Addressing Adult Obesity in Douglas County, Georgia, USA: A Community-Based Intervention Grounded in the Theory of Planned Behavior

Adult obesity remains a pressing public health issue in the United States, with rural and suburban communities experiencing a disproportionate burden. In Douglas County, Georgia, approximately 36% of adults are classified as obese, exceeding the state average of 34%. This paper describes the design and evaluation of the Douglas County Lifestyles Initiative (DCHLI), a community-based intervention grounded in the Theory of Planned Behavior (TPB). The initiative aims to reduce obesity and related chronic disease risk by promoting healthier dietary habits and increasing physical activity, focusing on middle‑aged adults (30–60 years), predominantly low‑income and minority populations.

The intervention was developed following a comprehensive needs assessment, including stakeholder interviews and focus groups, to understand local barriers such as food access, socioeconomic constraints, and cultural influences on behavior. The program includes nutrition education workshops, group exercise sessions, and mobile health coaching via SMS and social media platforms. Evaluation is conducted across three phases: formative, process, and outcome, which assess changes in knowledge, behavioral intentions, and actual lifestyle practices. The intervention emphasizes cultural competence by integrating traditional food practices, addressing language barriers, and aligning with the values of the diverse populations in the county.

This initiative provides a structured, evidence‑based model for addressing adult obesity within a multiethnic, socioeconomically diverse community. Its findings have significant implications for public health practice and policy, offering a replicable framework for other countries seeking to reduce obesity and its associated health burdens.

Description of Douglas County

Douglas County, located in the northwestern region of Georgia, is part of the Atlanta metropolitan area. With approximately 200 square miles, the county has a population of around 150,000. According to the United States Census Bureau, the community is diverse, with a racial composition of roughly 40% White, 54.6% Black, 12.7% Hispanic, and 5% other races. In 2022, the median age is 36.7, with a slightly higher proportion of females. Economically, the county's median household income is $76,930, and around 11.6% of the population lives below the poverty line. Douglas County is a bustling metropolitan area with 12 cities mixed with urban and rural environments, suburban neighborhoods, and agricultural and undeveloped lands. Douglas County, Georgia, has landmarks like Clinton Nature Preserve and Sweetwater Creek State Park. Large employers include APL Logistics, Silver Line Building Products, and WellStar Douglas Hospital. Douglas has grown steadily in the past decade, and its population has become much more diverse.

Community Needs Assessment

Adult obesity is a significant health concern in Douglas County, mirroring national and state trends. According to data from the County Health Rankings, approximately 36% of adults in Douglas County are classified as obese, compared to the Georgia state average of 34%. Overweight people have a body mass index (BMI) of 25 or higher, whereas obese people have a BMI of 30 or higher (World Health Organization [W.H.O.], 2022). The World Health Organization describes obesity and overweight as excessive or abnormal fat buildup that presents a health risk. Obesity is a risk factor for a range of chronic health conditions, including cardiovascular disease, type 2 diabetes, hypertension, Alzheimer's disease, dementia, liver disease, kidney disease, and certain types of cancer. 

Health Behaviors Contributing to Obesity

Physical inactivity and poor dietary habits are the two primary behavioral factors contributing to adult obesity in Douglas County. Environmental, socioeconomic, and cultural factors shape these behaviors. Other factors, such as genetic factors and personal choices, can also determine the risk of obesity. 1. Physical inactivity: Many adults' lifestyle of lack of exercise and reduced physical activity contributes to an increased risk of obesity and obesity-related diseases such as coronary heart disease, diabetes, and some cancers. When performed routinely, exercise has been proven to reduce the risk of obesity. According to County Health Rankings data, around 27% of Douglas County adults report participating in no physical activity outside of work. There is a high percentage of adequate access to physical activity locations; 76% of people in Douglas County live close to a park and recreation facility, yet a notable observation of a large population of residents not using these facilities. For residents in rural parts of the county, geographic isolation further reduces opportunities for regular exercise. Sedentary jobs and long commutes, shared in this suburban region, also contribute to inactivity. 2. Poor Dietary Habits: Many residents face challenges accessing healthy, affordable food. In Douglas County, 15% of people had low incomes and did not live close to grocery stores, limiting their ability to access healthy foods. Diets with greater nutrient density are more expensive than less healthy calorically-dense diets. Consumption of sugar-sweetened beverages is strongly linked to weight gain, cardiovascular disease, and type 2 diabetes and is highest among blacks and low-income individuals (Levy et al., 2012). Douglas County has areas classified as food deserts (where access to healthy and quality food is a problem due to cost, food options, or especially distance), where grocery stores are scarce, and convenience stores with limited healthy options dominate.

