Issues in Comprehensive Pediatric Nursing, 2015; 38(1): 22–38 ß Informa Healthcare USA, Inc. ISSN: 0146-0862 print / 1521-043X online DOI: 10.3109/01460862.2014.973081
IMPLEMENTATION OF AN AFTER-SCHOOL OBESITY PREVENTION PROGRAM: HELPING YOUNG CHILDREN TOWARD IMPROVED HEALTH
Laura Nabors, PhD1, Michelle Burbage, MS1, Kenneth D. Woodson, MPh1, and Christopher Swoboda, PhD2 1 School of Human Services and 2School of Education, College of Education, Criminal Justice and Human Services, University of Cincinnati, Cincinnati, Ohio, USA
Obesity prevention programs that are delivered in after-school programs are needed as a focus on curriculum can make it difficult to include this health programming during the school day. The current study examined the implementation of 2 pilot programs in different after-school programs for young children. There were 36 children in the intervention groups and 18 children in comparison groups. Children learned about healthy eating and increasing involvement in physical activity. Lessons were based on the Traffic Light Diet. Results indicated improvement in children’s reports of their eating habits. Activity levels improved in 1 school, but not in the other. Parents and children were satisfied with the program and children demonstrated good knowledge of the interventions to promote healthy eating. Future studies should include larger sample sizes and evaluation of the effectiveness of different components of the intervention. Nurses can play a key role in disseminating information and designing and leading after-school programs to improve child knowledge about healthy eating and exercise. Nursing students may also benefit from assisting with conducting these types of programs to improve their experience in health prevention programming. Keywords: After-school, eating program, healthy
Received 16 July 2014; revised 1 October 2014; accepted 1 October 2014
Correspondence: Laura Nabors, Ph.D., Mail Location 0068, School of Human Services, CECH, University of Cincinnati, Cincinnati, Ohio 45221-0068. Email: naborsla@ucmail. uc.edu
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INTRODUCTION Over the last few decades, the number of obese youth in America has been steadily increasing. Over the past 30 years childhood obesity has doubled and in 2010 more than one third of children in the United States were obese (Centers for Disease Control [CDC], 2013). With childhood obesity becoming a national epidemic programs to prevent obesity and encourage healthy lifestyles through improved eating and exercise habits are needed (Davis et al., 2007). Riggs, Sakuma, and Pentz (2007) proposed that promotion of healthy lifestyles, eating, and exercise is needed in order to reduce obesity rates in children. School-based prevention programs can be a way to teach children how to maintain a healthy lifestyle (CDC, 2013; Kropski et al., 2008). However, the importance of addressing academic issues can leave little time to implement prevention programs during the school day (Amis et al., 2012; Dzewaltowski et al., 2010). After-school programs provide another outlet for implementing obesity prevention programs in schools. There is the potential to reach many children, as 8.4 million children grades K–12 attend after-school programs and 18.5 million stated they would attend an after-school program if available in their area (Afterschool Alliance, 2013). This outlet is an understudied area for programming and adding health education to after-school programming is an important way to provide critical health education, in an era where this information might not be available in health education during the school day as a focus is often on academic material. Our obesity prevention program was adapted from the Traffic or Stop Light Diet developed by Leonard Epstein (Epstein, 2005; Epstein & Squires, 1988). The Traffic Light program has an evidence base for weight loss and lifestyle change through teaching healthy food and beverage choices to obese and overweight children (e.g. Epstein et al., 2012). Foods are coded as ‘‘red’’ or ‘‘stop’’ foods, ‘‘yellow’’ or ‘‘cautionary’’ foods, and ‘‘green’’ or ‘‘go’’ foods. Increasing physical activity levels is a critical component of the Traffic Light Program. The Traffic Light Program also emphasizes increasing daily physical activity. This is critical, as exercise is a primary intervention to prevent obesity in children (Dotterweich et al., 2012; Epstein et al., 2000; Stice et al., 2006). For this project, children also had individual coaching to enhance their attainment of healthy eating and exercise goals that they selected. A modified version of the Traffic Light Program was implemented during the school day and had positive impacts on child healthy behaviors (Scheztina et al., 2009, 2011). Our research team has implemented the program during summer programs with urban youth, who benefitted from participating in the program, in terms of improving
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their eating behaviors (Nabors et al., 2013). The current study extended knowledge by using motivational interviewing and implementing a modified version of the Traffic Light Diet, with emphasis on ‘‘red’’ and ‘‘green’’ foods with very young elementary school age children attending two different after-school programs. It is critical to understand whether evidence-based interventions, such as the Traffic Light Diet can be disseminated in novel settings, with children in the general population, as was the case for the current pilot studies. Coaches used motivational interviewing (MI) to assist and encourage each child when developing his or her weekly healthy eating and exercise goal. MI is a promising teaching and counseling technique in health promotion interventions for primarily older children and adolescents (Suarez & Mullins, 2008). The current study implemented this technique with an understudied group, which is young children (Erickson et al., 2005; Martins & McNeil, 2009). MI has been utilized in interventions with overweight and obese children (e.g. Resnicow et al., 2006; So¨derlund et al., 2009), but not as part of preventive interventions with young children who were not obese, as was the case for the current study. A pilot project for the CHEE program was implemented in two summer programs for younger (elementary school age) and older children (high school age) residing in an inner city, community (Burbage et al., 2013; Nabors et al., 2012). A manual was developed to review key concepts related to eating more green foods (e.g. fruits and vegetables) and fewer yellow and red foods (e.g. sweets, snacks, and desserts) as well as increasing levels of physical activity on a daily basis. Children participated in games and art activities, such as developing commercials and building games to encourage and educate about healthy eating to improve knowledge about eating higher numbers of green and fewer red foods. Children engaged in activities at each session and also discussed the importance of engaging in 30 minutes of physical activities on a daily basis (CATCH Physical Education; Kelder et al., 2003; Obama, 2010). Results indicated that participation in this program resulted in reduced consumption of French fries and chips for younger children and increased consumption of vegetables for older youth. Children and adolescents reported that they were satisfied with the program. Irrespective of their age, children had difficulty understanding the concept of yellow foods, and thus education focused on enhancing understanding of red and green foods for the current study. The current project also targeted younger children, added a comparison group, and evaluation of parent perceptions of the program. The aims of the current study were to describe the implementation and evaluation of the CHEE with younger children in after-school programs. Our specific objectives
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were to describe the implementation of the program in two different settings and to investigate whether children reported change in their knowledge about healthy eating and reported change in their eating and exercise behaviors after participating in the healthy eating and exercise sessions. METHOD Participants Children were recruited from those attending after-school programming at two different schools. The after-school programs at both schools had components focusing on academics, with tutoring to help children complete their homework. Children could select from different after school groups. Children in the intervention groups selected to participate in the CHEE program, whereas children in the comparison groups were participating in other after-school groups, such as yearbook development (scrapbooking) and young scientists (developing science projects). A university-based institutional review board approved this program evaluation project, and parent permission and child assent were required for participation in lessons for the project as well as for completion of surveys for this project. School 1 There were 17 children in the intervention group, including 9 boys and 8 girls (M ¼ 6.12, range 4–7 years). Fourteen of the children were African-American, 1 was Caucasian, 1 was Hispanic, and 1 was biracial. Eleven parents or guardians (5 mothers, 3 fathers, and 3 legal guardians) completed surveys to evaluate our program. There were 3 boys and 3 girls in the comparison group, 5 were African American and 1 child was biracial (M ¼ 6.5, range 5–9 years). School 2 There were 29 children in the intervention group, 21 were boys and 8 were girls (M ¼ 6.62, range 5–9 years). Twenty-one of the children were Caucasian, 5 were African-American, and 3 were biracial. Nine mothers, 2 fathers, and 2 legal guardians completed surveys. There were 12 in the comparison group, 6 males and 6 females (M ¼ 6.83, 5–9 years). Procedures and Description of the Intervention Five undergraduate students and one faculty member implemented the CHEE Program. Children were interviewed to complete brief surveys
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assessing their perceptions of their eating and exercise during the first group. Questions included requesting children to identify the number of fruits, vegetables, sweets, and chips/fries they had consumed ‘‘yesterday.’’ Weekly sessions at both schools focused on discussing red and green light foods and the importance of exercise. Table 1 presents a review of the lessons delivered at School 1. Eight sessions were delivered at School 1 and exercise occurred in the classroom on days where the class was not able to use the playground. Healthy eating activities focused on learning about red and green foods and eating a higher number of green than red foods. Children discussed eating fewer unhealthy foods, such as chips and cake and learned about healthy meals. Children worked weekly with a coach to discuss healthy eating and exercise. Each week they selected one healthy eating and one exercise goal which they would work to achieve at home. The following week the child would rate his or her progress toward each goal. Thirteen sessions were delivered at School 2. Sessions were held in the school gymnasium and there was time for exercise every class period. Table 2 presents the healthy eating and exercise activities conducted at School 2. Similar to lessons at School 1, Children and their group leaders discussed the importance of reducing intake of red foods, such as sweets and fried foods on a weekly basis. They reviewed the importance of consuming at least 4 green foods for every red food. During lessons, children also learned about the importance of daily physical activity and participated in organized activities in the gymnasium every class. Children also completed individual, weekly sessions with a coach to encourage them to achieve one healthy eating and exercise goal. At both schools, children participated in goal-setting with a coach. At the start of the session, coaches reviewed the child’s progress toward the previous week’s goals on 4-point Likert scales from poor (1) to very good (4). Then, each child selected one new healthy eating and exercise goal to work on at home for the upcoming week. Coaches emphasized self-efficacy for reaching goals and discussed the children’s ideas for being successful in reaching their new weekly goals at each meeting. Empathy was used if the child had reasons for not reaching goals set in the previous week. Parents received handouts with information about red and green foods and recipes for cooking healthy entrees, snacks, and desserts. Parents completed brief surveys to examine their satisfaction with the program and to assess whether they were receiving and using healthy eating recipes.
