School Based Interventions and their Evaluation for Obesity Control

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School Based Interventions and their Evaluation
for Obesity Control

• Sana Ghaddar, PhD, RD
• Thursday March 27, 2008

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Presentation Outline

• Prevention of childhood obesity Why school
  based?
• Implementation parameters and schema
• Role of family and community
• Logistics of a school-based Interventions
• Outcome and performance measures used for program
  evaluation
• Pilot study in Lebanon Methods and practical
  learning
• Recommendations

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Prevention of Childhood Obesity

• Tracking of childhood obesity into adulthood, and
  its direct correlation to a number of complex
  chronic diseases is well documented.
• Prevention of obesity most effective if initiated
  in early childhood (age 2-10).
• Key to prevention of childhood obesity is to
  involve all players in the life of the children
  children, school, family and community

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Multi-Component InterventionWhy School-Based?

• Elementary schools are the ideal setting to
  triage an interventional program that targets the
  child and involves the family and the community
• Setting where children convene together daily
  most of the year
• Schools can encourage parents to get involved
• Schools can be ideal location for
  community-initiated activities
• ? Ideal setting for culture- and
  environment-sensitive educational and practical
  programs

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School-Based Interventions Implementation

• Start Early Start in grade 1 and build-up until
  5th grade.
• Content Multi-component Diet, sedentary
  physical activities.
• Duration Minimal one year, multi-year
  preferred.
• Personnel Mainly teachers with involvement of
  social workers, nurses, dietitians and
  physicians when necessary.
• Sustainability Integrate into schools
  curriculum impact permanent
• changes to school environment that are
  conducive to
• desired influence on practices.
• Goal is to Interrupt tracking into adulthood
  Long term prevention of disease.
• NOT Losing few kilos quickly.

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Multi-Component Intervention

• School-based interventions that included multiple
  component programs for OW control and prevention
  generated superior results on improving
  anthropometric measurements and on adiposity
  outcomes 1,2, 3
• Multi-component programs include
• modifying the school curricula (nutrition
  education, physical activity education, sedentary
  behaviors),
• behavioral counseling,
• countering media influences,
• healthy school food environment,
• active physical environment, and
• parent/family involvement

(Sharma, Cochrane review, 2004 Summerbell,
Cochrane review, 2006 ADA position statement,
2006
(position statement of the ADA, JADA, 2006).
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Behavioral Strategies

• Prominent studies targeting prevention of
  childhood obesity utilized a behavioral component
  based mostly on the Social Cognitive Theory.
• Behavioral strategies included goal setting, use
  of role models, vicarious learning and changing
  norms
• Use of social cognitive theory models requires
  customization for cultural appropriateness with
  validation of the modified model.

American Dietetics Association position
Statement, 2006
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Schema of a School-Based Program
Repeat in each of years 2-5
First 3 months
Months 3 - 9
At month 9
Summer
Beginning of year 2

• Nutrition classes
• Information sent to parents
• - Physical activity sessions
• -2 x mon parent group sessions on
• - behavioral modification
• - nutrition lifestyle
• education

- Parent grp intervention sessions become
monthly - Reassess BMI _at_ 3, 6, 9 months

• Nutrition classes
• Information sent to parents
• - Physical activity sessions
• -2 x mon parent group sessions on
• - behavioral modification
• - nutrition lifestyle
• education

- Parent grp intervention sessions become
monthly - Reassess BMI _at_ 3, 6, 9 months
School-Based
All Students
-Repeat baseline assessment - Re-assign students
to appropriate weight subgroups based on BMI
Repeat baseline assessment for children and
parents
Repeat baseline assessment for children and
parents
-Repeat baseline assessment - Re-assign students
to appropriate weight subgroups based on BMI
Outdoor activity for children
Outdoor activity for children
OW/ROW Students
2 x mon parent-child dyad sessions on -
behavioral modification - nutrition lifestyle
education - Monthly wt measurements
2 x mon parent-child dyad sessions on -
behavioral modification - nutrition lifestyle
education - Monthly wt measurements
- Parent-child dyad sessions become monthly -
Reassess BMI _at_ 3, 6, 9 months
Clinic-Based
- Parent-child dyad sessions become
monthly - Reassess BMI _at_ 3, 6, 9 months
AUBMC / CRU - Obesity Research Group
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School-Based Interventions Role of Family
Community

• Objectives
• Reinforce nutritional education
• Cut down time spent on sedentary activity
• Encourage physical activity
• Instate lasting changes to family lifestyle
  geared towards health-promoting practices

School Days The 5-hour challenge Holidays
Organized programs
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School-Based Interventions Logistical Issues

• Development of interventional program as part of
  a prevention strategy, based on
  epidemiologically-derived predictive model for
  childhood obesity.
• Coordination between school management,
  government agencies, community organizations and
  family representatives.
• Development and validation of culturally and
  environmentally appropriate educational materials
  and assessment tools.

