The Journal of Texas Medicine: April 2012 Texas Medicine April 2012

 Nutrition Mission: Feasibility of a Health Promotion and Education Intervention in a Houston, Texas, Elementary School (With Review of the Literature)  

 The Journal – April 2012

 Tex Med. 2012;108(4):e1.

 By Chirag B. Patel, PhD, MSE; Joshua J. Strommen, MD; Andrea M. Elliott, MD; Gaia Muallem, MD; and Mona A. Eissa, MD, MPH, PhD

 Dr Patel, Dr Strommen, Dr Elliott, and Dr Eissa, Department of Pediatrics, The University of Texas Medical School at Houston, Houston, Texas; and Dr Muallem, Department of Medicine, University of Virginia Medical School, Charlottesville, Virginia. Send correspondence to Chirag B. Patel, PhD, MSE, University of Texas Medical School at Houston, 6431 Fannin St, Houston, TX 77030; email: chirag.b.patel[at]uth[dot]tmc[dot]edu.

Grant support: Ethics in Action Grant from the American Medical Association Ethics Group. The funding organization had no role in any of the following: design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. 

None of the authors has a conflict of interest, including specific financial interests and relationships and affiliations relevant to the subject of the manuscript. 

 Abstract  

 The prevalence rate of childhood obesity in Houston exceeds the national figures. Nutrition Mission, a 14-week health promotion and education intervention, was conducted to determine its feasibility and whether it would increase the nutrition and exercise (NE) knowledge of students in an elementary school. This novel student-initiated program used 44 medical students as volunteer instructors in 3 fifth-grade classrooms in a Houston, Texas, elementary school, in which most of the 35 students were socioeconomically disadvantaged and members of ethnic minoirties. Research subjects completed pretests and posttests containing demographic, lifestyle, and knowledge-based multiple-choice questions regarding NE content. The Nutrition Mission intervention consisted of weekly programs between September 2007 and December 2007. Outcomes were measured by responses to NE lifestyle and knowledge questions. We found a significant increase in NE knowledge as a result of the intervention (68.1% compared with 78.1%, P<0.001). Subjects’ gender and ethnicity affected responses to 2 lifestyle and 3 knowledge questions. The Nutrition Mission showed that a 14-week health promotion and education intervention conceptualized and implemented by medical students is feasible and can improve elementary school students’ knowledge of NE. Future studies will include student volunteers from other health care professions and assess whether improved knowledge contributes to improved measurable health outcomes.

 Introduction

 Childhood obesity affects more than 6 million American children, and reversal of this trend is not expected in the immediate future.¹ According to the US Department of Health and Human Services, the prevalence of overweight children has tripled over the past two decades.² African-American and Latino children have higher rates of overweight and obesity than do their Caucasian and Asian counterparts.^3,4 Independent of ethnicity, low socioeconomic status has been shown to be a risk factor for obesity in young children.⁵ Interventions should be offered at an early stage because childhood obesity has been shown to be predictive of adult obesity^6,7 and, in general, early education of socioeconomically disadvantaged children has been shown to be predictive of academic, behavioral, and psychological outcomes later in life.⁸ Furthermore, complications from childhood obesity, previously considered as adult conditions, have been shown to develop at an earlier age. Overweight and obese children have higher risks for cardiovascular disease, diabetes, metabolic syndrome, being bullied, social discrimination, and psychological and other maladies.^9-13

 Numerous studies have shown that the two-pronged approach of nutrition modification and increased physical activity is a commonly employed intervention for addressing the epidemic of childhood obesity.^14-16 Despite facing financial limitations and demands of standardized testing, schools have been shown to be ideal settings in which to implement childhood obesity interventions.¹⁷ Such interventions have been shown to be further enhanced when simultaneous efforts are made to involve the student’s parents and family.¹⁸ Although a national, comprehensive approach must be implemented,¹⁹ we focused on an ethnic minority-predominant population of Houston fifth graders to assess the feasibility and effectiveness of a nutrition- and physical activity-based curriculum. The school-based health promotion curriculum was deployed over a 14-week period by medical student volunteers, and pretest and posttest evaluation of subjects’ lifestyle and knowledge regarding nutrition and exercise (NE) was performed.

