SummaryThe Upper Cardozo Health Center, a federally qualified health center in inner-city Washington, DC, hosts a weekly group program to help overweight and obese children and their parents maintain a healthy weight through improved nutrition and increased physical activity. Adopted from the parent curriculum within the National We Can! program, the program consists of an individual medical visit that includes an assessment of obesity-related lifestyle behaviors, a group education session, and time for exercise. Periodically, the group goes on field trips that offer opportunities for physical activity and/or education about healthy eating. The program has increased participants’ health knowledge and improved their health-related behaviors, leading to stable body mass index in children and weight loss in adults who participate frequently.Moderate: The evidence consists of comparisons of participants’ health knowledge, health-related behaviors, BMI, and weight before and after joining the program, along with participant feedback through satisfaction surveys and anecdotal reports.
Developing OrganizationsUnity Health Care; Upper Cardozo Health Center; We Can!
Unity Health Care and Upper Cardozo Health Center are located in Washington, DC.
Date First Implemented2008
Age > Adolescent (13-18 years); Race and Ethnicity > American Indian or Alaska native; Black or African American; Age > Child (6-12 years); Vulnerable Populations > Children; Race and Ethnicity > Hispanic/Latino-Latina; Vulnerable Populations > Impoverished; Age > Preschooler (2-5 years); Vulnerable Populations > Racial minorities; Urban populations
Problem AddressedObesity is a widespread, growing problem that has devastating health consequences. Poor health-related behaviors, including lack of physical activity and poor eating habits, contribute significantly to this problem, particularly for low-income families. Primary care providers and clinics can play an important role in addressing the problem by encouraging healthy behaviors. However, they face competing priorities on a daily basis that make it difficult for them to do so, especially in low-income areas.1
- A growing epidemic: Between 1999 and 2008, the percentage of Americans categorized as overweight or obese [defined as body mass index (BMI) above the 94th percentile] grew from 27.5 to 32.2 percent for men and from 33.4 to 35.5 percent for women.2 Over the past 30 years, the prevalence of childhood obesity has more than tripled, from 5.0 to 19.4 percent in 2- to 5-year-olds, from 6.5 to 19.6 percent in 6- to 11-year-olds, and from 5.0 to 18.1 percent in 12- to 19-year-olds.3
- Especially for minority and low-income children and adults: Children who are ethnic minorities (especially African Americans, Latinos, and Native Americans) and/or who live in low-income families face a greater risk of obesity. For example, up to 24 percent of African-American and Latino children are above the 95th BMI percentile (classifying them as obese), with Hispanic boys and African-American girls having the highest rates of overweight/obesity.4 In Washington, DC (which has a high proportion of low-income and minority residents), approximately 19 percent of residents are obese.5
- Driven by poor health-related behaviors: High rates of overweight/obesity stem from poor health-related behaviors, including unhealthy diets and lack of physical activity. Less than one-quarter of youth consume at least 5 servings of fruits and vegetables daily, less than one-fifth participate in 60 minutes of physical activity daily, and about one-third watch 3 or more hours of television daily.6,7 Low-income families in urban areas face particular challenges in getting regular physical activity and eating healthfully, as outlined below:
- Challenges related to physical activity: Urban environments generally discourage walking and other physical activities. In addition, high-crime rates in inner cities force parents to limit outdoor activities for themselves and their children (including walking or biking to and from school). Finally, many inner cities have few, if any, well-equipped and maintained playgrounds, fields, and parks, which further limits opportunities for physical activity.
- Challenges related to healthy eating: Economic pressures and time constraints lead many low-income families to regularly consume inexpensive convenience foods high in calories and fat. Parents with the time and money to purchase and prepare nutritious foods at home often find it difficult to do so, since many low-income urban neighborhoods have few if any grocery stores that sell healthy foods, including fresh fruits and vegetables.
