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Childhood Obesity Study: A Pilot Study of the Effect of the Nutrition Education Program Color My Pyramid
The need for successful nutrition interventions is critical as the prevalence of childhood obesity increases. Thus, this pilot project examines the effect of a nutrition education program, Color My Pyramid, on children’s nutrition knowledge, self-care practices, activity levels, and nutrition status. Using a pretest–posttest, quasiexperimental design, 126 fourth- and fifth-grade students from experimental and control schools are compared. The intervention program incorporates an online component www.MyPyramid.gov, Orem’s Self-Care Deficit Nursing Theory, and consists of six classes taught over a 3-month period. Results indicated that the program increased nutrition knowledge in the control group. Furthermore, it increased activity time from pretest to posttest and decreased systolic blood pressure for children in both groups; however, there were no significant differences in BMI percentiles. The findings indicate that Color My Pyramid can be successfully employed in school settings and thus support school nursing practice.
Key Words: childhood obesity • nutrition education • Orem’s Self-Care Deficit Nursing Theory • health education • physical activity • health behaviors
The prevalence of overweight and obesity among school-age children in the United States has almost quadrupled during the past 25 years (Small, Anderson, & Melnyk, 2007). Racial differences place some children at higher risk. A recent study found that among children ages 6–11, 36.9% of non–Hispanic African American children and 42.8% of Hispanic American children were overweight or at high risk for becoming overweight, compared to 31.6% of non–Hispanic white children (Ogden, Carroll, & Flegal, 2008). Geographic differences illuminate additional risks. Results from the Youth Risk Behavioral Survey 2007 for the District of Columbia showed that 35.5% of predominantly African American high school students were overweight or obese (Eaton et al., 2008). The obesity trend is a concern because childhood obesity increases a child’s risk for long-term health problems, including type 2 diabetes, hypertension, liver disease, sleep apnea, and orthopedic difficulties (Crosson, Kessler, & Rosenstock, 2006; Dunn & Schwimmer, 2008). Obesity-related physical and psychological comorbidities increase the risk of premature death, the burdens of health care costs, and lost worker productivity (American Public Health Association [APHA], 2004a; Baker, Olsen, & Sorenson, 2007). Decreasing the incidence of obesity among children requires targeting their diet and activity levels (Nemet et al., 2005). Because 95% of all school-age children in the United States attend school, schools are uniquely positioned to address childhood obesity (APHA, 2004b). In all, 35–40% of children’s daily caloric intake occurs during the school day; therefore, a comprehensive nutrition intervention designed to prevent and reduce the number of overweight and obese children could logically be implemented in schools (APHA, 2004b). The Institute of Medicine (2004) recommended that schools "provide a consistent environment that is conducive to healthful eating behaviors and regular physical activity" (p. 15). It delineated several school-based interventions to address this recommendation, two of which are pertinent to the present study: (a) meals that meet the dietary guidelines set by the United States Department of Agriculture (USDA), as explained in MyPyra-mid.gov and (b) health curricula focused on nutritional eating, physical activity, and reducing sedentary behavior.
Self-care deficit nursing theory (Orem, 2001) was the theoretical framework used to develop the interventions, measurement approaches, and self-assessment components of this study. Self-care is defined as taking responsibility and performing activities to promote and maintain one’s health state. Self-care agency is the learned ability to perform self-care and meet one’s own needs; it involves knowledge, experience, skill range, and motivation. Self-care activities or practices involve three types of operations as follows: (a) estimative: acquiring information, (b) transitional: planning and decision making, and (c) productive: acting and evaluating (Cox & Taylor, 2005; Dennis, 1997; Orem, 2001; Renpenning, Bekel, Denyes, Orem, & Taylor, 2004). The intervention in this study was structured to assist children to take responsibility for their own food choices and physical activity rather than relying on parental decision making. The nutrition education classes were designed to increase children’s self-care agency by providing information, increasing motivation, giving children opportunities to participate in activities, and encouraging peer support. The researchers taught children how to evaluate their dietary intake using the computer program MyPyramid.gov Kids Blast-Off Game (USDA, 2007). The overall goal of the program was to improve children’s nutrition-related self-care operations. To determine the outcomes of the program, the researchers measured knowledge, an important component of self-care agency, and self-care practices using an instrument that specifically measures self-care operations.
