Multi-Component School Nutrition Programs to Improve Nutritional Behavior

1

• Multi-Component School Nutrition Programs to
  Improve Nutritional Behavior Nutritional Status
  of Children Adolescents

Laurie Anderson
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Agenda

• Background
• Methods
• Program effectiveness
• intake behaviors
• physiologic indicators
• health status
• school achievement

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Nutrition Review Team
Jonathan Fielding Community Guide Task
Force William Dietz CDC NCCDPHP
DNPA Jay Hirschman USDA Food and
Nutrition Services Charlotte Neumann UCLA
Maternal Child Nutrition Mary Frances Piccano
NIH Office of Dietary Supplements Barry
Popkin UNC-Chapel Hill Walter Willett
Harvard School of Public Health
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Nutrition Review Staff
Laurie Anderson Community Guide Branch
Lynne Smith Community Guide
Branch Study
Abstractors Carolynne Shinn Brandeis
University Elizabeth Fiddler University of
Washington Karin Johnson Fred Hutchinson
Cancer Research Victoria Warren-Mears Oregon
Health and Science Univ. Technical Analytic
Support Susan Norris CDC NCCDPHP
DDT Xuanping Zhang CDC NCCDPHP DDT

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Nutrition Consultation Team
James W. Anderson University of Kentucky Mary B.
Burdick Veterans Administration Tim Byers
University of Colorado Susan
Crockett General Mills Adam Drewnowski
University Washington Christina Economos Tufts
University Diane Finegood Canadian
Institute of Nutrition, Metabolism and
Diabetes Karen Glanz Emory
University Beverly Green Group Health
Cooperative Ellen Harris USDA
Richard Harvey Veterans Administration

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Consultation Team (Cont.)
Greg Heath CDC NCCDPHP DNPA Lori
A. Kaley Maine Nutrition Network
Shiriki K. Kumanyika University of
Pennsylvania Ester Myers American Dietetic
Association Ike Okosun Mercer
University Gretel Pelto
Cornell University James Sallis San
Diego State University Howell Wechsler CDC
NCCDPHP DASH  Curt Weidmer
California DHS
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LOGIC FRAMEWORK NUTRITION COMMUNITY HEALTH
Intermediate Outcomes
Modifiable Determinants
POPULATION FOOD INTAKE Food
Consumption Patterns (e.g.
fruits, vegetables) Intake of Nutrients and Food
Components Vitamins Minerals Fiber Fats Other
food constituents Dietary supplements Alcohol Ener
gy balance
Food Supply Factors -Agriculture
policy -Nutrition policy -Science and technology
-Food production, processing, storage and
distribution -Food fortification -Food safety
Physiologic Indicators Growth Adipose
tissue Musculoskeletal Gastrointestinal Metabolic
Cardiovascular Reproductive Immunological Neurolog
ical
I N T E R V E N T I O N S
Community Health Outcomes
Environmental Factors Food
Availability Price -Neighborhoods -Schools
-Worksites -Homes -Local, state national
food assistance programs

• Morbidity
• Mortality
• Measures of
• Health Fitness
• Quality of Life

Life Stage Requirements Pregnancy Lactation
Childhood Adolescence Adulthood
Older Adulthood
Consumer Demand -Household
resources -Nutrition knowledge -Cultural
practices -Psychosocial characteristics
-Taste and preferences -Advertising and
marketing
Genetics, Co-morbidities
Physical Activity Patterns
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Priority Ranked Topics

• Food beverage availability in schools
• Comprehensive community approaches to increase
  fruit vegetable intake
• Food and beverage advertising to children
• Food beverage availability, price, portion
  size, and labeling in restaurants

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Other Systematic Reviews of School-based
Nutrition Interventions

• Resnicow 1997
• 16 school-based CVD trials, computed
• ratio of to effects based on p values
• Diet outcomes 35/141 25
• Adiposity 7/77 9
• Blood pressure 15/67 22
• Lipids 16/60 27

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Other Systematic Reviews of School-based
Nutrition Interventions

• Campbell 2001
• 10 studies of obesity prevention ( 8 in schools
  or nursery schools)
• Concluded there was limited quality data on
  effectives of obesity prevention programs and no
  generalizable conclusions could be drawn.
• They suggest strategies to reduce sedentary
  behavior and increase physical activity may be
  fruitful.