Target Population

The target population for addressing adult obesity in Douglas County would be middle-aged adults (ages 30-60), particularly those from low-income and minority groups. This age group is more susceptible to obesity-related chronic diseases, making lifestyle change intervention programs very essential to this age group. 

Current Community Resources

1) Douglas County created Partners for a Healthy City (PHC), a program that supports local organizations' efforts to develop policies that foster healthy environments. Trainers have helped more than 335 organizations implement changes, including making fresh, local produce available to employees, installing bike racks, increasing access to drinking water, and ensuring healthy options are available at meetings.

2) Douglas County initiated the Movin' After School initiative to increase physical activity and eliminate unhealthy beverages in before- and after-school programs. This initiative will affect approximately 1,500 students and was adopted in all 36 programs in Millard Public Schools, the second-largest district in Douglas County.

3) Local organizations, such as the Douglas County Public Health Department, run initiatives like diabetes prevention workshops and nutrition education programs. 

4) The Cobb and Douglas Public Health (CDPH) program promotes and protects the health and safety of the residents of Cobb and Douglas counties and eliminates barriers to ensure equality for all.

5) Healthier meals for Douglas County students through a partnership with the Gretchen Swanson Center for Nutrition, Omaha Public Schools recently committed to serving healthier meals to the more than 49,000 students it serves each day.

6) Douglas County also has several parks and recreational areas that encourage physical activity.

Social determinant of health

According to the World Health Organization, the non-medical factors affecting health outcomes are the social determinants of health (SDH). They are the conditions in which people are born, grow, work, live, and age, as well as the more extensive collection of systems and forces influencing day-to-day living situations. In Douglas County, Georgia, several social factors contribute to the high rates of obesity.

Economic stability/income

Economic stability is one of the most significant social determinants of health, influencing obesity in Douglas County. According to county health ranking, 11.6% of the county's population lives below the poverty line, and this population may experience financial constraints that limit their ability to purchase healthy foods. Lower-income households are more likely to rely on inexpensive, calorie-dense, and nutrient-poor foods because they are often cheaper and more accessible than fresh, healthy alternatives. Some populations of Douglas County suffer unstable employment, such as multiple jobs, long working hours, and low wages, and these people may have no time for food preparation or exercise, leaving them with fast foods and sedentary lifestyles. Unemployment or underemployment can limit a person's ability to make healthy lifestyle choices (Employment | County Health Rankings & Roadmaps, n.d.). 

Access to healthy foods

The type and frequency of food in a community determine the food residents would purchase. Limited access to healthy foods is one of the primary social determinants of health that influence the prevalence of adult obesity (Lee et al., 2019). According to county health ranking, in Douglas County, Georgia, 15% of the population has limited access to healthy food. The lack of access to nutritious food directly influences dietary patterns and behaviors. Douglas County has areas classified as food deserts (where access to healthy and quality food is a problem due to cost, food options, or especially distance), where grocery stores are scarce, and convenience stores with limited healthy options dominate. In the United States, food desert areas have been strongly linked with obesity (Lee et al., 2019). As of 2019, 6 census tracts in Douglas County, located in the northern portion, are considered food deserts. Across all portions of Douglas County, 59% of low-income residents are at least a mile from access to healthy foods (Georgia Health Data Hub, n.d.).

