Content uploaded by Karen Hye-cheon Kim Yeary
Author content
All content in this area was uploaded by Karen Hye-cheon Kim Yeary on Jul 22, 2015
Content may be subject to copyright.
634
The WORD (Wholeness, Oneness, Righteousness,
Deliverance): A Faith-Based Weight-Loss
Program Utilizing a Community-Based
Participatory Research Approach
Karen Hye-cheon Kim, PhD
Laura Linnan, ScD, CHES
Marci Kramish Campbell, PhD, MPH, RD
Christine Brooks
Harold G. Koenig, MD
Christopher Wiesen, PhD
Despite multidisciplinary efforts to control the nation’s obesity epidemic, obesity has persisted as one of the
U.S.’s top public health problems, particularly among African Americans. Innovative approaches to address obe-
sity that are sensitive to the unique issues of African Americans are needed. Thus, a faith-based weight-loss inter-
vention using a community-based participatory research approach was developed, implemented, and evaluated
with a rural African American faith community. A two-group, quasi-experimental, delayed intervention design
was used, with church as the unit of assignment (treatment n=2, control n=2) and individual as the unit of
observation (treatment n=36, control n=37). Weekly small groups led by trained community members met for
8 weeks and emphasized healthy nutrition, physical activity, and faith’s connection with health. The mean
weight loss of the treatment group was 3.60 ±0.64 lbs. compared to the 0.59 ±0.59-lb loss of the control group.
Keywords: community-based participatory research; weight loss; churches; African American; obesity
Whether the information concerning obesity and overweight has been reported as
prevalence rates (Mokdad et al., 2003), annual deaths attributable to obesity (Allison,
Fontaine, Manson, Stevens, & VanItallie, 1999), years of life lost (Fontaine, Redden,
Wang, Westfall, & Allison, 2003), or disease burden (Must et al., 1999), the overall
message is clear: Obesity is a major U.S. public health problem of epidemic propor-
tions. Compared to other segments of the population, African Americans bear one of the
highest burdens of the obesity epidemic, with 31.1% of Blacks being obese compared
to 19.6% of Whites (Mokdad et al., 2003).
Karen Hye-cheon Kim, University of Arkansas for Medical Sciences, Little Rock. Laura Linnan and
Marci Kramish Campbell, University of North Carolina at Chapel Hill. Christine Brooks, Joint Orange
Chatham Communities in Action, Chapel Hill, North Carolina. Harold G. Koenig, Duke University Medical
Center, Durham, North Carolina. Christopher Wiesen, University of North Carolina at Chapel Hill.
Address correspondence to Karen Hye-cheon Kim, University of Arkansas for Medical Sciences, 4301
West Markham Street, #820, Little Rock, AR 72205-6720; phone: (501) 526-6720; e-mail: khk@uams.edu.
Health Education & Behavior, Vol. 35 (5): 634-650 (October 2008)
DOI: 10.1177/1090198106291985
© 2008 by SOPHE
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
Although African Americans bear a greater proportion of the nation’s obesity
burden, they are less likely to benefit from weight-loss programs compared to Whites
(Kumanyika, 2002). This has been attributed to social and cultural barriers (Cooper
et al., 2001; Kumanyika, 2002), including differential body-image ideals, cultural food
attitudes, fewer models for physical activity, and normative views of overweight
and obesity (Kumanyika, 2002). Thus, to successfully address disparities in obesity,
multiple sociocultural factors need to be addressed. A community-based participatory
research (CBPR) approach offers a potentially influential way to incorporate socio-
cultural factors associated with obesity into an appropriate program for African
Americans by involving them in the development and implementation of these
programs.
CBPR aims to address the complex reality of health—including racial/ethnic
disparities—by collaborating with communities (Viswanathan et al., 2004). Through
fostering dialogue and partnership to improve community health, the strengths and
insights of all partners are integrated to address ethnic/racial health disparities in a pow-
erful way (Corbie-Smith, Thomas, Williams, & Moody-Ayers, 1999). CBPR has been
used to address and understand factors surrounding various health outcomes, such as
hypertension, various cancers, and diabetes (Viswanathan et al., 2004). However, the
use of CBPR to create a weight-loss program sensitive to the unique issues of African
Americans has not been fully explored.
Historically, the Black church has been an influential force in African American
communities through which entrée, legitimacy, and credibility was granted to outsiders
(Baskin, Resnicow, & Campbell, 2001). Thus, partnership with Black churches is a
necessity for weight-loss interventions that aim to have community-wide influence
(Baskin et al., 2001). The powerful role of some Black churches in attending to the
needs of Black Americans and defining the values and norms of the communities they
serve also provides a means through which community-level sociocultural barriers can
be addressed and changed (Eng & Hatch, 1991).
Although numerous studies have successfully used Black churches as intervention
sites to change obesity-related health behaviors, such as physical activity and diet, to
prevent chronic disease (Campbell et al., 1999; Yanek, Becker, Moy, Gittelsohn, &
Koffman, 2001), few have specifically evaluated the effectiveness of weight-loss
programs. An 8-week weight-loss program among Black women resulted in an average
6 ±5-lb weight loss in the treatment group. This program consisted of group nutrition
education and behavioral counseling and activities, an exercise component, and con-
sultations with a dietitian. However, there was no control group (Kumanyika &
Charleston, 1992). In their weight-loss intervention, McNabb and colleagues reported
a weight loss of 10 ±10.28 pounds compared to a 1.9 ±4.25 gain in the control group
(McNabb, Quinn, Kerver, Cook, & Karrison, 1997). Their 14-week intervention con-
sisted of weekly small groups addressing behavioral and sociocultural issues related to
weight co-led by trained lay facilitators and health professionals. These church-based
weight-loss studies have shown promising results but are few in number. Furthermore,
they were conducted in urban settings and included only female participants; whether
church-based weight-loss programs are successful in rural settings with female and
male participants is not clear. Although these programs incorporated African American
cultural components, elements of the unique faith culture were not incorporated. Thus,
this article will describe a faith-based weight-loss intervention for a rural African
American community using a CBPR approach.
