c values (P<0.05), their BMI valu es significantly increase d over the same time

PAGE 116

116 (P<0.05). The goal of the CMS progr am is for the youth to decrease both BMI and Hb A1c measures. These findings cannot be easily explained. While previous research findings suggest that Hb A1c values improve with weight loss of about 10 lb or fi ve percent of body weight (Wing, Marcus, Epstein, & Salata, 1987), other research findings suggest that elevated Hb A1c values may improve without weight loss but from increasing activity alone (American Diabetes Association (ADA), 2006). Program youths Hb A1c measures at six-m onths pre-program ranged from 4.5% to 13.5% ( M = 5.67, SD = 1.8) and six-months post-program Hb A1c measures ranged from 4.4% to 7.9% ( M = 5.35, SD = 0.65). Unfortunately, there is no t enough research available to elucidate whether different Hb A1c values ha ve different susceptibilities to diet and exercise, or not. For example, would a Hb A1c of 5.5% be more sensit ive to diet and exercise, without weight loss, than a Hb A1c of 6.5%? There was a wide range in Hb A1c values. The wide range of Hb A1c measurements among youths is suggestive of outlier values. However, the mixed general linear model used to analyze the data, the Unstructured Covari ance Matrix, was valid because the assumptions were satisfied. Other possible limitations of Hb A1c findings may include: 1) laboratory results can differ depending on the analytical technique; and 2) bi ological variation betwee n individuals can be up to one percentage point. For example, two i ndividuals with the same average blood sugar can have Hb A1c values that differ by up to one percentage point ( Rohlfing, Wiedmeyer, & Little, 2002).

PAGE 117

117 With regard to the BMI findings, an important note to make is that youths BMI values were not calculated using the recommended ageand gender-specific growth charts for youth. Since the IRB process prohibited the researcher from collecting members date of birth a necessary component for calcula ting ageand gender-specific BMI percentiles, youths BMI values were calculated using the BMI formula fo r adults. Thus, the BMI findings in this study are appropriate to reveal only a general trend of the youths BMI values and do not accurately depict their true BMI measurements. The sixmonths pre-program BMI measures ranged from 22.8 to 50.9 ( M = 34.9, SD = 6.64) and six-months postprogram BMI measures ranged from 22.2 to 62.2 ( M = 37.0, SD = 9.15). According to the NIH (2006) definitions, a healthy adult weight is a BMI of 18.5-24.9; overweight is 25-29.9; and obese is 30 or higher. While the BMI for adults is a simple, inexpensive method of screening fo r weight categories, it does not ta ke into account age, gender, or muscle mass. Nor does it dist inguish between lean body mass and fat mass. As a result, some people, such as heavily muscled athletes, may have a high BMI even though they don't have a high percentage of body fat. In others, such as elderly people, BMI may appear normal even though muscle has been lost with aging (IOM, 2005). Although the adult BMI is not as accurate for youths, it was useful in that it demonstrated the general trend in the youths BMI measures. Essentially, BMI is a simple mathematical formula based on height and weight that is used to measure fatness. The researcher did evaluate weight independent of BMI values in this study and weight si gnificantly increased over time (P<.05). However, youths heights also incr eased significantly over time (P<0.05). These findings are attributable to the f act the youths were growing.

PAGE 118

118 Thus, the increase in BMI measures may be partly explained by recalling that BMI does not distinguish between lean body mass and fat mass. According to the po st-program interview findings, youths improvement in diet and exercise may have increased the participants lean body mass. Additionally, fatness and BMI have been found to be closely correlated with maturation stage (or development age) am ong girls (Kaplowitz, Slora, Wasserman, Pedlow, & HermanGiddens, 2001). For example, early maturing girls are almost twice as lik ely to be overweight than average-maturing girls (Adair and Gordon-La rsen, 2001). There is limited research on the correlation between boys. According to Wang (2002) early sexual maturation is associated with overweight in girls but not in boys. The rising BMI findings in this st udy do not take into account the maturational development of the youths. The use of the ageand sex-specific BMI percentiles would have compensated for the matu rational changes among yout hs more than using the adult BMI calculations. There were no significant diffe rences between gender or ethnic groups for BMI or Hb A1c findings. In another program, gender also had no influence on BMI change s, nor did pubertal status or the degree of participan ts obesity (Eliakim et. al., 2002). Previous programs demonstrate that youths whose parents are not overweight have significantly greater decreases in BMI compared to youths of obese parents (Eliakim et al., 2002). In the CMS program, parents were freque ntly overweight and di agnosed with type II diabetes. Additionally, programs that include parents or significant caretakers have greater effect on weight loss than those that do not include pa rents or significant caretakers (Jain, 2004). The CMS youths BMI and Hb A1c measures were evaluated over a short period of time. By following the youths biological measures over a longer period of time, significant

PAGE 119

119 improvement in BMI values may also occur; si milar to the significant improvement in the Hb A1c values. It takes time for behavior al changes to improve BMI measures. The following qualitative findings elucidate the post-program improvements that the youths and parents reported they made to their diet and exercise regimes. Additionally, the qualitative findings illuminate ar eas the CMS program may improve. Discussion of Qualitative Findings Five main themes emerged from the interview data and field notes. First, all youths and parents reported positive post-pr ogram nutrition and exercise beha vior changes. Second, parents reported that youths were reluctant to change pos t-program health behaviors. The last three themes revealed areas that the CMS program c ould use to improve curr iculum methodology: 1) the presence of impediments to engaging yout hs; 2) the existence of program service deficiencies; and 3) additional pa rent concerns that went beyo nd the priorities of the program (that may have affected their ability to participate). Positive Post-Program Behavior Change Youths and parents reported positive post-pr ogram improvement in diet and exercise behavior. During the interviews, youths and pare nts stated that they consume more fruits, vegetables, and whole grains; and less sugary beve rages, junk food, as well as less salt, sugar, and fat. They also stated that they watch portion sizes, read food labe ls, and exercise more. This finding is consistent with the quantitative data findings that that Hb A1c values for the youths significantly improved pos t-program. With regard to the youths BMI values, it may be that the full effect of the CMS program on t hose values may not fully emerge until some time beyond the last post-program data collection peri od. Despite youths reported changes in diet and exercise, the BMI findings may be partly explained by recalli ng that BMI does not

PAGE 120

120 distinguish between lean body mass and fat mass or especially, adjustment related to potential hormone-related growth velocity changes that often occur during the pubertal phase. Reluctance To Change Post-Program Behaviors Although all youths and parents re ported positive post-program di et and exercise changes, parents stated that those change s did not come easy for the youths According to parents, youths were frequently reluctant to make healthful ch anges. Examples of the reluctance among youths to change included: (1) apathy for exercising; 2) dislike of certain healthier foods; 3) aversion to following the food pyramid for dail y food allowances; 4) practicing different habits when away from home; 5) asserting thei r identity; and 6) not using measuring cups at home. The greater reluctance to changes in diet and exercise among youths may be related to differences in age, experience, and perspectiv e, as well as differences in experience during program participation. Although th e presence of parents during pr ogram participation adversely affected the participation of yout hs in the program, the presence of parents appears to positively affects post-program behaviors of youths. T hus, CMS should devise ways to enhance the experience of parents in dur ing program participation. One parent stated that the program may want to consider recording and monitoring BMI and Hb A1c measurements for the parents. One parent shared that she has lost 4 dress sizes afte r attending the program with her child. BMI data may be more appropriate for adults than for youths and may provide pa rents with objective standards, in addition to dre ss sizes, by which parents can me asure post-program progress and compliance. The CMS program is in a unique position to in troduce youths to types of exercise and foods that are appealing. Rather than providing water as the beve rage of choice in the program, the youths could be given a choi ce of low-calorie beverages. A further recommendation would be to instruct parents how to pack the youths lunches so that they are appealing.

PAGE 121

121 Impediments to Engaging Youths Snack and exercise methodologies fostered solitary and p arallel (side-by-side) play among the youth. Solitary and parallel play activ ities are more appropriate for younger children. School-age children and adolesce nts require activities that fo ster associative play among members of the group. Associative play be gins among the preschool age (London, Ladewig, Ball, & Bindler, 2006) when children begin to in teract with each other during play. School age child and adolescents continue this type of interaction: bonding over games, competitions, and projects. Youths in the CMS pr ogram did not appear to have a meaningful opportunity to get to interact with each other during play. Unlike youths, parents articulated that they looked forward to attending each session. Parents bonded by sharing recipes and cooking ti ps and looked forward to experiencing the feeling of camaraderie each week. The program is in a position to create oppor tunities for communication that fosters friendship and support among youths. In turn, yout hs would look forward to coming to weekly sessions, rather than attending because they have to or not attending at all, as attested to by the dismal attendance and graduation rates. One sugge stion is that the CMS instructors may want to ask the youths, prior to the beginning of the pr ogram, what games and sports that they enjoy playing with their friends. The CMS instructors could then offer those activities to the youths. Class observations and interviews indicated that parents may be enjoying the CMS program more than youths. That could be because parental presence during the snack and exercise segments impedes the ability of youths to get to know one another. A parent shared that she embarrassed her daughter because the parent was the class clown during exercise (drawing unwanted attention to the daughter).