 Materials and methods

 Study design 
Our nonrandomized prospective study, called Nutrition Mission (NM), used pretests and posttests flanking an intervention. The intervention was a curriculum designed to use best practices from various studies^20-23 to address childhood obesity, adapted to the needs of the target population. This study was approved by The University of Texas Health Science Center at Houston Institutional Review Board. 

 Study population 
The Houston Independent School District is the largest in Texas and seventh largest in the United States. Because the purpose of this study was to assess the feasibility and effectiveness of a nutrition- and physical activity-based curriculum in a population of ethnic minority and socioeconomically underprivileged students, it was conducted at MacGregor Elementary School (MES) in Houston, Texas. Seventy-four percent of MES students participate in the US Department of Agriculture’s reduced-price or free National School Lunch Program ( http://www.fns.usda.gov/cnd/Lunch/).²⁴ In addition to serving an ethnic minority and socioeconimically disadvantaged population, MES was chosen because of its proximity to the medical school that provided the volunteers. To ensure a high participation rate, 4 of the authors attended a MES meeting for parents before the academic year began and informed them that the study would take place and encouraged them to watch for the consent form. Parental consent forms (in both English and Spanish) were provided to the parents of all students in the 3 fifth-grade classrooms on the first day of school (via a take-home packet) and needed to be signed before the first NM session to enroll the student into the study.  

 Medical student volunteers 
Volunteers were recruited from the first- and second-year classes of students attending The University of Texas Medical School at Houston (UT-Houston). Recruitment occurred at a sign-up table during the new student orientation and publicized informational meetings for prospective volunteers. A website was created to announce events and provide information for volunteers (http://www.uth.tmc.edu/ama_tma/nutrition_mission/). Before their NM session, the volunteers met with one or two of the authors to receive an orientation that addressed any concerns or questions related to their interaction with the fifth graders. In addition, these orientation sessions ensured consistency of teaching for a given NM session by reviewing learning objectives and discussing ideas on how to present the objectives to the subjects in a fun yet memorable way. To convey the information in an age-appropriate manner, volunteers were specifically dissuaded from using formal lecture-style presentations and slide presentations. Before each session, one or two volunteers were designated as leaders for each classroom. These volunteer leaders were the primary liaisons between the authors and the other volunteers, and they were responsible for ensuring that the lessons prepared by the volunteers were feasible given the time constraints and grade level, and for gathering supplies for the session. To provide flexibility and encourage creativity, volunteer leaders were allowed to submit a budget request not exceeding $35 at least one week ahead of their NM session. On the day of the NM session, the authors provided approved supplies to the volunteer leaders.  

 Intervention  
Nutrition Mission sessions occurred eight times over the course of the 14-week curriculum (September 2007 to December 2007), as shown in Table 1. The curriculum emphasized three key areas: balanced diet using all aspects of the food pyramid; daily physical activity, either indoors or outdoors; and function and differences between macronutrients. To ensure a high quality of teaching materials, we partnered with the John P. McGovern Museum of Health and Medical Science (MHMS) to borrow teaching aids for purposes of in-class instruction. Examples of teaching aids included models of fat and muscle (to distinguish differences in density) and a 3-dimensional model of the current food pyramid (http://www.mypyramid.gov/). Throughout the 14-week intervention period, homework assignments reinforcing objectives of previous sessions were used to keep the students engaged during weeks when no NM sessions were scheduled. To ensure consistency of curricular implementation, a guide was created for the fifth-grade teachers and contained step-by-step explanations regarding the content of each NM session and the schedule of NM homework to be assigned. 