Kim et al. / Faith-Based Weight Loss 635
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
636 Health Education & Behavior (October 2008)
METHOD
Community Collaboration
From a 13-year partnership between the University of North Carolina at Chapel Hill
(UNC-CH) and various community organizations across North Carolina, a research
team was formed, consisting of investigators and a rural African American faith com-
munity. At a community coalition meeting, the investigator met a community organizer
from the faith community. The community coalition met monthly in the community and
consisted of various community leaders representing nonprofit service organizations
and faith communities. From this meeting, mutual interests to improve the health of the
rural faith community were identified, and a partnership began. The research team, also
known as the Wholeness, Oneness, Righteousness, Deliverance (WORD) Leadership
Team, consisted of pastors, church board representatives, and congregation members of
three rural African American churches in one city of central North Carolina in addition
to representatives from nonprofit community organizations and investigators from
UNC-CH. The churches were identified through the community organizer’s connection
and identification of them as the main churches serving this particular rural community.
All three churches were Black Protestant churches (Steensland et al., 2000) and repre-
sented AME Zion, Holiness, and Pentecostal denominations. All community members
on the WORD Leadership Team were pastors or members of the three churches.
After obtaining approval from the university’s Institutional Review Board, a com-
munity health-assessment survey was designed, distributed, and evaluated to identify
community assets and needs. The health assessment indicated that body weight was the
health issue of most interest to the community. Focus groups were then conducted to
inform the design of the intervention. In designing the intervention, the WORD
Leadership Team developed, implemented, and evaluated information from the health-
assessment survey and focus groups, with each partner contributing their expertise in
constructing the intervention. The intervention was then implemented through preex-
isting networks identified and accessed by the WORD Leadership Team. This article
will report the focus group and intervention components from this collaboration.
Focus Groups
A trained facilitator conducted five focus groups (one pilot, two groups with men,
and two groups with women) to inform intervention development, particularly how
faith informed perceptions of weight and related behaviors. Focus-group participants
were recruited from the participating churches through the WORD Leadership Team’s
extensive networks. Announcements were made at participating churches, sign-up
sheets were distributed after church services, and potential participants were informed
through word of mouth. Selection criteria for those eligible included being (a) an
African American, (b) an adult aged 18 or older, (c) a member of a church or a partic-
ipant in church activities, and (d) a resident in a Southern rural community. Focus
groups with women ranged from 10 to 13 participants per group, whereas focus groups
with men ranged from 5 to 7 participants per group. The focus-group guide was devel-
oped by the WORD Leadership Team and included questions about participants’ per-
ceptions, beliefs, and attitudes regarding weight, perceived barriers and facilitators of
weight loss, and preferences concerning intervention components. There were probes
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
about the role of faith throughout the focus-group guide. The focus-group guide was
pilot-tested and the questions refined. Data from the focus groups were used to deter-
mine healthy-weight topics of interest, barriers and facilitators of weight loss, how the
sociocultural (e.g., faith, social support) environment was related to healthy weight, and
logistical issues related to the intervention.
Intervention—Overview
The intervention was an 8-week, behaviorally focused weight-loss program known
as the WORD (Wholeness, Oneness, Righteousness, Deliverance), in which partici-
pants met once a week for 2 hours in WORD groups (8 to 10 people) led by a pair of
trained community members known as WORD Leaders (or lay health leaders). WORD
Leaders were members of a participating church and were assigned to facilitate WORD
groups that consisted of participants from their respective churches. The study design
was a two-group, pretest-posttest, quasi-experimental delayed treatment design, where
church was the unit of assignment and individuals within the churches, the unit of
observation. The previous church-based weight-loss literature, information from the
focus groups, and insider knowledge from the WORD Leadership Team were used to
inform the intervention.
Intervention—WORD Leaders
WORD Leaders served as lay health advisors by facilitating WORD groups and by
supporting WORD group members through engaging preexisting social networks in
participating churches. The lay health advisor model (Eng & Hatch, 1991; Jackson &
Parks, 1997) was chosen primarily because of its emphasis on social networks. Black
churches are characterized by strong social networks within the church and between the
church and the broader community (Eng & Hatch, 1991). Thus, interventions built on
these networks promote cultural appropriateness and sustainability (Eng & Hatch,
1991; Kumanyika & Charleston, 1992). The WORD Leadership team confirmed that
the lay health advisor model would work very well in their community.
Standard protocol for recruiting lay health leaders was used to recruit WORD Leaders
(Jackson & Parks, 1997). The networks of WORD Leadership team members were used
to recruit 10 WORD Leaders. WORD Leaders were recruited from the three participat-
ing churches and qualifications included (a) an association with a participating church
through membership or participation in a church activity, (b) adult aged 18 or older, and
(c) interest in health.
WORD Leaders participated in four training sessions (2.5 hours per session) for a
total of 10 hours of intensive training. The sessions were delivered during the course
of 4 weeks. WORD Leaders received training in specific content areas related to
healthy weight, such as calorie counting, low-fat eating, physical activity, serving
sizes, portion control, cooking, and eating out. Behavioral strategies for weight loss,
social support theory, and the stages-of-change transtheoretical model were also
included in the training. Preexisting weight-loss materials and results from the focus
groups informed training content and material and reflected the diverse skills of the
WORD Leadership team, which included insider community knowledge and obesity
expertise. Twelve WORD Leaders completed the training and were certified to facili-
tate WORD groups.
Kim et al. / Faith-Based Weight Loss 637
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
638 Health Education & Behavior (October 2008)
Intervention—WORD Group Participant Recruitment
WORD Leaders and the WORD Leadership Team made announcements at church
events, distributed sign-up sheets at church, and posted flyers and posters in churches
to recruit WORD group participants. Information about the intervention was also spread
through word of mouth. Recruitment of WORD group participants began approxi-
mately 1 month before the intervention. Two weeks before the intervention, a WORD
Health Day open to the whole community was held at a participating church to further
advertise the program. The WORD Health Day consisted of vendors from different
community-health representatives (i.e., local health department, cooperative extension),
activities, and speakers. All adults aged 18 or older were allowed to participate in
WORD groups. Selection criteria for WORD group participants eligible for program
evaluation included (a) association with a participating church through membership or
participation in a church activity, (b) adult age (18 or older), and (c) African American
race. Potential treatment participants were asked to write down their name and phone
number on sign-up sheets if they were interested in participating in a WORD group.