PAGE 122

122 Unlike their parents, youths did not express feelings of camaraderie with their peers. A variety of factors may influence the relatively diminished bonding among youths. It may be that youths are shy due to age or other causes. Ho wever, because the youth and parents participate together for exerciseand snack-activities, the pr esence of the parents may impede the ability of youths to get to know one another. The CMS pr ogram may want to consider separating youths and parents for some activities a nd joining them for group discussions of their separate activities. Since research demonstrates that parental involvement in program s is vital for positive program outcomes, it is very important that parent s are as involved in a program as youths. The CMS program was mandatory for the youths and parents. A significant decline in attendance was observed with each consecutive cl ass; only one of the five enrolled youths completed all four classes. Adolescents frequently experience boredom, ti me stress, and lack of choice (lack of control) in their daily lives. In Shaw, Caldwell, and Kleibe r (1995), adolescents reported high levels of time stress and boredom re lated not only to lack of options but also to participation in adult-structured activities. In addition, adolescent s, at times, participated in activities to please others rather than to please themselves. Since the CMS program is mandatory, it places time stress on the participants. This challenge may not be readily resolved. It may be necessary for CMS instructors to acknowledge that they are aware of the lo ss of control that the youths ma y be feeling and then have the youths talk about it as part of the program. The instructors should continue to improve on program dynamics; provide an atmos phere that is engaging to the yout h to keep them interested. Additionally, within the program, youths should be given ch oices whenever possible. For example, rather than having the program inst ructors provide the snacks, the program could

PAGE 123

123 provide each youth with a gift certificate to purchase his or he r snacks in accordance with food label requirements for nutrition. This would bring more variety to the snack activity, diminish the sense of loss of control, enhance participa tion, enhance associative play among youths, and improve attendance (as the youths would know that others are relying on them). Program Service Deficiencies The aerobic exercise was impeded by the lo cation of the activity. The activity was implemented in the front lobby of the CMS agen cy. The youths and the parents had to find a place to workout between the chairs. It also a ppeared that youths were self-conscious when CMS patients arrived for their scheduled appoint ments (as the activity occurred while the CMS office was open for daily business). The location issue could be remedied with an appropriate change in venue. The exercise activity could occur in the spaci ous staff lounge or in some ot her CMS room. Also, some youth participants did not dress appropriately for ex ercise this factor hindered their movement abilities. CMS instructions for exer cise attire should be modified to avoid this issue in the future. The youths and the parents were challenged with the skill-le vel necessary for the video aerobic activity; they frequently missteped. This may be remedied by the use of ageand skillappropriate aerobic video activities. The CMS instructors may want to invite youths to discuss the types of activities that they enjoy playing with their friends. The researcher also observed that snack portions appeared to be small under the circumstances. The youths and their parents may have been hungry at that time of day, especially after the unaccustomed ex ercise that they had just comp leted. The small servings risk creating a negative association in the minds of the participants that a healthful diet means deprivation.

PAGE 124

124 Vegetable plates at session three appeared to precipitate the most disappointment among the youths. They ate mostly the carrots and the dip. Program inst ructors may want to include a greater variety and a greater po rtion of appealing vegetables to the youths and the parents. One parent suggested that in structors may want to go out of the norm of what people think they wouldnt like at the snack activity. The parent suggested that instructors serve vegetables other than the typical carrots and broccoli. In addition, larger, more satisfying portions may reinforce the perception that snacks are nutritious and satisfying. Additional Parent Concerns During and after the post-program interviews, two parents shared pe rsonal concerns that went beyond the expertise of the program; one ha ving had been sexually abused as a child, and the other feeling overwhelmed by life generally. Since improve ments in emotional well-being and behavior are positively correlated with weight loss (Dreimane et al., 2006), the CMS program may want to consider the feasibility of providing social or psyc hological counseling to the youths and the parents. The interviews and in-class observation findings suggest that the CMS program is eliciting dietetic and exercise be havioral changes among youths and pare nts. The findings also clarified some areas in need of improving the CMS progr am: 1) engaging the youth to get to know each other; 2) engaging the youth with activities that they enjoy and look forw ard to participating in; and 3) separating the parents for some activities. Implications for Health Policy and Future Research The next step for the CMS behavioral interven tion program is to have the youths followed long-term, such as one to two years post-prog ram, to see whether their BMI and Hb A1c measures are improving or not improving. The longterm study could also include preand postprogram ageand sex-specific BMI percentiles. In doing so, the research would address a

PAGE 125

125 limitation in this study that the researcher did not include age-a nd sex-specific BMI percentiles. In the meantime, the CMS program instructors c ould continue to work to improve the program by including feasible suggestions from this study. The program instructors may want to think a bout ways to get the youths and parents to buy into the program. They may want to consid er following parents biological measures of BMI and Hb A1c. Another way for the program instructors to get the youths and pare nts to buy into the program would be to create clear expectations fo r the youths and parents from the onset. For example, youths and parents could be told to ex pect to a change in th eir clothing size within three months if they follow program guideline s. Since the youths and parents outcome priorities may be different than those of the program instructors priorities, it may also be helpful to address expectations on an i ndividual basis with the input of the participants. Rather than graduation certificates, the progr am may want to consider store gift cards. Additionally, the program may want to separate the youths according to age groups because their ages ranged from 7 to 18 years. Pa rents and youths could be separated for all of the activities as well. The identification of effective teaching met hods utilized in the CMS program and other programs enables health providers to replicat e and improve successful intervention methods. Behavior may be influenced by the following: 1) reciprocal determin ism; 2) behavioral capability; 3) expectations; 4) self-efficacy; 5) observational learning; and 6) reinforcement (NIH, 2003) (Table 2-1). Behavioral change results from an interacti on between an individual and three key factors identified as personal, environmental, and be havioral (reciprocal determinism). Research

PAGE 126

126 suggests that environmental factor s may influence children's health behaviors more than personal ones because children are not so worried about th eir health (Gochman, 1987). The involvement of parents in the CMS program is crucial is because parents control much of the home environment. A possible way to improve youths compliance with the food diary activity would be to have the parents res ponsible to monitor the activity at home. In addition, the parents could also participate in the ac tivity (observational learning). Individuals are more likely to adopt a modeled behavior if behavior change results in outcomes they value, and if the model is: 1) similar to the observer, 2) has admired stat us, and 3) has functional value (Bandura, 1977). The CMS program provides behavioral skills tr aining to youths and parents in the way of nutrition and exercise lectures, and snack and exer cise activities. However, the learning of skills just begins in the CMS classroom, and ends within the complexity of the external environment such as home and school. Thus, the CMS program may want to creatively engage youths and parents during after hours. Fo r example, the youths could be responsible for shopping for the weekly program snacks using food labels. The learning concepts of expectation and self-efficacy were less utilized by the CMS program. There were not explicit explanations for youths or pare nts as to how their nutrition and exercise choices would affect their health ou tcomes (expectations) in a measurable way, or obvious tactics to build the youths and parents confidence so that they would feel that that could change their behavior (self-efficacy). Factors that motivate an indivi dual's expectations as they go through the process of setting goals for themselves include self-efficacy, feedbac k, and the anticipated time to goal attainment (Bandura, 1986; 1989). If the youths and parent s felt that they were capable of achieving the goal (self-efficacy), they would be likely to work hard and not give up.

PAGE 127

127 The youths and parents could be given one-on-one individual w eekly feedback using their weekly food diaries, and they w ould be more able to adjust th eir goals to be feasible and realistic. Feedback, in turn, improves self-efficacy. Also, shor t-term goals are more effective than long-term goals. Weekly incremental goals for reduced fat and increased fiber and fruits and vegetables, and physical outcome expecta tions could be included in the curriculum. According to Margolis and McCabe (2004), stra tegies for improving self-efficacy may include: 1) establishing small, incremetal goals for particip ants; 2) reinforcing effo rt and persistence; 3) emphasizing modeling; and 4) pr oviding feedback through record-k eeping (Margolis & McCabe 2004). According to Bandura (2004), an effective program includes sim ilar components to effectuate self-efficacy. The components include 1) information regarding the desired behavior; 2) the development of social and self-management skills; 3) building a res ilient sense of efficacy such as supporting the exercise of control in the face of difficulti es and setbacks in everyday life; and 4) enlisting and creating so cial supports for desired persona l change such as enlisting participants' caregivers in the effort. Future research can go beyond observation and de scription of the theoretical concepts, and measure whether the utilization of a particular learning concept in the CMS program actually elicits behavioral changes among the youths. For example, this study revealed that the CMS is utilizing reinforcement methods, such as giving out program graduation certificates. However, this reinforcement method does not appear to work. There are a variety of reinforcement rewards that have been utilized in other programs that have been shown to improve program outcomes including stars, modest prizes, jump r opes, and water bottles. As aforementioned, store gift cards may be more effective to improve attendance and outcomes.