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Other Systematic Reviews of School-based
Nutrition Interventions

• EPPI Center 2001 Systematic review of research
  on barriers to healthy eating, children aged11 to
  16
• 22 intervention studies identified but only 7
  studies provided
• impact of intervention for all outcomes
• equivalent study groups at baseline
• report both baseline and follow up data
• post intervention data on all study groups
• Conclusion insufficient quality research

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Other Systematic Reviews of
School-based Nutrition Interventions

• Ammerman 2002 Efficacy of behavioral
  intervention to modify dietary fat and fruit and
  vegetable intake
• School setting (3 studies)
  pooled mean diff in change fat as kcal
  2.19 (1.49 2.89) greater decrease
• Among children and adults combined (n22
  studies) in a variety of settings, increase
  of 0.6 servings in fruit vegetable servings/day
  reported

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Other Systematic Reviews of
School-based Nutrition Interventions

• Kristjansson B. 2002 protocol for effectiveness
  of school feeding programs for low-income
  children to reduce disparities in
• nutrient intake
• nutritional status
• cognition
• school attendance
• performance
• In progress

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Nutrition Topic Under Review  Multi-component
school-based interventions for improving
nutrition related behavior status of children
and adolescents
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• Rationale

• 53 million U.S. children in school 6 hours a day
• gt95 5-17 year olds enrolled in school
• Nutrition key for healthy growth development
• 79 eat lt5 servings of fruit vegetables a day
  
• 34 kcal from total fat ( lt 30 recommended)
• 13 kcal from saturated fat (lt 10 recommended)
• YRBS 2001
• USDA 1989-91 CSFII

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• Rationale

• Dietary and physical activity patterns in
  childhood associated with adult health status
• In US other countries rates of overweight and
  obesity in children adolescents have increased
• 14 at risk for overweight
  gt85th percentile but lt95th percentile
  BMI
• 10 are overweight
  gt95th percentile
  BMI
• CDC growth
  charts NCHS 2000
  

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• Rationale

• More recently in children are increased rates of
  hyperlipidemia, hypertension, and type 2
  diabetes, previously limited to adults
• Obesity typically persists from childhood
  adolescent into adulthood
• U.S. obesity-attributable medical expenditures
  reached 75 billion in 2003 (Finkelstein 2004)

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Research Question

• Do multi-component, school-based nutrition
  interventions improve nutritional behavior and
  nutritional status of children and adolescents?

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Research Question

• Do multi-component, school-based nutrition
  interventions improve nutritional behavior of
  children and adolescents?

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Intervention Definition

• School-based nutrition interventions are
  implemented in the school settings to promote
  healthy nutritional attitudes, knowledge and
  behavior, including eating and physical activity
  among school-aged children and adolescents.
• target food policy, environmental factors and/or
  nutrition education
• school administrators, food service staff,
  teachers or parents or directly to students
• delivered by regular classroom teachers or by
  special program instructors

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Educational Components

• Classroom instruction by teacher /- nutrition
  education instruction
• Physical activity incorporated into life style
• Integrated learning (nutrition included across
  curriculamath, writing, social studies, etc)
• Media literacy and consumer education
• Food gardening, food prep, cooking
• Self-evaluation (diet evaluation, food records)
  for middle and high school ages
• Food service staff training
• Peer training

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Environmental Components

• Time and place for school meals, snacks
• School resources for food prep and service
• Media messages posters, school intercom, radio,
  etc.
• Social marketing
• School menus/pricing, a la carte
• Vending machines/contents and pricing (junk food
  tax)
• Classroom snacks and special treats
• Food as rewards (reading programs, good behavior)
• Fund raising activities for school groups

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Other Components

• Policy, stake holder participation in planning
  decision making
• Government policies
• School board
• Principals
• Food service
• Parents, teachers
• Kids
• Parent/family education and involvement
  (newsletters, family fun activities)
• Community (community centers, grocery stores)

