key: cord-0834797-j505ngyw authors: Wieland, Mark L.; Njeru, Jane W.; Asiedu, Gladys B.; Zeratsky, Katherine A.; Clark, Matthew M.; Goetze, Rachel; Patten, Christi A.; Kelpin, Sydney S.; Novotny, Paul; Lantz, Kiley; Ahmed, Yahye; Molina, Luz; Porraz Capetillo, Graciela; Osman, Ahmed; Goodson, Miriam; Sia, Irene title: Pilot Social Network Weight Loss Intervention With Two Immigrant Populations During the COVID-19 Pandemic date: 2022-01-24 journal: Am J Health Promot DOI: 10.1177/08901171211053450 sha: 5b3868b16cda25786140b4e761777eeed2db0d70 doc_id: 834797 cord_uid: j505ngyw PURPOSE: To examine the feasibility and acceptability of a social network weight loss intervention delivered by lay health promoters (HPs) to immigrant populations. DESIGN: Single-arm, non-randomized, pilot study of a social network weight loss intervention developed by a community-based participatory research partnership and delivered by HPs. SETTING: Community-based setting in Southeastern Minnesota, United States. SAMPLE: Somali and Hispanic immigrants to the United States: 4 social networks of adults (2 Hispanic and 2 Somali) with 39 network participants. INTERVENTION: Twelve-week behavioral weight loss intervention delivered by HPs (4 weeks in-person and then 8 weeks virtual). MEASURES: Feasibility was assessed by recruitment and retention rates. Acceptability was assessed by surveys and focus groups with HPs and participants. Behavioral measures included servings of fruits and vegetables, drinking soda, and physical activity. Physiologic measures included weight, blood pressure, glucose, cholesterol, and triglycerides. ANALYSIS: Paired t-tests of pre- to post-intervention changes at the end of 12 weeks of treatment. RESULTS: Recruitment was feasible and post-intervention was 100%. Participants highly rated the intervention on satisfaction, motivation, and confidence to eat a healthy diet, be physically active, and lose weight. Participants were motivated by group social support and cohesion of their social networks. On average, participants lost weight (91.6 ± 15.9 to 89.7 ± 16.6 kg, P < .0001), lowered their systolic blood pressure (133.9±16.9 to 127.2 ± 15.8 mm Hg; P < .001), lowered their diastolic blood pressure (81 ± 9.5 to 75.8 ± 9.6 mm Hg; P < .0001), had more servings of vegetables per day (1.9 ± 1.2 to 2.6 ± 1.4; P < .001), and increased their physical activity (2690 ± 3231 to 6595 ± 7322 MET-minutes per week; P = .02). CONCLUSION: This pilot study of 2 immigrant communities who participated in a peer-led weight loss social network intervention delivered during the COVID-19 pandemic demonstrated high feasibility and acceptability. Participants lost weight, improved their health status, and improved their health behaviors. Immigrants often arrive to the United States (US) at a healthier weight compared to the general US population, but these healthy weight advantages disappear over time, and rates of obesity, with associated complications, rise. [1] [2] [3] [4] [5] [6] [7] Obesity is precipitated, in part, by systematic factors that promote the adoption of unhealthy behaviors after immigration, namely, a sedentary lifestyle and consumption of calorie dense foods. [8] [9] [10] [11] Evidence-based health promotion programs are effective at changing dietary and health behaviors in general populations, 12 but despite calls for interventions to address obesity and obesity-related behaviors among immigrant populations, [13] [14] [15] few treatment studies have been reported. Results of existing studies suggest that interventions culturally tailored to immigrant groups may be more successful than applying standard (not culturally targeted) interventions. 16, 17 One difficulty in designing interventions to promote weight loss and healthy behaviors is that the reasons for weight gain among immigrant groups are multiple and complex, including individual, interpersonal, social, community, and policyrelated factors. 18, 19 Community-based participatory research (CBPR) is a means to collaboratively investigate health topics. [20] [21] [22] Rochester Healthy Community Partnership (RHCP) is a 16-year CBPR partnership in Minnesota that develops evidence-based health promotion interventions with immigrant groups. In the "Healthy Immigrant Families" (HIF) project, RHCP partners co-created an intensive face-to-face familyfocused intervention of 12 modules delivered to Somali and Hispanic participants by bilingual interventionists. 23 At 12 months, there were significant improvements in the primary outcome of dietary quality compared with wait list controls, 24 suggesting this tailored intervention could meet the unique needs of immigrant communities. However, the intensity of the intervention (home-based with multiple family members and professional HPs) limits its dissemination potential, and the intervention did not explicitly target healthy weight loss nor specifically recruit overweight or obese participants. RHCP then conducted a social network analysis among 1301 adults, both Hispanic (n = 610) and Somali (n = 691), and found that obesity clustered by social networks. 25, 26 Past research demonstrated that a range of social network characteristics are associated with obesity-related behaviors 27 and outcomes. 