PAGE 128

128 With regard to thematic coding procedures in this study, in the future it will be important for the researcher to choose another researcher to assist in cross-coding th e interview and in-class observation transcripts in order to validate the thematic findings. In this study, the researcher identified themes in the transcripts without the assistance of anot her researcher. It would be interesting to include the input of the progr am instructors in the study methodology. For example, after the qualitative da ta is thematically coded by two researchers, one or both of the researchers could then meet with the program instructors to elicit feedback and suggestions regarding their finding s. The program instructors could also be interviewed after the program. This would allow the res earcher to gain insight of the instructors perception of the CMS program. Future research offers the opportunity to re duce or eliminate some limitations unique to this study design. In the intervie ws, youths and parents may have shared only what they thought the researcher wanted to hear that they have made positive changes to their lifestyle. It is difficult to know whether youths an d parents accurately reported thei r behavioral changes. In the future, behavioral change data may be more accurately collected if youths and parents would bring their recorded dail y diet and exercise regimes to the interview. In-hom e observation by the researcher might also be helpful. Ideally, a control group would strengthen the va lidity of the study findings. Youths that participate in the program could be compared to youths that do not par ticipate in the program (and receive only routine in-offi ce educational sessions). Other opportunities for study design improveme nt include the opportunity to reduce or eliminate some other limitations unique to this stu dy, including sample size, time-span, and external environmental influence. For example, by replicating the study in other programs, the

PAGE 129

129 aggregate results effectively enlarge the sample size to statistically significant proportions of affected youth. Analysis of larger sample sizes may be ab le to tease out time-spans and environmental influences that, in concert with interventi on programs, correlate with desired behavior modification. For example, 100 future studies of similar intervention programs would enlarge the sample size to 6,000 youth. The larger aggreg ate study population, more likely than not, may confirm that BMI and Hb A1c are inappropriate measures of efficacy for children and adolescents. However, the larg er study may be able to demons trate, through qualitative analysis, the efficacy of certain intervention methodologies up to some period, such as 24 months after the conclusion of the program, without subsequent intervention but declining efficacy thereafter without renewed intervention. Future research may also target external environmental events that precipitate undesired dietetic and exercise be havior with a view toward eliminati ng those events. For example, peer group influence may be shown to have more proportional influence on positive or negative outcomes than does parental influence. That is, graduates of intervention programs may be influenced more by peers than by the parents of the graduates. It may be possible to evaluate the interplay between school interventi on programs, peers, and parents, and the net effect on youths who graduate from intervention programs. There is not enough qual itative research concerning program evaluation. Only one of nine the programs in the literature re view used qualitative research. This study demonstrates the usefulness of a mixed-method design to illuminate biological measures findings and to enhance program effectiveness.

PAGE 130

130 The CMS program is fulfilling objectives of national and state public health policies. Currently, Healthy People 2010 seeks to reduce ov erweight among youths to five percent. In Florida, the "Governor's Task Force on Obesity has recommended that health care providers promote lifelong nutrition and physical activit y by implementing programs that promote healthier lifestyles and disease ma nagement for overweight-related i llnesses such as diabetes and hyperinsulinemia (Florida Department of Health, 2004). With the initiation of the CMS program, health care providers at Tallahassee CMS have demonstrated a commitment to go beyond typica l in-office nutrition and exercise education. They are dedicated to improve the CMS program despite the challenges. As previously mentioned, separating youths and parents during the program (while keeping it as a family intervention), and creating clear program expecta tions of youths and parents, emerged as areas requiring improvement. The CMS program is propagating future informed adults who can advocate for healthful diets and exercise. The take-hom e message for policy makers is that program evaluation informs public policy, with either qualitativ e or quantitative data or bot h, and is aimed toward providing information that helps policy makers decide how a certain program may be understood in terms of better or worse social outcomes. Strategi es and methodologies that are identified as successful for distinct population group subsets may be replicated in behavior intervention programs that target similar populations. Potentially, the CMS program may be im plemented by other CMS agencies, and eventually, by outpatient health clinics generally. Future research may compare other CMS programs or programs similar to this CMS progr am public and private intervention programs, their methodologies, and their relative efficacy.

PAGE 131

131 Summary A design that includes both quantitative and qualitative methods of evaluation offers the potential for gathering complete accurate, contextualized evidence needed to evaluate the effectiveness of a health inte rvention program (Creswell, Fe tters, and Ivankova, 2004). This mixed-method is particularly appropriate when biological outcomes, that are dependent on diet and exercise behavioral change s, are being followed for only a short-term following the program intervention. For example, the CMS program appear ed to have successfully motivated behavioral changes relative to diet and exer cise behaviors. However those behavioral changes may be more evident in BMI outcomes if members were follo wed for a longer period of time. Overall, programs have demonstrated modest success in maintaining or decreasing weight and BMI (Dreimane et al., 2006; Eliakim et al., 2002; Monzavi et al., 2006; Sa voye et al., 2004; Speith et al., 2000; Taylor, Mazzone, Wrotniak, 2005) an d in success at improving other biological measures associated with overweight-related i llnesses (Monzavi et al., 2006; Taylor, Mazzone, & Wrotniak, 2005). For example, in Eliakim, et al. (2002), the study used for this studys sample size calculation, youths demonstrated a significant decrease (P<0.05) in BMI at 3-months postprogram a decrease from 26.1.3 kg/m to 25.4 0.3 kg/m. In this study, youths experienced a significant decrease in Hb A1c values by time interaction from six-months pre-program to sixmonths post-program (P<0.05) a decrease from 5.67.8% to 5.35 0.65%, whereas their BMI measurements significantly in creased (P<0.05) over the same time an increase from 34.9.64kg/m to 37.0.15 kg/m. There were no significant diffe rences between gender or ethnic groups for BMI or Hb A1c findings. The decrease in Hb A1c measures a nd increase in BMI measures may be partly explained by recalling that BM I does not distinguish between lean body mass and fat mass or

PAGE 132

132 especially, adjustment related to potential hormone-related growth velocity changes that often occur during the pubertal phase. According to the post-program interview findings, the youths were increasing their exercise levels a nd improving their dietary intake. Although the youths BMI values were not cal culated using the recommended ageand gender-specific growth charts for you th, it was useful in that it demonstrated the general trend in the youths BMI measures. Essentially, BMI is a simple mathematical formula, based on height and weight that is used to measure adiposity. The qualitative analyses elucidated several area s of program implementation as factors that may adversely influence the ability of youths a nd parents to internaliz e CMS principles for healthier living. The most obvi ous factor is the absence of a methodology for ensuring attendance. Other factors include, incompatib le exercise skill leve ls, exercise venue and equipment, and the absence of implementation me thods that foster asso ciative interaction among youths. Future research offers the opportunity to re duce or eliminate some limitations unique to this study, including sample size, span, and external environmental influen ce. Identification of effective intervention methods utilized in vari ous disease prevention programs enables other health providers to replicate and improve succ essful intervention methods and facilitates the generalization of successful met hods to broader populations.

