Start Strong Walking and Breakfast Program

1
Start Strong Walking and Breakfast Program

• Presentation as part of
• Public Health Nutrition

2
Outline

• Background to school breakfast and walking
  programs
• Start Strong program description
• Results and discussion
• Conclusions and recommendations

3
Background
4
What is the Need for School Interventions in
Nutrition and Physical Activity?

• Past 30 years, the obesity rate for 6-11 year
  olds has tripled
• At least 15 of US children are overweight
• Childhood obesity influenced by many factors
  (IOM)
• Reduced access and affordability of nutritious
  foods in communities
• Decreased opportunity for physical activity to
  and from as well as at school
• Food insecurity
• 10 of all American children experience food
  deprivation
• Certain populations at highest risk for obesity
• Boys Hispanic-American
• Girls African-American
• Long-term health risks associated with childhood
  obesity

5
Significance of nutrition in schools

• Improvement in academic performance
• Improvement in psychosocial functioning
• Emphasis of healthy body image
• Promotion of healthy body weight
• Promotion of long-term health outcomes
• Development of optimal lifelong eating habits

6
Importance of School Breakfast- determined by
SBP data

• SBP a low-cost health intervention
• Affect of breakfast consumption on total energy
  intake
• Breakfast skippers are more likely to be
  overweight
• Higher dinner intake increases risk of overweight
• Association of food insecurity and obesity
• Decrease in overweight among food-insecure
  participants
• Affect of school breakfast consumption
• Fewer hungry children, nurse visits, disciplinary
  problems
• Improvement in academic performance, body image,
  healthy eating practices, and translates to
  better family eating habits

7
School Breakfast Program Need and Utilization

• Offered more in low-income vs. high income
  neighborhoods
• Targets groups with free/reduced cost meals
• Addresses issue of breakfast-skipping
• ¼ of students fail to eat breakfast
• Race black and hispanic adolescents highest
  rate
• Age older age groups more likely to skip
• Gender girls more likely to skip than boys

8
School Breakfast Program Barriers

• Time
• Late buses, school arrivals or long commutes
• Students not hungry in the morning
• Stigma associating the SBP with poverty

9
Importance of Physical Activity in School

• ½ of 6-17 year-olds go without daily physical
  activity
• 40 decrease in active commuting since the 1970s
• Only 5 of children walk or bike to school
• Walking or biking to school is associated with an
  average of 24 minutes of increased daily exercise

10
Physical Activity in School Associated With

• Increased physical activity outside of school
• Decreased BMI
• Decreased incidence of chronic disease
• Improved cardiovascular fitness
• Decreased TV screen-time
• Decreased consumption of high-fat snacks
• Improved academic performance

11
School Walking Programs and Active Transportation

• Improve the health and physical fitness of
  individuals
• Increase metabolism and circulation
• Decrease illness and absenteeism
• Improve concentration and learning
• Encourage an overall increase in physical
  activity
• Support the health of the community
• Limit traffic pollution and congestion
• Encourage parent/teacher involvement
• Reallocate school transportation resources

12
Utilization of Active Transportation Programs

• Demographic disparities
• Low SES is a determinant for low overall physical
  activity
• Participants of programs are more likely to have
  lower SES
• Gender differences
• Boys more active than girls

13
Barriers to Active Transportation

• Unsafe neighborhoods
• Inclement weather
• Traffic and congestion
• Lack of sidewalks and crosswalks
• Suburban sprawl

14
Start Strong Program Description
15
Purpose of Start Strong

• Start Strong is a program working to combine
  walking to school with healthy breakfasts in
  order to enhance student health and build
  community involvement in your elementary school.

16
Program Objectives

• Decrease potential for student injury
• Increase number of students walking to school
• Increase number of students consuming a healthy
  breakfast
• Improve school breakfasts

17
Logic Model
Long Term Outcomes
Intermediate Outcomes
Short Term Outcomes
Inputs
Outputs
Resources
Activities
Decreased Obesity Rates
Add to evidence base for breakfast and Walk to
School Activities
Increased of students walking to school
Grant money
Focus Groups
District Wide Policy Change
Increased participation in school lunch program
Breakfast changes District Wide
Staff
Promotions
Healthier students
Volunteers
Nutrition Ed
Increased student academic success
changes in Nutrition Services due to increased
revenue
changes in school breakfasts
Taste Tests
Great evaluation
Develop health champions within schools
Walk to School expansion
Improved knowledge
18
Program Schools