Began goal-setting, with selection of a healthy eating and a healthy exercise goal. Discussed the importance of reducing red foods in daily diet. Created stop light poster, and children discussed what foods were green and red foods. Also learned healthy exercises to do while watching TV. Reviewed food groups using food pyramid and My Plate. Practiced making healthy meals according to My Plate using play foods. Review of goal-setting progress with coach and development of new goals for the coming week. Completed healthy refrigerator exercise where children drew what was in their refrigerator and discussed what healthy foods could be added. Drew examples of healthy meals that were loaded with fruits and vegetables.
#3
#4
#2
Pre-intervention survey was completed. Introduced ideas about green (fruits, veggies) and red foods (not healthy for you, such as cake) and used play foods to illustrate green and red foods. Drew pictures of favorite foods. Talked about how exercise is fun and an important daily activity. Learned new red and green foods. Used toy foods to discuss healthy foods and children developed ‘‘healthy’’ meals with toy foods. Drew pictures of their favorite healthy foods and meals. Discussed the importance of daily exercise.
Healthy Eating Activities
#1
Group
Table 1. Outline of lessons and exercise activities at School 1
(continued )
Activities were inside the classroom. Completed 30 jumping jacks and ran in place for 30 seconds. Played musical chairs. Played board and card games and practiced naming red and green foods.
Activities were inside the classroom. Played toss with tennis balls, danced, and juggled. Board and card games also were available, such as ‘‘Uno’’ and ‘‘Chutes and Ladders.’’ Children named a green food when they went up a ladder and a red food when they went down a chute. During ‘‘Uno’’ if a child played a green card he or she named a green food and if a red card was played named a red food. Activities were on the playground. Jumped rope, green ball toss (name a green food and toss the football), and free play on swings and children selected games of tag. Relay race with children viewing pictures of red and green foods, deciding category of food (red versus green), and then running a lap in the relay race.
Frisbee, football, and tag
Exercise Activities
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Goal setting with coaches occurred. Played board and card games and emphasized review of red/green foods as part of the games.
Final check on goals and all children attending group won a prize for working hard to reach their healthy eating and exercise goals. Posttest was given
#7
#8
#6
Goal setting with coaches occurred. Discussed importance of 30 minutes of exercise per day and the importance of exercising outside. My Plate was explained and children drew a healthy meal, according to My Plate specifications on paper or they drew the meal on a paper plate. Goal setting with coaches occurred. Reviewed exercises children could complete at home. Review of red and green foods and children drew posters of healthy foods.
Healthy Eating Activities
#5
Group
Table 1. Continued
Activities were inside the classroom and focused on the class ‘‘dance.’’ Children played ‘‘limbo’’ and developed their own fun fruit and vegetable dances that other children could ‘‘copy.’’ Children also enjoyed freestyle time, to create their own dances. Games of musical chairs were played at the end of the dance. Activities were on the playground. Exercise included hula hoops, jump rope, and tag. Children also engaged in free play where they elected to play with Frisbees and take turns on the swings and jungle gym. Children had requested another dance for the final class (activities were the same as those described in week 6).
Activities were on the playground. Exercise included hula-hoops, jump rope, and tag. Children also engaged in free play where they elected to play with Frisbees and take turns on the swings and jungle gym.
Exercise Activities
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#6
#5
#4
#3
#2
#1
Group
Pre-intervention survey was completed. Introduced ideas about green (fruits, veggies) and red foods (not healthy for you, such as cake) and used play foods to illustrate green and red foods. Drew pictures of favorite foods. Talked about how exercise is fun and an important daily activity. Learned new red and green foods. Used toy foods to discuss healthy foods and children developed ‘‘healthy’’ meals with toy foods. Drew pictures of their favorite healthy foods and meals. Discussed the importance of daily exercise. Began goal-setting, with selection of a healthy eating and a healthy exercise goal. Discussed the importance of reducing red foods in daily diet. Created stop light poster, and children discussed what foods were green and red foods. Also learned healthy exercises to do while watching TV. Review of goal-setting progress with coach and development of new goals for the coming week. Review of My Plate and drew pictures of healthy meals using ideas from My Plate. Goal setting with coaches occurred. Discussed importance of 30 minutes of exercise per day and the importance of exercising outside. Completed healthy refrigerator exercise where children drew what was in their refrigerator and discussed what healthy foods could be added. Goal setting with coaches occurred. Reviewed exercises children could complete at home. Storytelling activity where children developed stories about superhero green foods. Children
Healthy Eating Activities
Table 2. Outline of lessons and exercise activities at School 2
(continued )
Played a game called ‘‘Matt-ball,’’ similar to kickball rules. Played other running games, such as freeze tag in the gym.
Played Frisbee and basketball in the gym. Also 10 minutes of free play where the children played tag, etc.
Played handball and kickball in the gym. Learned rules of sportsmanship, such as taking turns during team sports.
Played handball and kickball in the gym. Also held relay race with red and green foods (see above).
Played handball, Frisbee, and toss in the gym.
Played team handball game.
Exercise Activities
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#12 #13
#11
#10
#9
#8
#7
Group
discussed healthy lunches and reviewed pictures of healthy lunches. Goal setting with coaches occurred. Discussed what to pack in a healthy lunch for school. Reviewed importance of eating green foods. Small groups of children developed healthy food cheers and presented to the class. Goal setting with coaches. Children reviewed learning about red and green foods. No goal setting activity. Children reviewed learning about red and green foods and developed ideas for posters to show what they had learned about red and green foods as well as exercising. Check to see if children recalled goals from week 8. Then, goal setting with coaches occurred. Children created their own placements to take home, with pictures of healthy foods to eat. Discussed eating during the holidays. Also, reviewed that small portions of red foods are acceptable if more green foods are consumed (Slogan: 4 green foods to every 1 red food). Children were interviewed to see if they recalled their goals from Week 10. prior to the goal setting exercise. Then, goal setting with coaches occurred. Children completed their own newspaper headlines and illustrated a front page of a newspaper where they taught other children about healthy eating. Post-intervention survey completed. Posters created for parents for ‘‘parent day’’ to show learning about healthy foods and about exercise.