PAGE 133

133 APPENDIX A CMS PROGRAM CURRICULUM Week 1 General Overview and Introduction Outline I. Pre-preparation A. Health/diet history participants form 1. Ensure that all participants ha ve received/completed these forms: a. Participant form b. Guardian form 2. NOTE: These forms sent out mi nimum one week prior to class B. Assessment 1. Review participants records a. If no A1C value is noted in previous four weeks, this data will be assessed/collected first class b. If A1C are noted in patient chart a month or less prior to first day of class, no A1C is necessary on first day C. Flow sheet 1. A flow sheet, which includes hei ght, weight, and A1C data for each participant will be used 2. Data will be entered by the end of first class for each participant D. Food: Fruit (apples, oran ges, bananas) and fla vored water (Fruit2O) E. Prizes: (for example, paddleballs) II. Introduction A. Overview of goals of the clinic 1. Emphasize healthy lifestyle, not weight loss 2. Review layout of class a. begin with exercise session each class b. either participants remain with parent/guardian or are separated c. review topics to be covered 3. Provide snacks a. sliced fruit b. water III. Class begins A. Exercise session 1. Parents/Guardians and children all participant in this activity

PAGE 134

134 2. This takes place in the lounge room B. (Return to conference room) Distribute pre-test for 1. Participants 2. Parents/Guardians C. Food Guide Pyramid and Eating Smart: Keeping Your Eating Under Rap 1. Distribute handouts 2. Identify categories 3. Discuss total servings for each group/category 4. Review appropriate portion sizes u tilizing food models and Eating Smart handout D. What does a calorie look like? 1. Display various foods demonstrat ing what 20, 60, and 120 kcals look like a. 20 calories demonstrat ed with appropriate servings of i. air popped popcorn ii. cookie iii. cracker iv. pretzel b. 60 calories i. small apple ii. small banana iii. 4 oz juice iv. 2 Hersheys kisses c. 150 calories i. 12 ounces of cola ii. 9 ounces of juice iii. 8 ounces of whole milk E. Exercise 1. Review Hey Couch Potatoes on Eating Smart handout to emphasize the benefits of exercise 2. Distribute Lean Routines for exercise journal F. Distribute Food Journals 1. Emphasize the need to document what and HOW MUCH was consumed every day until the next class a. offer incentives for completion b. emphasize need to include beverages 2. Discuss the need to familiarize with portion sizes

PAGE 135

135 G. Closing 1. Distribute prizes 2. Address questions Week 2 Focus: Diabetes Prevention Outline I. Pre-Preparation A. Obtain copies of handouts, as appropriate B. Food: popcorn and flavored water C. Obtain prizes D. Obtain food/beverage samples for childrens di scussion (colas, diet colas, juice, etc) II. Exercise A. Class will be led by Dr. A. Mobley (or other provider) B. Once again, both children and parent s/guardians are to participate III. Snack offered: Popcorn and water IV. Review A. Brief discussion and review concerning prev ious class on portion sizes and serving sizes B. Discuss journal entries 1. Food journals a. What patterns emerged? b. What types of beverages consumed? c. How are portion sizes? V. Discussions A. Parents/Guardians in Conference Room for discussion led by Roberta Stevens, M.S., R.D., C.D.E. 1. What is Type II Diabetes? a. the disease b. the risks c. the health effects d. how to prevent or manage 2. How does diet play a role? a. beverage choices b. Food labels handout (what do I look for?) (additional handouts may be provided by Roberta Stevens) c. Fast food/best choices i. Calorie books for fast foods obtained from Lily via Suzanne Laws ii. Discover Nutrition Anytime Anywhere: Menu Makeovers handout

PAGE 136

136 B. Children in Lounge area for discussion 1. What does Type II diabetes mean for you? a. what is happening to your body? b. what are the risks? c. what are the health effects? d. what can you do? 2. How does your diet play a role? (emphasizing sugars and excessive calories) a. review beverage options (j uice, milk, water, soda) b. incorporate label reading introduction into this c. taste test of regular vs. diet sodas 3. Fast Food options a. excessive portion sizes b. healthier fast food choices (offe ring a calorie count comparison) 4. Incorporate a :Jeopardy-like form at, dividing group into teams to guess calories of various fast foods or w hat-is-the-better-option in a fast food setting VI. Closing A. Children and parents/guardians all gather in Conference Room B. Review and encourage continued jo urnal entries (food and exercise) C. Address questions D. Distribute prizes Week 3 Focus: Virtual Supermarket Tour Outline I. Pre-preparation A. Virtual Tour B. Handout: Discover Nutrition Anytime Do-It-Yourself Supermarket Tour C. Bring a measuring cup (1 c, c for so lids) to use for demonstration purposes highlighting portion sizes II. Exercise session III. Virtual Tour-in general, en courage them to begin at produc e and end at meats (from both a health and food safety perspective) A. Produce 1. Ask: How many fruit/vegetable se rvings per day? For review (5d) 2. What do we get from fruit/vegetable? a. lots of vitamins (A, C) and minerals b. plant chemicals, known as phytochemi cals, which may have a role in preventing many diseases such as cancer c. GOAL is to get as many colors in your diet everyday 3. Ask: What are your favorite fruits and vegetables?

PAGE 137

137 4. Highlight different fruit such as kiwi, star fruit, mango, etc, and different vegetables, br occosprouts, broccoflower, etc. 5. Highlight fruit and vegetables as great snacks a. apple and cheese b. banana and peanut butter c. mini carrots with sandwich d. dried fruit (raisins, apricots, etc.) e. prepared vegetables make it really easy!! B. Snack Chips 1. focus on high amount of fat, calories, sodium 2. while occasionally fine, can displ ace more nutrient dense snacks 3. ACTIVITY: Have everyone pick up a bag of chips and look at the labels a. how many calories? b. what is considered a serving size? 4. Compare pretzels to chips a. look at labels b. Ask: are you really savi ng anything in calories c. Suggest pretzels dipped in mustard as a snack, add a piece of fruit and you are doing great!! 5. ACTIVITY with popcorn: a. have everyone pick up microwavable popcorn b. tour guide can use popcorn kernels (for air-popped popcorn as gold standard) c. Ask: What are the serving sizes and calories for each? d. Is there a best one? Let them decide e. Great high fiber and (can be) low calorie snack if chosen wisely f. add some yogurt cheese, fruit, or nuts for higher satiety C. Bread/Cereal 1. Lower calorie breads typically mean thinner slices 2. Look for high fiber breads (Natur es Own White Wheat, or 100% Whole Wheat) Key here is that the first ingredient says WHOLE wheat 3. Cereals a. look for higher fiber cereal >5 g/serving) b. granola cereals can be very high calorie c. watch serving sizes on cereal (have them look at the serving sizes) d. cereals can make a great snack e. may consider mixing a high fiber cereal (like All-Bran) with a high sugar/low fiber cereal (Frosted Flakes) D. Juice 1. Calcium fortified orange juic e for those who arent getting enough calcium

PAGE 138

138 2. NO MORE THAN 8 ounces per day of ANY juice 3. Review class discussion about juice a. briefly look at labels for calories per serving b. highlight 100% fruit juices (Juicy Juice, Motts) E. Milk/Yogurt/Cheese 1. aim for 3 servings/d (this include s high calcium foods such as cheese, yogurt, etc.) 2. look at the huge variety of yogur ts (drinkable, whipped, regular, with added crunch/granola, etc.) 3. calcium fortified cottage cheese 4. cheese sticks for snacks, etc F. Frozen foods section: Meat alternatives 1. Boca Burgers 2. Harvest Burger recipe crumbles 3. Veggie hot dogs (e.g. Yves Good Dogs) G. Meat 1. Key here is FAT (therefore calories) and saturated fat 2. Leaner is better 3. Meat can ABSOLUTELY be a part of a healthy diet 4. Still, limit red meat when possible 5. Seek >90% lean meats WARNING: ground turkey may not be sa ving you anything in fat and calories (since it may have ski n, dark meat, etc, ground in therebe sure to read the labels!!! 6. Advantages/disadvantag es to cooking poultry with/without skin a. cook with skin for flavor b. remove before eating 7. Beef a. >90% lean b. key words are top round, eye ro und, loin, or London broil c. when frying, may consider draining the fa t and then rinsing with hot water to remove more fat H. Pork Tenderloins can be a wonderful option I. Fish/Shellfish 1. limit frying 2. aim for one serving/week J. Miscellaneous

PAGE 139

139 1. Soups can be a great snack that fills you up a. Campbells Healthy Request, Healthy Choice soups, etc.) 2. Beans-great fiber, protein, vitamins, and minerals a. rice and beans make a great meal b. also try bean burritos, etc 3. Nuts also make a great snack a. watch portion sizes b. awesome protein and minerals c. high satiety value TAKE HOME MESSAGE: Aim for a majority of your foods from grains, fruits, and vegetables,, fair amount of lean meats, poultry, low fat da iry, and least amount of fats, oils, and sweets. Week 4 Focus: Healthy Meals, Healthy Snacks Outline I. Pre-Preparation weeks ahead A. Seek student volunteers from FSU Student Dietetic Association (at least 2) II. Preparation A. Make copies of the Post-test for participants B. Make copies of the post test for parents C. Make copies of handouts to be in cluded in the end-of-class book D. Make copies of the feedback form E. Obtain food for pizzas (student activity) 1. Utensils a. toaster oven/conventional oven b. knives to prepare condiments for pizza c. spoons/forks to serve condiments d. can opener 2. Plates a. large platter or individual paper pl ates and/or bowls for buffet line of toppings b. serving (paper) plates 3. Napkins 4. Food a. English muffins b. Tomato sauce c. Shredded mozzarella cheese d. Pepperoni e. Pineapple

