Taking Steps Together

Abstract

Objectives. Successful childhood obesity intervention models that build sustainable behavioral change are needed, particularly in low-income, ethnic minority communities disparately affected by this problem. Method. Families were referred to Taking Steps Together (TST) by their primary care provider if at least one child had a body mass index ≥85%. The TST intervention comprised 16 weekly 2-hour classes including educational activities, group cooking/eating, and physical activities for parents and children. TST's approach emphasized building self-efficacy, targeting both children and parents for healthy change, and fostering intrinsic motivation for healthier living. Pre-post intervention data were collected on health-related behaviors using a survey, and trained staff measured weight and height. Results. Adults (n = 33) and children (n = 62) were largely Hispanic/Latino and low-income. Adults and children significantly increased their fruit and vegetable consumption and weekly physical activity, and adults significantly decreased sugared beverage consumption and screen time. No change in body mass index was observed for adults or children. Conclusions. This family-focused childhood obesity intervention integrated evidence-based principles with a nonprescriptive approach and produced significant improvements in key healthy behaviors for both adults and children.

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Health Education & Behavior
2015, Vol. 42(2) 194 –201
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DOI: 10.1177/1090198114547813
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Article
Childhood obesity rates have tripled since 1980 (Ogden &
Carroll, 2010). Nearly one in every three U.S. children ages
2 to 19 years, or 23 million, are overweight or obese (Ogden
& Carroll, 2010). Dramatic childhood obesity rate disparities
exist according to socioeconomic status (Eagle et al., 2012)
and ethnicity (National Survey of Children’s Health, 2012).
Although Minnesota ranks 41st in the rate of childhood obe-
sity by state (National Survey of Children’s Health, 2012),
Minnesota’s health disparities are greater than the national
average. Forty-four percent of Hispanic/Latino children are
overweight/obese compared with 24% of the state’s White
children. The potential immediate consequences of obesity
to children are numerous and include obstructive sleep
apnea, nonalcoholic fatty liver disease, and type 2 diabetes
(Abete, Astrup, Martínez, Thorsdottir, & Zulet, 2010; Barlow
& Expert Committee, 2007). Childhood obesity is also linked
with increased rates of adult disease and mortality from isch-
emic heart disease to breast cancer (Must, Phillips, &
Naumova, 2012; Owen et al., 2009).
The 2007 Expert Committee Recommendations (Barlow
& Expert Committee, 2007) suggest a staged management
algorithm for addressing childhood overweight and obesity
that begins with a basic behavioral change plan suitable for a
primary care office and progresses to more time- and resource-
intensive interventions. Primary care providers play a pivotal
role in identifying and managing childhood obesity, yet they
face challenges that restrict their ability to help patients make
key obesity-related behavioral changes in a clinic setting.
While some successes have been documented (Wald, Moyer,
Eickhoff, & Ewing, 2011), many well-crafted primary care
clinic-based interventions have not shown success in behav-
ioral change or body mass index (BMI; Hughes et al., 2008;
Wake et al., 2009). Ultimately, if a child is unsuccessful at
achieving a healthier BMI, the 2007 algorithm suggests that
she/he be referred to a multidisciplinary pediatric obesity care
team (Spear et al., 2007), including the involvement of a
547813HEBXXX10.1177/1090198114547813Health Education & BehaviorAnderson et al.
research-article2014
1Hennepin County Medical Center, Minneapolis, MN, USA
2University of Minnesota, Minneapolis, MN, USA
3St. Catherine University, St. Paul, MN, USA
Corresponding Author:
John D. Anderson, Department of Pediatrics, Hennepin County Medical
Center, 701 Park Avenue, Minneapolis, MN 55415, USA.
