a research grant proposal

Running head: A GRANT PROPOSAL FOR A SCHOOL-BASED INTERVENTION ON BMI 1

A Grant Proposal for a School-based Intervention on BMI Z Scores in 5TH Grade Students

A Research Grant Proposal

Presented to the faculty of the School of Nursing

California State University, San Marcos

Submitted in partial satisfaction of the requirements for the degree of

MASTER OF SCIENCE

in

Nursing

Family Nurse Practitioner

by

Jennifer F. Burgess

SPRING SEMESTER

2016

6 A GRANT PROPOSAL FOR A SCHOOL-BASED INTERVENTION ON BMI

DEDICATION

I would like to dedicate this work to my wonderful husband who has always been so supportive in

everything I do and to my kids who had to do their homework alongside mom.


ACKNOWLEDGEMENTS

Thanks to Dr. Denise Boren and Dr. Deb Bennett for being on my committee and for all your help.

8

A GRANT PROPOSAL FOR A SCHOOL-BASED INTERVENTION ON BMI

Preface........................................................................................................................... #2-4

Abstract ............................................................................................................................. #5

Dedication ........................................................................................................................ # 6

Acknowledgments............................................................................................................. #7

Chapter

1. INTRODUCTION ................................................................................................ #9-11

2. LITERATURE REVIEW ................................................................................... #11-25

3. THEORY .................................……………………………………………………. #25

4. METHODOLOGY

Background/Hypothesis…………………………………………………… .......#26

Study Population/Sampling…………………………………………………#26-27

Intervention .................................................................................................... #27-28

Instrument…………………………………… ................ …………………..#28-29

Data Collection and Coding …………………………………………………#29-30

Statistical Analysis…………………………………………… ..……………… #30

Bias…………………………………………………………… ..………………#31

Ethical Considerations…………………………… .....…………………………#31

5. GRANT

Face Page .............................................................................................. Form page 1

Description, Project/Performance Sites, Senior/Key Personnel,

Other Significant Contributors, and Human Embryonic Stem Cells....Form page 2-3

Detailed Budget for Initial Budget Period............................................Form page 4-5

Budget for Entire Proposed Period of Support........................................Form page 6

Biographical Sketch- Program Director/Principal Investigator ……Form page 7-8

Other Biographical Sketches............................................................ Form page 9-10

Checklist..................................................................................................Form page 11

6. REFERENCES…………………………………………………………………#32-35

Appendix A: ................................................................................................ Student Assent Appendix B: ........................................................................................... Informed Consent Appendix C: ............................................................................................. IRB Application


A Grant Proposal for a School-Based Intervention on BMI Z scores in 5th Grade Students

Pediatric obesity is a rising epidemic in the United States and for most of the

industrialized world (Ling, King, Speck, Kim, & Wu, 2014; Safron, Cislak, Gaspar, &

Luszczynska, 2011). Obesity has many known effects on chronic health problems and there has

been many studies done on the effects of obesity and adults. Childhood obesity has not been

studied as much but with the potential to effect a child across the lifespan the effect of obesity

cannot be underestimated. Obesity studies in adults show the links between cardiovascular

disease, hypertension, metabolic syndrome, and diabetes mellitus. These comorbid conditions

which were only associated with adults in earlier generations are now starting to be seen in

younger age groups (Kothandan, 2014; Hollar et al., 2010.) These conditions are associated with

increased cost of care and the potential for significant fiscal impact for future healthcare and

employer costs (Jain & Langwith, 2013; Ling, King, Speck, Kim, & Wu, 2014). There are likely

many factors effecting obesity like genetics, environment, and social interactions. The rapid rate

with which obesity has increased in the last 40 years suggests that genetics alone is not the

problem. The decrease in the amount of calories being expended along with the increased

consumption of high calorie food in large portions also seems to play an important role in this

increase. Societal changes with more women in the work force, increased meals being eaten in

restaurants, and more time spent in sedentary activities like television viewing, all seem to play a

role in the obesity epidemic (Ling, King, Speck, Kim, & Wu, 2014). Environmental changes of

inner city living make areas less conducive to activity. Minority children and children from

lower socioeconomic backgrounds are more likely to be overweight and children who are obese

are more likely to be obese as adults. (Patino-Fernandez, Hernandez, Villa, & Delamater, 2013).