PAGE 140

140 f. Onions g. Green pepper h. Tomatoes i. Mushrooms F. Have paper/pens available for parent activity G. Pens are also needed for post-te st for participants and parents II. Exercise Dr. Mobley (or other providers) III. Parents: healthy Meals, Healthy Living A. Review health risks of obesity B. Include in discussion 1. (review of) what is hyperinsulemia-risks 2. (review of) what is diabetes-r isks, prevention, management 3. (review of) how managing their wei ght will be a lifetime challenge 4. (review of) how it will be much more difficult for your children to first tackle this as adults. They are much more impressionable now and, therefore, we want to take advantage of that impressionability C. The importance of nutrition and exerci se in managing hyperi nsulemia and/or Diabetes (i.e. the role of diet and lifestyle) D. EXTREMELY important and invaluable position you have as a ROLE MODEL for them in terms of both diet AND exercise a. they watch what you do b. they learn from what you do c. they count on you to make available, pr epare, and/or serv e healthful snacks and meals d. however, empowering them with the same knowledge and abilities to choose, prepare, obtain, and/or serve for themse lves (either at home or away from home) is the MOST important thing that you can do for them (because the impression you have made on them should be one that influences them and stays with them even if you are not around at the time they have to make the healthful decisions for themselves) E. What you bring into the house matters (recap supermarket tour) F. While all foods can fit, you want to encour age the healthful ones and find ways to incorporate those into their daily meal plans 1. involve your children in meal planning 2. take them to the grocery store with you G. Parent Activity: Meeting the Challenges

PAGE 141

141 Description: Divide the parents into two groups (if enough are pr esent; in the event that there is not a minimum of two in each group, combine the activity) 1. Group I: a. identify/list the challenges you f ace in offering and/or preparing healthy snacks (allow about three minutes for this) b. List how you can meet that challenge (problem-solve!) (allow about five minutes for this). Also include a list of some healthy snacks that would work well with your children 2. Group II a. Identify/List the challenges you face in offering and/or preparing healthy meals (including lunch for school) (allow three minutes for this) b. List how you can meet that challenge (allow five minutes to problem-solve) and give examples of some hea lthy meals (even something that you havent tried before!) 3. Discussion of the aboveincorporating the following: 1. all foods can fit into a hea lthy meal plan 2. planning for all meals (i ncluding lunches and/or snacks) when grocery shopping is imperative 3. Being a positive role model for your children is invaluable 4. Look for some other ideas in your take-home packet (lean me at choices, h ealthy lunch makeovers, supe rmarket tour list, etc.) 4. Post-test questionnaire 5. Feedback questionnaire IV. Participants A. Review health risks of obesity B. Include in discussion 1. (review of) what is hyperinsulemia-risks 2. (review of) what is diabetes -risks, prevention, management 3. (review of) how managing their we ight will be a lifetime challenge 4. (review of) how it will be much more difficult for them to first tackle this as adults. (pre/post-test question) C. The importance of nutrition and exerci se in managing hyperinsulinemia and/or Diabetes (i.e. the role of diet and lifestyle) D. REMEMBERING THAT ALL FOODS CAN FIT!! E. Activity The children are to be divided into two groups: This will allow one FSU student volunteer to manage/ove rsee the food activity

PAGE 142

142 while another FSU student volunteer oversees the paper activity 1. Group A: meeting the challenge Have participants list the types of snac ks they have typically eaten that may or may not fit well into a healthy meal plan What are some ideas they ha ve for healthy snacks? Lets see which group can come up with the mo st ideas that fit include a va riety of foods from the FGP 2. Group B: Food Activity first a. discuss all of the food groups repr esented in the pizza snack (can they tell you what groups fit where?) b. discuss the low fat mozzarella, the l eaner pepperoni, and all of the different vegetable (and fruit!) toppings that can be included 3. Each group will then switch 4. Post-test quiz V. End-of-clinic A. Distribute certificates B. Distribute packets C. Discuss follow-up clinic sessions Food Guide Pyramid: Guide to Daily Food Choices A Food Diary Example Eating Smart: Keep Your Eating Under Rap Snack Attack Nutrition Fact Sheet: 7 Steps to Being More Active Nutrition Fact Sheet: Straight Facts about Beverage Choices Handout: Recommended Reading & Websites Splenda information with Sample Positive Diabetes Journal, September 2006 Diabetes Health Journal, September 2006

PAGE 143

143 APPENDIX B INTERVIEW GUIDE Youth Questions 1. Tell me a little bit about yourself. 2. Tell me how you happened to go to the program. 3. Tell me about the program. What kinds of things did you do in the program? 4. What kinds of things did you learn about how you eat and exercise? 5. Since the program, do you eat healthier food? Do you exercise more than you did before the program? If so, in what kind of ways? 6. Was the program fun? Did you like it? If so, tell me what was fun about it? 7. Were there any parts of the program that were not fun or that you didn't like? If so, which parts? 8. Do you think your friends would like the program? Why or why not? Parent Questions 1. Tell me a little bit about yourself. 2. Why did you attend the program? 3. What was the program like for you? 4. What kinds of things did you learn? 5. Did it motivate you to improve nut rition and exercise routines for your child/family? 6. Since the program, have you changed how you do things at home (example: grocery purchases, cooking, exercise)? How? 7. Do you think your child learned anything new? Did your child want to change (diet and exercise routines)? Does y our child do anything differen tly after the program? 8. Can you tell me about what you liked about the program? Were there any aspects of the program that you didn't like? 9. Did your child want to attend the program? Did you? Why or why not?

PAGE 144

144 10. Did you think your child liked the program? What things did he/she like or not like? 11. If you were giving advice to the progr am organizers to the program, what would you say? 12. Would you recommend the program to othe r parents or children? Why or why not?

PAGE 145

145 APPENDIX C HIPAA IDENTIFYING FACTORS 1. Names; 2. All geographical subdivisions sm aller than a state, including street address, city, county, precinct, ZIP code, and their equivalent geocodes, except for the initial three digits of a ZIP code, if according to the current publicly availa ble data from the Bureau of the Census: (1) The geographic unit formed by combining all ZIP codes with the same three initial digits contains more than 20,000 people; and (2) The initi al three digits of a ZIP code for all such geographic units containing 20,000 or fewer people is changed to 000; 3. All elements of dates (except year) for dates directly relate d to an individual, including birth date, admission date, disc harge date, date of death; and all ages over 89 and all elements of dates (including y ear) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older; 4. Phone numbers; 5. Fax numbers; 6. Electronic mail addresses; 7. Social Security numbers; 8. Medical record numbers; 9. Health plan beneficiary numbers; 10. Account numbers; 11. Certificate/license numbers; 12. Vehicle identifiers and serial numbe rs, including license plate numbers; 13. Device identifiers and serial numbers; 14. Web Universal Resource Locators (URLs);

PAGE 146

146 15. Internet Protocol (IP) address numbers; 16. Biometric identifiers, incl uding finger and voiceprints; 17. Full face photographic images and any comparable images; and 18. Any other unique identifying number, characteri stic, or code (note this does not mean the unique code assigned by the inves tigator to code the data).

PAGE 147

147 APPENDIX D CHART DATA COLLECTION FORM Data Collection Form Physician/Clinic Name_____________/___________________ Demographics ________Subject Identification Number ________Age ________Gender (1. Male 2. Female) ________ Race Medical Diagnosis(es) ___________________ ______________________________________ Medication(s) __________________________ ______________________________________ 12 to 6 Month Pre-Test Measurements __/__/__Date (Month/Day/Year) ________Weight (in kg) ________Height (in meters) ________BMI ________Hb AIc ________ No. visits 12 months pre-program Day-of-Program Measurements __/__/__Date (Month/Day/Year) ________Weight (in kg) ________Height (in meters) ________BMI ________Hb AIc 3-Month Post-Program Measurements 6-Month Post-Program Measurements __/__/__Date (Month/Day/Year) __/__/__Date (Month/Day/Year) _______Weight (in kg) _______Weight (in kg) _______Height (in meters) _______Height (in meters) _______BMI _______BMI _______ Hb AIc _______ Hb AIc _______ No. visits 6 months postprogram Calculations/Comments