Email: john.anderson@hcmed.org
Taking Steps Together: A Family- and
Community-Based Obesity Intervention
for Urban, Multiethnic Children
John D. Anderson, MD1, Rachel Newby1, Rebecca Kehm2,
PatriciaBarland, RD, LD, IBCLC 1, and Mary O. Hearst, PhD3
Abstract
Objectives. Successful childhood obesity intervention models that build sustainable behavioral change are needed, particularly
in low-income, ethnic minority communities disparately affected by this problem. Method. Families were referred to Taking
Steps Together (TST) by their primary care provider if at least one child had a body mass index ≥85%. The TST intervention
comprised 16 weekly 2-hour classes including educational activities, group cooking/eating, and physical activities for parents
and children. TST’s approach emphasized building self-efficacy, targeting both children and parents for healthy change, and
fostering intrinsic motivation for healthier living. Pre–post intervention data were collected on health-related behaviors using
a survey, and trained staff measured weight and height. Results. Adults (n = 33) and children (n = 62) were largely Hispanic/
Latino and low-income. Adults and children significantly increased their fruit and vegetable consumption and weekly physical
activity, and adults significantly decreased sugared beverage consumption and screen time. No change in body mass index was
observed for adults or children. Conclusions. This family-focused childhood obesity intervention integrated evidence-based
principles with a nonprescriptive approach and produced significant improvements in key healthy behaviors for both adults
and children.
Keywords
family health, health disparities, nutrition, obesity, physical activity/exercise

Anderson et al. 195
behavioral counselor, dietitian, exercise specialist, and the
primary care provider. There are numerous barriers to offer-
ing an intervention of this intensity and resource demand such
as the availability of multidisciplinary weight management
programs; the variability of insurance coverage for weight
management services (Lee, Sheer, Lopez, & Rosenbaum,
2010; Simpson & Cooper, 2009); physical barriers (schedul-
ing, parking, location); and organizational barriers (clinic
environment; Kitscha, Brunet, Farmer, & Mager, 2009).
Given these barriers, families, providers, and communi-
ties often must employ evidence-based elements of success-
ful obesity interventions in unique ways that adapt to local
available clinical and community-based resources. Yet while
evidence exists to support specific programmatic approaches,
the literature is sparse in describing programs that have dem-
onstrated changes that were sustainable in the long term
(Oude Luttikhuis et al., 2009; Reinehr, Temmesfeld,
Kersting, de Sousa, & Toschke, 2007; Savoye et al., 2011).
Taking Steps Together (TST) was a 16-week healthy life-
style intervention based in the community for families address-
ing childhood obesity. While TST targeted children between 7
and 17 years of age in its recruitment process, the entire family
was invited to participate in the intervention. The content and
structure of TST’s curriculum were founded to promote the
evidence-based healthy behaviors defined in the 2007 Expert
Committee recommendations (Barlow & Expert Committee,
2007). These targeted behaviors include reduced screen time,
increased frequency of eating breakfast, increased weekly
physical activity, decreased consumption of sugared bever-
ages, and increased fruit and vegetable consumption.
Additional evidence-based program elements included com-
bining dietary, physical activity, and behavioral components
(Oude Luttikhuis et al., 2009); engaging the child’s family in
the intervention (Golley, Magarey, Baur, Steinbeck, & Daniels,
2007; Kalarchian et al., 2009; Sacher et al., 2010); providing a
sufficiently intensive intervention (Spear et al., 2007;
Whitlock, O’Connor, Williams, Beil, & Lutz, 2010); incorpo-
rating parenting education (Agras et al., 2012; Hurley, Cross,
& Hughes, 2011; Rhee, Lumeng, Appugliese, Kaciroti, &
Bradley, 2006; Robertson, Thorogood, Inglis, Grainger, &
Stewart-Brown, 2012; Satter, 1986); and basing the interven-
tion in the community (Foster et al., 2012; Savoye et al., 2011).
The curriculum emphasized unique strategies and a model
for behavioral change designed to promote healthy behaviors
that are sustainable. Self-determination theory describes that
the most powerful and sustainable form of motivation is
intrinsic motivation, where the individual pursues a specific
behavior because it provides her/him with personal satisfac-
tion and enjoyment. This is in contrast to extrinsic motivation,
where the individual’s behavior is intended to achieve out-
comes separable from the behavior itself, and often the indi-
vidual is responding to external pressures or consequences
(Silva et al., 2008). While extrinsic motivators such as con-
cerns about the health consequences of obesity are important
in families’ readiness to change (Eckstein et al., 2006; Rhee,
De Lago, Arscott-Mills, Mehta, & Davis, 2005), the hypoth-
esis behind TST is that the most potent motivator for sustain-
able healthy change is identifying with healthy behaviors that
are fun, enjoyable, and intrinsically rewarding (Silva et al.,
2008). Therefore, while educational content was woven into
every class, activities were primarily experiential; exposing
families to exercise that was fun and healthy foods that were
delicious. Examples include dancing, outdoor scavenger
hunts, making art out of food, and three delicious ways to
cook healthy greens. Another core strategy TST utilized was
to foster participant self-efficacy through structured activities
and dialogue where children and their parents identified the
barriers and resources for healthy living in their communities.