Obesity is a significant concern for all advanced practice registered nurses (APRNs) as the


increasing overweight and obese population seek medical care. Obese children’s medical

problems will only increase as they mature into obese adults. APRNs will be at the frontline of

care for this population to care for them with the comorbidities that accompany obesity. Diabetes

mellitus, cardiovascular disease, musculoskeletal problems and metabolic syndrome are only a

few of the problems associated with obesity that are being seen in younger populations

(Elizondo-Montemayor, Gutierrez, Moreno, Martínez, Tamargo, & Treviño, 2013). The

increasing prevalence of obesity in school-aged children makes intervention at an early age an

important consideration to improving the rates of obesity and co-morbidities. Schoolchildren

represent a unique population where access to a very large percentage of their population is

possible for most of the week while they attend school. Interventions directed at this population

have the ability to reach a great number of children that might not be able to be reached by any

other method. Schools reach across ethnic and socioeconomic divides and provide opportunities

to reach children that may not have access to regular primary care. Primary prevention is a cost

effective method for dealing with problems if the interventions are effective. Promotion of

physical activity and good nutritional choices are the basis of this grant proposal. The overall

goal of this intervention is to reduce the rate of childhood obesity and improve health and

nutrition status by improved knowledge and implementation of nutrition and exercise in school-

aged children. The purpose of this study is to test the nutritional and physical activity

intervention in its ability to lower the BMI z scores of the children participating in the

intervention. It is hypothesized that there will be a clinically significant change in BMI z scores

of children who receive the educational and physical activity intervention.

The research question being asked will be “Can a school based intervention of physical

activity and nutrition education in 5th grade students’ effect their BMI z scores?” The hypothesis


is that there will be a clinically significant change in the dependent variable, BMI z scores, of

children who receive the educational and physical activity intervention, the independent variable.

The theory incorporated in the project is Bandura’s theory of self-efficacy. The educational and

physical aspects of the intervention correspond to Bandura’s theory, giving the students the

confidence and the tools to make a positive impact on their BMI.

Review of Literature

A search was done with CINAHL in the California State University San Marcos

(CSUSM) Library using the terms “school-based intervention” and “obesity” provided the

studies as the basis for the topic of discussion. All articles were from peer reviewed journals.

Articles that were older than 5 years were dropped and only articles in English were reviewed.

Articles were further narrowed to only deal with general school population. Studies directed to

specific disease states without addressing pediatric obesity were filtered from the studies. Seven

articles were acquired with an additional 3 from the reference lists of articles obtained from the

search.

The review of literature yielded several themes related to addressing obesity through the

school system. Some studies just addressed a nutritional education, some addressed a physical

activity interventions, a combination of both with environmental interventions and one addressed

the barriers perceived by parents and staff to interventions.

A randomized control trial in the Los Angeles school district made changes in the

environment in the school cafeteria and provided a peer leader club with social marketing of the

intervention. The changes made in the cafeteria were a greater variety of bite sized/sliced fruits

and vegetables with lunch, free chilled filtered tap water in the cafeteria with lunch, and posters


showing nutritional information of the lunch offerings of the day. The peer leader club was a

club where 7th grade students were taught about the intervention and taught how to discuss

healthier food options with their peer group. Peer leaders were present during lunch and handed

out promotional items and conducted taste tests to promote the intervention. A film promoting

the intervention was shown. All classes saw a trailer some time prior to the actual film to excite

interest in the film. Posters promoting physical activity were posted near the gymnasium.

Handouts to take home were sent to parents and parent/student activities given to take home. The

study found that fruit servings increased significantly and greater numbers of children obtained

lunch from the cafeteria during the time of the intervention. The sale of snacks from the school

snack bar also decreased significantly during the time of the intervention. Water consumption

increased with students having significant intent to use refillable bottle when the water was

available. While the changes did not continue after the intervention was completed, the authors

propose that continued use of the intervention would assist in continuing the change. (Bogart et

al., 2014)

The implementation of an intervention in 6 school districts in Florida, Georgia, and Texas

was conceived and developed by UnitedHealth Group (UHG), an insurance company, to address

the rising costs of care being associated with the obesity. Though no theoretical basis is

identified in this study, primary prevention at a young age is considered a more cost effective

method of managing the obesity problem. The intervention, Activate for Kids (AFK), trains

school nurses and supports them in addressing barriers to obesity prevention and treatment with a

wellness coordinator. As support, each school district had their own wellness coordinator that

was salaried by UHG. The wellness coordinator was available to the school nurse to assist with

planning undertakings addressing obesity. The coordinator was allowed to tailor their responses

