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Impact of the Take Charge Course
Gains in health status were achieved both during the 8 week course and into the second year following class completion (Table 2). The average weight lost during the 8 week course was 4 pounds (n=16; p<0.05; range= +5 to –18 pounds). Longer-term weight loss is available for follow-up periods ranging from 3 months post graduation to 2 years later (mean follow-up period =11 months). Using the last known weight as compared to baseline, there was an average 14 pound weight loss (n=16; p<0.01; range= +13 to –52). The ratio of weight reducers to weight gainers during the class period was 2.25:1 and in the follow-up period was 4.3:1. Group support and food-related content were rated most important by participants in the class. English and Spanish speaking participants ranked support, cooking information, and health information similarly high in importance. Although exercise and relaxation were seen as much less important components of the course, according to long-term follow-up interviews, exercise practices increased following the course. One third of the respondents wanted instruction on exercises appropriate to their disabilities (joint problems, hip pain, pacemaker, use of a cane). Most participants continued using class recipes and techniques for reducing fat.

Drop-outs (attended 2-5 sessions) were surveyed to see whether objections to the class caused their limited attendance. Explanations for low attendance were personal and unrelated to the course. In spite of lower attendance, these participants were able to list concepts they learned from the course and behaviors they changed as a result of their participation.

Take Charge instructors realized early in the course that eating habits of patients did not result from a lack of information but instead reflected larger psychosocial issues. The course was not designed to cure eating disorders, but by combining motivational activities with health education was able to successfully circumvent emotional factors that led to the unhealthy diet choices of many of the patients.

The evaluation interviewers summarized participant response to the intervention as “effusively happy.” This satisfaction is credited in large part to empowerment derived from the social support and self-esteem enhancing activities. The instructors credit the wholistic approach of the Take Charge course for impacting the lives of participants beyond its primary aim of encouraging patients to adopt healthy diets. For many participants, the class provided the impetus to pursue new careers and fulfill old aspirations, from enrolling in piano classes to starting a home business. Some Alumni members returned to teach subsequent classes, taking over teaching responsibilities from the instructors. The alumni instructors were recruited for their natural leadership and commitment to the class; all had completed high school, some had additional training or education. These alumni instructors served as role models for participants, enhanced the cultural content of the class, and validated the impact of the course, making their involvement invaluable.

Patient Profile
Participants in the English language class were primarily African American and ranged from young adults to great grandmothers. A majority of the participants were middle-aged or older and lived alone, while some were raising their grandchildren. Many participants were on disability as a result of their weight related comorbidities and spent much of their time alone at home.
Participants in the Spanish language class were more likely to be living in families. Most of them were women with husbands and younger children. A majority were recent immigrants from Mexico or Central America. Although this group was also overweight and had related diseases such as hypertension and diabetes, they were less likely to be as obese as participants in the English language group.

The Class Curriculum
The curriculum of the Take Charge class was created to reflect the wholistic approach taken by Family Medicine towards patient needs and it emphasized the role of biopsychosocial factors in health. The course curriculum consisted of diet education, fitness exercise, and empowerment and motivational activities. Medical issues related to obesity, such as the relationship between fat and heart disease, were taught by the physician instructor during class discussions. The physician instructor also addressed individual health questions of patients and referred them to their primary care physicians for follow-up as needed.

Participants were instructed to follow a very low-fat, high fiber vegetarian diet, restricting daily fat intake to about 20 grams. The content of the diet education included cooking demonstrations and samples, healthy food displays, and information on shopping, reading labels, and calculating fat and fiber gram intake.

The class devoted time to low impact aerobic exercise, stretching, deep breathing, and meditation relaxation. Empowerment activities designed to enhance self-esteem, raise consciousness, motivate behavior change, and provide support were also regular curriculum features. Active peer support was delivered through group “go-rounds” and a “listening exercise.” The focus of the go-rounds was to provide each person time to share with the group and learn about others. The one-on-one listening exercise allowed participants to explore thoughts and feelings with a partner who practiced listening without offering advice. To expand this peer support beyond the classroom, participants were encouraged early in the program to exchange contact information and set up walking dates. As the class progressed, exercises like identifying “10 things I want to do in this lifetime” were incorporated into the Take Charge curriculum to address the deeper motivational needs of participants, especially those on disability who had been out of work for several years. The instructors felt that participants found lifestyle change easier when they were occupied with other lifetime goals and were busy with activities that satisfied them and kept their minds off food.