School-based obesity treatment and prevention programs: all in all, just another brick in the wall?

School-based gardening, cooking and nutrition intervention increased vegetable intake but did not reduce BMI: Texas sprouts - a cluster randomized controlled trial

BACKGROUND

Although school garden programs have been shown to improve dietary behaviors, there has not been a cluster-randomized controlled trial (RCT) conducted to examine the effects of school garden programs on obesity or other health outcomes. The goal of this study was to evaluate the effects of a one-year school-based gardening, nutrition, and cooking intervention (called Texas Sprouts) on dietary intake, obesity outcomes, and blood pressure in elementary school children.

METHODS

This study was a school-based cluster RCT with 16 elementary schools that were randomly assigned to either the Texas Sprouts intervention (n = 8 schools) or to control (delayed intervention, n = 8 schools). The intervention was one school year long (9 months) and consisted of: a) Garden Leadership Committee formation; b) a 0.25-acre outdoor teaching garden; c) 18 student gardening, nutrition, and cooking lessons taught by trained educators throughout the school-year; and d) nine monthly parent lessons. The delayed intervention was implemented the following academic year and received the same protocol as the intervention arm. Child outcomes measured were anthropometrics (i.e., BMI parameters, waist circumference, and body fat percentage via bioelectrical impedance), blood pressure, and dietary intake (i.e., vegetable, fruit, and sugar sweetened beverages) via survey. Data were analyzed with complete cases and with imputations at random. Generalized weighted linear mixed models were used to test the intervention effects and to account for clustering effect of sampling by school.

RESULTS

A total of 3135 children were enrolled in the study (intervention n = 1412, 45%). Average age was 9.2 years, 64% Hispanic, 47% male, and 69% eligible for free and reduced lunch. The intervention compared to control resulted in increased vegetable intake (+ 0.48 vs. + 0.04 frequency/day, p = 0.02). There were no effects of the intervention compared to control on fruit intake, sugar sweetened beverages, any of the obesity measures or blood pressure.

CONCLUSION

While this school-based gardening, nutrition, and cooking program did not reduce obesity markers or blood pressure, it did result in increased vegetable intake. It is possible that a longer and more sustained effect of increased vegetable intake is needed to lead to reductions in obesity markers and blood pressure.

CLINICAL TRIALS NUMBER

NCT02668744 .

Demographics and anthropometrics impact benefits of health intervention: data from the Reduce Obesity and Diabetes Project

OBJECTIVE

To determine the efficacy of a 4-month school-based health, nutrition and exercise intervention on body fatness and examine possible effects of demographic and anthropometric covariates.

METHODS

Height, weight, waist circumference and body composition were measured in a diverse population of 644 NYC middle school students (mean ± SD age 12.7 ± 0.9 years; 46% male; 38% Hispanic, 17% East Asian, 15% South Asian, 13.5% African American, 8.5% Caucasian, 8% other) during the fall and spring semesters. Year 1 participants (n = 322) were controls. Experimental participants (year 2, n = 469) received a 12-session classroom-based health and nutrition educational programme with an optional exercise intervention.

RESULTS

Groups were demographically and anthropometrically similar. The intervention resulted in significant reductions in indices of adiposity (ΔBMI z-scores [-0.035 ± 0.014; p = 0.01], Δ% body fat [-0.5 ± 0.2; p < 0.0001] and Δwaist circumference [-0.73 ± 0.30 cm; p < 0.0001]). Intervention effects were greater (p = 0.01) in men (ΔBMI z-score = -0.052 ± 0.015) versus women (0.022 ± 0.018), participants who were obese (ΔBMI z-score -0.083 ± 0.022 kg m-2) versus lean (-0.0097 ± 0.020 kg m-2) and South Asians (Δ% body fat -1.03 ± 0.35) versus total (-0.49 ± 0.20%) participants (p = 0.005).

CONCLUSION

A 4-month school-based health intervention was effective in decreasing measures of adiposity in middle school students, particularly in men, participants who were obese and South Asians.

School-based versus after-school delivery of a universal wellness programme - A randomized controlled multi-arm trial

Positive self-image and body image as well as high self-esteem and media literacy are considered protective factors against health-compromising behaviours. Investigation of the optimal setting for body image prevention programmes is important to maximize outcomes from such programmes. Most universal wellness programmes are school based and thus delivered to a "captive" population. Only a few reports have been published about wellness programmes delivered in after-school settings, and none of them compared delivery after school to delivery in a school-based setting.

AIMS

To assess the acceptability, feasibility and efficacy of an interactive wellness preventive programme (In Favour of Myself) when delivered in a school-based setting versus an after-school setting.