13

A GRANT PROPOSAL FOR A SCHOOL-BASED INTERVENTION ON BMI

to the needs of the school nurse. The study was qualitative with semi-structured interviews using

open-ended questions performed by the authors. The interviewees were school nurses, the

wellness coordinators, district administrators, leaders in the AFK project from UHG, and a

parent and child from a district. From the interviews, the authors were able to see common

themes in the barriers and facilitators to school nurses implementing obesity interventions. One

barrier to implementing the interventions were in the initiation of the AFK study. It was difficult

managing one more initiative as well as all the other duties necessary to a school nurse. The

timing of the initiation of study at the beginning of the school year placed an additional burden at

an already extremely busy time. District administration was a barrier or facilitator depending on

their level of support. Wellness coordinators were able to assist the nurses in applying for grants

that they would not have been able to do without the assistance. Education level of the school

nurse might have played a role in full participation especially in those applying for grant

assistance. The intervention gained more support as the year progressed and there was increased

awareness at all levels of the health impact of healthy weight, increased wellness activities at the

schools, and increased personal satisfaction with interventions nurses were able to offer. One

problem that had been noted was that some districts did BMI screening but had no interventions

to offer for those in need. This program allowed them the opportunity to offer interventions

which improved school nurses’ motivation. Wellness coordinators acted as a networking agent

between the nurses and community, nurses and the district, and also between nurses. The

coordinator was able to help the school nurses access resources needed to implement change.

Before the coordinator, nurses felt that they were isolated in their own districts but after the

intervention they had greater opportunities for ideas and encouragement from others. This study

is limited in that it does not examine whether the intervention was effective in changing in the


obesity rates. An empowered school nurse will be an effective change agent and giving them the

coordinator to have a greater ability to effect that change will be more effective was concluded

by the authors. Further extension of this study would be a longitudinal study on the change in

BMI as children progress through school. Pre and post intervention testing to see if BMI and

other health markers change could be checked and quantified. Public schools are always in need

and the additional salary of another individual as well as the increased time commitment would

be difficult to sell to school districts without studies that show it will work. Access to a

committed person who also wants to effect change is likely to increase the changes we need to

see in U.S. schoolchildren (Jain & Langwith, 2013).

Safron, Cislak, Gaspar, and Luszczynska (2011) performed a systematic review of

systematic reviews and meta-analyses analyzing the effectiveness of school-based interventions

on weight related behaviors, like nutrition, physical activity, and health outcomes. The reviewed

studies encompassed a total of 196 trials. The data show that interventions related to BMI,

weight and/or obesity can have significant change in outcomes for these indices. Intervention

groups did experience significant change in some intervention populations. Increasing PA or

decreasing sedentary behavior was also significantly associated with a significant change in

57.3% of the interventions. Dietary behavior interventions produced the significant change more

than other interventions with 96 % of the interventions being effective. Characteristics of the

participants and their effects on outcome was another aspect studied. Gender appears to play a

significant role in some interventions with girls obtaining greater benefit than boys. Age also

appears to play a role. Larger effects were seen in younger populations with elementary schools

being the most significant, middle school some significance, and high school interventions were

non-significant. The type of intervention that produced significance in these ages varied as well.


Interventions that were associated with significant change in elementary school children

decreased the amounts of sedentary behaviors. Middle school interventions with moderate to

vigorous PA were associated with significant effect in that population. Interventions that targeted

a general population and were not specifically targeted to a certain population, like specific

ethnic minorities, were more effective. The final aspect studied was behavior and family

components. Interventions that addressed PA by reducing sedentary behavior or increasing

exercise were more effective in producing a result than those interventions that addressed

nutrition or nutrition and PA. School based activity, particularly compulsory activity like

physical education, is seen to provide better results in decreasing BMI. PA is seen to provide

significant reductions in BMI, weight, or obesity prevalence. The significant reductions that were

found were small and this is theorized because the studies that yielded results were done on a

general population. The general population would have a full range of students across the BMI

scale. Any change to BMI post intervention might be small as the normal BMI individuals are

part of the population. There is another theory as to why change within the general population

and not targeted populations work. It’s thought that behaviors in the general population are more

easily changed as opposed to individuals who have already have ingrained habits. Parental

participation as part of interventions was found to be effective especially if they were involved in

setting goals or if they received educational materials. The authors found that 1 out of every 3

school based intervention produced a significant reduction in weight, BMI, or obesity

prevalence. Focusing on those that do produce change and trying to incorporate them into the

current school curriculum are what the authors advocate (Safron, Cislak, Gaspar, and

Luszczynska, 2011).


Inner city children in Rotterdam were the targeted population of the next study. It

proposed an intervention to improve healthy eating and active lifestyle. The intervention

included 3 more physical education classes per week, voluntary sport activities outside of school,

3 curriculum lessons on nutrition, healthy lifestyle, and active living. The final component of the

study is administration of the Euro fit test which measures height, weight and 9 different

measures of fitness. The Euro fit test was administered at the beginning of the school year and at

the end of the school year. It used a randomized controlled trial without the intervention group

being blinded. Children, grades 3-5 and 6-8, were measured and analyzed separately. At the

beginning of the study the prevalence of overweight children in the 3-5 grade was 24.4% and

31.2% in the 6-8 grade. Post intervention the 3-5th graders had significantly smaller increase in

waist circumference, significantly faster run times, and a significant difference in the prevalence

of overweight children. There were no significant effects found in the 6-8 grade group. Possible

reasons for this difference is that older students are usually more involved in organized sport as

opposed to younger children, making physical intervention changes too small to be significant.

