The Faith, Activity and Nutrition (FAN) Program

African Americans have a higher cancer mortality rate than Americans of any other racial group and are 31% more likely to die of stroke and 23% more likely to die of heart disease than Caucasians, according to 2005 age-adjusted death rates reported by the Centers for Disease Control and Prevention (CDC). The CDC's National Center for Chronic Disease Prevention and Health Promotion identified four modifiable health risk behaviors: lack of physical activity, poor nutrition, tobacco use and excessive alcohol consumption, as playing a major role in the development and early death associated with chronic illnesses such as cardiovascular disease and cancer. The World Health Organization estimates that if these four modifiable health risk behaviors were eliminated, at least 80% of all heart disease, stroke, and type 2 diabetes would be prevented, and more than 40% of cancer cases would be prevented. In a 2009 report, the National Center for Chronic Disease Prevention and Health Promotion emphasized the importance of community-based public health efforts that prioritize prevention with interventions that facilitate and support individual responsibility and behavior change in school, workplace, faith-based, and medical settings.

The Faith, Activity, and Nutrition (FAN) Program is a 15-month, faith-based participatory intervention designed to increase physical activity and fruit and vegetable consumption and reduce blood pressure among African American church members by targeting social, cultural, and policy influences within the church. It was developed under a partnership between South Carolina's 7th Episcopal District of the African Methodist Episcopal (AME) church, the University of South Carolina, the Medical University of South Carolina, Clemson University, and Allen University. As part of the AME Church Health Ministry, the FAN Program aims to help AME church members become stronger in health by (1) becoming more physically active at a moderate intensity (e.g., brisk walking) for 30 minutes daily, at least 5 days per week, (2) eating 2 cups of fruit and 2.5 cups of vegetables daily, (3) eating whole grain foods (e.g., whole wheat bread and brown rice and pasta), (4) eating less fat, especially saturated fat, and (5) consuming less salt. The FAN Program helps churches select activities to implement that are consistent with the structural ecologic model by: (1) creating opportunities for physical activity and healthy eating, (2) making the opportunities appropriate and fun, (3) setting organizational guidelines and providing support, and (4) getting the message out through church channels. The FAN Program involves a church-wide implementation of a set of core physical and healthy eating activities; the creation of a bulletin board to highlight upcoming FAN activities; the regular distribution of educational materials and handouts supporting FAN goals; and the dissemination of FAN health benefit messages and church policy practices supporting FAN from the pulpit.
 
Because congregants' needs and interests and available resources vary among churches, the first step in implementing the FAN Program is to create a committee of up to five key leaders and active church members. In selecting committee members, churches are encouraged to include the following: the pastor, the church health director, a FAN coordinator, and members who are passionate about health. Committee members should represent a cross-section of the congregation (men, women, youth, and seniors), be good role models, and be people who can motivate and involve other church members. It is recommended that committee members meet monthly to brainstorm new ideas for promoting health in the church and should be willing to take a key role in ensuring the success of the FAN Program by being true advocates for physical activity and healthy eating.

After the committee is created, the next step is training. The original version of the FAN Program, which was reviewed for this summary, included training in two parts: a Committee Training to develop a customized plan for implementing the program, and a Cook Training based on the Dietary Approaches to Stop Hypertension (DASH) diet plan. These full-day trainings were delivered face to face.

The FAN Committee Training was designed to assist in the development of a customized church activities plan and budget for implementing the intervention. Activities are organized by the structural ecological model described earlier. The training provides an overview of the FAN Program and its goals, links study goals to scripture and to the AME church's health mission, defines physical activity and healthy eating, engages the pastor in supporting FAN, and facilitates brainstorming activities the church can do to promote physical activity and healthy eating. By watching and reading the FAN Committee Training materials, the committee members learn:

-- How to build physical activity and healthy eating into ongoing church events and activities
-- Techniques for spreading information to congregants about the importance of physical activity and healthy eating
-- How to develop guidelines and practices that the pastor can put in place to support health programs

Upon completion of the online training, the FAN Committee would have the beginnings of a written plan outlining a variety of church activities that highlight ways to eat healthier and incorporate physical activity into regular church functions, with knowledge of how to use the online FAN resource materials for ongoing monthly support of the program. The FAN Committee was encouraged to focus on a new behavioral strategy (consistent with Social Cognitive Theory) each month for increasing physical activity or healthy eating.

