A three-year evaluation of the know your body program in inner-city schoolchildren

A Community Guide Systematic Review: School Dietary and Physical Activity Interventions

CONTEXT

Schools can play an important role in supporting a healthy lifestyle by offering nutritious foods and beverages and providing opportunities for physical activity. A healthy diet and regular physical activity may reduce the risk of obesity. This manuscript reports on a Community Guide systematic review examining the effectiveness of interventions in schools combining school meal or fruit and vegetable snack programs and physical activity.

EVIDENCE ACQUISITION

Studies meeting the intervention definition were identified from a literature search (search period: January 1990-November 2019). Community Guide systematic review methods were used to assess effectiveness as measured by dietary behavior, physical activity, and weight changes; analyses were conducted in 2020.

EVIDENCE SYNTHESIS

Interventions (n=24 studies) were considered effective for increasing physical activity (median increase=21.8 minutes/day; interquartile interval= -0.8 to 27.4 minutes/day), modestly increasing fruit and vegetable intake (median relative increase=12.1%; interquartile interval= -4.6%, 73.4%), and decreasing the prevalence of overweight and obesity (median decrease=2.5 percentage points; interquartile interval= -8.1, -1.6 percentage points) among elementary school students through sixth grade. There were not enough studies to determine the effectiveness of interventions for middle- and high-school students.

CONCLUSIONS

School meal or fruit and vegetable snack interventions combined with physical activity were effective in increasing physical activity, with modest effects for improving fruit and vegetable consumption and reducing the prevalence of overweight and obesity among elementary students. These results may inform researchers and school administrators about healthy eating and physical activity interventions.

Identifying effective interventions to promote consumption of protein-rich foods from lower ecological footprint sources: A systematic literature review

Addressing overconsumption of protein-rich foods from high ecological footprint sources can have positive impacts on health such as reduction of non-communicable disease risk and protecting the natural environment. With the increased attention towards development of ecologically sustainable diets, this systematic review aimed to critically review literature on effectiveness of those interventions aiming to promote protein-rich foods from lower ecological footprint sources. Five electronic databases (Medline, Web of Science, Scopus, Embase and Global Health) were searched for articles published up to January 2021. Quantitative studies were eligible for inclusion if they reported on actual or intended consumption of protein-rich animal-derived and/or plant-based foods; purchase, or selection of meat/plant-based diet in real or virtual environments. We assessed 140 full-text articles for eligibility of which 51 were included in this review. The results were narratively synthesised. Included studies were categorised into individual level behaviour change interventions (n = 33) which included education, counselling and self-monitoring, and micro-environmental/structural behaviour change interventions (n = 18) which included menu manipulation, choice architecture and multicomponent approaches. Half of individual level interventions (52%) aimed to reduce red/processed meat intake among people with current/past chronic conditions which reduced meat intake in the short term. The majority of micro-environmental studies focused on increasing plant-based diet in dining facilities, leading to positive dietary changes. These findings point to a clear gap in the current evidence base for interventions that promote plant-based diet in the general population.

Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease

BACKGROUND

A number of school-based policies or practices have been found to be effective in improving child diet and physical activity, and preventing excessive weight gain, tobacco or harmful alcohol use. Schools, however, frequently fail to implement such evidence-based interventions.

OBJECTIVES

The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices to address child diet, physical activity, obesity, tobacco or alcohol use.Secondary objectives of the review are to: Examine the effectiveness of implementation strategies on health behaviour (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of school staff involved in implementing health-promoting policies, programs or practices; describe the cost or cost-effectiveness of such strategies; and describe any unintended adverse effects of strategies on schools, school staff or children.

SEARCH METHODS

All electronic databases were searched on 16 July 2017 for studies published up to 31 August 2016. We searched the following electronic databases: Cochrane Library including the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase Classic and Embase; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Dissertations and Theses; and SCOPUS. We screened reference lists of all included trials for citations of other potentially relevant trials. We handsearched all publications between 2011 and 2016 in two specialty journals (Implementation Science and Journal of Translational Behavioral Medicine) and conducted searches of the WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/) as well as the US National Institutes of Health registry (https://clinicaltrials.gov). We consulted with experts in the field to identify other relevant research.

SELECTION CRITERIA

'Implementation' was defined as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised or non-randomised) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by school staff to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

Citation screening, data extraction and assessment of risk of bias was performed by review authors in pairs. Disagreements between review authors were resolved via consensus, or if required, by a third author. Considerable trial heterogeneity precluded meta-analysis. We narratively synthesised trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

MAIN RESULTS

We included 27 trials, 18 of which were conducted in the USA. Nineteen studies employed randomised controlled trial (RCT) designs. Fifteen trials tested strategies to implement healthy eating policies, practice or programs; six trials tested strategies targeting physical activity policies or practices; and three trials targeted tobacco policies or practices. Three trials targeted a combination of risk factors. None of the included trials sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials examined multi-strategic implementation strategies and no two trials examined the same combinations of implementation strategies. The most common implementation strategies included educational materials, educational outreach and educational meetings. For all outcomes, the overall quality of evidence was very low and the risk of bias was high for the majority of trials for detection and performance bias.Among 13 trials reporting dichotomous implementation outcomes-the proportion of schools or school staff (e.g. classes) implementing a targeted policy or practice-the median unadjusted (improvement) effect sizes ranged from 8.5% to 66.6%. Of seven trials reporting the percentage of a practice, program or policy that had been implemented, the median unadjusted effect (improvement), relative to the control ranged from -8% to 43%. The effect, relative to control, reported in two trials assessing the impact of implementation strategies on the time per week teachers spent delivering targeted policies or practices ranged from 26.6 to 54.9 minutes per week. Among trials reporting other continuous implementation outcomes, findings were mixed. Four trials were conducted of strategies that sought to achieve implementation 'at scale', that is, across samples of at least 50 schools, of which improvements in implementation were reported in three trials.The impact of interventions on student health behaviour or weight status were mixed. Three of the eight trials with physical activity outcomes reported no significant improvements. Two trials reported reductions in tobacco use among intervention relative to control. Seven of nine trials reported no between-group differences on student overweight, obesity or adiposity. Positive improvements in child dietary intake were generally reported among trials reporting these outcomes. Three trials assessed the impact of implementation strategies on the attitudes of school staff and found mixed effects. Two trials specified in the study methods an assessment of potential unintended adverse effects, of which, they reported none. One trial reported implementation support did not significantly increase school revenue or expenses and another, conducted a formal economic evaluation, reporting the intervention to be cost-effective. Trial heterogeneity, and the lack of consistent terminology describing implementation strategies, were important limitations of the review.