Differing implementation in the higher grades and/or different activities offered in higher grade

levels are offered as possible explanations for the cause. The difference between the 2 outcomes

requires further study though the results obtained for younger grades appeared promising (Jansen

et al., 2011).

Rural elementary school children are also experiencing higher rate of pediatric obesity.

This is contrary to popular belief that children who live in rural communities will be more active

and eat healthier foods due to their environmental setting with access to fresh foods. Children in

rural areas are more likely to be overweight or obese than urban children. A study done in

Kentucky used repeated measures to evaluate PA and nutrition improvement in rural children.


Four schools were chosen based on their low School Health Index scores and their rural area.

Goals of the intervention were improving physical education curriculum, improving health and

nutrition education, promoting involvement of the family and community, and changing school

policy to be in line with Healthier US School Challenge. Children were assessed at baseline and

monthly thereafter for a total of 5 measurements. The measurement for PA was measured by

amount of steps taken by using a pedometer. Nutrition levels were measured by the School

Physical Activity and Nutrition (SPAN) questionnaire. The intervention was significant for

increasing the percentage of children meeting PA recommended levels. Girls who had started out

not meeting the recommended levels more than boys exceeded them by the final measurement.

The intervention was significant for the percentage of children meeting nutritional requirements

with greater intake of fruits and vegetables occurring in the older grades with no difference for

genders. The limitations on this study is that there is lack of a control group and no

randomization. Nutrition intake was self-reported. The measurements assessed do look

promising for assessments of this type being integrated into current curriculum. Physical

education requirements which were not legislated at the time of this study are advocated by the

authors (Ling, King, Speck, Kim & Wu, 2014).

There are 2 main areas for pediatric obesity interventions, through the school or through

the family. Kothandan’s (2014) systematic review compares the 2 frameworks to see if one is

more effective than the other. Parental influence on children’s nutrition and activity levels can be

significant and schools can also be a platform for change in a child’s life. The systematic review

included studies whose interventions included PA, diet and nutrition, modifying diet and

exercise, health promotion methods, or combinations of the interventions. The interventions

were either family or school based with measurement outcomes being height and weight, BMI,


percentage overweight, or BMI z scores. BMI z scores factor gender and age and give BMI as a

standard deviation in comparison to others in the same group. Other secondary measures such as

body fat distribution, lipid profiles, behavior change, either nutrition or activity, and cost of

intervention, were also included in the studies examined. Studies collected came from published

material and also grey literature. All studies were graded Ib and A using the National Institute of

Clinical Excellence (NICE) grading scheme meaning there was at least 1 randomized control

trial. A total of 13 studies were reviewed, 8 which were family based and the remaining 5 were

school based interventions. Outcomes post intervention measuring weight found 7 of the 7

family based studies measuring weight and 4 of the 4 school based studies measuring weight

reported a statistical significance weight decrease. Statistically significant change in BMI was

measured in 6 of the 7 family based studies measuring BMI and in 4 of the 5 school based

studies. Only family based studies measured BMI Z scores, which also were found to be

significant. One study which had a p<0.0001 for 6 months, had a p<0.7 at the 12 month follow

up bringing up concerns about the long-term efficacy of the intervention which were not

addressed by the study. In 1 out of 3 school based interventions and 3 out of 3 family based

interventions the percentage of overweight children was significantly decreased. One family

based intervention had a significance of p=0.0001, 0.0004, and 0.02 at 6, 12 and 18 months

respectively, post intervention. From the grey literature there was a consensus statement from an

international assembly that emphasized the use of family based interventions that included a

behavioral element in treating overweight children. While there was significant change found in

both family based interventions and school based interventions, each type of intervention yielded

their own advantages. Family based interventions were found to be more cost effective with the

shared experience being incorporated into family life. School based interventions had greater


change in moving obese children to non-obese BMI categories. The obese children might have

been able to implement the teachings and skills learned through the school intervention. Poor

compliance was a factor in all studies but more so in family based interventions, possibly

because everyone has to take part in the intervention. The review found no conclusive winner as

to which is the more effective method of intervening. The author does state that using height,

weight, and BMI are crucial to being able to support the effectiveness of interventions and that

further longitudinal designed studies should be implemented for further research (Kothandan,

2014).

Many children from low socioeconomic backgrounds are part of the public school

system. A large proportion of their daily caloric intake, up to 50%, is from the food they receive

through school lunch programs. These children are part of the population who are most at risk

for obesity. Hollar et al. (2010) conducted a pilot study that addressed many different levels.

