Start Strong Walking and Breakfast Program

1. Start Strong Walking and Breakfast Program Presentation as part of Public Health Nutrition

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

3. Background

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

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

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

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

8. School Breakfast Program Barriers • Time • Late buses, school arrivals or long commutes • Students not hungry in the morning • Stigma associating the SBP with poverty

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

10. Physical Activity in School Associated With: • Increased physical activity outside of school • Decreased BMI • Decreased incidence of chronic disease • Improved cardiovascular fitness • Decreased TV screen-time • Decreased consumption of high-fat snacks • Improved academic performance

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

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

13. Barriers to Active Transportation • Unsafe neighborhoods • Inclement weather • Traffic and congestion • Lack of sidewalks and crosswalks • Suburban sprawl

14. Start Strong Program Description

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

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

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

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

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

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

21. Analysis of Hands-Up Survey Data • Proportion calculated for each breakfast and transportation category • Used a two-sample proportion hypothesis test to compare each intervention school to the control school • Significance was defined as a two-sided p-value <.05

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

23. Hands Up Survey Results and Discussion

24. Hands Up Student Breakfast and Transportation Survey “Please enter the number of students who raise their hand for each of the following”:

26. Hands Up Survey: “Where did you eat breakfast today?” * Significant compared to control (p<.05)

28. Hands Up Survey: “How did you get to school today?” * Significant compared to control (p<.05)

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

30. Parent/Guardian Interview Results and Discussion

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

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

33. Qualitative Breakfast Data • Breakfast is important • Provides energy • Improves learning • 1st meal of the day • Breakfast at home • Family eats together • Late bus arrival • Food isn’t good enough at school

34. How to Improve Breakfast Participation • Parents would participate if • More nutritious food • More organic food • Better quality food • Don’t participate because • Time constraints • Lack of trust

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

36. Qualitative Responses - Walking • Parents think walking is important for themselves and their children • They think walking • Encourages socialization • Benefits health • Improves concentration • More students walk to school when it is “Walking Wednesday”

37. Barriers to Walking Participation • Distance – Biggest barrier • Safety • Weather • Lack of sidewalks and construction

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

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

40. Teacher/Staff Interview Results and Discussion

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

42. Teacher/Staff Responses - Breakfast • 12 of 17 thought parents were participating • 5 of 17 thought that communication was improved with parents • 10 of 16 thought students’ knowledge of healthy eating changed • 9 of 17 thought students’ attitude towards breakfast eating had changed • 12 of 17 thought students doing better academically because of breakfast

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

44. How to Improve Breakfast Participation • Implement more frequent taste tests • Getting kids back to class on time • Permanent nutrition program aside from PE instruction

45. Teacher/Staff Responses - Walking • 7 of 17 thought it improved school communication and trust • 9 of 15 believed the walking program is safe • 12 of 17 believed students more aware of health benefits of walking • 7 of 17 believed students’ attitude towards walking had changed • 4 of 17 thought children doing better academically

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

47. How to Improve Walking Participation • Staff participation is currently keeping the walking program afloat • Get more parents to participate • Staff is overburdened and want this to be parents’ responsibility

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

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

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