AUTHORS' CONCLUSIONS

Given the very low quality of the available evidence, it is uncertain whether the strategies tested improve implementation of the targeted school-based policies or practices, student health behaviours, or the knowledge or attitudes of school staff. It is also uncertain if strategies to improve implementation are cost-effective or if they result in unintended adverse consequences. Further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Parental Influence on Models of Primary Prevention of Cardiovascular Disease in Children

BACKGROUND

Lifestyle behaviors such as overeating and physical inactivity contribute significantly to CVD, the leading cause of morbidity and mortality among adults globally. CVD risk factors that begin in children often track into adulthood. Parents are believed to influence the health behaviors of their children.

OBJECTIVE

To review the literature on parental influence on children's health beliefs and behaviors, particularly eating and exercise behaviors as indicators of CV health, school-based CVD risk reduction programs, and racial/ethnic, gender and socioeconomic considerations for models of primary prevention of CVD in children.

METHODS

Seventeen studies that included parents as either a source of information, change agent or participant in a CVD risk reduction intervention were identified searching the Medline, CINAHL and PsycINFO databases from 1980 through 2002.

RESULTS

Children's lifestyle health beliefs and behaviors are significantly influenced by positive parental modeling and involvement in exercise and healthy eating; parental influence on children's behavior lasts beyond adolescence; parents are effective teachers of health habits at home when prompted by health educators; and parental influences vary by ethnicity/race, socioeconomics and gender.

CONCLUSIONS

A broader base of knowledge that is socioculturally sensitive must be developed about what parents and children believe is healthy, how parents model beliefs and behaviors for their children, and how to build self-efficacy for positive health behaviors.

Comparison of two school-based programmes for health behaviour change: the Belo Horizonte Heart Study randomized trial

OBJECTIVE

To assess the efficacy of two school-based programmes to promote students' willingness to engage in lifestyle changes related to eating habits and physical activity behaviours.

DESIGN

Elementary school-based health promotion intervention, designed as a multicomponent experimental study, based on a behavioural epidemiological model.

SETTING

Nine intervention and eight comparative public and private elementary schools.

SUBJECTS

The goal was to determine the impact on the longitudinally assessed outcomes of two programmes that addressed healthy nutrition and active living in a cohort of 2038 children. The evaluations used pre-intervention and follow-up student surveys that were based on the Transtheoretical Model of the stages of behaviour change.

RESULTS

In the intervention group, there were significant (P < 0·001) differences between the pre- and post-intervention times in the stages of change, with a reduction in the percentage of children at the pre-contemplation and contemplation stages and increased percentages at the preparation, action and maintenance stages, leading to healthier behaviours in fatty food consumption, fruit and vegetable consumption, physical activity and time spent in sedentary activities. The determinants of the behaviour stage were the intervention programme, the type of school and the presence of motivated teachers. The comparison group did not show significant differences between the pre- and post-intervention times for any of the stages of behaviour.

CONCLUSIONS

The intervention programme encouraged the students to make healthy lifestyle choices related to eating habits and physical activity behaviours.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

BACKGROUND

The World Health Organization (WHO) estimates that 1.9 million deaths worldwide are attributable to physical inactivity and at least 2.6 million deaths are a result of being overweight or obese. In addition, WHO estimates that physical inactivity causes 10% to 16% of cases each of breast cancer, colon, and rectal cancers as well as type 2 diabetes, and 22% of coronary heart disease and the burden of these and other chronic diseases has rapidly increased in recent decades.

OBJECTIVES

The purpose of this systematic review was to summarize the evidence of the effectiveness of school-based interventions in promoting physical activity and fitness in children and adolescents.

SEARCH METHODS

The search strategy included searching several databases to October 2011. In addition, reference lists of included articles and background papers were reviewed for potentially relevant studies, as well as references from relevant Cochrane reviews. Primary authors of included studies were contacted as needed for additional information.

SELECTION CRITERIA

To be included, the intervention had to be relevant to public health practice (focused on health promotion activities), not conducted by physicians, implemented, facilitated, or promoted by staff in local public health units, implemented in a school setting and aimed at increasing physical activity, included all school-attending children, and be implemented for a minimum of 12 weeks. In addition, the review was limited to randomized controlled trials and those that reported on outcomes for children and adolescents (aged 6 to 18 years). Primary outcomes included: rates of moderate to vigorous physical activity during the school day, time engaged in moderate to vigorous physical activity during the school day, and time spent watching television. Secondary outcomes related to physical health status measures including: systolic and diastolic blood pressure, blood cholesterol, body mass index (BMI), maximal oxygen uptake (VO2max), and pulse rate.

DATA COLLECTION AND ANALYSIS

Standardized tools were used by two independent reviewers to assess each study for relevance and for data extraction. In addition, each study was assessed for risk of bias as specified in the Cochrane Handbook for Systematic Reviews of Interventions. Where discrepancies existed, discussion occurred until consensus was reached. The results were summarized narratively due to wide variations in the populations, interventions evaluated, and outcomes measured.

MAIN RESULTS

In the original review, 13,841 records were identified and screened, 302 studies were assessed for eligibility, and 26 studies were included in the review. There was some evidence that school-based physical activity interventions had a positive impact on four of the nine outcome measures. Specifically positive effects were observed for duration of physical activity, television viewing, VO2 max, and blood cholesterol. Generally, school-based interventions had little effect on physical activity rates, systolic and diastolic blood pressure, BMI, and pulse rate. At a minimum, a combination of printed educational materials and changes to the school curriculum that promote physical activity resulted in positive effects.In this update, given the addition of three new inclusion criteria (randomized design, all school-attending children invited to participate, minimum 12-week intervention) 12 of the original 26 studies were excluded. In addition, studies published between July 2007 and October 2011 evaluating the effectiveness of school-based physical interventions were identified and if relevant included. In total an additional 2378 titles were screened of which 285 unique studies were deemed potentially relevant. Of those 30 met all relevance criteria and have been included in this update. This update includes 44 studies and represents complete data for 36,593 study participants. Duration of interventions ranged from 12 weeks to six years.Generally, the majority of studies included in this update, despite being randomized controlled trials, are, at a minimum, at moderate risk of bias. The results therefore must be interpreted with caution. Few changes in outcomes were observed in this update with the exception of blood cholesterol and physical activity rates. For example blood cholesterol was no longer positively impacted upon by school-based physical activity interventions. However, there was some evidence to suggest that school-based physical activity interventions led to an improvement in the proportion of children who engaged in moderate to vigorous physical activity during school hours (odds ratio (OR) 2.74, 95% confidence interval (CI), 2.01 to 3.75). Improvements in physical activity rates were not observed in the original review. Children and adolescents exposed to the intervention also spent more time engaged in moderate to vigorous physical activity (with results across studies ranging from five to 45 min more), spent less time watching television (results range from five to 60 min less per day), and had improved VO2max (results across studies ranged from 1.6 to 3.7 mL/kg per min). However, the overall conclusions of this update do not differ significantly from those reported in the original review.