They did a multi-level intervention that addressed interpersonal characteristics, community

characteristics, and government policies effecting all the factors that combine for weight

management. On the interpersonal level, students were educated in nutritional and physical

activity. Motivational materials like handouts, multimedia presentations, and assemblies were

implemented. A school garden was started so children could grow and taste foods they may

never have tried before as well as being a physical activity. The community characteristics

changed the environment by putting in the school garden. County extension and Organic

Gardening magazine participated to work with teachers and students. Breakfast, lunch, and

snacks were provided by the school to students. Cafeteria food service staff, with the help of a

dietitian and the principal researcher, changed school menu offerings to include more high fiber

foods, foods with lower glycemic index, and less saturated and trans-fats. They changed the


curricula to reflect a theme of nutrient rich foods. The curricula was provided as part of the study

and the foods discussed in class were promoted in the cafeteria with tastings and posters.

Parental paperwork was sent home to keep parents informed of the food of the month. Changes

by the study were implemented school wide. The government level incorporation used USDA

and State agricultural services to assist with their intervention. The authors note that the

increased physical activity called for by their intervention was not working until the governor

passed a mandate requiring 150 minutes of physical education weekly. After the mandate the

schools adopted the PA portion of the study. There was significant improvement for the students

who received free and reduced lunches in BMI z scores, weight z scores, blood pressure (BP),

and on standardized tests. This longitudinal study followed the students over the course of 2

years. While the intervention children experienced a significant decrease in the anthropometric

measurements, researchers found that over the course of the summer all students in the

intervention and control groups experienced a significant rise in diastolic BP. The intervention

group’s rate of increase was less than the control groups but still significant. Hollar et al. (2010)

felt that further studies should add a summer portion to interventions to address the losses in

positive improvements. Interventions that improve anthropometric measures especially in areas

that have students from low socioeconomic background need further studying. The inclusion of

community and implementing policy change is a substantial step for many school districts and

might be more than many would be willing to implement. Further studies are recommended by

the authors. Further implementation without so much involvement to see if it produced similar

results would be an interesting comparison study (Hollar et al., 2010).

Assessing the effect of individualizing a school based intervention on anthropometric and

physiologic measurements and metabolic syndrome risks is the basis of the next study. Mexican


school children from Monterrey were invited to participate in the study. The study was a quasi-

experimental design where 96 children ages 6-12 in the 1st- 6th grade from low socio-economic

Hispanic background participated in the study. The students had BMIs greater than 85th

percentile and were taking no medications for hypertension, hyperlipidemia, or hyperglycemia.

All children were measured for height, weight, percentage of body fat, waist circumference,

tricipital skinfold, blood pressure, and BMI. The children had a blood analysis done at baseline

and at 10 months, the end of the intervention. Blood was analyzed for fasting glucose and lipids.

All these measurements were used to calculate metabolic syndrome and risk factors for

metabolic syndrome. The intervention involved dietary changes and increasing physical activity.

The children were seen by a registered dietitian every 3 weeks for 30 minutes. Parents or

caregivers were required to attend the meeting. During the visit the dietitian took anthropometric

measurements and diet and activity assessment for the last 24 hours were done with parent and

child. Meal and activity planning for the next 3 weeks as well as healthy eating education were

also done with parent and child. At the end of the intervention there was significant change in

risk factors for metabolic syndrome, with decreases in hypertriglyceridemia, hypertension, and

waist circumference and increases in high density lipoprotein cholesterol (HDL). The caloric

intake, body fat percentage, blood pressure, were also significantly decreased by the end of the

intervention. The authors conclude that the individualized approach to each student with family

involvement as well as the health and diet education were important factors in the success of this

study (Elizondo-Montemayor, Gutierrez, Moreno, Martínez, Tamargo, & Treviño, 2013).

Patino-Fernandez, Hernandez, Villa, & Delamater (2013) did a qualitative study looking

at the perceived barriers to schoolchildren’s health and weight by parents and school staff. The

study held different focus groups with staff as 1 focus group and parents in 3 focus groups.


Participants in both groups received refreshments and a gift card for their participation. The staff

focus group (n=7) was held in English and included teachers, a counselor, district manager and a

food service manager. Parental focus groups were held in Spanish with 3 parents attending each

focus group (n=9). The authors asked open ended questions to the different groups regarding:

perceptions and knowledge of weight and childhood obesity, nutrition and diet of children

including food choices, physical activity and sedentary behavior of children, parental/staff

perceptions of their role in child nutrition/diet and physical activity, and a school based

intervention program. From the focus groups 5 themes emerged from the questions. These

themes were factors contributing to childhood obesity, division of responsibility for child eating

behaviors, challenges of healthy eating, division of responsibility for child physical activity, and

barriers to child physical activity. There were differing views on these themes from the staff and

the parents. The factors that contribute to childhood obesity from the parental perspective were

busy work schedules with less time for physical activity and increased consumption of fast food.

