Obesity is a public health concern in many developed countries. In New Zealand just like many other developed countries, the prevalence of obesity is disturbing. According to research, the prevalence of obesity was 33% in 2011. In 2 years it shot to 38.2%. The statistics on obesity among the Maori community currently surpasses that of the country. Research indicates that close to half of the adult population is obese. Another 34% of them are reported as overweight but not obese. The rate of obesity among Maori adults has increased from 27% in 2007 to 32% in 2017. Over 18% of children in the Maori community are obese and another 21% reported as overweight but not obese. This set of facts provides the justification for coming up with an intervention plan that deals with obesity as a public health concern. The intervention plan will include a mix of strategies aimed at bringing down the prevalence of obesity as well as determinants that predispose to the condition. Strategies aimed at change of dietary and nutritional habits, physical activity, fitness and sleep and behavioral changes are sought in the intervention plan. The intervention engages several stakeholders such as the District Health Board of Manukau District as well as related organizations such as Healthy Families New Zealand and the Healthy Outcomes for All. An evaluation of the intervention plan which assesses the effectiveness of the strategies is then presented.
Summary of the Main features of the Intervention Plan
This section of the paper provides a description of the strategies and approaches that the intervention plan intends to employ in dealing with the prevention and reduction of the prevalence of obesity and overweight among the Maori community living in the Manukau District. A conceptual framework for the analysis of the issues is also provided.
A diet and nutrition strategy as a part of an intervention for obesity will encompass several areas. To begin with training sessions for affected persons both in workplaces and in learning institutions will help to lay the ground work. Dietary fat has for a long time been thought to be the major determinant for obesity and overweight. Through research it has emerged that intake of large amounts of mono-unsaturated and poly-unsaturated fats have no linkage with obesity (Wilson et al, 2012). Higher intake of whole grain meals has also been associated with a reduced risk of obesity. Refined grain on the other hand is a determinant of obesity and weight gain. By collaborating with the District Health Boards and willing partners, nurses and nutritionists ought to be engaged in the dissemination of this knowledge to affected groups.
The relationship between alcoholic beverages and weight gain is interesting. A study revealed that women who only engaged in light to moderate consumption of alcohol (less than 30g per day) had reduced risks of becoming overweight as compared with heavy drinkers (Zapico et al, 2012). The intervention plan is to help obese persons to make the right decisions regarding their diet and replace unhealthy dietary options with diets loaded with fruits and vegetables. This component of the intervention can be achieved by increasing the availability of healthier food options for obese and overweight people in workplaces and learning institutions (Sevinç et al, 2011). After sufficient capacity has been developed in them to make the right food choices, the trainers can provide them with food timetable to guide them on how to follow a healthy eating routine while at home.
The second component of the intervention will focus on physical activity, lifestyle and sleep for the persons who are overweight or obese. Increased levels and frequency of physical activity are associated with lower risks of developing obesity (Salvadori et al, 2014). It also helps in the maintenance of healthy weight after losing weight. On the contrary, a lifestyle that is characterized by less physical activity (less than 30 minutes a day) predisposes one to the risk of developing obesity. Through engaging physical trainers, the intervention can provide bicycles for the affected persons to ride to work for instance. Creation of a workplace culture that enables the loss of weight is also a vital component of the strategy mix (Prendergast et al, 2016). For instance, the obese persons can be organized into clusters where they meet after work for cycling or Zumba classes or even aerobics. To help the persons avoid a sedentary lifestyle at home, they can be provided with a home timetable that specifies activities to be completed at home with specified timelines. The timetable should specify the time to spend on each activity including sleep. According to Sammito (2016) women who spent fewer than 5 hours were 32% likely to become overweight as compared to those who slept 6 hours or more in which case the likelihood of becoming overweight and developing obesity was 12%.
According to data available from the New Zealand Health Survey, obesity is major public health concern. The study was conducted in Manukau district (where the Maori community is predominantly found), of the sampled population of adults 38% were obese (Rush et al, 2010). This numbers has increased rapidly from what it was in 2006/7 which was only 33%. The problem of obesity and overweight in Manukau District is of public health concern because it is 10% higher compared to the prevalence of obesity in other counties.