28 Furthermore, Social network interventions, which involve purposeful utilization of existing social networks in the natural environment, 29 have been shown to positively affect behavior change in a variety of settings and health outcomes. 30 Social network interventions have not been tested in immigrant groups, but they may be especially promising in these populations, where networks are more homogenous (i.e., higher homophily) than non-immigrant networks. 31, 32 The objective of this study was to pilot test a social network-informed, CBPR-derived, health promotion program for feasibility outcomes in adults with overweight (BMI 25 to <30) or obesity (BMI ≥ 30) from Hispanic and Somali immigrant communities. To achieve this objective, RHCP used a social ecological theoretical framework to re-design the HIF intervention to account for the dynamic interplay between personal, social, and environmental factors of health behaviors. The materials were tailored for overweight and obese adults from Hispanic and Somali immigrant communities to be delivered by lay HPs within their social networks. We expected that the social network intervention would be a feasible and acceptable approach for health promotion in these immigrant communities. We explored if the intervention was associated with a reduction in body mass index (BMI) and other biomarkers associated with obesity and promoted the adoption of a healthy lifestyle. The adaptation of the intervention occurred during the onset of the coronavirus-2019 (COVID-19) pandemic. Using a pre-post study design, four social networks of adults (2 Hispanic and 2 Somali) with 39 network participants were enrolled to receive the in-person intervention (which was modified with the onset of COVID-19). This study was approved by the Mayo Clinic Institutional Review Board (IRB# 19-011574) and participants provided written informed consent. Lay HPs were selected from network opinion leaders identified in the network analysis or by community partners within the Hispanic and Somali communities. These individuals were approached by RHCP members who explained the study and HP role. Our study team recently described the training procedures for interventionists. 33 For this project, the training was streamlined to account for delivery in networks, thereby enhancing intervention scalability. In the HIF intervention, we learned that while startup training is important, ongoing training and supervision is crucial. The HPs and the intervention oversight clinicians met every 2 weeks for 1 hour to review the content for the next 2 sessions and to answer questions related to the ongoing groups (initially in-person, and then by telephone during the COVID-19 pandemic). The intervention consisted of community-based mentoring and education delivered by trained Hispanic and Somali HPs to their social networks over a period of 3 months. HPs provided support and monitored progress on goals toward improved diet, physical activity level, and weight loss via six evidence-based strategies: Tracking, Goal Setting, Mindfulness, Social Support, Problem-Solving Skills, and Motivational Strategies. 34 Participants were informed that one of the goals was for a weight loss of 3%. Additional goals included reduction of portion sizes of calorie dense foods, a shift of relative dietary content to increase fruit and vegetable consumption, and 150 minutes per week of moderate to vigorous physical activity. Each of the twelve sessions was to target a particular behavior for weight loss ( Figure 1 ). All sessions included goal setting, review of food and/or activity tracking, and positive reflections. Specific strategies for weight loss, including regular weigh-ins, completion of food and physical activity records, reducing portion sizes, planning meals, use of My-Plate for dietary proportions, removing problem foods from the home, increasing physical activity level, and reducing sedentary behavior were incorporated into the intervention. The intervention began in February 2020, and in mid-March, the weekly face-to-face group visits were canceled in response to COVID-19 physical distancing guidelines (4 sessions completed). The study team, including HPs and RHCP community and academic partners, met to discuss options for the study. Participants all endorsed enthusiasm for continuing the intervention, but it was felt that participants were not prepared to transition the education sessions to virtual formats (communities had not yet coalesced around shared video communication platforms in the early days of the pandemic). Instead, each social network came together on a closed social media platform to continue at least weekly check-ins and more frequent communication, where HPs and network members promoted tracking, goal setting, social support, problemsolving, and motivational strategies. In this way, the group session strategies (but not content) were sustained ( Table 1) . All network members participated in these sessions during weeks 4-12, with average attendance of 80%-100% at each meeting. The HPs from each group also met virtually every 2 weeks with study staff to provide support and answer questions. Baseline and 3-month measures were conducted in-person according to institutional pandemic guidelines for study visits. Study participants reported age, gender, ethnicity, country of birth, language spoken at home, annual household income, and education level. Feasibility was assessed via recruitment (goal of 4 social networks; 2 Hispanic and 2 Somali) and retention rates at 3month follow-up. Acceptability constructs were explored with survey items derived from the health communication assessment tool produced by the National Cancer Institute. 