School - based universal prevention programs for pediatric obesity: State of the literature, future directions, and policy implications

About 95% of youth attend school (Story, Kaphingst, & French, 2006) and there are a variety of way in which schools can impact children’s weight and health status including promoti[r]

SCHOOL- BASED UNIVERSAL PREVENTION PROGRAMS FOR PEDIATRIC OBESITY: STATE OF THE LITERATURE,

FUTURE DIRECTIONS, AND POLICY IMPLICATIONS

Tran Thanh Nam, Assoc.Prof.PhD1 Abstract: Pediatric obesity is a growing public health concern To date there

has been limited success with childhood obesity prevention and interventions This may be due in part, to the challenge of reaching and engaging partners in preventions and interventions Among partners, schools provide an ideal place to provide preventive health services The goal of the current paper is to discuss the roles of schools in preventing pediatric obesity and overweight Specifically, the current paper will discuss the rationale for targeting schools for prevention efforts, results of school-based research and education programs, areas for further research, and policy implications of the research findings which can be applied for Vietnam

Keywords: pediatric obesity; school-based prevention programs; literature

review; policy implication

1 Introduction

Pediatric obesity is a growing public health concern In 1974, roughly five percent of youth were considered obese; in 2002, roughly 15 percent of youth were considered obese (CDC; 2005) Although there are many explanations for why children are becoming more obese, it is clear that interventions and policies are needed to address this issue Childhood overweight is such a widespread problem that the World Health Organization suggests that preventive public health policies are needed to effectively address this problem (James & Kerr, 2005; WHO, 1997) Schools provide an ideal place to provide preventive health services Thus, the goal of the current paper is to discuss the roles of schools in preventing pediatric University of Education – Vietnam National University, Hanoi;

obesity and overweight Specifically, the current paper will discuss the rationale for targeting schools for prevention efforts, results of school-based research programs, areas for further research, and policy implications of the research findings

2 Childhood obesity in Vietnam

Childhood obesity is a rising health concern in Vietnam, however, research in this area is not extensive Obesity is a risk factor for the onset of diseases such as type II diabetes, cardiovascular diseases, stroke and other metabolic disorders Childhood obesity is equally concerning, where excessive fat mass can affect many of the body’s systems from an early age Children who are obese are at greater risk of being obese as adults In terms of quality of life, obese children can find movement and breathing difficult and uncomfortable They also tend to be less self-confident with their appearance

According to Thanh CTY, Khan NC, Dat DT, 2004, in 1995, the prevalence of childhood obesity among primary school children in Ho Chi Minh City was 1.4% according to the CDC definition of obesity (BMI >95th percentile).5,6 Then, prevalence rose to 10.4% during 2002-2003, 16.3% in 2007,7 and 20.8% in 2008-2009 (International Obesity Task Force definition of overweight and obesity) Similarly, the figure was 10.4% in Hai Phong City (2000), 5.8% in Nha Trang (2001), and 10.4% in Buon Ma Thuot (2004) (Thanh CTY, Khan NC, Dat DT, 2004) In 2012, a survey on over 3,000 children at primary schools in Hanoi showed that 23.4% of them were overweight and 17.3% were obese Another survey conducted in 2013 on 2,375 children aged 4-9 years at kindergartens and primary schools in the city’s Hoan Kiem district, Hanoi, Vietnam indicated that the overweight and obese rate was 39.9%; more boys were obese than girls Among over 150 overweighed and obese children, 15.3% of them have high cholesterol levels As much as 82.7% of those children were physically inactive for over 120 minutes per day, while 18.7% consumed more calories than recommendations In Ho Chi Minh City, within seven years from 2002 to 2009, the rate of overweight and obese grade-schoolers increased by three to four times Head of the department Tran Dac Phu said the heath sector should build a proper strategy to prevent obesity among children and implement effectively the national strategy of preventing non-communicable diseases in 2015-2025 (Vietnam: Childhood obesity on the rise; 2016, Jul 26)

3 Targeting Schools

School-based interventions and policies provide a natural setting for the prevention and intervention of pediatric overweight and obesity Schools provide an established institution with corresponding infrastructure that will capture the target population About 95% of youth attend school (Story, Kaphingst, & French, 2006) and there are a variety of way in which schools can impact children’s weight and health status including promoting “good nutrition, physical activity, and healthy weights among children through healthful school meals and foods, physical education programs and recess, classroom health education, and school health services” (Story et al., 2006), p 110)