Beginning with the third NM session, the classrooms were provided with a set of light-duty sports equipment (eg, jump ropes or basketballs) for the subjects to check out and use at home for up to 1 week; this coincided with the content of the third session to teach the students creative ways to use sports equipment indoors in an effort to encourage at-home physical activity. The eighth and final session was an outdoor field day and celebration of the intervention. Activities at the field day served to reinforce concepts learned over the previous weeks. More volunteers than usual were required for the last session. The week after the last session, subjects completed a posttest to be compared  with their pretest. 

The sessions (from 2 pm to 3 pm) led into the end of the school day in each of the 3 fifth-grade classrooms, thanks to the cooperation of the teachers who were in charge of planning their students’ daily schedule. The Figure outlines the schedule of a typical NM session. Stations addressed the major learning objectives of each session: for example, during the second session on balanced meals and cholesterol, objectives included learning components of a balanced meal; how to ensure balanced meals during breakfast, lunch, and dinner; sources of cholesterol and the meaning of “good” (high-density lipoprotein) and “bad” (low-density lipoprotein) cholesterol; and the negative effects of a high cholesterol diet, such as “clogged arteries” (atherosclerosis). After consulting with their classroom’s volunteer leader(s) before the NM session, volunteers used the above mentioned resources and teaching aids to convey the learning objective at their respective stations. At the end of the NM session, the learning objectives were reiterated by the volunteer leaders. The subjects were also reminded that before the next NM session, their teachers would distribute a NM assignment reinforcing the current session’s learning objectives. 

Before and after the implementation of the NM curriculum, subjects completed a survey consisting of binary (eg, male/female, true/false) and multiple-choice questions. The surveys were administered by the MES teachers. Because the surveys were written at a grade-appropriate level and to prevent response bias across the 3 classrooms, the teachers were asked to not provide clarification to the students during the survey. The survey comprised 23 questions that were divided into three sections: demographics (2 questions), lifestyle (7 questions), and knowledge (14 questions). The demographic question regarding ethnicity specified four response options (African American, Asian, Caucasian [white], and Latino), and the subjects were instructed to choose one. Ethnicity was assessed in this study to evaluate differences in response based on this demographic factor and because of the ethnic disparity in obesity prevalence experienced by children in the age group under study. The pre-NM and post-NM survey responses were used to evaluate changes in lifestyle and knowledge as a result of the curricular intervention. 

 Statistics 
Data analysis was performed by using Intercooled Stata 9.2 (Stata Corp., College Station, Texas). The significance level was set at alpha = 0.05. Sample size calculation revealed that 30 subjects would provide sufficient power to the study (beta = 0.12) under the hypothesis of 2 additional NE knowledge questions answered correctly from pre-NM to post-NM (representing a 14.3% absolute increase) with a standard deviation of 25%. Lifestyle questions had 2 answer options, while responses for knowledge questions were coded in a binary fashion as incorrect=0 and correct=1; a two-tailed paired Student’s t test was performed to compare pre-NM and post-NM responses to lifestyle and knowledge questions. Data were stratified and analyzed by each of the subjects' gender and ethnicity to determine whether these demographic parameters affected responses to lifestyle and knowledge NE questions (two-tailed unpaired Student’s t test). At most, 3 respondents (8.6%) did not answer some questions, and these cases are noted in the data tables; paired analyses of these questions were thus performed for respondents with both pre-NM and post-NM responses.  

 Results

Of the 35 students among the 3 fifth-grade classrooms (age range: 10-11 years), 100% enrolled in the study:  51.4% of subjects were male, 60.0% were African-American, and 25.7% were Latino. A total of 44 UT-Houston medical students (25% first-year and 75% second-year) volunteered for NM. For each session, 4 to 6 medical students volunteered in each of the 3 classrooms. However, for the eighth and final session (field day), 20 medical students volunteered. 

