It’s only a Thursday night, but the fellowship hall is packed. A woman is talking. She thanks her pastor. She thanks God. And then she begins to talk about food—how hard it was, at first, to cut back on the things she had loved. Gravy. Butter. Pound cakes. “And last but not least,” she says, “Baptist people’s most favorite dessert: sweet potato pie.”

The audience laughs. They know what she means because they have all given up something to be here tonight. But they’ve also gotten something back. For many, it’s been new friends, new waistlines, and a new devotion to health. And so tonight, when they gathered, the table was heavy with fruits and vegetables and light on desserts. Because this is a gathering of PRAISE!

The PRAISE! (Partnership to Reach African Americans to Increase Smart Eating!) project, with its 60 participating churches in eight North Carolina counties, began with a call from the National Cancer Institute (NCI) for nutrition interventions (programs that help people make behavior changes), aimed at minorities. Carolina teams are old hands at community-based nutrition interventions, but this time the project would include the gamut of NCI’s dietary recommendations for healthy eating and blood studies—firsts for UNC-CH nutrition intervention research.

When the nutrition professors received funding in September 1996, the enormity of the project sank in, and they worried that they might have taken on too much, recalls Boyd Switzer, associate professor of nutrition. They needed to tailor their message to their participants’ culture and lifestyles. And, they weren’t interested in the fleeting; they wanted to create a program that would become woven into the fabric of each church community, that would be managed by church members, and that would outlive an 11-month intervention.

First, the researchers had to identify target counties, with similar urban or rural characteristics, that could be paired as intervention and control counties. Funeral home directors provided leads on church locations and congregation sizes.

The team mailed project materials to pastors and followed up with phone calls, explaining every aspect of the project and offering to set up presentations for Sunday services. The project’s name, which lent itself to a spiritual message, helped get a foot in the door with pastors, and the project’s faith-based framework further inclined pastors to listen. Even so, recruitment wasn’t easy.

“Among [the barriers to recruiting churches] were credibility, trust, tradition, and economics,” says Lee Downing, pastor of Friendship Missionary Baptist Church in Fayetteville, N.C., Although pastors admitted that food at church events was high in salt and fat, they didn’t want just anybody bringing just any project into their churches. One woman remarked to Chanetta Washington, UNC-CH intervention specialist, that her church had scrutinized the Carolina team to see if they were people with whom the church wanted to be associated. How the investigators treated those in subordinate positions, how the African Americans on the team were treated, and whether the team respected church traditions were important considerations in deciding to be part of the project. Downing feels that Carolina’s “professional yet personable staff, which included African Americans in key positions” helped to secure his church’s trust.

The PRAISE! team stressed that an estimated 30 to 70 percent of cancers may be diet related and that African Americans suffer certain cancers and diet-related diseases at higher rates than the general population while they represent fewer than 5 percent of participants in NCI-funded trials. Hearing this, some individuals decided to be part of PRAISE! as a way to help other African Americans. But people who viewed cancer as a death sentence didn’t even want to hear the word, and some worried that a large university would use them as pawns for science.

So, reaction to the project veered from dubiety to keen interest. “The thing that made them interested was that we were going to help people eat better—we call it ‘eat smarter,’” says Bethany Jackson, clinical associate professor of nutrition. The project emphasized the healthful components present in the population’s diet and suggested ways to modify traditional recipes to meet NCI’s dietary guidelines, without sacrificing taste.

The PRAISE! team realized that gradual modifications that approximated the flavors people enjoyed were the key to acceptance. For example, collards, a great choice nutritionally, become a high-fat, high-salt food when seasoned with ham hocks or fatback. PRAISE! suggested using chicken broth and smoked turkey instead. “We were very careful not to come in and say ‘Okay, throw out everything that you always enjoyed, and now, here’s something new,’” says Alice Ammerman, assistant professor of nutrition. Part of the appeal was the project’s flexibility. “Healthier eating was possible, within each family’s means and without a radical departure from the foods we enjoy,” Downing says.

