School-based Programs Promoting Nutrition and PA

Part 1: Needs Assessment

• Describe in detail the population and setting with which you will work. Identify the public health problem. Use surveillance data to support the needs of the community. As appropriate, discuss the health disparities of your target community. (20 points)

Clarke County School district is responsible for almost 14,000 students between the ages of 4 and 18, with the largest percentage of these children in Pre-K through 5^th grade. Every day, approximately 7,600 students walk into one a Clarke County’s 14 elementary schools yearning for education (Clarke County School District, 2016). But learning isn’t the only things these children are hungry for. Nutrition and physical activity are crucial to their growing bodies and minds. The county it self has a poverty rate of 36.7%, which extends to the children enrolled in the county’s public school system (U.S. Census Data, 2012). Due to this higher than average level of poverty, Clarke County Schools participate in the community eligibility provision (CEP) program. CEP is a way to serve universal free breakfast and lunch to all students in high poverty schools and school districts (USDA, 2016). All of Clarke County’s 21 schools participate and every student receives free breakfast and lunch. This provides the community support without assigning different statuses to students of different incomes. The hope behind this program was to provide healthy meals to students who may not be able to otherwise receive one.

Obesity is defined as having larger than ideal weight for height and can be measured using CDC growth charts. As of 2012, 17% of American children were obese (Ogden, Carroll, Kit, & Flegal, 2014). The greatest increase in the prevalence obesity was seen between first and third grade and non-Hispanic black children had the highest prevalence (Cunningham , Kramer , & Narayan 2014). This is pertinent to Clarke County, as about 50% of the student population is non-Hispanic black. Between kindergarten and eighth grade, the prevalence of obesity increased by 65% among non-Hispanic white children, 50% among Hispanic children, nearly 120% among non-Hispanic black children, and more than 40% among children of other races (Asian, Pacific Islander, Native American, and multiracial children)(Cunningham et al., 2014). Additionally, children from top 20% of income percentile have a lower prevalence of obesity than their other socioeconomic counterparts. At all ages, the poorest percentile of the population has the highest prevalence of obesity (Cunningham et al., 2014). Additionally, children who are overweight or obese tend to remain so as they age. Cunningham and colleagues found that “overweight kindergartners had four times the risk of becoming obese by the age of 14 years as normal-weight kindergartners” (Cunningham et al., 2014).

Childhood obesity has been defined as a global crisis, as it is increasing in almost every corner of the earth, both developed and underdeveloped. Childhood obesity may have adverse morbidity and mortality effects in the adulthood of the child (Karnik & Kanekar, 2015). Health risks from childhood obesity are physical, social, and psychological. Negative self-esteem and body image can affect behavior and slow progress in school and social settings. Cardiovascular diseases, hypertension, type 2 diabetes, and respiratory issues are all common afflictions seen in adults who were obese as children (Vucenik & Stains, 2012).

While there are many factors that may influence obesity prevalence in children, including genetics, socioeconomic status, and stress level, the imbalance between caloric intake and caloric utilization is one of the most easily intervened (Karnik & Kanekar, 2015). Generally, the calories that a child consumed through food and beverages lead to obesity if they are not used for energy activities. Many children prefer high-sugar, high-fat or energy-rich foods and in this day and age, lack of physical activity has become the norm. This combination can lead to weight gain very quickly. Studies have found that this lack of physical activity can be attributed to lack of access to a safe and conducive area for children to exercise and unsupportive familial attitudes towards exercise. This is why physical education courses and healthy eating education in school are so crucial to children’s health.

• What stakeholders may be needed along the way? Describe the role of each stakeholder, and the questions they may want answered about the intervention. Also briefly describe how a successful intervention would impact that stakeholder, and how an unsuccessful program might impact that stakeholder. Stakeholders may be individuals, groups, or organizations. (20 points)

Part 2: Intervention Identification

• State and define the intervention strategy – what does it mean? What populations has this strategy been used with? What settings has it been used in? How are your community characteristics similar or different to those of the communities in which the strategy has been effective? (20 points)

The interventions summarized in the Community Guide varied widely in style but all centered around promoting healthy attitudes, knowledge, and behaviors. Most of the studies revolved around students in grades 3-5 with an average age of 9.3 years but all levels K-12 were included. The various interventions were directed at school administrators, food service staff, teachers, parents, or directly to the students and focused on increasing fruit and vegetable intake and decreasing fat and saturated fat intake. In order to address these needs, interventions targeted food policy, environmental factors, and/or nutrition education. Results and study outcomes were based on behavioral outcomes and reports of dietary intake.

