The Pathways study: a model for lowering the fat in school meals

Promoting Physical Activity Among Native American Youth: a Systematic Review of the Methodology and Current Evidence of Physical Activity Interventions and Community-wide Initiatives

Promoting physical activity using environmental, policy, and systems approaches could potentially address persistent health disparities faced by American Indian and Alaska Native children and adolescents. To address research gaps and help inform tribally led community changes that promote physical activity, this review examined the methodology and current evidence of physical activity interventions and community-wide initiatives among Native youth. A keyword-guided search was conducted in multiple databases to identify peer-reviewed research articles that reported on physical activity among Native youth. Ultimately, 20 unique interventions (described in 76 articles) and 13 unique community-wide initiatives (described in 16 articles) met the study criteria. Four interventions noted positive changes in knowledge and attitude relating to physical activity but none of the interventions examined reported statistically significant improvements on weight-related outcomes. Only six interventions reported implementing environmental, policy, and system approaches relating to promoting physical activity and generally only shared anecdotal information about the approaches tried. Using community-based participatory research or tribally driven research models strengthened the tribal-research partnerships and improved the cultural and contextual sensitivity of the intervention or community-wide initiative. Few interventions or community-wide initiatives examined multi-level, multi-sector interventions to promote physical activity among Native youth, families, and communities. More research is needed to measure and monitor physical activity within this understudied, high risk group. Future research could also focus on the unique authority and opportunity of tribal leaders and other key stakeholders to use environmental, policy, and systems approaches to raise a healthier generation of Native youth.

K-12 School Food Service Staff Training Interventions: A Review of the Literature

BACKGROUND

School food service professionals are vital to implementing national nutrition standards in school meal programs. Appropriate and effective training for these professionals may be one key to producing healthful meals that students are excited to eat and also meet United States Department of Agriculture (USDA) nutrient guidelines. A systematic literature review was conducted to understand the scope of interventions conducted with food service staff.

METHODS

PubMed, Web of Knowledge, and Science Direct databases were searched for articles detailing school food service training interventions in K-12 school settings within the United States.

RESULTS

Of 2341 articles retrieved, 17 articles describing 14 food service training interventions met the inclusion criteria. While food service staff training was an important component of many comprehensive school health and school meal interventions, there were few studies that specifically addressed school food service staff trainings. Although some best practices can be concluded from the current literature, major gaps in knowledge about effective school food service training interventions and validated research tools remain.

CONCLUSIONS

As new professional standards are mandated by the USDA, a more thorough evaluation and understanding of best practices is vital to maximize the effectiveness of food service staff training.

Physical activity and cardiovascular risk factors in Spanish children aged 11-13 years

INTRODUCTION AND OBJECTIVES

The prevalence of childhood obesity has increased in recent decades. The aim was to determine whether a 3-month intervention on daily physical activity at school could affect body weight and cardiovascular risk factors associated with childhood obesity.

METHODS

A total of 137 children (12[1] years old) volunteered to participate in an observational cross-sectional study. Children were allowed to join one of the following groups: a) sedentary group (2h/week of physical education at school); b) active group (2h/week of physical education at school plus 3h/week extra physical activity), and c) sports group (2h/week of physical education at school plus 5h/week extra physical activity). Anthropometric characteristics, blood pressure, physical condition (estimated by the Course-Navette test), and biochemical parameters related with cardiovascular risk factors were determined.

RESULTS

Body weight, body mass index, waist circumference, sum of skinfold thickness, body fat percentage, and fat mass index of children were decreased with high physical activity level, whereas body water content significantly increased with activity. Parameters related with cardiovascular risk -triglycerides, insulin, systolic blood pressure, and homeostatic model assessment index- presented lower values in the sports group. Maximal oxygen uptake and maximum heart rate (Course Navette test) progressively increased with activity. Children participating in a total of 7h/week of physical activity presented significantly lower odds ratio of having high levels of the following cardiovascular risk factors: waist circumference, fat mass index, and homeostatic model assessment index.

CONCLUSIONS

Physical activity is important for metabolic health in children. Children with higher levels of physical activity presented better anthropometric and biochemical profiles.

Middle-school students’ school lunch consumption does not meet the new Institute of Medicine's National School Lunch Program recommendations

Objective

To compare the school lunch consumption of Texas middle-school students with the 2009 Institute of Medicine's (IOM) school meal report recommendations. These new lunch menu patterns increase fruit to one serving and vegetables to two servings, with 50 % wholegrain food.