AUTHORS' CONCLUSIONS

The evidence suggests the ongoing implementation of school-based physical activity interventions at this time, given the positive effects on behavior and one physical health status measure. However, given these studies are at a minimum of moderate risk of bias, and the magnitude of effect is generally small, these results should be interpreted cautiously. Additional research on the long-term impact of these interventions is needed.

Promotoras' roles in integrative validity and treatment fidelity efforts in randomized controlled trials

Promotoras from the communities in which interventions are implemented can be effective contributors to validity and fidelity efforts. This article describes a 48-week randomized controlled trial Madres para la Salud (Mothers for Health) and illustrates the use of promotoras as collaborative members of the research team to contribute to attaining integrative validity and treatment fidelity. Madres para la Salud implements a culturally tailored physical activity program to effect changes in body fat, systemic and fat tissue inflammation, and depression symptoms. The significance of Madres para la Salud treatment validity and fidelity processes includes cultural tailoring of a social support intervention, and a promotora model to incorporate initial and ongoing fidelity monitoring.

Hip-Hop to Health Jr. Obesity Prevention Effectiveness Trial: postintervention results

The preschool years offer an opportunity to interrupt the trajectory toward obesity in black children. The Hip-Hop to Health Jr. Obesity Prevention Effectiveness Trial was a group-randomized controlled trial assessing the feasibility and effectiveness of a teacher-delivered weight control intervention for black preschool children. The 618 participating children were enrolled in 18 schools administered by the Chicago Public Schools. Children enrolled in the nine schools randomized to the intervention group received a 14-week weight control intervention delivered by their classroom teachers. Children in the nine control schools received a general health intervention. Height and weight, physical activity, screen time, and diet data were collected at baseline and postintervention. At postintervention, children in the intervention schools engaged in more moderate-to-vigorous physical activity (MVPA) than children in the control schools (difference between adjusted group means = 7.46 min/day, P = 0.02). Also, children in the intervention group had less total screen time (-27.8 min/day, P = 0.05). There were no significant differences in BMI, BMI Z score, or dietary intake. It is feasible to adapt an obesity prevention program to be taught by classroom teachers. The intervention showed positive influences on physical activity and screen time, but not on diet. Measuring diet and physical activity in preschool children remains a challenge, and interventions delivered by classroom teachers require both intensive initial training and ongoing individualized supervision.

Lessons learned from evaluations of California's statewide school nutrition standards

OBJECTIVES

We assessed the impact of legislation that established nutrition standards for foods and beverages that compete with reimbursable school meals in California.

METHODS

We used documentation of available foods and beverages, sales accounts, and surveys of and interviews with students and food service workers to conduct 3 studies measuring pre- and postlegislation food and beverage availability, sales, and student consumption at 99 schools.

RESULTS

Availability of nutrition standard-compliant foods and beverages increased. Availability of noncompliant items decreased, with the biggest reductions in sodas and other sweetened beverages, regular chips, and candy. At-school consumption of some noncompliant foods dropped; at-home consumption of selected noncompliant foods did not increase. Food and beverage sales decreased at most venues, and food service à la carte revenue losses were usually offset by increased meal program participation. Increased food service expenditures outpaced revenue increases.

CONCLUSIONS

Regulation of competitive foods improved school food environments and student nutritional intake. Improvements were modest, partly because many compliant items are fat- and sugar-modified products of low nutritional value. Additional policies and actions are needed to achieve more substantive improvements in school nutrition environments and student nutrition and health.

School health education programs in Crete: evaluation of behavioural and health indices a decade after initiation

OBJECTIVE

To assess the long-term effectiveness of a school-based health education intervention program 10 years after its initiation.

METHOD

In 1992 the total population of first grade students from three counties of Crete participated in the study. Over 1000 students were randomly selected for initial and periodic evaluation. Biochemical and behavioural parameters (anthropometric, lipoproteins, blood pressure, physical activity, dietary record and health habits) were measured. Re-evaluation of the program was performed at 3, 6 and 10 years after its initiation.

RESULTS

Ten years after the initiation of the program, the results showed that BMI had increased significantly less (p<0.001) and performance in the shuttle run test was significantly better (p<0.001) in the intervention group as compared to the control group. The reduction in total cholesterol noted in both groups was significantly greater in the intervention group than in the control group (p<0.001). The incidence of smoking was also significantly lower in the intervention group (intervention group 7%, control group 13%, p<0.005).

CONCLUSION

This program appears to improve children's health and decrease risk factors for chronic diseases. If these positive effects are maintained in the forthcoming decades, the risk of chronic diseases may well be reduced.

Implementation Quality: Lessons Learned in the Context of the Head Start REDI Trial

This study uses data collected in the intervention classrooms (N = 22) of Head Start REDI (Research-based, Developmentally Informed), a randomized clinical trial testing the efficacy of a comprehensive preschool curriculum targeting children's social-emotional competence, language, and emergent literacy skills delivered by teachers who received weekly coaching support. Multiple dimensions of implementation (Dosage, Fidelity, Generalization, and Child Engagement) were assessed across curriculum components. Results indicated that REDI Trainers perceived significant growth in teacher implementation quality over time but that patterns differed by implementation dimension. Dosage and Fidelity of all intervention components were high at the beginning of the year and remained so over time while Generalization was low at baseline but increased significantly across the year. Variation in implementation was associated with variation on several child outcome measures in the social-emotional domain but not in the language and literacy domains.

After-school program to reduce obesity in minority children: a pilot study

This study explored a community-based after-school program's effect on obesity in minority children. Study participants included 178 third through fifth graders (47% Latino, 25% Asian, and 18% African-American) enrolled in America SCORES Bay Area. Outcomes were attendance, change in fitness (20-meter shuttle test), and body mass index (BMI) z-score over eight months. At baseline, 52 percent of children were overweight or obese. Children attended SCORES > 4 days/week and fitness significantly improved (p < 0.01). BMI z-score decreased by 0.04 (p = 0.10) overall, and by 0.05 (p = 0.08) among obese children, but increased among African-American children. These results suggest that SCORES increases fitness and may improve BMI in some minority children. Effect modification by race may relate to differential growth patterns or engagement in SCORES. These findings suggest community-based programs could effectively address obesity. A randomized trial of the SCORES program is warranted to rigorously examine this type of after-school program's impact on child health.

Practices and representations of health education among primary school teachers

AIMS

School is one of the key settings for health education (HE). The objectives of this study are to assess primary school teachers' self-reported teaching practices in HE and to describe their representation concerning their role in HE.

METHODS

A quantitative study was conducted on a sample of primary school teachers (n = 626) in two French regions in order to analyze their practices and representations in HE. A hierarchical clustering dendogram was performed on questions exploring representations of HE. Multiple linear regression analysis helped explain the motivation and self-perceived competency score.