35 This survey also included questions about the perceived impact of the intervention on motivation and confidence. After completing the intervention, focus group were conducted with all HPs and a subset of participants to explore overall experience with the program, facilitators of success during the COVID-19 pandemic, and opportunities for improvement and future expansion of the program. Four focus groups were conducted: HPs (n = 4); Somali women (n = 6); Somali men (n = 6), and Hispanic mixed gender (n = 7). Focus groups with HPs were conducted in English while Somali and Hispanic groups were conducted in Somali and Spanish, respectively, by bilingual RHCP members with qualitative moderation training. 36 All interviews were recorded, translated by the moderator (if applicable), and transcribed for analysis. Weight was measured to the nearest .1 kg using a portable scale (Seca 880 Digital Floor Scale). Participants were asked to remove shoes prior to measurements. Seated blood pressure (systolic and diastolic) measurements were made on the right arm using an automated blood pressure device after sitting quietly for five minutes. 37 Blood pressure was measured three times and the average of the second and third readings were used in analyses. Waist circumference was measured to the nearest .1 cm at the narrowest part of the torso between the ribs and the iliac crest. Fasting glucose and cholesterol were collected as whole blood samples by a single finger prick. The portable Whole Blood Lipid Screen Cholestech LDX Analyzer was used to analyze specimens, which combines enzymatic methodology and solid-phase technology measured by reflectance photometry to measure total cholesterol, triglycerides, and glucose in whole blood. A dietary screener of seven items adapted from the Food Behavior Checklist, which has been used successfully among diverse low-income populations, 38 was used to assess servings of fruits and vegetables per day as well as the extent to which participants consume fruits/vegetables as snacks and regular soda (4-point Likert scales). MET-minutes per week for energy expended from carrying out physical activity was assessed using the International Physical Activity Questionnaire. 39 Categorical variables were reported with counts and percentages. Means and standard deviations were reported to describe continuous variables. Changes in continuous endpoints were tested with two-sided, paired t-tests using the difference of the post-measurement minus the premeasurement values. Because the distributions of the triglyceride and MET-minute values were skewed, they were log transformed for analysis. All tests were done with 5% type I error rates. All analyses were done using SAS version 9.4. (SAS and all other SAS Institute Inc product or service names are registered trademarks or trademarks of SAS Institute Inc, Cary, NC, USA). Qualitative data from the focus groups were analyzed using template analysis. [40] [41] [42] Using this approach, a template of themes from a small section of the data and targeted themes were developed and then applied to the larger dataset. Data from HPs were used as a template to inform the rest of the analysis from participant transcripts. There were 39 study participants: median age was 48 years, 60.5% were female, 93% were born outside the US, 59% self-identified as Hispanic, and 41% self-identified as Somali. Most participants reported annual household income <$30,000 (51.3%) and education level of high school or lower (60.6%). Recruitment targets were achieved: 4 social networks (2 Hispanic and 2 Somali; total N = 39). The retention rate in the program at 12 weeks was 100%, with all 39 participants completing 12-week measures (one participant abstained from the post-intervention acceptability survey). In the post-intervention survey, participants reported very high acceptability and 95% said participating in the program made them want to do new things to be healthy. Participants also reported that the program caused them to feel much more confident about healthy behaviors and weight loss (Table 1) . Results from focus group analysis were clustered into two main categories (Table 2) : program successes and facilitators and challenges and opportunities for improvement. Comparing pre-and post-intervention health measures, there were improvements in weight, blood pressure, total cholesterol, triglycerides, servings of fruits and vegetables per day, use of fruits and vegetables as snacks, drinking regular soda, and physical activity. There were no changes in glucose, waist circumference, or