StartStrong Presentation

Start Strong Walking and Breakfast Program: 

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

Outline: 

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

Slide3: 

Background

What is the Need for School Interventions in Nutrition and Physical Activity?: 

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

Significance of nutrition in schools: 

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

Importance of School Breakfast- determined by SBP data: 

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

School Breakfast Program Need and Utilization: 

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

School Breakfast Program Barriers: 

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

Importance of Physical Activity in School: 

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

Physical Activity in School Associated With:: 

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

School Walking Programs and Active Transportation: 

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

Utilization of Active Transportation Programs: 

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

Barriers to Active Transportation: 

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

Start Strong Program Description: 

Start Strong Program Description

Purpose of Start Strong: 

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.

Program Objectives: 

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

Logic Model: 

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

Program Schools: 

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)

Intervention: 

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

Data Collection: 

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

Analysis of Hands-Up Survey Data : 

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

Analysis of Key Informant Interviews: 

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

Hands Up Survey Results and Discussion: 

Hands Up Survey Results and Discussion

Hands Up Student Breakfast and Transportation Survey: 

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

Hands Up Survey: “Where did you eat breakfast today?”: 

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

Hands Up Survey: “How did you get to school today?”: 

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

Hands Up Survey Limitations: 

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

Parent/Guardian Interview Results and Discussion: 

Parent/Guardian Interview Results and Discussion

Parent Interviews: 

Parent Interviews

Parent Responses - Breakfast: 

Parent Responses - Breakfast

Qualitative Breakfast Data: 

Qualitative Breakfast Data

How to Improve Breakfast Participation: 

How to Improve Breakfast Participation

Parent Responses - Walking: 

Parent Responses - Walking

Qualitative Responses - Walking: 

Qualitative Responses - Walking

Barriers to Walking Participation: 

Barriers to Walking Participation

Parents’ Suggestions: 

Parents’ Suggestions

Limitations: 

Limitations

Teacher/Staff Interview Results and Discussion: 

Teacher/Staff Interview Results and Discussion

Teacher/Staff Interviews: 

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

Teacher/Staff Responses - Breakfast: 

Teacher/Staff Responses - Breakfast

Qualitative Breakfast Data: 

Qualitative Breakfast Data

How to Improve Breakfast Participation: 

How to Improve Breakfast Participation

Teacher/Staff Responses - Walking: 

Teacher/Staff Responses - Walking

Qualitative Walking Data: 

Qualitative Walking Data

How to Improve Walking Participation: 

How to Improve Walking Participation

Barriers to Walking Participation : 

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

Teacher/Staff Suggestions: 

Teacher/Staff Suggestions

Limitations: 

Limitations

Discussion: 

Discussion

Discussion of Limitations: 

Discussion of Limitations Ideal study design would be an RCT Assumption that control and intervention schools were identical in: Student populations Family SES Surrounding physical environments Limited timeframe for conducting: Hands-up surveys Key informant interviews

Potential Sources of Error: 

Potential Sources of Error Observers not blinded toward control or intervention schools Self-reported data Students may not have understood survey questions Parents may not have understood questions Self-selection of key-informant interviewees

Conclusions and Recommendations: 

Conclusions and Recommendations

Conclusions: 

Conclusions Start Strong program positively impacts: Students’ breakfast consumption habits and attitudes toward healthy eating Students’ attitudes toward walking to school Built environment must be conducive for students to walk to school (weather, distance, safety, cross-walks) Further research required to determine the impact of this program on the community Research will help support school policies and programs that can further positively impact the healthy eating behavior and physical activity of children

Recommendations: Future Research: 

Recommendations: Future Research Establish larger sample sizes Collect data at multiple time points Longer timeframe for data collection Consideration of weather and distance in assessing feasibility of walking programs

Recommendations: 

Recommendations Improve teacher/staff and parent participation Offer more opportunities for incentives Clarify roles for teachers/staff and parents Improve communication Relationship-building opportunities Implement walking program during a warmer season Create drop-off points for walking school bus Conduct school bus weekly rather than monthly

Acknowledgments: 

Acknowledgments

Questions?: 

Questions?

