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Weight Loss on WIC: Assessing the Level of Interest and Weight Loss

Success When a Weight Loss Program is Offered to Mothers Receiving

Benefits from the Women, Infants and Children Program

Maryann Walsh

Master Project

Submitted to the Graduate College of Bowling Green State University in partial

fulfillment of the requirements for the degree of

MASTER OF FOOD AND NUTRITION

April 2011

Project Committee:

Dr. Younghee Kim

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Table of Contents

Introduction…………………………………………………………………………….4

Significance of the Problem……………………………………………………………4

Statement of the Problem……………………………………………………………...5

Significance of the Study………………………………………………………………6

Purpose of the Study…………………………………………………………………...6

Literature Review………………………………………………………………………6

The Women, Infants and Children Program………………………………....6

Behaviors/ Barriers to Weight Loss In Low-Income Women………………..8

Food Choices and Grocery Shopping Habits…………………………………11

The Use of Pedometers in Weight Loss………………………………………..13

The Use of Weight- Ins…………………………………………………………15

Weight Loss Protocol Design…………………………………………………..16

Methods………………………………………………………………………………….20

Overview………………………………………………………………………...20

Recruitment……………………………………………………………………..20

Inclusion Criteria……………………………………………………………….21

Exclusion Criteria………………………………………………………………21

Initial Contact with Participants……………………………………………....21

Secondary Contact with Participants………………………………………….23

Final Contact with Participants………………………………………………..24

Results…………………………………………………………………………………...24

Table 1…………………………………………………………………………...24

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Table 2………………………………………………………………………….25

Sources………………………………………………………………………………….27

Appendix 1: Recruitment Flyer……………………………………………………….32

Appendix 2: Weight Loss on WIC Introductory Survey…………………………….33

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Introduction

Before the advent of overly processed convenience and fast foods, being food

insecure typically meant being underweight and malnourished. In the present day with an

abundance of inexpensive, calorie dense foods available, the opposite has come to

fruition. As of 2008, the CDC has reported that 34% of the U.S. population is considered

obese (BMI of 30 or greater) (31). Government food assistance programs such as the

Supplemental Nutrition Assistance Program (Snap, formerly Food Stamps) and Women,

Infants and Children (WIC) help those that are food insecure by providing supplemental

foods (1)

The major difference in the foods offered by SNAP and WIC is that SNAP

provides an electronic funds transfer card which can be used to purchase any food item

the client desires (1). WIC however provides specific healthy food items including

protein sources (beans, peanut butter), whole grains (whole grain bread or brown rice and

cereals) fruits and vegetables, 100% juices and milk, cheese and eggs (2). Unfortunately,

even with food assistance programs like these that provide access to healthy foods, there

is still a prevalence of obesity in those with a low socioeconomic status (3).

Significance of the Problem

Due to insufficient access to affordable weight loss counseling/programs, women

with low socioeconomic status do not have the ability to receive weight loss guidance and

education. These women belonging to the lower socioeconomic groups also tend to be the

most in need of accessible weight loss/weight management programs.

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Black and others at New York University critically reviewed ninety studies

published between 1997 through 2007 on neighborhood determinants of obesity through

the PubMed and PsychInfo databases. Their findings were that neighborhoods with

decreased economic and social resources have higher incidences of obesity. They also

found that residents of low-income urban areas would typically report greater barriers to

physical activity, such as limited opportunities for daily walking exercise and reduced

access to stores that sell healthy foods, especially large supermarkets (3).

The National Longitudinal Survey of Youth 1979 was utilized in a study

conducted at the City University of New York. The data showed that low-income women

who participated in the food stamp program demonstrated a 9.1% increase in the

predicted probability of current obesity (4). Possible explanations for this could be that by

having supplemental foods to have in the household, this leaves more funds available for

fast food and convenience food consumption.

This study will provide education as well as guidance for women on the WIC

program who desire to lose weight and make healthier choices each day.

Statement of the Problem

The less access that low-income individuals have to weight loss programs the

more likely this group is to remain overweight or obese. In turn, conditions that result

from overweight and obesity such as heart disease, diabetes, high blood pressure, etc. will

be more prevalent amongst the low-income; this will lead to higher public health care

expenses as well as many low-income individuals utilizing government funded health

care.