Education

Education levels are strongly linked to health outcomes, including obesity. It has been proposed that better lifestyles and lower obesity rates result from higher levels of educational achievement among those with increased health knowledge and material and financial means (Witkam et al., 2021). In a nationwide assessment, Douglas County is within the lowest category for health literacy, meaning between 36% and 59% of the population is expected to have limited health literacy (UnitedHealth Group, 2024). Lower educational attainment is associated with reduced health literacy, making it more challenging for individuals to understand the long-term health risks of obesity or make informed decisions about nutrition and physical activity. School is vital in shaping health behaviors and promoting good dietary choices. Although many schools actively participate in programs to combat obesity, such as the Movin' After School initiative and Healthier Meals for Douglas County students, more can still be done, especially in promoting physical activity and education programs.

Social and community context

Social and community networks play a crucial role in shaping health behaviors. Food culture refers to what we do, think, and feel about food as individuals or groups within the social and environmental constructs at that time. Food culture goes above individual factors influencing food choices, including cultural practices and socialization. For instance, Southern cuisine, which is popular in the region, often includes high-calorie, fried, and processed foods. 

Cultural competence skill in addressing adult obesity in Douglas County

Douglas County, Georgia, is a diverse community with different cultural values, ideals, traditions, assumptions, and backgrounds. Cultural competence skills are essential in developing intervention programs to address adult obesity in Douglas County, Georgia, which is primarily a behavior-driven condition. Cultural competence is the capacity of an individual and organization to understand, behave, and respect the values, beliefs, and attitudes of different cultural groups and to incorporate these differences in the development, implementation, and evaluation of policies and health education and promotion programs. (Luquis and Pérez, 2003). Reflecting on applying awareness of cultural values and practices to address adult obesity in Douglas County, Georgia. 

Community-Based Nutrition Education

In 2022, in Douglas County, Georgia, black or African Americans are the largest ethnic group, with about 48.1% (Douglas County, GA | Data USA). Southern cuisine is prevalent among African American residents, often including high-fat, fried, and carbohydrate-heavy foods such as fried chicken, macaroni and cheese, and cornbread (Bovell-Benjamin et al., 2010). Many traditional meals are deeply rooted in cultural and familiar traditions, challenging dietary change. Public health initiatives should integrate culturally familiar foods into healthy eating education (Woodside et al., 2022). Instead of discouraging traditional meals, programs can focus on modifying cooking methods (e.g., baking instead of frying) and incorporating more fruits and vegetables. Also, providing cooking demonstrations featuring healthier versions of popular cultural dishes can make dietary changes more acceptable and sustainable. Hispanic families may have strong traditions of cooking homemade meals, but many traditional dishes are high in refined carbohydrates, rice, and fatty meats; educational programs on portion control and eating time should be encouraged.

Physical Activity Programs

Social norms around exercise vary across cultures. In some African American and Hispanic communities, structured exercise may not be a common practice, and daily movement may be associated more with work or responsibilities rather than leisure or health (Griffith et al., 2018). Exercise programs should be adapted to cultural preferences and community norms. For example, dance-based fitness classes or community jogging can appeal more to diverse populations than traditional gym workouts. Also, creating women-only fitness classes or family-oriented physical activities can address cultural barriers that discourage women from participating in public exercise programs. Women-only fitness programs can also address cultural barriers to exercising publicly due to modesty, safety concerns, or family obligations prioritizing caretaking over personal health. 

Addressing language and socioeconomic barriers

Language barriers can prevent non-English-speaking residents from accessing nutrition and exercise programs. Providing bilingual resources and interpreters at healthcare facilities and wellness events can improve engagement among Hispanic and other immigrant populations. Health messages should be culturally relevant and designed to align with the values and beliefs of different communities. According to county health ranking, 11.6% of the population lives below the poverty line, and 15% of Douglas County, Georgia's population has limited access to healthy food. Expanding access to farmers' markets that accept Supplemental Nutrition Assistance Program (SNAP) benefits and encouraging grocery stores to stock culturally relevant healthy foods can make nutritious eating more practical for low-income families.