• Maple Elementary
• 64.5 participating in free/reduced program,
  12.9 breakfast participation
• Dearborn Park Elementary
• 75 participating in free/reduced program, 21.6
  breakfast participation
• Emerson Elementary
• 77 participating in free/reduced program, 46
  breakfast participation
• Wing Luke Elementary
• 72 participating in free/reduced program, 24.4
  breakfast participation
• Beacon Hill (control)

19
Intervention

• Breakfast taste tests
• Walking School Bus
• Monthly walk and breakfast promotions
• October 2006 start, planned through June 2007

20
Data Collection

• Hands-up Surveys (at Dearborn Park, Emerson, and
  Beacon Hill)
• Questions about where/if students ate breakfast
  and how they traveled to school
• Parent interviews (at Dearborn Park, Emerson,
  Maple, and Wing Luke)
• Questions about opinions on breakfast and
  walking, perceptions of program, and possible
  barriers to participation
• Teacher/staff interviews (at Dearborn Park,
  Emerson, Maple, and Wing Luke)
• Questions about perceptions of program,
  participation, and evaluation of effects

21
Analysis of Hands-Up Survey Data

• Proportion calculated for each breakfast and
  transportation category
• Used a two-sample proportion hypothesis test to
  compare each intervention school to the control
  school
• Significance was defined as a two-sided p-value
  lt.05

22
Analysis of Key Informant Interviews

• Yes/No questions analyzed quantitatively
• Qualitative questions analyzed by grouping
  answers into main themes
• Relevant responses were quoted in the qualitative
  results
• Statistical analysis could not be performed due
  to small sample sizes
• Results presented explicitly as fractions

23
Hands Up Survey Results and Discussion
24
Hands Up Student Breakfast and Transportation
Survey
Please enter the number of students who raise
their hand for each of the following
Car School Bus Walked with an adult Walked without an adult Bicycle Other

Ate breakfast both at home and school Ate breakfast just at home Ate breakfast just at school Ate breakfast somewhere else Did not eat breakfast

25
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Hands Up Survey Where did you eat breakfast
today?
Dearborn Park (n 265) Emerson (n 180) Beacon Hill(n 335)
At home and at school 38 (14) 56 (31) 31 (9)
Only at home 135 (51) 61 (34) 230 (69)
Only at school 59 (22) 52 (29) 38 (11)
Someplace else 6 (2) 6 (3) 7 (2)
No breakfast 26 (11) 5 (3) 29 (9)
Significant compared to control (plt.05)
27
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Hands Up Survey How did you get to school
today?
Dearborn Park (n 271) Emerson (n 177) Beacon Hill(n 330)
Car or carpool 119 (44) 87 (49) 181 (55)
School bus 125 (46) 65 (37) 95 (29)
Walked with an adult 11 (4) 6 (3) 34 (10)
Walked without an adult 15 (6) 17 (10) 14 (4)
Walked gt2 blocks 24 (10) 27 (15) 26 (8)
Significant compared to control (plt.05)
29
Hands Up Survey Limitations

• Unequal counts between walking and breakfast
  questions
• Some children (especially younger ones) did not
  understand the question about walking more than 2
  blocks to school
• Many classes were taking a field trip that day
• At Emerson, day care across the street affected
  childrens answers

30
Parent/Guardian Interview Results and Discussion
31
Parent Interviews

• 32 participation rate (8 of 25)
• All the parents had heard of Start Strong
• 7 of 8 had met other parents
• 6 of 8 had met teachers
• 5 of 8 had helped with nutrition homework

32
Parent Responses - Breakfast

• Eating breakfast is very important to all the
  parents
• 3 of 8 have children eating breakfast at school
• 5 parents knew that parents can come to school
  breakfast, but only 3 have done it
• Half the parents like the breakfast served
• Half the parents think communication has improved

33
Qualitative Breakfast Data

• Breakfast is important
• Provides energy
• Improves learning
• 1st meal of the day
• Breakfast at home
• Family eats together
• Late bus arrival
• Food isnt good enough at school

34
How to Improve Breakfast Participation

• Parents would participate if
• More nutritious food
• More organic food
• Better quality food
• Dont participate because
• Time constraints
• Lack of trust

35
Parent Responses - Walking

• All the parents support the walking program
• 3 of 8 parents said their children walk to school
  and 2 responded that they sometimes walk
• All the parents think the walking program is safe
• Results were mixed if it improves communication
  (5 of 8 said yes)

36
Qualitative Responses - Walking

• Parents think walking is important for themselves
  and their children
• They think walking
• Encourages socialization
• Benefits health
• Improves concentration
• More students walk to school when it is Walking
  Wednesday

37
Barriers to Walking Participation

• Distance Biggest barrier
• Safety
• Weather
• Lack of sidewalks and construction

