The Use of Narrative as a Treatment Approach for Obesity: A Storied Educational Program Description

The Use of Narrative as a Treatment Approach for Obesity:  A Storied Educational Program Description

 

Marcus Griffith, MD; Jeana Griffith, PhD; Mellanese Cobb, MPH; Vladimir Oge, MPH

Perm J 2016 Summer;20(3):Mar 17, 2016

https://doi.org/10.7812/TPP/15-029

Abstract

Introduction: Childhood obesity is a health care crisis according to the leading pediatric advocacy groups (National Medical Association, American Academy of Pediatrics, and American Diabetes Association) and the White House. The problem has reached epidemic proportions for all children, but it has an even greater impact on racial minorities. The subject of childhood obesity can lead to a host of medical, psychological, and social problems, including low self-esteem and discrimination. We wrote an interventional children’s book and workbook (The Tale of Two Athletes: The Story of Jumper and The Thumper) and developed a three-step intervention based on the narrative. The intervention’s purpose is to increase public awareness, reduce stigma, and to help members of underserved communities become more comfortable discussing obesity.
Methods: In classrooms and other community settings, a storied education program is presented to students of various ages. Interactive storytelling is the first step: live narration with direct listening and active participation. Didactic information on obesity is shared, including a sociocultural explanation for why the issue is more problematic among racial minorities. The audience is then introduced to the story of Jumper and The Thumper, two larger-than-life characters who experience different outcomes as a result of their choices about diet and exercise. True examples are described during the narration about these two young men, accompanied by cartoons and photographs for visual emphasis. The next step is reading: audience members are provided with a book to reinforce what was learned. Readers are allowed to more closely examine the importance of making healthy choices. Practicing positive behaviors and decision making through games and exercises from the companion workbook is the final step. These activities help children and their families live a healthier lifestyle. The goal is that these three steps, linked to a common narrative, will have a meaningful impact on obesity by creating behavioral change.
Results: Children, parents, and health care professionals have stated their enthusiastic response to the information and message and that they have made positive changes in children’s eating and exercise habits. The program has been presented in community forums, churches, medical meetings, and elementary schools in at-risk communities.
Conclusion: New strategies must be developed to lead, uplift, and empower through health and wellness education and through community collaboration if we are to change the direction of course toward this devastating condition that affects our most valuable commodity—our children. This community-based educational approach is a means to help recognize and treat obesity in underserved communities.

Introduction

Obesity is a health care crisis according to leading medical and patient advocacy groups (Centers for Disease Control and Prevention,1 American Academy of Pediatrics,2 American Diabetes Association,3 American Medical Association,4 and National Medical Association5) and the White House.6 Obesity is defined by excess body fat, which is not the same as overweight. A person may be overweight because of extra muscle, bone, water, and/or fat.7 Although obesity rates have reached epidemic proportions, there is a lack of culturally competent interventions to educate the public and to prevent and combat this condition. We developed an innovative, culturally competent approach with narrative to address this deficiency.

The statistics on obesity in both children and adults are alarming; however, facts, figures, and epidemiologic information do not tell the whole story. Obesity has grown into such an enormous public health problem that even the untrained observer can recognize that it is out of hand. The challenges faced in elementary school lunchrooms are one clue to this growing problem. According to the National Health and Nutrition Examination Survey, more than 33% of adults and 17% of youths in the US are obese.8 Rates of obesity among children and adolescents have tripled since 1980, with an estimated 12.5 million children and adolescents aged 2 to 19 years identified as obese or overweight.8

The problem of obesity in children and adolescents is perhaps one of the most pressing public health concerns in the US. Studies suggest that individuals who experience problems with excess weight during childhood are commonly overweight or obese as adults. The best method for preventing this potentially lifelong problem is to control it during childhood through education and behavioral intervention.9

Obesity may have the greatest impact on racial minorities. Minority populations and low-income communities appear to have the highest risk. The 2001 report The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity10 was one of the first to call attention to obesity as a major health problem. More recently, First Lady Michelle Obama launched the Let’s Move initiative to examine root causes and offer practical solutions.11

Obesity is believed to be a preventable illness that many believe will one day have greater rates of morbidity and mortality than any other health condition. Because racial minorities experience higher rates of obesity than whites, this disease state is linked to health care disparities in the US. According to a 2001 Institute of Medicine report, racial and ethnic disparities exist regardless of socioeconomic status.12 The reported data suggest that racial and ethnic minorities tend to receive a lower quality of health care than whites, even when analyses control for access-related factors, such as insurance status and income. Key epidemiologic indices on these differences include higher morbidity and mortality from the leading causes of death, poorer quality of care, and worse outcomes.12

A Community-Based Educational Approach

A critical service line in the battle against obesity is the need for new methods of communication between health care organizations and underserved communities. Traditional strategies for communicating messages about obesity and other chronic diseases have failed to improve population health, as evidenced by worsening rates. New, culturally competent interventions must be developed so as to build relationships between people from different races, cultures, and ethnicities. The spectrum of health-related problems linked to obesity is well documented; it includes diabetes, hypertension, respiratory problems, and depression. Low self-esteem, depression, and social discrimination associated with childhood obesity are frequently unaddressed.10 Battling the medical complications of obesity and forming solutions for associated emotional distress has been the focus of my (MG’s) work.