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Excluded

• Feeding programs
• Weight management programs for overweight
  children

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Outcomes

• Nutrition knowledge attitudes
• Dietary behavior
• fruit vegetable intake, fat intake
• Physical activity
• Physiologic indicators
• BMI, weight percentile, obesity prevalence
• Skinfold thickness
• Health status
• blood pressure, plasma cholesterol

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Search Results

• Literature search
• 1980-2003, publications, dissertations,
  government reports, US non-US
• 1500 abstracts, 150 papers, 76 studies
• dual abstraction completed on 76 studies
• 13 studies did not meet inclusion criteria
• 14 studies (22) excluded due to limitations
• in quality
• 51 reports of 46 studies

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Body of Evidence
Identified 46 studies described in 51 reports
Suitability of Study Design Suitability of Study Design Suitability of Study Design
Execution Greatest Moderate Least
Good (0-1 limitations) 2 0 0
Fair (2-4 limitations) 40 4 5
Limited (5 limitations) 10 0 4
Best Evidence Subset 46 studies
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Study Aims
25 Cardiovascular disease risk reduction 16
Healthy diet 8 Cancer risk reduction 2
Obesity prevention 1 Diabetes risk
reduction 2 CVD cancer risk
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CHARACTERISTICS OF INTERVENTIONS
32 Curriculum Behavioral Awareness 10
Curriculum Behavioral Awareness Environment
16 Curriculum Behavioral Awareness
Home/Family 15 Curriculum Behavioral Awareness
Physical Activity 5 Curriculum Behavioral
Awareness Physical Activity Home/Family 6
Curriculum Community 10 Curriculum
Peer/Social Support 14 Curriculum Environment
16 Environment School Menu/Pricing
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CHARACTERISTICS OF STUDY POPULATIONS

• Grades included studies
• K-6 40
• 7-9 8
• 10-12 6
• Mean age
• 10-11 years (often not reported)

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OUTCOMES REPORTED
Behaviors dietary intake 40 physical
activity13
School Policy
Environmental support for healthy choices
Knowledge 25 nutritional needs food
content Attitudes 13 self-care body
image Abilities 5 self-assessment behavioral
change skills media literacy

Physiologic 16 Indicators body size
composition growth fitness Health status 12
blood pressure cholesterol general
health School Achievement attendance
participation performance social behavior
Multi-component School-based Nutrition Interventio
ns
Nutrition health messages
Promotion of self-awareness, self-efficacy
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Behavioral Outcomes

• Intake of Fruit and Vegetables
• Intake of Fat and Saturated Fat

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Fruit Vegetable Intake Effects ? I -
? C
Program Duration 2 years 1 year 2-3
months
11 studies reporting 14 effect measures
Resnicow 1992 Nicklas 1998 Gortmaker
1999 Gortmaker 1999b Sahota 2001 Birnbaum
2002 Stewart 1997 Perry 1998 Fries 2001 Friel
1999 Reynolds 2002
2
Intervention included school menu/food choice
component
Median effect size All studies 6 Studies
with school menu/food choice component 11
34

• kcal from Fat Intake Effects ? I - ?
  C

Nader 1999 Walter 1988 Lytle 1996 Perry
1998 Reynolds 2000 Gortmaker 1999 Gortmaker
1999b Ellison 1990 Vandogen 1995

Self-report
Observed
Median effect size -6
Boy
Girl
9 studies reporting 12 effect measures
35
Other Fat Intake Effects ? I - ? C
10 studies reporting 13 effect measures
Birnbaum 2002 Resnicow 1995 Davis 1995 Turin
2001 Holcomb 1998 Sallis 2003 Manios
1999 Steward 1997 Fries 2001 Simmons-Morton
1991
Self-report high fat foods
Observed
Median effect size -2.5
Boy
Girl
36
Saturated Fat Intake Effects ? I - ? C
Absolute Mean Difference
Vandongen (1995) girls, boys Walter
(1988) Brx, Wch Bush (1989) Reynolds
(2000) Gortmaker (1999b) Ellison (1990)
girls,boys Perry (1998) Lytle (1996) Manios (1999)
37