Obesity in Manukau is a societal problem; all people are affected from infant to adolescents and old adults. According to the study mentioned above, in 2011, approximately 149000 people were obese. This figure represents about 33% of the Maori population (Counties Manukau Health 2015). In just 2 years the prevalence had risen to 38.2%. The prevalence of obesity among adults in Manukau now stands at 40%. Among children of ages 2-14 the prevalence of obesity is steady at 19% according to the same study. Women of the ages 25-44 are the worst hit by the problem (CDC 2018). They have recorded the highest prevalence of obesity in all the age-gender categories.
The effects of obesity among the Maori community have increased over the last few years since 2011. The risk of developing other lifestyle diseases such as cancers, diabetes, hypertension and high blood pressure is increased among the Maori population (Counties Manukau Health 2014). The general poor quality of life and ill health caused by obesity increases the likelihood of premature deaths. The burden of treating and taking care of obese people to the family is high. This is made complex by the increased risk of other associated conditions. The economic burden to the District Health Board is also significant as it has to allocate more resources towards the treatment of the condition.
This section of the paper gives a recap of the mix of strategies that can be implemented in order to prevent and reduce the prevalence of obesity and overweight among the Maori population in the Manukau District.
Given that the major determinant of obesity is poor diet, the intervention plan must target the eating habits of the people. According to Utter et al, (2010) provision of nutrition program trainings by qualified nutritionists and nurses at the workplaces and in schools is a priority. The plan for the awareness creation through nutrition trainings is to create sufficient capacity in obese and overweight people on the need to take healthy foods. The next step would be to increase the availability of healthy food options in schools and also in the workplace as recommended by the Center for Disease Control (CDC 2018). This can be implemented by having healthy food kiosks set up in strategic locations in the workplace and schools. To encourage people to take up healthy food options the prices can be adjusted to make them affordable. Wilson et al, (2012) posit that in order to ensure adherence to a healthy diet, the nutrition program can offer healthy food timetable for every individual to help them regulate their meals at home and in the workplace.
Study shows that self-stigma and lack of self-esteem is a major enabling factor that causes individuals who are overweight to become obese. This is attributable to the fact that overweight individuals face the challenge of being stigmatized in the community and as such live an unhealthy mental life. The consequence is that the social environment created around obese people is not conducive for social interactions like play and other physical activities (Sammito 2016). Through individualized and group trainings for obese and overweight people, they can be empowered to begin to think and act differently. Personal goal setting skills are valuable tools for achieving this intervention plan. Counseling activities for both adults and children must be aimed at reducing the amount of time individuals spend behind the TV screens as well laptops and other electronic devices. Change of behavior ought to target a more active lifestyle.
The third mix of strategies should focus on ways of enhancing the amount of physical activity among the obese and overweight persons. Lack of physical exercises and living a sedentary lifestyle predisposes one to weight gain and obesity Cormack et al, 2018). A good start for this plan is to build capacity in the obese and overweight persons to understand the need for engaging in physical exercise through training. Assigning of personal trainers to take them through the program is also very necessary. In the intervention plan, setting of weekly targets for weight loss is essential. Proposed activities for engagement should include Zumba which is popular among the Maori community (Lal et al, 2012). Provision of bicycles to encourage individuals to take up cycling classes as a form of physical exercises is also good.
The Maori community living in Manukau District is the principal stakeholder in this initiative because it is for them. Getting the Maori people to be involved in this study will not be easy. According to Theodore et al, (2015) Maori people, being indigenous, are generally not receptive to new information. The initiative will access the people though their leaders. If their leaders are convinced that the obesity control initiative is a worthwhile venture, the community will easily get on board. The Maori Leadership Forum is an excellent platform to pitch the intervention to the community leadership because all the tribal groupings will be represented. The idea shall be presented to the tribal leaders for them to approve so that the community members can participate.
As pointed out by Boyd Swinburn in his presentation to the ELT in Anderson et al, (2016), there is no one single magical answer to the problem of obesity. The implementation and the evaluation of a working intervention plan must involve all the stakeholders in the public health sector in Manukau District such as the District Health Board (DHBs), and organizations working in obesity prevention programs such as Healthy Families New Zealand (HFNZ) and Better health Outcomes for All (BHOfA). District Health Boards are created under the New Zealand Public Health and Disability act to deliver health and disability services to citizens. As such it is a stakeholder by default. Healthy families New Zealand is an initiative that supports health promotion initiative working in Manukau District. Given the convergence of interests, the initiative will engage HFNZ as partners in the intervention. Better Health Outcomes for All is an initiative for obesity work stream that is already operational in Manukau District. It will be necessary to involve them as stakeholders in order to streamline and coordinate efforts.