This empowers families as the experts of their own homes
and communities and the best qualified to generate their own
solutions for a healthier lifestyle (Wilfley, Kass, & Kolko,
2011). The intent of this strategy is that families leave the
program with a greater sense of self-efficacy and are better
equipped to respond to future challenges and to sustain the
healthy lifestyles they have adopted. Finally, the program not
only engaged parents in the intervention but also targeted par-
ents directly for healthy behavioral change by involving them
in all of the intervention activities and having them set their
own weekly individual health-related goals that were spe-
cific, measureable, and attainable. Existing evidence has
shown the importance of parental involvement in childhood
obesity interventions for promoting sustainable positive
results for their obese or overweight children (Collins et al.,
2011; Golley et al., 2007; Kalarchian et al., 2009; Sacher
et al., 2010). While other studies of childhood obesity inter-
ventions have measured both child and parent health-related
outcomes (Bean, Wilson, Thornton, Kelly, & Mazzeo, 2012;
Elder et al., 2014), there is minimal literature examining the
relationship between program outcomes for parent partici-
pants and the long-term sustainability of healthier weights for
their children. A core philosophy behind the TST intervention
is that not only parental involvement but also positive paren-
tal health-related outcomes represent key instruments to
achieving sustainable change for their children.
The hypothesis of the study is that a childhood obesity
intervention utilizing these strategies will be efficacious in
helping families achieve the evidence-based healthy behav-
iors described above (Barlow & Expert Committee, 2007)
and ultimately healthier BMIs. Furthermore, with its unique
characteristics, this approach intends to lay the foundation
for healthy change that is sustainable. The first step in this
process and the purpose of this article is demonstrating the
feasibility of the initial 16-week intervention.
Method
Study Location and Population
The intervention was geographically based at two
Minneapolis Park and Recreation Community Centers in

196 Health Education & Behavior 42(2)
low-income, multiethnic communities in Minneapolis,
Minnesota. These community centers were chosen because
of the close proximity to families’ homes and access to the
kitchen space and exercise facilities.
Primary care providers and dietitians within the Hennepin
County Medical Center (HCMC) system referred families
with children ages 7 to 17 using a referral tool in the elec-
tronic health record. HCMC, the state’s only major safety-
net hospital, primarily serves low-income people, immigrant
communities, and communities of color—the communities
most disparately affected by childhood obesity. Inclusion cri-
teria included families with at least one child between the
ages 7 and 17 with a BMI% ≥85% and fluency in English or
Spanish. All other children and adults in the family were also
invited to participate. The intervention occurred from May
2010 to January 2013. During the first year, the program
allowed rolling enrollment with families completing the
entire curriculum but graduating at different times. In
response to participant feedback, enrollment was subse-
quently changed to a cohort model with six cohorts of fami-
lies starting and completing the 16-week program together at
two program sites. The recruitment and retention goal was
five families per cohort at each location. The study was
approved by the HCMC and University of Minnesota
Institutional Review Boards.
TST Intervention Structure
TST was 16 weeks long with 2-hour classes occurring once
per week. Based on initial participant feedback and prelimi-
nary evaluations, the program duration was adjusted early in
the study period from 12 to 16 weeks to accommodate the
necessary curriculum and family requests. Each class session
consisted of three 40-minute elements: cooking and eating,
interactive educational activities, and physical activity.
Children and parents attended the weekly sessions together
to build relationships within and between families, allow
parents to role model for their children, and to work toward
behavior change together. All classes were facilitated in
Spanish and English. Program staff included a bilingual pro-
gram coordinator, dietitians, pediatricians, guest chef, other
local community experts on nutrition and exercise, and a
large group of bilingual and culturally aware volunteers.