RESULTS

Three quarters of the teachers declare they work in HE. Only one third of them declare they work in a comprehensive HE perspective. The HE approach is often considered in terms of specific unique curriculum intervention. Two thirds of the teachers say they work alone in HE, the other third associate other partners and choose mainly school health services. Parents are rarely (12%) involved in HE initiatives. It is essentially the practice of HE, teacher training and teachers' representation of HE that condition their motivation to develop HE.

CONCLUSIONS

Teachers can take different approaches to HE. Teachers' representation of HE plays an important role in the development of HE activities: some teachers consider that HE is the mission of the health professionals and the parents. Our expectations of teacher involvement should be realistic, should take into account the representations of their role, the difficulties they encounter, and should be sustained by specific training.

The impact of school-based prevention of overweight on psychosocial well-being of children

This review aimed to gain insight in the extent to which psychosocial effects of obesity prevention programmes have been studied, to give an overview of the methods used to measure the particular psychosocial aspects and - if possible - to quantify the effects found. Intervention studies (n = 267) covering the period 1990-October 2005 were derived from seven reviews about childhood obesity interventions. An additional search identified 2754 studies covering the period January 2005-February 2008. In total, 2901 papers (excluding 120 duplicates) were screened for inclusion. Sixty-nine papers covering 53 interventions were included and screened on measuring psychosocial variables. All original authors were contacted. Seven of the selected interventions measured psychosocial variables, five of which evaluated a net intervention effect as compared with a control condition. Only two interventions reported a statistically significant net intervention effect (a decrease in use of purging or diet pills and a decrease in peer ratings of aggression and observed verbal aggression). We conclude that a minority of childhood obesity interventions investigate the effects of their programmes on psychosocial well-being of children and adolescents. It is recommended that in the future, these programmes will be evaluated in a uniform way on a broad range of psychosocial aspects.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6-18

BACKGROUND

The World Health Organization estimates that 1.9 million deaths worldwide are attributable to physical inactivity. Chronic diseases associated with physical inactivity include cancer, diabetes and coronary heart disease.

OBJECTIVES

The purpose of this systematic review is to summarize the evidence of the effectiveness of school-based interventions in promoting physical activity and fitness in children and adolescents.

SEARCH STRATEGY

The search strategy included searching several databases. In addition, reference lists of included articles and background papers were reviewed for potentially relevant studies, as well as references from relevant Cochrane reviews. Primary authors of included studies were contacted as needed for additional information.

SELECTION CRITERIA

To be included, the intervention had to be relevant to public health practice, implemented, facilitated, or promoted by staff in local public health units, implemented in a school setting and aimed at increasing physical activity, report on outcomes for children and adolescents (aged 6 to 18 years), and use a prospective design with a control group.

DATA COLLECTION AND ANALYSIS

Standardized tools were used by two independent reviewers to rate each study's methodological quality and for data extraction. Where discrepancies existed discussion occurred until consensus was reached. The results were summarized narratively due to wide variations in the populations, interventions evaluated and outcomes measured.

MAIN RESULTS

13,841 titles were identified and screened and 482 articles were retrieved. Multiple publications on the same project were combined and counted as one project, resulting in 395 distinct project accounts (studies). Of the 395 studies 104 were deemed relevant and of those, four were assessed as having strong methodological quality, 22 were of moderate quality and 78 were considered weak. In total 26 studies were included in the review. There is good evidence that school-based physical activity interventions have a positive impact on four of the nine outcome measures. Specifically positive effects were observed for duration of physical activity, television viewing, VO2 max, and blood cholesterol. Generally school-based interventions had no effect on leisure time physical activity rates, systolic and diastolic blood pressure, body mass index, and pulse rate. At a minimum, a combination of printed educational materials and changes to the school curriculum that promote physical activity result in positive effects.

AUTHORS' CONCLUSIONS

Given that there are no harmful effects and that there is some evidence of positive effects on lifestyle behaviours and physical health status measures, ongoing physical activity promotion in schools is recommended at this time.

Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation

The first purpose of this review was to assess the impact of implementation on program outcomes, and the second purpose was to identify factors affecting the implementation process. Results from over quantitative 500 studies offered strong empirical support to the conclusion that the level of implementation affects the outcomes obtained in promotion and prevention programs. Findings from 81 additional reports indicate there are at least 23 contextual factors that influence implementation. The implementation process is affected by variables related to communities, providers and innovations, and aspects of the prevention delivery system (i.e., organizational functioning) and the prevention support system (i.e., training and technical assistance). The collection of implementation data is an essential feature of program evaluations, and more information is needed on which and how various factors influence implementation in different community settings.

Review of external validity reporting in childhood obesity prevention research

BACKGROUND

The translation and dissemination of prevention intervention evidence into practice is needed to address significant public health issues such as childhood obesity. Increased attention to and reporting of external validity information in research publications would allow for better understanding of generalizability issues relevant to successful translation. To demonstrate this potential, recent reports of childhood obesity prevention interventions were evaluated on the extent to which external validity dimensions were reported.

METHODS

Childhood obesity prevention studies that were controlled, long-term research trials published between 1980 and 2004 that reported a behavioral target of physical activity and/or healthy eating along with at least one anthropometric outcome were identified in 2005. Studies were summarized between 2005 and 2006 using review criteria developed by Green and Glasgow in 2006.

RESULTS

Nineteen publications met selection criteria. In general, all studies lacked full reporting on potential generalizability and dissemination elements. Median reporting over all elements was 34.5%; the mode was 0% with a range of 0% to 100%. Most infrequent were reports of setting level selection criteria and representativeness, characteristics regarding intervention staff, implementation of intervention content, costs, and program sustainability.

CONCLUSIONS

The evidence base for future prevention interventions can be improved by enhancing the reporting of contextual and generalizability elements central to translational research. Such efforts face practical hurdles but could provide additional explanation for variability in intervention outcomes, insights into successful adaptations of interventions, and help guide policy decisions.

Wise Mind project: a school-based environmental approach for preventing weight gain in children

OBJECTIVE

The Wise Mind pilot study compared the efficacy of an environmental approach for prevention of inappropriate weight gain in children with an active control condition that used an environmental approach for modifying expectancies related to the use of alcohol, tobacco, and drugs.

RESEARCH METHODS AND PROCEDURES

A total of 670 second to sixth grade students from four schools were enrolled in the study. The study spanned 2 academic years, and 586 students were available for evaluation at the end of the study. Two schools were randomly assigned to each treatment arm. The environmental approach for weight gain prevention focused on modification of eating habits and physical activity, and the active control group focused on modification of expectancies related to substance use.