Despite the promise that the school environment has a positive impact on student weight and general health, many of the practices that commonly occur in school settings can actually have a negative impact on student weight One commonly cited concern is the availability of a la carte, food courts and vending machine items (Kubik, Lytle, & Story, 2005) that sell non-nutritious foods and sweetened beverages Many school districts have signed contacts with fast food and beverage distributors as a source of revenue to supplement shrinking budgets (Story et al., 2006) Another practice that is likely to have an impact on children’s weight status is the lack of adequate physical activity through structured physical education classes or unstructured play periods such as recess Some investigators have suggested that the No Child Left Behind Act of 2001 forces schools to cut out non-academic subjects such as health and physical education classes so that they can focus more on the academic subjects that are being tested (Story et al., 2006; Wiecha et al., 2004)

However, despite the trend towards policies and practices that are inconsistent with a health promotion message, these policies and practices could be modified or reversed to bring them more in line with a healthy weight message For example, many schools provide meals for students through the Federal School Lunch Program that are in competition with the high-fat, low-nutrient foods that are typically offered by for-profit companies (Story et al., 2006) The infrastructure for having an impact on children’s health is present, but needs to be modified to take full advantage of its influence Thus, since schools are already providing these services, it is easier to help them provide the most appropriate services rather than starting from the beginning and developing infrastructure

overweight children who are not able to enroll in medical center based intervention programs and those who are at risk for becoming overweight in the future (Ells, Campbell, Lidstone, Kelly, Lange, & Summerbell, 2005) Second, universal prevention programs in schools will potentially be able to modify factors promoting obesity on both environmental and individual levels An environment that is reinforces healthy weight messages is more likely to support students’ efforts than one that contains influences that are inconsistent with health promotion and obesity reduction Finally, school-based programs allow students to participate in activities with their peers and have the potential to provide peer-group reinforcement and decrease the stigma associated with participating in such a prevention program and improve outcomes

4 Research on School-based Prevention Programs

Several review papers have highlighted the current state of the research on prevention programs in schools A recent conceptual paper reports that of eight recent school-based prevention programs, one was targeted towards improving health, two were targeted towards increasing physical activity, and five consisted of multiple components (Ells et al., 2005) Reductions in weight as well as sedentary time were found for the health promotion and multiple component programs though there were no effects for the physical activity programs Unfortunately, the original research articles that were summarized in this paper are not widely available and thus it was not possible for the author of the current paper to review these studies for more specific details

The school-based obesity prevention literature is balanced out by several well-designed programs of research in this area One prevention in German schools contained eight hours of education about lifestyle choices including eating fruits and vegetables, reducing the consumption of high-fat foods, increasing physical activity to one hour per day and decreasing television watching to one hour per day At the three-month follow-up, children in the control schools had increases in their fat mass while children in the prevention schools did not (Muller, Asbeck, Mast, Lagnase, & Grund, 2001) The results of this study suggest that a minimal amount of education can have an impact on the body mass of students

that are taught in different subject areas with classroom teachers who volunteered to participate in the study (Spiegel & Foulk, 2006) The modules were designed to be integrated into core classroom curricular activities In addition, participants in the prevention group exercised with a 10-minute exercise video each day Those in the intervention group decreased their BMI by 2% and there were significantly less children in the intervention group classified as overweight or as being at risk for overweight Although both groups increased their consumption of fruits and vegetables, the intervention group had a greater increase The intervention group also showed a significantly greater increase in physical activity both at school and outside of school This study is notable in that the educational component is incorporated into multiple subject areas which reinforces the messages learned across contexts as well as being consistent with educational goals

In summary, school-based prevention efforts are likely to be effective in reducing obesity and improving other health-related behaviors such as decreased television viewing and healthier food choices The results of a recent meta-analysis summarizes the effectiveness of school-based interventions reported the effect size to be 50, a medium effect according to Cohen’s d (Haddock, Shadish, Klesges, & Stein, 1994) The meta-analysis also shows that parent participation at the medium level resulted in a large effect size while other levels of participation were associated with medium effect sizes Despite the promising results of these prevention programs, further research is needed

5 Future Directions

Several steps need to be taken in order to ensure that universal prevention programs for children are effective First, more studies should be conducted to determine the effectiveness of a wide-range of prevention programs Current prevention programs have mostly been tested in middle-school aged student without corresponding efforts at examining these programs in elementary and high school students Elementary and high school students are likely to benefit from preventions as well and it is important to ensure that the programs are developmentally appropriate and are acceptable within the unique environment of each type of educational setting Research efforts should also focus on determining the ages at which particular kinds of prevention efforts are most effective

example for a program that could be easily adapted into a universal program Carrel, Clark, Peterson, Nemeth, Sullivan, and Allen (2005) selected children with BMI’s greater than the 95th percentile and randomly assigned them to standard

gym classes or lifestyle fitness classes The lifestyle fitness classes were designed to maximize the amount of physical movement engaged in during each class and make fitness and nutrition more appealing to children by being ore fun Both groups had classes for 45 minutes five times every two weeks during the school-year Compared to the standard gym class group, the lifestyle fitness group had significantly greater decreases in body fat and significantly better cardiovascular fitness In addition, post-intervention, the lifestyle fitness group had significantly better fasting levels than they had at baseline while there were no changes in the standard gym class group; however, there were no significant between-group differences post-treatment