Potential participants from churches in the community were then contacted by WORD
Leaders or by WORD Leadership Team members to confirm their enrollment.
A total of 73 individuals representing four churches enrolled in the WORD program,
with two churches (36 participants) in the treatment group and two (37 participants) in
the control group. Participation rates of church attendees were approximately 42% in
treatment churches and 31% in control churches.
Intervention—WORD Groups
The intervention was theory based and used concepts from stages-of-change trans-
theoretical model (Prochaska, Redding, & Evers, 2003), social cognitive theory
(Baranowski, Perry, & Parcel, 2003), and social support models (Heaney & Israel,
2002). Theory was interwoven in the learning modules for each week. For example,
each learning module asked participants what stage they were in for a particular behav-
ior change (i.e., increasing physical activity), how their barriers to move to the next
stage of change could be overcome, and how support from group members, family, or
friends could help facilitate the behavior change process. In addition to a learning mod-
ule (30 minutes), WORD group meetings consisted of measurements and mingling (10
minutes), a review of the previous week’s topic (10 minutes), physical activity with an
exercise tape (15 minutes), a Bible study about health (15 minutes), and prayer (5 min-
utes). Learning-module topics included calories, low fat, physical activity, fruits and
vegetables, portion sizes, eating out, and healthy cooking. WORD Leaders followed a
detailed training manual organized by topic in facilitating WORD groups.
Control
Of the two churches in the control group, one was recruited with the three original
participating churches representing the community. This church received the interven-
tion 1 month after the intervention arm of the study was completed. The second church
was recruited from another community at a later time to have a comparable number of
treatment and control churches and participants. This church was similar to the others
in denomination and ethnicity. This second control church enrolled in the study after the
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
WORD Leaders had been recruited and trained, thus instead of receiving the interven-
tion, participants from this control church were mailed a health magazine once a month
for 3 months after the intervention arm of the study was completed. The health maga-
zine was designed specifically for the WORD and included content that was included
in the intervention. Health magazine contents included educational topics about physi-
cal activity, low-fat foods, portion size, and eating out in addition to Bible study and
goal-setting guides.
Data Collection and Methods
Anthropometrics. Anthropometric measurements were collected from all participants
at baseline and follow-up. Height was measured using a stadiometer. Weight was assessed
with a Tanita scale (Jebb, Cole, Doman, Murgatroyd, & Prentice, 2000), and waist and
hip-circumferences were measured using a measuring tape. Body mass index (BMI) was
calculated from dividing weight in kg by height in meters squared (Dalton, 1997).
Health-Behavior Variables. Self-administered questionnaires were also delivered
at baseline and follow-up to all participants. Physical activity was assessed through a
16-item checklist that measured frequency and duration of different types of activity.
From the checklist, metabolic equivalent task (MET) hours per week were calculated
(Campbell et al., 2004). Percentage of calories from fat was assessed through the
National Cancer Institute Quick Food Scan based on frequency of intake of 16 foods
(Thompson et al., 1998). Fruit and vegetable intake was measured by the National
Cancer Institute’s Fruit and Vegetable Scanner (Thompson et al., 2004). Gender, eth-
nicity, age, education, employment, martial status, and income were also assessed.
Interviews
WORD Leaders from the intervention arm of the study were interviewed to assess
their perceptions of program satisfaction and efficacy. Questions included changes they
observed their members make as a result of the project, why they thought members
made those changes, personal changes as a result of the project, what they liked most
and least about the program curriculum, and the possibility of sustainability in their
church. Each interview lasted approximately 60 minutes.
ANALYSES
Focus Groups
Focus-group discussions were transcribed verbatim, checked for accuracy, and
entered into a software program for the management of text data (i.e., NVivo 2.0). An
iterative process based on grounded theory was used in a more detailed analysis of the
text (Glaser & Strauss, 1967). Emerging themes and codes from initial analyses were
reduced to its essential points, and then the core meaning of each reduction was inter-
preted. This process was iterative, in which rereadings of the text were conducted to
refine codes, data reductions, and data interpretations. Coding decisions and emergent
findings were discussed until an agreement regarding common themes and codes was
Kim et al. / Faith-Based Weight Loss 639
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
reached (Edstrom & Devine, 2001). To ensure validity of inferences, findings were
discussed with the WORD Leadership Team; any disagreements were resolved through
discussion. Data analyses included (a) identification of common themes, (b) develop-
ment of categories of themes, (c) identifying convergence and deviation across groups,
and (d) incorporation of findings in intervention development.
Intervention
Frequencies were examined for all variables, and ttests were conducted to examine
significant baseline differences in variables between the treatment and control. Given
prior literature (Ball, Crawford, Ireland, & Hodge, 2003) and the significant differences
between baseline BMI, education, and income between treatment and control churches,
these variables were controlled for in subsequent analyses. Multiple regressions were
conducted using PROC MIXED from SAS 9.1 to examine significant differences
between treatment and control in anthropometrics and health-behavior variables from
baseline to 8-week follow-up. Intracluster correlation (ICC) because of nesting of par-
ticipants within churches was accounted for in all analyses. The mean change of each
outcome variable (anthropometrics and health behaviors) from baseline to 8-week
follow-up was regressed against treatment assignment (treatment or control). Then a
second series of multiple regressions were conducted with baseline BMI, education,
and age in the model to account for baseline differences between treatment and control.
Differences in outcome measures between treatment and control, within treatment, and
within control over time were determined from the analyses. An intent-to-treat analysis
was also done, in which the average of the percentage change of body weight was
imputed for body-weight data missing at follow-up. Results from the intent-to-treat
analysis did not differ significantly from results computed from analyses in which
intent to treat was not done; thus, we report results for which the data was not imputed.