Healthy Eating Activities
Table 2. Continued
Children played handball in the gym. Children had requested another dance in the gym to celebrate the ending of the group sessions.
Children requested development of another obstacle course in the gym. Also, played handball and follow the leader, which were activities requested by children.
Children held first dance. Children developed their own fun fruit and vegetable dances that other children could ‘‘copy.’’ Children also enjoyed freestyle time, to create their own dances. Children built an obstacle course out of materials donated by the gym teacher. Children conducted races to see how fast they could complete their obstacle course and their progress was timed by the coaches or adult leaders of the session. Activities in the gym.
Various running games, races, and games of tag in gym.
Played handball, basketball, relay races, and follow the leader, with the leader picking different exercises for the group to ‘‘copy.’’
Exercise Activities
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At the end of the final group, children again completed the eating and exercise survey that was administered at the beginning of the program. They also completed an interview question to determine what they learned from participating in the program. RESULTS School 1 Results of the repeated measures analysis for number of sweets consumed pre- to post-intervention indicated a significant difference, Wilks’ Lambda ¼ .576, F(1,14) ¼ 10.29, p ¼ .006. As presented in Table 3, children in the intervention group were consuming fewer sweets post-intervention, whereas consumption of sweets increased for those children in the comparison group at post-intervention. Repeated measures analyses for pre- to post-intervention reports of change in consumption of fruits, vegetables, and fries/chips and exercise were not significant. Post-intervention, children in the intervention group reported what they had learned about red and green foods. Red foods were defined as ‘‘not good for you’’ or not healthy. Ten of the 14 children (71.4%) correctly defined red foods. Children provided examples of red foods, such as cookies, French fries, hotdogs, and cake. In contrast, green foods Table 3. Pre- to post-intervention change in the intervention group and comparison group at School 1 Intervention Group Question
Time
Pre-intervention Post-intervention Fruit consumed Yesterday Pre Post Vegetables consumed yesterday Pre Post Chips and fries consumed yesterday Pre Post *Sweets (cakes, donuts, etc.) Pre Post
Comparison Group
Mean
Standard Deviation
Mean
Standard Deviation
0.91 1.00 1.10 0.70 2.09 1.81 1.54 0.91 1.82 0.65
0.30 – 1.10 0.82 1.04 1.17 0.1.12 1.22 0.75 0.67
0.80 0.80 2.0 1.17 1.33 1.83 0.67 1.17 1.00 1.60
0.45 0.45 0.89 0.98 0.52 1.17 0.52 0.75 0.71 0.89
*Significant difference between groups at time 1 (pre-intervention) versus time 2 (post-intervention) measurements. There were 6 children in the comparison group and 11 in the intervention group at the two measurement intervals. Some children did not answer all of the questions.
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were defined as being ‘‘good for you’’ or healthy and 13 of the children (92.9%) provided a definition showing an understanding of green foods. Green foods were more readily described, and examples typically were fruits (e.g. apples, strawberries) with some vegetables listed, such as carrots or green beans. Surveys were sent to 11 parents of children in the intervention group. Ten (91%) of the parents reported that their child discussed weekly goals at home. Nine parents (82%) reported that their child identified red and green foods at home. However, only 8 parents (73%) reported receiving the recipes sent home with children. Fifty-five percent (n ¼ 6) of parents reported that their child was exercising more and 45% (n ¼ 5) indicated that their child was eating more healthy foods since beginning the group. Children participated in 6 goal setting sessions. The repeated measures ANOVAs for the children’s ratings for their progress toward their healthy eating and exercise goals did not indicate significant differences in ratings over the 6 sessions. Mean rating for eating goals was 2.33 (range 2.33–3). Mean rating for exercise goals was 2.667 (range 2–3). The authors’ reviews of graphs of individual children’s reports of their progress toward their healthy eating and exercise goals revealed wide individual differences.1 Anecdotal data revealed that some children discussed their goals with their parents and attempted to reach them with parental support, while others did not. Children reported liking goal setting, but becoming discouraged if goals were not attained. School 2 Findings were significant for the repeated measures analysis for pre- to post-intervention change in child report of fruit consumption, Wilks’ Lambda ¼ .757, F(1, 28) ¼ 8.973, p ¼ .006. Children in the intervention group reported increased fruit intake at the post-intervention measurement, whereas children in the comparison group reported decreased fruit intake at this assessment. Repeated measures analyses were not significant for the other questions addressing child report of eating behaviors pre- and post-intervention. The means and standard deviations for each question are presented in Table 4. Inspection of the means in Table 4 indicated that of chips/fries and sweets decreased, but that changes were not statistically significant. Results indicated a significant pre- to post-intervention difference between groups in the number of days they exercised in the past week, Wilks’ Lambda ¼ .849, F(1,26) ¼ 4.607, p ¼ .041. As shown 1
Information gleaned from graphs of individual children’s ratings of their achievement of eating and exercise goals are available from the corresponding author.
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Table 4. Pre- to post-intervention change in the intervention group and comparison group for School 2 Intervention Group Question *Number of days exercised this past week Did you exercise yesterday
Time
Mean
Pre-intervention 4.50 Post-intervention 4.67 Pre-intervention 0.74 Post-intervention 0.89 *Fruit consumed Yesterday Pre 0.944 Post 1.833 Vegetables consumed yesterday Pre 1.00 Post 1.526 Chips and fries consumed yesterday Pre 0.6111 Post 0.5000 Sweets (cakes, donuts, etc.) Pre 1.000 Post 0.3684
Comparison Group
Standard Deviation
Mean
Standard Deviation
2.68 2.38 0.45 0.32 0.872 1.150 1.247 1.264 0.849 0.618 1.247 0.597
5.00 3.44 0.74 0.75 1.333 0.750 0.750 1.167 0.833 1.00 0.917 0.833
2.87 2.33 0.45 0.45 0.985 0.866 1.055 1.337 1.114 1.28 1.084 1.029
*Denotes a significant difference between groups at time 1 (pre-intervention) versus time 2 (post-intervention) measurements. There were 12 children in the comparison group and 19 children in the intervention group who completed survey questions at the two time points. Some children did not answer all survey questions.
