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

1. Multi-Component School Nutrition Programs to Improve Nutritional Behavior & Nutritional Status of Children & Adolescents Laurie Anderson

2. Agenda • Background • Methods • Program effectiveness • intake behaviors • physiologic indicators • health status • school achievement

3. Nutrition Review Team Jonathan Fielding Community Guide Task Force William Dietz CDC NCCDPHP DNPA Jay Hirschman USDA Food and Nutrition Services Charlotte Neumann UCLA Maternal & Child Nutrition Mary Frances Piccano NIH Office of Dietary Supplements Barry Popkin UNC-Chapel Hill Walter Willett Harvard School of Public Health

4. Nutrition Review Staff Laurie Anderson Community Guide Branch Lynne Smith Community Guide Branch Study Abstractors: Carolynne Shinn Brandeis University Elizabeth Fiddler University of Washington Karin Johnson Fred Hutchinson Cancer Research Victoria Warren-Mears Oregon Health and Science Univ. Technical & Analytic Support: Susan Norris CDC NCCDPHP DDT Xuanping Zhang CDC NCCDPHP DDT

5. Nutrition Consultation Team James W. Anderson University of Kentucky Mary B. Burdick Veterans Administration Tim Byers University of Colorado Susan Crockett General Mills Adam Drewnowski University Washington Christina Economos Tufts University Diane Finegood Canadian Institute of Nutrition, Metabolism and Diabetes Karen Glanz Emory University Beverly Green Group Health Cooperative Ellen Harris USDA Richard Harvey Veterans Administration

6. Consultation Team (Cont.) Greg Heath CDC NCCDPHP DNPA Lori A. Kaley Maine Nutrition Network Shiriki K. Kumanyika University of Pennsylvania Ester Myers American Dietetic Association Ike Okosun Mercer University Gretel Pelto Cornell University James Sallis San Diego State University Howell Wechsler CDC NCCDPHP DASH  Curt Weidmer California DHS

7. LOGIC FRAMEWORK NUTRITION & COMMUNITY HEALTH Intermediate Outcomes Modifiable Determinants POPULATION FOOD INTAKE Food Consumption Patterns (e.g. fruits, vegetables) Intake of Nutrients and Food Components Vitamins Minerals Fiber Fats Other food constituents Dietary supplements Alcohol Energy balance Food Supply Factors -Agriculture policy -Nutrition policy -Science and technology -Food production, processing, storage and distribution -Food fortification -Food safety Physiologic Indicators Growth Adipose tissue Musculoskeletal Gastrointestinal Metabolic Cardiovascular Reproductive Immunological Neurological I N T E R V E N T I O N S Community Health Outcomes Environmental Factors Food Availability & Price -Neighborhoods -Schools -Worksites -Homes -Local, state & national food assistance programs • Morbidity • Mortality • Measures of Health & Fitness • Quality of Life Life Stage Requirements Pregnancy Lactation Childhood Adolescence Adulthood Older Adulthood Consumer Demand -Household resources -Nutrition knowledge -Cultural practices -Psychosocial characteristics -Taste and preferences -Advertising and marketing Physical Activity Patterns Genetics, Co-morbidities

8. Priority Ranked Topics • Food & beverage availability in schools • Comprehensive community approaches to increase fruit & vegetable intake • Food and beverage advertising to children • Food & beverage availability, price, portion size, and labeling in restaurants

9. Other Systematic Reviews of School-based Nutrition Interventions • Resnicow 1997 16 school-based CVD trials, computed ratio of + to – effects based on p values Diet outcomes 35/141 25% Adiposity 7/77 9% Blood pressure 15/67 22% Lipids 16/60 27%

10. Other Systematic Reviews of School-based Nutrition Interventions • Campbell 2001 10 studies of obesity prevention ( 8 in schools or nursery schools) Concluded there was limited quality data on effectives of obesity prevention programs and no generalizable conclusions could be drawn. They suggest strategies to reduce sedentary behavior and increase physical activity may be fruitful.

11. Other Systematic Reviews of School-based Nutrition Interventions • EPPI Center 2001 Systematic review of research on barriers to healthy eating, children aged11 to 16 22 intervention studies identified but only 7 studies provided: • impact of intervention for all outcomes • equivalent study groups at baseline • report both baseline and follow up data • post intervention data on all study groups Conclusion: insufficient quality research

12. Other Systematic Reviews of School-based Nutrition Interventions Ammerman 2002 Efficacy of behavioral intervention to modify dietary fat and fruit and vegetable intake • School setting (3 studies) pooled mean diff in change fat as % kcal 2.19 (1.49 – 2.89) greater decrease • Among children and adults combined (n=22 studies) in a variety of settings, increase of 0.6 servings in fruit & vegetable servings/day reported

13. Other Systematic Reviews of School-based Nutrition Interventions • Kristjansson B. 2002 protocol for effectiveness of school feeding programs for low-income children to reduce disparities in • nutrient intake • nutritional status • cognition • school attendance • performance In progress