Design

Lunch food records were collected from middle-school students from four schools in south-east Texas in the spring of 2008, and entered into the Nutrition Data System for Research software. Average intake was calculated for those consuming meals according to the National School Lunch Program (NSLP; n 5414) and for those consuming lunch from other sources (n 239). The percentage of students selecting each food group was calculated.

Setting

Middle schools in south-east Texas.

Subjects

Middle-school students in south-east Texas.

Results

Students consuming NSLP meals reported consuming almost --><$>\tfrac{1}{2}<$><!-- serving of fruit, --><$>\tfrac{3}{4}<$><!-- serving of vegetables, 8 oz of milk and --><$>\tfrac{1}{3}<$><!-- serving of whole grains at lunch. Non-NSLP consumers reported almost no intake of fruit, vegetables or milk, and consumed --><$>\tfrac{1}{4}<$><!-- serving of whole grains at lunch. Among NSLP consumers, about 40 % selected and consumed a fruit serving. About two-thirds of students selected a vegetable, consuming about 67 %. Less than 4 % selected a dark green or orange vegetable.

Conclusions

Students’ lunch intake did not meet the new IOM recommendations. Few students selected dark green or orange vegetables, and only 40 % selected fruit. Whole grains consumption was low. Interventions with all stakeholders will be necessary to improve students’ food and beverage selections overall when school meal patterns are revised.

Measures of the food environment: a compilation of the literature, 1990-2007

BACKGROUND

Valid and reliable measures are required to assess any effect of the food environment on individual dietary behavior, and form the foundation of research that may inform obesity-related policy. Although many methods of measuring the food environment exist, this area of research is still relatively new and there has been no systematic attempt to gather these measures, to compare and contrast them, or to report on their psychometric properties.

EVIDENCE ACQUISITION

A structured literature search was conducted to identify peer-reviewed articles published between January 1990 and August 2007 that measured the community-level food environment. These articles were categorized into the following environments: food stores, restaurants, schools, and worksites. The measurement strategies in these studies were categorized as instruments (checklists, market baskets, inventories, or interviews/questionnaires) or methodologies (geographic, sales, menu, or nutrient analyses).

EVIDENCE SYNTHESIS

A total of 137 articles were identified that included measures of the food environment. Researchers focused on assessing the accessibility, availability, affordability, and quality of the food environment. The most frequently used measure overall was some form of geographic analysis. Eighteen of the 137 articles (13.1%) tested for any psychometric properties, including inter-rater reliability, test-retest reliability, and/or validity.

CONCLUSIONS

A greater focus on testing for reliability and validity of measures of the food environment may increase rigor in research in this area. Robust measures of the food environment may strengthen research on the effects of the community-level food environment on individual dietary behavior, assist in the development and evaluation of interventions, and inform policymaking targeted at reducing the prevalence of obesity and improving diet.

Overweight in urban, low-income, African American and Hispanic children attending Los Angeles elementary schools: research stimulating action

Objective

This study was undertaken to establish the prevalence and severity of nutritional problems among low-income children of elementary school age in the Los Angeles Unified School District (LAUSD) in order to collect baseline data to inform policy-makers.

Design and methods

A cross-sectional survey of children in 14 elementary schools was conducted from January to June, 1998. Nine hundred and nineteen children were measured and interviewed. The planning, design and data analysis were carried out in collaboration with key LAUSD policy-makers.

Results

More than 35% of the sample was classified as being at risk for overweight or overweight according to body mass index.

Conclusion

There is a high prevalence of children who are at risk for overweight or who are overweight in Los Angeles. This finding has triggered the development of multiple school-based intervention programmes.

Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with 'best practice' recommendations