in Table 4, children in the intervention group reported exercising less pre-intervention and more post-intervention than children who were in the comparison group. Children’s definitions of red and green foods were almost identical to those provided by children at School 1. Children provided several definitions for exercise such as, ‘‘it keeps you healthy,’’ ‘‘do it every day,’’ to listing exercises they had learned during their group. Eighty percent of the children reported they learned a lot in the groups, 15% learned ‘‘some,’’ and 2 reported their knowledge remained the same. Thirty-five percent of the children recalled eating and exercise goals at a 2 week interval, whereas 71% of the children recalled goals at a 1 week interval. Thirteen parents or caregivers completed surveys. Ten (77%) reported that their child discussed what he or she was learning at home. Only 5 (38.5%) mentioned that their child mentioned healthy eating and exercise goals. Eleven (84.6%) stated that their children correctly identified red and green foods. Eight (61.5%) indicated they had received recipes. Fifty-four percent (n ¼ 7) of parents reported that their child was exercising and 50% (n ¼ 6) indicated that their child was eating more healthy foods since beginning the CHEE program. Children participated in 7 goal setting sessions. Significant differences in progress toward eating and exercise goals were not discovered
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across the 13 sessions. The mean score and range was identical for healthy eating and exercise goals (M ¼ 3.75, range 2.75–4). Similar to observations for School 1, authors observed large variations between child ratings when inspecting individual graphs of child progress in goal setting over time. Finally, inspection of goals the children selected across both schools indicated that children in both schools selected similar weekly goals. Specifically, the children selected eating more fruits as a goal more often than eating more vegetables. Exercise goals varied on the sports the children liked and whether they were allowed to play outside after returning home from school as well as whether they were enrolled in extracurricular sports activities. DISCUSSION Study findings indicated that a modified version of the Traffic Light Diet (Epstein, 2005; Epstein & Squires, 1988), emphasizing consuming more green and fewer red foods, and emphasizing the importance of activity, can be successfully disseminated in after-school obesity prevention programs. Our findings showed that very young children were able to learn about red and green light foods in a relatively short period of time. Results indicated that children understood the importance of consuming more green than red foods in order to have a healthy lifestyle. Children also reported some positive changes in eating and activity levels, demonstrating some support for the value of dissemination of the Traffic Light Diet in novel settings. Specifically, at School 1 children in the intervention group showed reductions in consumption of sweets. There was not significant positive change in activity levels for children who were participating in the intervention group at School 1. At School 2, children participating in the intervention showed improvement in consumption of fruits. It was encouraging that inspection of the mean differences for several questions about healthy eating were in a direction favoring ‘‘being healthier’’ at post-test, but these differences were not statistically significant. If the program were very effective, one might have expected change across all questions. Future research needs to include observational data and physiological data (e.g. data collected with accelerometers and data about body mass index) in order to more accurately assess change. Child report of change in physical activity showed an increase in activity levels for children in the intervention group who were attending School 2. This may have occurred due to greater chances to emphasize physical activity with classes held in the gymnasium at School 2. Emphasis and time spent in physical education is decreasing at many
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schools, and holding after—school programming in the gymnasium to involve young children in activities can be a valuable way to contribute to the health and engagement of activity of young children who might otherwise not have access to recreational physical activities on sports teams and through playing outside after the school day has concluded. This was the case for children at School 2, and involvement in fun activities improved their involvement in physical activity. Some of the children appeared to benefit from the coaching intervention, in terms of improved progress in meeting their eating and exercise goals, while others did not show improvement. Specifically, inspection of the graphs of children’s progress toward goals showed that some children responded well to this approach. It may be that motivational interviewing is successful only if children are overweight (Resnicow et al., 2006; So¨derlund et al., 2009). Nurses are in a good position to implement motivational interviewing when working with young children who are overweight in schools. This one-on-one technique is positive and child-focused and an easy method to learn to encourage children to attain healthy eating and exercise goals. Although parents were not receiving formal training about the CHEE program, many were learning about red and green foods from their children and from handouts and recipes that were sent home weekly with the children. Some of the parents were receiving recipes and handouts; however, some were lost in the transition from school to home. It may be advisable to request parent emails, so that materials can be sent to them in a convenient and accessible manner. Despite the inconsistency of information actually ‘‘getting to’’ parents, they reported that their children were satisfied the CHEE program and were learning new things as a result of participating in the program. Health professionals in schools and other community settings are in a good position to report information about healthy eating and ideas for healthy recipes on school websites and at events, such as health fairs, that parents might attend. This may be another avenue for reaching families with important health promotion materials. Several factors limited the generalizability of findings these studies. For example, ours were samples of convenience and in addition the comparison groups were not matched groups, weakening the research design. In addition, several children did not complete the survey at the end of the program. Moreover, the dose of the intervention and level of engagement in physical activity differed greatly across schools. At School 1 the sample was comprised of primarily African American youth, while at School 2 the majority of the students were Caucasian and
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the programs were taught in a classroom at School 1 and in the gymnasium for School 2. Thus, the programs differed, as did the settings, which has positive implications (the program can be delivered in different settings) and negative ones, because the projects were conducted differently in each setting. Providing an incentive for attending the final group might improve participation. Data are limited to self-report. As such, a social desirability bias could have influenced our results. Moreover, parent permission and child assent were needed for participation. Some parents may not have wanted their child to participate in our program. This may have limited recruitment; however, obtaining parent consent and child assent were important steps in our research process. Observations of physiologic measures (e.g. using accelerometers), gathering data using food diaries, and use of mealtime observations would yield objective information on whether change occurred for children participating in the intervention groups. Further research will be needed to examine the effectiveness of the CHEE program and determine whether the Traffic Light Diet can be successfully disseminated in after-school settings. Given the significance of the need for obesity prevention programming in our nation, it will be important to continue examining application of existing programs in after-school programs and to determine if the prevention programs result in lasting change in children’s knowledge and behaviors, and subsequently result in change in parent knowledge and health and wellness behaviors at home. Nurses and other health professionals are in a position to reach out to after-school programs and design and implement nutrition and exercise activities to promote health knowledge of young children. This is an under-utilized avenue for improving access to children who can benefit from being involved in healthy eating classes and having additional opportunities to participate in physical activities in school gymnasiums (these settings may be under-used in some school settings). Graduate students and nursing students also can gain valuable experience when helping implement this programming and this may improve their knowledge of and ideas about delivering health promotion programming in unique settings where they can reach children who may be in need of additional opportunities to engage in physical activity and learn about nutrition. ACKNOWLEDGMENTS The authors would like to thank the school, staff, and students who participated in this project and thank those at the School of Human Services at the University of Cincinnati who supported our work.
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DECLARATION OF INTEREST The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper. REFERENCES Afterschool Alliance. (2013). Afterschool essentials: Research and polling. Retrieved from http://www.afterschoolalliance.org/Essentials_and_Polling_2013_032713.pdf. Amis, J. M., Wright, P. M., Dyson, B., Vardaman, J. M., & Ferry, H. (2012). Implementing childhood obesity policy in a new educational environment: the cases of Mississippi and Tennessee. American Journal of Public Health, 102, 1406–1413. Burbage, M., Pangallo, J., Gardocki, S., Edwards, C., Carpenter, J., & Nabors, L. (2013). Nutrition and exercise education in urban Appalachian settings. Poster presented at the National Conference for the Society of Pediatric Psychology in New Orleans, LA. Centers for Disease Control and Prevention. (CDC, 2013). Retrieved from http:// www.cdc.gov/healthyyouth/obesity/facts.htm. Davis, M. M., Gance-Cleveland, B., Hassink, S., Johnson, R., Paradis, G., & Resnicow, K. (2007). Recommendations for prevention of childhood obesity. Pediatrics, 120, S229–S253. Dotterweich, A. R., Greene, A., & Blosser, D. (2012). Using innovative playgrounds and cross-curricular design to increase physical activity. Journal of Physical Education, Recreation and Dance, 83, 47–55. Dzewaltowski, D. A., Rosenkranz, R. R., Geller, K. S., Coleman, K. J., Welk, G. J., Hastmann, T. J., & Milliken, G. A. (2010). HOP’N after-school project: an obesity prevention randomized controlled trial. International Journal of Behavioral Nutrition and Physical Activity, 7, 90. doi: 10.1186/1479-5868-7-90, 12 pages. Epstein, L. H. (2005). The Traffic Light Childhood Weight Control Program: Traffic light: Kids program. University of Buffalo, NY: Author. Epstein, L. H., Gordy, C. C., Raynor, H. A., Beddome, M., Kilanowski, C. K., & Paluch, R. (2012). Increasing fruit and vegetable intake and decreasing fat and sugar intake in families at risk for childhood obesity. Obesity, 9, 171–178. Epstein, L. H., Paluch, R. H., Gordy, C. C., & Dorn, J. (2000). Decreasing sedentary behaviors in treating pediatric obesity. Archives of Pediatric and Adolescent Medicine, 154, 220–226. Epstein, L. H., & Squires, S. (1988). The Stoplight Diet for children. Boston. MA: Little, Brown and Company. Erickson, S. J., Gerstle, M., & Feldstein, S. W. (2005). Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings. Archives of Pediatric and Adolescent Medicine, 159, 1173–1180. Kelder, S. H., Mitchell, P. D., McKenzie, T. L., Derby, C., Strikmiller, P. K., Luepker, R. V., & Stone, E. J. (2003). Long-term implementation of the CATCH physical education program. Health Education & Behavior, 30, 463–475. Kropski, J. A., Keckley, P. H., & Jensen, G. L. (2008). School-based obesity prevention programs: An evidence-based review. Obesity, 16, 1009–1018.
