The problems of obesity, metabolic syndrome, and diabetes in the inner-city Latino and African-American populations with severe and persistent mental illness are well documented and complex.

In response to the New York City Department of Health and Mental Hygiene's mandate for quality assurance, our continuing day-treatment program chose treating obesity as the subject of an ongoing quality improvement study that began in 2005. At the Community Support Services Program of Metropolitan Hospital Center, we implemented a comprehensive protocol to improve body mass index (BMI) and increase exercise in these populations. All clients with a BMI higher than 30 (the index for obesity) qualified for this ongoing study, resulting in 33 participants.

The interventions and our program are based on and informed by cognitive-behavioral therapy, dialectical behavior therapy, and adherence techniques. All staff members are trained in these therapies through workshops and in-service sessions that are ongoing. The daily treatment we offer includes teaching the clients to identify and anticipate personal obstacles to healthy eating and exercise and to develop their own interventions to change their behavior.

Clients identify personal intervention strategies in therapy groups. Some examples of groups in which we promote these behavioral changes are nutritional coaching, coping skills, diabetes, healthy cooking, community meeting, and "waist watcher." In waist watcher, clients are weighed weekly, and we focus on motivation and goal setting. We reinforce interventions in medication and treatment plan sessions.

The team encourages all clients to exercise for a half hour per day five days per week. Clients choose their exercise class: walking group, sit and stretch, yoga, or gym. We award certificates when walking, weight loss, and exercise milestones are achieved. Each time a client earns any three certificates, he or she is eligible to be in the Member of the Month poll. We enhance participation in the indoor walking group by adding music via stereo.

In group sessions, clients identify personal obstacles to making healthy food choices and eating healthy portion sizes. They receive support and feedback from peers and staff. For example, clients may select one achievable step toward behavioral change to practice per week. These steps are chronicled in progress notes.

In the initial 21 months, 67% of clients (N=22) lost weight, 64% (N= 21) lost five pounds or more, and 52% (N=17) lost from ten to 39 pounds. There was a fivefold increase in exercise session participation. No control group was used. We continue to monitor for weight loss, weight loss maintenance, and increased exercise to evaluate the longer-term effectiveness of our interventions.

One major challenge has been to transform the clients' concepts of portion size. We instruct them in the use of measuring cups to learn and achieve healthy portion sizes.

Another challenge is to teach clients to eat healthily on very limited budgets. We guide them in making healthy choices in how to budget money (oatmeal versus doughnuts, using food pantries for staples, shopping wisely for healthy food in grocery stores, and bypassing junk food in fast-food outlets). We also work with clients to help them integrate healthy eating patterns into their diverse cuisines and cultures. Many clients have been able to switch from fried foods to broiled or baked foods and to add more fruits and vegetables to their diets while maintaining their native cuisine's flavors. Many lost weight by incorporating these adjustments into their meals and by eating appropriate portion sizes of their cuisines.

We emphasize enjoyment of food and broadening the range of pleasurable activities pursued by each client. The community's attitude to food has evolved from "eat all you can eat" to an appreciation of a more balanced, healthy diet in appropriate portions.