Policy Development and governmental support

Policymakers and governmental agencies should create programs that address the root causes of obesity. This program involves funding more community fitness programs and integrating these programs in different social groups like schools, subsidizing the cost of healthy foods, mostly in low-income areas, and implementing culturally tailored health promotion campaigns.

Social determinant of health

According to the World Health Organization, the non-medical factors affecting health outcomes are the social determinants of health (SDH). They are the conditions in which people are born, grow, work, live, and age, as well as the more extensive collection of systems and forces influencing day-to-day living situations. In Douglas County, Georgia, several social factors contribute to the high rates of obesity.

Economic stability/income

Economic stability is one of the most significant social determinants of health, influencing obesity in Douglas County. According to county health ranking, 11.6% of the county's population lives below the poverty line, and this population may experience financial constraints that limit their ability to purchase healthy foods. Lower-income households are more likely to rely on inexpensive, calorie-dense, and nutrient-poor foods because they are often cheaper and more accessible than fresh, healthy alternatives. Some populations of Douglas County suffer unstable employment, such as multiple jobs, long working hours, and low wages, and these people may have no time for food preparation or exercise, leaving them with fast foods and sedentary lifestyles. Unemployment or underemployment can limit a person's ability to make healthy lifestyle choices (Employment | County Health Rankings & Roadmaps, n.d.). 

Access to healthy foods

The type and frequency of food in a community determine the food residents would purchase. Limited access to healthy foods is one of the primary social determinants of health that influence the prevalence of adult obesity (Lee et al., 2019). According to county health ranking, in Douglas County, Georgia, 15% of the population has limited access to healthy food. The lack of access to nutritious food directly influences dietary patterns and behaviors. Douglas County has areas classified as food deserts (where access to healthy and quality food is a problem due to cost, food options, or especially distance), where grocery stores are scarce, and convenience stores with limited healthy options dominate. In the United States, food desert areas have been strongly linked with obesity (Lee et al., 2019). As of 2019, 6 census tracts in Douglas County, located in the northern portion, are considered food deserts. Across all portions of Douglas County, 59% of low-income residents are at least a mile from access to healthy foods (Georgia Health Data Hub, n.d.).

Education

Education levels are strongly linked to health outcomes, including obesity. It has been proposed that better lifestyles and lower obesity rates result from higher levels of educational achievement among those with increased health knowledge and material and financial means (Witkam et al., 2021). In a nationwide assessment, Douglas County is within the lowest category for health literacy, meaning between 36% and 59% of the population is expected to have limited health literacy (UnitedHealth Group, 2024). Lower educational attainment is associated with reduced health literacy, making it more challenging for individuals to understand the long-term health risks of obesity or make informed decisions about nutrition and physical activity. School is vital in shaping health behaviors and promoting good dietary choices. Although many schools actively participate in programs to combat obesity, such as the Movin' After School initiative and Healthier Meals for Douglas County students, more can still be done, especially in promoting physical activity and education programs.

Social and community context

Social and community networks play a crucial role in shaping health behaviors. Food culture refers to what we do, think, and feel about food as individuals or groups within the social and environmental constructs at that time. Food culture goes above individual factors influencing food choices, including cultural practices and socialization. For instance, Southern cuisine, which is popular in the region, often includes high-calorie, fried, and processed foods. 

Cultural competence skill in addressing adult obesity in Douglas County

Douglas County, Georgia, is a diverse community with different cultural values, ideals, traditions, assumptions, and backgrounds. Cultural competence skills are essential in developing intervention programs to address adult obesity in Douglas County, Georgia, which is primarily a behavior-driven condition. Cultural competence is the capacity of an individual and organization to understand, behave, and respect the values, beliefs, and attitudes of different cultural groups and to incorporate these differences in the development, implementation, and evaluation of policies and health education and promotion programs. (Luquis and Pérez, 2003). Reflecting on applying awareness of cultural values and practices to address adult obesity in Douglas County, Georgia. 