Interviews
Themes and codes were created from the substantive content of the transcripts, and
an iterative process based on grounded theory was used in a more detailed analysis of
the text (Glaser & Strauss, 1967).
RESULTS
Focus Groups
A total of 35 individuals participated in four focus groups; 66% of the participants
were women. The mean age was 56 ±15.8, a little less than half (41%) were married,
76% had a high school education or less, and the majority was employed (58%). On
average, the sample was obese (BMI =34.2 ±8.0), and reported fair to good health
(68%) on a scale from poor to excellent. The majority reported dieting (68%) and being
successful at losing weight from dieting (57%). However, only 27% reported being very
sure that they could lose weight. Regarding health behaviors’ role in weight loss, a
majority agreed that eating healthier food (more fruits and vegetables and fewer high-
fat foods) would help control their weight (74%) along with exercise (64%). Almost all
reported that taking care of their body as “God’s holy temple” meant eating healthier
640 Health Education & Behavior (October 2008)
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
Kim et al. / Faith-Based Weight Loss 641
(91%) and being more physically active (82%). When asked who would be most help-
ful to them in trying to lose weight, family members ranked first (30%), doctor or health
care provider second (23%), followed by spouse/partner (20%), close friends (10%),
church friends/pastor (10%), other (3%), and no one (3%).
Both men and women mentioned the role of others in promoting or discouraging
healthy weight and related health-behavior change. In the context of a health program,
the role of others (social support, social pressure, competition) was expressed positively
for health behavior change.
If you know that every week when we come out here, we’re gonna have to weigh. You know
that you don’t want to be the one that comes out here with no success, you know ...even
if I just lost a half pound...you know, it’s better than going out there facing every-
body....I know when I get ready to lose weight, I always like have a partner, and that way
we encourage each other and, you know, call up, when you get to the point you feel like
what’s the use, then you can say encouraging words to each other.—Female, age 51
[It would be good to have a] game day where they have . . . men running against each
other...a race like they get out there and they run....Who can run the longest? Or who
finishes a mile the fastest or something like that. Just to keep them competitive. It would
help me and [my friend] because [he] would get out there, and I would run beside him and,
you know, [if] he catch up to me, I’ll keep running, and he’s gonna say, “Well, I’m not
gonna let [him] beat me tomorrow. You know what I’m saying. So he’s gonna try to get out
there and beat me every time. And get out there, it’ll help me. It’ll help him too. He’ll get
fast as we’ll get stronger.—Male, age 20
Well, [a program] would pretty much encourage me, encourage someone else, especially
when I reach my goal. And I reach my goal and I see that someone else is, maybe, strug-
gling with the same situation that I was in. Come and go with me...in a program that
would put you on the right track or help you on the right road or, once I achieve my goal,
that would give enough thrill and enthusiasm to say, “Hey, come on, let’s go up to the
church and...we do this together.—Male, age 45
In contrast, the role of others was expressed as a barrier for healthy weight in a “real-
world” setting, outside of an organized health program.
And sometimes it’s who you are around. If I’m by myself, I don’t tend to eat as much. But
when I’m socializing with other people, I eat just because I see everyone else eat.—
Female, age 46
Peer pressure. Our first battle is that. If, say, if the four of us go out to eat and I’m the
vegetarian, and all of them come sit at the table, and they got fried chicken, and they got
all their meats and none, for nothing about my veggies, my, just vegetables. And the first
time either might say, “Man, you better get up from here—nobody want that food you’re
eating. You know, eat something that’s good for you.” And it may, if you’re not strong
enough, you gonna say, “Well, hey, maybe I’ll try a piece.” But, no, you shouldn’t
because that’s not part of your lifestyle. So you all have enough faith and [are] strong
enough to be able to say, “Well, look, you eat what you want and I’m gonna eat what I
want.”—Male, age 45
Thus, the role of others in obtaining and maintaining a healthy weight was context
specific, whereby social support was positive when attending a health program and neg-
ative outside of a program setting. Besides the positive and negative roles of others, lack
of time, inconvenience, and lack of knowledge about healthy cooking were the most
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
642 Health Education & Behavior (October 2008)
frequently mentioned barriers for healthy weight. Women in particular expressed how
“unhealthy food” and overeating filled emotional needs.
I just rather be happy than hungry. That’s just the way I feel. I mean, I have people, I
have clients that diet, and they’re just miserable. But they [are] hungry. I mean, you
know, what kind of life is it to be hungry and unhappy? I rather eat and be happy.
—Female, age 38
Men often talked about the role of willpower and goal setting to maintain a healthy
weight; many mentioned the importance of “push[ing] away from the table.” Men also
talked about the importance of community resources (i.e., access to affordable gym
equipment, transportation) in physical-activity facilitation. Some men said that their
knowledge of weight’s relationships with health problems brought them out of denial
about being overweight, and knowledge of nutrition and physical activity enabled them
to work toward having a healthy weight.
For both men and women, religious and spiritual beliefs were intertwined with per-
ceptions of weight control. Food was expressed as temptation, and eating too much con-
veyed greed.
It’d just be like, um, [having a] cookie here now. I know that I wasn’t supposed to eat it,
but I took a tip of it and lay it back down. And I do eat potato chips, but I didn’t eat them.
You see, there is temptation. I didn’t eat. I didn’t eat it.”—Female, age 77
Female participant, age 66: I think eating is not really the problem; it’s knowing how to eat
and when to eat because we got to eat, and I think we can eat smaller servings instead of
just eating a whole lot. Most the time we eat, go back and get another serving, go back and
get another. But if we just eat a smaller serving, that helps us a whole lot.
Facilitator: Why do we keep on going back?
Female participant, age 66: Greed. We’re greedy. I’m not gonna waste. I’m gonna eat it.
Facilitator: Let me ask this: [Do] most of you know about portion sizes and measurements?
Female participant, age 37: Do we know about them or do we follow them? (group laughs)
Facilitator:You say that you know, but you don’t do. What is it that makes you not do?
Female participant, age 57: We know. We just don’t do.
Female participant,age 57: Greed. Like in one diet, you [eat] half a cup of vanilla ice cream:
What’s the point, you know?