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Significance of the Study

There is currently an insufficiency of studies examining the desire for low-income

women to lose weight and the success of these women to loss weight after a weight loss

program is initiated. The significance of this study is to gauge the success of a weight

loss program within the WIC program and if a weight loss program should be offered

within local WIC agencies.

Purpose of the Study

The purpose of this study is to design a weight loss protocol for either post-

partum women or mothers of children receiving WIC benefits. The protocol would

provide education on how to utilize the healthy foods that WIC offers as well as

education on meal planning and calorie consumption. A group of women would then be

recruited within the WIC agency to participate in the study. It is hoped that this study will

be able to demonstrate that it is possible for low income women to achieve a healthy

weight without having to spend money on expensive “diet food” including special

shakes, bars, frozen meals, etc.

Literature Review

The Women, Infants and Children Program

The WIC program is a supplemental food program that was created to serve those

women, infants and children in need of food assistance (5). Along with receiving food

vouchers (typically 3 months at a time in check form), prenatal and postpartum moms can

receive breastfeeding advice and all clients receive nutrition counseling regularly

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(typically every 3-6 months). WIC currently serves over 9.1 million individuals in the

US. The goal of WIC is to enhance the nutrition status of Women, Infants and Children

with low income (1) In order to receive WIC a family must be at 185% of poverty,

receiving state cash assistance (TANF), receiving food stamps (SNAP) or be receiving

state medical assistance which are all indicators of a low family income. Therefore, when

a woman is actively receiving WIC’s services they fit the description of being low-

income.

When a woman is on WIC and she provides proof of a confirmed pregnancy and

that she is under prenatal care (typically a doctor’s note stating this information) then she

begins receiving WIC benefits. The food package for a pregnant woman varies from state

to state but generally looks like this: 5.5 gallons of milk (16 ounces can be used towards

cheese), 1 jar of peanut butter, 4 cans of beans (or 1 pound of dried beans), 2 cans of

concentrated juice, 2 dozen eggs, 36 ounces of select cereals, choice of 2 loaves of whole

grain bread or 2 one pound bags of brown rice, and a $10 voucher for fresh, frozen or

canned fruits and vegetables (2).

Once a pregnant woman on WIC gives birth, she then is eligible to receive the

following: the same food package as a pregnant woman, minus 1.5 gallons of milk, 1

dozen eggs and minus the bread/rice option. If the woman is partially breastfeeding she

receives the same as the non-breastfeeding client but with additional milk and juice and

she also receives bread. Lastly, when a woman is fully breastfeeding she receives the

largest food package: The same as a pregnant woman with the addition of 6 cans of tuna,

pink salmon or sardines (2).

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In 1974, years after the initiation of the WIC program, the food packages began to

follow guidelines that coincided with the Dietary Guidelines for Americans. This came

about when the USDA found that when proper nutrition (including the dietary guidelines

of macro and micronutrients) was provided for low-income mothers, Medicaid cost

savings averaged $12-15,000 per infant. This was exciting news that further emphasized

the importance of the WIC program. In 2009, the WIC program upgraded their food

packages again replacing items like 2% and whole milk for children over 2 with 1% and

skim milk as well as replacing white breads with whole grain breads. These changes were

in place to emphasize the importance of the prevention of obesity, which since 1974 had

reached epidemic proportions (6)

Behaviors/ Barriers to Weight Loss In Low-Income Women

While it may be clear that a large number of women participating in the WIC

program are overweight (BMI of 25-29.9), not all may have the desire or interest to lose

weight. An important element of designing the protocol is to include an initial evaluation

of reservations/barriers and motivators. In previous studies of weight loss programs in

low-income women, participants identified higher self-esteem, the ability to be more

physically active, better health, and less societal prejudices toward them as benefits to

losing weight. Barriers to weight loss included lack of personal effort, lack of social

support, inadequate finances, and low self-esteem. Participants believed that group

support weight loss programs modeled after Weight Watchers® would be beneficial (7).

Another factor to consider in post partum weight loss is the amount of stress that

the mother may be under. One study showed that stressful experiences triggered

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emotional eating and reduced participants' ability to practice healthy eating behaviors (8).

