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Multi-Component School Nutrition Programs to Improve Nutritional Behavior & Nutritional Status of Children & Adolescents. Laurie Anderson. Agenda. Background Methods Program effectiveness intake behaviors physiologic indicators health status school achievement. Nutrition Review Team.

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

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Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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

Laurie Anderson


Agenda

Agenda

  • Background

  • Methods

  • Program effectiveness

    • intake behaviors

    • physiologic indicators

    • health status

    • school achievement


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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 PopkinUNC-Chapel Hill

Walter Willett Harvard School of Public Health


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

Nutrition Consultation Team

James W. AndersonUniversity of Kentucky

Mary B. Burdick Veterans Administration

Tim Byers University of Colorado

Susan Crockett General Mills

Adam Drewnowski University Washington

Christina EconomosTufts 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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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

Energy 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

Neurological

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

Physical

Activity

Patterns

Genetics,

Co-morbidities


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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 15/6722%

    Lipids16/6027%


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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.


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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 (n=22 studies) in a variety of settings, increase of 0.6 servings in fruit & vegetable servings/day reported


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

Nutrition Topic Under Review

Multi-component school-based interventions for improving nutrition related behavior & status of children and adolescents


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

Rationale

  • 53 million U.S. children in school 6 hours a day

  • >95% 5-17 year olds enrolled in school

  • Nutrition key for healthy growth & development

    • 79% eat <5 servings of fruit & vegetables a day*

    • 34 % kcal from total fat ( < 30% recommended)†

    • 13% kcal from saturated fat (< 10% recommended)†

      *YRBS 2001

      † USDA 1989-91 CSFII


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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 >85th percentile but <95th percentile BMI*

    • 10% are overweight >95th percentile BMI

      *CDC growth charts NCHS 2000


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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)


Research question

Research Question

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


Research question1

Research Question

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


Intervention definition

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


Educational components

  • Classroom instruction by teacher +/- nutrition education instruction

  • Physical activity incorporated into life style

  • Integrated learning (nutrition included across curricula—math, 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

Educational Components


Environmental components

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


Other components

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)


Excluded

Excluded

  • Feeding programs

  • Weight management programs for overweight children


Outcomes

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


Search results

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


Body of evidence

Body of Evidence

Identified: 46 studies described in 51 reports

Best Evidence Subset: 46 studies


Study aims

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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

CHARACTERISTICS OF STUDY POPULATIONS

  • Grades included: # studies

    K-6 : 40

    7-9: 8

    10-12: 6

  • Mean age

    10-11 years (often not reported)


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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

Interventions

Nutrition & health

messages

Promotion of

self-awareness,

self-efficacy


Behavioral outcomes

Behavioral Outcomes

Intake of Fruit and Vegetables

Intake of Fat and Saturated Fat


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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

Median effect size: All studies 6%

Studies with school menu/food choice component 11%

Intervention included school menu/food choice component


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

% 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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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)


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

Limitations of outcome measures:

  • self report

  • social desirability

  • validity of instruments


Anthropometric outcomes

Anthropometric Outcomes

BMI

Triceps Skinfold


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

Adiposity Effects: BMI %  I - % C

Age range: 9-15 yrs

11 studies reporting 16 effect measures

Program Duration

5 years

2 years

1 year

<1 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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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

boys

girls


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

Limitations of outcome measures:

  • developmental trajectories

  • accuracy of skinfold measure

  • sensitivity to detect change/ program duration sufficiency

  • intervention program intent


Health status outcomes

Health Status Outcomes

Systolic Blood Pressure

Serum Cholesterol


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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%


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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%


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

Limitations of outcome measures:

  • developmental trajectories

  • normal variability in B/P & interpretation of program effects

  • differences in cholesterol measurements


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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…………………


Modified physical education

Modified physical education

Intervention components

Modified curricula and policies

Studies designed to modify the amount of physical activity during PE

Lifetime activities and games


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

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%


Multi component school nutrition programs to improve nutritional behavior nutritional status of children adolescents

Aerobic Capacity: Modified School PE

Median=8.4%

-5%

0%

5%

10%

15%

20%

25%

30%

Net % change from baseline

Aerobic Capacity


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