The participants expressed that to overcome temptation, greed, and other barriers to
healthy weight, one needed to have faith in God.
But that’s where the faith comes in to help us with that temptation.—Female, age 51
If you have faith serving the Lord, I think that if you’re willing, really looking for a healthy
person that you will try to keep up...and you wouldn’t . . . just flop down and just eat
anything.”—Male, age 44
Faith, it plays the biggest part of everything. If you got faith, you can overcome any obsta-
cles. As far as your health goes...[if] a person puts God first, [then] anything that he do,
he can succeed.”—Male, age 46
Faith in God gave the believer willpower and faith in oneself to make healthy
changes. To obtain faith, one needed to practice spiritual disciplines, such as prayer and
reading the Bible. The Word of God (the Bible) was viewed as spiritual food to
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
empower one against physical food and the temptations associated with fleshly
appetites and desires.
You can’t really have that much faith in God if you don’t get into the Word and read and
know what it’s all about. If you read, you turn your plate down and fast, do your health and
everything, God will grant these things to you. And you got to learn how to give it to
Jesus—to turn it over to him.—Female, age 53
And His Word is just like ...food...you got to read His Word...His Word will give
you the faith to control yourself and govern yourself to what you suppose to do, because
if you don’t believe in what He says, you can’t believe in yourself.—Male, age 45
In Christianity, we like to meditate on the Word of God. We learn to, in his words it teaches
how to maintain our weight, what to eat. There’s a lot of food that we shouldn’t eat that
we do eat. And we come to meditation, most of us do.—Male, age 46
Results from focus groups were used to inform the structure of the intervention.
A small-group format was implemented to facilitate social support, as was a lay-health-
advisor model to promote healthy behaviors in congregations and communities outside
of the “health program” context. Data from the focus groups were also essential in
developing the intervention’s curriculum. Exercises concerning the link between emo-
tions and foods were included, and one session was devoted to healthy cooking. The
connection between faith and health was integrated throughout the curriculum via the
inclusion of a health Bible study in every session, which facilitated discussion of how
to apply knowledge of positive-health-behavior change through increasing faith in God.
Intervention Results
Participant Characteristics
Participants in the treatment and control groups were well matched by gender,
race/ethnicity, employment, income, and marital status (see Table 1). However, baseline
BMI, education, and age significantly differed between the treatment and control
groups. The treatment group was older, had a higher average baseline BMI, and a lower
proportion of those completing a bachelor’s education or more. Thus, these variables
were controlled for in subsequent analyses.
There was a total of 12 dropouts, so 61 participants were available for analysis (treatment
n=27, control n=34). Dropouts were more likely to be female and reported family emer-
gencies, scheduling conflicts, and unexpected job demands as reasons for dropping out of the
program. Dropouts did not differ by intervention group. No adverse effects were reported.
Of the 73 intervention participants, 52 were women (treatment n=25, control n=
27). The sample was 100% African American. The mean (SD) age was 54.1 ±13.3
years (range 23-83). The majority of those in the treatment group had a high school edu-
cation or less, whereas slightly more than half of the control-group participants reported
having at least a bachelor’s degree. Most were employed and married. Forty-one per-
cent of the treatment group reported an income of less than $20,000 compared to 13%
of the control group. On average, participants were obese, with treatment participants
having an average BMI of 39.8 (7.9) and control participants having an average BMI of
34.7 (8.4; World Health Organization, 1998). Regarding health behaviors, participants
engaged in 205.4 ±169.7 METs of physical activity, consumed 48.9% ±12.8% of their
calories from fat, and ate 3.5 ±2.6 servings of fruits and vegetables a day.
Kim et al. / Faith-Based Weight Loss 643
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
644 Health Education & Behavior (October 2008)
Anthropometrics
From baseline to 8-week follow-up, the treatment group, on average, lost 3.0 (0.87)
more pounds compared to the control group (see Table 2), significant at p=.001. There
was also a significant difference in hip circumference change, with the treatment group,
on average, having a 2.5 (1.1) cm (p=.04) greater decrease in hip circumference than
the control group. The mean change of weight (–3.6 [0.64] pounds) and hip circumfer-
ence (–3.6 [0.84] cm), in addition to waist circumference (–4.4 [1.1] cm), was also
highly significant within the treatment group (p<.01). Controlling for baseline BMI,
education, and age decreased the magnitude of the difference between the treatment’s
mean weight loss and the control’s mean weight loss (treatment lost 2.8 ±0.89 more
pounds than the control), but the weight-loss results remained highly significant (p=
.003). Controlling for baseline BMI, education, and age also decreased the magnitude
and significance of the difference between the treatment group’s mean hip circumfer-
ence and the control group’s mean hip circumference over time (–3.4 [0.86] cm; p=
.05). However, the mean change in weight (–3.5 [0.65] pounds), waist circumference
(–3.7 [1.1] cm), and hip circumference (–3.4 [0.86] cm) within treatment group
Table 1. Characteristics of WORD Participants at Baseline
Characteristic Treatment Control Total pValue
Demographic measures
Gender (women) 69% 73% 71% .739
Ethnicity (African American) 100% 100% 100% .293
Age 57.7 (11.5) 50.9 (14.2) 54.1 (13.3) .034
Education .0001
High school or less 64% 33% 46%
Some college 33% 14% 25%
Bachelor or more 3% 53% 29%
Employment (employed) 64% 76% 70% .273
Marital status (married) 70% 51% 60% .118
Income .076
<$20,000 41% 13% 26%
$20,000-$29,000 29% 20% 19%
$30,000-$49,000 26% 23% 25%
≥$50,000 15% 43% 30%
Anthropometric measures
BMI (kg/m2
2) 39.8 (7.9) 34.7 (8.4) 37.2 (8.5) .009
WHR 0.89 (0.08) 0.86 (0.09) 0.87 (0.09) .092
Waist girth (cm) 113.4 (14.5) 101.3 (14.7) 107.3 (15.7) .001
Hip girth (cm) 127.5 (14.9) 118.6 (16.7) 123.0 (16.4) .019
Health behavior measures
Physical activity (METs)
Total 163.7 (147.3) 245.8 (181.9) 209.4 (168.4) .040
Moderately vigorous recreation 53.6 (69.8) 98.8 (107.0) 76.8 (93.0) .040
Calories from fat (%) 47.8 (10.8) 49.9 (14.7) 48.9 (12.8) .627
Fruit/vegetable intake (servings) 3.6 (2.3) 3.4 (3.0) 3.5 (2.6) .802
NOTE: Values are expressed as mean ±standard deviation or percentage (%). WORD =Wholeness,
Oneness, Righteousness, Deliverance; WHR =waist-hip ratio; MET =metabolic equivalent task.