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Martins, R. K., & McNeil, D. W. (2009). Review of motivational interviewing in promoting health behaviors. Clinical Psychology Review, 29, 283–293. Nabors, L., Burbage, M., Pangallo, J. (2013). Delivery and evaluation of a pilot obesity prevention project for urban Appalachian children. Open Journal of Pediatrics, 3, 300–305 http://dx.doi.org/10.4236/ojped.2013.34054 Published Online December 2013 (http://www.scirp.org/journal/ojped/). Nabors, L. A., Bartz, J., Strong, A., Hoffman, S., Steffer, E., & Pangallo, J. (2012). Children’s Healthy Eating and Exercise Program Manual. University of Cincinnati, OH: Author. Obama, M. (2010, May). Eat Healthy. Retrieved October 27, 2014 from http:// www.letsmove.gov/eat-healthy. Resnicow, K., Davis, R., & Rollnick, S. (2006). Motivational interviewing for pediatric obesity: conceptual issues and evidence review. Journal of the American Dietetic Association, 106, 2024–2033. Riggs, N. R., Sakuma, K., & Pentz, M. A. (2007). Preventing risk for obesity by promoting self-regulation and decision-making skills: Pilot results from the PATHWAYS to Health Program (PATHWAYS). Evaluation Review, 31, 287–310. Schetzina, K. E., Dalton III , W. T., Lowe, E. F., & Stern, H. P. (2009). A coordinated school health approach to obesity prevention among Appalachian youth: the Winning with Wellness Pilot Project. Family & Community Health, 32, 271–285. Schetzina, K. E., Dalton III , W. T., Pfortmiller, D. T., Robinson, H. F., Lowe, E. F., & Stern H. P. (2011). The Winning With Wellness pilot project: rural appalachian elementary student physical activity and eating behaviors and program implementation 4 years later. Family & Community Health, 34, 154–162. So¨derlund, L. L., Nordqvist, C., Angbratt, M., & Nilsen, P. (2009). Applying motivational interviewing to counselling overweight and obese children. Health Education Research, 24, 442–449. Stice, E., Shaw, H., & Marti, C. N. (2006). A meta-analytic review of obesity prevention programs for children and adolescents: the skinny on interventions that work. Psychological Bulletin, 132, 667–691. Suarez, M., & Mullins, S. (2008). Motivational interviewing and pediatric health behavior interventions. Journal of Developmental & Behavioral Pediatrics, 29, 417–428.
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IMPLEMENTATION OF AN AFTER-SCHOOL OBESITY PREVENTION PROGRAM: HELPING YOUNG CHILDREN TOWARD IMPROVED HEALTH
Laura Nabors, PhD1, Michelle Burbage, MS1, Kenneth D. Woodson, MPh1, and Christopher Swoboda, PhD2 1 School of Human Services and 2School of Education, College of Education, Criminal Justice and Human Services, University of Cincinnati, Cincinnati, Ohio, USA
Obesity prevention programs that are delivered in after-school programs are needed as a focus on curriculum can make it difficult to include this health programming during the school day. The current study examined the implementation of 2 pilot programs in different after-school programs for young children. There were 36 children in the intervention groups and 18 children in comparison groups. Children learned about healthy eating and increasing involvement in physical activity. Lessons were based on the Traffic Light Diet. Results indicated improvement in children’s reports of their eating habits. Activity levels improved in 1 school, but not in the other. Parents and children were satisfied with the program and children demonstrated good knowledge of the interventions to promote healthy eating. Future studies should include larger sample sizes and evaluation of the effectiveness of different components of the intervention. Nurses can play a key role in disseminating information and designing and leading after-school programs to improve child knowledge about healthy eating and exercise. Nursing students may also benefit from assisting with conducting these types of programs to improve their experience in health prevention programming. Keywords: After-school, eating program, healthy
Received 16 July 2014; revised 1 October 2014; accepted 1 October 2014
Correspondence: Laura Nabors, Ph.D., Mail Location 0068, School of Human Services, CECH, University of Cincinnati, Cincinnati, Ohio 45221-0068. Email: naborsla@ucmail. uc.edu
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Implementation of an after-school obesity prevention program
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INTRODUCTION Over the last few decades, the number of obese youth in America has been steadily increasing. Over the past 30 years childhood obesity has doubled and in 2010 more than one third of children in the United States were obese (Centers for Disease Control [CDC], 2013). With childhood obesity becoming a national epidemic programs to prevent obesity and encourage healthy lifestyles through improved eating and exercise habits are needed (Davis et al., 2007). Riggs, Sakuma, and Pentz (2007) proposed that promotion of healthy lifestyles, eating, and exercise is needed in order to reduce obesity rates in children. School-based prevention programs can be a way to teach children how to maintain a healthy lifestyle (CDC, 2013; Kropski et al., 2008). However, the importance of addressing academic issues can leave little time to implement prevention programs during the school day (Amis et al., 2012; Dzewaltowski et al., 2010). After-school programs provide another outlet for implementing obesity prevention programs in schools. There is the potential to reach many children, as 8.4 million children grades K–12 attend after-school programs and 18.5 million stated they would attend an after-school program if available in their area (Afterschool Alliance, 2013). This outlet is an understudied area for programming and adding health education to after-school programming is an important way to provide critical health education, in an era where this information might not be available in health education during the school day as a focus is often on academic material. Our obesity prevention program was adapted from the Traffic or Stop Light Diet developed by Leonard Epstein (Epstein, 2005; Epstein & Squires, 1988). The Traffic Light program has an evidence base for weight loss and lifestyle change through teaching healthy food and beverage choices to obese and overweight children (e.g. Epstein et al., 2012). Foods are coded as ‘‘red’’ or ‘‘stop’’ foods, ‘‘yellow’’ or ‘‘cautionary’’ foods, and ‘‘green’’ or ‘‘go’’ foods. Increasing physical activity levels is a critical component of the Traffic Light Program. The Traffic Light Program also emphasizes increasing daily physical activity. This is critical, as exercise is a primary intervention to prevent obesity in children (Dotterweich et al., 2012; Epstein et al., 2000; Stice et al., 2006). For this project, children also had individual coaching to enhance their attainment of healthy eating and exercise goals that they selected. A modified version of the Traffic Light Program was implemented during the school day and had positive impacts on child healthy behaviors (Scheztina et al., 2009, 2011). Our research team has implemented the program during summer programs with urban youth, who benefitted from participating in the program, in terms of improving
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their eating behaviors (Nabors et al., 2013). The current study extended knowledge by using motivational interviewing and implementing a modified version of the Traffic Light Diet, with emphasis on ‘‘red’’ and ‘‘green’’ foods with very young elementary school age children attending two different after-school programs. It is critical to understand whether evidence-based interventions, such as the Traffic Light Diet can be disseminated in novel settings, with children in the general population, as was the case for the current pilot studies. Coaches used motivational interviewing (MI) to assist and encourage each child when developing his or her weekly healthy eating and exercise goal. MI is a promising teaching and counseling technique in health promotion interventions for primarily older children and adolescents (Suarez & Mullins, 2008). The current study implemented this technique with an understudied group, which is young children (Erickson et al., 2005; Martins & McNeil, 2009). MI has been utilized in interventions with overweight and obese children (e.g. Resnicow et al., 2006; So¨derlund et al., 2009), but not as part of preventive interventions with young children who were not obese, as was the case for the current study. A pilot project for the CHEE program was implemented in two summer programs for younger (elementary school age) and older children (high school age) residing in an inner city, community (Burbage et al., 2013; Nabors et al., 2012). A manual was developed to review key concepts related to eating more green foods (e.g. fruits and vegetables) and fewer yellow and red foods (e.g. sweets, snacks, and desserts) as well as increasing levels of physical activity on a daily basis. Children participated in games and art activities, such as developing commercials and building games to encourage and educate about healthy eating to improve knowledge about eating higher numbers of green and fewer red foods. Children engaged in activities at each session and also discussed the importance of engaging in 30 minutes of physical activities on a daily basis (CATCH Physical Education; Kelder et al., 2003; Obama, 2010). Results indicated that participation in this program resulted in reduced consumption of French fries and chips for younger children and increased consumption of vegetables for older youth. Children and adolescents reported that they were satisfied with the program. Irrespective of their age, children had difficulty understanding the concept of yellow foods, and thus education focused on enhancing understanding of red and green foods for the current study. The current project also targeted younger children, added a comparison group, and evaluation of parent perceptions of the program. The aims of the current study were to describe the implementation and evaluation of the CHEE with younger children in after-school programs. Our specific objectives