- Leading to devastating health consequences: Overweight/obesity causes serious health problems, including cardiovascular disease, hypertension, and diabetes. In a population-based sample, approximately 60 percent of obese children between the ages of 5 and 10 years had at least 1 cardiovascular disease risk factor such as elevated total cholesterol, triglycerides, insulin, or blood pressure, while 25 percent had 2 or more risk factors.4
- Unrealized potential of primary care: Primary care providers can play an important role in helping adult and pediatric patients maintain a healthy weight. Too often, however, they lack adequate time and/or resources to help parents and children recognize and address weight-related problems. Key challenges facing them (especially in low-income areas) include lack of reimbursement for weight-related services, inadequate knowledge on how best to help, and increased demands for other, competing services.8
Description of the Innovative ActivityThe Upper Cardozo Health Center hosts a weekly group program with overweight or obese parents and children that focuses on healthy eating and physical activity. Each session consists of an individual medical visit that includes an assessment of obesity-related lifestyle behaviors, a group education session, and an opportunity to engage in physical activity. Periodically, the center organizes group field trips to grocery stores, hiking trails, and other sites that offer opportunities for physical activity and/or education about healthy eating. Key program elements include the following:
- Marketing program to target population: Pediatricians and other primary care providers can refer parents and/or children who are overweight or obese to the program. Parents can also learn about the program through posters and flyers throughout the health center. Clinicians also wear special t-shirts on Wednesdays to spark interest in the program.
- Weekly sessions: Offered in both English and Spanish, classes take place at the health center from 5:00 p.m. to 7:30 p.m. every Wednesday. Sessions draw an average of 20 participants, with attendance ranging between 12 and 40. Parents and children attend as families (thus alleviating childcare concerns) and can join the class or stop participating at any time. Presented as fun and supportive, each session includes three separate components, outlined below:
- Individual medical visit and lifestyle assessment: During the first hour, physicians, physician assistants, and nurses conduct individual medical visits and lifestyle assessments in a private examination room. (While waiting their turn, participants gather in a common area and eat healthy snacks, and children play with toys or a Nintendo Wii). The visit includes taking vital signs, measuring and tracking growth versus a normal growth chart (for pediatric patients), collecting information about nutrition and physical activity history (particularly food intake and activity in the past week), discussing challenges and barriers to living a healthy lifestyle, and helping the participant set specific goals related to their behaviors (e.g., switching from whole to lower-fat milk). Providers document the visit in the patient’s medical record.
- Group education: During the subsequent 45 minutes, the group participates in an educational session that includes a lecture followed by group discussion on a topic embraced by the We Can! program as well as evidence-based guidelines on pediatric and adult obesity prevention and treatment. Typically, adults and children meet in separate groups and receive tailored education. All presentations encourage healthy eating and regular physical activity for children, and emphasize how parents also can benefit from these behaviors. Examples of topics covered include reducing consumption of sugary beverages, fast food, and processed foods; increasing fruit and vegetable intake; eating appropriate food portions; enjoying family mealtime; making healthful ingredient substitutions in recipes; engaging in low-cost physical activities; and reducing screen time.
- Group physical activity: During the final 45 minutes, the group participates in moderate-to-vigorous physical activity. Children play games using the We Can!–endorsed Coordinated Approach to Child Health (CATCH) toolkit, which contains index cards that describe easy-to-play games. Adults can use onsite exercise equipment (e.g., weights, elliptical machine, treadmill), follow an exercise video, or participate in an exercise class (e.g., yoga, zumba, dance) led by a visiting instructor. During the summer, the class may walk to the nearby recreation facility to visit the playground and/or water-spray park.
- Periodic field trips: Periodically, the clinic replaces the Wednesday night session with a Saturday session; after the medical visit, the group goes on a field trip that is free to patients. To date, field trips have included grocery store scavenger hunts; tours of a local farmers’ market; ranger-led nature hikes; visits to the National Zoo, Washington Youth Garden, and National Arboretum; and outdoor activities hosted by the Sierra Club Inner-City Outings.
- Special events: Occasionally, the program hosts special events during one or more weekly sessions. For example, the Sister to Sister Foundation, which focuses on women and cardiovascular disease, ran the group sessions for several weeks in 2009, providing speakers on heart health and heart disease and hosting a biking event. In addition, We Can! hosted the national launch of its Deliciously Healthy Family Recipes cookbook at the Upper Cardozo Health Center in October 2010; the launch included physical activity stations and a cooking demonstration.
References/Related ArticlesInformation about the Upper Cardozo Clinic is available at: http://www.unityhealthcare.org/HealthCenters/ServiceUpperCardozo.html.
Serendipity in DC: First Lady’s Health Center Visit Generates High-Level Visibility for We Can! We Can! Voices. October 27, 2009. Available at: http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/downloads/marketing_voices.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
National Institutes of Health, National Heart Lung and Blood Institute. We Can! program Web site. Available at: http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/index.htm
National Institutes of Health, National Heart Lung and Blood Institute. We Can! Progress Report: Curriculum Implementations by the Intensive Sites. January 2007. Available at:
http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/downloads/progsummary.pdf. This resource includes data on the impact of the We Can! national program.