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
Kim et al. / Faith-Based Weight Loss 645
remained significant at the p<.01 level after controlling for baseline BMI, education,
and age (see Table 3).
Health Behaviors
Compared to control participants, treatment participants reported 6.2 (2.2) METs
greater recreational physical activity from baseline to follow-up (p=.01). There was
also a significant change in mean recreational physical activity over time within treat-
ment group (3.5 [1.6] METs, p<.05). These relationships remained significant at the
p<.05 level after controlling for selected demographic characteristics (i.e., baseline
BMI, education, and age), with treatment participants reporting 6.4 (2.2) greater METs
of recreational physical activity compared to the control group over time and 3.8 (1.7)
greater METs of recreational physical activity within treatment group over time.
Interview Results
WORD Leaders reported that the project was a success. One WORD Leader said,
“People was sincere in what they were hearing...people think a lot about their health
now . . . the program opens up eyes to these kinds of things.” Another said, “Overall, it
was a good program. We got a lot out of it. It was one of the best programs we had.
People who never participated, participated in this one.” Desire to improve health, feel-
ing better, and the program’s faith orientation were reasons that WORD Leaders
believed their group members made positive changes in health.
Since the program was based on the Word, it helped—it was more powerful. The people
of God see the necessity of doing better to work for the Lord...faith that God would help
them and that the body is as important as the soul to God.
Table 2. Effect of the WORD on Anthropometric Measures and Health Behaviors
Control-
Treatment Control Treatment
pValue for
Mean Mean Mean Between-Group
Change (SE) Change (SE) Change (SE) Comparison
Anthropometrics
Weight (lbs) –3.6 (0.64)** –0.59 (0.59) –3.0 (0.87) .001
Waist (cm) –4.4 (1.1)** –1.8 (1.0) –2.6 (1.5) .08
Hip (cm) –3.6 (0.84)** –1.1 (0.78) –2.5 (1.1) .04
Health behaviors
Total physical activity 1.5 (2.7) –3.1 (2.4) 4.6 (3.6) .21
(METs)
Recreational physical 3.5 (1.6)* –2.8 (1.4) 6.2 (2.2) .01
activity (METs)
Calories from fat (%) –6.6 (4.3) –3.0 (3.9) –3.6 (5.8) .54
Fruit and vegetable servings 0.01 (0.59) –0.31 (0.52) 0.31 (0.79) .69
NOTE: Values represent mean changes (standard errors); each regression model tested the effect of
the treatment over time on anthropometrics and health behaviors. WORD =Wholeness, Oneness,
Righteousness, Deliverance; MET =metabolic equivalent task.
*p<.05 difference from baseline within group. **p<.01 difference from baseline within group.
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
646 Health Education & Behavior (October 2008)
WORD Leaders also reported making personal changes in their own health habits,
particularly in the area of nutrition. They attributed these personal changes to the train-
ing that they received to deliver the curriculum: “Some of the things we went over made
me take a look at myself...made me feel more stronger in faith, understanding, believ-
ing... in helping counsel people about overweight.” Regarding the curriculum, WORD
Leaders commented positively on the clear organization and presentation of materials
and the spiritual components of prayers and Bible studies. For improvement, WORD
Leaders recommended less text, more hands-on activities, and more examples concern-
ing application. All WORD Leaders interviewed said that they anticipated that the
program would continue if they “talked it up” and encouraged others to become
involved; they said that the exercise- and health-oriented Bible study components of the
study would be the most likely aspects of the project to continue.
DISCUSSION
The WORD intervention resulted in significant weight loss (3.00 lbs ±0.87) from
baseline to 8-week follow-up in treatment participants compared to control participants.
Although this weight loss was significant, it was relatively modest compared to other
African American church-based weight-loss interventions. McNabb et al. (1997)
reported a 10-lb weight loss in their treatment group compared to a 2-lb gain in the con-
trol after 14 weeks. Kumanyika and Charleston (1992) reported a weight loss of 6 lbs
in their treatment group after 8 weeks; there was no control group in their study design.
In both studies, participants were African American women, and the intervention
Table 3. Effect of the WORD on Anthropometric Measures and Health Behaviors Controlling
for Baseline BMI, Education, and Age
Control-
Treatment Control Treatment
pValue for
Mean Mean Mean Between-Group
Change (SE) Change (SE) Change (SE) Comparison
Anthropometrics
Weight (lbs) –3.5 (0.65)** –0.72 (0.69) –2.8 (0.89) .003
Waist (cm) –3.7 (1.1)** –1.9 (0.97) –1.9 (1.4) .20
Hip (cm) –3.4 (0.86)** –1.1 (0.80) –2.3 (1.2) .05
Health behavior
Total physical activity 2.3 (2.7) –3.2 (2.3) 5.5 (3.6) .13
(METs)
Recreational physical 3.8 (1.7)* –2.6 (1.4) 6.4 (2.2) .01
activity (METs)
Calories from fat (%) –5.9 (4.2) –1.4 (3.7) 4.5 (5.5) .43
Fruit and vegetable 0.10 (0.60) –0.42 (0.52) –0.52 (0.79) .51
servings
NOTE: Values represent mean changes (standard errors); each regression model tested the effect
of the treatment over time on anthropometrics and health behaviors and controlled for baseline
BMI, education, and age. WORD = Wholeness, Oneness, Righteousness, Deliverance; MET =
metabolic equivalent task.
*p<.05 difference from baseline within group. **p<.01 difference from baseline within group.