Implementation of an after-school obesity prevention program
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were to describe the implementation of the program in two different settings and to investigate whether children reported change in their knowledge about healthy eating and reported change in their eating and exercise behaviors after participating in the healthy eating and exercise sessions. METHOD Participants Children were recruited from those attending after-school programming at two different schools. The after-school programs at both schools had components focusing on academics, with tutoring to help children complete their homework. Children could select from different after school groups. Children in the intervention groups selected to participate in the CHEE program, whereas children in the comparison groups were participating in other after-school groups, such as yearbook development (scrapbooking) and young scientists (developing science projects). A university-based institutional review board approved this program evaluation project, and parent permission and child assent were required for participation in lessons for the project as well as for completion of surveys for this project. School 1 There were 17 children in the intervention group, including 9 boys and 8 girls (M ¼ 6.12, range 4–7 years). Fourteen of the children were African-American, 1 was Caucasian, 1 was Hispanic, and 1 was biracial. Eleven parents or guardians (5 mothers, 3 fathers, and 3 legal guardians) completed surveys to evaluate our program. There were 3 boys and 3 girls in the comparison group, 5 were African American and 1 child was biracial (M ¼ 6.5, range 5–9 years). School 2 There were 29 children in the intervention group, 21 were boys and 8 were girls (M ¼ 6.62, range 5–9 years). Twenty-one of the children were Caucasian, 5 were African-American, and 3 were biracial. Nine mothers, 2 fathers, and 2 legal guardians completed surveys. There were 12 in the comparison group, 6 males and 6 females (M ¼ 6.83, 5–9 years). Procedures and Description of the Intervention Five undergraduate students and one faculty member implemented the CHEE Program. Children were interviewed to complete brief surveys
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assessing their perceptions of their eating and exercise during the first group. Questions included requesting children to identify the number of fruits, vegetables, sweets, and chips/fries they had consumed ‘‘yesterday.’’ Weekly sessions at both schools focused on discussing red and green light foods and the importance of exercise. Table 1 presents a review of the lessons delivered at School 1. Eight sessions were delivered at School 1 and exercise occurred in the classroom on days where the class was not able to use the playground. Healthy eating activities focused on learning about red and green foods and eating a higher number of green than red foods. Children discussed eating fewer unhealthy foods, such as chips and cake and learned about healthy meals. Children worked weekly with a coach to discuss healthy eating and exercise. Each week they selected one healthy eating and one exercise goal which they would work to achieve at home. The following week the child would rate his or her progress toward each goal. Thirteen sessions were delivered at School 2. Sessions were held in the school gymnasium and there was time for exercise every class period. Table 2 presents the healthy eating and exercise activities conducted at School 2. Similar to lessons at School 1, Children and their group leaders discussed the importance of reducing intake of red foods, such as sweets and fried foods on a weekly basis. They reviewed the importance of consuming at least 4 green foods for every red food. During lessons, children also learned about the importance of daily physical activity and participated in organized activities in the gymnasium every class. Children also completed individual, weekly sessions with a coach to encourage them to achieve one healthy eating and exercise goal. At both schools, children participated in goal-setting with a coach. At the start of the session, coaches reviewed the child’s progress toward the previous week’s goals on 4-point Likert scales from poor (1) to very good (4). Then, each child selected one new healthy eating and exercise goal to work on at home for the upcoming week. Coaches emphasized self-efficacy for reaching goals and discussed the children’s ideas for being successful in reaching their new weekly goals at each meeting. Empathy was used if the child had reasons for not reaching goals set in the previous week. Parents received handouts with information about red and green foods and recipes for cooking healthy entrees, snacks, and desserts. Parents completed brief surveys to examine their satisfaction with the program and to assess whether they were receiving and using healthy eating recipes.
Began goal-setting, with selection of a healthy eating and a healthy exercise goal. Discussed the importance of reducing red foods in daily diet. Created stop light poster, and children discussed what foods were green and red foods. Also learned healthy exercises to do while watching TV. Reviewed food groups using food pyramid and My Plate. Practiced making healthy meals according to My Plate using play foods. Review of goal-setting progress with coach and development of new goals for the coming week. Completed healthy refrigerator exercise where children drew what was in their refrigerator and discussed what healthy foods could be added. Drew examples of healthy meals that were loaded with fruits and vegetables.
#3
#4
#2
Pre-intervention survey was completed. Introduced ideas about green (fruits, veggies) and red foods (not healthy for you, such as cake) and used play foods to illustrate green and red foods. Drew pictures of favorite foods. Talked about how exercise is fun and an important daily activity. Learned new red and green foods. Used toy foods to discuss healthy foods and children developed ‘‘healthy’’ meals with toy foods. Drew pictures of their favorite healthy foods and meals. Discussed the importance of daily exercise.
Healthy Eating Activities
#1
Group
Table 1. Outline of lessons and exercise activities at School 1
(continued )
Activities were inside the classroom. Completed 30 jumping jacks and ran in place for 30 seconds. Played musical chairs. Played board and card games and practiced naming red and green foods.
Activities were inside the classroom. Played toss with tennis balls, danced, and juggled. Board and card games also were available, such as ‘‘Uno’’ and ‘‘Chutes and Ladders.’’ Children named a green food when they went up a ladder and a red food when they went down a chute. During ‘‘Uno’’ if a child played a green card he or she named a green food and if a red card was played named a red food. Activities were on the playground. Jumped rope, green ball toss (name a green food and toss the football), and free play on swings and children selected games of tag. Relay race with children viewing pictures of red and green foods, deciding category of food (red versus green), and then running a lap in the relay race.
Frisbee, football, and tag
Exercise Activities
Implementation of an after-school obesity prevention program 27
Goal setting with coaches occurred. Played board and card games and emphasized review of red/green foods as part of the games.
Final check on goals and all children attending group won a prize for working hard to reach their healthy eating and exercise goals. Posttest was given
#7
#8
#6
Goal setting with coaches occurred. Discussed importance of 30 minutes of exercise per day and the importance of exercising outside. My Plate was explained and children drew a healthy meal, according to My Plate specifications on paper or they drew the meal on a paper plate. Goal setting with coaches occurred. Reviewed exercises children could complete at home. Review of red and green foods and children drew posters of healthy foods.
Healthy Eating Activities
#5
Group
Table 1. Continued
Activities were inside the classroom and focused on the class ‘‘dance.’’ Children played ‘‘limbo’’ and developed their own fun fruit and vegetable dances that other children could ‘‘copy.’’ Children also enjoyed freestyle time, to create their own dances. Games of musical chairs were played at the end of the dance. Activities were on the playground. Exercise included hula hoops, jump rope, and tag. Children also engaged in free play where they elected to play with Frisbees and take turns on the swings and jungle gym. Children had requested another dance for the final class (activities were the same as those described in week 6).