Other factors—for example, wanting quick weight-loss results—made it difficult for

these mothers to follow recommended healthful lifestyle practices. Nutritionists/dietitians

can address these concerns by including information about ways to deal with stress and

emotional eating and emphasizing the benefits of healthful eating and physical activity in

their program plans.

The mental health status of the participant must be considered as well when

initiating a weight loss program. The prevalence of post partum depression is

significantly higher in lower-income women compared to more affluent women (29).

Two hundred and nineteen families were examined by self-reporting depression for low-

income rural women experiencing depressive symptoms. Just over one half (52.5%) of

respondents who were experiencing depressive symptoms self-reported depression,

whereas 47.5% of respondents self-reported no depression. Women reporting depression

were significantly likelier to report physical health problems, injury/illness, and more

frequent physician visits. Women reporting no depression were significantly likelier to

have been pregnant in the previous 3 years. The study concluded that women reporting

depression had more health care system exposure and perhaps depressive symptomology

knowledge. Public health campaigns should educate about depressive symptoms,

including postpartum depression, to reduce stigma and increase treatment seeking (9).

In Sonoma Country California (an area with a high Hispanic population) a study

was done to assess depression symptoms in women under 45 years old in five California

counties. A significant negative association was found between the number of people in

the household and depressive symptom scores, that is, with fewer people in the household

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depression increased (15). This result may indicate the need for a support system that is

more accessible to individuals in smaller households or it may be an artifact of Hispanics

having larger families and lower depression scores. The results indicated that there is a

critical need to provide mental health resources to low-income women, especially those

with young children as well as consider the mental health of a participant of a weight loss

program.

Eating habits in early post-partum need to be considered when conducting a

weight loss study on post-partum women. In a study focusing on early post-partum

women, The Eating Stimulus Index (ESI) was given to participants in order to determine

the relationship between motivations to eat with diet quality and food intake in 115

overweight/obese, low-income women in early postpartum (10). Regression analysis

indicated that convenience-eating resistance was the strongest predictor of diet quality in

the post partum women, followed by vegetable taste preference, and the availability of

fruits and vegetables. Convenience eating resistance was also the strongest predictor of

discretionary energy intake. This study was valid because it showed the importance of

knowing your clients ability to access certain foods before expecting them to eat these

certain foods. This study also showcased the validity of the ESI as a useful tool in dietary

behavior assessment.

Another barrier to consider in healthy eating habits among low-income women is

their ability to budget their resources, whether it is a combination of personal income and

food vouchers or just food vouchers (food stamps, WIC checks, etc). Tarasuk and others

found that a woman's intakes of energy, milk products, and vegetables decreased

significantly as the time since she received income increased (16). When their food

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security status was considered, women who were food secure or marginally insecure

showed no significant within-month patterns, but significant declines in energy,

carbohydrate, vitamin B-6, and fruit and vegetable intake were observed for women with

moderate or severe adult food insecurity. The food intakes of women in deprived

circumstances are sensitive to the decline in household resources following the receipt of

a monthly check. This indicates that it is necessary to provide education in meal planning

and in budgeting one’s food allowance within a weight loss program.

Food Choices and Grocery Shopping Habits

A crucial aspect of initiating any weight loss protocol is to evaluate the food

selection and consumption behaviors of the participants in the program. Wiig and Smith

set out to investigate factors affecting food choice and health beliefs among low income

women taking into consideration their weight and socioeconomic status (11). Ninety-two

low-income women ages 18-65 with at least 1 child age 9-13 were asked to participate in

focus groups. The results were extremely interesting: 75% had a BMI over 25 and most

were in charge of doing the grocery shopping for the families. Many of the women

blamed their health problems such as hypertension, overweight/obesity and diabetes on

genetics or their metabolism. Many of the women claimed they enjoyed eating fruits and

vegetables but the cost was what deferred them from eating more of them. This clearly

shows that there needs to be more adequate education on how to better stretch one’s food

dollar especially when supplemental nutrition programs are being utilized.