• Polyunsaturated/ Saturated Fat Ratio ? I - ? C

Absolute Mean Difference
Manios Walter Brx, Wsch Vandongen
girls Vandongen, boys Ellison girls, boys
2
2
4 studies reporting 15 effect measures
38

• Limitations of outcome measures
• self report
• social desirability
• validity of instruments

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Anthropometric Outcomes

• BMI
• Triceps Skinfold

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Adiposity Effects BMI ? I - ? C
Age range 9-15 yrs
11 studies reporting 16 effect measures
Program Duration 5 years 2 years 1 year lt1
year
Walter 1999 Nader 1999 Bush 1989 Sallis
2003 Tell 1987 Sahota 2001 Vandogen 95 Stewart
1997 Harrell 1999 Killen 1988 Hoper 1996
2
9
Median Effect Size All studies 0 Boys
-2.7 Girls -0.3
Boy
Girl
Boys Girls
no physical activity component
41

• Adiposity Effects Triceps Skinfold ? I -
  ? C

8 studies reporting 12 effect measures
(Age)
Goldberg 1980 (8) Nader 1999 (9) Bush
1989 (10.5) Tell 1987
(11) Vandongen 95 (11) Harrell 1999
(8.9) Killen 1988 (15) Hopper 1996
(10.5)
Median Effect Size All studies 0 Boys
4.3 Girls -5.4
Boy
Girl
Boys Girls
no physical activity component
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Adiposity Effects Triceps Skinfold ? I - ?
C
Absolute Mean Difference
girls
boys
Bush 89 Harrell 99 Killen 88 Goldberg 80 Tell
97 Vandongen 95 girls Vandongen 95 boys
girls
boys
43

• Limitations of outcome measures
• developmental trajectories
• accuracy of skinfold measure
• sensitivity to detect change/ program duration
  sufficiency
• intervention program intent

44
Health Status Outcomes

• Systolic Blood Pressure
• Serum Cholesterol

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Health Effects Systolic B/P ? I - ? C
10 studies reporting 16 effect measures
Program Duration 5 years 2 years 1 year 2
months
Walter 1988 Resnicow 92 Nader 1999 Goldberg
1980 Bush 1989 Vandongen 95 Stewart 1997 Harrell
1999 Killen 1988 Tell 1987
10 studies reporting 16 effect measures
Median effect size 0.3
46
Health Effects Systolic B/P ? I - ? C
Bush Harrell (risk, ed PA) Killen (girls,
boys) Nader Stewart Vandongen, boys Vandongen,
girls Resnicow (hi, med, lo) Goldberg
8 studies reporting 30 effect measures
47
Health Effects Serum cholesterol ? I -
? C
11 studies reporting 14 effect measures
Program Duration 5 years 2-3 years 1
year 2-3 months
Walter 1988 Webber 1996 Resnicow 1992 Goldberg
1980 Nader 1999 Bush 1989 Tell 1987 Vandongen
1995 Stewart 1997 Gans 1990 Harrell 1999
Median effect size -3
48
Health Effects Serum cholesterol ? I - ? C
Harrell 99, risk, ed PA Bush 89 Gans
90 Goldberg 80 Resnicow 92 Tell 97 Vandongen 95,
boys Vandongen 95, girls Walter 88, Brx,
Wsch Webber 96

• 9 studies reporting 21 effect measures

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• Limitations of outcome measures
• developmental trajectories
• normal variability in B/P interpretation of
  program effects
• differences in cholesterol measurements

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Multicomponent School-based Nutrition
Interventions Increase Fruit and Vegetable
Intake and Decrease Intake of Fat and Saturated
Fat in School Age Children

• There is sufficient evidence to conclude that
  multicomponent school-based nutrition
  interventions are effective in ..
• magnitude of program effect differed by

51
Modified physical education

• Intervention components
• Modified curricula and policies
• Studies designed to modify the amount of physical
  activity during PE
• Lifetime activities and games

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In-school Physical Activity Modified School PE
-20
0
20
40
60
80
100
120
140
Net change from Baseline
MVPA (m/w)
class MVPA
Energy expenditure
Median 50.3
Median 10
53
Aerobic Capacity Modified School PE
Median8.4
-5
0
5
10
15
20
25
30
Net change from baseline
Aerobic Capacity