Obesity is an ongoing concern for children in the United States. The obesity epidemic among children in the United States has been recognized for more than a decade. Knowledge about the short- and long-term adverse sequelae of childhood obesity continues to increase. In the United States, several populations are at increased risk for obesity, including children who live in low-income communities as well as ethnic minorities (Borradaile et al., 2008; Brandes, 2007; Bush et al., 2007; Kumanyika & Grier, 2006). The 2004 RAND Report (2008) indicated that in Washington, DC, 36.3% of children aged 6–12 years were overweight; the rate was even higher in poorer wards of the city. Several school-based intervention programs have been shown to increase children’s knowledge regarding healthy foods and self-efficacy. Pearlman, Dowling, Bayuk, Cullinen, and Thacker (2005) compared physical activity and nutrition programs in public elementary schools with high-minority student enrollment and schools with low-minority enrollment. The findings indicated that public schools with a higher percentage of minority students were less likely to provide nutrition and physical activity programs than schools with low-minority enrollment. Schools with high-minority enrollment were more likely to lack an environment that provided outdoor tracks and walking paths. Eighty-five percent of all the elementary schools sold soft drinks, chips, candy, and fast food. The researcher also concluded that school principals’ support of health initiatives played a pivotal role in the success of these interventions. In the school-based intervention entitled "Wellness, Academics and You" (WAY), 1,031 fourth- and fifth-grade students were enrolled in a program that consisted of six modules, each of which followed a 10-min aerobic exercise routine. Fourth- and fifth-grade teachers from four states participated in workshops to learn the WAY program and the specific plans for interventions in their schools. Children who participated in the WAY intervention had significantly lower body mass indexes (BMIs) and significantly greater increase in activity levels and intake of fruits and vegetables than the control group post intervention (Spiegel & Foulk, 2006). The program was conducted over a 12-week period with a 6-month follow-up. A community-based pilot after-school program, "Kids Living Fit" (KLF), focused on teaching children in grades two through five and their parents about lifestyle choices related to food and activities (Speroni, Early, & Atherton, 2007). In this quasiexperimental study, children in the intervention group participated in weekly fitness presentations, wore pedometers, completed food and activity diaries, and participated in monthly presentations by a dietician for a 12-week period. Separate parent classes were part of the program. The researchers compared BMI percentiles for age, gender, and waist circumference between the intervention group (n = 80) and the comparison group (n = 105). Children who participated in the KLF program had a significant (2.3%, p << .01) decrease in BMI percentile between base line measurements and follow-up after 12 weeks. Speroni and associates (Speroni, Tea, Earley, Niehoff, & Atherton, 2008) then followed up with a 24-week study of the KLM program undertaken with sixteen 8- to12-year-olds in a hospital setting. In this study, mean BMI, BMI percentile, and waist circumference also decreased in this small group (Speroni et al., 2008). Frenn et al. (2003) implemented a combined Internet and video intervention in two urban low-to middle-income middle schools to encourage students to consume a diet low in fat and to increase their physical activity. Healthy snacks along with gym classes were provided to the students. Gym class was found to be beneficial in increasing physical activity. The interventions conducted using the Internet led to a decrease in fat consumption (Frenn et al., 2003). The conclusion of the researchers was that the teaching intervention using the Internet and video may help children at risk for becoming overweight to decrease their caloric intake and to increase their amounts of exercise. The literature review shows that several studies of interventions designed to improve knowledge, eating habits, and activity levels of children have been conducted. The intervention for the present study differs from these previous studies in two of the following ways: (a) it was designed to increase children’s personal responsibility for their own nutrition by emphasizing self-care and (b) it encouraged self-assessment using the USDA food pyramid tool and Internet game MyPyramid.gov. The purpose of this pilot project was to determine the effect of the nutrition education program Color My Pyramid on the nutrition knowledge, nutrition self-care practices, physical activity, and nutrition status of school-age children. The program was designed by the researchers to reduce and prevent childhood obesity in children and was based on the revised USDA food pyramid, as well as the supplemental online program MyPyramid.gov.
Research Questions
A pretest–posttest, quasiexperimental design was used in this pilot study. Children’s nutrition knowledge, nutrition self-care practices, physical activity, and nutrition status were measured before and after the Color My Pyramid intervention, and outcomes from the two schools were compared. Both schools received the education and activity content, but the experiential learning implemented in the two schools differed, with School 1 students receiving a more didactic presentation on playing the Blast-Off Game and the students in School 2 using individual computers to evaluate their diets in small groups.
Sample
Measures Descriptions of the instruments used in this study are presented in Table 2. Instrument reliability was established using coefficient  . Content validity for the instruments had been established earlier using the USDA guidelines (USDA, 2007) for the knowledge instrument and subsequent review by a panel of experts for the other instruments. Children were taken out of class for the physical assessment components of the study.
All of the anthropometric measurements were taken by the researchers and followed the procedures of Lohman, Roche, and Martorell (1988). BMI calculations were based on the formula Weight (kg)/ Height (m)2. Weight-for-age percentiles, height-for-age percentiles, and BMI-for-age percentiles were generated using the computer program Epi-Info (Centers for Disease Control and Prevention, 2007). To understand the prevalence of hypertension often associated with obesity, children’s blood pressures were measured. All the physical measurements were performed in less than10–15 min per child, which minimized their absence from the classroom.