Wiig and Smith also set out to examine grocery shopping behaviors and food

stamp usage of low-income women with children to identify factors that influence their

food choices on a limited budget (12). This study also utilized focus groups. Ninety-two

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women, of whom 76% were either overweight or obese with a mean age of 37 were given

a grocery list consisting of 177 items. Each participant was asked to prioritize the items if

they only had $50 to spend (this number was taken from the average amount of food

stamp allotment). Surprisingly meats were given highest priority, and the biggest barriers

to buying, and transportation and store accessibility were listed as most common barriers

to shopping frequency. Participants used various strategies to make their food dollars

stretch by buying what was on sale (even if these items were not the healthiest of

choices). This study clearly showed that the participants needed to be taught strategies to

prepare meals without as much meat, which is typically expensive and can be high in

saturated fat and cholesterol. Also, it appeared to be necessary to better educate the

participants on how to purchase fruits and vegetables more cost effectively (frozen or

canned instead of fresh).

Wiig and Smith most recently conducted a cross-sectional study that investigated

low-income, urban Minnesotan women's past-month food purchases and their

associations with race, homelessness, and aspects of the food system, including food

shelf (food pantry) and food store usage (13). These associations were factors believed to

influence food choice and grocery shopping behavior. The subjects were surveyed on

demographics, the US Department of Agriculture’s 18-item Household Food Security

Survey Module, and grocery shopping questions related to food purchases and food

stores visited in the past month. Participants consisted of a convenience sample of 448

low-income, urban Minnesotan women, and the data was collected from February

through May 2008. The sample breakdown was as follows: 44% African American, 35%

American Indian, 10% white, and 11% other/mixed race; 37% were homeless. The rate of

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“less healthy” food group purchases were higher compared to “healthy” food group

purchases. One extremely interesting finding was that food shelf (food pantry) usage

increased the odds of purchasing less healthy choices at supermarkets. Also, it was seen

that race has a direct relationship to protein choices but not to fruit, vegetable and whole

grain choices. This information solidifies the fact that in a research study such as the one

being conducted it is necessary to help develop strategies on how any money available

for food should be spent.

Another important factor to consider is the ambition of the women to go and

utilize her supplemental food checks. In a rather large study focusing on 454 participants

86% were Hispanic, 7% non-Hispanic black, and 7% of other ethnic backgrounds.

Participants reported purchasing a wide variety of items (14). The 10 most frequently

mentioned items were oranges, apples, bananas, peaches, grapes, tomatoes, carrots,

lettuce, broccoli, and potatoes. In conclusion, low-income women used the supplement

provided almost fully, and purchased a wide variety of fresh fruits and vegetables for

their families. No particular barriers arose to redemption of the vouchers by either the

participants or the retail vendors.

The Use of Pedometers in Weight Loss

The plan for the study is to make it as convenient as possible for the clients

participating in the study to fully participate. Pedometers are being given to each

participant as well as instructions on how to use the pedometer and how to incorporate

them into their everyday lives. In a meta-analysis focused on the use of pedometers in

weight loss interventions participants lost an average of 1.27 kg (.05 kg per week) during

the interventions (17).

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When pedometers were given to sedentary office workers, average steps per day

went from 7,029 ± 3,100 (SD) at baseline to a plateau of 10,480 ± 3,224 steps/day by

3.96 ± 3.28 weeks of the intervention. On average, participants experienced significant

decreases in BMI, waist girth, and resting heart rate. Reductions in waist girth and heart

rate were significantly related to the increase in steps per day. In addition, reductions in

BMI were predicted by the initial steps per day (18).

Another systematic review showed very similar results when adding a pedometer

to a weight loss program: pedometer users significantly increased their physical activity

by 2183 steps per day over baseline (95% CI, 1571-2796 steps per day, P < .0001) (19).

Overall, pedometer users increased their physical activity by 26.9% over baseline. An

important predictor of increased physical activity was having a step goal such as 10, 000

steps per day (P = .001). When data from all studies were combined, pedometer users

significantly decreased their body mass index by 0.38 (95% CI, 0.05-0.72; P = .03).

These studies are encouraging because using pedometers is a convenient,

inexpensive and fun way to track steps and to encourage additional steps (such as using

the stairs instead of the elevator). Having a pedometer can significantly cause an increase

in physical activity when goals are set for the number of steps per day, and the fact that a

client’s own home or place of employment can be their “stepping ground” makes

pedometers a very convenient weight loss aid (20). An amount of 10,000 steps a day

(which is equivalent to about 5 miles) done by a 175lb male walking 2 mph burns 398

calories, which is an impressive amount of calories to burn while going about one’s day

(21).