RESULTS

Using an intention to treat design, the study found no differences in weight gain prevention between the two interventions. The weight gain prevention program was associated with reduction of total caloric intake, reduction of dietary fat intake, reduction of protein intake, and increased physical activity in comparison with the active control group and relative to baseline. These changes in food intake were attributed to changes in food selections that resulted from modification of school cafeteria menus and food preparation.

DISCUSSION

The Wise Mind school-based weight gain prevention program induced behavioral changes in healthy eating and physical activity but did not induce significant changes in body weight in comparison with the control arm. Recommendations for future research are provided.

Students' perceptions of the impact of nutrition policies on dietary behaviors

Poor dietary habits, rising rates of overweight students, and lack of oversight of vending contracts prompted the Los Angeles Unified School District (LAUSD) to develop and implement 2 of the most comprehensive nutrition policies in the country. The Healthy Beverage Resolution and Obesity Prevention Motion limit the types of and access to beverages and snacks on school campuses. This study used qualitative and quantitative methods to document the development, implementation, and impact of the LAUSD nutrition policies. Questionnaires were administered to 399 12th-grade students in 2 LAUSD high schools to determine knowledge of the policies, perceptions of the impact of the policies on student dietary behaviors, and attitudes toward the policies and the school nutrition environment. Over one half of all students indicated that the policies impacted the foods and beverages they consumed at school, whereas only about one fifth indicated the policies impacted what they ate or drank at home/outside of school. However, for those students who indicated the policies had an impact, they reported they ate or drank fewer of the banned items both at school and at home/outside of school. These results point to the need for additional research to determine if school policies impact student behaviors outside of the school setting. Removing unhealthy food items from schools may not be enough to improve student's overall dietary behaviors. A coordinated multilevel approach including nutrition education, physical education, and parental involvement along with policies and modifications in food service is recommended.

School-based obesity prevention: Research, challenges, and recommendations

Childhood overweight is one of the most serious problems currently affecting individual and public health. Schools represent a logical site for prevention because children spend 6-8 hours a day there during most of the year. Although reports of school-based overweight or obesity prevention programs exist, there are no summaries specifying which interventions are effective in preventing weight gain in the school environment. Researchers generally consider randomized controlled trials to be the most reliable and valid findings; so, naturally they are the best for providing evidence on which to base curriculum and policy guidelines. Consequently, the purpose of this paper is to provide an overview of school-based randomized controlled studies intended to prevent increases in schoolchildren's body weight or body mass index. This paper addresses the successes and other positive health outcomes, as well as the limitations of the school-based research. The goal of this paper is to assist school health administrators with curriculum decisions related to overweight or obesity prevention in schools. Following the critique, the challenges of childhood overweight or obesity prevention are discussed, and recommendations for further research, school activities, and policy changes are made.

Interventions to prevent obesity in children and adolescents: a systematic literature review

OBJECTIVE

Preventive measures to contain the epidemic of obesity have become a major focus of attention. This report reviews the scientific evidence for medical interventions aimed at preventing obesity during childhood and adolescence.

DESIGN

A systematic literature review involving selection of primary research and other systematic reviews. Articles published until 2004 were added to an earlier (2002) review by the Swedish Council on Technology Assessment in Health Care.

METHODS

Inclusion criteria required controlled studies with follow-up of at least 12 months and results measured as body mass index, skinfold thickness or the percentage of overweight/obesity. Children could be recruited from normal or high-risk populations.

RESULTS

Combining the new data with the previous review resulted in an evaluation of 24 studies involving 25 896 children. Of these, eight reported that prevention had a statistically significant positive effect on obesity, 16 reported neutral results and none reported a negative result (sign test; P=0.0078). Adding the studies included in five other systematic reviews yielded, in total, 15 studies with positive, 24 with neutral and none with negative results. Thus, 41% of the studies, including 40% of the 33 852 children studied, showed a positive effect from prevention. These results are unlikely to be a random chance phenomenon (P=0.000061).

CONCLUSION

Evidence shows that it is possible to prevent obesity in children and adolescents through limited, school-based programs that combine the promotion of healthy dietary habits and physical activity.

A meta-analytic review of obesity prevention programs for children and adolescents: the skinny on interventions that work

This meta-analytic review summarizes obesity prevention programs and their effects and investigates participant, intervention, delivery, and design features associated with larger effects. A literature search identified 64 prevention programs seeking to produce weight gain prevention effects, of which 21% produced significant prevention effects that were typically pre- to post effects. Larger effects emerged for programs that targeted children and adolescents (vs. preadolescents) and females, programs that were relatively brief, programs that solely targeted weight control versus other health behaviors (e.g., smoking), programs evaluated in pilot trials, and programs wherein participants must have self-selected into the intervention. Other factors, including mandated improvements in diet and exercise, sedentary behavior reduction, delivery by trained interventionists, and parental involvement, were not associated with significantly larger effects.

Hip-Hop to Health Jr. for Latino preschool children

OBJECTIVE

Hip-Hop to Health Jr. was a diet/physical activity intervention designed to reduce gains in BMI (kilograms per meter squared) in preschool minority children.

RESEARCH METHODS AND PROCEDURES

Twelve predominantly Latino Head Start centers participated in a group-randomized trial conducted between Fall 2001 and Winter 2003. Six centers were randomized to a culturally proficient 14-week (three times weekly) diet/physical activity intervention. Parents participated by completing weekly homework assignments. The children in the other six centers received a general health intervention that did not address either diet or physical activity. The primary outcome was change in BMI, and secondary outcomes were changes in dietary intake and physical activity. Measures were collected at baseline, post-intervention, and at Years 1 and 2 follow-up.

RESULTS

There were no significant differences between intervention and control schools in either primary or secondary outcomes at post-intervention, Year 1, or Year 2 follow-ups.

DISCUSSION

When Hip-Hop to Health Jr. was conducted in predominantly black Head Start centers, it was effective in reducing subsequent increases in BMI in preschool children. In contrast, when the program was conducted in Latino centers, it was not effective. Although the intervention did not prevent excessive weight gain in Latino children, it was very well received. Future interventions with this population may require further cultural tailoring and a more robust parent intervention.

Position of the American Dietetic Association: individual-, family-, school-, and community-based interventions for pediatric overweight

The American Dietetic Association (ADA), recognizing that overweight is a significant problem for children and adolescents in the United States, takes the position that pediatric overweight intervention requires a combination of family-based and school-based multi-component programs that include the promotion of physical activity, parent training/modeling, behavioral counseling, and nutrition education. Furthermore, although not yet evidence-based, community-based and environmental interventions are recommended as among the most feasible ways to support healthful lifestyles for the greatest numbers of children and their families. ADA supports the commitment of resources for programs, policy development, and research for the efficacious promotion of healthful eating habits and increased physical activity in all children and adolescents, regardless of weight status. This is the first position paper of ADA to be based on a rigorous systematic evidence-based analysis of the pediatric overweight literature on intervention programs. The research showed positive effects of two specific kinds of overweight interventions: a) multicomponent, family-based programs for children between the ages of 5 and 12 years, and b) multicomponent, school-based programs for adolescents. Multicomponent programs include behavioral counseling, promotion of physical activity, parent training/modeling, dietary counseling, and nutrition education. Analysis of the literature to date points to the need for further investigation of promising strategies not yet adequately evaluated. Furthermore, this review highlights the need for research to develop effective and innovative overweight prevention programs for various sectors of the population, including those of varying ethnicities, young children, and adolescents. To support and enhance the efficacy of family- and school-based weight interventions, community-wide interventions should be undertaken; few such interventions have been conducted and even fewer evaluated.