TST Curriculum: Content and Delivery Tools
Educational topics and activities for the TST curriculum
were selected by utilizing a logic model framework through
which each activity targeted one or more health-related
behavior outcomes (see online supplement, Appendix A;
available online at http://heb.sagepub.com/supplemental).
Educational topics included “Know your greens: Vegetable
identification, taste test and cooking lesson,” “Food Fight:
Your child’s appetite and parenting (Agras et al., 2012;
Hurley et al., 2011; Satter, 1986),” “Play 101: Considering
‘then vs. now’?” “What are the barriers and solutions to play-
ing outside (especially in winter)?” “What’s in your bottle?
Sugared drinks and healthful alternatives,” and others. One
consistent nutritional message avoided restrictive dietary
recommendations but instead emphasized the value of bal-
anced meals and snacks (Abete et al., 2010). A large variety
of educational topics were intentionally chosen to target the
range of issues faced by parents and children of different
ages, and learning activities employed varied strategies to
engage all participants. For example, in the sugared beverage
activity, children were consistently fascinated by the act of
measuring out the amount of sugar in a variety of common
beverages (e.g., soda, chocolate milk, juice), while parents
appreciated a small group discussion about beverage choices
with TST’s dietitian. The recipes and cooking for each class
were chosen to complement the learning topic of that class.
For example, cooking leafy green vegetables in three differ-
ent ways followed the “Know Your Greens” activity. A guest
chef and/or dietitian facilitated the cooking activities, teach-
ing families different recipes and healthy cooking tech-
niques. Families were encouraged to share their own healthy
cooking techniques and culturally specific recipes through-
out the course. Physical activities included zumba, yoga,
handball, soccer, relay races, and other group games.
An important aspect of the intervention that supported
behavior change strategies was the family ownership of the
program—families created their own guidelines about atten-
dance, participation, and graduation. Through a structured
discussion during the first class, the participating cohorts of
families consistently chose to “allow” one to three of the 16
classes that a given family could miss and still graduate from
the program. Putting this decision in their hands was intended
to reduce attrition and enhance participant engagement.
Finally, social media tools augmented class activities. TST’s
Facebook page and recipe blog provided an interactive net-
work for families to share how they were translating what
was learned in class to their home environments. Families
had the opportunity to engage with TST staff and learn from
each other as they posted online pictures of their latest
kitchen creations or fun physical activities.
Measurements and Data Collection
All outcome data were collected using a survey for all par-
ticipants (children and adults) at both the start and comple-
tion of the 16-week course. Questions included basic
demographic information (age, gender, ethnicity, and health
insurance type) and self-reported evidence-based health-
related behaviors (Barlow & Expert Committee, 2007).
Specifically, participants were asked to report the following:
hours per day of television and/or computer time, number of
days per week eating breakfast, number of days per week
engaging in at least 30 minutes of exercise or play, number
of servings of sugared beverages consumed per day, number of
servings (1/2 cup) of fruits consumed per day, and number of

Anderson et al. 197
servings (1/2 cup) of vegetables consumed per day. In the
case of young children (typically <10 years old), a parent
completed the survey for the child. Older children completed
the survey on their own, often with some assistance from a
parent. Trained staff measured weight using a bathroom
scale with participants in socks, no shoes, and wearing street-
clothes. A Seca Stadiometer was used for height within 0.5 of
a centimeter (Seca, Birmingham, UK; www.seca.com).
Data Analysis
Data were imported from Microsoft Excel and analyzed using
Stata v. 11.1 (StataCorp, College Station, TX). Descriptive
statistics included participants who were not lost to follow-up
(n = 95). There were no differences in baseline age, sex,
insurance status, or BMI between those who were lost to fol-
low-up and those who remained in the intervention. However,
there was a significant difference in racial distribution
between those lost to follow-up and those remaining in the
intervention with American Indians and African Americans
more likely to discontinue the intervention. Differences in
pre- and postintervention measures were tested using a paired
t test for continuous measures and chi-square for categorical
variables, using a p = .05 as a significance level.