Childhood obesity is a global epidemic and rising trends in overweight and obesity are apparent in both developed and developing countries. Available estimates for the period between the 1980s and 1990s show the prevalence of overweight and obesity in children increased by a magnitude of two to five times in developed countries (e.g. from 11% to over 30% in boys in Canada), and up to almost four times in developing countries (e.g. from 4% to 14% in Brazil). The goal of this synthesis research study was to develop best practice recommendations based on a systematic approach to finding, selecting and critically appraising programmes addressing prevention and treatment of childhood obesity and related risk of chronic diseases. An international panel of experts in areas of relevance to obesity provided guidance for the study. This synthesis research encompassed a comprehensive search of medical/academic and grey literature and the Internet covering the years 1982-2003. The appraisal approach developed to identify best practice was unique, in that it considered not only methodological rigour, but also population health, immigrant health and programme development/evaluation perspectives in the assessment. Scores were generated based on pre-determined criteria with programmes scoring in the top tertile of the scoring range in any one of the four appraisal categories included for further examination. The synthesis process included identification of gaps and an analysis and summary of programme development and programme effectiveness to enable conclusions to be drawn and recommendations to be made. The results from the library database searches (13,158 hits), the Internet search and key informant surveys were reduced to a review of 982 reports of which 500 were selected for critical appraisal. In total 158 articles, representing 147 programmes, were included for further analysis. The majority of reports were included based on high appraisal scores in programme development and evaluation with limited numbers eligible based on scores in other categories of appraisal. While no single programme emerged as a model of best practice, synthesis of included programmes provided rich information on elements that represent innovative rather than best practice under particular circumstances that are dynamic (changing according to population subgroups, age, ethnicity, setting, leadership, etc.). Thus the findings of this synthesis review identifies areas for action, opportunities for programme development and research priorities to inform the development of best practice recommendations that will reduce obesity and chronic disease risk in children and youth. A lack of programming to address the particular needs of subgroups of children and youth emerged in this review. Although immigrants new to developed countries may be more vulnerable to the obesogenic environment, no programmes were identified that specifically targeted their potentially specialized needs (e.g. different food supply in a new country). Children 0-6 years of age and males represented other population subgroups where obesity prevention programmes and evidence of effectiveness were limited. These gaps are of concern because (i) the pre-school years may be a critical period for obesity prevention as indicated by the association of the adiposity rebound and obesity in later years; and (ii) although the growing prevalence of obesity affects males and females equally; males may be more vulnerable to associated health risks such as cardiovascular disease. Other gaps in knowledge identified during synthesis include a limited number of interventions in home and community settings and a lack of upstream population-based interventions. The shortage of programmes in community and home settings limits our understanding of the effectiveness of interventions in these environments, while the lack of upstream investment indicates an opportunity to develop more upstream and population-focused interventions to balance and extend the current emphasis on individual-based programmes. The evidence reviewed indicates that current programmes lead to short-term improvements in outcomes relating to obesity and chronic disease prevention with no adverse effects noted. This supports the continuation and further development of programmes currently directed at children and youth, as further evidence for best practice accumulates. In this synthesis, schools were found to be a critical setting for programming where health status indicators, such as body composition, chronic disease risk factors and fitness, can all be positively impacted. Engagement in physical activity emerged as a critical intervention in obesity prevention and reduction programmes. While many programmes in the review had the potential to integrate chronic disease prevention, few did; therefore efforts could be directed towards better integration of chronic disease prevention programmes to minimize duplication and optimize resources. Programmes require sustained long-term resources to facilitate comprehensive evaluation that will ascertain if long-term impact such as sustained normal weight is maintained. Furthermore, involving stakeholders in programme design, implementation and evaluation could be crucial to the success of interventions, helping to ensure that needs are met. A number of methodological issues related to the assessment of obesity intervention and prevention programmes were identified and offer insight into how research protocols can be enhanced to strengthen evidence for obesity interventions. Further research is required to understand the merits of the various forms in which interventions (singly and in combination) are delivered and in which circumstances they are effective. There is a critical need for the development of consistent indicators to ensure that comparisons of programme outcomes can be made to better inform best practice.

Impact of the Pathways intervention on dietary intakes of American Indian schoolchildren

BACKGROUND

The Pathways study was a randomized, 3-year trial of obesity prevention in American Indian Children. An important goal of the Pathways intervention was to significantly decrease the percentage of calories eaten as fat by the intervention children, relative to controls. This paper reports the effects of the Pathways intervention on dietary intake.

METHODS

Two types of dietary data were analyzed from random samples of children in 41 schools: direct observation of school lunch intake at baseline (2nd grade) and follow-up (5th grade) (n=470), and 24-hour dietary recalls at follow-up only (n=620). Nutrient contents of school meals and recalls were calculated by NDS and NDS-R software (University of Minnesota), using vendor products and recipes from each school.

RESULTS

Based on lunch observations, the intervention was associated with significant decreases in mean percentage of calories from total fat (3.6%) and saturated fat (2.1%) relative to controls, and a significant increase in the percentage of calories from total carbohydrate (3.7%). Compared with the control children, intervention children reported significantly smaller 24-hour intakes of energy (263 kcal), protein (9.5 g), total fat (15.1 g), saturated fat (6.0 g), and polyunsaturated fat (2.3 g); and as a percent of calories, total fat (2.5%) and saturated fat (1.1%). Mean intake of carbohydrates as a percentage of calories was significantly greater in intervention children by 2.5%, compared with controls.