Staff perspectives were that parents are responsible for their child’s eating and activity habits and

that use of technology instead physical activity as recreation was a contributing factor. The

perspective on the division of responsibility for children’s eating behaviors was different for staff

and parents. Parents believed that school meals were not good quality and that the school should

be responsible for providing a healthy meal. They also believed that teachers should provide

more information about nutrition and provide hands on guidance and not use candy and pizza as

a rewards system. Staff believed that nutrition education should come from parents and that

parents should not send their children to school with unhealthy foods. The staff also said that

candy and pizza were useful as fundraising events and that they had not received any complaints

from parents regarding pizza and candy as a reward system. Challenges to healthy eating for


parents were time constraints for working parents and healthy food choices being more

expensive than fast food. Parents complained that children won’t try new foods and don’t like the

taste of new foods. Staff felt that challenges were lack of money within the district to buy

healthier foods and that there was little they could do as individuals to impact the problem. They

also felt that children bringing unhealthy items to school from home was part of the challenge.

Parental perspective on the division of responsibility for children’s activity were that schools

should provide more structured physical activity at school whereas staff felt that parents were

responsible for their children receiving enough physical activity. Barriers to children’s physical

activity was one area that had some consensus from staff and parents. Barriers parents felt to

their children’s physical activity were parental time constraints, parental inactivity, and unsafe

environment. Staff also felt that the environmental barriers of unsafe neighborhoods and lack of

community parks also created barriers. Within the school environment they felt that time

constraints due to academic curriculum provided a barrier to physical activity. The authors feel

that parent and staff play an essential role in the success of school based interventions. They feel

that interventions would need to address parental empowerment in nutrition and activity while

also empowering the staff with healthier food choices for students and curriculum that can

influence students’ choices in nutrition and activity. Collaboration with the community was also

advocated as a way to increase initiatives and interventions for the children.

Dissemination of an intervention into practical use after the initial study is the basis of the

study by van Nassau, Singh, van Mechelen, Brug, & Chin A Paw (2014). It is noted while many

studies show evidence that interventions are effective few transition into actual practice. The

purpose of this study is to transfer the evidence based intervention into use in practice. The

intervention was the Dutch Obesity Intervention in Teenagers (DOiT) and it was being


implemented as nutrition and exercise lessons incorporated into the school biology and physical

education lessons. The initial study showed that the intervention was effective in decreasing

waist circumference, caloric intake, and increasing physical activity in the study group. The

authors used interventional mapping to re-evaluate the initial study. Interventional mapping is

cyclical, focusing on 3 parts, Effective elements, Plan development, and Delivery. Within those

parts are subgroupings. Effective elements is made up of needs assessment, performance

objectives, and methods strategies. Plan development is made up of program plan,

implementation of plan and evaluation of plan. The Delivery is implementation and evaluation.

Focus groups and interviews were conducted to determine how effective components of the

intervention were for the participants. The intervention can be assessed and reassessed for

improvements using interventional mapping over the use of DOiT. Teacher interviews addressed

several components: the content of lessons and layout of material; the teacher’s manual; the

preferred teaching strategies; and the option of adding in a parental component. Parent focus

groups addressed content of homework assignments and the option of parental involvement in

the program. Student focus groups addressed the layout of materials, homework assignments and

the content of computer tailored advice. Data from the interviews and focus groups were adapted

into the original intervention. The interviews and focus groups brought 8 changes into the

intervention. The 8 changes included: education regarding daily, healthy breakfast; 2 versions of

the intervention including an easier version for certain groups of students; the length of time of

the intervention was increased to 2 years; PA was adopted as part of the PE lessons; layout of

teaching materials changed; a parental component was developed; an environmental component

involving the canteen was developed; and increased practical advice and options for teachers to

implement the intervention. Adoption of the 8 changes enabled the tailoring of the intervention


and making it more effective for real life use. The inclusion of stakeholders’ opinions allows for

the increased likelihood of support for the implementation. The authors will continue to use

interventional mapping after the nationwide implementation of DOiT to continue to evaluate the

effectiveness and reassess needs and performance. It was felt that revisiting and reassessing with

stakeholders using intervention mapping made this intervention more effective and relevant to all

involved.

Theory

Theory integrated with this project is Bandura’s Theory of Self-Efficacy. There are 4

main components to the theory of self-efficacy; mastery experiences, social modeling, social

persuasion, and psychological responses. Mastery experience is when a task is successfully

mastered giving the student knowledge that the task can be mastered. Social modeling is seeing

others successfully complete the task. This imparts the belief in the watcher that they too can

master the task. Social persuasion is bolstering the person’s belief with positive verbal

persuasion that they can master the task. Psychological response is how a person deals with

stress and anxiety in response to the task. It can be a determinant in accomplishing tasks. This

theory is very appropriate for an intervention that involves weight loss. The classroom is a place

to increase confidence in your ability to complete weight loss. It is a place that can practice

social persuasion as well as social modeling with all students performing the same tasks (Current

Nursing, 2012).