This section of the paper takes a look at the intended outcomes that are targeted to be achieved upon successful implementation of the intervention plan. It takes a look at the expected changes with regard to the problem of obesity as well as its determinants.
The changes that are sought in an intervention plan for tackling obesity are principally to bring down the prevalence of obesity among the Maori people. It also targets to see a reduction in the determinant factors or predisposing factors for obesity. This is informed by the fact that if and when the predisposing factors are dealt with adequately, the risk of developing obesity is either reduced or eliminated altogether. According to Tobias et al, (2014) predisposing factors for obesity include but are not limited to; poor diet (fatty and high calorie intake), lack of physical exercise, sedentary lifestyle, genetic factors and lifestyle habits such as smoking, drinking and drug use.
One of the major goals of an intervention plan for obesity is to see healthy dietary habits among the affected population (Shultz et al, 2014). Specifically, the intervention plan objectifies to eliminate the consumption of unhealthy foods that are obesity enabling; these include fatty foods as well as foods with high calorie content such as carbohydrates and fat. These are to be replaced by a diet which is characterized by plenty of vegetables and fruits (Lederer et al, 2015). By the end of the two months of the intervention, the intervention plans to have set up a healthy foods joint in every school in Manukau Dsitrict to enable access by students and teachers in the workplace. An intervention plan for obesity must seek to cause a change of preference for fast foods to homemade, properly cooked foods. Junk and fast foods must be eliminated completely.
As a matter of necessity, another key goal sought by the intervention plan is a behavioral change among the targeted people. The development of overweight and obesity is enabled by poor decision making in life which can only be altered if the individuals are inspired to change their attitudes and behavior (Mahmood et al, 2014). The condition obesity is associated with a poor mental health attributed to the fact that most obese people live in fear of being stigmatized by the society. In essence they end up stigmatizing themselves. They tend to withdraw from the general society and do not socialize. The social environment around them becomes one that is not facilitative of healthy social relationships. This forms the basis for the intervention plan to objectify getting the affected persons to be able to develop self-esteem, and a feeling of self-love and appreciation so that by the end 8 months, 50% of participants should be able to begin socializing and engaging in outdoor activities as evidence of self-love and acceptance. The goal is to inspire them towards positive thinking which helps them to develop positive energy while disregarding sources of negative energy.
As part of seeking behavior change, the intervention plan also seeks to change other habits and lifestyles that enable the development of obesity. Enabling factors present in lifestyle such as smoking, drinking and drug use (Pearson et al, 2014). Creating in the obese and overweight persons the capacity to make a decision to stop the use of drugs and cigarettes is a priority area for the intervention plan.
Another important objective that must be met by the intervention is to get the obese and overweight persons to engage in physical exercises. Taking the right, healthy diet alone is not enough to reverse the trend of obesity. An intervention plan that involves a mix of a healthy diet as well as physical exercises makes an effective weight control management (Howe et al, 2015). Physical exercises in achieving this goal it is compulsory that the targeted individuals are first enabled to appreciate the need of engaging in an active lifestyle. The intervention must discourage the tendency to live a sedentary lifestyle marked by spending endless hours behind TV screens, laptops video games or other electronic media. The initiative targets to help participants to reduce their screen time by 50% by the end of 24 months. As posited by Lacy et al, (2015) the plan is to substitute these hobbies with healthier more physically engaging outdoor activities which help the individual to burn their calories, avoid fat deposition and reduce obesity and overweight. The goal is that all participants should be enrolled on an exercise or fitness program where their weights can be monitored regularly. The participants will through the physical exercise be expected to lose 5kg of their body weight every month until a BMI less than 25 is achieved.
This section of the paper gives a detailed description of the specific evaluation plan activities that are going to be implemented to conduct an assessment of the effectiveness of the intervention plan. It attempts to create link between the measurements of change in the stated problem as well as the determinants of obesity.