drinking other sugar-sweetened beverages (fruit drinks, punch, or sports drinks) ( Table 3 ). In this community-based participatory pilot study among members of two immigrant communities, a social network weight loss intervention delivered by lay HPs was feasible and acceptable. Study participants highly rated the intervention, and all participants completed the program despite the shift from in-person to remote meetings due to the onset of COVID-19, and overall, participants lost weight and made positive diet and physical activity changes. The findings of this pilot project suggest that a weight loss intervention designed by a team of experts partnered with community stakeholders can be successfully delivered by lay community members to members of their social networks. Survey results from this study indicated that motivation and confidence to eat a healthier diet and be physically active were positively impacted by the intervention. Qualitative results suggested that this motivation and confidence were facilitated by social network effects and peer mentorship. Participants felt supported by their HP and peers in culturally concordant groups to achieve their health goals. This trust and support also facilitated group accountability, which in turn facilitated individual motivation. Peer mentoring has been shown in past research to be effective in promotion of healthy eating and physical activity among groups with low socioeconomic position. 43, 44 It is striking that all participants completed the program despite the shift in format from in-person to virtual due to the COVID-19 pandemic. Importantly, new educational content was not delivered after week 4, further supporting the importance of social network factors as a primary mechanism for behavior change in this intervention. Therefore, the ways of reaching and supporting participants may be more important than how much health information is provided. Simulation models from a previous study suggested that traditional weight loss interventions frequently fail because they lack consideration of the participant's social networks, and that networkdriven interventions may be highly effective. 45 Therefore, interventions using social networks in immigrant communities to interface with evidence-based programs for positive behavior change represent a promising public health approach. The 100% end of study retention also speaks to a strength of CBPR for health promotion among immigrant groups. Study participants lost 2% of their body weight on average. The goal of this intervention was to guide and support participants to achieving a 3% weight loss. Initially, this project was designed to be an in-person intervention and it may be that the shift to a remote intervention and cessation of delivery of new content past week 4 due to COVID-19 precautions had a negative impact on weight loss outcomes. However, it is notable that despite this unexpected shift in treatment delivery method, 36% of participants lost at least 3% of their body weight. Additionally, COVID-19 has been associated with weight gain in the United States. 46, 47 This partnered with observed significant reductions in blood pressure, cholesterol, Health promoters as learners and supporters HPs saw themselves as learners on the job, trying to simultaneously understand the content of the intervention and implementing it: navigating the group dynamics and how to approach participants to follow through especially in sharing sensitive information such as their weight were described as difficult. As learners they were engaged with participants in all program activities and saw this as reinforcement for participation. Intervention participants however perceived HPs engagement as very supportive, emotionally and physically. Group support and motivation from others Social support provided motivation for physical activity and healthy living and the motivation for participants to maintain participation. "Teaching the eyes" Visual representation was an important factor in participants motivation and ability to follow through the intervention program. MyPlate for each of the participants…it's very good and because they-it's a way-a good way to teach the eyes how much you are supposed to eat. The MyPlate concept that was adapted for the intervention was important to assist with portion control. Yes, something very important that we had was The Plate that we got so we could see the portions that we were eating. Also, very important the booklet that we needed to fill out and noticing the progress of our nutrition, the weight each week and all that. [Hispanic group] The tracking sheet booklet that was filled out enabled participants to track the progress they were making each week and make adjustments for change. But when I started the plan, we discovered the problem that we were eating too many carbohydrates, lots of bread, too many starches and very few vegetables. Learning new things For many of the participants in the program, the knowledge they acquired about nutrition and physical activity was helpful. Many admitted they didn't know much about nutrition before the program. I learned the importance of the