The proposed intervention will be somewhat similar in target audience, as elementary students are the focus. Additionally, we will focus on increasing fruit and vegetable intake, but in the form of snacks, which may help with reducing fat intake (but that is not the major goal). This intervention will be delivered directly to the students by their educators and a nutrition graduate student or registered dietitian. The information disseminated to the students will be coordinated with food service in the form of an included fruit or vegetable at after-school snack time, as Clarke County School District participates in the After-school Snack Program (ASP). These students will also receive a small “homework” assignment to complete with their parents to reinforce the nutrition information learned at school. This intervention will need to be multicomponent; as there more evidence that this type of intervention is effective. Very little was mentioned about physical activity (PA) in the Community Guide, but this intervention will have a PA emphasis as well as a dietary component.

• Is the strategy recommended by the Task Force? Why or why not? (10 points)

The strategy does not have sufficient evidence to be recognized as recommended by the Task Force. The Task Force looked at 45 reports to come to this conclusion. Each report presented a differing intervention, population, length of study, or outcome, which would make reaching a “recommended” consensus difficult. As not every school is the same proving that a single intervention style is recommended would be impossible.

• Provide at least 3 examples from existing articles (peer-reviewed preferably, but could come from other places). These should be different than the research-tested intervention programs(RTIP) listed already. You can include or link to this information, but you should provide different examples. (45 points total)
  1. Describe the intervention – what did the authors do? What was the procedure? How long was the intervention? Please describe individual components as well as the broader intervention plan.
  2. What were the outcomes measured?
  3. What amount of change did they find?

Increasing the Fruit and Vegetable Consumption of Fourth-Graders: Results from the High 5 Project(1)

28 elementary schools were paired based on ethnic proportion and free or reduced meal rates with one serving as a control school and the other receiving the intervention. The intervention was based on the Social Cognitive Theory and utilized three components; a classroom component, a parent component, and a food service component. 14 lessons were taught in the classroom, with aspects of modeling, self-monitoring, problem solving, reinforcement, and taste testing. Curriculum Coordinators lead these sessions with the assistance of the teachers. Two 30-45 minutes lessons are taught per week with one reinforcement/ challenge day in between for 7 weeks. Parents were informed of the intervention and were encouraged to help with small homework assignments at least once a week and work to eat 5 servings of fruits and vegetables themselves, to effectively model behavior. Foodservice workers were training on purchasing, preparing and promoting the fruits and vegetables included in the intervention curriculum. They were guided by dietitians and received “stars” for their implementation of the intervention.

The children were subjected to a 24-hour dietary recall interviews via telephone on the weekends and in person during the school week. A sample of students was also observed in the cafeteria to assess fruit and vegetable consumption. Psychosocial measures, such as knowledge, self-efficacy and social norms were evaluated via an in-class questionnaire. Parental intake of fruits and vegetables was also evaluated using a questionnaire sent home with the student.

Fruit, vegetable and fruit and vegetable intake increased significantly in students but not in parents. At follow up the intervention favored a significant improvement of total fat, saturated fat, beta carotene, and vitamin C but caloric consumption did not change between groups. This infers that fat consumption was replaced somewhat with carbohydrates in the form of fruits and vegetables. Additionally, the students significantly increased knowledge and self-efficacy of the benefits of eating fruits and vegetables.

5-a-Day Power Plus: Process Evaluation of a Multicomponent Elementary School Program to Increase Fruit and Vegetable Consumption (2)

Fourth and fifth graders in 10 intervention and 10 control schools were targeted to increase fruit and vegetable consumption. Behavioral curriculum, parental involvement, food service modification and industry support were all used in the 8-week program. Two 40-45 minute lessons were taught a week to students who were split into teams. These teams had fruit and vegetable consumption competitions and were awarded prizes for those who ate more than two servings at lunch. Activity packets and information were sent home with the students to encourage parental involvement as well as snack packs for the fifth graders. These packets typically included tips and recipes for parents to act upon. In the cafeterias, promotional materials that used characters and messages from the curricula were implemented as well as increasing the variety and choice of fruits and vegetables. Lastly, a local producer provided some fruits and vegetables for taste testing, snack packs, and expansion of choice in the cafeterias.

Program implementation was monitored in the form of observations of the teachers and cafeteria space and cards signed by parents to ensure they received the packets each week. Student dietary recalls were performed to assess the fruit and vegetable intakes of children.

75% of parents returned the cards indicating that they had worked through the packets with their children. Observations confirmed that 90% of the curricula lessons and taste testing was implemented. Student intakes of fruits and vegetables were higher at schools that had a higher percentage of curricula taught. Additionally, intervention schools saw their students choosing significantly more fruit and vegetables at lunch than control schools.