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The use of Weigh Ins

Monitoring of the participant’s progress is a crucial aspect of any weight-loss

program. With self-reporting of progress comes the occurrence of over and under

reporting, and not all participants may own scales so scheduled weigh-ins are often

necessary. Haq and others found that there was a significant difference between measured

and reported weight (mean difference=−3.75 lb, p=0.0001) and height (mean

difference=+0.35 in., p=0.0007). The mean difference between measured and reported

BMI was −1.14 kg/m2 (p=0.0001) (22). Unemployed, retired, or disabled women were

more likely to under-report their BMI than employed women (p=0.001). This is relevant

information because many of the clients of WIC are unemployed. Another interesting

finding within this study is that six percent of subjects who were initially considered

eligible for the study on the basis of the self-report were eventually excluded from the

study because they did not meet the inclusion criterion for BMI. This shows that it is

important to do an in-person weigh in when pre-screening the clients for participation,

without relying on self-reporting.

The frequency of weigh-ins is an aspect that needs to be considered. Butryn found

that 36.2% of study participants reported weighing themselves at least once per day, and

more frequent weighing was associated with lower BMI and higher scores on

disinhibition and cognitive restraint (23). Other participants who did not weigh daily still

showed favorable results; therefore this is an element that will have to be discussed with

the participant. The psychological outcome of weighing one’s self everyday (especially

without seeing results) can deter weight loss efforts for some, so this is an area that needs

to be explored with the participant individually.

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Wing and others randomly assigned 314 participants who had lost a mean of 19.3

kg of body weight in the previous 2 years to one of three groups: a control group, which

received quarterly newsletters (105 participants), a group that received face-to-face

intervention (105), and a group that received Internet-based intervention (104) (24). The

content of the programs in the two intervention groups was the same, emphasizing daily

self-weighing and self-regulation, as was the frequency of contact with the groups. The

primary outcome was weight gain over a period of 18 months. As compared with

receiving quarterly newsletters, and the internet based interventions, a self-regulation

program based on daily weighing improved maintenance of weight loss, particularly

when delivered face to face, it was the most successful approach to weight loss

monitoring and maintenance.

Weight Loss Protocol Design

The creation of an effective weight-loss protocol requires careful planning and

consideration of the demographic involved. Gustafson and others set out to assess the

cost-effectiveness of a 16-week weight loss intervention (it was named “Weight-Wise”)

for low-income midlife women (25). The study design was a randomized controlled trial

conducted in North Carolina in 2007. It tested a weight loss intervention among 143

women (40–64 years old, mean BMI=35.1 kg/m). The participants were randomized to

one of two groups: special intervention (n = 72) and a wait-listed control group (n = 71).

The effectiveness of the study was measured in changes in weight, systolic and diastolic

blood pressure, total cholesterol, and HDL cholesterol.

Cost-effectiveness was measured by calculating life years gained (LYG) from

changes in weight, based on a years life lost (YLL) algorithm. The results showed that

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intervention participants had statistically significant decreases in weight (kg) (−4.4 95%

CI=− 5.6, −3.2) and in systolic blood pressure (− 6.2 mm Hg, 95% CI=− 10.6, −1.7)

compared to controls. The total cost of conducting Weight-Wise was $17,403, and the

cost per participant in the intervention group was $242. (Both were funded by the

University of North Carolina School of Medicine and Public Health.) The incremental

cost per life year gained from a decrease in obesity was $1862. These results showed that

the “Weight-Wise” protocol is effective and could be considered for use in future group

weight loss programs for women with low income.

Often evidence-based interventions may not match the specific population or

health concern of interest. The Multisource Method (MSM), which, in combination with

a workshop format, may be used by health professionals and researchers in health

promotion program development (26). The MSM draws on deviating from past protocols

and processes, focus groups, community advisors, behavioral change theory, and

evidence-based strategies. The MSM can be a useful method to follow when you are

creating a protocol/program for a demographic which has not been previously

represented and when you have no earlier information to draw from.

Klohe-Lehman and others set out to examine if greater nutrition knowledge vs.

gains in knowledge promote more successful weight loss in low-income, overweight and

obese mothers with young children. The design consisted of a convenience sample of

mothers and their children who were measured for height and weight; mothers completed

demographic and nutrition knowledge questionnaires pre- and post intervention (27). The

141 participants were recruited from government and public health clinics and

elementary schools. Inclusion criteria for mothers were: family income <200% federal

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poverty level; overweight/obese; and Hispanic, African-American, or white

race/ethnicity.