Method

Background

Obesity has become an epidemic in the U. S. with the specter of chronic disease problems

as obese children become obese adults. The goal is to reduce the rate of childhood obesity and

improve health and nutritional status by improved knowledge and implementation of nutrition,

exercise and decreasing sedentary behaviors in school-aged children. This study will address the

large population of overweight and obese children currently enrolled in the U.S. public school

system. The purpose of this study is to test a nutritional and physical activity intervention in its

ability to lower the BMI z scores of 5th grade children participating in the intervention. A change

of 0.25 in the mean BMI Z scores has been found to have a clinically significant improvement

(Ford, Hunt, Cooper, & Shield, 2010). If the intervention, as the independent variable, can cause

a clinically significant change in the dependent variable, BMI z scores of the participating

children, curriculum and activities of the study could change school policies and curriculum.

This could prove highly significant to nursing practice as improved BMI z scores are correlated

with improved health status. The hypothesis is that there will be a clinically significant change in

the dependent variable, BMI z scores, of children who receive the educational and physical

activity intervention, the independent variable.

Study Population/Sampling

In this repeated measures study, we will compare BMI z-score measured at pre

intervention and post intervention on a group of 5th grade students. The participants will be from

2 elementary schools, Garden Road School and Valley Elementary School in the Poway Unified

School District. The study protocol will be approved by the Institutional Review Board (IRB)


from California State University San Marcos (CSUSM). Non-randomized, cluster sampling will

be used to choose the study population. The study will comprise all 5th grade classes at Garden

Road School and Valley Elementary School in the Poway Unified School District including any

4th/5th grade combination classes. Inclusion criteria will be all students in those classes that have

parental consent and student assent. Exclusion criteria is children in those classes unable to

perform the physical activity will be excluded as well as children with casts or prosthetic devices

unless it is able to be removed for weigh-in. Any child with a disorder effecting growth will also

be excluded from the study. A change of 0.25 in the BMI z score would be considered significant

as that is a clinically significant change in BMI. (Ford, Hunt, Cooper, & Shield, 2010) The

sample size needed is 154 (N=128 + 20% Loss Factors with a power of 0.80 with an alpha of

0.05). The approximate population of 5th grade classes at both sites is 170.

Intervention

The intervention will use the curriculum, Nutrition to Grow On, which was developed by

the California Department of Education (CDE) and the United States Department of Agriculture

(USDA). Nutrition to Grow On curriculum includes 9 lesson plans that incorporate 1 hour

weekly in class lesson with a ½ hour outdoor gardening activity. The curriculum was developed

by the CDE and fits California curriculum standards. It was tested on 4th graders with pre and

posttest analysis. The 4th graders showed increased knowledge on nutrition and increased

preferences for fruit and vegetables (California Department of Education, 2013). The physical

activity portion of the intervention will be incorporated as part of the physical education of the

students as a daily running program. A running program incorporates vigorous exercise in a

shorter period of time that includes all students. The state of California requires that all

elementary students receive 200 minutes of physical education in a 10 day period (California


Department of Education, 2015). Twenty minutes of daily running would satisfy the

requirement. Running programs can be supported by the parent teacher association (PTA) and

continued by them once the study is completed.

Instrument

“A z-score is the deviation of the value for an individual from the mean value of the

reference population divided by the standard deviation for the reference population. Because z-

scores have a direct relationship with percentiles, a conversion can occur in either direction using

a standard normal distribution table (Centers for Disease Control and Prevention, 2013).” The

reference population data that the Z score is being measured against comes from the National

Health and Nutrition Examination Survey (NHANES). The data from these surveys was used for

the growth charts published in 2000 by the CDC. The categories of overweight and obese were

then defined as those above the 85th and 95th percentile respectively. BMI Z scores are

considered to be the most reliable measurement of adiposity in children especially for

longitudinal study. (Inokuchi, Matsuo, Takayama, & Hasegawa, 2011). BMI Z scores have

several strengths. It is interval scale that allows comparisons across ages and genders. Since it is

an interval scale, it is able to quantify extreme values. It is also more useful than percentiles for

assessing changes in growth status as children age. The limitation in using BMI z scores come

from the difficulties in understanding the standard deviation as opposed to percentiles. Due to

this, it is not in wide popular use as a method to explain obesity in children. (Preedy, 2012, p. 30)