Action Schools! BC: A school-based physical activity intervention designed to decrease cardiovascular disease risk factors in children (3)

In a study meant to assess cardiovascular outcomes of students in fourth and fifth graders, physical activity interventions took place in the classrooms. 10 schools were chosen, and 7 were placed into the intervention arm. The “active school” framework was implemented, which emphasizes a whole-school approach rather than just the typical physical education classes. This model targets 6 areas; school environment, scheduled physical education, extracurricular, school spirit, family and community, and classroom action. Classroom action was the component focused on in this intervention article. Teachers were asked to deliver 15 minutes of moderate to vigorous physical activity daily to achieve 75 minutes of extra PA per week. To do this, the teachers provided opportunities in the classroom for students to “snack on” physical activities such as skipping, dancing, and resistance exercises. In addition to this, students took place in 2 40-minute PE classes per week. Therefore, the school provided 150 minutes of moderate to vigorous activity per week.

These researchers measured cardiovascular fitness (in the form of a shuttle run), blood pressure, tanner staging, physical activity, and took blood samples to assess cholesterol and lipoprotein levels. PA was assessed using a modified version of the physical activity questionnaire for children (PAQ-C), which is comprised of a 7 day self-report. This questionnaire was administered 3 times over the 10-month data collection period.

Physical activity increased at all three questionnaires for intervention students. A 20% improvement in cardiovascular fitness and blood pressure was also noted for students in the intervention arm.

1. Reynolds KD, Franklin FA, Binkley D, Raczynski JM, Harrington KF, Kirk KA, Person S. Increasing the Fruit and Vegetable Consumption of Fourth-Graders: Results from the High 5 Project. Preventive Medicine 2000;30(4):309-19. doi: http://dx.doi.org/10.1006/pmed.1999.0630.
2. Story M, Mays RW, Bishop DB, Perry CL, Taylor G, Smyth M, Gray C. 5-a-day Power Plus: process evaluation of a multicomponent elementary school program to increase fruit and vegetable consumption. Health Education & Behavior 2000;27(2):187-200.
3. Reed KE, Warburton DER, Macdonald HM, Naylor PJ, McKay HA. Action Schools! BC: A school-based physical activity intervention designed to decrease cardiovascular disease risk factors in children. Preventive Medicine 2008;46(6):525-31. doi: http://dx.doi.org/10.1016/j.ypmed.2008.02.020.

Part 3: Intervention Fit

• Provide a logic model and SMART Objectives for your intervention. You should have a SMART objective for each behavior you anticipate changing. (35 points; 10 points for SMART objectives, 25 points for the logic model)
  • SMART Objectives
    • Following the 8 lessons, 75% of students will report eating at least 3 servings of fruits or vegetables a day.
    • Following 8 lessons, 50% of students will report 60 minutes of all-purpose physical activity a day.
    • At least 50% of students will attend 6 out of 8 lessons.

• Explain the logic of why this intervention may work. (15 points)
  • Assuming that 30% of Barrow Elementary School’s 571 students were to attend the After School Program, 175 packets would need to be created for each lesson. These packets would be filled with information about the fruit or vegetable snack the students tried that day, a recipe of how to prepare that produce, and a raw version of the produce (for example a baggie of blueberries on the day the students try a blueberry parfait). Increasing the availability of fruits and vegetables by sending them home has shown to be  one of the most effective ways to increase consumption (Blanchette et al). Incorporating healthy snacks into the daily routine of children can increase the likelihood that they will reach for an apple instead of a bag of potato chips when they are hungry. Sending packets home to the parents with a produce item may affect the likelihood that the parents can model behavior and incorporate fruits and vegetables in daily living (Perry et al.). Parents who eat fruits and vegetables are more likely to positively affect their children, especially girls’, intake of these foods (Fisher et al).
  • Playing games that relate back to the material of the lesson can increase the memory and cognition of the lesson itself.  An example of this reinforcement is a variation of “Red Light, Green Light”, in which there will be “green”, healthy foods, and “red” fatty, unhealthy foods (again, the apple versus potato chips idea). Even small increases in physical activity (around 15 minutes), like would be performed in these games, can have meaningful effects on children’s health and increase their overall PA (Reed et al).
• Discuss limitations of the selected strategy, and things to look out for/be mindful of along the way. Examples may be limitations of resources, community capacity, or anticipated effect of the intervention. (15 points)
  • Students may not frequent After School Programs as frequently as expected. We will begin with the typical number reported by Barrow Elementary School. Students will be counted at the first two sessions and averaged so that more exact numbers can be met later in the intervention. We will also send a flyer home with students the month before the intervention starts in order to spark interest with parents.
  • Students may forget to give parents information packets. To combat this, as the students are between the ages of 4 and 11, a faculty member will distribute packets to parents at pick-up. For students who take a bus home after the program, a small note and ribbon will be tied to their backpacks, in which the packet will be. This small sign should be able to attract parent’s attention.
  • Parents may not look at packet or utilize resources given. To increase likelihood of parental involvement, students will receive a sticker each time they bring back a parent-signed form indicating the produce was used at home (either in the recipe or not). At the end of the intervention, students with more than 5 stickers will receive a small prize.
• What data would you collect to know if you are implementing the strategy the way it was intended (process evaluation/implementation monitoring)? Refer back to your logic model and the Logic Model module as needed. Be sure to cover dose, reach, fidelity, and implementation. (40 points)
  • Dose-  One 20 minute lesson will be delivered a week with 10 minutes previous for snacks to be handed out and 30 minutes afterwards in which to play reinforcement games. At least 1/2 of students enrolled will attend 6 of 8 lessons
  • Reach- A minimum of 85 students will attend the intervention program.
  • Fidelity-
    • How faithful is the program that was actually delivered to the program that was planned
      • Pre and post-intervention surveys will be given that will gauge the participant’s intakes of fruits, vegetables, and high fat snack foods as well as any physical activity done in transportation or for leisure.
      • To ensure proper delivery of the program, a checklist will be utilized by the lesson presenter and at least one other staff member. This list will include an area to record time spent teaching the lesson, any questions the children had, and a spot to check off snack time, lesson material, and play time. Additionally, a researcher will be present at at least 4 of 8 lessons to monitor and evaluate program consistency.
    • What elements are missing?
      • A feedback survey will be given at the end of the intervention. This will allows participant’s and their guardians to identify any shortcomings or successful components of the program.
  • Implementation
    • Data will be collected and analyzed from the three surveys to conclude what components of the intervention worked well and which ones need to be changed or tweaked.