vegetables, because I didn't have that [knowledge] in my brain, that I needed to eat a lot of vegetables or to add vegetables to everything… But when I started the plan, we discovered the problem that we were eating too many carbohydrates, lots of bread, too many starches and very few vegetables. Then when we started with the plan. [Hispanic group] Others expressed that having a plan and a program to follow was new and important. The new knowledge enabled them to change their habits around eating, preparing foods, and being physically I was adding to my meals: fruits and vegetables, that never before I gave to my family. I didn't even know that cooking so healthy was so tasty. American Journal of Health Promotion 0(0) Other group reinforcement included helping each other, maintaining positivity, being together, and sharing ideas of what had worked for individuals. Our group is 2 groups. Those over fifty years old and those under fifty years. So, we have a competition, each group is thinking of ways to defeat the other group, and that was motivational but you have to understand that this challenge was not one of those that says let's get ahead of them. It was more of a group who knew one another truthfully, the motivation stemmed from not falling behind from the group because the group themselves were motivating you. That's kind of a little bit time-consuming because they were not on time, but they were kind of motivated. They want to do the program, but they kind of sometimes not on time and then not… time's a factor when you've got a group, because some people can at 1 time, and other people can't, and it's just a struggle. Some people can make it a certain day and other people can't. [HP] There were varying group and individual dynamics and having to learn and navigate those dynamics posed a challenge for HPs. These included varying work schedules for participants. Challenges for participants Many of the challenges reported included letting go of habits, meeting cultural expectations, competing priorities, etc. So we get invited to events like weddings, and we cannot refuse it…I mean in our culture itself, is that when someone puts a plate in front of you and you do not eat, but just touch a little bit... And another thing is when someone puts a plate in front of you most of the time, they take it as disrespect if you don't eat it. [Somali men] (continued) COVID-19 pandemic challenges versus opportunities All participants reported that the pandemic had an impact on the intervention but also created opportunities and avenues for them to stay connected with each other and still participate in the program. I think if my group was like-they were more enjoying when we were inperson. They made some friends that they have time to do things together and then see each other out of the house. They were kind of happier when we were doing it in-person. [HP] Inability of participants to register and exercise in at the gym, follow weekly physical activities in a group setting, take walks with friends, get out for errands were reported as post-COVID challenges. There were a lot of things since we were all getting together. We talked about our families; we were helping each other with many things. That has gone out of the way now since COVID we cannot get together. and triglycerides suggests that 2% weight loss during this time was clinically meaningful. Successful weight loss and improvements in other biometric measures were supported by healthy changes to diet and physical activity during this intervention. At baseline, study participants reported consuming an average of 3.6 servings of fruits and vegetables per day. Fruit and vegetable intake increased to 5.5 servings daily, approaching the dietary recommendation of six servings of fruits and vegetables per day. Physical activity also increased more than two-fold on average. Therefore, healthy changes in diet and physical activity during this pilot were both statistically significant and clinically meaningful. This study had several limitations. The study was not randomized and lacked a control group; therefore, a causative statement cannot be made. Additionally, practice-based conclusions cannot be drawn based on the biometric data presented. Third, health behaviors were based on self-report, which are not as accurate as objectives measures. Because individual groups operated both formally through weekly sessions and informally through their social network ties, an accurate assessment of intervention dose could not be assigned to each participant or group. Finally, the intervention switched from face-to-face to virtual and educational modules were truncated after week 4 due to the pandemic, so the intervention was not delivered as intended. Future studies should use randomization and direct measures of health behaviors should be included. During the COVID-19 pandemic, in this preliminary study, lay health promoters from two immigrant communities were able to shift from an in-person 12-session behavioral social network weight loss intervention to a remote intervention. Participants remained active in the program, they found it highly acceptable and motivating, and they achieved