Results
Of the 283 adults and children initially recruited for participa-
tion, 95 (33.6%) completed the 16-week intervention and pro-
vided both pre- and postintervention data for the outcomes of
interest. Specific intervention completion rates for adults and
children were 31.4% and 34.8%, respectively. Only these 95
individuals (33 adults and 62 children) were included for
analysis. Of the families who completed the intervention and
were analyzed, 26 had only one parent who attended the pro-
gram (23 mothers, 3 fathers) while three families had both
parents attending. Families had one to four children with a
mean of 2.1 participating children per family.
Tables 1 and 2 present demographic characteristics and
outcome measures at baseline and postintervention of all
cohorts of adult and child participants, respectively. Sample
sizes differ somewhat for each variable because of incom-
plete individual level data. Adults participating in the inter-
vention program were primarily female (75.8%) and
Hispanic/Latino (78.8%), with a mean age of 38.0 years
(SD = 9.4). About half of the children participating in the
intervention were female (47.5%), and child participants
were primarily Hispanic/Latino (79.0%), with a mean age of
8.7 years (SD = 3.3). At baseline, 48.2% of adults reported
being uninsured while 44.4% reported having public health
insurance. For children, 6.1% were reported as uninsured
and 75.5% as having public insurance at baseline.
Among adults, there was a statistically significant increase
in reported average daily servings of fruits (1.8 to 2.6 servings
per day, p = .001); average daily servings of vegetables (1.9 to
2.8 servings per day, p < .001); and average number of days
per week with at least 30 minutes of physical activity (2.6 to
3.9 days per week, p = .001). A statistically significant
decrease was reported in average daily consumption of sug-
ared drinks (1.3 to 0.7 servings per day, p = .002) and the
average number of hours of TV and/or computer screen time
per day (2.7 to 2.0 hours per day, p = .041).
Among children, there was a statistically significant
increase in reported average daily servings of fruits (2.6 to
3.3 servings per day, p = .006); average daily servings of
vegetables (1.9 to 2.7 servings per day, p < .001); and aver-
age number of days per week with at least 30 minutes of
physical activity (4 to 4.9 days per week, p = .001).
For both adult and child participants, mean BMI did not
significantly change from pre- to postintervention. When
BMI was assessed categorically, there was a significant
change for both children and adults (p < .001). The propor-
tion of obese children (BMI percentile ≥95%) decreased
from 57.9% at baseline to 52.6% at follow-up, though the
proportion of obese adults (BMI ≥ 30) increased from 51.6%
to 58.0%. However, only two adults in the program had dif-
ferent pre- and post-BMI categorizations, and thus the sig-
nificant change in adult BMI category proportions was likely
affected by the small sample size. There was no significant
change in breakfast consumption for adults or children and
no significant changes in number of sugar drinks consumed
or daily screen time behavior for children.
Because complete data were not available for all partici-
pants in the analysis, a sensitivity analysis was completed
using only those participants with complete data for all vari-
ables (adult n = 23; child n = 38). From the sensitivity analy-
sis, health insurance status was identified as a major source
of missing data. Of the 34 individuals excluded from the sen-
sitivity analysis due to incomplete data, 56% did not report
their health insurance status on their pre- and/or postinter-
vention survey. The sensitivity analysis also produced results
that were consistent with findings from the broader analysis
except amount of screen time watched among adults, which
was no longer statistically significant (p = .145). All other
findings from the sensitivity analysis were statistically com-
parable with the final results used for this analysis.
Discussion
The results of this study demonstrate the feasibility of Taking
Steps Together as a promising intervention for improving
evidence-based healthy behaviors for both parents and chil-
dren in low-income, multiethnic families with an overweight
or obese child. Of note, when compared with child partici-
pants, parents showed broader improvement in health-related
behaviors including increased fruit and vegetable consump-
tion, increased physical activity, in addition to decreased
sugared beverage consumption and screen time. Children did
show significantly increased fruit and vegetable consump-
tion and increased physical activity. Neither parents nor

198 Health Education & Behavior 42(2)
children demonstrated a significant change in mean BMI
(absolute or percentile, respectively). We did not expect dra-
matic BMI changes due to the relatively brief duration of the
intervention, and since the first step in achieving a health
weight is BMI stabilization.