On the eve of the grand opening of my (MG’s) medical practice, in 1994, I got the sad news that my best friend had died from a massive heart attack. I had always dreamed of becoming a physician and running my own office. I had imagined that this day would be filled with a sense of accomplishment and excitement; but instead, it was overshadowed with grief. That night I experienced a profound sense of loss, and I made a commitment to fight obesity. When I opened my office the following day, I began to incorporate that fight into my daily clinical practice. Over the years, I  have continued to explore new education and prevention strategies designed for clinical and community settings.

I (MG) wrote the story of Jumper and The Thumper several years later, while working in a mental health treatment center for children and adolescents with severe behavioral and emotional problems. The vast majority of the patients were African American, low-income, and were obese or overweight. The children learned about diet, nutrition, and exercise as components for improving their mental and physical health. As we worked with dieticians, encouraged a reduction in television and video game time, and promoted increased physical activity, our activities reinforced the guidelines on obesity recommended by the American Academy of Pediatrics.13

During the last several years I (MG) traveled throughout the US and received a number of awards for my work on obesity. The work began through telling a story about how a dear friend lost his life because of complications from obesity. I then used the story as a platform to develop a community-based educational program to address both the mental and the physical health problems associated with obesity. The intervention’s purpose is to increase public awareness, to reduce stigma, and to help constituents of underserved populations become more comfortable discussing obesity. The program also incorporates nutrition, exercise, and other behavioral strategies to combat weight gain. Community-based educational programs that teach the benefits of healthy eating, nutrition, and exercise have proved to be effective tools for controlling weight and promoting positive behavioral change.14

The initiative centers around a children’s book that my wife and I (MG) wrote, entitled The Tale of Two Athletes—The Story of Jumper and The Thumper. The story in the book is told through the eyes of a little girl named Jasmine who attended one of my presentations at a community event in Seaside, CA. Jasmine is battling childhood obesity and heard the story The Tale of Two Athletes. This inspirational story is based on my lifelong friendship with Joe Drake, a professional football player who died prematurely because of obesity. Recently, after reading a magazine article on the number of football players who have died from obesity-related complications, I discovered from an ESPN story that Joe was the heaviest player in the history of the National Football League to die.15

Following the presentation, Jasmine sought me (MG) out and asked if I could help her. She told me that she had also struggled with her weight all through her life and could relate to many of the points in the story. As we talked, Jasmine was curious about the two characters, Jumper and The Thumper, and wanted to know more about their lives. She stated that she would never forget the story and did not want to end up like The Thumper. Jasmine made a promise that she would begin trying to live a healthier lifestyle. In addition to children, adults struggling with obesity are receptive to the program’s message. The interactive narrative, based on a true story, attempts to inspire change and create solutions. It is an alternative approach for examining the causes of obesity and forming solutions, especially in the context of racial minorities and underserved communities.

One of the activities that generated the most excitement resulted from the relationship that we formed with the park rangers at Davidson-Arabia Nature Preserve in DeKalb County, GA. Two park rangers and I (MG) led three groups of patients on a series of nature hikes through the forest in an effort to increase exercise and to create exposure to a new experience. We instructed the patients on the importance of exercise and appreciation of nature. Staff members from the day treatment program also participated to help ensure safety. To my surprise, many of the children had never been outside of the city or spent time in the woods. The healing power of nature was quite evident as their negative behaviors decreased during our outings. I made sure that the children with the most severe behavioral issues were placed in my group, with the appropriate accompanying staff. No major issues were encountered.

One rainy day when we were unable to go outside for our nature hike, a young man shared with me the pain he experienced because of excess weight. I (MG) asked him to write down his feelings, and he entitled his story “My Life as an Obese Child.” His name just happened to be Joseph—the same name as my late friend. I was inspired to create a story and use it as a component of a comprehensive obesity program at the center (up until the book was written the story was told from memory in the old tradition of story telling). I told the story about Jumper and The Thumper so as to convey a powerful message about obesity, from and about someone the children knew.

The story about my (MG’s) relationship with Joe Drake continues to be integral to my personal and professional life. On February 28, 2012, I closed my private practice after 18 years of service and accepted a position with Kaiser Permanente in GA. Coincidently, as I was closing my office for the final time and was saying goodbye to my patients, the first copy of the published book arrived. Closing my office and simultaneously receiving the first printed copy of The Tale of Two Athletes was a powerfully emotional experience, especially considering what had happened the night before opening my office in 1994. The moment of closure marked for me a beginning and an end at the same time. Although it was an end to my private practice, a new opportunity began in my quest to honor my friend in the fight against obesity through the telling of The Tale of Two Athletes.