38
Parents Suggestions

• All would like to participate
• Ride the bus with child
• Designate a point to drop off children at the
  walking school bus
• Better communication with promoters of the
  program
• Better communication between parents
• Parents need more time to participate

39
Limitations

• Low participation because of non-response
• Possibility of misinterpreting questions
• Disconnected numbers
• Short timeframe for conducting interviews
• Questions were sometimes vague and confusing to
  the parents

40
Teacher/Staff Interview Results and Discussion
41
Teacher/Staff Interviews

• 48 (17/35) staff members participated in survey
• Of those who participated in survey
• All 17 were familiar with the program
• All 17 had students participate in the program
• All 17 believed the program was beneficial for
  students
• 13 conducted classroom interventions on health,
  nutrition, and/or exercise
• 7 had parents/guardians involved in students
  class work

42
Teacher/Staff Responses - Breakfast

• 12 of 17 thought parents were participating
• 5 of 17 thought that communication was improved
  with parents
• 10 of 16 thought students knowledge of healthy
  eating changed
• 9 of 17 thought students attitude towards
  breakfast eating had changed
• 12 of 17 thought students doing better
  academically because of breakfast

43
Qualitative Breakfast Data

• Kids liked the taste tests
• More likely to try new foods introduced
• Enjoy variety
• New foods healthier
• Kids eat more fruit when it is offered
• Kids more alert when eat breakfast
• Kids more aware of what healthy eating means

44
How to Improve Breakfast Participation

• Implement more frequent taste tests
• Getting kids back to class on time
• Permanent nutrition program aside from PE
  instruction

45
Teacher/Staff Responses - Walking

• 7 of 17 thought it improved school communication
  and trust
• 9 of 15 believed the walking program is safe
• 12 of 17 believed students more aware of health
  benefits of walking
• 7 of 17 believed students attitude towards
  walking had changed
• 4 of 17 thought children doing better academically

46
Qualitative Walking Data

• Parent participation declined in the winter
• More opportunities to interact with parents
  during a walk
• Making a connection is hard
• Program is too small to make a difference
• Kids are excited about the program
• Prizes and incentives help
• Program considered safe with adult supervision

47
How to Improve Walking Participation

• Staff participation is currently keeping the
  walking program afloat
• Get more parents to participate
• Staff is overburdened and want this to be
  parents responsibility

48
Barriers to Walking Participation

• Bad weather
• Lack of crosswalks
• Lack of neighborhood street safety
• Confusion about responsibility
• Too much burden placed in teachers
• Too much burden/expectation placed on adults who
  volunteered at the start

49
Teacher/Staff Suggestions

• Use school assemblies for nutrition ed
• Receive materials from Start Strong to build a
  curriculum
• Sending letters home ineffective
• Materials should be multilingual
• Dedicated trails contribute to safety and ease
• More incentives

50
Limitations

• 52 of staff members did not participate
• Scheduling conflicts
• Feeling they had nothing to contribute
• More staff than teachers interviewed
• Questions about academic performance not relevant
  to all interviewed
• Difficulty in assessing cognitive improvement
  from breakfast

51
Discussion
52
Discussion of Limitations

• Ideal study design would be an RCT
• Assumption that control and intervention schools
  were identical in
• Student populations
• Family SES
• Surrounding physical environments
• Limited timeframe for conducting
• Hands-up surveys
• Key informant interviews

53
Potential Sources of Error

• Observers not blinded toward control or
  intervention schools
• Self-reported data
• Students may not have understood survey questions
  
• Parents may not have understood questions
• Self-selection of key-informant interviewees

54
Conclusions and Recommendations
55
Conclusions

• Start Strong program positively impacts
• Students breakfast consumption habits and
  attitudes toward healthy eating
• Students attitudes toward walking to school
• Built environment must be conducive for students
  to walk to school (weather, distance, safety,
  cross-walks)
• Further research required to determine the impact
  of this program on the community
• Research will help support school policies and
  programs that can further positively impact the
  healthy eating behavior and physical activity of
  children

56
Recommendations Future Research

• Establish larger sample sizes
• Collect data at multiple time points
• Longer timeframe for data collection
• Consideration of weather and distance in
  assessing feasibility of walking programs

57
Recommendations

• Improve teacher/staff and parent participation
• Offer more opportunities for incentives
• Clarify roles for teachers/staff and parents
• Improve communication
• Relationship-building opportunities
• Implement walking program during a warmer season
• Create drop-off points for walking school bus
• Conduct school bus weekly rather than monthly

58
Acknowledgments

• Donna Johnson
• Mary Podrabsky
• Katie Busby
• Mollie Greves
• Kirsten Frandsen

59
Questions?
60
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