PRAISE! involved blood measures, needed to check carotenoids (a measure of fruit and vegetable intake) and lipid levels. Jackson recalls that the mere mention of blood collection would elicit a collective groan from a congregation, uneasy at the thought of needles. Fear of needles wasn’t the only reason the prospect of blood samples disturbed some prospective participants.

Many congregrants knew about the infamous Tuskegee Syphilis Study (1932-1972), in which researchers withheld treatment from 400 black men without their informed consent. The PRAISE! team addressed concerns by discussing Tuskegee openly and vowing to share fully all information from the study. President Clinton’s formal apology for Tuskegee in May 1997 increased concern. Four attorneys who were members of a participating church, unsettled by the potential for DNA testing, grilled one staff member on the specifics of blood collection.

The team revised the PRAISE! consent form to stipulate that blood samples would be used only for nutrition-related measures, that no DNA testing would be done, and that neither blood nor information collected in the course of the project would be shared with any person or entity not part of the project. After discussion with church leadership, pastors signed consent-to-participate forms for their churches, and 20 churches were recruited for the intervention’s first wave. (The 60 churches comprised three waves of 20 each.)

From experience, the team knew that frequent contact with project personnel was important to participants. So, they hired coordinators for each study county. Trained by team members to field questions and offer support, the coordinators became readily accessible resources and representatives of Carolina. Each pastor selected a Health Action Team (HAT) leader and a church liaison, who recruited HAT members. Although there were variations among the churches, generally the HATs planned and carried out PRAISE! activities, and the liaisons coordinated trips to health departments for measurement groups and handled surveys and questionnaires.

From each church, about 22 individuals stepped forward to be part of the measurement group—height, weight, and blood samples were taken from this group before the intervention and at its conclusion. For the first wave, groups of three to four PRAISE! personnel moved among churches after Sunday services, taking body measurements and scheduling trips to county health departments for blood work. The team hadn’t appreciated fully the logistics involved—the measuring took longer than expected and people were anxious to go home after services. And there was what Switzer calls the “nightmare” of the balance-beam scales—they wouldn’t fit into every car and needed recalibration after each move. Surprisingly, participants were patient and cooperative through these early kinks. For subsequent waves, all measuring took place at health departments.

Before the intervention began, 97 percent of all participants (in Ammerman’s words “an amazing turnout”) completed psychosocial questionnaires and food-frequency surveys. Some discussed attitudes toward behavior change and food in focus groups. The data (along with body measurements) provide a baseline with which data collected at the intervention’s conclusion can be compared to gauge the intervention’s effectiveness. Plus, knowledge of participants’ attitudes toward food—say, that 93 percent of the women and 73 percent of the men feel it’s “very important that others enjoy their cooking” and that many feared the PRAISE! recipes wouldn’t taste good—helped the team fine-tune the intervention’s design.

Unlike most interventions, PRAISE! left implementation of the project up to the congregations. This decision didn’t trouble Washington. “I knew from conversations with church members that PRAISE! was seen as a church effort, and people wanted to do their best for their churches,” she says. For Washington, the greatest challenge was translating the investigators’ theoretical methodology into a user-friendly format that would feel comfortable to participants and effectively teach the PRAISE! nutrition lessons: eat more fruits and vegetables, eat more fiber, and eat less fat.

The researchers forged a partnership with the churches through the pastors and HAT leaders. In workshops, HAT leaders discussed the nutrition guidelines and ways to share them with their congregations. Investigators and participants credit this approach with the project’s high participation rate. “The partnership approach fostered increased participation, as church members were more apt to take ownership in the program and to accept personal responsibility for their health,” Downing says.

From the onset, participants understood that some counties would be randomly selected to proceed with the intervention, and others would serve as the control, receiving the intervention later. Anticipation was high, and the researchers feared controls might begin their own nutritional programs. So, they developed materials for two additional interventions—Honoring Seniors and Stress Reduction. “I don’t know of any other project that has done so much to keep a control group interested,” Jackson says.