To evaluate the effectiveness of the healthy diet programs for obese individuals, a timetable specifying what foods they ought to take at home should be provide to them by the nutritionists in the program. The food timetables should specify the food rations for every meal as well as meal intervals (Theodore et al, 2015). To assess the adherence to the food timetable and the nutrition program, the nutritionists from the District Health Board and the HFNZ should conduct random home visits at meal times to see for themselves how the persons involved are preparing and taking meals. As Counties Manukau Health (2015) presents, the intervention plan also mentioned the need for healthy food options to be availed at workplaces and institutions of learning in order to facilitate access by the overweight and obese persons. The public health officers from the DHB can liaise with the institutions’ administrations to help set up the healthy food kiosks.
One of the major objectives sought by any intervention for obesity is to achieve weight loss for the affected people. After getting obese persons to sign up for weight loss programs, an evaluation mechanism must be put in place to ensure they are realizing the goal progressively (Anderson 2016). Through consultations with the district health board, specific hospitals within the Manukau district can be designated to help the persons monitor their weight. Obese persons can be registered in the said facilities where they can report for their weights to be measured weekly, fortnightly and monthly or after whatever period agreeable as long as there is consistency. This will help the intervention to monitor their progress and advice on how to better their chances of losing weight.
In the current dispensation, there is plenty of digital technology that can be used in the intervention program to help with evaluating the effectiveness of the activities in the intervention. Obese persons can take up physical exercises such as Zumba classes and cycling for instance (Prendergast 2016). Their trainers from the program can provide them with didgital devices such as Personal Digital Assistants, pagers or other electronic devices which can guide their physical exercises even in the absence of the trainers. The trainers can give directions as to how the exercises ought to be conducted even when they’re away. This helps the intervention to ensure the effectiveness of the intervention in instilling a healthy lifestyle for affected persons.
According to CDC (2018) obesity predisposes to a host of other conditions such as diabetes, cancers, high blood pressure, hypertension and stroke. Most of the time individuals who have obesity also present with the above mentioned conditions. An evaluation plan that works well must have strategies in place to monitor the rate of progression of these conditions alongside the weight loss and behavioral change. An improvement in the associated conditions would be an indicator of the success of the intervention plan (Göhner et al, 2012). For instance, if an obese person adheres to the intervention program’s guidelines on a healthy diet, exercise and behavioral change, a corresponding decline in conditions such as high blood pressure and hypertension should be observed. In essence, the measurements of the progress of high blood pressure and blood glucose levels in obese patients can be used as a measure of the success of the intervention plans (Swinburn et al, 2014).
Major ethical questions are expected to arise in the course of the intervention. The intervention must seek the voluntary consent of the overweight and obese persons before enrolling them in the said programs because they reserve the right to agree or decline to the same. Given the fact that obese people tend to be very sensitive to how they are treated, it is necessary that the intervention sensitizes the personnel involved on how to handle them without further increasing the risk of them feeling unwanted (Teevale et al, 2018).
Discussed in the section below are some of the mechanisms that the evaluations plan will make use of in order to manage risks: Firstly, the evaluation plan will engage the use of core indicators that are recommended in the measurement of the success of an intervention plan. This includes the adoption of standard operating procedures as set out by the different professional practices such as nursing, public health and counseling (Mercer et al, 2013). The evaluation plan will ensure that the needs of the end user, who in this case is the obese persons, are aligned with the evaluation methods, activities and outcomes. The risk of the obese persons relapsing and falling back into the same enabling habits for obesity is also an issue that the evaluation plan must address by putting in place sufficient mechanisms (Howe et al, 2015). To this end the evaluation plan should have program persons who are dedicated to the follow up of all persons enrolled in the intervention. The evaluation plan also targets to involve all the stakeholders including (HFNZ, HOfA and DHBs) in the allocation of resources towards the management of all risks that may arise from the intervention program such as health complications.
Statistical results regarding obesity as presented in this paper paint a picture of a serious public health concern. This explains why obesity among the Maori community of the Manukau District has attracted a multi-level intervention plan in efforts to reduce the prevalence of the condition. The intervention plan covered tackles the prevention of obesity as well as the determinants. Factors such as dietary and nutritional habits, physical activity, fitness and sleep, behavioral changes and how they hold potential to remedy the problem have been explored in the intervention plan. The evaluation plan proves that the intervention plan as described can work if the said activities are followed up with assessment. The Maori community of Manukau stands to benefit a lot from the intervention plan if adopted by the public health department.
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