Summary And Conclusion

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Cultural issues arise in conjunction with health programs in general, including weight management programs, because of the belief that attending to cultural factors will allow for services that are better aligned with the client's needs and circumstances and thus more sensitive and effective. In addition, cultural influences on obesity treatment are of particular interest because of the disproportionate prevalence of obesity in U.S. ethnic minority populations. Culture influences obesity and weight change through several attitudinal and behavioral pathways that converge in food intake and energy output. Differences in weight related attitudes and practices can be readily documented among U.S. ethnic groups. In particular, compared to middle-class whites, some population groups with a higher prevalence of obesity have more tolerant views about obesity.

Cultural perspectives on obesity treatment should be viewed along all relevant dimensions, such as age, gender, and socioeconomic status. Moreover, both clients and providers bring cultural issues to the treatment setting, and the cultural competence of providers is a critical element of cultural sensitivity. Inasmuch as the treatment setting is the professional's domain, so should the building of cultural bridges be considered a primary responsibility of the treatment provider. However, there is a sense that addressing cultural influences adequately will ultimately require a paradigm expansion in the obesity treatment—away from more narrowly conceived clinical treatment models to broader health promotion paradigms—or at least a stronger and clearer articulation of the existing paradigmatic guidance on this issue.

The validity of attending to cultural and contextual influences in the design and delivery of obesity treatment can be established on a theoretical basis. However, success in cultural adaptations is inherently difficult to define and evaluate. We do not yet have many examples of scientifically rigorous models of culturally adapted weight management programs and are far from knowing whether these will improve overall treatment outcomes in specific populations. Some components of possible cultural adaptations have been outlined, and these can be formatively evaluated. Other salient cultural influences may be difficult to articulate and assess because they are tied to subtle symbolic meanings learned through affective rather than rational mechanisms. Finally, if a certain level of cultural appropriateness is a minimum standard for any program, then it is difficult to justify the conduct of studies in ethnic minority populations in which no cultural adaptations have been made. Finally, the time course for effectiveness of cultural adaptations may be long, that is, far out into the maintenance phase of behavior change rather than observable in the short term.

Appendix Examples of Culturally Adapted Weight Loss or Lifestyle Change Programs

First author and year (ref.)

Program description highlighting components of cultural adaptation

Lasco, 1989 (118)

Kumanyika, 1992 (119)

Cousins, 1992 (128)

Domel, 1992 (120)

Community Health Assesment and Promotion Project (CHAPP) was a 10-week nutrition and exercise program designed by a community coalition on the basis of data from a needs assessment Numerous supports were provided, e.g., child care, transportation, and a home visit to build family support Ancillary topics and activities were included in response to participants' requests (e.g., a class on makeup, a wardrobe and fashion analysis, and a theater party) Participant feedback and suggestions were solicited and incorporated Church-based program for African-American women (8-week group program) Built on an existing church-based high blood pressure screening, referral, and monitoring program Adapted a State Health Department weight loss curriculum

Program conducted in churches and aligned with church program schedule and policies Project director was actively involved and often attended sessions

Individual and team competitions (pooling $1.00 per week fees to give prizes to three participants -g who were most successful in meeting their goals); teams for mutual support |

Cuidando el Corazon was a 1-year weight loss program for Mexican-American women who were ®

married with at least one preschool child Bilingual manual with nutrition, exercise, and behavior information and modified to reflect cultural =3 values of the population; family condition included content on parenting skills to encourage healthful eating

Cookbook with fat-modified traditional Mexican-American foods Behavior modification strategies illustrated in simple terms

Spouses were encouraged to attend classes; separate classes were held for preschool children Weight control program for black women was offered at literacy program sites or recreation centers q (11 weeks)

Emphasized being able to lose weight at low cost and active learner participation

(continued on next page)

Appendix Continued

First author and year (ref.)