CONCLUSIONS

The Pathways intervention successfully reduced the intake of percent calories from fat and saturated fat, at school lunch and over the whole day.

Pathways curriculum and family interventions to promote healthful eating and physical activity in American Indian schoolchildren

BACKGROUND

Pathways, a multisite school-based study aimed at promoting healthful eating and increasing physical activity, was a randomized field trial including 1704 American Indian third to fifth grade students from 41 schools (21 intervention, 20 controls) in seven American Indian communities.

METHODS

The intervention schools received four integrated components: a classroom curriculum, food service, physical activity, and family modules. The curriculum and family components were based on Social Learning Theory, American Indian concepts, and results from formative research. Process evaluation data were collected from teachers (n=235), students (n=585), and families. Knowledge, Attitudes, and Behavior Questionnaire data were collected from 1150 students including both intervention and controls.

RESULTS

There were significant increases in knowledge and cultural identity in children in intervention compared to control schools with a significant retention of knowledge over the 3 years, based on the results of repeating the third and fourth grade test items in the fifth grade. Family members participated in Family Events and take-home activities, with fewer participating each year.

CONCLUSION

A culturally appropriate school intervention can promote positive changes in knowledge, cultural identity, and self-reported healthful eating and physical activity in American Indian children and environmental change in school food service.

Changes in the nutrient content of school lunches: results from the Pathways study

BACKGROUND

Pathways, a randomized trial, evaluated the effectiveness of a school-based multicomponent intervention to reduce fatness in American-Indian schoolchildren. The goal of the Pathways food service intervention component was to reduce the fat in school lunches to no more than 30% of energy from fat while maintaining recommended levels of calories and key nutrients.

METHODS

The intervention was implemented by school food service staff in intervention schools over a 3-year period. Five consecutive days of school lunch menu items were collected from 20 control and 21 intervention schools at four time periods, and nutrient content was analyzed.

RESULTS

There was a significantly greater mean reduction in percent energy from fat and saturated fat in the intervention schools compared to the control schools. Mean percentages of energy from fat decreased from 33.1% at baseline to 28.3% at the end of the study in intervention schools compared to 33.2% at baseline and 32.2% at follow-up in the control schools (P<0.003). There were no statistically significant differences for calories or nutrients between intervention and control schools.

CONCLUSIONS

The Pathways school food lunch intervention documented the feasibility of successfully lowering the percent of energy from fat, as part of a coordinated obesity prevention program for American-Indian children.

Impact of the Pathways food service intervention on breakfast served in American-Indian schools

BACKGROUND

Pathways was a multisite, multicomponent obesity prevention intervention for American-Indian schoolchildren. The goal of the school breakfast and lunch component was to reduce fat content of school meals to 30% or fewer calories from fat without compromising dietary quality.

METHODS

An intensive 3-year intervention was implemented with school food service staff. Five consecutive days of school breakfast menu and recipe information was collected at 20 control and 19 intervention schools at four time intervals. Data were analyzed at nutrient and (in final year) food levels.

RESULTS

Average total fat decreased in intervention schools from 16.0 grams at baseline to 13.6 grams by end of study, compared with 16.6 and 16.7 grams at baseline and final measurement in control schools (P<0.030). Percentage of calories from saturated fat were also significantly reduced from 12.0 to 8.9%, compared with 12.1 to 10.6% in control schools (P<0.014). There were no significant differences in total energy or other nutrients by treatment condition across four time points. Food-level data revealed a consistent pattern of more lower-fat items served in intervention schools compared to control schools.

CONCLUSIONS

Pathways was successful in achieving its overall goal of reducing dietary fat in meals served for school breakfasts.

Measuring contextual characteristics for community health

OBJECTIVE

To conceptualize and measure community contextual influences on population health and health disparities.

DATA SOURCES

We use traditional and nontraditional secondary sources of data comprising a comprehensive array of community characteristics.

STUDY DESIGN

Using a consultative process, we identify 12 overarching dimensions of contextual characteristics that may affect community health, as well as specific subcomponents relating to each dimension.

DATA COLLECTION

An extensive geocoded library of data indicators relating to each dimension and subcomponent for metropolitan areas in the United States is assembled.