Third, more research should focus on understanding the moderators of prevention effects Several moderators of treatment have been identified including gender and race (e.g., Gortmaker et al., 1999) While researchers have speculated as to why these interventions have differential effects across populations, it will be important to go back to the basic literature to determine what might be accounting for these differences and how to address these issues in future intervention studies

Fourth, researchers should focus on developing universal prevention programs that are easily implemented and sustainable after a research team has developed the program Schools provide an excellent opportunity for making changes in practices and policies that are likely to impact students’ weight However, few prevention programs have examined the effectiveness of preventions that are as simple as removing vending machines from schools or limiting the type of food that is used as rewards in schools, both practices that are associated with increased BMI in students (Kubik et al., 2005) Although many communities have already begun adapting their policies and practices to address the pediatric obesity epidemic, no research has determined the efficacy of these efforts using rigorous methodologies Researchers will need to partner with states and with local school districts to assist in the study design and collect appropriate data Researchers will need to educate policy makers and school officials about the scientific method and the benefits of assessing outcomes through multiple methods Educators and policy makers will need to educate researchers about the particular demands of the state, community, and school to ensure that research projects are meeting the needs of the participants and stakeholders as well

weight status with respect to feeding, parental food habits, children’s exposure to particular types of food and nutrition knowledge, and physical and sedentary behaviors (Ells et al., 2005) Thus, it makes sense that interventions and policies that support families in their efforts to produce healthy children would be more effective than efforts that focus solely on children in schools Few studies have examined the inclusion of parents as a component of a universal prevention, but results from weight-loss treatment studies show that parents have the ability to influence children’s dietary habits, but found no impact of parental inclusion on children’s weight loss (Ells et al., 2005) Although the role of parents will vary throughout development, parents might be encouraged to eat meals with their children in elementary school, come to the school themselves for parent classes on nutrition, exercise, and health, and participate in physical activities at the school during the school day or after hours and on weekends (Story et al., 2006)

6 Policy Implications

States have begun to address the pediatric obesity epidemic Current policies that are being introduced by states include a re-emphasis on nutrition and physical education through curricular means, changing the school environments to be more consistent with messages of health and well-being, and restricting access to vending machines and changing the type of food that is offered through them (Rosenthal & Chang, 2004) A smaller number of states are focused on educating education departments about weight and working with community groups (Rosenthal & Chang, 2004)

It is commendable that legislation is being passed to help reduce the pediatric obesity, but it is important that policies be firmly grounded in empirical evidence At this point, there is not sufficient evidence to support changes to current school policies (Katz et al., 2005) However, there are several areas of policy that suggest priorities for high-quality prevention research Observational studies suggest that adding one hour of physical education class per week will decrease BMI in students, particularly females (Datar & Sturm, 2004) Research also suggests that limiting access to food and beverages and reducing the amount of food used as rewards in classrooms can decrease BMI (Kubik et al., 2005) Thus, these practices should be tested to determine whether the additional physical education and reduced opportunity to consume food and beverage are causally related to obesity

as the Department of Education, Department of Health and Human Services, Department of Agriculture, and the National Institutes of Health

7 Conclusion

In summary, pediatric obesity is a health concern that will be best addressed through multiple levels of prevention and intervention One promising venue for universal prevention efforts are public and private schools Research has shown school-based preventions can be effective in reducing overweight and obesity in youth, but fewer studies have examined universal prevention programs in schools More research is needed to determine which policies should be implemented or modified to reduce the prevalence and incidence of pediatric obesity and the lifetime health consequences that are associated with it

References.

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2 Caballero, B., Clay, T., Davis, S M., Ethelbah, B., Rock, B H., Lohman, T et al (2003) Pathways: A school-based, randomized controlled trial for the prevention of obesity in American Indian schoolchildren The American Journal of Clinical Nutrition, 78, 1030-1038

3 Carrel, A L., Clark, R., Peterson, S E., Nemeth, B A., Sullivan, J., & Allen, D B (2005) Improvment of fitness, body composition, and insulin sensitivity in overweight children in a school-based exercise program Archives of Pediatric and Adolescent Medicine, 159, 963-968

4 Datar, A., & Sturm, R (2004) Physical Education in Elementary School and Body Mass Index: Evidence from the Early Childhood Longitudinal Study American Journal of Public Health, 94, 1501-1506

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