The FAN Cook Training provided cooks, lead kitchen staff, and other members responsible for planning church menus, preparing food, and catering with the skills and resources needed to prepare healthier food options that are high in fruits, vegetables, and whole grains and low in fat and salt. By watching and reading the FAN Cook Training materials, those involved with church meal preparation learn:

-- Healthy eating and cooking based on the DASH diet
-- Tips for preparing creative and flavorful healthy meals
-- Techniques for spreading information about healthy eating
-- Kitchen safety procedures
-- Food/market shopping tips
-- Healthy makeovers for traditional recipes

After the original FAN Program study was reviewed for this summary, the program’s training component was revised to reach churches of other denominations, and the FAN Committee Training and FAN Cook Training were integrated into a single full-day training, now provided entirely online.

Following training, the church holds a kick-off event to officially launch the FAN Program. The online training materials provide some suggested ideas for this event, such as having the pastor prepare a sermon that ties healthy living to scripture, inviting motivational speakers to speak to the congregation, giving demonstrations on how to safely start an exercise program, providing a bag with different fruits and vegetables to church congregants, and having the church cook or lead kitchen staff give demonstrations of healthy snacks or meals.

In addition, three packets, each with monthly materials, are available online to support implementation of the FAN Program (in the study reviewed, these materials were mailed to participants):

-- A FAN Committee Packet that gives an overview of the month's behavioral goal or area of focus, creative ways to emphasize the goal, along with a bulletin insert plus one or more educational brochures or skills-based worksheets to share with the congregation, and suggested activities to implement within the congregation

-- A Pastor's Packet that includes ideas for how the pastor may serve as a positive role model for the congregation and support FAN goals

-- A Cook's Packet that includes healthy recipes, handouts, and other healthy eating resources for monthly distribution to the congregation

Although the intervention was designed for use with AME church leaders and members and the study reviewed for this summary was conducted in AME churches, the program has been used with churches of other denominations.

-- 6-8 hours for training (the original FAN Program study included two 4- to 6-hour trainings)
-- About 11 hours for monthly meetings, each 30-45 minutes long, of the FAN Committee across 15 months (this planning can be integrated into healthy ministry meetings if they exist)
-- 10-20 minutes each for 9 "core activities" in physical activity to be incorporated into existing church programs already in place (for example, 10 minutes of physical activity before, during, and after the service; 10-minute activity breaks before, during, and after choir practice; 10-minute physical activity breaks during meetings or during church-sponsored events; 20-minute walking excursions following service)
-- About 12 hours for 12 "core activities" in healthy eating, each lasting about an hour inclusive of selection, preparation, and execution, to be incorporated into regular, meal-related church events whenever possible (for example, church food-tasting events, pot luck dinners or after-service luncheons, holiday side dishes and desserts)

The FAN Program targets churches, their pastors, other church leaders, and church members. Although the original study targeted these individuals in AME churches, the intervention can be used with leaders and members of churches of other denominations.

The FAN Program is implemented within churches (e.g., AME, Baptist, Methodist). Although the original study was conducted in AME churches, the intervention can be used in churches of other denominations.

Materials required for implementation include:

-- The University of South Carolina Prevention Research Center website

For costs associated with this program, please contact: Sara Wilcox. (See products page on the EBCCP website for contact information).

A randomized controlled trial evaluated the effects of the 15-month FAN Program among the 1,257 congregants of 74 AME churches in South Carolina on reported weekly moderate-to-vigorous physical activity (MVPA) and daily fruit and vegetable consumption. Churches were randomized to an immediate FAN intervention or waitlist control (delayed intervention). Each intervention church sent two individuals to attend a hands-on Cook Training with a chef and registered dietician, who provided examples of healthy meals and snacks, engaged the trainees in healthy food menu planning, encouraged the redesign of favorite church meal recipes to be healthier, and demonstrated the development of flavor in foods through healthy ingredients. Up to five members also attended a FAN Committee Training. Intervention church committees and pastors received monthly mailings that included incentives promoting FAN program messages (for example, church fans, cups aprons); handouts supporting FAN goals that could be distributed to church members; and tools (recipes) for church cooks. Pastor mailings included motivational information, a goal of the month, and an activity for the pastor to try (for example, sharing pedometer step counts with the congregation). Follow-up technical assistance calls were made by study staff to pastors, FAN coordinators, and cooks, to track program implementation and help with problem-solving. Intervention churches received a stipend of up to $1,000, depending on church size, to assist with covering the costs associated with implementing the FAN Program for 15 months.

