Combating Childhood Obesity in East Oakland

June 2019Diana Austin

In an effort to address the seemingly intractable problem of childhood obesity, the UCSF School of Nursing partnered with the Oakland Unified School District, Federally Qualified Health Centers serving Oakland schools, and the Alameda County Center for Healthy Schools and Communities to design and test a promising group intervention for some of the Bay Area’s most vulnerable children. The results of the six- to 10-week intervention, recently published online in the Journal of School Nursing, showed “a significant decrease in soda consumption, increased support from classmates, and an increased number of exercise days.”

Finding innovative solutions to the obesity problem has only become more urgent. After plateauing between 2009 and 2012, the prevalence of obesity among youth aged 2 to 19 in the United States continued to climb, reaching 18.5 percent as of 2016, according to a report from the National Center for Health Statistics. The data tell an even more sobering story for youth of color. While obesity rates among non-Latinx white and Asian youth were 14.1 percent and 11.0 percent, respectively, non-Latinx black and Latinx children and adolescents had obesity rates of 22.0 percent and 25.8 percent, respectively. Those higher obesity rates can contribute to persistent health disparities. Children with obesity are at risk for health problems that include metabolic syndrome, diabetes and early heart disease, as well as the psychological effects of weight-based discrimination, bullying and teasing.

Building on an Established Infrastructure

The project leveraged funding from The Atlantic Philanthropies to place UCSF nurse practitioners (NPs) and NP students in school-based health centers (SBHCs) at three underserved East Oakland middle schools, in collaboration with Alameda County Public Health Department nutritionists and Center for Healthy Schools and Communities staff. (The Safeway Foundation, Children’s Hospital Oakland Research Institute and the national School-Based Health Alliance provided additional funding to two of the sites.) The project was part of UCSF’s Elev8 Healthy Students and Families, an Atlantic Philanthropies-funded program to provide an integrated model for delivering primary health and dental care in Oakland middle schools.

Naomi Schapiro “Elev8 had good infrastructure in place [in the SBHCs], and we decided it was a great opportunity to evaluate what we could do with group obesity visits at these three sites,” says Naomi Schapiro, professor in Family Health Care Nursing, who led the project study.

Schapiro and her team based their intervention on a shared medical appointment (SMA) model, which uses a group setting to deliver patient education about healthy behaviors and offers peer support for the development of self-management skills.

Engaging Students with Hands-On Activities

At each site, health educators and clinicians facilitated groups that met before, during or after school. The sessions involved group education, peer discussion and various hands-on activities, including food preparation, exercise sessions, martial arts and hip-hop dancing. In addition, students received individual attention in an effort to assess risk factors, behaviors and their understanding of the week’s educational topics.

The emphasis was on fun and life skills. For example, during food preparation activities, the facilitator introduced students to new ways to incorporate fruits and vegetables into their diets. They made healthy smoothies, vegetable quesadillas and other foods that would be both simple to prepare and appealing to youth.

“We tried our best to make each lesson engaging,” says Atziri Rodriguez, of Oakland’s Native American Health Center, who coordinated the program at one of the sites. “The things that came out of the peer-to-peer discussions were particularly valuable for nutrition. Instead of a provider saying, ‘Let me talk to you about the five food groups,’ the students engaged in peer-to-peer conversations about real food, like how to make broccoli taste good.”

Schapiro described the “corner-store challenge,” aimed at arming students with the skills to find healthy food in any setting. They would walk to a local drugstore, where nutritionists challenged them to find the healthiest snacks they could – those with the least salt and fat – for under $5. Each student then received a $5 gift card to purchase the snacks, which they brought back to the center to share with the group. Schapiro notes that while some parts of Oakland are less of a food desert than other underserved communities, many areas don’t have a full-service grocery store within walking distance of schools or homes.

“A drugstore isn’t always going to have fresh fruits and vegetables, so they learn to pick the healthiest alternative,” she says.

School-Based SMAs Reduce Stress, Build Trust, Offer Important Efficiencies

In high-stress communities, adverse childhood experiences (ACEs) like abuse, parent incarceration or divorce are common, and over the past three decades, a robust body of research has arisen that links ACEs to poor health outcomes, including obesity and its related problems. Consequently, stress management activities – such as mindfulness training and, for one group, work with a therapist – were an important component of the program. The SMA model can be particularly effective for such activities, because it provides a safe space for people experiencing ongoing community trauma to come together to share their experiences and coping mechanisms with peers who have similar lived experiences.

“It built a rapport between youth and staff by creating safe spaces and open dialogue,” says Rodriguez.

And because providers are working with multiple patients at one time, the SMA may also be a more efficient and sustainable way of delivering time-consuming counseling and education.

The project also highlighted the benefits of the school-based setting, Rodriguez says, because the students are already there and accessible. They don’t need to remember a separate appointment or secure additional transportation, leading to fewer missed sessions and higher retention rates.

Planting the Seeds for Long-Term Change

On the final day of the program at each site, researchers surveyed the students about what they had learned and what changes they had made in their diet and lifestyle. They found a significant decrease in the consumption of soda – thought to be a key driver of childhood obesity – and high-fat, high-sodium foods like chips and french fries.

Moreover, when the investigators evaluated knowledge retention 18 months after the group visits were finished, they were surprised to find how much the students remembered. They could describe the hands-on activities in detail – the “corner-store challenge” was particularly memorable – and said they enjoyed them more than the didactic elements, such as lessons reviewing the food pyramid.

Researchers were also surprised at how much information the students had eventually brought home to their families. “In focus groups we did right after the intervention, students said they weren’t talking to their parents. But when we talked to students 18 months later, they said they had talked to their parents,” Schapiro says. This led, for example, to students reporting that parents were reading nutrition labels and changing the kinds of foods they brought into the house.

Among the students’ favorite components of the intervention were the stress-reduction and mindfulness modules. Schapiro says that one of the students clearly saw the connection between stress – when she was “sad” – and eating more junk food. “That’s hard enough for an adult to recognize, much less a sixth-grader. It was a powerful moment,” says Schapiro.

The investigators found that the most difficult thing for students to change was their level of physical activity, although post-intervention surveys indicated an increase in the number of days students reported engaging in such activity. Schapiro says this may be related to the fact that in poorer communities, there are few opportunities for students to engage in organized sports, and many neighborhoods lack safe spaces for outdoor exercise. Surveys done in East Oakland reveal that less than 50 percent of respondents feel that it’s safe to exercise outside during the day.

Keeping the Momentum Going

The grant from The Atlantic Philanthropies allowed the researchers and members of the involved community groups to disseminate their findings at school-based health conferences and at a meeting of the American Public Health Association before publishing the paper in the Journal of School Nursing.

Now, Schapiro and her colleagues are looking at opportunities to continue the group obesity management model in the existing sites and other SBHCs using the infrastructure they developed, with an emphasis on the behavioral and mental health components. In addition, Schapiro and School of Nursing colleague Victoria Keeton are working on a grant proposal to use a trauma-informed care methodology when working with overweight youth. And Rodriguez and colleagues at Native American Health Center are planning to replicate their version of the SMA intervention at the same middle school in Oakland.

“We’re thinking about incorporating things like body acceptance and possibly moving away from doing things that might inadvertently increase stigma, like weighing kids,” she says.

“I hope that the students developed the skills and knowledge they need – that we planted a seed that will lead them to make healthier lifestyle choices,” says Rodriguez.