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
consisted of weekly small-group meetings led by either a health professional alone or
in conjunction with a lay facilitator.
There may be several explanations for why the WORD produced a lower average
weight loss than previous church-based interventions for African Americans, but the
most critical factor is likely the short, 8-week time frame of the program. Previous
weight-loss interventions have reported maximum weight loss at 24 weeks (6 months;
Avenell et al., 2004a, 2004b). Thus, the weight loss produced in an 8-week time span of
the WORD could have reflected a small proportion of the program’s potential effective-
ness. Moreover, the WORD was a minimal-intensity weight-loss intervention that was
delivered solely by lay health advisors (WORD Leaders). Other weight-loss interven-
tions have been delivered by health professionals or by lay facilitators in conjunction
with health professionals (Kumanyika & Charleston, 1992; McNabb et al., 1997).
Therefore, both intervention intensity and duration was less, yet a medium intervention
effect was achieved. Trade-offs between intensity, duration, and reach must be made if
weight-loss programs are to be disseminated widely beyond the clinic setting. Finding
the right combination that ensures positive weight-loss outcomes yet achieves high par-
ticipation and sustainability is critically important. Finally, a 2- to 3-lb weight-loss dif-
ference between intervention and control participants with this minimal intervention is
quite promising and, on a population basis, would have important public health benefits.
What distinguishes the WORD from previous African American, church-based
weight-loss interventions is the incorporation of the church’s faith culture in the
program, the delivery of the intervention by lay health advisors alone, and its CBPR
approach. Although the specific tailoring of the program by the community’s religious
faith was not tested, program evaluations by WORD Leaders identified the incorpora-
tion of faith’s relationship with health as a key reason for the program’s positive recep-
tion and effectiveness. The use of the lay-health-advisor model enhanced the possibility
of program sustainability through building on natural social networks within the faith
community in an economical way. The CBPR approach also oriented program devel-
opment, with program feasibility and sustainability as an important focus.
Besides contributing to program sustainability, using a CBPR approach facilitated
the organization of community representatives to promote health. From the program,
preexisting networks were strengthened and new ties were formed. In-depth interviews
with WORD Leadership Team members revealed evidence of greater community cohe-
siveness, particularly between churches that had not interacted with each other in a con-
siderable way before: “A part of us were from different denominations and didn’t get a
chance to see each other...[so] we got a chance to expound on the spiritual side and
we were giving each other respect.” Perhaps this increased sense of community cohe-
siveness will lead to greater community organizing in the future. Equipping community
members to be WORD Leaders through training may have also increased community
capacity. In in-depth interviews, WORD Leaders reported that they felt more confident
in themselves, and better able to help others: “[The program helped me] to be a better
leader, community person, and Christian.”
There are several limitations to the study. Although the study design adequately
tested the program’s effects on selected outcomes by including a control group and con-
trolling for baseline differences between treatment and control in analyses, the lack of
randomization and subsequent differences in baseline characteristics between groups
leaves open the possibility that treatment effects occurred because of demographic
characteristics. However, these were controlled for in the analysis, which minimizes
this limitation. The purposive sampling in one rural,African American faith community
Kim et al. / Faith-Based Weight Loss 647
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
also limits the external validity of this study; these results may be unique to this partic-
ular community. Given these limitations, however, this study offers promising prelimi-
nary results that a faith-based weight-loss program using a CBPR approach is effective
in a rural, African American faith community. Future CBPR-based weight-loss studies
engaging a larger and more representative sample with a longer timeframe need to be
conducted to test the WORD’s full potential.
Implications for Practice
The WORD is a pilot study that gives some insights into what may be achieved with
a brief, 8-week, culturally relevant, faith-based weight-loss program. Future weight-
loss programs may benefit from coordinating intervention activities by working collab-
oratively with church members to plan and deliver these programs. In our partnership,
we engaged partners to bring forth each partner’s unique expertise. We found that our
partners were interested in serving as lay health advisors to promote healthy weight in
a rural, faith-based setting. The program’s faith-based foundation also promoted
program acceptance and perceived effectiveness. Faith-based versus faith-placed inter-
ventions have been debated recently (DeHaven, Hunter, Wilder, Walton, & Berry,
2004). “Faith-placed” sees the church as a setting where the program is adapted to fit
into, whereas “faith-based” sees the church as an organic entity with cultural norms and
social structures from which health programs can be built and integrated. Future inter-
ventions in churches may benefit from taking a faith-based approach that embraces how
faith informs health-related perceptions, beliefs, and behaviors and then explicitly
applies this understanding in developing and implementing interventions.
References
Allison, D. B., Fontaine, K. R., Manson, J. E., Stevens, J., & VanItallie, T. B. (1999). Annual
deaths attributable to obesity in the United States. Journal of the American Medical
Association, 282(16), 1530-1538.
Avenell, A., Brown,T. J., McGee, M. A., Campbell, M. K., Grant, A. M., Broom, J., et al. (2004a).
What are the long-term benefits of weight reducing diets in adults? A systematic review of ran-
domized controlled trials. Journal of Human Nutrition and Dietetics, 17(4), 317-335.
Avenell, A., Brown, T. J., McGee, M. A., Campbell, M. K., Grant, A. M., Broom, J., et al.
(2004b). What interventions should we add to weight reducing diets in adults with obesity?
A systematic review of randomized controlled trials of adding drug therapy, exercise, behav-
iour therapy or combinations of these interventions. Journal of Human Nutrition and
Dietetics, 17(4), 293-316.
Ball, K., Crawford, D., Ireland, P., & Hodge, A. (2003). Patterns and demographic predictors of
5-year weight change in a multi-ethnic cohort of men and women in Australia. Public Health
Nutrition, 6(3), 269-281.
Baranowski, T., Perry, C. L., & Parcel, G. S. (2003). How individuals, environments, and health
behavior interact: Social cognitive theory. In F. M. Lewis (Ed.), Health behavior and health
education: Theory, research, and practice (pp. 165-184). San Francisco: Jossey-Bass.