clinically meaningful changes in weight loss, blood pressure, cholesterol, healthy changes in nutrition, and increased weekly physical activity. Future research with larger sample sizes will be integral to better understand and expand these initial findings. • What is already known on this topic: Immigrants to the United States frequently gain weight and can experience the onset of obesity-related health conditions, but utilization of evidence-based health promotion programs is low. • What does this article add: In this pilot project, the training of lay health promoters from immigrant communities in the delivery of a weight loss program to members of their social networks demonstrated strong feasibility and acceptability, and resulted in weight loss, lower blood pressure, lower cholesterol, and improvements in nutrition and physical activity levels. • What are the implications for health promotion practice or research: This study suggests that interventions using social networks in immigrant communities to interface with evidence-based resources for positive behavior change represent a promising public health approach. 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Educ Health (Abingdon) The seventh report of the Joint National Committee on Prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report Selecting items for a food behavior checklist for a limitedresource audience International physical activity questionnaire: 12-country reliability and validity The utility of template analysis in qualitative psychology research The influence of 'significant others' on persistent back pain and work participation: a qualitative exploration of illness perceptions Doing template analysis Impact of peer nutrition education on dietary behaviors and health outcomes among Latinos: A systematic literature review Making and maintaining lifestyle changes with the support of a lay health advisor: Longitudinal qualitative study of health trainer services in northern England Exploiting social networks to mitigate the obesity epidemic Longitudinal weight gain and related risk behaviors during the COVID-19 pandemic in adults in the US Self-quarantine and weight gain related risk factors during the COVID-19 pandemic The authors thank the RHCP partners who contributed to the organization, implementation, and dissemination of this work, and to the health promoters -Rosario Guerrero, Hindi Elmi, Eleazar Flores, and Mohamud Nur. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This publication was supported by NIH Grant No. R01 HL 111407 from the National Heart, Lung, and Blood Institute and by CTSA GrantNo. UL1 TR000135 from the National Center for Advancing Translational Science (NCATS), and by the Mayo Clinic Office of Health Disparities Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. The funding bodies had no role in study design; in the collection, analysis, and interpretation of data; writing of the manuscript; and in the decision to submit the manuscript for publication. Mark L. Wieland  https://orcid.org/0000-0001-6166-3949 All study procedures were approved by the Mayo Clinic Institutional Review Board, IRB# 19-011 574 M. Wieland participated in study design, interpretation of data, drafting of the article and approved the submitted article. J Njeru participated in study design, interpretation of data, drafting of the article and approved the submitted article. G. Asiedu participated in study design, data analysis, interpretation of data, drafting of the article and approved the submitted article. K. Zeratsky participated in interpretation of data, drafting of the article and approved the submitted article. M. Clark participated in study design, interpretation of data, drafting of the article and approved the submitted article. R. Goetze participated in study design, interpretation of data, drafting of the article and approved the submitted article. C. Patten participated in study design, interpretation of data, drafting of the article and approved the submitted article. S. Kelpin participated in study design, interpretation of data, drafting of the article and approved the submitted article. P. Novotny participated in data analysis, interpretation of data, drafting of the article and approved the submitted article. K. Lantz participated in interpretation of data, drafting of the article and approved the submitted article. Y. Ahmed participated in study design, interpretation of data, drafting of the article and approved the submitted article. L. Molina participated in study design, interpretation of data, drafting of the article and approved the submitted article. G. Porraz Capetillo participated in study design, interpretation of data, drafting of the article and approved the submitted article. A. Osman participated in study design, interpretation of data, drafting of the article and approved the submitted article. M. Goodson participated in study design, interpretation of data, drafting of the article and approved the submitted article. I Sia participated in study design, interpretation of data, drafting of the article and approved the submitted article. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.