Responses to the 7 lifestyle questions are summarized in Table 2. The percentage of subjects playing outdoors on the weekends increased significantly (P<0.0032) from before NM (51.4%) to after NM (74.3%). Responses to the 14 NE knowledge questions are summarized in Table 3. The correct response rate increased significantly from pre-NM to post-NM for 4 knowledge questions: What does a calorie measure? (28.1% to 87.5%, P<0.00001), What can you find on a food label? (71.9% to 84.4%, P<0.044), How many minutes a day should you exercise? (75.0% to 93.8%, P<0.032), and Is there such thing as good fat and bad fat? (78.8% to 97.0%, P<0.032). For the remaining questions, the correct response rate showed no significant difference between post-NM and pre-NM. The overall NE knowledge correct response rate increased significantly from pre-NM to post-NM (68.1% to 77.8%, P<0.001). No significant differences were seen in response to lifestyle and knowledge questions among the classrooms. 

Results of stratification by gender and ethnicity are summarized in Table 4. Because African-American and Latino ethnicities had a prevalence of greater than 25% each, stratification by ethnicity was performed only on these 2 ethnicities. Two NE lifestyle questions revealed differences by ethnicity. Before NM, the percent of African-American subjects who played mostly outside on the weekends was significantly greater than that of Latino subjects; after NM, the percent of respondents who played outdoors on the weekends increased in both subgroups (14.3% and 33.% absolute increase for African-American and Latino subjects, respectively), eliminating the significant difference. Although no significant disparity existed before NM, after NM the percent of African-American subjects who played on an organized team or individual sport was significantly greater than that of Latino subjects; this was attributable to a 33.3% absolute reduction in the percent of Latino subjects who responded affirmatively.  

Three NE knowledge questions showed differences by gender or ethnicity. Before NM, the percent of male subjects who knew what a calorie measures was significantly greater than that of female subjects; after NM, the percent of respondents who responded correctly increased in both subgroups (50.4% and 70.6% absolute increase for male and female subjects, respectively), eliminating the significant difference. Before NM, the percent of African-American respondents who correctly answered the question What body systems are affected by food? was significantly greater than that of Latino subjects; after NM, the disparity in correct response rate was widened (P<0.001) due to a 15.0% absolute increase in correct response rate in the African-American subgroup with no change in the Latino subgroup. Finally, although we found no significant difference before NM in correct response rate by African-American and Latino subjects to the question Which of the following builds muscle? the percent of African-American subjects who correctly answered the question after NM was greater than that of Latino subjects (P<0.0042) due to a 22.2% absolute decrease in correct response rate in the Latino subgroup with no change in the African-American subgroup. 

 Discussion

The novelty of this study stems from its medical student-driven fundraising, design, and implementation. Overall, a significant increase in NE knowledge resulted from the intervention (68.1% compared with 78.1%, P<0.001). The specific NE knowledge questions that resulted in a significant increase in correct response rate related to what a calorie measures, the contents of a nutritional label, recommendations on the number of minutes a day one should exercise, and whether there is such a thing as good fat and bad fat.

Support from the elementary school administration, teachers, and subjects’ parents was a critical factor in the 100% enrollment rate achieved in the study, which indicates the feasibility of implementing interventions such as NM. 

 School-based interventions for overweight and obese children have previously been reviewed in the literature.^25-31 Of relevance to this study, reports of elementary school-based interventions in the United States and abroad include educational, dietary, environmental, physical activity, behavior modification, and family outreach interventions that promote healthier lifestyles. It has been suggested previously that interventions should be customized to the needs of the local area.³² We designed the NM curriculum and in-school intervention to fit the needs of an ethnic minority-predominant and socioeconomically underprivileged elementary school. A review of the literature revealed other in-school interventions confronting overweight and obesity that target comparable populations. For purposes of comparison across nations, ethnic minority has been defined relative to the respective ethnic distribution in each country, while socioeconomically underprivileged has been defined as ≥50% of students participating in free lunch or reduced-price lunch programs (for studies in the USA) or another definition as specified by studies in other countries (see Appendix). 