14. Nutrition Topic Under Review Multi-component school-based interventions for improving nutrition related behavior & status of children and adolescents

15. Rationale • 53 million U.S. children in school 6 hours a day • >95% 5-17 year olds enrolled in school • Nutrition key for healthy growth & development • 79% eat <5 servings of fruit & vegetables a day* • 34 % kcal from total fat ( < 30% recommended)† • 13% kcal from saturated fat (< 10% recommended)† *YRBS 2001 † USDA 1989-91 CSFII

16. Rationale • Dietary and physical activity patterns in childhood associated with adult health status • In US & other countries rates of overweight and obesity in children & adolescents have increased • 14% at risk for overweight >85th percentile but <95th percentile BMI* • 10% are overweight >95th percentile BMI *CDC growth charts NCHS 2000

17. Rationale • More recently in children are increased rates of hyperlipidemia, hypertension, and type 2 diabetes, previously limited to adults • Obesity typically persists from childhood & adolescent into adulthood • U.S. obesity-attributable medical expenditures reached $75 billion in 2003 (Finkelstein 2004)

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

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

20. Intervention Definition School-based nutrition interventions are implemented in the school settings to promote healthy nutritional attitudes, knowledge and behavior, including eating and physical activity among school-aged children and adolescents. • target food policy, environmental factors and/or nutrition education • school administrators, food service staff, teachers or parents or directly to students • delivered by regular classroom teachers or by special program instructors

21. Classroom instruction by teacher +/- nutrition education instruction • Physical activity incorporated into life style • Integrated learning (nutrition included across curricula—math, writing, social studies, etc) • Media literacy and consumer education • Food gardening, food prep, cooking • Self-evaluation (diet evaluation, food records) for middle and high school ages • Food service staff training • Peer training Educational Components

22. Environmental Components • Time and place for school meals, snacks • School resources for food prep and service • Media messages: posters, school intercom, radio, etc. • Social marketing • School menus/pricing, a la carte • Vending machines/contents and pricing (junk food “tax”) • Classroom snacks and special treats • Food as rewards (reading programs, good behavior) • Fund raising activities for school groups

23. Other Components Policy, stake holder participation in planning & decision making • Government policies • School board • Principals • Food service • Parents, teachers • Kids Parent/family education and involvement (newsletters, family fun activities) Community (community centers, grocery stores)

24. Excluded • Feeding programs • Weight management programs for overweight children

25. Outcomes • Nutrition knowledge & attitudes • Dietary behavior • fruit & vegetable intake, fat intake • Physical activity • Physiologic indicators • BMI, weight percentile, obesity prevalence • Skinfold thickness • Health status • blood pressure, plasma cholesterol

26. Search Results Literature search • 1980-2003, publications, dissertations, government reports, US & non-US • 1500 abstracts, ~150 papers, 76 studies • dual abstraction completed on 76 studies • 13 studies did not meet inclusion criteria • 14 studies (22%) excluded due to limitations in quality • 51 reports of 46 studies

27. Body of Evidence Identified: 46 studies described in 51 reports Best Evidence Subset: 46 studies

28. Study Aims 25 Cardiovascular disease risk reduction* 16 Healthy diet 8 Cancer risk reduction* 2 Obesity prevention 1 Diabetes risk reduction *2 CVD & cancer risk

29. CHARACTERISTICS OF INTERVENTIONS 32 Curriculum + Behavioral Awareness 10 Curriculum + Behavioral Awareness + Environment 16 Curriculum + Behavioral Awareness + Home/Family 15 Curriculum + Behavioral Awareness + Physical Activity 5 Curriculum + Behavioral Awareness + Physical Activity + Home/Family 6 Curriculum + Community 10 Curriculum + Peer/Social Support 14 Curriculum + Environment 16 Environment + School Menu/Pricing

30. CHARACTERISTICS OF STUDY POPULATIONS • Grades included: # studies K-6 : 40 7-9: 8 10-12: 6 • Mean age 10-11 years (often not reported)

31. OUTCOMES REPORTED Behaviors dietary intake 40 physical activity13 School Policy Environmental support for healthy choices Knowledge 25 nutritional needs food content Attitudes 13 self-care body image Abilities 5 self-assessment behavioral change skills media literacy Physiologic 16 Indicators body size & composition growth fitness Health status 12 blood pressure cholesterol general health School Achievement attendance participation performance social behavior Multi-component School-based Nutrition Interventions Nutrition & health messages Promotion of self-awareness, self-efficacy

32. Behavioral Outcomes Intake of Fruit and Vegetables Intake of Fat and Saturated Fat

33. Fruit & Vegetable Intake Effects %  I - %  C Program Duration 2 years 1 year 2-3 months 11 studies reporting 14 effect measures Resnicow 1992 Nicklas 1998 Gortmaker 1999 Gortmaker 1999b Sahota 2001 Birnbaum 2002 Stewart 1997 Perry 1998 Fries 2001 Friel 1999 Reynolds 2002 2 Median effect size: All studies 6% Studies with school menu/food choice component 11% Intervention included school menu/food choice component

