Q&A: Community-based lifestyle intervention improves CV metrics for Black men
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Black men who participated in a 24-week community-based physical activity and education intervention experienced a marked improvement in CV health scores, according to data published in The American Journal of Preventive Cardiology.
Higher CV scores, using the American Heart Association’s Life’s Simple 7 metrics — physical activity, diet, cholesterol, BP, BMI, smoking and glycemic response — have been associated with lower risk for CVD, type 2 diabetes, cancer and mortality among all race groups. Yet nationally, Black men have the lowest levels of Life’s Simple 7 metrics, according to Joshua J. Joseph, MD, MPH, FAHA, assistant professor of medicine in the division of endocrinology, diabetes and metabolism at The Ohio State University College of Medicine in Columbus. The African American Male Wellness Agency and Ohio State University researchers worked with community partners in the greater Columbus, Ohio, area to develop a pilot program, Black Impact, with the goal of improving metrics and reducing CVD risk for Black men. The single-arm, lifestyle intervention program combined weekly physical activity and health education with trainers and coaches.
Healio spoke with Joseph and Timiya S. Nolan, PhD, APRN-CNP, a nurse scientist and assistant professor at The Ohio State University College of Nursing, about the need to improve CV health in Black men, the advantages of “co-designing” a trial with community members and building on success to improve health outcomes in under-resourced areas.
Healio: Nationally, Black men have the lowest AHA’s Life’s Simple 7 metrics compared with other groups. Why is that?
Joseph: We examined several studies. In all the analyses, Black men have had the lowest levels. Part of that is due to high rates of diabetes and hypertension among Black men, as well as high rates of obesity, low rates of physical activity and a higher rate of smoking when compared with men from other race groups. The question becomes, why? It is a hard question to answer. We think it is partially due to mistrust of the health care system. We know that Black men are less likely to visit a doctor and have a good relationship with a provider, which is important. We think it is partially due to the social determinants of health — things like socioeconomic status and how that influences health over time. Racism, especially structural racism, is a persistent source of stress, drives mistrust and social determinants of health and is associated with lower Life’s Simple 7.
Healio: How did the Black Impact program come together?
Nolan: The Black Impact program is the brainchild of the African American Male Wellness Agency and Ohio State University coming together as a collaborative to talk about these issues around Black men dying early. In 2018, we began working with the agency to develop a grant mechanism to help us build something that would improve those Life’s Simple 7 metrics in Black men. Looking at the literature, we found the American Diabetes Association’s Diabetes Prevention Program (DPP) had a reputation for success, as well as the AHA’s evidence-based hypertension management program, Check. Change. Control. We talked with our stakeholders, exploring the ways we could modify or adapt those interventions to fit Black men.
What we came up with was Black men in teams to create a source of camaraderie and competition to keep people motivated for 24 weeks together to exercise and use health coaches. Out of this, we met our goal: More men did attain Life’s Simple 7 metrics. But what also came out of this, which was unexpected, was a brotherhood that these men developed. That is still strong even today.
Joseph: Oftentimes when putting together studies, people sit in an ivory tower and decide what will work best for communities. What is truly different about Black Impact is we used a model of co-design. We went to the community, met with stakeholders and community members. We asked, “What will work for you? What is something you would take advantage of that will improve your health?” That is the piece that is different.
The second thing that is different is we brought together more than 15 community partners to make this happen. It is not just Ohio State and African American Male Wellness. We ran these sessions at Columbus Recreation and Parks facilities. Cardinal Health donated BP cuffs. We had the Mobile Education Kitchen come out and included grocery store tours. We worked with OhioHealth because many of our men were in their health system. These collaborations and partnerships helped drive the program’s success.
Healio: What did the men do during the intervention?
Joseph: We had 74 men (mean age, 52 years) assigned to one of six teams who meet weekly for about 2 hours. They completed 45 minutes of physical activity and participated in 45 minutes of health education. The physical activity was led by a personal trainer and these were group workout sessions. The health education was based around the DPP and the AHA’s Check. Change. Control. Every week, there was a different lesson plan. For example, one week might focus on the Dietary Approaches to Stop Hypertension (DASH) diet, and we would discuss things like low-sodium options. Participants also completed surveys at baseline, 12 and 24 weeks. We evaluated the change in a Life’s Simple 7 score (range 0-14) from baseline to 12 and 24 weeks, adjusting for age, education and income.
In fully adjusted models, Life’s Simple 7 score at baseline was 7.12 and increased by a mean of 0.67 at 12 weeks and 0.93 at 24 weeks. The nearly 1-point increase in CV health score from baseline to 24 weeks in Black Impact is a large effect size considering a 1-point higher score is associated with 18% and 19% lower odds of stroke and MI, respectively.
Healio: What was some of the feedback from participants?
Nolan: Overwhelmingly, the men were excited about participating in this program because they got to be with other Black men in a very positive and social manner during the COVID-19 pandemic. It was a moment where they could gather safely and talk about life. It was supposed to be 90-minute sessions and they often lasted for 2 hours. That was a highlight the participants mentioned. They also talked about receiving education from Black providers and how important it was that they felt they were not just a number. These men felt someone was genuinely concerned with their well-being. As we think about ways we can better support Black men, certainly we cannot assure racial concordance all the time. But we can assure that any provider who is caring for a Black man in their office can have cultural competency and implicit bias training. They can try to meet that person where they are. We did host a training on implicit bias mitigation strategies with Dr. Quinn Capers, IV. We know that is key as we think about caring for Black men.
Healio: What are the next steps for this program? What do you hope to learn going forward?
Joseph: One of the things we talked about was the elements we used in this project are all available in other cities. We have health systems in other cities. We have parks and recreation facilities in other cities. That is why we did not use a fancy facility. All the pieces of this are very replicable.
The next phase for us is to work with our community partners so we can start Black Impact 2.0. This time, instead of 74 men, we want a couple of hundred men. We will have an intervention group and a delayed intervention control group this time. The partners are very interested in doing that. Most important, many of the men are asking if they can participate in the program again. They are asking to serve as coaches or mentors for the new cohort. We are going to invite those men to the table like we did before. So, there may be some variations so we can incorporate some of the men who already went through the program, perhaps in a different role. We want to continue to have that engagement and dialogue and co-design solutions for individuals.
Nolan: If you are creating things within the community, the community can sustain it once we are able to train the trainers. We have created a model that we hope to follow through in this larger study to examine efficacy with our Black Impact program. It’s wonderful hearing the men talk about their experiences, how grateful they were to be a participant and seeing them after continuing with heart healthy behaviors. Many are still losing weight. I have so much gratitude.
For more information:
Joshua J. Joseph, MD, MPH, FAHA, can be reached at joshua.joseph@osumc.edu; Twitter: @joshuajosephmd.
Timiya S. Nolan PhD, APRN-CNP, can be reached at nolan.261@osu.edu; Twitter: @TSNolanPhD.
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