Community-Based Nutrition Education

In 2022, in Douglas County, Georgia, black or African Americans are the largest ethnic group, with about 48.1% (Douglas County, GA | Data USA). Southern cuisine is prevalent among African American residents, often including high-fat, fried, and carbohydrate-heavy foods such as fried chicken, macaroni and cheese, and cornbread (Bovell-Benjamin et al., 2010). Many traditional meals are deeply rooted in cultural and familiar traditions, challenging dietary change. Public health initiatives should integrate culturally familiar foods into healthy eating education (Woodside et al., 2022). Instead of discouraging traditional meals, programs can focus on modifying cooking methods (e.g., baking instead of frying) and incorporating more fruits and vegetables. Also, providing cooking demonstrations featuring healthier versions of popular cultural dishes can make dietary changes more acceptable and sustainable. Hispanic families may have strong traditions of cooking homemade meals, but many traditional dishes are high in refined carbohydrates, rice, and fatty meats; educational programs on portion control and eating time should be encouraged.

Physical Activity Programs

Social norms around exercise vary across cultures. In some African American and Hispanic communities, structured exercise may not be a common practice, and daily movement may be associated more with work or responsibilities rather than leisure or health (Griffith et al., 2018). Exercise programs should be adapted to cultural preferences and community norms. For example, dance-based fitness classes or community jogging can appeal more to diverse populations than traditional gym workouts. Also, creating women-only fitness classes or family-oriented physical activities can address cultural barriers that discourage women from participating in public exercise programs. Women-only fitness programs can also address cultural barriers to exercising publicly due to modesty, safety concerns, or family obligations prioritizing caretaking over personal health. 

Addressing language and socioeconomic barriers

Language barriers can prevent non-English-speaking residents from accessing nutrition and exercise programs. Providing bilingual resources and interpreters at healthcare facilities and wellness events can improve engagement among Hispanic and other immigrant populations. Health messages should be culturally relevant and designed to align with the values and beliefs of different communities. According to county health ranking, 11.6% of the population lives below the poverty line, and 15% of Douglas County, Georgia's population has limited access to healthy food. Expanding access to farmers' markets that accept Supplemental Nutrition Assistance Program (SNAP) benefits and encouraging grocery stores to stock culturally relevant healthy foods can make nutritious eating more practical for low-income families.

Policy Development and governmental support

Policymakers and governmental agencies should create programs that address the root causes of obesity. This program involves funding more community fitness programs and integrating these programs in different social groups like schools, subsidizing the cost of healthy foods, mostly in low-income areas, and implementing culturally tailored health promotion campaigns.

The community health issue of adult obesity in Douglas County reveals how behavioral and environmental factors can contribute to health issues. Over one in three adults in Douglas County are considered obese, which shows how significant this community issue is (Centers for Disease Control and Prevention [C.D.C], 2020). Adults are at greater risk for obesity-related chronic diseases, making interventions in this group both critical and impactful. Increasing awareness programs, access to healthy foods, and opportunities for exercise in neighborhoods, schools, and workplaces can help children and adults eat nutritious meals and reach recommended daily physical activity levels. TPB provides a structured approach to understanding why people engage (or fail to engage) in obesity-preventive behaviors and helps design interventions that directly target behavioral intentions. The TPM would also help participants learn about healthy eating habits and physical activity while ensuring they develop self-efficacy, behavioral intentions, and motivation to sustain long-term change. Conducting an evaluation is critical in ensuring that Healthy Douglas is practical, efficient, culturally relevant, feasible, and meets the needs of its intended audience in addressing adult obesity in Douglas County. Looking ahead, the success of this program depends on community engagement, program delivery, and a good evaluation plan.