METHODS

A randomized controlled multi-arm trial with 224 adolescent girls aged 13-15 years old was conducted. There were 102 girls participating in the after-school setting and 102 girls in the school-based setting. The programme contained nine 90-minute lessons, delivered weekly over 2 months. An intention-to-treat assessment was performed three times: at baseline, at the programme's conclusion (two months) and at follow-up (3 months).

RESULTS

At programme termination and follow-up, the impact of In Favour of Myself was higher among participants in the after-school setting than in the school-based setting with respect to advertisement strategies, media pressure, gap between current and ideal body image, drive for thinness and self-esteem.

CONCLUSIONS

This study provides support for a community-led approach to promote health behaviours, an approach that currently is a significant feature of health improvement policy and practice.

The impact of behavioural risk reduction interventions on willingness to pay to avoid sexually transmitted infections: a stated preference study of justice-involved youth

Risky health behaviours, such as smoking, drinking and risky sex, are substantial contributors to US morbidity rates and healthcare costs. While economic models typically regard preferences as stable, a growing literature suggests that information, including how it interacts with intentions and attitudes, plays an important role in unhealthy behaviours. Relatedly, a large health literature demonstrates that theory-based behavioural interventions can successfully change risky behaviour. This study uses the contingent valuation survey method to investigate the impact of behavioural interventions on a novel outcome measure: the willingness to pay (WTP) to avoid the consequences associated with risky behaviour. Using novel pre- and post-intervention data from Project MARS (Motivating Adolescents to Reduce Sexual Risk) this study estimates the impact of the intervention on elicited WTP to avoid sexually transmitted infections (STI). It is found that after the intervention, participants' elicited WTP to avoid STIs were significantly higher, and more sensitive to differences in infection severity. These results suggest that the intervention may affect risky sexual behaviour by changing the perceived value of avoiding the consequences of risky sexual behaviour. Additionally, these findings contribute to an ongoing debate regarding the construct validity of contingent valuation studies in health economics.

A feasibility test of a brief motivational interview intervention to reduce dating abuse perpetration in a hospital setting

OBJECTIVE

To describe the intervention development process and feasibility testing of a hospital-based brief intervention to reduce the perpetration of adolescent dating abuse (ADA). To our knowledge, this intervention is the first to focus exclusively on ADA perpetration reduction via a motivational interview-type intervention in this setting.

METHOD

The rationale for and the six Intervention Mapping steps used to generate the intervention are described. Feasibility is conceptualized as intervention acceptability, demand, implementation, practicality, integration, and limited-efficacy.

RESULTS

The Real Talk intervention was integrated smoothly into the emergency department setting. Participants did not experience any negative impact, and the vast majority (86%) reported that they felt helped. Quantitative assessments suggest that the intervention reduced the number of participants in the pre-contemplation stage of change regarding their use of relationship violence, and may have moved them forward into the action stage. Real Talk participants were more likely than those in the control group to tell friends to help them stay calm around their partner after drinking alcohol, and to talk with their doctor to get help for their problems.

CONCLUSIONS

Real Talk was developed to meet an unmet need for tertiary ADA interventions in non-school settings. It was developed in accordance with a recommended framework, informed by theory, and subsequently tested for feasibility. Feasibility assessment results suggest that Real Talk can be implemented in health care settings and may influence attitudinal and behavioral outcomes in the desired directions.

Common scientific and statistical errors in obesity research

This review identifies 10 common errors and problems in the statistical analysis, design, interpretation, and reporting of obesity research and discuss how they can be avoided. The 10 topics are: 1) misinterpretation of statistical significance, 2) inappropriate testing against baseline values, 3) excessive and undisclosed multiple testing and "P-value hacking," 4) mishandling of clustering in cluster randomized trials, 5) misconceptions about nonparametric tests, 6) mishandling of missing data, 7) miscalculation of effect sizes, 8) ignoring regression to the mean, 9) ignoring confirmation bias, and 10) insufficient statistical reporting. It is hoped that discussion of these errors can improve the quality of obesity research by helping researchers to implement proper statistical practice and to know when to seek the help of a statistician.

Best (but oft-forgotten) practices: expressing and interpreting associations and effect sizes in clinical outcome assessments

This article reviews methods used to facilitate the interpretation and evaluation of group-level differences in clinical outcome assessments. These methods complement and supplement tests of statistical significance. Examples, including studies in nutrition, are used to illustrate the application of the interpretation methods for group-level comparisons from experimental or observational studies. In addition, specific pitfalls of evaluating change in meta-analysis studies are described. A set of recommendations is provided. This review is intended as an introduction for the novice and as a refresher for the experienced researcher.