Narratives—A Three-Step Approach

I (MG) developed a three-step approach based on The Tale of Two Athletes to educate the community about obesity. Storytelling is the primary concept that moves from active listening to live narration as the first step. Live narration aims to make an impact on the audience through direct listening and active participation. Didactic information on obesity is shared, including statistics, easy-to-understand epidemiologic information, and a sociocultural explanation for why the issue is more problematic among racial minorities. Jumper and The Thumper are then introduced to the audience as two larger-than-life characters who experience different outcomes resulting from their choices in diet and exercise. The true examples about the young men are described during the narration, accompanied by cartoons and photographs to enhance the visual experience and highlight the realities of the problem. At the end of the story, when The Thumper dies, the true names of the characters and a photograph of the characters are revealed. The audience then realizes that the narrator is Jumper, which hopefully inspires them and impresses on them the importance of diet, nutrition, and exercise in the battle against obesity.

The next step of the educational process is reading the book to reinforce what was learned in the live community educational program. The book provides more intimate details about the two young men and allows the reader to more closely examine and identify with the characters and to realize the importance of making healthy choices.

The final step of the program uses the companion workbook that my wife and coauthor, Jeana Griffith, PhD, wrote to personalize the story for each reader. Participants practice positive behaviors and decision making through games and exercises that help them set goals for physical activity and a healthier diet. The hope is that these three steps, linked to a common narrative, will make a meaningful impact for creating behavioral change related to obesity.

The use of narratives and storytelling is now recognized as a culturally competent approach for reaching racial minorities and underserved populations. This method may be a more effective process for sharing health information in communities where traditional health education has failed. Storytelling may also be a means of easing the disconnect between health care professionals and underserved communities.16

The intention is to offer a culturally competent message that allows the audience to see, hear, understand, and feel what obesity is all about and that they are not alone in their struggles. The story about the two characters, Jumper and The Thumper, offers an opportunity for the participants to build a relationship with the characters and the storyteller. An expectation is that the listeners will become immersed in the story and identify with the message. This process, which Banks16 describes, emphasizes the importance of building trust between the presenter and the audience, using the experiences within the story to create “a sense of oneness.”16 Furthermore, the companion workbook to The Tale of Two Athletes is an example of how stories can incorporate games to engage audiences and reinforce learning.

The University of Chicago and the University of Ibadan, in Nigeria, formed a partnership for reducing gaps in how adolescents receive knowledge on sexual health in disadvantaged communities. The researchers developed this initiative as they observed similarities between disadvantaged communities in developing African nations and the US.17 Gilliam et al17 combined traditional storytelling with technologies of social media and game design to reshape adolescent sexual health behaviors. They believe that stories and games can be used to communicate information about other preventable illnesses where traditional health messaging has been unsuccessful.

The researchers on the initiative developed a script with integrated images, music, videos and personal messaging to appeal to a select audience. Story content was developed through a series of workshops with South Side Chicago youth and touched on themes significant to that environment, including neighborhood violence, loss, abortion, sexual violence, and bullying. Personal experiences were incorporated into a narrative-driven game. The game was used in an interactive method to educate and to test knowledge on sexual health and other topics, such as rape, gender inequality, incarceration, and parent communication. Following the intervention the authors found that the participants were more knowledgeable and had improved critical thinking with regard to the subject matter.17

Similarly, the children’s workbook created from The Tale of Two Athletes uses games, images, and concepts from the story to improve knowledge and critical thinking about obesity and healthy lifestyle choices. Using the workbook is the third and final step, following active listening to the story and reading the book. Once families are inspired by the story to make changes in their lifestyle, the workbook shows them, step by step, how to make these changes. Games and fun activities in the workbook further educate participants about obesity and healthier food intake. The workbook also has charts and provides resources to help families set individual goals.

Discussion

Storytelling has been used since the beginning of human communication as a means to preserve history, culture, ideas, and teaching. Ideally it is an interactive process between the storyteller and the audience that helps listeners to conceptualize and makes the message more meaningful. I (MG) have been using a narrative approach in my obesity education programs as a means of conveying health information to diverse populations (African-American and Hispanic populations). I have attempted to construct a program that engages the audience and inspires behavioral change through humor, didactic material, and a true, compelling story.

Health interventions typically focus on changing individual behavior through traditional health policy and communications. These approaches have done little to reduce the differences in prevalence, mortality, and burden of chronic diseases in underserved communities. Examples include heart disease, diabetes, preterm births, human immunodeficiency virus, and obesity, which continue to disproportionately affect African Americans, Hispanic, Native Americans, and low-income communities.16

Conclusion

Next steps are to expand programs by obtaining grants and sponsorships to promote it. We hope the three-step approach of active listening to the narrative, reading the book, and practicing what was learned by using the workbook will serve as an additional model in the fight against obesity. Up to this point, the program has been funded by the article’s authors. The resources to get it done were inspired by the love of a friend and all those who have lost someone because of obesity.

The Use of Narrative as a Treatment Approach for Obesity:  A Storied Educational Program Description

The Use of Narrative as a Treatment Approach for Obesity:  A Storied Educational Program Description

The Use of Narrative as a Treatment Approach for Obesity:  A Storied Educational Program Description

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgement

Leslie Parker, ELS, provided editorial assistance.

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