Intervention Color My Pyramid was based on the revised USDA Food Guide Pyramid (USDA, 2007) and the online component www.MyPyramid.gov The intervention consisted of six classes taught over a period of 3 months. The classes included content on (a) general nutrition concepts, (b) moderation and variety, (c) portion sizes, (d) exercise and activity, (e) introduction to MyPyramid.gov for Kids, and (f) experiential learning with the Blast Off Game. The educational tool MyPyramid for Kids can be accessed at http://www.mypyramid.-gov/kids/index.html and was developed by the USDA to educate school-age children about the food guide pyramid. The Web site mypyramid.gov includes links to classroom materials, a poster, tips for families, and the interactive computer game MyPyramid Blast-Off Game. The Blast-Off Game teaches children about the food pyramid and physical activity. The Blast-Off Game was developed by the USDA based on the data from 13 focus groups composed of first- through fifth-grade students and teachers. Following the focus group research, the game was then pilot tested with 16 children. This led to the current online version of the game. The Blast-Off game is an entertaining way for students to increase their knowledge about the basic food groups, physical activity, and making healthy food choices. It was created to help children learn to choose food and activities that will help them meet their daily food group and calorie requirements, include three meals and a snack each day, avoid high fat and sugar foods, and include 60 min of physical activity in their daily schedules. In the game, students must choose food and physical activity times from options presented on a scrolling bar and then place the selections on a rocket ship. Once the selections are complete, students can then attempt to "Blast-Off" to see whether they have an appropriate balance of fuel (food and activities) to reach Planet Power (USDA, 2007).
Ethical Considerations
Procedure
Data Analysis
Using ANOVA, there was a significant difference in nutrition knowledge between School 1 and School 2 from pre- to posttest, with School 1 making the greatest gains (F = 4.916, p = .029). When data from School 1 and School 2 were combined, there was no significant improvement between pretest and posttest scores for nutrition knowledge (t = .92, p = .360). The effect size for the nutrition education program was small (d = 0.163; the values of study variables appear in Table 3).
With the scores from the two schools combined, there was a significant improvement between pretest and posttest scores for self-care practices (t = 1.981, p = .05). There was no significant difference in change scores between School 1 and School 2, although School 1 made the most improvement (F = 1.1852, p = .279). The nutrition education program had a small effect on behavior (d = 0.261). On the pretest, the children reported 31.41 min for "minutes of physical activity yesterday," with a range of 0–180 min. The posttest "minutes of physical activity yesterday" was 60.13 min, with a range of 0–330 min. There was a significant increase in activity time pre and post the nutrition intervention (t = 3.779, p < .001). There was no significant difference in activity level between the two schools. The intervention had a medium effect size on activity (d = 0.598). Several measures of nutritional status (blood pressure and percentiles for height, weight, and BMI) were analyzed, combining both schools. The results are presented in Table 3. Significant decreases in systolic blood pressure (t = 5.85, p < .001), but not in diastolic blood pressure (t = 1.40, p = .16) were noted. There was a medium effect size for the education program on systolic blood pressure (d = 0.578). Although there were increases in the height-for-age percentiles and decreases in the weight-for-age and BMI percentiles, these were not significant. Additionally, when BMI percentiles were grouped by underweight, normal, overweight, and obese, there were no significant changes in group numbers as students moved into different weight category groups from their pretest to posttest weight group (McNemar-Bowker test = 3.20, p = .362; see Table 4 for BMI percentile values by pretest and posttest). There were no significant differences on any of the nutritional status variables between the two schools. Regarding demographic variables, there were no significant differences in scores of pretest knowledge, posttest knowledge, pretest practices, posttest practices by either gender, grade, or school breakfast program.
The results of this study are consistent with the findings of other nutrition studies with low-income, minority populations (Eaton et al., 2008; Ogden et al., 2008). Similar to previous school-based education programs (Speroni et al., 2007; Spiegel & Foulk, 2006), children in this study increased their activity levels and improved their eating behaviors. The findings from this study parallel the findings of Frenn et al. (2003) that Internet interventions can lead to improvement in children’s nutrition and activity behaviors. Both the pretest and posttest data show a high prevalence of overweight and obesity among this population. These findings were consistent with the current trends of overweight and obesity among children living in low socioeconomic urban areas in the United States (Kumanyika & Grier, 2006), as well as with more geographically specific data (Eaton et al., 2008; RAND, 2008) in which children in Washington, DC, were disproportionately likely to be overweight or obese. The rates for Wards 6 and 7, where this study was conducted, were that 24.2% and 21% of children (6–12 years) were overweight, and 40.4% and 29% were obese, respectively (RAND, 2008), similar to the results in this study.