National Institutes of Health, National Heart Lung and Blood Institute. We Can! Strategy Development Workshops. January 2011. Available at: http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/downloads/2010strategyworkshop.pdf.
ResultsThe program has increased participants’ health knowledge and improved their health-related behaviors, leading to stable BMI in children and weight loss in adults who participate frequently. It has also generated high levels of satisfaction among participants. (More detailed results are available from the innovator.)
Moderate: The evidence consists of comparisons of participants’ health knowledge, health-related behaviors, BMI, and weight before and after joining the program, along with participant feedback through satisfaction surveys and anecdotal reports.
- Enhanced knowledge, improved behaviors: Surveys administered at implementation (April 2008) and again 16 months later (August 2009) show that participants had increased their health knowledge and improved many health-related behaviors between the time of their first and most recent visits. Behavior improvements include drinking fewer sodas, eating more fruits and vegetables, reducing screen time, and increasing levels of physical activity. Despite variation in the number of sessions that participants attended, the improvements were statistically significant for both adults and children.
- Stable BMI in children, weight loss in regularly participating adults: On average, children have maintained a stable BMI since joining the program. Adults have modestly reduced their BMI since joining, but this decline was not statistically significant. Some adults have lost weight since joining, and this decline was statistically significant for those attending at least eight classes. Information provided in July 2012 indicates that with each subsequent class attended, there is a statistically significant drop in BMI percentile in children.
- Highly satisfied participants: Surveys and anecdotal reports indicate high levels of satisfaction with the program. Participants place a high value on the medical visit component and express appreciation for the following aspects of the program: comfort and convenience of the clinic location; the staff’s caring attitude; the participatory nature and positive, fun tenor of the sessions; and the ability to receive support from other participants.
Context of the InnovationUnity Health Care is a private, nonprofit organization that operates 25 federally qualified health centers in Washington, DC, including 9 located in homeless shelters and 2 in jails. The largest of Unity Health Care’s community-based clinics, Upper Cardozo Health Center employs over 100 staff who handle approximately 70,000 patient visits a year, mostly with Spanish-speaking immigrants. The impetus for the program came from clinic providers, who felt they had little time and few resources to address weight-related issues during office visits. Hearing these concerns, a family practice fellow from a local university working at Upper Cardozo decided to research obesity prevention programs as part of a required public health project. The fellow discovered the We Can! program, which was created in 2005 as a national education program to assist parents and communities in helping children ages 8 to 13 years achieve and maintain a healthy weight. Developed jointly by the National Heart, Lung, and Blood Institute, the National Institute of Diabetes and Digestive and Kidney Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Cancer Institute, We Can! offers educational curricula; tools; and activities that encourage healthy eating, promote physical activity, and seek to limit video, computer, and television “screen time.”
Planning and Development ProcessSelected steps included the following:
- Becoming a We Can! site and adapting its parent program: The clinic obtained We Can! materials by registering on the program’s Web site. The family practice fellow met with Dr. Luis Padilla, the health center’s medical director, and several staff to review the program components and discuss implementation of its four-session parent curriculum. The group made decisions about key operational issues, such as when to hold program sessions, how to advertise them, how to handle registration, and how to address participants’ questions and concerns.
- Initial advertising before launch: The health center distributed flyers to patients and hung posters around the clinic to advertise the program for roughly 4 months before program launch.
- Recruiting staff volunteers: Initially, program developers at the health center recruited volunteers to run the sessions. After 5 months, Unity Health Care began paying staff overtime pay for running the sessions, first out of grant funds and then from third-party reimbursement for some services provided to program participants (see Funding Sources section for details).
- Testing and refining the program: The clinic initially ran only four sessions, as outlined in the We Can! parent curriculum. Program leaders found that parents enjoyed the opportunity for regular interaction and discussion, and that facilitators needed more time to cover all topics. As a result, it was decided to hold sessions on an ongoing basis, complemented by a medical visit and incorporating children’s games from the CATCH program.
- Expanding the program: Unity Health Care expanded the program to two additional clinics in the District of Columbia, with expansion to a third planned in 2011.