Attitudes towards exercise and physical activity behaviours in Greek schoolchildren after a year long health education intervention

OBJECTIVE

To examine the short term effects of a health education programme on Greek primary schoolchildren

METHODS

The school based intervention programme was applied to 29 children in the 6th grade of the 2nd Primary School of Agios Stefanos (approximately 12,000 inhabitants); 49 pupils from the 1st Primary School constituted the control group. To assess the effectiveness of the intervention, attitude and behavioural variables were measured before and after the intervention.

RESULTS

After adjustment for initial differences in the assessed variables, pupils who took part in the intervention had more positive attitudes towards physical activity than the control group and scored significantly more highly on their intention to participate in physical activity. Moreover, pupils in the intervention group reported more hours/week spent in organised physical activities than pupils in the control group (mean (SD) 3.54 (0.32) v 2.54 (0.26), p<0.020). Finally, a higher proportion of pupils in the intervention classes matched the recommendations of 60 minutes of moderate to vigorous physical activity daily (77.4% v 55.1%, p<0.043).

CONCLUSIONS

Within the limitations of the study, the data show that school health education programmes have the potential to slow the age related decline in physical activity and help pupils establish lifelong, healthy physical activity patterns. Promoting healthy habits and physical activity behaviours during childhood may prevent some of the leading causes of morbidity and mortality in the Greek population, and also decrease direct healthcare costs and improve quality of life.

“Kids Choice” School lunch program increases children's fruit and vegetable acceptance

The "Kids Choice" school lunch program used token reinforcement, food choice, and peer participation to increase children's fruit and vegetable consumption without later drops in food preference sometimes found in past research and often called 'overjustification effects.' Participants included 188 school children (92 boys, 96 girls; mean age = 8.0; 95% Caucasian). After four baseline meals, children were randomly assigned for 12 meals to receive token reinforcement for eating either fruits or vegetables. Observers recorded fruit and vegetable consumption and provided token reinforcement by punching holes into nametags each day children ate their assigned foods, then once a week children could trade these tokens for small prizes. Fruit and vegetable preference ratings were gathered with child interviews during baseline, and during follow-up conditions two weeks and seven months after the token reinforcement program. Consumption increased for fruit and for vegetables and the increases lasted throughout reinforcement conditions. Two weeks after the program, preference ratings showed increases for fruit and for vegetables. Seven months later, fruit and vegetable preferences had returned to baseline levels, suggesting the need for an ongoing school lunch program to keep preferences high, but also showing no signs of "overjustification effects" from the token reinforcement used in the "Kids Choice" school lunch program.

Health and nutrition education in primary schools of Crete: follow-up changes in body mass index and overweight status

The current study examines the long-term effects of a school-based 'Health and Nutrition Education programme' on body mass index (BMI) changes and the prevalence of overweight. The intervention group consisted of all pupils registered in the first grade of two counties of the island of Crete in 1992, while all pupils registered in a third county formed the control group. For evaluation purposes, a representative sample was examined at baseline (1992) following the 6-y intervention (1998) and 4 y after the programme's cessation (2002). The data presented here are based on pupils with full anthropometrical data in all three examination periods (284 intervention group pupils and 257 control group pupils). Former intervention group pupils had lower average BMI (by 0.7 kg/m2, s.e. 0.28, P = 0.019) at the 10-y follow-up compared to the control group subjects, while no differences were detected in the prevalence of obesity between the two groups. The findings of the current study indicate that the beneficial effects of the programme on pupils' BMI continue, to an extent, 4 years after its cessation. However, the lack of significant differences in the prevalence of overweight between the two groups indicates that the effects of the intervention may not be equally distributed in the population, with greater effects in certain subgroups and less or none in others.

Measurement of outcomes, mediators, and moderators in behavioral obesity prevention research

BACKGROUND

Measurement enables intervention scientists to determine whether their interventions had the intended outcome effects and the expected pathways of effects across mediating variables. Low reliability of measurement (i.e., substantial random error) attenuates the relationships of these measures to other variables, including treatment effects. This attenuation may indicate that interventions were not effective, when in truth they were. There has been little assessment of the quality of measurement in obesity prevention trials.

METHOD

A brief review is provided of measurement issues within classical test theory. Seventeen obesity prevention trials were then identified in the literature. The extent to which the reliability and validity of the measures were reported in the articles was assessed.

RESULTS

With few exceptions reliability coefficients of measures were not reported in the obesity prevention literature. When they were reported, there was evidence that low reliability attenuated reported intervention outcome relationships.

CONCLUSIONS

The quality of measurement is important in intervention science and consequently should be clearly presented in scientific reports of outcomes. Better measures are needed in obesity prevention to provide appropriate tests of state of the art interventions. A brief overview is provided of each of the articles in this special issue on measurement in the Girls health Enrichment Multisite Studies (GEMS).

Comparison of the dietary intakes of two different groups of children (grades 4 to 6) before and after the Kahnawake Schools Diabetes Prevention Project

The diet of Mohawk children (grades 4 through 6) was assessed using 24-hour recalls after 4 years' participation in the Kahnawake Schools Diabetes Prevention Project. Analysis compared mean intakes of energy, fat, and sucrose, and proportions of children consuming each food. No significant difference was found in the mean intake of energy, fat, and sucrose. There was a significant decrease in the frequency of consumption of high-fat foods (P<.05) and fruits (P<.001), and a significant increase in the energy contribution of white sugar (P<.05). Results illustrate the complexity of food choices and suggest that specific nutrition education targets need to reflect newly available food-items.

Using social cognitive theory to explain discretionary, "leisure-time" physical exercise among high school students

PURPOSE

To examine whether knowledge of high school students' actions of self-regulation, and perceptions of self-efficacy to overcome exercise barriers, social situation, and outcome expectation will predict non-school related moderate and vigorous physical exercise.

METHODS

High school students enrolled in introductory Physical Education courses completed questionnaires that targeted selected Social Cognitive Theory variables. They also self-reported their typical "leisure-time" exercise participation using a standardized questionnaire. Bivariate correlation statistic and hierarchical regression were conducted on reports of moderate and vigorous exercise frequency.