PRINCIPAL FINDINGS

We describe the development of community contextual health profiles, present the rationale supporting each of the profile dimensions, and provide examples of relevant data sources.

CONCLUSIONS

Our conceptual framework for community contextual characteristics, including a specified set of dimensions and components, can provide practical ways to monitor health-related aspects of the economic, social, and physical environments in which people live. We suggest several guiding principles useful for understanding how aspects of contextual characteristics can affect health and health disparities.

How the CATCH eat smart program helps implement the USDA regulations in school cafeterias

This article describes the implementation of the U.S. Department of Agriculture's National School Lunch Program (NSLP) standards in school lunch menus in 56 intervention and 20 control schools from the Child and Adolescent Trial for Cardiovascular Health (CATCH) 5 years after the main trial, compared with 12 schools previously unexposed to CATCH. School food service personnel completed questionnaires to assess CATCH guideline implementation, demographic data, behavioral constructs, training, program material use, and participation in competing programs. Five days of menus and recipes were collected from school cafeteria staff, averaged, and compared to USDA School Meal Initiative (SMI) standards. Significant differences between intervention and unexposed schools were found for training and knowledge of CATCH and in mean percentage energy from fat and carbohydrates. Intervention schools most closely met USDA SMI recommendations for fat. Thus, the CATCH Eat Smart Program assisted school cafeterias in meeting USDA guidelines 5 years postimplementation.

Preventive strategies against weight gain and obesity

A well-resourced, comprehensive, population-based set of strategies is needed to attenuate and eventually reverse the current trends of increasing obesity prevalence now apparent in most countries. The Epidemiological Triad (host, vector, environment) has proven to be a robust model for other epidemics and is applied to obesity. Host-based strategies are primarily educational and these tend to be most effective among people with higher incomes and higher educational attainment. The main vectors for a high-energy intake are energy-dense foods and drinks and large portion sizes and, for low energy expenditure, machines that promote physical inactivity. Vector-based strategies that alter food formulation can have a significant impact, particularly through influencing common, high-volume foods. The increasingly 'obesogenic' environments are probably the main driving forces for the obesity epidemic. There are many environmental strategies that can influence the physical, economic, policy or socio-cultural environments, but the evidence base for these potentially powerful interventions is small. Children should be the priority population for interventions, and improving the general socio-economic conditions for disadvantaged, marginalized or poor population sectors is also a central strategy for obesity prevention. The key settings for interventions are schools, homes, neighbourhoods, primary health care services and communities. The key macroenvironments for interventions are the transport and infrastructure sector, the media and the food sector.

Diet quality of young children who received nutrition education promoting lower dietary fat

OBJECTIVE

: To evaluate the impact of nutrition education promoting lower dietary fat on the overall diet quality in children using a multidimensional index that measures nutrient and food intakes in relation to US dietary recommendations.

DESIGN

: Prospective cohort study with two intervention and two control groups. Children with elevated low density lipoprotein (LDL) cholesterol were randomized to one of two intervention groups or an at-risk control group. The intervention children received either the parent-child autotutorial (PCAT) programme, a 10-week home-based self-instruction nutrition education programme, or nutrition counselling from a registered dietitian. Children with non-elevated plasma cholesterol formed the not-at-risk control group. Dietary and blood data were collected at baseline and at 3 months.

SETTING

: Paediatric practices in suburbs north of Philadelphia, PA.

SUBJECTS

: Two hundred and twenty-seven 4-10-year-old children with elevated LDL cholesterol between the 80th and 98th percentiles, and 76 age- and gender-matched children with non-elevated plasma cholesterol, were studied.

RESULTS

: Children who received PCAT or counselling significantly improved their overall diet quality (-0.6 and -0.4 change in diet quality index (DQI) scores) compared with at-risk control children. Children who received either form of nutrition education were more likely to meet the recommendations for three components of the DQI (total fat, saturated fat, sodium) (OR >1.7), but did not improve their intakes of three components of the DQI (vegetables and fruits, complex carbohydrates, calcium) at 3 months.

CONCLUSIONS

: Nutrition education promoting lower dietary fat improved children's overall diet quality. However, several dietary behaviours important for long-term health remained unchanged.