34. % kcal from Fat Intake Effects %  I - %  C Nader 1999 Walter 1988 Lytle 1996 Perry 1998 Reynolds 2000 Gortmaker 1999 Gortmaker 1999b Ellison 1990 Vandogen 1995 Self-report Observed Median effect size -6% Boy Girl 9 studies reporting 12 effect measures

35. Other Fat Intake Effects %  I - %  C 10 studies reporting 13 effect measures Birnbaum 2002 Resnicow 1995 Davis 1995 Turin 2001 Holcomb 1998 Sallis 2003 Manios 1999 Steward 1997 Fries 2001 Simmons-Morton 1991 Self-report high fat foods Observed Median effect size -2.5% Boy Girl

36. Saturated Fat Intake Effects %  I - %  C Absolute Mean Difference Vandongen (1995) girls, boys Walter (1988) Brx, Wch Bush (1989) Reynolds (2000) Gortmaker (1999b) Ellison (1990) girls,boys Perry (1998) Lytle (1996) Manios (1999)

37. Polyunsaturated/ Saturated Fat Ratio  I -  C Absolute Mean Difference Manios Walter Brx, Wsch Vandongen girls Vandongen, boys Ellison girls, boys 2 2 4 studies reporting 15 effect measures

38. Limitations of outcome measures: • self report • social desirability • validity of instruments

39. Anthropometric Outcomes BMI Triceps Skinfold

40. Adiposity Effects: BMI %  I - % C Age range: 9-15 yrs 11 studies reporting 16 effect measures Program Duration 5 years 2 years 1 year <1 year Walter 1999 Nader 1999 Bush 1989 Sallis 2003 Tell 1987 Sahota 2001 Vandogen 95 Stewart 1997 Harrell 1999 Killen 1988 Hoper 1996 2 9 Median Effect Size: All studies 0% Boys -2.7% Girls -0.3% Boy Girl Boys & Girls no physical activity component

41. Adiposity Effects: Triceps Skinfold%  I - %  C 8 studies reporting 12 effect measures (Age) Goldberg 1980 (8) Nader 1999 (9) Bush 1989 (10.5) Tell 1987 (11) Vandongen 95 (11) Harrell 1999 (8.9) Killen 1988 (15) Hopper 1996 (10.5) Median Effect Size: All studies 0% Boys 4.3% Girls -5.4% Boy Girl Boys & Girls no physical activity component

42. Adiposity Effects: Triceps Skinfold I -  C Absolute Mean Difference girls boys Bush 89 Harrell 99 Killen 88 Goldberg 80 Tell 97 Vandongen 95 girls Vandongen 95 boys boys girls

43. Limitations of outcome measures: • developmental trajectories • accuracy of skinfold measure • sensitivity to detect change/ program duration sufficiency • intervention program intent

44. Health Status Outcomes Systolic Blood Pressure Serum Cholesterol

45. Health Effects: Systolic B/P I -  C 10 studies reporting 16 effect measures Program Duration 5 years 2 years 1 year 2 months Walter 1988 Resnicow 92 Nader 1999 Goldberg 1980 Bush 1989 Vandongen 95 Stewart 1997 Harrell 1999 Killen 1988 Tell 1987 10 studies reporting 16 effect measures Median effect size 0.3%

46. Health Effects: Systolic B/P I -  C Bush Harrell (risk, ed & PA) Killen (girls, boys) Nader Stewart Vandongen, boys Vandongen, girls Resnicow (hi, med, lo) Goldberg 8 studies reporting 30 effect measures

47. Health Effects: Serum cholesterol%  I - % C 11 studies reporting 14 effect measures Program Duration 5 years 2-3 years 1 year 2-3 months Walter 1988 Webber 1996 Resnicow 1992 Goldberg 1980 Nader 1999 Bush 1989 Tell 1987 Vandongen 1995 Stewart 1997 Gans 1990 Harrell 1999 Median effect size -3%

48. Health Effects: Serum cholesterol  I -  C Harrell 99, risk, ed & PA Bush 89 Gans 90 Goldberg 80 Resnicow 92 Tell 97 Vandongen 95, boys Vandongen 95, girls Walter 88, Brx, Wsch Webber 96 9 studies reporting 21 effect measures

49. Limitations of outcome measures: • developmental trajectories • normal variability in B/P & interpretation of program effects • differences in cholesterol measurements

50. Multicomponent School-based Nutrition Interventions Increase Fruit and Vegetable Intake and Decrease Intake of Fat and Saturated Fat in School Age Children • There is sufficient evidence to conclude that multicomponent school-based nutrition interventions are effective in …………………….. • magnitude of program effect differed by…………………