Resources Used and Skills Needed
- Staffing: The program requires no additional staff, as existing staff lead the sessions. Seven individuals [usually two to three providers (MD, DO, NP, PA), three medical assistants, and a receptionist] staff the weekly sessions.
- Costs: First-year program costs totaled $50,000, including approximately $35,000 for staff overtime and $15,000 for the purchase of exercise equipment, a television, a Nintendo Wii, food, and other supplies. Ongoing costs are moderate, consisting primarily of food and supplies. (As noted, third-party reimbursement now covers staff-related overtime costs.)
Funding SourcesUnity Health Care; Wholesome Wave Foundation
Unity Health Care initially funded program activities, with support from a few small grants. In September 2008, the District of Columbia Department of Health provided a $50,000 grant that covered staff overtime costs and supplies through August 2009. Since then, the center has been able to bill insurers (including Medicaid managed care organizations and the DC Healthcare Alliance program) for the individual portion of the program. Reimbursement covers a one-on-one medical encounter with a provider using standard CPT coding based on complexity (99212-99215), as outlined by the American Academy of Family Physicians and the American Academy of Pediatrics (see Tools and Other Resources). Information provided in July 2012 indicates that the program is the recipient of a national grant through the Wholesome Wave Foundation, which enables providers to provide "prescriptions" for fresh fruit and vegetables, to be purchased at local farmer's markets in DC. This kind of funding supports the behavioral changes families are making on their own and addresses a specific financial barrier to healthier choices that many families face.
Tools and Other ResourcesWe Can! tools and resources are available at:
Information about the CATCH program (a We Can!–endorsed initiative) is available at: http://www.catchinfo.org/.
The American Academy of Family Physicians offers a free guide to running group visits for patients with obesity. Available at: http://www.aafp.org/dam/AAFP/documents/patient_care/fitness/GroupVisitAIM.pdf.
The American Academy of Pediatrics offers its members a list of medical billing codes that can be used to bill for conversations about obesity. Available at: http://www.aap.org/en-us/about-the-aap/aap-facts/Documents/ObesityCodingFactSheet0208.pdf.
Getting Started with This Innovation
- Adopt or adapt a proven program: Adapting a proven, government-endorsed program with a clear evidence base (e.g., We Can!) helped the health center win support from Unity Health Care leaders and outside funders.
- Find a program champion: This type of program needs a passionate champion who is a well-respected, well-connected leader in the community. The champion can build support and enthusiasm for the initiative within the health center and enlist the assistance of stakeholders (such as recreation facility directors and grocery store managers) throughout the community.
- Seek initial cash infusion: An initial cash infusion can fund the purchase of exercise and other equipment. After these purchases have been made, ongoing operational costs tend to be low if third-party reimbursement for staff time is available.
- Accommodate participant scheduling needs: Working parents, particularly those in low-income neighborhoods, may find it difficult to attend sessions due to work and childcare requirements. Consequently, program leaders may need to make special accommodations to meet their needs. For example, the Upper Cardozo program was originally designed just for parents. Program leaders soon realized that participation would increase if parents could bring their children. Upper Cardozo also holds some activities on Saturdays to facilitate family participation.
- Design field trips to allow travel as a group: Many community activities are free, but low-income, non–English-speaking populations may be intimidated by the idea of traveling to and participating in them on their own. To avoid this problem, the center invites all participants to meet at the clinic first and then travel as a group to field-trip sites.
Sustaining This Innovation
- Track and monitor program impact: Quantitative data documenting the program's benefits will complement qualitative reports, thereby increasing sustainability. Objective evidence of a positive impact makes it easier for funders to justify continued support.
- Seek reimbursement: Securing third-party reimbursement for staff time—the major component of ongoing costs—by utilizing providers (MD, DO, PA, NP) helps ensure sustainability of the program.
- Maintain environment that engages patients: Sessions that focus on obesity and “rules” for healthy eating can erode participant enthusiasm. Conversely, session attendance will remain high if the program is fun and participants can engage with and learn from each other.
- Refine program over time: The program need not be “perfect” at the initial launch. An imperfect program can be refined over time based on staff and participant feedback.
O'Brien S, Holubkov R, Reis E. Identification, evaluation, and management of obesity in an academic primary care center. Pediatrics. 2004;114(2):e154-9. [PubMed]
Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US Adults, 1999-2008. JAMA. 2010;303(3):235-41. [PubMed]
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Service Delivery Innovation Profile
Original publication: July 20, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: June 20, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.