We compared the results of this study with interventions on fourth or fifth graders that took place over a time period of at most one school semester.^33-36 As in the present study, these studies entail most of the critical components recommended for childhood obesity interventions (eg, curriculum, coordination, family/community involvement, and evaluation).^{30, 31}  

Similar to the present study, McGaffey et al targeted fifth graders in Pittsburgh, Pennsylvania, without a control arm.³³ As with NM, their intervention was primarily educational in nature; it consisted of a single 62-minute session that was implemented by a physician, professor of design, and a primary care fellow, and provided take-home materials. A 14-question survey assessing participants’ knowledge of obesity, disease, nutrition, portion size, and exercise was administered before the intervention. Immediately and 1 week post-intervention, the complete response rate increased in 10 and 11 questions, respectively. Tuuri et al targeted fourth or fifth graders in East Baton Rouge Parish, Louisiana, using a control arm.³⁴ Their intervention, similar to NM, was educational in nature; it consisted of lessons emphasizing fruit and vegetable consumption along with a wellness exhibit. The intervention was implemented by school personnel over 12 weeks. After the intervention, participants had increased nutrition knowledge and confidence in consuming fruits and vegetables.  

Goran and Reynolds targeted fourth graders in Los Angeles, California, using a control arm.³⁵ In addition to an educational component, their intervention contained a family outreach component. Over the course of 8 weeks, school personnel oversaw eight 45-minute computer-based lessons (via compact disk) and administered four 45-minute family-based assignments. The intervention resulted in reduced obesity in females, increased light-intensity physical activity in females, decreased light-activity physical activity in males, and improved outcomes with respect to the psychosocial aspects of physical activity.  

Stephens and Wentz targeted fourth graders in Cleveland, Ohio, using a control arm.³⁶ Their intervention was primarily based on physical activity (three 30-to-35-minute physical activity sessions per week) and was implemented by medical students over the course of 15 weeks. After the intervention, participants experienced improvement in flexibility, body composition, and heart rate response to submaximal exercise.  

Combined with the results of NM, these results indicate that an in-school health promotion educational and/or physical activity intervention ranging from as short as 1 hour to as long as 15 weeks can result in significant improvements in knowledge and biometrics. However, whether these improvements are sustained remains to be determined. Common themes among during-school interventions targeting ethnic minority-predominant and/or socioeconomically underprivileged elementary school students have been noted. 

A gender (knowledge: what a calorie measures) and ethnic (lifestyle: playing outside on the weekends) disparity disappeared after NM. The ethnic disparities that were maintained (1 NE knowledge question) or appeared (1 NE lifestyle question and 1 NE knowledge question) after NM raise issues regarding subpopulation cultural differences within a population of ethnic minority and socioeconomically underprivileged elementary school students.²² Although the need for gender- and culture-focused interventions has been been discussed previously,³⁵ a potential confounding factor of linguistic disparity exists but was not evaluated in this study. Despite the disproportionate rate of pediatric obesity in ethnic minority groups, the interethnic group differences must be further understood to better design interventions to reduce the overall obesity rate. Limited information in the literature precludes placing the gender and ethnic differences observed in this study into appropriate perspective.  

The nonsignificant decrease in percentage of respondents playing outside before and after NM (lifestyle question 1) may be attributable to seasonal changes. For example, a study by Cooper et al quantifying time spent outdoors and physical activity in a similarly aged cohort of English schoolchildren reported a significant decrease in the amount of time spent outdoors between the summer and winter months,³⁷ corresponding to the timeline of the NM curriculum. Although outdoor play is not the only form of physical activity, Cooper et al demonstrated a significant increase in quantifiable physical activity outdoors compared with indoors (more than 2.5-fold higher).³⁷ In regard to the nutrition and exercise survey (Table 3) question 7 about the recommended daily physical activity in children, including a fourth option (60 minutes) may have allowed for a more accurate assessment of respondent knowledge, given that this is the minimum amount of time recommended by the American Heart Association, the Centers for Disease Control and Prevention, and the US Department of Health and Human Services. 

