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With assistance from a dietitian and community health worker, residents of a low-income community are changing their living environment in an effort to reduce their diabetes risk.
For the population of East Los Angeles, which is overwhelmingly Mexican American, the risk of obesity-related conditions such as diabetes and heart disease is markedly higher than for most other populations. Research suggests that this is largely attributable to the environment, both in the neighborhood and in the home. “There is a much greater reliance on processed foods, higher rates of TV watching, and less physical activity, particularly where neighborhoods are not considered safe,” says Dr. William McCarthy, a professor at the UCLA Fielding School of Public Health. “All of these factors are associated with obesity risk.”
Most people appreciate the importance of eating well and staying fit. But a Fielding School group led by McCarthy, in partnership with researchers at USC and leaders from the East Los Angeles community, has devised a strategy that goes beyond merely advising residents about their diet and physical activity. Through the use of community health workers and a registered dietitian, the Cardiovascular Disease Risk Reduction Study works with at-risk residents on a makeover of the family living environment. A major part of these makeover sessions involves changing the “choice architecture” of the home – including moving the healthiest foods to the front of the refrigerator and pantry, confining the television to parts of the home where it’s less likely to be used during meal times, and strategically placing athletic shoes and exercise equipment so that they are accessible and in plain sight – and, thus, never out of mind.
It’s an approach that takes its cue from the field of behavioral economics, which says that people’s moment-to-moment choices are heavily influenced by what’s immediately in front of them. “Our goal is to create a home and neighborhood environment where the healthier option becomes the easy choice, and the less healthy option becomes the more difficult choice,” McCarthy explains.
When McCarthy and colleagues originally conceived the idea of including face-to-face coaching sessions in the home as part of the study, they figured it was impractical. They assumed residents would be suspicious of community health workers (known as promotores) wanting to enter their home. But members of the project’s community advisory board assured the research team that the promotores would be warmly welcomed into the study participants’ homes, and that has proved to be the case. Indeed, McCarthy says, to a greater extent than in any study he has previously directed, the community has shaped the content of the intervention.
As part of the UCLA-USC Center for Population Health and Health Disparities, the project targets healthy adults in families that have one member diagnosed with diabetes. “What can happen to one member of the family is likely to happen to another member, given their shared home environment,” McCarthy says. Over the course of more than a dozen interactions – two in the home, as well as group sessions at the Roybal Comprehensive Health Center in East Los Angeles – the promotores provide counseling on diabetes prevention through healthier eating, exercise and limited TV viewing.
To make the healthy food choice the easier choice, a registered dietitian accompanies a promotora on the home visits and, with permission from the study participants, affixes an adhesive-backed colored dot onto every food product in the refrigerator and pantry. Red dots are applied to food products that should be consumed once a month or less, such as sugary beverages and high-fat pastries. Green dots are applied to what should be “everyday” foods – fresh fruits and vegetables, minimally processed foods and whole grains. Yellow dots are applied to foods of intermediate nutritional quality – refined bread, sugar-sweetened cereals – that, if eaten more frequently than once a week, might jeopardize health. Rather than banning the red-dot foods, the dietitian recommends placing them in the back of the refrigerator or pantry, so that extra effort is required to retrieve them.
A similar tactic is used to promote physical activity. Multiple studies have concluded that the positioning of the television affects the amount of viewing, which is associated with obesity risk. The study participants are advised to keep the television out of the kitchen and bedrooms – where, in addition to promoting sedentary ways, it interferes with family conversation and homework for the children. “TV watching should be a social affair,” McCarthy says. By positioning athletic shoes where they’re conspicuous – next to the front door – they are not only easy to retrieve, but they serve as a visual reminder not to watch TV without first getting in some activity.
McCarthy notes that while many studies have focused on the effects of the neighborhood and community on diet and exercise, surprisingly little attention has been paid to the role of the home environment. “The home is where a lot of people spend many hours a day, and it’s common sense that what’s in the home is going to affect people’s lifestyle choices,” he says. “We suspect this general approach is going to become a model for communities all over the country.”
The cornerstone of the project is the peer-to-peer educational approach using promotores – members of the community who are trained to advise the families on minimizing their risk of obesity-related conditions. “I speak their language, understand their struggles and customs, and can talk to them about what we’re doing without using scientific terms,” says Rosalba Cain, one of the promotores. “I am recognized as one of them, which makes it easier to talk about nutrition in our community, how we cook, how we become busy and how we can go about finding time to educate ourselves.”
Most of the project’s staff, like Cain, has close ties to the community. The majority of the staff members are housed in the Roybal Comprehensive Health Center, located in East Los Angeles. A series of interviews and meetings held in East Los Angeles prior to the project helped to gather information on barriers to healthy eating and physical activity, as well as guidance on a culturally appropriate and East L.A.-specific intervention strategy and educational curriculum. Community volunteers helped to recruit participating families.
“It’s a lot easier to help people modify their behavior when you’re familiar with their everyday lives,” says Rudy Salinas, a longtime resident recruited to the community advisory board through his membership in the Rotary Club of East Los Angeles. “That’s the kind of input we’ve been able to provide.”
The study team has sought to earn the community members’ trust by looking out for the best interests of the residents even as it adheres to the rigors of scientific research. Study participants who aren’t randomly assigned to the experimental group receive education about cancer screening and early detection. “Offering an alternative program of helpful health information as the control condition shows them that we are serious about helping every study participant,” says Nancy Calderón, an MPH student at the Fielding School who serves as the project manager.
The researchers have impressed upon the community participants their desire to ensure that the changes made through the project are sustainable. “They are concerned about what’s going to happen after the funding is gone,” Calderón says. “So we have invited them to be agents of change. By providing appropriate education and discussing healthier lifestyle choices possible given the constraints of their neighborhood environment, we are equipping them to be the educators of the community in the future.