RESULTS

Each predictor variable was significantly associated with measures of moderate and vigorous exercise frequency. All predictor variables were significant in the final regression model used to explain vigorous exercise. After controlling for the effects of gender, the psychosocial variables explained 29% of variance in vigorous exercise frequency. Three of four predictor variables were significant in the final regression equation used to explain moderate exercise. The final regression equation accounted for 11% of variance in moderate exercise frequency.

CONCLUSIONS

Professionals who attempt to increase the prevalence of physical exercise through educational methods should focus on the psychosocial variables utilized in this study.

Hip-Hop to Health Jr., an obesity prevention program for minority preschool children: baseline characteristics of participants

BACKGROUND

The prevalence of obesity in the United States is a significant public health problem. Many obesity-related risk factors are more prevalent in minority populations. Given the recalcitrant nature of weight loss interventions for adults, prevention of overweight and obesity has become a high priority. The present study reports baseline data from an obesity prevention intervention developed for minority preschool children.

METHODS

Hip-Hop to Health Jr. is a 5-year randomized controlled intervention that targets 3- to 5-year-old minority children enrolled in 24 Head Start programs. Our primary aim is to test the effect of the intervention on change in body mass index. Data were collected on sociodemographic, anthropometric, behavioral, and cognitive variables for the children and parents at baseline.

RESULTS

Participants included 416 black children, 337 black parents, 362 Latino children, and 309 Latino parents. Using body mass index for age and sex > or = the 95th percentile as the definition of overweight, 15% of the black children and 28% of the Latino children were overweight. More than 75% of the parents were either overweight or obese.

DISCUSSION

The development of interventions to effectively prevent or control obesity early in life is crucial. These data highlight the escalating problem of weight control in minority populations.

Health and nutrition education in primary schools of Crete: changes in chronic disease risk factors following a 6-year intervention programme

The effectiveness of a health and nutrition education programme, in changing certain chronic disease risk factors, was assessed after the 6 years intervention period was completed. The school-based intervention programme was applied to all children registered in the first grade (age 5.5-6.5 years) in 1992 in two counties of Crete, while the children from a third county served as a control group. In order to assess the effectiveness of the intervention, a variety of biological and behavioural parameters were measured before and following completion of the intervention in a randomly selected school-based sample of 602 intervention group (IG) and 444 control group (CG) pupils. At the end of the 6-year period, it was found that biochemical indices generally improved significantly more in the IG compared with the CG (mean change for IG v. CG was -0.27 v. -0.12 mmol/l for total cholesterol (TC); -0.07 v. +0.24 for TC:HDL and -0.13 v. +0.14 for LDL:HDL). Similarly, the changes observed in the anthropometric variables in the two groups were in favour of the IG (+3.68 v. +4.28 kg/m2 for BMI; +2.97 v. +4.47 mm for biceps skinfold). Total energy intake and consumption of total fat and saturated fat increased significantly less in the IG compared with the CG (+747.7 v. 1534.7 kJ (+178.7 v. +366.8 kcal); +5.9 v. +18.8 g and +0.8 v. +5.1 g respectively), while time devoted to leisure time physical activity and cardiovascular run test performance increased significantly more in the IG (+281 v. +174 min/week and +2.5 v. +1.2 stages respectively). The findings of the present study underline the importance of such programmes in health promotion and disease prevention. Although the long-term effects of these programmes can only be assessed by tracking this population through to adolescence and adulthood, these programmes seem to have the potential to lead to a healthier lifestyle and thus a reduction in risk factor levels.

The efficacy of behavioral interventions to modify dietary fat and fruit and vegetable intake: a review of the evidence

BACKGROUND

The evidence suggesting that nutrition, particularly dietary saturated fat and fruit and vegetable intake, is related to chronic disease risk has prompted considerable research on behavioral interventions focusing on dietary change. No clear understanding has emerged, however, of the degree to which these interventions can materially influence dietary change, or the types of intervention that are most effective and for whom. Therefore, the primary objective of the current study was to evaluate the overall effectiveness of behavioral dietary interventions in promoting dietary change related to chronic disease risk reduction. A secondary goal was to explore the relative effectiveness of specific intervention features and among different population subgroups.

METHODS

We conducted an evidence-based review and secondary analysis of existing literature. Our data sources included reports of randomized controlled trials and other study designs identified from multiple searches of MEDLINE, EMBASE, PsycINFO, CINAHL, AGELINE, and AGRICOLA. We included all studies on humans (including children, adolescents, and adults) published in English since 1975 that had been conducted in North America, Europe, or Australia; that had sample sizes of at least 40 subjects at follow-up; that were not based on controlled diets; and that otherwise met inclusion criteria. Through dual review, we abstracted detailed information on study characteristics, methodology, and outcomes relating to consumption of fruits, vegetables, and fats.

RESULTS

From 907 unduplicated articles originally identified, we retained 104 articles reporting on 92 independent studies. The studies were similarly successful in reducing intake of total and saturated fat, and increasing fruit and vegetable intake. More than three-quarters of the studies (17 of the 22 reporting results for fruit and vegetable intake) reported significant increases in fruit and vegetable intake, with an average increase of 0.6 servings per day. Similar consistent decreases were seen in intake of saturated fat and total fat (7.3% reduction in the percentage of calories from fat). Interventions appeared to be more successful at positively changing dietary behavior among populations at risk of (or diagnosed with) disease than among general, healthy populations. Two intervention components seemed to be particularly promising in modifying dietary behavior-goal setting and small groups.

CONCLUSIONS

The majority of the interventions reviewed resulted in meaningful improvements in dietary factors behaviors associated with the prevention of chronic disease, particularly among individuals at elevated disease risk. The lack of similarity across studies in outcome measures, study design, analysis strategy, and intervention technique hampered our ability to draw broad conclusions about the most effective behavioral dietary interventions, but our findings offer insight into intervention components that may hold promise for future research efforts.

The Team Nutrition pilot study: lessons learned from implementing a comprehensive school-based intervention

Team Nutrition (TN) is an educational and promotional initiative developed by the US Department of Agriculture to change children's eating behaviors through social marketing techniques. This article reports on the process evaluation of a TN pilot project targeting students in kindergarten to grade 4 and systematically documents the implementation experience. Even with a very short start-up period, schools implemented most components of this multichannel nutrition intervention and formed new, supportive relationships with local media and community partners. School teachers and administrators, along with foodservice professionals, generally expressed support for and satisfaction with TN, citing the positive experience and gains for students. The lessons learned from this study highlight the management and organizational issues involved in a comprehensive intervention. These include the importance of local coordinators to support and create a bridge between teachers and cafeteria staff and to forge links with key external partners. To function effectively, coordinators themselves may need training in coalition building and working with media. Relationships formed with parents, local businesses, other educational institutions, health organizations, and the media offer promise for helping to sustain nutrition education efforts. The TN process evaluation identified multiple ideas for pursuing these partnerships more successfully.