The results of this study should be considered in the context of its limitations. First, despite the 100% enrollment rate, the sample size (n=35) was relatively small compared with other studies, precluding multivariate regression analysis to identify predictors of NE lifestyle and knowledge question responses. Second, we had no control cohort to strengthen the argument that the NM intervention alone accounted for the changes observed between the pretest and posttest questioning, given that Texas schools are required to implement some form of a coordinated school health program. Third, anthropomorphic (eg, waist-to-hip ratio and body mass index) and physiological data (eg, resting heart rate, serum lipids, and fasting blood glucose) were not collected in order to detect translation of NE education into improved health outcomes. Fourth, we found a nonsignificant reduction (P>0.15) in the correct response rate to 5 NE knowledge questions, providing valuable information to improve teaching of the NM curriculum. 

The NM program is sustainable, reproducible, and can be implemented at relatively low cost. The long-term sustainability was assured by a hand-off of program design and execution from one group of NM leaders to the next during the spring semester. To ensure sustainability, prospective NM leaders must have served as NM volunteers the previous year. This provided for baseline experience and knowledge of the NM curriculum and its execution. The reproducibility of the program by other institutions, based on the curriculum described in this manuscript, is possible once students identify the school and classroom in which the project will take place (obtaining all the necessary permissions) and identify mutually agreeable dates between the elementary school's calendar and their institution's examination schedule. Once these important steps are performed during the summer break, student volunteers should be forthcoming during the institution’s new student orientation. The NM program was executed on a $450 budget that covered costs for copying fees, flyers, and posters; light-duty sports equipment for the subjects to check out; allowance for volunteers to purchase items as part of their lesson; and food and supplies for the end-of-course field day. 

This study suggests that a 14-week health promotion and education intervention is feasible and can improve elementary school students’ lifestyle and knowledge regarding nutrition and exercise. Nutrition Mission may serve as a model for other medical schools (as well as for nursing and other schools) wishing to provide health promotion interventions in neighboring elementary schools. Future studies will investigate the inclusion of student volunteers from other health care professions and whether improved knowledge contributes to improved measurable health outcomes. An increased number of modest grants targeting childhood obesity would enable other health professions' students to implement comparable interventions. Further investigation is needed into the ethnic factors responsible for disparities in outcomes following interventions targeting pediatric obesity. 

 The ethnicity-specific differences in lifestyle and knowledge responses observed after the intervention reiterate the need for further culture-specific considerations during intervention execution and improved understanding of the role of ethnic differences in NE lifestyle and knowledge. Inclusion of anthropomorphometry and other biometrics in future studies will help determine if the changes observed here can be translated into improvements in objective indicators of health.

 Acknowledgments

The authors are grateful to Audiey Kao, MD, PhD, and Faith Lagay, PhD (American Medical Association Ethics Group), and Patricia K. Allen, EdD; Mrs. Kay Boyd, Mrs. Alisa Gans, and Mrs. Audrey Johnson (MacGregor Elementary School); Adam Benjamin and Becky Seabrook (John P. McGovern Museum of Health and Medical Science); and The University of Texas Medical School at Houston medical students who volunteered for NM.  