The intervention consisted of eight weekly weight- loss classes emphasizing diet,

physical activity, and behavior modifications based on the Social Cognitive Theory and

were administered to the mothers. The outcomes measured were: Improvements in

maternal nutrition knowledge and weight loss. Statistical Analyses Performed were:

Paired-samples t tests, repeated measures analysis of variance, analysis of covariance,

Pearson correlations, and x2 statistics. The results were that nutrition knowledge of

mothers increased in all areas. Participants with weight loss ≥2.27 kg (responders) had

greater knowledge than those who did not; the drawback however was that the actual net

gain was similar for those who lost and did not lose weight. Weight gainers only

improved in two areas on the test, whereas weight-loss responders increased knowledge

in all six.

Responders appeared more aware of diet, weight loss, and health information.

This study is an important reference because it shows that weight-management programs

should include a strong component of nutrition education to alleviate knowledge

inequalities and promote more effective weight control. In low-income mothers, greater

initial knowledge may be more predictive of weight loss than gains in knowledge during

an intervention. This is great knowledge to have going in to the said study that will be

conducted.

Jordan and others discussed the evaluation of a nutrition and physical activity

program for reducing body weight and improving nutrition attitudes in mothers of young

children. A convenience sample of 114 intervention mothers and 33 comparison mothers

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was recruited from public health clinics and community centers (28). Eligibility criteria

included Hispanic, African American, or white ethnicity; body mass index of at least 25

kg/m, low income (<200% of the federal poverty index); and youngest child aged 1 to 4

years. For intervention participants, height, weight, percentage of body fat, waist

circumference, demographics, nutrition attitudes, and dietary intake were measured at

weeks 0 and 8; height, weight, percentage of body fat, and waist circumference were

reassessed at 6 months. Overweight mothers in the comparison group provided

anthropometric and demographic data at weeks 0 and 8. Changes in anthropometrics,

attitudes, and dietary intake were evaluated in intervention mothers. Anthropometric data

of intervention vs. comparison group mothers were examined. Differences in

anthropometrics and attitude scores between weight loss responders (≥2.27 kg) and non-

responders (<2.27 kg) were assessed at week 8. Intervention participants lost weight, an

average of −2.7 kg. Comparison mothers gained a slight amount of weight, an average of

.1 kg by week 8. Weight loss responders had healthier eating attitudes and fewer

perceived barriers than the non-responders post-intervention. In conclusion, the dietary

and physical activity curriculum studied is a valuable resource for weight management

programs serving low-income women.

A meta-analysis found thirteen study interventions centered solely on diet

modification, five focused only on physical activity, and five concentrated on a

combination of both (30). The preponderance of studies targeted WIC and urban

recipients. While the majority of intervention studies supported the use of the

Transtheoretical Model of Change (TTM) for weight loss and preventing weight gain,

researchers noted that challenges still exist and further interventions are needed.

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Methods

Overview

The study will take place from mid-January to mid-March and will focus on providing

informal, individualized weight loss education and recommendations for mothers who

participate in the WIC program. By using an open-ended approach it will allow the

women to talk one on one with a nutritionist and ask questions and gain insight as to how

they can change their eating habits in order to lose weight.

Due to the varying levels of financial resources and access to safe venues for exercise

among the mothers, pedometers are being given to the mothers. The pedometers will be

provided in order to provide a simple to use, inexpensive way for the women to track

their daily steps and make them aware of opportunities for daily exercise within their

individual lives. The researcher is providing funding for the pedometers. Reporting of

steps will not be required from the women, however at the end of the study the women

will be required to disclose how often and to what extent they used the pedometers.

Recruitment

Recruitment of participants will begin the project. Information flyers will be posted in

two WIC office locations, both of which are run by the same agency (Tri-Town

Community Action Agency of Johnston, RI). Contact information in the form of both e-

mail and office phone number of the student who is conducting the project will be given

on the flyer. This sign will be posted at the beginning of December and recruitment will

take place from December to mid January (Appendix 1). All data recorded during contact

with the participants will be recorded in Table 1.