PAGE 148

148 LIST OF REFERENCES Adair, L. S., & Gordon-Larsen, P. (2001). Matu rational timing and overweight prevalence in US adolescent girls. Am J Public Health, 91(4), 642-644. Alaimo, K., Olson, C. M., & Frongillo, E.A. (2001). Low family income and food insufficiency in relation to overweight in US children [Electronic version]. Archives of Pediatrics & Adolescent Medicine 155(10), 1161-1167. Allen, N. A. (2004). Social cognitive theo ry in diabetes exercise research: An Integrative literature review. The Diabetes Educator, 30(5), 805-819. American Academy of Pediatrics (2003). Prevention of pedi atric overweight and obesity: Committee on nutrition. Pediatrics, 112(2), 424-430. American Beverage Association (2006). School beverage guidelines Q and A [On-line]. Retrieved January 12, 2007 from: http://www.am eribev.org/schools/GuidelineQandA.asp American Diabetes Association (2006) [On-line]. Obesity and children. Retrieved January 12, 2007 from: http://www.diabetes.org/home.jsp Anderson, R. M., Funnell, M. M., Butler, P. M., Arnold, M. S., Fitgerald, J., T., & Feste, C. C. (1995). Patient empowerment: Resu lts of a randomized controlled trial. Diabetes Care, 18, 943-949. Bandura, A. (2006). Guide for constructing self-efficacy scales In Pajares, F., and Urden, T., self-efficacy beliefs of adolescents Greenwich, CT: Information Age Publishing. Bandura, A. (2004). Health promotion by social cognitive means. Health Education and Behavior 31(2), 143-164. Bandura, A. (1997). Self-efficacy: The exericise of control. New York: Freeman. Bandura, A. (1989). Bandura, A. (1989).Hum an agency in social cognitive theory. American Psychologist, 44 1175-1184. Bandura, A. (1986). Social foundations of thought and acti on: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall. Bandura, A. (1977). Social learning theory (1rst ed.). Pearson. Barclay, L. & Vega, C. (2006). New guidelines for management of hyperglycemia of type II diabetes. Medscape Nurses. Retrieved February 23, 2006 from http://www.medscape.com/viewarticle/541953 Barlow, S. E., & Dietz, W. H. (1998). Obesity evaluation and treatment: Expert committee recommendations. Pediatrics, 102(3), e29.

PAGE 149

149 Benight, C. C., & Bandura, A. (2004). Social cognitive theory of a posttraumatic recovery: The role of perceived self-efficacy. Behavior Research and Theory, 42(10),1129-1148. Blake, R. L. (1989). Integrat ing quantitative and qualitative methods in family research. Fam Syst Med, 7, 411-427. Carter, R. C. (2002). The impact of public schools on childhood obesity. JAMA, 21802180. Carroll, W. R., & Bandura, A (1987). Translatin g cognition into action: the role of visual guidance in learning. J Mot Behav 19(3), 385-98. Cary, N. C. (1989). SAS/STAT users guide, version 6 (4th ed ). SAS Institute Inc. Centers for Disease Contro l and Prevention (2004). Youth Risk Behavioral Surveillance Survey: Youth online comprehensive results. MMWR Morb Mortal Wkly Report, 53(24), 536. Centers for Disease Control and Prevention (CDC ), National Center for Health Statistics, National Health Nutrition Examination Survey (NHANES) (2005). Prevalence of overweight among children and adolescents ages 6-19 years, for selected years 1963-65 through 1999-2002. Retrieved July 13, 2004 from http://www.cdc.gov/nchs/products /pubs/pubd/hestats/overwght99.htm Chapman-Novakofski, K. and J. Karduck. (2005 ) Improvement in knowledge, social cognitive theory variables, and movement through stages of change after a community-based diabetes education program. J Amer. Dietetic Assoc 105(10):1613-1616. Childrens Medical Service Program (2006) [Online]. CMS network Available at: http://www.cms-kids.com/CMSNTally.htm Creswell, J. W., Fetters, M. D., & Ivankova, N. V. (2004). Designing a mixed methods study in primary care. Annals of Family Medicine, 2, 7-12. Cusatis, D. C., & Shannon, B. M. (1996). In fluences on adolescent eating behavior. J Adolesc Health, 18, 227-34. Dallas, J.S., & Foley, T. P. (1996). Hypothyroidism. In: Lifeshitz F. ed. Pediatric endocrinology. New York, NY: Springer-Verlag. Daniels, S. R., Arnett, D. K., Eckel, R. H., Gidding, S. S., Hayman, L. L., Kumanyika, S., Robinson, T. N., Scott, B. J., St. Jeor, S., & Williams, C. L. (2005). Overweight in children and adolescents: Pathophysiology, conse quences, prevention, and treatment. Circulation, 111, 19992012.

PAGE 150

150 Davis, C. S. (2002). Statistical methods for the anal ysis of repeated measurements New York: Springer Verlag. DeVahl, J., King, R., & Williamson, J. W. ( 2005). Academic incentives for students can increase participation in and effectiveness of a physic al activity program. JAmCollHealth, 53(6),295-298. Dietz, W. H. (1998). Health consequences of obesity in youth: Childhood predictors of adult disease. Pediatrics, 101(3 Pt 2), 518-525. Dietz, W. H. (2004). Over weight in childhood and adoles cence [Electronic version]. The New England Journal of Medicine, 350(9), 855-857. Dietz, W. H., Gross, W.L., Kir kpatrick, J.A. (1982). Blount disease (tibia vara): another skeletal disorder associated with childhood obesity. J Pediatr, 101:735-737. Dilorio, F. C. (1991). SAS applications and programming: A gentle introduction. Belmont, CA: Duxbury Press. Dowda, M., Ainsworth, B. E., Addy, C. L., Saunders, R., & Riner, W. (2001). Environmental influences, physical activity, and weight status in 8to 16-year-olds [Electronic version]. Archives of Pediatrics & Adolescent Medicine 155(6), 711-717. Dreimane, D., Safani, D., MacKenzie, M., Hal vorson, M., Braun, S., Conrad, B., & Kaufman, F. (2006). Feasibility of a hospital-ba sed, family-centered intervention to reduce weight gain in overweight and adolescents. Diabetes and Research and Clinical Practice. Ebbeling, C. B., Pawlak, D. B. & Ludwig, D. S. (2002). Childhood obesity: Pulic-health crisis, common sense cure. Lancet, 360, 473-482. Edwards, L. (2000). Modern st atistical techniques for the anal ysis of longitu dinal data in biomedical research. Pediatr Pulmonol, 30(4), 330-344. Eisenberg, M. E., Neumark-Sztainer, D., & St ory, M. (2003). Associations of weightbased teasing and emotional well being am ong adolescents [Electronic version]. Archives of Pediatrics and Adol escent Medicine, 157(8), 733-738. Eliakim, Kaven, Berger, Friedlant, Wolack, & Namet (2002). The effect of a combined intervention on body mass index and fitness in ob ese children and adolescents a clinical experience. Eur J Pediatr, 161, 449-454. Fajans, S. S. (1990). Classification and diagnosis of diabetes. In Rifkin, H., & Porte, D., editors. Diabetes mellitus theory and practice (4th ed.). New York: Elsevier. Finkelstein, E. A., Fiebelkorn, I. C., & Wa ng, G. (2003). Nationa l medical spending

PAGE 151

151 attributable to overweight a nd obesity: How much, and who's paying [Electronic version]? The Policy Journal of the Health Sphere, W3, 219-226. Florida Department of Health ( 2004). Obesity in Florida: Repo rt of the Governor's task force on the obesity epidemic. Retrieved Sept. 4, 2005 from http://www.doh.state.fl.us/Family/GTFOE/report.pdf Florida Statutes (2006). Section 456.057(5)(a) 4. Franz, M. J., Splett, P. L., Monk, A., Barry, B., McClain, K., Weaver, T., Upham, P., Bergenstal, R., & Mazze, R. S. (1995). Cost-effectiveness of medical nutrition therapy provided by dieticians for persons with non-insulin dependent diabetes mellitus. Journal of the American Dietetic Association, 95(9), 1018-1024. Freedman, D. S., Dietz, W. H., Srinivasnet, S. R., Berenson, G. S. (1999). The relation of overweight to cardiovascular risk factors among children and adolescents: The bogalusa heart study. Pediatrics, 103(6), 1175-1182. Frick, K. D., Milligan, R. A., White, K., Serw int, J. R., & Pugh, L. C. (2005). Nursesupported breastfeeding promotion: A fr amework for economic development. Nursing Economics 23(4), 165-172. Fried, E. J. & Nestle, M (2002) The growing political movement against soft drinks in schools. JAMA, 288, 2181-2181. Gochman, D. S. (1987) Youngsters' health cognitions: cr oss-sectional and longitudinal analyses Health Behavior Systems, Louisville, KY. Goldestein, D. E., Parker, K. M., England, J. D. (1982). Clini cal application of glycosolated Hemoglobin measurements. Diabetes 31(supp), 70-78. Gonzalez, J. L., & Gilmer, L. ( 2006). Obesity prevention in pediat rics: A pilot pediatric resident curriculm intervention on nutrition and obesity education and counseling. J Nat Med Assoc. 98(9), 1483-1488. Hall, B. (2007) [On-line]. What is ethnography? Retrieved May 1, 2007 from: http://www.sas.upenn.edu/anthr o/CPIA/METHODS/Ethnography.html Hanna, J. S., & Howard, B. V. (1994). Dietar y fats, insulin resistance and diabetes. J Cardiovasc Risk 1, 31-37. Hardy, L. R., Harrell, J. S., & Bell, R. A. ( 2004). Overweight in children: Definitions, measurements, confounding factors, & health consequences. Journal of Pediatric Nursing