Study churches were asked to recruit 13, 32, or 63 members, depending on the church size (small, medium, or large, respectively), for outcome measurements. Church size was defined as small if there were fewer than 100 members, medium if there were 100 to 500 members, and large if there were more than 500 members. To be eligible for the study, participants had to be at least 18 years old, be free of serious medical conditions or disabilities that would make small changes in physical activity or diet difficult, and regularly attend church (at least once monthly). Study participants were recruited by a pastor-appointed FAN coordinator to attend a baseline assessment and a follow-up assessment 15 months later (post-intervention or waitlist control). After providing informed consent, participants completed the baseline assessment. Church pastors made announcements at worship services to promote participation, and study staff called participants to remind them to attend the pre- and post-assessment sessions and, if unable to attend any of these sessions, to attend a future assessment session at a nearby church assigned to the same condition. Participants who completed a measurement session were entered into periodic drawings for a $15 gift card.

Twelve hundred fifty-seven church members from 74 AME churches completed a baseline assessment and were randomized to either the FAN intervention or waitlist control. The mean age of the total sample was 54.1 years; 99% were African American, 76% were women, 32% were high school graduates, and 28% were college graduates. Fifty-four percent of church participants were married or a member of an unmarried couple, 43% had an annual household income of $0-$29,999, 37% had a household income of $30,000-$59,999, and 21% had an annual household income of at least $60,000. Sixty-two percent of participants were obese; however, 11% were of normal weight at baseline based on their body mass index (BMI), the average blood pressure at baseline was normal, and 93% were non-smokers at baseline.
 
At baseline and 15 months after baseline, daily fruit and vegetable consumption and self-reported moderate-to-vigorous physical activity (MVPA) in a typical week for the prior month were measured as study outcomes. The daily fruit and vegetable consumption outcome was measured by a modified version of the National Cancer Institute's (NCI) fruit and vegetable all-day screener, omitting 1 of the 10 items in the screener (french fries). The weekly MVPA outcome was measured by a modified version of the Community Health Activities Model Program for Seniors (CHAMPS) questionnaire, consisting of 36, instead of 41, items. The CHAMPS questionnaire items ask the respondent to report the total number of hours per week (from less than 1 hour to 9 hours or more) of doing various physical activities.

• From baseline to 15-month follow-up, for all church members randomized (including those who did not provide data at follow-up), intervention church members reported increased leisure-time MVPA, while control church members reported decreased leisure-time MVPA (p=.02), after adjusting for church members nested within churches, implementation wave (1, 2, or 3), church size (small, medium, or large), and church member age, gender, and education (i.e., some college or higher versus high school graduate or less).

• At 15-month follow-up, among church members with both baseline and follow-up data, members in intervention churches reported more hours of leisure-time MVPA weekly than members in control churches (p=.03), after adjusting for baseline hours of leisure-time MVPA weekly, church members nested within churches, implementation wave (1, 2, or 3), church size (small, medium, or large), and church member age, gender, and education (i.e., some college or higher versus high school graduate or less).

• At 15-month follow-up, among church members with both baseline and follow-up data, members in intervention churches reported more cups of fruit and vegetables daily than members in control churches (p=.03), after adjusting for baseline cups of fruit and vegetables consumed daily, church members nested within churches, implementation wave (1, 2, or 3), church size (small, medium, or large), and church member age, gender, and education (i.e., some college or higher versus high school graduate or less)

Additional Findings

Subsequent to the original study reviewed for this summary, two dissemination and implementation studies were conducted. The findings from these studies are reported below. These studies were not reviewed or rated by EBCCP.

• In the 2018 study, conducted in a rural, medically underserved county in South Carolina, 54 churches were randomly assigned to an intervention or control group. All churches in the county were invited to participate. The churches were identified as predominantly Black/African American (92.6%), predominantly White (5.6%), and predominantly multiracial (1.9%); 46% of churches were Baptist, and 20% were non-denominational or independent. Church attendees completed post-test questionnaires only. In comparison with control group church attendees, those in the intervention group had significantly more physical activity opportunities (p<.0001), healthy eating messages (p<.0001), physical activity messages (p<.0001), and pastor support for healthy eating (p<.0001) and physical activity (p<.0001). Intervention group church members were also less inactive in comparison with control group church members (p=.02). 

• The 2020 study, which used a single-group design, was a statewide implementation conducted in partnership with the Conference of the United Methodist Church. Among the 93 churches that participated, 42% were primarily African American, 25% had 500 or more members, and 45% had a health ministry. Data were collected at the church level at baseline and 12 months. From baseline to 12-month follow-up, FAN coordinators from participating churches reported an increase in the implementation of physical activity (p<.0001) and healthy eating (p<.0001) program components.