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Inclusion Criteria

The following is the inclusion criteria for the program:

Must either be on WIC as a post-partum or breastfeeding mother –or-

Must have at least 1 child on WIC

Must be either a client of the two office’s participating in the program or must be

able to travel to either of the offices.

Must be able to walk (for the pedometer portion of the program)

Exclusion Criteria

The following is exclusion criteria for the program:

Not being on WIC or having a child on WIC

Those who are currently pregnant or are planning on becoming pregnant between

mid January to the end of March.

Initial Contact with Participants

Initial contact will begin with the planning of 2-3 initial meeting times. The woman will

choose a meeting date and time that works best with their schedule. Those who cannot

make it to the set meeting times will then be offered an individual appointment with the

administrator of the study.

During the initial meeting, participants’ height, weight and waist circumference will be

taken as the baseline data. The participants will then be asked to write down their biggest

barrier to weight loss and to also fill out a short informative survey (Appendix 1). While

they are filling out the survey the administrator will calculate the basal metabolic rate of

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each participant and then multiply by 1.2 (sedentary) for every participant, regardless of

what they may self report for their typical daily exercise.

Next the participants will each be given a pedometer and will be instructed how to

use it to incorporate physical activity into their daily routines. Afterwards, the

participants will be given a general “pep talk” about healthier eating focusing on whole

grains, fruits and vegetables (the importance of them and how to stretch one’s food

budget to include more of them) as well limiting sugars and watching caloric intake.

The “pep talk” will be an interactive, open-forum group conversation outlined as follows:

1. Swapping refined, white breads for whole grain versions

a. Why whole grains are healthier

b. Why they aid in weight loss

c. How to find inexpensive whole grain products

2. Incorporating fruits and vegetables into one’s daily diet

a. Why fruits and vegetables are so important to human health

b. Why fruits and vegetables aid in weight loss

c. How to stretch one’s dollar when buying fruits and vegetables

3. Limiting sugars in one’s diet

a. The importance of cutting out sugar sweetened beverages completely

b. How to choose foods low in sugar

c. Why excessive sugar hinders weight loss

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4. Calorie counting/watching

a. Why calorie counting is an effective way to keep one’s diet under control

b. How to count calories easily while practicing portion control

c. How calorie counting equates to weight loss

The purpose of the pep talk is to educate and provide a forum for the participants to ask

questions and learn. The participants will not be tested in any way on the information

given. It is hoped that the 24-hour recall taking place in the second contact will reflect the

initiation of practicing the habits associated with the education provided. After the brief

educational portion of the initial contact session, the participants will be given contact

information, both email and office telephone number of the program administrator. They

will be encouraged to call the administrator whenever questions should arise or if they

just need some motivational words or ideas. The participants will be sent on their way

and will be given a date approximately 1 month from the present date to come to the WIC

office for a weigh in. Monthly weigh ins will be scheduled 2 times throughout the

program after the initial weigh in, 1 to mark the mid-way point and 1 more for the final

assessment.

Secondary Contact with Participants

Secondary contacts will be arranged by appointment with each participant. The

participant’s weight will be taken and then the participant will have time to discuss how

the first month went and what they think they need help improving upon. Each

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participants will also be asked to provide a 24 hour recall. It is hoped that this 24 hour

recall will help assess the participant’s compliance with the healthy eating habits

discussed at the initial contact.

Final Contact with Participants

The third and final contact with the participants will be scheduled as a group meeting like

the first contact and will take place after 2 months. At this time weight and waist

circumference will be taken. The participants will be given an opportunity to discuss as a

group how they feel about their weight loss (if any weight was lost).

Results

The mean weight loss was 9.4 lbs with the most weight in pounds being lost at 20.2 lbs

(10% weight loss for participant). The lowest amount of weight loss in pounds was 4.2

lbs (3% weight loss for participant). The overall greatest loss was 10.2 % body weight

loss (a 13.6 lb weight loss from a starting weight of 132.6) (Table 1).

For the waist circumference data, the greaest loss in inches was 7 inches, with the least

amount of inches lost being 0 (Table 1).