Activities were on the playground. Exercise included hula-hoops, jump rope, and tag. Children also engaged in free play where they elected to play with Frisbees and take turns on the swings and jungle gym.
Exercise Activities
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#6
#5
#4
#3
#2
#1
Group
Pre-intervention survey was completed. Introduced ideas about green (fruits, veggies) and red foods (not healthy for you, such as cake) and used play foods to illustrate green and red foods. Drew pictures of favorite foods. Talked about how exercise is fun and an important daily activity. Learned new red and green foods. Used toy foods to discuss healthy foods and children developed ‘‘healthy’’ meals with toy foods. Drew pictures of their favorite healthy foods and meals. Discussed the importance of daily exercise. Began goal-setting, with selection of a healthy eating and a healthy exercise goal. Discussed the importance of reducing red foods in daily diet. Created stop light poster, and children discussed what foods were green and red foods. Also learned healthy exercises to do while watching TV. Review of goal-setting progress with coach and development of new goals for the coming week. Review of My Plate and drew pictures of healthy meals using ideas from My Plate. Goal setting with coaches occurred. Discussed importance of 30 minutes of exercise per day and the importance of exercising outside. Completed healthy refrigerator exercise where children drew what was in their refrigerator and discussed what healthy foods could be added. Goal setting with coaches occurred. Reviewed exercises children could complete at home. Storytelling activity where children developed stories about superhero green foods. Children
Healthy Eating Activities
Table 2. Outline of lessons and exercise activities at School 2
(continued )
Played a game called ‘‘Matt-ball,’’ similar to kickball rules. Played other running games, such as freeze tag in the gym.
Played Frisbee and basketball in the gym. Also 10 minutes of free play where the children played tag, etc.
Played handball and kickball in the gym. Learned rules of sportsmanship, such as taking turns during team sports.
Played handball and kickball in the gym. Also held relay race with red and green foods (see above).
Played handball, Frisbee, and toss in the gym.
Played team handball game.
Exercise Activities
Implementation of an after-school obesity prevention program 29
#12 #13
#11
#10
#9
#8
#7
Group
discussed healthy lunches and reviewed pictures of healthy lunches. Goal setting with coaches occurred. Discussed what to pack in a healthy lunch for school. Reviewed importance of eating green foods. Small groups of children developed healthy food cheers and presented to the class. Goal setting with coaches. Children reviewed learning about red and green foods. No goal setting activity. Children reviewed learning about red and green foods and developed ideas for posters to show what they had learned about red and green foods as well as exercising. Check to see if children recalled goals from week 8. Then, goal setting with coaches occurred. Children created their own placements to take home, with pictures of healthy foods to eat. Discussed eating during the holidays. Also, reviewed that small portions of red foods are acceptable if more green foods are consumed (Slogan: 4 green foods to every 1 red food). Children were interviewed to see if they recalled their goals from Week 10. prior to the goal setting exercise. Then, goal setting with coaches occurred. Children completed their own newspaper headlines and illustrated a front page of a newspaper where they taught other children about healthy eating. Post-intervention survey completed. Posters created for parents for ‘‘parent day’’ to show learning about healthy foods and about exercise.
Healthy Eating Activities
Table 2. Continued
Children played handball in the gym. Children had requested another dance in the gym to celebrate the ending of the group sessions.
Children requested development of another obstacle course in the gym. Also, played handball and follow the leader, which were activities requested by children.
Children held first dance. Children developed their own fun fruit and vegetable dances that other children could ‘‘copy.’’ Children also enjoyed freestyle time, to create their own dances. Children built an obstacle course out of materials donated by the gym teacher. Children conducted races to see how fast they could complete their obstacle course and their progress was timed by the coaches or adult leaders of the session. Activities in the gym.
Various running games, races, and games of tag in gym.
Played handball, basketball, relay races, and follow the leader, with the leader picking different exercises for the group to ‘‘copy.’’
Exercise Activities
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At the end of the final group, children again completed the eating and exercise survey that was administered at the beginning of the program. They also completed an interview question to determine what they learned from participating in the program. RESULTS School 1 Results of the repeated measures analysis for number of sweets consumed pre- to post-intervention indicated a significant difference, Wilks’ Lambda ¼ .576, F(1,14) ¼ 10.29, p ¼ .006. As presented in Table 3, children in the intervention group were consuming fewer sweets post-intervention, whereas consumption of sweets increased for those children in the comparison group at post-intervention. Repeated measures analyses for pre- to post-intervention reports of change in consumption of fruits, vegetables, and fries/chips and exercise were not significant. Post-intervention, children in the intervention group reported what they had learned about red and green foods. Red foods were defined as ‘‘not good for you’’ or not healthy. Ten of the 14 children (71.4%) correctly defined red foods. Children provided examples of red foods, such as cookies, French fries, hotdogs, and cake. In contrast, green foods Table 3. Pre- to post-intervention change in the intervention group and comparison group at School 1 Intervention Group Question
Time
Pre-intervention Post-intervention Fruit consumed Yesterday Pre Post Vegetables consumed yesterday Pre Post Chips and fries consumed yesterday Pre Post *Sweets (cakes, donuts, etc.) Pre Post
Comparison Group
Mean
Standard Deviation
Mean
Standard Deviation
0.91 1.00 1.10 0.70 2.09 1.81 1.54 0.91 1.82 0.65
0.30 – 1.10 0.82 1.04 1.17 0.1.12 1.22 0.75 0.67
0.80 0.80 2.0 1.17 1.33 1.83 0.67 1.17 1.00 1.60
0.45 0.45 0.89 0.98 0.52 1.17 0.52 0.75 0.71 0.89
*Significant difference between groups at time 1 (pre-intervention) versus time 2 (post-intervention) measurements. There were 6 children in the comparison group and 11 in the intervention group at the two measurement intervals. Some children did not answer all of the questions.
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were defined as being ‘‘good for you’’ or healthy and 13 of the children (92.9%) provided a definition showing an understanding of green foods. Green foods were more readily described, and examples typically were fruits (e.g. apples, strawberries) with some vegetables listed, such as carrots or green beans. Surveys were sent to 11 parents of children in the intervention group. Ten (91%) of the parents reported that their child discussed weekly goals at home. Nine parents (82%) reported that their child identified red and green foods at home. However, only 8 parents (73%) reported receiving the recipes sent home with children. Fifty-five percent (n ¼ 6) of parents reported that their child was exercising more and 45% (n ¼ 5) indicated that their child was eating more healthy foods since beginning the group. Children participated in 6 goal setting sessions. The repeated measures ANOVAs for the children’s ratings for their progress toward their healthy eating and exercise goals did not indicate significant differences in ratings over the 6 sessions. Mean rating for eating goals was 2.33 (range 2.33–3). Mean rating for exercise goals was 2.667 (range 2–3). The authors’ reviews of graphs of individual children’s reports of their progress toward their healthy eating and exercise goals revealed wide individual differences.1 Anecdotal data revealed that some children discussed their goals with their parents and attempted to reach them with parental support, while others did not. Children reported liking goal setting, but becoming discouraged if goals were not attained. School 2 Findings were significant for the repeated measures analysis for pre- to post-intervention change in child report of fruit consumption, Wilks’ Lambda ¼ .757, F(1, 28) ¼ 8.973, p ¼ .006. Children in the intervention group reported increased fruit intake at the post-intervention measurement, whereas children in the comparison group reported decreased fruit intake at this assessment. Repeated measures analyses were not significant for the other questions addressing child report of eating behaviors pre- and post-intervention. The means and standard deviations for each question are presented in Table 4. Inspection of the means in Table 4 indicated that of chips/fries and sweets decreased, but that changes were not statistically significant. Results indicated a significant pre- to post-intervention difference between groups in the number of days they exercised in the past week, Wilks’ Lambda ¼ .849, F(1,26) ¼ 4.607, p ¼ .041. As shown 1
Information gleaned from graphs of individual children’s ratings of their achievement of eating and exercise goals are available from the corresponding author.