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7. Wright CM, Parker L, Lamont D, Craft AW. Implications of childhood obesity for adult health: findings from thousand families cohort study. BMJ. 2001;323(7324):1280-1284. 
8. Arnold DH, Doctoroff GL. The early education of socioeconomically disadvantaged children. Annu Rev Psychol. 2003;54:517-545. 
9. Lobstein T, Jackson-Leach R. Estimated burden of paediatric obesity and co-morbidities in Europe. Part 2. Numbers of children with indicators of obesity-related disease. Int J Pediatr Obes. 2006;1(1):33-41. 
10. Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics. 1998;101(3 Pt 2):518-525. 
11. Wijga AH, Scholtens S, Bemelmans WJ, et al. Comorbidities of obesity in school children: a cross-sectional study in the PIAMA birth cohort. BMC Public Health. 2010;10:184. 
12. Deckelbaum RJ, Williams CL. Childhood obesity: the health issue. Obes Res. Nov 2001;9(suppl 4):239S-243S. 
13. Lumeng JC, Forrest P, Appugliese DP, Kaciroti N, Corwyn RF, Bradley RH. Weight status as a predictor of being bullied in third through sixth grades. Pediatrics. 2010;125(6):e1301-e1307. 
14. Briggs M, Safaii S, Beall DL. Position of the American Dietetic Association, Society for Nutrition Education, and American School Food Service Association--Nutrition services: an essential component of comprehensive school health programs. J Am Diet Assoc. 2003;103(4):505-514.
15. Nicklas TA, Yang SJ, Baranowski T, Zakeri I, Berenson G. Eating patterns and obesity in children. The Bogalusa Heart Study. Am J Prev Med. 2003;25(1):9-16. 
16. Schwartz MB, Puhl R. Childhood obesity: a societal problem to solve. Obes Rev. 2003;4(1):57-71. 
17. Peterson KE, Fox MK. Addressing the epidemic of childhood obesity through school-based interventions: what has been done and where do we go from here? J Law Med Ethics. 2007;35(1):113-130.
18.  Nader PR, Sellers DE, Johnson CC, et al. The effect of adult participation in a school-based family intervention to improve children's diet and physical activity: the Child and Adolescent Trial for Cardiovascular Health. Prev Med. 1996;25(4):455-464. 
19. Hill JO, Trowbridge FL. Childhood obesity: future directions and research priorities. Pediatrics. 1998;101(3 Pt 2):570-574. 
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21. Boon CS, Clydesdale FM. A review of childhood and adolescent obesity interventions. Crit Rev Food Sci Nutr. 2005;45(7-8):511-525. 
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23. Edwards B. Childhood obesity: a school-based approach to increase nutritional knowledge and activity levels. Nurs Clin North Am. 2005;40(4):661-669, viii-ix. 
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  Appendix: Common Themes Among During-School Interventions Targeting Ethnic Minority-Predominant and/or Socioeconomically Underprivileged Elementary School Students

 Overall, common themes are evident among during-school interventions targeting ethnic minority-predominant and/or socioeconomically underprivileged elementary school students (see Appendix Table). First, the core intervention was usually educational in nature, including lecture-based lessons, interactive sessions with school personnel or volunteers, and interactive sessions with computer-based software. Interventions with a physical activity component enhanced the schools’ current physical education program, used brief (10 to 15 minutes) daily physical exercise routines, and layered considerable (~30 min) physical exercise routines on top of current physical education classes. Many of these studies used objective metrics to assess physical activity, ranging from pedometry to accelerometry to the number of yards run in 9 minutes.  

Studies investigating dietary modification (eg, encouraging low-fat milk and fruit and vegetable consumption) targeted the school meals directly by working with the cafeteria staff members and their suppliers or indirectly by using promotional and marketing campaigns (eg, thematic posters around the school) to encourage students to eat more healthfully.  

Family outreach interventions included take-home materials for parents and presentations at parent-teacher association meetings. In most studies, control populations (at the school or student level) were used to compare changes in the intervention cohort. Study duration was usually one school semester or one school year, although some studies spanned more than one school year and performed ongoing evaluation of students in comparison to baseline metrics.  

In terms of geographical location, most of the reviewed studies were conducted in the United States, while the remaining ones were conducted in Australia, Canada, or Germany. In US studies, the most frequent ethnic minorities were African-Americans and Latinos, although Asians and Native Americans were present to an extent in a few studies. Among the reviewed studies, a few stood out as being unique. One study performed an educational intervention on the primary caregivers of the students but measured the outcome (body mass index z-score) in the students.^6,7 Another study promoted water consumption to reduce the prevalence of overweight, installing water fountains as an environmental intervention.^4,5    

 Appendix and Appendix Table References

1. Chomitz VR, McGowan RJ, Wendel JM, et al. Healthy Living Cambridge Kids: a community-based participatory effort to promote healthy weight and fitness. Obesity (Silver Spring). Feb;18 Suppl 1:S45-53.
2.  Hoelscher DM, Springer AE, Ranjit N, et al. Reductions in child obesity among disadvantaged school children with community involvement: the Travis County CATCH Trial. Obesity Silver Spring). Feb;18 Suppl 1:S36-44. 
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