Table 1:

Weight Data:

Waist Circumference Data:

Column n Mean Variance Std. Dev. Std. Err. Median Range Min Max Q1 Q3

var1 8 9.375 31.045 5.571804 1.9699302 8.2 16 4.2 20.2 4.5 12.6

Column n Mean Variance Std. Dev. Std. Err. Median Range Min Max Q1 Q3

var1 8 3.25 4.5 2.1213202 0.75 3 7 0 7 2 4.5

25

Table 2:

Initial Contact

Anthropometrics

1 (63in)

2 (65.5in)

3 (61in)

4 (59in)

5 (60in)

6 (68in)

7 (60.5in)

8 (62in)

Weight (lbs) 152 169.4 137.8 128.4 132 202.2 165.4 132.6

Waist

Circumference (inches)

33 37 41 29 28 44 39 26

Secondary Contact

Anthropometrics Use Pedometer?

1 (63in) Yes

2 (65.5in) Yes

3 (61in) No

4 (59in) Yes

5 (60in) Yes

6 (68in) No

7 (60.5in) Yes

8 (62in) Yes

Weight (lbs) 145.8 167.2 142.2 124 134.8 191 167.6 129.2

Waist

Circumference (inches)

32 37 42 28 28 41 39 26

Final Contact

Anthropometrics

Use Pedometer?

1 (63in)

2 (65.5in)

3 (61in)

4 (59in)

5 (60in)

6 (68in)

7 (60.5in)

8 (62in)

Weight (lbs) 140.4 164.6 133.6 120 127.8 182 157.4 119

Waist Circumference (inches)

28 37 39 26 26 37 35 23

Discussion

It is evident through the data that the program was a success. When the second

contact occurred and 3 of the 8 clients has gained weight, it prompted that student

researcher to ask each participant (including those who had lost weight) if there was

anything they would like to change/add to the program. Four of the 8 participants

mentioned that they felt their success could be greater if they could be “checked up on”

each week between the monthly weigh-ins. All participants, including those who had not

expressed initial interest in the weekly contacts from the researcher agreed to take part in

26

them. It was decided that due to the fact that all of the participants had cell phones with

text messaging capabilities (as well as the researcher) that weekly “text check-ins” would

be appropriate on Fridays to provide motivation to continue healthy eating habits

throughout the weekend. The researcher would text message each of the 8 participants

each Friday afternoon and ask how they were doing and what their plans were for the

weekend, if plans included a party or social situation where food was involved the

researcher would call the client to obtain more information and provide motivation and

tips on how to not overindulge while still enjoying themselves. The participants

expressed that these weekly “text check-ins” helped keep them on track with their healthy

eating and gave them motivational strategies to continue to stick with their healthy eating

habits.

Besides the weekly “text check-ins” a majority of the clients expressed approval

of the informal nutrition counseling sessions incorporated into their monthly weigh-in

contacts. It was hoped that the informality of the monthly contacts would initiate an open

forum for the participants to ask questions and discuss barriers to losing weight all while

helping to develop strategies for continuing their weight loss success or maintaining their

weight loss if their desired weight was reached.

Lastly, 6 of the 8 participants claimed that they used the pedometers between the

1st and 2nd contact, while none of the participants claimed to use the pedometers by the 3rd

contact. In hopes of keeping the process as simply and unintimidating as possible the

participants were not required to track their pedometer use, perhaps had they been

required to even greater weight loss results would have been seen. The pedometers main

purpose was to serve as an incentive and as a fun way to encourage physical activity

27

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32

Appendix 1

Looking to shed some pounds in

2011?

Participate in the “Weight Loss on WIC Study” taking place this January through March.

Requirements to Participate:

Must be either a post-partum mom on WIC or a mom with children receiving WIC benefits.

Must be 18 or over.

Must be able to make it to this WIC office 3 times throughout the 2 month study.

Contact Maryann Walsh to register or for more info: walshm@bgsu.edu

401-519-1933

33

Appendix 2

Weight Loss on WIC Introductory Survey Name:__________________________

Email:____________________________

Phone:______________________________

Date of Birth:________________ Height:____________

Current Weight:_________

Goal Weight:_________

Current Waist Circumference:_________

Please briefly describe past weight loss efforts/programs which you have tried (if any):

What did you like/dislike about these methods/programs:

What is your biggest challenge to weight loss?

Do you have any medical conditions that would affect your weight loss on this program?