While the TST intervention is founded on existing evi-
dence (Abete et al., 2010; Agras et al., 2012; Barlow &
Expert Committee, 2007; Golley et al., 2007; Hurley et al.,
2011; Kalarchian et al., 2009; Oude Luttikhuis et al., 2009;
Rhee et al., 2006; Sacher et al., 2010; Satter, 1986; Spear
et al., 2007; Whitlock et al., 2010), there are several unique
elements to the program that are supported by the positive
findings of this study. Engaging children and their parents as
equal participants in programming and directly addressing
the importance of their interactions around food is an effec-
tive means of promoting behavioral change in both groups.
Although not directly measured, building participant owner-
ship of the program and self-efficacy may empower families
to identify their strengths and challenges and set their own
course toward better health. Finally, the study results support
an intervention approach that fosters intrinsic motivation for
healthy behaviors. From the course content to the delivery
methods, TST reinforces that eating healthy foods and being
physically active should, and needs to be enjoyable. These
unique elements of TST are designed to lay the foundation
for truly sustainable healthy changes.
The TST intervention resulted in meaningful healthy
changes in an ethnically diverse, low-income population
with disproportionately high rates of childhood obesity. The
nature of the intervention and its intentional responsiveness
to the unique needs and culture of its participants make it
adaptable and its results translatable to other diverse com-
munities. Another strength and yet unplanned outcome of
this study’s intervention is the development of community
leaders. While formal leadership training was not a part of
the TST intervention, graduate families have taken the
Table 1. Characteristics of Taking Steps Together Parents at Baseline and Postintervention, Elliot and Windom Locations, Minneapolis,
Minnesota, 2010 to 2012 (N = 33).
Variable nBaseline, M ± SD Follow-Up, M ± SD Stat Testap Value
Age (years) 33 38.0 ± 9.4
Gender (%) 33
Female 75.8
Male 24.2
Race (%) 33
African 3.0
African American 15.2
American Indian 0.0
White 3.0
Hispanic 78.8
Multiracial 0.0
Health insurance (%) 27
Uninsured 48.2 44.4 33.72 .001
Public (MA/MHP) 25.9 29.6
Private 3.7 3.7
Medicaid 3.7 11.1
Assured Care 14.8 11.1
Refused 3.7 0.0
BMI 31 33.5 ± 9.4 34.0 ± 13.2 −0.59 .558
BMI categories (%) 31
<25 9.7 9.7 54.00 <.001
≥25 to <30 38.7 32.3
≥30 51.6 58.0
Daily servings of
Fruit 33 1.8 ± 1.0 2.6 ± 1.3 −3.77 .001
Vegetables 32 1.9 ± 0.9 2.8 ± 1.4 −4.20 <.001
Sugared drinks 32 1.3 ± 0.9 0.7 ± 0.9 3.40 .002
No. of days active 30 minutes or more 32 2.6 ± 2.0 3.9 ± 1.9 −3.51 .001
TV/computer (hours/day) 33 2.7 ± 1.8 2.0 ± 1.7 2.13 .041
Breakfast (days/week) 31 3.8 ± 2.7 4.7 ± 2.3 −1.78 .085
Note. BMI = body mass index.
aCategorical variables tested using Pearson chi-square statistic with Fisher’s exact p value reported due to zero cells. Continuous variables used paired t
test statistic.

Anderson et al. 199
initiative to create their own healthy activity groups from a
gardening club to a cooking group. Other graduate families
have returned to the program as volunteers and mentors to
new participants.
This study has several limitations. The small sample size
affects our ability to detect significant changes in health-
related behaviors and also reduces the generalizability of the
results. Only a third of the participants completed the inter-
vention, with those who left citing barriers such as schedul-
ing conflicts and transportation difficulties. This high rate of
attrition affects the interpretation of the study’s positive
findings as it is possible that the subset of families who
graduated from the program were more motivated to
improve their health. Without a randomized control group,
we are limited in our ability to assert that the healthy changes
made by participants were a direct result of the intervention
and not, in part, due to a greater degree of motivation for
health improvement among graduating participants. While
the participants included in the final results analysis
attended the vast majority of the TST classes, we do not
have precise attendance data for each individual. Therefore,
we are not able to assess the effect of program dose on par-
ticipant outcomes. The principles of building self-efficacy
and intrinsic motivation for sustaining healthy behaviors
among participants were important elements of the inter-
vention model. Yet self-efficacy and motivation were not
directly measured. Finally, because data regarding health-
related behaviors were self-reported, the accuracy of those
data are uncertain.