Review and analysis of evaluation measures used in nutrition education intervention research

The purpose of this review is to provide a summary of the kinds of evaluation measures used in 265 nutrition education intervention studies conducted between 1980 and 1999 and an analysis of psychometric issues arising from such a review. The data are summarized in terms of tables for interventions with each of six key population groups: preschool children, school-aged children, adults, pregnant women and breast-feeding promotion, older adults, and inservice preparation of professionals and paraprofessionals. Measures evaluating knowledge and skills or behavioral capabilities were most widely used in studies with preschool, school-aged, and inservice populations (50%-85%) and less widely used in studies with the other groups, particularly breast-feeding promotion (5%). Measures of potential psychosocial mediators or correlates of behavior such as outcome expectancies, self-efficacy, or behavioral intention were used in 90% of behaviorally focused studies with school-aged children and in about 20% of studies with adults. Dietary intake measures were used in almost all studies, primarily food recalls, records, and quantitative food frequency questionnaires. Short frequency instruments involving only foods targeted in the intervention such as fruits and vegetables are increasingly being used. Measures of specific observable behaviors are also increasingly being used. Physiologic parameters were used in about 33% of behaviorally focused interventions with school-aged children and adults, 20% with older adults, and 65% with pregnant women and/or their infants. Criterion validity of newly developed intake instruments and content validity of instruments measuring mediating variables were reported in the majority (range 50%-90%) of studies. Reliability and stability of measures of mediating variables were reported in 50% to 75% of studies, with reliability coefficients mostly about .6 to .7. Two major conclusions from this review are that evaluation measures should be appropriate to the purpose, duration, and power of the intervention and that measures should have adequate validity and reliability in relation to both the outcomes and characteristics of the target audience. Major implications are that considerable preliminary work needs to be done before any intervention study to develop and test evaluation instruments so that they are appropriate and have adequate psychometric properties, and cognitive testing of published instruments with each new target audience is essential. We will then be better able to make judgments about the effectiveness of nutrition education.

Assessing community change at multiple levels: the genesis of an evaluation framework for the California Healthy Cities Project

More than 40 cities have participated in the California Healthy Cities Project since its inception in 1988. Because Healthy Cities efforts are community driven, these cities address diverse health and social issues using a wide variety of strategies. This complexity, in addition to the usual difficulties associated with evaluating community interventions, creates many challenges for evaluation. Given the community building and process orientation of Healthy Cities, it may be most appropriate to measure intermediate community changes that have been linked to health outcomes in previous research or, at a minimum, theoretically. The California Healthy Cities evaluation framework conceptualizes change at five levels: individual, civic participation, organizational, interorganizational, and community. The framework, developed collaboratively with Healthy Cities participants, attempts to synthesize current thinking and practice on evaluation of community projects by applying concepts from community capacity/competence, social ecology, and urban planning.

Public health interventions for the prevention and treatment of obesity

Epidemic obesity is one of the few undesirable consequences of humanity's mastery of the environment. This article reviews public health approaches to preventing and treating obesity. The most encouraging efforts to date have been interventions targeting children in both medical and community surroundings. Treating and preventing obesity in adults has been less successful. It is suggested that taking an environmental health perspective on the obesity problem may facilitate the advancement of scientific understanding of this important health issue.

Child pedestrian injury prevention project: student results

BACKGROUND

Few comprehensive pedestrian safety interventions for primary-school-age children have been developed and evaluated. This paper reports the impact of the 3-year (1995-1997) Child Pedestrian In jury Prevention Project (CPIPP) on a cohort of 1603 children followed from age 6 to 9 years. This multicomponent project comprised an educational intervention for students, their parents and teachers, and the local community, as well as several environmental interventions. The primary aim of CPIPP was to improve children's road-related behavior and to enhance the safety of their road environment.

METHODS

Three communities were assigned to the treatment conditions: (1) high-education, community, and environmental interventions; (2) moderate-education intervention only; and (3) comparison (usual road safety education). Children's pedestrian knowledge and road crossing and playing behaviors were assessed using a pre- and posttest self-report questionnaire. Their self-reported road crossing behaviors were validated using an observational schedule and brief interview.

RESULTS

Children in the high and moderate intervention groups were significantly more likely to cross the road with adult supervision (P = 0.013) and play away from the road (P = 0.000) than the comparison group. No differences were detected in children's pedestrian safety knowledge between the intervention and comparison groups.

CONCLUSIONS

While several methodological limitations may have influenced the study outcomes, these data nonetheless indicate that in the study sample the CPIPP educational intervention deaccelerated the natural increase in children's pedestrian-related risk behavior.

Outcomes from a school-based nutrition education program alternating special resource teachers and classroom teachers

This study modified a successful nutrition program to improve its transferability and potential for institutionalization. Specific aims were to determine: 1) if 16 nutrition lessons taught alternately by special resource teachers (SRT) and classroom teachers, could produce outcomes equivalent to 24 SRT lessons; and 2) teachers' reactions to the program. The quasi-experimental design used classrooms (19 treatment and 19 comparison) in matched schools. Surveys and plate waste measured children's outcomes, and classroom teachers were observed and interviewed. Treatment students showed greater knowledge and self-efficacy scores and consumed 0.36 more servings of fruits and vegetables at lunch. Behavioral differences between groups were greater when SRTs provided all instruction. Teachers supported the program and anticipated teaching more nutrition on their own, but noted serious structural barriers. Findings support the need for long-term contact to induce behavior change and the advantage of using teachers specifically trained in nutrition and experiential education.

Evaluation of a health and nutrition education program in primary school children of Crete over a three-year period

BACKGROUND

No national policy for health education in schools exists to date in Greece. The first attempt to apply a school-based health education intervention program was launched in 1992 on all 4,171 pupils registered in the first grade in two counties of Crete. The 1,510 pupils registered in a third county served as controls.

METHODS

The school-based intervention and the seminars organized for parents were primarily aimed at improving children's diet, fitness, and physical activity. Pupils in the first grade in a representative sample of 40 schools were examined prior to the intervention program on a variety of health knowledge, dietary, physical activity, fitness, anthropometric, and biochemical indices. The same measurements were taken after 3 years of the program on 288 intervention group and 183 control group pupils.

RESULTS

Positive serum lipid level changes occurred to a greater extent in the intervention group than the control group. BMI increased less in the intervention group than for controls. The increase in health knowledge and physical activity and fitness levels occurred to a higher extent in the intervention group compared to controls.

CONCLUSIONS

The short-term changes observed in the present study are markedly encouraging and indicate great potential for progressive improvement. Continuation and expansion of such a program may prove to be beneficial in initiating long-term changes.