PAGE 152

152 He, Q, & Karlberg, J (1999). Prediction of a dult overweight during the pediatric years. Pediatr Res, 46, 697-703. Hendy, H. M., Williams, K. E., & Camise, T. S. (2005). "Kids Choice" school lunch program increases children's fruit and vegetable acceptance. Appetite, 45(3), 250-63. Huck, S., Cormier, W., & Bounds, W. (1974). R eading statistics and research. New York: HarperCollins, 103-31. Institute of Medicine (2005). Nutrition standards for foods in school [On-line]. Available at http://www.iom.edu/project.asp?id=30181 Ivankova, N. V., Creswell, J. W. & Stick, S. L. (2006). Using mixed-methods sequential explanatory design. Field Methods, 18(1), 3-20. Jain, A. (2004). What works for obesity: A summary of research behind obesity interventions. London, UK: BMJ Publishing Group. Johnson, J. G., Cohen, P., Kasen, S., & Br ook, J. S. (2002). Childhood adversities associated with risk for eating disorders or weight problems during adolescence or early adulthood. American Journal of Psychiatry, 159, 394-400. Kaplowitz, P. B., Slora, E. J. Wasserman, R. C., Pedlow, S. E., Herman-Giddens, M. E. (2001). Earlier onset of puberty in girls: Relati on to increased body mass index and race. Pediatrics, 108(2), 347-353. Klesges, R. C., Stein, R. J., Eck, L. H., Isbell, T. R. and Klesges, L. M. (1991) Parental influence on food selection in young child ren and its relationships to childhood obesity. American Journal of Clinical Nutrition 53 859. Krueger, C., and Tian, L. (2004). A comparison of the general linear mixed model and repeated measures ANOVA using a dataset with multiple missing data points. Biol Res Nurs, 6(151). Kuehl, R. O. (2000). Design of experiments: Statis ticl principles of rese arch design and analysis (2nd ed.). Duxbury Press. Lazzer, S., Meyer, M., Derumeaux, H., Boirie, Y., & Vermorel, M. (2005). Longitudinal changes in activity patterns, physical capacities, ener gy expenditure, and body co mposition in severely obese adolescents during a multidisciplinary weight-reduction program. International Journal of Obesity 29, 37-46. Leinung, M.C, & Zimmerman, D. (1994). Cushing's disease in children. Endocrinol Metab Clin North Am. 23, 629-639.

PAGE 153

153 Little, R. J. A. (1995). Modeling the dropout mechanism in longitudinal studies. Journal of the American Statistical Association, 90, 1112-1121. London, M. L., Ladewig, P. W., Ball, J. W. & Bindl er, R. C. (2006). Maternal & Child Nursing Care (2nd ed.). London: Prentice Hall. Loos, R. J., & Bouchard, C. (2003). Obesity---is it a genetic disorder? J Intern Med, 254(5), 401-424. Ludlow, A. P., & Gein, L. (1995). Relationshi ps among self-care, self-efficacy and Hb A1c levels in individuals with non-insulin dependent diabetes mellitus (NIDDM). Ca J Diabetes Care, 19, 10-15. Luepker, R., Perry, C., McKinlay, S., Nader, P., Parcel, G., Stone, E., Webber, L., Elder, J., Feldman, H., Johnson, C., Kelder, S., and Wu M. (1996). Outcomes of a field trial to improve children's dietary patterns and physical activity: The child a nd adolescent trial for cardiovascular health (CATCH). Jama 275, 768-776. Manson, J. E., Nathan, D. M., Krolewski, A. S ., Willett, W. C., & Hennekens, C. H. (1992). A prospective study of exercise and incidence of diabetes among US male physicians. JAMA, 268(1). Mast, M., Krtzinger, I., Knig, E ., and Mller, M. J. (1997). Gender differences in fat mass of 5 to 7 year-old children. Journal of Obesity, 22(9), 878-884.Maternal and Child Health Bureau (MCHB) (2006). The national survey of children with special health care needs [Online]. Available at: ureau.http ://mchb.hrsa.gov/chscn/pages/prevalence.htm#income Maxwell, S. E., & Delaney, H. D. (1990). Designing experiments and analyzing data. Belmont, CA: Wadsworth. McGehee, M. M., Johnson, E. Q., Rasmussen, H. M., Sahyoun, N., Lynch, M. M., & Carey, M. (1995). Benefits and costs of me dical nutrition therapy by registered dieticians for patients with hyperinsulinemia. Journal of the American Dietetic Association, 95, 1041-1043. Margolis, H. & McCabe, P. P. (2004). Self-efficacy: A key to improving the motivation of struggling learners. The Clearing House, 77, 241. Medicine.net (2007). Body mass index (BMI) for children and teens Retrieved July 09, 2007 from http://www.medicinenet.com/sc ript/main/art.as p?articlekey=41284 Miller, C. K., Edwards, L., Kissling, G., & Sanville, L. (2002). Nutrition education improves metabolic outcomes among older adults with diabetes mellitus: Results from a randomized contol group. Prev Med, 34, 252-259. Monzavi, R., Dreimane, D., Geffner, M. E., Bra un, S., Conrad, B., Klier, M. & Kaufman, F. R. (2006). Improvement in risk factors for metabolic syndrome and

PAGE 154

154 insulin resistance in overweight youth who ar e treated with lifestyle intervention. Pediatrics, 117(6), e1111-e1118. National Center for Health Statistics (NCHS) (2000). 2000 CDC growth charts: United States. Retrieved August 20, 2004 from http://www.cdc/gov/growthcharts/ National Center for Health Statistics (NCHS ) (2005). Prevalence of overweight among children and adolescents: United States, 1999-2002. Retrieved January 1, 2005 from http://www.cdc.gov/nchs/products /pubs/pubd/hestats/overweight99.htm National Conference of State Legislatures. He alth promotion program state legislation and statute database: Obesity, obesity-childhood, physical activity and nutrition. (Accessed May 25, 2006, at http:/www.ncsl.org/prog rams/health/phdatabase.htm) National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI) (1998). Clinical guidelines on the identifica tion, evaluation, and treatm ent of overweight and obesity in adults. HHS, Public Health Service (PHS), xxiii. Retrieved March 8, 2005 from: http://www.nhlbi.nih.gov/guide lines/obesity/ob_home.htm National Institutes of Health (NIH) (2003). Theory at a Glance: A guide for health promotion practice. National Cancer Institute. Retrieved Sept 24, 2005 at /redirect.cgi?r=http://www.cancer.gov/can cerinformation/theory-at-a-glance Nestle, M. & Jacobson, M. F. (2000). Halti ng the obesity epidemic: A public health policy approach. Public Health Reports, 115, 12-24. QSR International (2002). NVivo 2.0 Doncaster, Victoria, Austra lia. Retrieved July 11, 2007 at www.qsrinternational.com Parcel, G. S., Simons-Morton, B., O-Hara, N. M., Baranowski, T., & Wilson, B. (1989). School promotion of healthful diet a nd physical activity: im pact on learning outcomes and self-reported behavior. Health Educ Q. 16(2), 181-99. Parjares (2002). Overview of social cognitive theory and of self-efficacy Retrieved Sept. 26, 2005 from http://www.emor.e du/EDUCATION/mfp/eff.html Plourde, G. (2002). Impact of obesity on glucose and lipid profiles in adolescent different age groups in relation to adulthood [Electronic version]. BMC Family Practice 3. Retrieved online March 8, 2005 from http://www.pubmedcentral.nih.gov/articl erender.fcgi?tool=pubmed$pubmedid=1 2379160 Potts, R. & Swisher, L (1998). Effects of te levised safety models on children's risk taking and hazard identification. J Pediatr Psychol 23(3), 157-63.