Baskin, M. L., Resnicow, K., & Campbell, M. K. (2001). Conducting health interventions in
Black churches: A model for building effective partnerships. Ethnicity and Disease, 11(4),
823-833.
Campbell, M. K., Demark-Wahnefried, W., Symons, M., Kalsbeek, W. D., Dodds, J., Cowan, A.,
et al. (1999). Fruit and vegetable consumption and prevention of cancer: The Black Churches
United for Better Health project. American Journal of Public Health, 89(9), 1390-1396.
648 Health Education & Behavior (October 2008)
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
Kim et al. / Faith-Based Weight Loss 649
Campbell, M. K., James, A., Hudson, M. A., Carr, C., Jackson, E., Oakes, V., et al. (2004).
Improving multiple behaviors for colorectal cancer prevention among African American
church members. Health Psychology, 23(5), 492-502.
Cooper, R. S., Kennelly, J. F., Durazo-Arvizu, R., Oh, H. J., Kaplan, G., & Lynch, J. (2001).
Relationship between premature mortality and socioeconomic factors in Black and White
populations of U.S. metropolitan areas. Public Health Reports, 116(5), 464-473.
Corbie-Smith, G., Thomas, S. B., Williams, M. V., & Moody-Ayers, S. (1999). Attitudes and
beliefs of African Americans toward participation in medical research. Journal of General
Internal Medicine, 14(9), 537-546.
Dalton, S. (1997). Body weight terminology, definitions, and measurement. In S. Dalton (Ed.),
Overweight and weight management: The health professional’s guide to understanding and
practice (pp. 1-38). Gaithersburg, MD: Aspen.
DeHaven, M. J., Hunter, I. B., Wilder, L., Walton, J. W., & Berry, J. (2004). Health programs in
faith-based organizations: Are they effective? American Journal of Public Health, 94(6),
1030-1036.
Edstrom, K. M., & Devine, C. M. (2001). Consistency in women’s orientations to food and nutri-
tion in midlife and older age: A 10-year qualitative follow-up. Journal of Nutrition Education,
33(4), 215-223.
Eng, E., & Hatch, J. W. (1991). Networking between Black churches and agencies: The lay health
advisor model. Journal of Prevention in Human Services, 10(1), 123-146.
Fontaine, K. R., Redden, D. T., Wang, C., Westfall, A. O., & Allison, D. B. (2003). Years of life
lost due to obesity. Journal of the American Medical Association, 289(2), 187-193.
Glaser, B., & Strauss, A. (1967). The discovery of grounded theory. Chicago: Aldine.
Heaney, C. A., & Israel, B. A. (2002). Social networks and social support. In F. M. Lewis (Ed.),
Health behavior and health education: Theory, research, and practice (pp. 185-209). San
Francisco: Jossey-Bass.
Jackson, E. J., & Parks, C. P. (1997). Recruitment and training issues from selected lay health
advisor programs among African Americans: A 20-year perspective. Health Education &
Behavior, 24(4), 418-431.
Jebb, S. A., Cole, T. J., Doman, D., Murgatroyd, P. R., & Prentice, A. M. (2000). Evaluation of
the novel Tanita body-fat analyser to measure body composition by comparison with a four-
compartment model. British Journal of Nutrition, 83(2), 115-122.
Kumanyika, S. K. (2002). The minority factor in the obesity epidemic. Ethnicity and Disease,
12(3), 316-319.
Kumanyika, S. K., & Charleston, J. B. (1992). Lose weight and win: A church-based weight loss
program for blood pressure control among Black women. Patient Education and Counseling,
19(1), 19-32.
McNabb, W., Quinn, M., Kerver, J., Cook, S., & Karrison, T. (1997). The PATHWAYS church-
based weight loss program for urban African-American women at risk for diabetes. Diabetes
Care, 20(10), 1518-1523.
Mokdad, A. H., Ford, E. S., Bowman, B. A., Dietz, W. H., Vinicor, F., Bales, V. S., et al. (2003).
Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. Journal of the
American Medical Association, 289(1), 76-79.
Must, A., Spadano, J., Coakley, E. H., Field, A. E., Colditz, G., & Dietz, W. H. (1999). The dis-
ease burden associated with overweight and obesity. Journal of the American Medical
Association, 282(16), 1523-1529.
Prochaska, J. O., Redding, C. A., & Evers, K. E. (2003). The transtheoretical model and stages
of change. In F. M. Lewis (Ed.), Health behavior and health education: Theory, research,
and practice (pp. 99-120). San Francisco: Jossey-Bass.
Steensland, B., Park, J. Z., Regnerus, M. D., Robinson, L. D., Wilcox, W. B., & Woodberry, R. D.
(2000). The measure of American religion: Toward improving the state of the art. Social
Forces,79(1), 1-28.
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
Thompson, F. E., Kipnis, V., Subar, A. F., Schatzkin, A., Potischman, N., Kahle, L., et al. (1998).
Performance of a short instrument to estimate usual dietary intake of percent calories from
fat. European Journal of Clinical Nutrition, 52, S63.
Thompson, F. E., Midthune, D., Subar, A. F., Kahle, L. L., Schatzkin, A., & Kipnis, V. (2004).
Performance of a short tool to assess dietary intakes of fruits and vegetables, percentage
energy from fat and fibre. Public Health Nutrition, 7(8), 1097-1105.
Viswanathan, M., Ammerman, A., Eng, E., Garlehner, G., Lohr, K. N., Griffith, D., et al. (2004,
August). Community-based participatory research: Assessing the evidence (Summary).
Evidence Report/Technology Assessment, pp. 1-8.
World Health Organization. (1998). Obesity: Preventing and managing the global epidemic.
Report of a WHO consultation on obesity June 3-5, 1997. Geneva, Switzerland: Author.
Yanek, L. R., Becker, D. M., Moy, T. F., Gittelsohn, J., & Koffman, D. M. (2001). Project Joy:
Faith based cardiovascular health promotion for African American women. Public Health
Reports, 116(Suppl. 1), 68-81.
650 Health Education & Behavior (October 2008)
at UAMS Library on July 22, 2015heb.sagepub.comDownloaded from