Best (but oft-forgotten) practices: expressing and interpreting associations and effect sizes in clinical outcome assessments

This article reviews methods used to facilitate the interpretation and evaluation of group-level differences in clinical outcome assessments. These methods complement and supplement tests of statistical significance. Examples, including studies in nutrition, are used to illustrate the application of the interpretation methods for group-level comparisons from experimental or observational studies. In addition, specific pitfalls of evaluating change in meta-analysis studies are described. A set of recommendations is provided. This review is intended as an introduction for the novice and as a refresher for the experienced researcher.

A resistant-starch enriched yogurt: fermentability, sensory characteristics, and a pilot study in children

The rising prevalence of obesity and the vulnerability of the pediatric age group have highlighted the critical need for a careful consideration of effective, safe, remedial and preventive dietary interventions.  Amylose starch (RS2) from high-amylose maize (HAM) ferments in the gut and affects body weight.   One hundred and ten children, of 7-8 (n=91) or 13-14 (n=19) years of age scored the sensory qualities of a yogurt supplemented with either HAM-RS2 or an amylopectin starch.  The amylopectin starch yogurt was preferred to the HAM-RS2-enriched yogurt by 7-8 year old panelists ( P<0.0001).  Appearance, taste, and sandiness scores given by 13- to 14-year-old panelists were more favorable for the amylopectin starch yogurt than for HAM-RS2-enriched yogurt ( P<0.05).  HAM-RS2 supplementation resulted in acceptable (≥6 on a 1-9 scale) sensory and hedonic ratings of the yogurt in 74% of subjects.  Four children consumed a HAM-RS2-enriched yogurt for four weeks to test its fermentability in a clinical trial.  Three adolescents, but not the single pre-pubertal child, had reduced stool pH ( P=0.1) and increased stool short-chain fatty acids (SCFAs) ( P<0.05) including increased fecal acetate ( P=0.02), and butyrate ( P=0.089) from resistant starch (RS) fermentation and isobutyrate ( P=0.01) from protein fermentation post-treatment suggesting a favorable change to the gut microbiota.  HAM-RS2 was not modified by pasteurization of the yogurt, and may be a palatable way to increase fiber intake and stimulate colonic fermentation in adolescents.  Future studies are planned to determine the concentration of HAM-RS2 that offers the optimal safe and effective strategy to prevent excessive fat gain in children.

Cost-free and sustainable incentive increases healthy eating decisions during elementary school lunch

We aimed to develop a cost-free and sustainable program to influence healthier eating decisions during elementary school lunch. Baseline food and beverage choices were assessed for 9 days during lunch service at two racially and economically diverse elementary schools in Spartanburg County, SC, USA. After being informed that the labeled items on the daily lunch menu represented the healthiest choice, students were allowed to ring a call bell in the cafeteria for public recognition when they chose all of the identified healthiest food and beverage items during lunch service. Using menus matched to the baseline phase, food and beverage choices were measured during a 9-day intervention phase. After 30 days, food and beverage choices were reassessed during a 3-day follow-up phase. Healthiest food & beverage choices increased 49% with >60% of students choosing non-flavored milk over flavored milk during the intervention phase. There was no difference in the success of the program between the two schools. The program continued and healthy eating decisions were significantly sustained at a 30-day follow-up assessment. Public recognition through bell ringing appears to be an effective practice to sustain increases in healthy eating decisions during elementary school lunch and warrants expansion to larger scale, longitudinal trials.

Nutritively sweetened beverage consumption and body weight: a systematic review and meta-analysis of randomized experiments

Nutritively sweetened beverages (NSBs) may play a role in the obesity epidemic. We abstracted data from randomized controlled trials (RCTs) and evidence-based reviews through January 2009 concerning effects of consumption of NSBs on changes in body weight and adiposity. Studies included were those (i) conducted in humans; (ii) lasting at least 3 weeks; (iii) incorporating random assignment of subjects to conditions that differed only in the consumption of NSBs and (iv) including an adiposity indicator as an outcome. Twelve studies met the inclusion criteria. Meta-analysis of six studies that added NSBs to persons' diets showed dose-dependent increases in weight. Contrarily, meta-analysis of studies that attempted to reduce NSB consumption consistently showed no effect on body mass index (BMI) when all subjects were considered. Meta-analysis of studies providing access to results separately for subjects overweight at baseline showed a significant effect of a roughly 0.35 standard deviations lesser BMI change (i.e. more weight loss or less weight gain) relative to controls. The current evidence does not demonstrate conclusively that NSB consumption has uniquely contributed to obesity or that reducing NSB consumption will reduce BMI levels in general. We recommend an adequately powered RCT with overweight persons, for whom there is suggestive evidence of an effect.