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Table 4. Pre- to post-intervention change in the intervention group and comparison group for School 2 Intervention Group Question *Number of days exercised this past week Did you exercise yesterday
Time
Mean
Pre-intervention 4.50 Post-intervention 4.67 Pre-intervention 0.74 Post-intervention 0.89 *Fruit consumed Yesterday Pre 0.944 Post 1.833 Vegetables consumed yesterday Pre 1.00 Post 1.526 Chips and fries consumed yesterday Pre 0.6111 Post 0.5000 Sweets (cakes, donuts, etc.) Pre 1.000 Post 0.3684
Comparison Group
Standard Deviation
Mean
Standard Deviation
2.68 2.38 0.45 0.32 0.872 1.150 1.247 1.264 0.849 0.618 1.247 0.597
5.00 3.44 0.74 0.75 1.333 0.750 0.750 1.167 0.833 1.00 0.917 0.833
2.87 2.33 0.45 0.45 0.985 0.866 1.055 1.337 1.114 1.28 1.084 1.029
*Denotes a significant difference between groups at time 1 (pre-intervention) versus time 2 (post-intervention) measurements. There were 12 children in the comparison group and 19 children in the intervention group who completed survey questions at the two time points. Some children did not answer all survey questions.
in Table 4, children in the intervention group reported exercising less pre-intervention and more post-intervention than children who were in the comparison group. Children’s definitions of red and green foods were almost identical to those provided by children at School 1. Children provided several definitions for exercise such as, ‘‘it keeps you healthy,’’ ‘‘do it every day,’’ to listing exercises they had learned during their group. Eighty percent of the children reported they learned a lot in the groups, 15% learned ‘‘some,’’ and 2 reported their knowledge remained the same. Thirty-five percent of the children recalled eating and exercise goals at a 2 week interval, whereas 71% of the children recalled goals at a 1 week interval. Thirteen parents or caregivers completed surveys. Ten (77%) reported that their child discussed what he or she was learning at home. Only 5 (38.5%) mentioned that their child mentioned healthy eating and exercise goals. Eleven (84.6%) stated that their children correctly identified red and green foods. Eight (61.5%) indicated they had received recipes. Fifty-four percent (n ¼ 7) of parents reported that their child was exercising and 50% (n ¼ 6) indicated that their child was eating more healthy foods since beginning the CHEE program. Children participated in 7 goal setting sessions. Significant differences in progress toward eating and exercise goals were not discovered
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across the 13 sessions. The mean score and range was identical for healthy eating and exercise goals (M ¼ 3.75, range 2.75–4). Similar to observations for School 1, authors observed large variations between child ratings when inspecting individual graphs of child progress in goal setting over time. Finally, inspection of goals the children selected across both schools indicated that children in both schools selected similar weekly goals. Specifically, the children selected eating more fruits as a goal more often than eating more vegetables. Exercise goals varied on the sports the children liked and whether they were allowed to play outside after returning home from school as well as whether they were enrolled in extracurricular sports activities. DISCUSSION Study findings indicated that a modified version of the Traffic Light Diet (Epstein, 2005; Epstein & Squires, 1988), emphasizing consuming more green and fewer red foods, and emphasizing the importance of activity, can be successfully disseminated in after-school obesity prevention programs. Our findings showed that very young children were able to learn about red and green light foods in a relatively short period of time. Results indicated that children understood the importance of consuming more green than red foods in order to have a healthy lifestyle. Children also reported some positive changes in eating and activity levels, demonstrating some support for the value of dissemination of the Traffic Light Diet in novel settings. Specifically, at School 1 children in the intervention group showed reductions in consumption of sweets. There was not significant positive change in activity levels for children who were participating in the intervention group at School 1. At School 2, children participating in the intervention showed improvement in consumption of fruits. It was encouraging that inspection of the mean differences for several questions about healthy eating were in a direction favoring ‘‘being healthier’’ at post-test, but these differences were not statistically significant. If the program were very effective, one might have expected change across all questions. Future research needs to include observational data and physiological data (e.g. data collected with accelerometers and data about body mass index) in order to more accurately assess change. Child report of change in physical activity showed an increase in activity levels for children in the intervention group who were attending School 2. This may have occurred due to greater chances to emphasize physical activity with classes held in the gymnasium at School 2. Emphasis and time spent in physical education is decreasing at many
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schools, and holding after—school programming in the gymnasium to involve young children in activities can be a valuable way to contribute to the health and engagement of activity of young children who might otherwise not have access to recreational physical activities on sports teams and through playing outside after the school day has concluded. This was the case for children at School 2, and involvement in fun activities improved their involvement in physical activity. Some of the children appeared to benefit from the coaching intervention, in terms of improved progress in meeting their eating and exercise goals, while others did not show improvement. Specifically, inspection of the graphs of children’s progress toward goals showed that some children responded well to this approach. It may be that motivational interviewing is successful only if children are overweight (Resnicow et al., 2006; So¨derlund et al., 2009). Nurses are in a good position to implement motivational interviewing when working with young children who are overweight in schools. This one-on-one technique is positive and child-focused and an easy method to learn to encourage children to attain healthy eating and exercise goals. Although parents were not receiving formal training about the CHEE program, many were learning about red and green foods from their children and from handouts and recipes that were sent home weekly with the children. Some of the parents were receiving recipes and handouts; however, some were lost in the transition from school to home. It may be advisable to request parent emails, so that materials can be sent to them in a convenient and accessible manner. Despite the inconsistency of information actually ‘‘getting to’’ parents, they reported that their children were satisfied the CHEE program and were learning new things as a result of participating in the program. Health professionals in schools and other community settings are in a good position to report information about healthy eating and ideas for healthy recipes on school websites and at events, such as health fairs, that parents might attend. This may be another avenue for reaching families with important health promotion materials. Several factors limited the generalizability of findings these studies. For example, ours were samples of convenience and in addition the comparison groups were not matched groups, weakening the research design. In addition, several children did not complete the survey at the end of the program. Moreover, the dose of the intervention and level of engagement in physical activity differed greatly across schools. At School 1 the sample was comprised of primarily African American youth, while at School 2 the majority of the students were Caucasian and
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the programs were taught in a classroom at School 1 and in the gymnasium for School 2. Thus, the programs differed, as did the settings, which has positive implications (the program can be delivered in different settings) and negative ones, because the projects were conducted differently in each setting. Providing an incentive for attending the final group might improve participation. Data are limited to self-report. As such, a social desirability bias could have influenced our results. Moreover, parent permission and child assent were needed for participation. Some parents may not have wanted their child to participate in our program. This may have limited recruitment; however, obtaining parent consent and child assent were important steps in our research process. Observations of physiologic measures (e.g. using accelerometers), gathering data using food diaries, and use of mealtime observations would yield objective information on whether change occurred for children participating in the intervention groups. Further research will be needed to examine the effectiveness of the CHEE program and determine whether the Traffic Light Diet can be successfully disseminated in after-school settings. Given the significance of the need for obesity prevention programming in our nation, it will be important to continue examining application of existing programs in after-school programs and to determine if the prevention programs result in lasting change in children’s knowledge and behaviors, and subsequently result in change in parent knowledge and health and wellness behaviors at home. Nurses and other health professionals are in a position to reach out to after-school programs and design and implement nutrition and exercise activities to promote health knowledge of young children. This is an under-utilized avenue for improving access to children who can benefit from being involved in healthy eating classes and having additional opportunities to participate in physical activities in school gymnasiums (these settings may be under-used in some school settings). Graduate students and nursing students also can gain valuable experience when helping implement this programming and this may improve their knowledge of and ideas about delivering health promotion programming in unique settings where they can reach children who may be in need of additional opportunities to engage in physical activity and learn about nutrition. ACKNOWLEDGMENTS The authors would like to thank the school, staff, and students who participated in this project and thank those at the School of Human Services at the University of Cincinnati who supported our work.
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