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Study: Students eat healthier when nutrition programs involve teachers, staff, parents

Tailored programs could reduce obesity, help implement federal wellness policies

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Programs to promote healthy eating can substantially reduce the amount of unhealthy foods and beverages on school grounds if the programs focus on a school's specific needs and involve teachers, parents, staff, and administrators, according to a Kaiser Permanente Southern California study published in BioMed Central's open access journal International Journal of Behavioral Nutrition and Physical Activity.

The Healthy Options for Nutrition Environments in Schools (Healthy ONES) study used a public health approach to change nutrition environments and policies in eight elementary and middle schools, including the schools in the Lemon Grove School District, over a three-year period. The study was funded by the U.S. Department of Agriculture's National Research Initiative and included 400 students.

Researchers found that using a more participatory public health approach decreased by 30 percent the amount of unhealthy foods and beverages in intervention schools. Control schools, by comparison, had a 26 percent increase in these items. Healthy food brought from outside sources also increased during lunch in intervention schools.

"Schools are an ideal place for establishing life-long healthy eating habits, but until now that's been easier said than done," said study lead author Karen J. Coleman, PhD, from Kaiser Permanente Southern California's Department of Research and Evaluation. "The Healthy ONES study helped us understand how communities and schools could work together to get kids to eat healthier at school and help address childhood obesity."

This study reinforces the latest recommendations on obesity prevention from the Institute of Medicine. The new report, Accelerating Progress on Obesity Prevention, describes schools as "the heart of health." The report identifies school-based interventions as among the most promising to prevent childhood obesity and underscores the need to implement policies that change food environments within schools.

"If we want to have the broad reach and impact necessary to address the enormity of the childhood obesity epidemic, it's critical that we engage children and their families within school communities," said Loel Solomon, PhD, vice president of community health at Kaiser Permanente. "Powerful results like these are why school-based interventions are a key element of Kaiser Permanente's prevention strategy, and why we will be redoubling our efforts in schools in the years to come."

In the study, researchers worked with teachers and administrators to change certain unhealthy nutrition practices. They replaced food and beverage classroom rewards with nonfood prizes and implemented nutrition-conscious catering at schoolwide events and classroom celebrations. For fund-raising activities, they served healthy foods and beverages, awarded nonfood prizes, and included games such as a "prize walk," rather than a "cake walk." In addition, schools were able to make more money using healthy events like "jog-a-thons" than fall carnivals with popcorn and pepperoni pizza.

According to the study, a public health approach may be more effective in changing school environments and policies because of stakeholder engagement in intervention design, implementation, and evaluation. This differs from other traditional methods that fundamentally ignore the multiple school-level issues that may affect intervention effectiveness.

Although researchers hypothesized that these school environment and policy changes would reduce childhood obesity rates, no changes were observed. This is likely due to the short period of observation after the changes were implemented in the schools. Nevertheless, by building capacity within schools to make and sustain change, the Healthy ONES model could contribute significantly to efforts to prevent childhood obesity, the authors stated.

"Our findings are significant because previous school-based interventions often have had little success in changing behaviors," said Dr. Coleman. "The Healthy ONES study suggests that community-driven process interventions that focus on implementation and stakeholder engagement can help schools implement their current federally mandated wellness policies. These types of interventions may have a better chance to impact child obesity than other attempts to change school health practices."

This study is part of Kaiser Permanente's ongoing work to identify and treat childhood obesity through research and community programs. Previous research studies related to childhood obesity include:

- A study published in May in the Journal of Pediatrics found that children who are overweight or obese -- particularly older, non-Hispanic white girls -- are more likely to have a neurological disorder known as idiopathic intracranial hypertension, a rare condition that can result in blindness.

- Another study in the Journal of Pediatrics found that electronic health records and embedded tools can alert and direct pediatricians so they can better manage the weight of children and teenagers.

- A study in 2011 that used electronic health records of more than 700,000 patients to determine that children who are overweight or obese have a significantly higher prevalence of psoriasis, a chronic inflammatory disease of the skin.

- A study in February that found the prevalence of asthma among children and adolescents who are overweight or obese varies widely by race and ethnicity. The study also found that the association between childhood asthma and increasing body mass index is strongest in Hispanics and weakest in African Americans.

- A study that found extremely obese children have a 40 percent higher risk of gastroesophageal reflux disease and children who are moderately obese have a 30 percent higher risk of GERD compared to normal weight children,

- A study that found extreme obesity is affecting more children at younger ages, with 12 percent of African American teenage girls, 11.2 percent of Hispanic teenage boys, 7.3 percent of boys, and 5.5 percent of girls 2–19 years of age now classified as extremely obese.

Kaiser Permanente is working with HBO, the Institute of Medicine, the Centers for Disease Control and Prevention, National Institutes of Health and the Michael & Susan Dell Foundation to address obesity as a critical public health crisis with HBO's latest documentary series: The Weight of the Nation. The series and public health campaign spotlights the severity of the obesity epidemic and showcases strategies that work in order to catalyze action to end obesity.

Other study authors included Maggie Shordon, MPH, Susan L. Caparosa, MA, Magdalena E. Pomichowski, MA, of the Kaiser Permanente Southern California Department of Research and Evaluation; and David A. Dzewaltowski, PhD, of the Department of Kinesiology, Kansas State University.

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