Three-Year Improvements in Weight Status and Weight-Related Behaviors in Middle School Students: The Healthy Choices Study.

INTRODUCTION: Few dissemination evaluations exist to document the effectiveness of evidence-based childhood obesity interventions outside the research setting. OBJECTIVE: Evaluate Healthy Choices (HC), a multi-component obesity prevention program, by examining school-level changes in weight-related behaviors and weight status and the association of implementation components with odds of overweight/obesity. METHODS: We compared baseline and Year 3 school-level behavioral and weight status outcomes with paired t-tests adjusted for schools' socio-demographic characteristics. We used generalized estimating equations to examine the odds of overweight/obesity associated with program components. SETTING/PARTICIPANTS: Consecutive sample of 45 of 51 middle schools participating in the HC program with complete baseline and follow-up survey data including a subsample of 35 schools with measured anthropomentry for 5,665 7th grade students. INTERVENTION: Schools developed a multi-disciplinary team and implemented an obesity prevention curriculum, before and after school activities, environmental and policy changes and health promotions targeting a 5-2-1 theme: eat ≥ 5 servings/day of fruits and vegetables (FV), watch ≤ 2 hours of television (TV) and participate in ≥ 1 hours/day of physical activity (PA) on most days. MAIN OUTCOME MEASURES: 1) School-level percent of students achieving targeted behaviors and percent overweight/obese; and 2) individual odds of overweight/obesity. RESULTS: The percent achieving behavioral goals over three years increased significantly for FV: 16.4 to 19.4 (p = 0.001), TV: 53.4 to 58.2 (p = 0.003) and PA: 37.1 to 39.9 (p = 0.02), adjusting for school size, baseline mean age and percent female, non-Hispanic White, and eligible for free and reduced price lunch. In 35 schools with anthropometry, the percent of overweight/obese 7th grade students decreased from 42.1 to 38.4 (p = 0.016). Having a team that met the HC definition was associated with lower odds of overweight/obesity (OR = 0.83, CI: 0.71-0.98). CONCLUSIONS AND RELEVANCE: The HC multi-component intervention demonstrated three-year improvements in weight-related behaviors and weight status across diverse middle schools. Team building appears important to the program's effectiveness.

Implementing a multicomponent school-based obesity prevention intervention: a qualitative study.

OBJECTIVE: To explore barriers and facilitators to implementing and sustaining Healthy Choices, a 3-year multicomponent obesity prevention intervention implemented in middle schools in Massachusetts. METHODS: Using purposive sampling, 56 in-depth interviews were conducted with middle school employees representing different positions (administrators, teachers, food service personnel, and employees serving as intervention coordinators). Interviews were recorded and transcribed. Emergent themes were identified using thematic analyses. RESULTS: State-mandated testing, budget limitations, and time constraints were viewed as implementation barriers, whereas staff buy-in, external support, and technical assistance were seen as facilitating implementation. Respondents thought that intervention sustainability depended on external funding and expert assistance. CONCLUSIONS AND IMPLICATIONS: Results confirm the importance of gaining faculty and staff support. Schools implementing large-scale interventions should consider developing sustainable partnerships with organizations that can provide resources and ongoing training. Sustainability of complex interventions may depend on state-level strategies that provide resources for implementation and technical assistance.

Family physical activity and meal practices associated with disordered weight control behaviors in a multiethnic sample of middle-school youth.

OBJECTIVE: Family practices around weight-related behaviors can shape children's development of disordered weight control behaviors (DWCB), such as vomiting, taking laxatives, or taking diet pills without a prescription. This study examined family meal and physical activity (PA) practices associated with DWCB among a multiethnic sample of youth. METHODS: We assessed self-report data on frequency of family sit-down dinners, types of parental involvement in their children's PA, and DWCB are from 15,461 6th to 8th grade girls and boys in 47 middle schools participating in the Massachusetts Healthy Choices Study at baseline (2005). RESULTS: Youth who had family sit-down dinners every day had lower odds of DWCB (girls: odds ratio [OR] 0.3; 95% confidence interval [CI] 0.2-0.5; boys: OR 0.6; 95% CI 0.4-0.9) than youth who never had family sit-down dinners. Similar effect estimates were found for youth who had family sit-down dinners most days. Parental provision of rides to and from a PA event was also found to be protective against DWCB among girls (OR 0.7; 95% CI 0.5-0.9). In contrast, parental participation in PA with their children was associated with increased risk for DWCB (girls: OR 1.4; 95% CI 1.0-1.8; boys: OR 1.9; 95% CI 1.4-2.4). These associations did not differ by race/ethnicity or weight status. CONCLUSIONS: Programs emphasizing the importance of family meals may be beneficial in preventing DWCB in youth of all ethnicities. Further research is needed on how various methods of parental involvement in their children's PA are associated with DWCB.

The contribution of school environmental factors to individual and school variation in disordered weight control behaviors in a statewide sample of middle schools.

We investigated the contribution of school environmental factors to individual and school variation in disordered weight control behaviors (DWCB). Analyses were based on self-report data gathered from 18,567 middle-school students in 2005 and publicly available data on school characteristics. We observed large differences across schools in percent of students engaging in DWCB in the past month, ranging from less than 1% of the student body to 12%. School-neighborhood poverty was associated with higher odds of DWCB in boys. Preventive strategies need to account for wide variability across schools and environmental factors that may contribute to DWCB in early adolescence.

Dietary and physical activity factors related to eating disorder symptoms among middle school youth.