PAGE 155

155 Raskin, P. et al ((1994). Medical mana gement of non-insulin dependent (Type II) diabetes (3rd ed.). Alexandria, Va: American Diab etes Association. ReCapp (2006). Theories and approaches: How can I us e Social Learning Theory in my setting? Retrieved online March 18, 2006 from http://www.etr.org/recapp/th eories/slt/HowtoUse.htm Redding, C. A., Rossi, J. S., Rossi, S. R., Veli cer, W. F., & Prochaska, J. O. (2000). Health behavior models. The Interna tional Electronic Journal of Health Education, 3 (Special Issue), 180-193. Reinehr, T., Brylak, K., Alexy, U., Kersting, M., & Andler, W. (2003). Predictors to success in outpatient training in obese ch ildren and adolescents. International Journal of Obesity, 27(9), 1087-1092. Resnicow, K., Davis-Hearn, M., Smith, M., Baranow ski, T., Lin, L. S., Baranowski, J., Doyle, C., & Wang, D. T. (1997). Social-cognitive predicto rs of fruit and vegetable intake in children. Health Psychology 16(3), 272-276. Richardson, S. A., Goodman, N., Hastorf, A. H., & Dornbusch, S. M. (1961). Cultural uniformity in reaction to physical disabilities. Am Soc Rev, 26( ), 241-247. Rinderknecht, K., & Smith, C. (2004). Social cognitive theory in an after-school nutrition intervention for urban Native American youth. Journal of Nutrition and Education Behavior, 36(6), 298-304. Robles, E., Crone, C. C., White side-Mansell, L., Conners, N. A., Bokony, P. A., Worley, L. L. & McMillian, D. E. (2005). Voucher-based incentives for cigarette smoking reduction in a women's residential treatment program. Nicotine Tob Res, 7(1), 111-117. Rohlfing C, Wiedmeyer H.M., & Little R. ( 2002). Biological variati on of glycohemoglobin. Clin. Chem. 48 (7): 1116-8. Rose, M., Fliege, H., Hildebrandt, M., Schir op, T., & Klapp, B. F. (2002). The network of psychological variables in patie nts with diabetes and their im portance for quality of life and metabolic control. Diabetes Care, 25, 35-42. Rowan-Sazal, G., Joe, G. W., Chatham, L. R. & Simpson, D. D. (1994). A simple reinforcement system for methadone clients in a community-based treatment program. J Subst Abuse Treat, 11(3), 217-223. Ryan, G. W. & Bernard, H. R. (2003) Techniques to identify themes. Field Methods 15(1), 85109. Saelens, B. E., Sallis, J. F., Wilfley, D. E., Pa trick, K., Cella, J. A., & Buchta, R. (2002). Behavioral weight c ontrol for overweight adolescents initiated in primary care. Obesity Research 10, 22-32.

PAGE 156

156 Savoye, M., Berry, D., Dziura, J., Shaw, M., Serrecch ia, J. B., Barbetta, G., Rose, P., Lavietes, S., & Caprio, S. et al. (2004). Anthropometric and psychosocia l changes in obese adolescents enrolled in a weight management program. Journal of the American Dietetic Association, 105(3), 364-370. Searle, S. R. (1971). Linear models. Wiley, New York. Shaw, S. M., Kleiber, D. A., & Caldwell, L. L. (1995). Leisure and identity formation in male and female adolescents: A preliminary examination. Journal of Leisure Research 27(3), 245263. Sheaves, R., Jenkins, P., Wass, J., & Thorner, M. (1997). Clinical endocrine oncology. Oxford: Blackwell. Silvestri, J. M., Weese-Mayer, D.E., Bass, M.T., Kenny, A.S., Hauptman, S.A., Pearsall, S.M. (1993). Polysomnography in obese children with a history of sleep-associated breathing disorders Pediatr Pulmonol, 16,124-129. Skelley, A. H., Marshall, J. R., Haughey, B. P ., Davis, P. J., & Dunford, R. J. (1995). Self-efficacy and confidence in outcomes as dete rminates of self-care practices in inner-city, African-American women with noninsulin-dependent-diabetes. Diabetes Educator, 21, 38-46. Spieth, L., Harnish, J. D., Lenders, C. M., Raezer L. B., Pereira, M. A., Hangen, S. J., Ludwig, D. S. (2000). A low-glycemic index diet in the treatment of pediatric obesity. Arch Pediatr Adolesc Med 154(9), 947-951. Stange, K. C., & Zyzanski, S. J. (1989). Integrati ng qualitative and qua ntitative research methods. Fam Prac Med 21, 448-451. Stark, O., Atkins, E., Wolff, O. H., & Douglas J. W. B. (1981). Longitudinal study of obesity in the National Survey of Health and Development. British Medical Journal, 283, 13-17. Stone, D. (1998). University of Florida department of community and fa mily health: Social cognitive theory. Retrieved March 17, 2005 from http://hsc.usf.edu/~kmbrown/Socia l_Cognitive_Theory_Overview.htm Stunkard, A., Burt, V. (1967). Obesity and body im age II. Age at onset of disturbance in body image. Am J Psychiatry, 123(11), 1443-1447. Taras, H. L., Sallis, J. F., Paterson, T.L., Nader, P.R. & Nelson, J. A. (1989). Television's influence on children's di et and physical activity. J Dev Behav Pediatr 10,176-180. Taylor, M. J., Mazzone, M., Wrotniak, B. H. ( 2005). Outcome of an exercise and educational intervention for childre n who are overweight. Pediatric Physical Therapy, 17(3), 180-188.

PAGE 157

157 Trevino, R., Pugh, J., Hernandez, A., Menchaca, V., Ramirez, R., & Mendoza, M (1998). Bienstar: A diabetes risk-factor prevention program. Journal of School Health, 68(2), 62-7. Van Duyn, M. A. S., Kristal, A. R., Dodd, K. ( 2001). Association of awareness, intrapersonal and interpersonal factors, and st age of dietary change with fru it and vegetable consumption: A national survey. Am J Health Promt, 16, 69-79. Van Dyck, P. C., Kogan, M. D., McPherson, M. G., Weissman, G. R. & Newacheck, P. W. (2004). Prevalence and characte ristics of children with special health care needs. Arch Pediatr Adolesc Med, 158, 884-890. U. S. Department of Health and Human Services (2004). Nutrition and your health: Dietary guidelines for Americans [Electronic version]. Re trieved December 30, 2004 from http://www.health.gov/d ietaryguidelines/ U. S. Department of Health and Human Services (2001). The Surgeon General's call to action to prevent and decrease overweight and obesity : Measuring overweight and obesity. [Electronic version]. Retr ieved January 2, 2005 from http://www.surgeongeneral.gov/topi cs/obesity/calltoaction/1_1.htm U. S. Department of Health and Human Services (2000). Healthy People 2010: Understanding and improving health. Conference edition. Washington: Government Printing Office. U. S. Department of Health and Human Services (1990). Healthy People 2000: National health promotion and disease prevention objectives. Conference edition. Washington: Government Printing Office. Wang, Y. (2002). Is obesity associated with early sexual maturation? A comparison of the association in American boys versus girls. Pediatrics, 110(5), 903-910. Wang, G. & Dietz, W. H. (2002). Economic burden of obesity in youths aged 6 to 17 years: 1979-1999. Pediatrics 109(e81). Weinreich, N. K. (2005). Integrating quantitative and qualitative methods in social marketing research. Retrieved on Nov. 17, 2005 from http://www.socialmarketing.com/research.html Wing, R.R., Marcus, M. D., Epstei n, L.H., & Salata, R. (1987). Type II diabetic subjects lose less weight than their overwe ight non-diabetic spouses. Diabetes Care, 10, 563. Woo, K. S., Chook, P., Yu, C. W., Sung, R. Y., Qiao, M., Leung, S. S., Lam, C. W., Metreweli, C., & Celermajer, D. S. (2004). Effects of di et and exercise on obes ity-related vascular dysfunction in children. Circulation, 109, 1981-1886.

PAGE 158

158 WHO (2003). Diet, nutrition and the prevention of chronic diseases. World Health Organ Tech Rep Ser, 916, 1-149. Zador, I., Meyer, L. J., Scheets, D. R., Wittstruc k, T. M., Timmler, T., & Switaj, D. M. (2006). Hemoglobin A1c in obese children and adolescents who participated in a weight management program. Acta Paediatrica, 95(1), 105-107.

PAGE 159

159 BIOGRAPHICAL SKETCH Susan Wall is currently working as an Assist ant Professor at Flor ida State University College of Nursing. Her educational backgrou nd includes a Registered Nurse Diploma from Fanshawe College in Ontario, Ca nada, and a Bachelor and Master of Science of Nursing from the University of Florida. She is a Certified Nurse Midwife.