Food Perceptions and Dietary Behavior of American-Indian Children, Their Caregivers, and Educators: Formative Assessment Findings from Pathways

Dietary findings from a school-based obesity prevention project (Pathways) are reported for children from six different American-Indian nations. A formative assessment was undertaken with teachers, caregivers, and children from nine schools to design a culturally appropriate intervention, including classroom curriculum, food service, physical education, and family components. This assessment employed a combination of qualitative and quantitative methods (including direct observations, paired-child in-depth interviews, focus groups with child caregivers and teachers, and semistructured interviews with caregivers and foodservice personnel) to query local perceptions and beliefs about foods commonly eaten and risk behaviors associated with childhood obesity at home, at school, and in the community. An abundance of high-fat, high-sugar foods was detected in children's diets described by caregivers, school food-service workers, and the children themselves. Although children and caregivers identified fruits and vegetables as healthy food choices, this knowledge does not appear to influence actual food choices. Frequent high-fat/high-sugar food sales in the schools, high-fat entrees in school meals, the use of food rewards in the classroom, rules about finishing all of one's food, and limited family resources are some of the competing factors that need to be addressed in the Pathways intervention.

Process tracking results from the Treatwell 5-a-Day Worksite Study

PURPOSE

To report findings from Treatwell 5-a-Day process tracking.

DESIGN

Worksites were randomly assigned to a minimal intervention control, worksite-only condition, or worksite-plus-family condition.

SETTING

Twenty-two small community health centers in Massachusetts.

SUBJECTS

Employees of the community health centers.

INTERVENTION

Both intervention conditions included the formation of employee advisory boards; activities such as nutrition discussions and taste tests targeting individual behavior change; and point-of-purchase labeling as an environmental strategy. Worksite-plus-family sites incorporated activities such as family contests, campaigns, and picnics.

MEASURES

Documentation of the number and type of activities for extent of implementation; number of participants in activities for reach; program awareness and participation from the follow-up employee survey (n = 1306, representing 76% [range, 56%-100%] of the sample); change in fruit and vegetable consumption from a comparison between the follow-up and baseline surveys (n = 1359, representing 87% [range, 75%-100%] of the sample).

RESULTS

A higher number of activities per employee was significantly correlated with greater program awareness (.68; p = .006) and greater change in fruit and vegetable consumption (.55; p = .04). Greater participation in activities was significantly correlated with greater awareness (.67; p = .007), higher participation (.61; p = .02), and increase in fruit and vegetable consumption. (.55; p = .04).

CONCLUSIONS

These results provide quantitative indicators of a dose-response relationship between the number of intervention activities per employee and higher percentage of employee participation and observed increases in fruit and vegetable consumption.

Process evaluation in a multisite, primary obesity-prevention trial in American Indian schoolchildren

We describe the development, implementation, and use of the process evaluation component of a multisite, primary obesity prevention trial for American Indian schoolchildren. We describe the development and pilot testing of the instruments, provide some examples of the criteria for instrument selection, and provide examples of how process evaluation results were used to document and refine intervention components. The theoretical and applied framework of the process evaluation was based on diffusion theory, social learning theory, and the desire for triangulation of multiple modes of data collection. The primary objectives of the process evaluation were to systematically document the training process, content, and implementation of 4 components of the intervention. The process evaluation was developed and implemented collaboratively so that it met the needs of both the evaluators and those who would be implementing the intervention components. Process evaluation results revealed that observation and structured interviews provided the most informative data; however, these methods were the most expensive and time consuming and required the highest level of skill to undertake. Although the literature is full of idealism regarding the uses of process evaluation for formative and summative purposes, in reality, many persons are sensitive to having their work evaluated in such an in-depth, context-based manner as is described. For this reason, use of structured, quantitative, highly objective tools may be more effective than qualitative methods, which appear to be more dependent on the skills and biases of the researcher and the context in which they are used.

Pathways: a culturally appropriate obesity-prevention program for American Indian schoolchildren

Pathways, a culturally appropriate obesity prevention study for third-, fourth-, and fifth-grade American Indian schoolchildren includes an intervention that promotes increased physical activity and healthful eating behaviors. The Pathways intervention, developed through a collaboration of universities and American Indian nations, schools, and families, focuses on individual, behavioral, and environmental factors and merges constructs from social learning theory with American Indian customs and practices. We describe the Pathways program developed during 3 y of feasibility testing in American Indian schools, with special emphasis on the activities developed for the third grade; review the theoretical and cultural underpinnings of the program; outline the construction process of the intervention; detail the curriculum and physical education components of the intervention; and summarize the formative assessment and the school food service and family components of the intervention.