Limitations
Results indicated that most aspects of the Color My Pyramid program were effective. Several recommendations for future nutrition education programs for children emerged from this pilot study. The short course for teachers appeared to increase teacher "buy-in" to the project. Furthermore, familiarity with Color My Pyramid’s nutrition content and activity interventions allowed teachers to reinforce nutrition concepts in their classes. Researchers’ evaluation of the program included recommendations that the course be taught with more classes over a longer period of time. This would allow for greater integration of the content and reinforcement of dietary and activity changes, perhaps leading to a greater reduction of overweight and obesity. Future iterations of this program will include not only a prolonged intervention but also several modifications. Learning exercises will ask for more student involvement, expanding the estimative component. Then, as a foundation for the planning and decision making of the transitional component, students will be asked to keep a log of their daily intake for 1 week prior to the nutrition intervention. A subsequent 1-week log kept after the intervention will give children an opportunity to evaluate their choices, a component of the evaluative phase. To reinforce their knowledge, skills, and decision making, the children will be asked to evaluate their food logs using MyPyramid.gov, playing the Blast Off game. Thus, they will be more actively involved with their learning and will demonstrate how this knowledge can be used, even when researchers are no longer involved. Future studies should also involve a longer period of follow-up. This will determine whether changes resulting from the intervention are maintained over time. As further reinforcement of Color My Pyramid, future iterations will involve parents or surrogates. Not only are they be potential sources of reinforcement for children, they may also improve nutrition decision making in the home. Separate classes for parents can address the different focus of parental decision making, such as grocery shopping and menu planning. Furthermore, family members could encourage each other’s physical activity. The sample for this pilot study was narrowly circumscribed. Further testing should be done with children of different ages and cultures.
Because of the increase in childhood obesity in the United States, there is a need for nutrition education programs targeted at children. The purpose of this pilot study was to determine the effectiveness of such a program, Color My Pyramid, developed by the researchers. The design of this study was pretest/posttest, quasiexperimental. The sample consisted of 126 fourth and fifth graders at two schools. The intervention consisted of six classes with nutrition and exercise content and activities. The program demonstrated moderate effectiveness of a short-term nutrition education program. Scores for self-care practices, activity, and systolic blood pressure improved significantly. School nurses need to consider that a healthy lifestyle is a lifelong process. This study provides a foundation for how those skills can be developed and monitored even at a young age. The notion of self-care as a multifaceted and ever developing process was an ideal method, not just for developing this intervention but also for framing the rationale and processes for lifelong choices.
Jean Burley Moore, PhD, RN, is professor, assistant dean for Research Development at the School of Nursing, College of Health and Human Services, George Mason University, Fairfax, Virginia. Lisa Renee Pawloski, PhD, is associate professor and chair of the Center of Global and Community Health at the College of Health and Human Services, George Mason University, Fairfax, Virginia. Patricia Goldberg, MSN, RN, is a graduate research assistant at the School of Nursing, College of Health and Human Services, George Mason University, Fairfax, Virginia. Kyeung Mi Oh, PhD, RN, is assistant professor at the School of Nursing, College of Health and Human Services, George Mason University, Fairfax, Virginia. Ana Stoehr, MSN, RN, is instructor and coordinator for Masters in Nursing Administration at the School of Nursing, College of Health and Human Services, George Mason University, Fairfax, Virginia. Heibatollah Baghi, PhD, is associate professor at the Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, Virginia. Authors’ Note: Funding for this project was received from the Center for Nutrition, Diet and Health, Cooperative Extension Service, University of the District of Columbia. The authors acknowledge Washington DC School Personnel and George Mason University faculty and students, including Jeanne Sorrell, Linda Henry, Diane Pawloski, Susan Berkow, Claudia Rodriguez, Allan Weiss, Lila Fleming, Deborah Hobbs, and Elizabeth Dugan, for their assistance in planning and implementing this study, and to Margaret Mahon, Darrell Pinto, and Rita Ailinger for their review of this manuscript.
American Public Health Association. (2004a). The obesity epidemic in U.S. minority communities. Washington, DC: Author. (Issue Brief volume 1, no. 2).American Public Health Association. (2004b). What we know about childhood obesity: Basic definitions, trends, statistics, and consequences. Retrieved January 30, 2009, from http://www.apha.org/programs/resources/obesity/proresobesityknow.htm.Baghi, H, Noorbaloochi, S, & Moore, JB. (2007). Statistical and nonstatistical significance: Implications for health care researchers. Quality Management in Health Care, 16, 104-112[Medline] [Order article via Infotrieve]Baker, JL, Olsen, LW, & Sorensen, T. (2007). Childhood body-mass index and the risk of coronary heart disease in adulthood. The New England Journal of Medicine, 357, 2329-2337
This version was published on June
1, 2009 The Journal of School Nursing, Vol. 25, No. 3,
230-239 (2009)
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Abstract
INTRODUCTION