Blanchette, L. and Brug, J. (2005), Determinants of fruit and vegetable consumption among 6–12-year-old children and effective interventions to increase consumption. Journal of Human Nutrition and Dietetics, 18: 431–443. doi:10.1111/j.1365-277X.2005.00648.x

Part 4: Reflection

• Oftentimes when working with communities, the initial plan is not what ultimately happens. What would your second choice strategy be for your identified behavior and community? Why would you choose this strategy? In other words, in what ways would this strategy also address the needs of the community based on your assessment for Part 1? (25 points)

If my proposed intervention failed to occur, I would instead look at a scaled back approach that was still multi-approach but focuses only on the food and activity experienced by students at school. Working with food service employees to incorporate more fruit and vegetable options at the point of sale in the cafeteria would be the first step. This step would be similar to the environmental aspect of the 5-A-Day program in which food service workers would be educated on how to incorporate more produce into the menu. They would also label fruits and vegetables clearly and set up displays that would be attractive to the students (Havas et al). This could also be combined with price cuts to fruits and vegetables, as research has shown students are more likely to choose healthy options if they are cheaper than less healthy alternatives (Story et al). As for physical activity, a method as simple as getting parents to agree to enact walking “school buses” might be beneficial. Organizing this could be done relatively easily by sending out newsletters to inform parents and prompt them to enroll their children. As Barrow is in a mostly residential neighborhood with ample sidewalks, this would be an ideal intervention to begin.

These interventions would be useful to the community, as they would continue to allow time for children to be active and they could expose children to fruits and vegetables they might not normally have been introduced to. The physical activity recommendation for children is 1 hour a day, which could be attributed to by transportation walking (CDC). As for dietary needs, incorporating more fruits and vegetables into the breakfast and lunch menus of children at school could significantly effect the number of servings they get in a day. These two factors combined could contribute to the fight against childhood obesity.

• Reflect on how you may use the Community Guide, Nutrition Education Library, and other resources in the future. What did you like about these resources? What didn’t you like? Provide suggestions on how you would make the sites easier for practitioners to use. (20 points)

The topic that my intervention fell under in the Community Guide was not as useful as I had hoped. The section had not been updated since 2003, even though numerous school interventions have been conducted since this year. This is most likely due to the acknowledgement of difficulties in actually conducting and expounding results from these studies. Every school is different in both population and operation, so matching schools for interventions is a complicated process. additionally, many of the schools that are used for these programs are contacted for multiple studies over the years, which may skew results. Overall, it was nice to have a compilation of resources available off one website, as I would not want to individually dig through 45 articles, but the Community Guide needs to be updated. Simple steps to make this site easier after an update would be organizing resources by interventions, population size and age, and even in effectiveness. While most of the studies would multi-component and included both diet and PA, some focused more heavily on just one aspect. Listing studies by their focus would have made research more efficient. Organizing the site shouldn’t be too difficult, as the sidebar already lists out the different aspects of the specific topic, including setting and audience.