BACKGROUND: Dietary and physical activity (PA) behaviors can predict disordered weight control behaviors (DWCB) among youth. This study examines dietary and PA correlates of DWCB and differences by race/ethnicity and weight status in a diverse sample of youth. METHODS: Self-reported data on dietary weight management behaviors, strengthening/toning exercises, moderate-to-vigorous physical activity, and DWCB (vomiting, taking laxatives, and/or taking diet pills without a prescription) were obtained from 15,260 sixth to eighth graders in 47 middle schools participating in the Massachusetts Healthy Choices Study at baseline (2005). Generalized estimating equations were used to estimate odds of DWCB associated with dietary and PA behaviors and to examine for differences by race/ethnicity and weight status, adjusting for covariates and clustering of individuals within schools. RESULTS: Disordered weight control behaviors were reported by 3.6% of girls and 3.1% of boys. Youth who engaged in strengthening/toning exercises 7 days per week versus 0-3 days per week had increased odds of DWCB (girls odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.3 - 3.0; boys OR = 1.5; 95% CI = 1.0 - 2.2). Dietary weight management behaviors were associated with increased odds of DWCB (girls OR = 1.2; 95% CI = 1.1 - 1.3; boys OR = 1.3; 95% CI = 1.2 - 1.4) for each additional behavior. These associations did not differ by race/ethnicity or weight status. CONCLUSIONS: Persons promoting healthy dietary and PA behaviors among youth should consider the co-occurrence of strengthening/toning and dietary weight management behaviors with DWCB and the consistency in these associations across racial/ethnic and weight status groups.

Effect of the planet health intervention on eating disorder symptoms in Massachusetts middle schools, 2005-2008.

INTRODUCTION: The Planet Health obesity prevention curriculum has prevented purging and abuse of diet pills (disordered weight control behavior [DWCB]) in middle-school girls in randomized trials, but the effects of Planet Health on DWCB when implemented by schools under dissemination conditions are not known. METHODS: Massachusetts Department of Public Health and Blue Cross Blue Shield of Massachusetts disseminated Planet Health as part of the 3-year, Healthy Choices obesity prevention program in middle schools. We conducted an evaluation in 45 schools from fall 2005 to spring 2008. We gathered data from school staff to quantify intervention activities, and we gathered anonymous cross-sectional survey data from students on DWCB at baseline and Year 3 follow-up (n = 16,369). Multivariate logistic analyses with generalized estimating equations examined the effect of intervention activities on odds of students reporting DWCB at follow-up. RESULTS: Students in schools reaching a high number of youth with Planet Health lessons on reducing television viewing had lower odds of DWCB at follow-up (odds ratio [OR], 0.80 per 100 lesson-exposures; 95% confidence interval [CI], 0.74-0.85). In addition, reduced odds of DWCB at follow-up were found in schools with active staff teamwork (OR, 0.76; 95% CI, 0.66-0.86) and the presence of programs addressing television viewing goals with staff (OR, 0.38; 95% CI, 0.28-0.53). CONCLUSION: Combined evidence from efficacy and effectiveness trials and now from dissemination research indicates that appropriately designed obesity prevention programs can achieve DWCB prevention on a large scale.

Disordered weight control behaviors in early adolescent boys and girls of color: an under-recognized factor in the epidemic of childhood overweight.

OBJECTIVES: Ethnic disparities in childhood overweight are well-documented. In addition, disordered weight control behaviors (DWCB) have been linked to overweight and weight gain in multiple ways, but little is known about DWCB in youth of color, especially boys. We examined the distribution and determinants of ethnic and gender disparities in DWCB in early adolescents. METHODS: In fall 2005, 47 Massachusetts middle schools participating in the Healthy Choices overweight prevention study administered a self-report baseline survey assessing student sociodemographics, height, weight, and DWCB (vomiting or use of laxatives or diet pills in the past month to control weight). Data from 16,978 girls and boys were used in multivariate logistic regression models to estimate the odds of DWCB in youth of color compared with their white peers, controlling for individual- and school-level factors. RESULTS: Among white youth, 2.7% of girls and 2.3% of boys reported DWCB. The odds of DWCB were elevated 2-10 times in most ethnic groups relative to whites. Disparities were attenuated but persisted after controlling for multiple individual- and school-level factors. CONCLUSIONS: Ethnic disparities in DWCB must be considered in efforts to address the epidemic of childhood overweight.

Small-area estimation and prioritizing communities for obesity control in Massachusetts.

OBJECTIVES: We developed a method to evaluate geographic and temporal variations in community-level obesity prevalence and used that method to identify communities in Massachusetts that should be considered high priority communities for obesity control. METHODS: We developed small-area estimation models to estimate community-level obesity prevalence among community-living adults 18 years or older. Individual-level data from the Behavioral Risk Factors Surveillance System from 1999 to 2005 were integrated with community-level data from the 2000 US Census. Small-area estimation models assessed the associations of obesity (body mass index >or= 30 kg/m(2)) with individual- and community-level characteristics. A classification system based on level and precision of obesity prevalence estimates was then used to identify high-priority communities. RESULTS: Estimates of the prevalence of community-level obesity ranged from 9% to 38% in 2005 and increased in all communities from 1999 to 2005. Fewer than 7% of communities met the Healthy People 2010 objective of prevalence rates below 15%. The highest prevalence rates occurred in communities characterized by lower income, less education, and more blue-collar workers. CONCLUSIONS: Similar to the rest of the nation, Massachusetts faces a great challenge in reaching the national obesity control objective. Targeting high-priority communities identified by small-area estimation may maximize use of limited resources.