Program description highlighting components of cultural adaptation

Domel, 1992 (129)

Shintani, 1994 (1S1)

Fitzgibbon, 1995 (12S)

Agurs-Collins, 1997 (121)

Venkat-Narayan, 1997 (1SG)

McNabb, 1997 (122)

Vazquez, 1998 (46)

Weight control for Hispanic women was adapted from program developed for low-income black women Program was held in churches in low-income communities

Hispanic, bilingual dietitian was involved in making cultural adaptations such as translating information into Spanish, adding ethnic foods and recipes, stressing overall family health, and reformatting printed and audio materials to be applicable to Hispanic cultural preferences The Waianae Diet Program used a traditional Hawaiian diet (low in fat and very high in complex carbohydrates) to reduce weight and cardiovascular disease risk factors in Native Hawaiians Participants were encouraged to eat to satiety; calories were not restricted Program themes included family support, role modelling, and a whole-person approach Obesity prevention program for African-American girls and their mothers attending a tutoring program in an inner-city housing project 6-Week program with 1-hr weekly meetings Didactic information kept to a minimum All activities involved mother-daughter dyads

Topics addressed included health problems of African-American women and how to eat low fat in a fast-food restaurant

Each group developed a ''rap against fat'' using program information which was put to music, taped, and played at the final session Weight loss and exercise program for older African-American adults with type 2 diabetes Program was offered at an African-American university hospital

Program materials depicted African-American individuals, families, and community settings Program content was based on relevant language, social values, situations, foods, and flavorings Recipes used in dietary instruction were provided by participants

Program format allowed time for participants to discuss and problem solve regarding social context issues such as church meals Pima Pride was a lifestyle change program for Pima Indians in Arizona

Main emphasis was self-directed learning through monthly small group meetings led by a member of the community

Discussion focused on attitudes about current lifestyle in the community Local speakers were invited to address Pima culture and history

Newsletters sometimes carried poetry, stories, and folklore contributed by group members PATHWAYS was a church-based weight loss program for African-American women with type 2 diabetes (14 weeks)

Program was adapted from a successful clinical program for delivery in a community setting by trained lay volunteers

Emphasized health rather than appearance motivations for weight loss

Interactive, guided discovery approach to learning activities; small-group instruction

Buena Alimentación, Buena Salud (Good Eating, Good Health) was a nutrition intervention program designed for Carribean Latinos with type 2 diabetes (12 weeks) Intervention was developed by a multidisciplinary bilingual team of health professionals in collaboration with Latino community based on results of a planning survey and focus group interviews Intervention was designed for cultural sensitivity in relation to 12 concepts

Resulting features included involving bilingual/bicultural staff; offering the program in Spanish; |

emphasis on health risks of obesity; using a group setting; using interactive rather than didactic sessions; recommending modifications to traditional recipes; making intervention sessions into social events; and introducing the concept of empowerment Clinical program based on the Duke University Rice Diet, involving commonly available foods, daily 4 dietary counselling, nutrition education, and an exercise prescription, with the following cultural adaptations for African-American patients; Costs of program were reduced

Ethnic recipes were used in cooking classes Changes in ideas about exercise Open invitation to family members to attend weekly classes

Appendix Continued

First author and year (ref.)

Program description highlighting components of cultural adaptation

Keyserling, 2000 (125)

Oxemann, 2000 (126)

Most classes conducted by an African-American instructor

New Leaf...Choices for Healthy Living with Diabetes was designed for African-American women with type 2 diabetes

Cultural relevance and acceptability of program components were assessed in a series of focus groups Recipes build on positive aspects of the southern regional diet, e.g., the use of dry peas and beans Simplified counselling materials in both individually tailored and nontailored formats Telephone counselling provided by community diabetes advisers (African-American women with type 2

diabetes acting as peer counselors) Active discovery learning approach in group sessions

''Lighten Up,'' a church-based program for African-American men, women, and children (8-week group program)

Developed and implemented in collaboration with local faith community Bible study combined with a health message

Eight educational sessions based on the spiritual fruits of love, knowledge, peace, faith, kindness, joy, self-control, and Godliness All sessions were opened and closed with prayer

Participants brought food items from home for practice in label-reading skills

Feasibility study for POWER (Pounds Off with Empowerment), a program that adapted a state-of-the-art weight management research protocol for a primarily African-American men and women with type 2 diabetes served by a federally funded rural primary care clinic (8-week program that included two individual and six group sessions) Intervention materials included a ''toolbox'' with guidelines for monitoring and supporting adherence and problem solving

Interventionists used ''Continous Quality Programming.'' They obtained observational, conversational, and—in one arm—written feedback to make decisions about how to modify the program delivery/ content to improve adherence

Mayer-Davis, 2001 (127)

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