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School-Based Interventions Outcome Measures

• Tailored to strategic objectives
• Short term Reduce prevalence Higher change from
  OW to NW
• Long term Decrease incidence Lower change from
  NW to OW
• Short and long term objectives should be
• assessed separately, and not combined

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School-Based Interventions Evaluation Segments
NW
NW
Prevention Affecting Incidence
NW
Prevention Affecting Prevalence
OW
OW
OW
AUBMC / CRU - Obesity Research Group
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School-Based Interventions Evaluation of Obesity
Control - 1

• Knowledge Most examined ? and showed improvement
• Changes in practices in student and family
• TV watching, consumption of fruits and
  vegetables, consumption of soft drinks, time
  spent on physical activity etc.
• Improvement in fitness indices and PA readiness.
• Physical exam, blood chemistry and other
  diagnostics to correlate to existing chronic
  disease.

Hernandez B, Gortmaker SL, Colditz GA et alJ
Obes Relat Metab Disord. 1999
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School-Based Interventions Evaluation of Obesity
Control - 2

• Anthropometry
• BMI
• Positive outcome when including a secondary
  intervention in the program (targeting OW
  students for a more intensified treatment)1, 2
• Emphasis were mostly placed on weight stability
  during years of growth
• Waist circumference
• Waist to Hip Ratio
• Body composition (triceps skin-fold, biceps skin-
  folds, impedance analysis)

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School-Based Interventions Evaluation of
Students and Parents
All Students Anthropometric Measures Physical
Exam / Blood Chemistry Core Questionnaire Demogra
phics Socioeconomic Comorbidity Medical
history Food Intake and Physical / Sedentary
Activity Questionnaire Environmental Cultural
Influences Questionnaire
Parents of OW Students Anthropometric Measures
Blood Chemistry Core Questionnaire (One for
each parent) Comorbidity Medical history Dietary
Questionnaires (Parents dietary
habits) Physical Activity Questionnaire
OW / ROW Students Eating Behavior
Questionnaire Detailed Physical Activity
Questionnaire Self Esteem Questionnaire
All Students Anthropometric Measures Physical
Exam Core Questionnaire Demographics Socioeconomi
c Comorbidity Medical history Food Intake and
Physical / Sedentary Activity Questionnaire Envir
onmental Cultural Influences Questionnaire Bloo
d Chemistry
Parents of Overweight Students Anthropometric
Measures Blood Chemistry Core
Questionnaire (One for each parent) Comorbidity Me
dical history Dietary Questionnaires (Parents
dietary habits) Physical Activity Questionnaire
OW / ROW Students Eating Behavior
Questionnaire Detailed Physical Activity
Questionnaire Self Esteem Questionnaire
AUBMC / CRU - Obesity Research Group
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Pilot Study in Lebanon Practical Issues

• Three elementary schools in Greater Beirut one
  public, one free private, and one paid private
  targeting grades 3-5 (212 students).
• In public schools (compared to private)
• Students had no prior exposure to nutritional or
  lifestyle education.
• Students showed wide within-class variability in
  comprehension.
• Students had lower overall attention span.
• Teachers lacked discipline over students.
• Teachers did not consider PE class as an
  important component of curriculum.

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School-Based Interventions Recommended Approach

• Planning should involve all stakeholders
  Schools, parents, government, and community.
• Conduct preliminary epidemiological study to
  determine cultural and environmental predictors.
• Use results to customize interventional program
  and assessment tools.
• At the individual level Use constructs of
  behavioral theory and evaluate changes in
  constructs impacted by the intervention.

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School-Based Interventions Conclusions

• Programs and assessment tools validated in the US
  or Europe can be used only as starting models.
• Develop culturally appropriate programs and
  emphasize feasibility.
• Re-validate the refined program and assessment
  tools.
• School-based programs should involve the family
  and the community, be multi-component and
  sustained throughout all elementary school years.

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• Hernandez B, Gortmaker SL, Colditz GA et al.
  Association of obesity with physical activity,
  television programs and other forms of video
  viewing among children in Mexico city. Int J Obes
  Relat Metab Disord. 1999
• American Dietetic Association. Position of the
  American Dietetic Association Individual-,
  Family-, School-, and Community-Based
  Interventions for Pediatric Overweight. JADA
  2006 106925-945
• Singapore Ministry of Health. The State of Health
  2001. The Report of the Director of Medical
  Services Singapore. Ministry of Health
  Singapore, 2002 p 35 (http//www.moh.gov.sg/newmoh
  /pdf/pub/health_report.pdf).
• Sahota P, Rudolf MC, Dixey R, Hill AJ, Barth JH,
  Cade J. Evaluation of implementation and effect
  of primary school based intervention to reduce
  risk factors for obesity. BMJ 2001 3231027-1029
  
• Economos CD, Hyatt RR, Goldberg JP, Must A,
  Naumova EN, Collins JJ, Nelson ME. A community
  intervention reduces BMI z-score in children
  Shape Up Sommerville first year results. Obesity
  2007 151325-1336.
• Epstein, LH, Gordy CC, Raynor HA, Beddome M,
  Kilanowski CK, Paluch R. Increasing Fruit and
  Vegetable Intake and decreasing Fat and sugar
  Intake in Families at risk for Childhood Obesity.
  Obesity research 2001 9(3)171-178.
• Flodmark C-E, Marcus C, Britton M. Interventions
  to prevent obesity in children and adolescents a
  systematic literature review. Int J Obes
  200630579-589.

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Thank you!