Future efforts will seek to address the aforementioned lim-
itations and also to examine the sustainability of the healthy
changes resulting from the TST intervention. The TST inter-
vention could be evaluated with a larger sample size and
using a randomized wait-list control group. Additional
Table 2. Characteristics of Taking Steps Together Children at Baseline and Postintervention, Elliot and Windom Locations,
Minneapolis, Minnesota, 2010 to 2012 (N = 62).
Variable nBaseline, M ± SD Follow-Up, M ± SD Stat Testap Value
Age (years) 62 8.7 ± 3.3
Gender (%) 61
Female 47.5
Male 52.5
Race (%) 62
African 0.0
African American 17.7
American Indian 0.0
White 1.6
Hispanic 79.0
Multiracial 1.6
Health insurance (%) 49
Uninsured 6.1 16.3 48.11 .001
Public (MA/MHP) 46.9 42.9
Private 18.4 14.3
Medicaid 20.4 18.4
Assured Care 8.2 8.2
Refused 0.0 0.0
BMI percentile 57 88.5 ± 17.2 86.6 ± 22.4 1.01 .315
BMI percentile categories (%) 57
<85% 24.6 26.3 59.98 <.001
≥85% to <95% 17.5 21.1
≥95% 57.9 52.6
Daily servings of
Fruit 62 2.6 ± 1.5 3.3 ± 1.6 −2.83 .006
Vegetables 61 1.9 ± 1.2 2.7 ± 1.4 −5.69 <.001
Sugared drinks 61 1.5 ± 1.4 1.3 ± 1.1 1.13 .263
No. of days active 30 minutes or more 60 4.0 ± 2.0 4.9 ± 2.0 −3.37 .001
TV/computer (hours/day) 59 2.6 ± 1.8 2.4 ± 1.9 0.97 .337
Breakfast (days/week) 59 5.3 ± 2.2 5.1 ± 2.3 0.67 .504
Note. BMI = body mass index.
aCategorical variables tested using Pearson chi-square statistic with Fisher’s exact p value reported due to zero cells. Continuous variables used paired t
test statistic.

200 Health Education & Behavior 42(2)
measurement tools could also be considered including
24-hour diet logs and accelerometers to obtain more reliable
information on participants’ behavioral changes. Precise pro-
gram attendance measurements will be performed. Measures
of self-efficacy and intrinsic versus extrinsic motivation will
be used in future studies. Posts on TST’s Facebook page and
recipe blog will be monitored to examine whether a relation-
ship exists between use of these social media tools and par-
ticipants’ outcomes.
Program graduates are currently leading a new, fully funded
project entitled “Next Steps” where they have developed their
own family-led health maintenance programs, which are being
offered to newly graduated TST families. The community
leaders of this new program received 10 weeks of formal lead-
ership training prior to developing and initiating their pro-
grams. As a part of this project TST participants are having
health-related behavior and BMI data measured at several
long-term follow-ups. This will allow future publications to
evaluate both the feasibility of the new “Next Steps” programs
and the sustainability of TST’s initial health benefits.
Conclusion
The Taking Steps Together intervention is a promising
approach to achieve sustainable, positive changes in health-
related nutrition and physical activity behaviors for both
children and their parents. For clinicians and others develop-
ing childhood obesity programs the results of this study
encourage consideration of intervention models that com-
bine evidence-based content with a delivery method that is
experiential and emphasizes healthy behaviors that are
intrinsically rewarding. The TST intervention warrants fur-
ther study to more deeply examine these initial findings and
also to explore the sustainability of the program’s effects.
Acknowledgments
The authors would like to thank the Minneapolis Parks and
Recreation Department for use of their facilities as well as the par-
ents, children, and many volunteers that allowed this program to
occur.
Authors’ Note
The research plan was approved by the Hennepin County Medical
Center and University of Minnesota institutional review boards.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: Funding
for this research was provided by the Greater Twin Cities United
Way and the Epic Foundation.
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