The control congregations plunged into the additional interventions, surprising the team with their ardor and creativity. As part of their Honoring Seniors project, one Durham County church began taping services for distribution to homebound members. For Stress Reduction activities, churches hosted support groups for members struggling to care for elderly relatives or handicapped children and sponsored meditation classes.

HAT leaders received intervention manuals, a suggested calendar for events, and cookbooks used in earlier church-based interventions. To counter initial resistance to dietary changes, Washington suggested expanding menus to include more healthful options rather than dropping traditional foods. For one church, this meant keeping the highly anticipated pork barbecue (served with a smaller spoon) but adding more vegetables to the homecoming menu. Attractively presented food that also was delicious won over skeptics. “The HAT ladies prepared some beautiful meals for different occasions,” Johnny Way, a participant, says. “A lot of people would look at [the PRAISE! foods] and say ‘I don’t want that stuff,’ but when the event was over, there wasn’t too much food left.” The team provided PRAISE! pot holders, aprons, church fans, and other items to promote the project.

Because the researchers are interested in which activities fostered the most change in participants’ eating habits, they asked intervention churches to implement eight core activities, which included a PRAISE! bulletin board to announce events, pastor workshops, and food events. Optional activities included gleaning and music fests.

Most churches linked PRAISE! activities to regularly scheduled church events such as homecomings, family fun days, and women’s breakfasts. HATs ensured that menus included foods prepared using PRAISE! recipes and displayed project materials that covered nutritional goals and ways to make favorite recipes more healthful. HATs and liaisons devised ingenuous methods to teach congregants about good nutrition and new foods—one church used “food jeopardy” and “fruit bingo.”

Gloria Henderson, a HAT leader, feels that the project was good for her church because “not only did it help us learn to eat better, but the fellowship it promoted was great too.”

Pastors of intervention churches attended three sessions lead by Joseph Paige, former dean of the Shaw University School of Divinity. He provided biblical references so pastors could incorporate the project into their services. Citing I Corinthians 3:16, Paige suggested stressing that the human body is God’s temple and that to do God’s work an individual must be healthy. A prostate cancer survivor, Paige also spoke candidly about his experience and the importance of early detection.

Throughout the project, participants filled out questionnaires and surveys so investigators could ascertain what participants learned from an event, which activities they liked or disliked, and what affected their motivation to change. Investigators use these “process measures” to study the process of initiating change and to gain a sense of the effectiveness of the project.

Along the way, Nature staged its own intervention. Hurricane Floyd devastated many of the participating communities, and some individuals lost everything. The PRAISE! team collected food and clothing, secured a commercial truck, and turned one county coordinator office into a distribution site. “Church members were touched that the PRAISE! team had helped them out of compassion and done things that were beyond the scope of the intervention,” Washington says.

The researchers hope that the participating congregations have institutionalized the project, so it can be sustained and shared with others. “We are committed to applying and sharing the lessons learned from this outstanding project,” Downing says. As they enter the fifth and final year of funding, the researchers are exploring ways to help churches make the transition to self-sufficiency.

The PRAISE! team scruples to characterize the intervention as effective until all data are collected and analyzed. Instead, they point to a wealth of anecdotal evidence that indicates the intervention hit its mark. As participant Gisele Ashford says, “[W]hat it has done for me, more than anything else, is it let me know that I have choices. You know those generational curses that we have in our families such as diabetes and high blood pressure? Well, now I know that I don’t have to receive that. I can make a difference in my family’s life because of PRAISE!” Ashford, who is teaching the project’s lessons to her young children, says that it was “a blessing” to be part of PRAISE!

Many participants, previously unaware that diet has a significant impact on health status, are grateful for the information the project imparted. “It has been an eye opener,” participant Rayvonnia Jackson says. “Yes, it was a lot of work, but it was worth every moment because the knowledge that we have now we can use forever.”

The camaraderie that developed between congregrants and Carolina researchers was an unexpected bonus. James Brown, pastor of a PRAISE! church says, “What we found with PRAISE! is a group of friends that cared about us, understood our plight, and worked to show us a better way of life. And, I feel like a million bucks!”