References: 

References Ask, Anne S. Changes in dietary pattern in 15 year old adolescents following a 4 month dietary intervention with school breakfast, Nutrition Journal 2006, 5:33. Berrigan et al. Active transportation Increases Adherence to Activity Recommendations. American Journal of Preventative Medicine. 2006: 31 (3). Bickel G, Carlson S, Nord M: Household Food Security in the United States 1995–1998; Advanced Report. Alexandria/Va, Food and Nutrition Service, United States Department of Agriculture, 1999 www.fns.usda.gov/oane/MENU/Published/FSP/FiLES/foodsec98.pdf. Carter, The Impact of Public Schools on Childhood Obesity. JAMA 2002. Cooper, R, et al, Active travel to school and cardiovascular fitness in Danish children and adolescents. Med Sci Sports Exerc. 2006 Oct;38(10):1724-31) Cooper, A.R. et al. Physical Activity Levels of Children who walk, cycle, or are driven to school. American Journal of Preventative Medicine. 2005: 29 (3) 179-184. Center for Disease Control and Prevention (CDC): Obesity: http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm Healthy School Program: http://www.cdc.gov/nccdphp/dnna/kidswalk/ Crepinsek, M.K. et. al., J Am Diet Assoc. 2006;106:1796-1803 Eisenmann JC, Physical activity, TV viewing, and weight in U.S. youth: 1999 Youth Risk Behavior Survey. Obes Res. 2002 May;10(5):379-85). Evenson, K.R. et al. Girls’ perception of physical environmental factors and transportation: reliability and association with activity and active transport to school. International Journal of Behavioral Nutrition and Physical Activity. 2006; 3:28. Erickson, SJ et al, Are overweight children unhappy?: Body mass index, depressive symptoms, and overweight concerns in elementary school children. Arch Pediatr Adolesc Med. 2000 Sep;154(9):931-5). FRAC websites: FRAC Wellness Guide 2006: http://www.frac.org/pdf/wellness_guide 2006.pdf FRAC USBP Pilot Summary FRAC School Breakfast Program

References: 

References Fulton JE, Shisler JL, Yore MM, Caspersen CJ. Active transportation to school: findings from a national survey. Res Q Exerc Sport. 2005;76:352–7. Injury Free Coalition For Kids of Seattle: Breakfast and child obesity: What’s the link? http://courses.washington.edu/nutr531/StartStrong/Breakfast%20and%20Child%20Obesity.doc IOM Fact sheet – Childhood obesity in the United States (2004). Available at: http://www.iom.edu/Object.File/Master/22/606/FINALfactsandfigures2.pdf. Accessed 3-1-07. Kids Count: State-level data online. Available at: http://www.aecf.org/kidscount/sld/snapshot.jsp. Accessed 3-1-07. Kleinman RE, Murphy JM, Little M, Pagano,M, Wehler CA, Regal K, Jellinek MS: Hunger in children in the United States: Potential behavioral and emotional correlates. Pediatrics 1998;101:100–111. Miech, R.A et al. Trends in the association of poverty with overweight among US adolescents, 1971-2004. JAMA 2006. Position of the ADA: Local Support For Nutrition Integrity In Schools. J Am Diet Assoc. 2006;106:122-133. Safe Routes To School: http://www.saferoutesinfo.org Radcliffe, B et al. The Queensland School Breakfast Project: A health promoting schools approach. Nutr Diet 2005; 62:33-40. Recommendations for Strengthening Community Programs for Youth. New York, NY: Carnegie Corporation of New York, 1994. M. Sharma et al, School-based interventions. The International Association for the Study of Obesity. Obesity Reviews 7, 261-269 (2006). Sirard JR, Ainsworth BE, McIver KL, Pate RR. Prevalence of active commuting at urban and suburban elementary schools in Columbia, SC. Am J Public Health. 2005;95:236–40. Sirard JR, Riner WF Jr, McIver KL, Pate RR. Physical activity and active commuting to elementary school. Med Sci Sports Exerc. 2005 Dec; 37(12):2062-9. Tudor-Locke C, Ainsworth BE, Popkin BM. Active commuting to school: an overlooked source of children’s physical activity? Sports Med. 2001;31:309 –13.

References: 

References Tudor-Locke, C, et al. Omission of active commuting to school and the prevalence of children's health-related physical activity levels: the Russian Longitudinal Monitoring Study. Child Care Health Dev. 2002 Nov;28(6):507-12). United States Department of Agriculture (USDA): USDA Nutrition Insights: Eating school breakfast greatly improves schoolchildren’s diet quality. USDA School Breakfast Program. USDA SBP Fact Sheet: http://www.ns.usda.gov/cnd/breakfast/ US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000]. http://www.healthypeople.gov/document/HTML/Volume2/22Physical.htm http://www.healthypeople.gov/document/HTML/Volume2/19Nutrition.htm Walking School Bus: http://www.walkingschoolbus.org