A reduction of 0.25 BMI Z score is considered clinically significant. It is associated with

decreased adiposity and improved metabolic health. (Ford, Hunt, Cooper, & Shield, 2010) There

are several factors that might have an effect on the internal validity of the study. These factors

are history, maturation and the Hawthorne effect. History is external events, usually something


on a large scale that can affect many people. Little can be done to avoid interference if such an

event should happen. The children will all be able to go home after school and external events

will play a role in their lives. Maturation is always a concern when studying children. The type

of instrument being used, the BMI Z score, factors in age and gender. It also uses the data from

NHANES comparing the data against years of data collected on similar children. This should

alleviate maturation limitations. The timing of the intervention to begin at the beginning of the

school year will help to normalize the intervention for the students, decreasing the Hawthorne

effect. At the beginning of the school year, the students have little expectations as to how the

school day will proceed. Timing the intervention at the beginning of the year and including the

whole 5th grade class at both schools decreases some the effect of being in the study. There will

be limitations to the generalizability of the study. The population is urban with little ethnic

diversity. There are varying socioeconomic levels within that population. The area encompasses

house from the million dollar range to low income housing.

Data Collection and Coding

Gender is the only data that will require coding for statistical analysis as it is a nominal value.

Males will be coded as 1 and females as 2. Age and weight are ratio scale data. They will be

measured on stadiometer and digital scale to avoid parallax. Calibration of measuring devices

will performed prior to data collection to ensure accuracy of measurements. Data collection and

calibration for weight and height will follow the guidelines used by the CDC in the NHANES

Anthropometric Procedures Manual (2007). (See Appendix B) Students’ identification numbers

will be used as an identifier for all data collection. The 5th grade was chosen as a study group as

they participate in the state physical fitness testing which is conducted on 5th, 7th, and 9th graders

in California. As part of this testing, weight and height are measurements taken. The students


know of the testing and expect to have measurements tested during the 5th grade. The study

would add 2 additional times where weight and height would be measured. These 2 additional

times would be before the intervention began and 1 month after the intervention was completed.

This would help to increase validity as it would be less intrusive as it is an expected measure.

Students’ demographic information is already collected by the school. The information required

for our study are the day measurements were taken, height, weight, birthday, and gender. This

allows for calculation of the BMI Z score. Child’s gender and birthday will be obtained from

school records. Once all the data has been collected it can be turned into BMI Z scores. A

calculator provided by Children’s Hospital of Philadelphia will be used to calculate the BMI Z

scores. (The Children's Hospital of Philadelphia, 2014) This calculator uses the data from the

CDC and uses the formula X = M (1 + LSZ)**(1/L), L ≠ 0 to do calculations. L, M, and S come

from the NHANES data collected by the CDC. X is the BMI calculated from height and weight

data where BMI=kg/m2. This calculator would give the BMI Z score (CDC, 2004). The data

collected by the CDC has been used to create growth charts which pools data from the U.S. from

1963-1994. Data in the age 2-20 years were grouped by age and statistically smoothed. (CDC,

2002, p6) 50th percentile correlates to BMI 0 SD. The 50th percentile changes dependent on the

age of the individual being measured. Analysis of data for BMI Z scores using the calculator will

use the data from the CDC growth chart files.

Statistical Analysis

A two tailed paired t-test will be used to analyze the data with N=154, α=0.05, CI=0.95

and effect of 0.25. Mean BMI z score pre intervention will be compared to the mean BMI z score

post intervention.


Bias

Possible sources of bias can come from the intervention not being blinded. There could

also be some attrition of subjects. Using as much of the 5th grade classes as possible alleviates

the potential problem of not having enough data. Bias on the part of the researcher can be a

possible source of bias as they can have preconceived views about the study.

Ethical Considerations

The population being studied is a vulnerable population. IRB approval will be obtained

prior to the study implementation. Parents will be informed of the study through paperwork sent

home with students and with researchers’ attendance at back to school night to discuss the

intervention and to obtain consent. Assent from the student population will be obtained prior to

the start of the study. The study will be confidential with student numbers acting as identifiers.

Anthropometric data will be collected in a curtained area to provide privacy for the students. All

data collected will be encrypted and stored on a computer with a HIPAA compliant drive and

kept in a locked cabinet in a secure environment.

Continuation Format Page

Program Director/Principal Investigator (Last, First, Middle):

Continuation Format Page OMB No. 0925-0001/0002 (Rev. 08/12 Approved Through 8/31/2015) Page

OMB No. 0925-0001 and 0925-0002 (Rev. 10/15 Approved Through 10/31/2018)

BIOGRAPHICAL SKETCH Provide the following information for the Senior/key personnel and other significant contributors.

Follow this format for each person. DO NOT EXCEED FIVE PAGES.

NAME: Jennifer Burgess

eRA COMMONS USER NAME (credential, e.g., agency login):

POSITION TITLE: Program Director/Principal Investigator

EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, include postdoctoral training and residency training if applicable. Add/delete rows as necessary.)

INSTITUTION AND LOCATION

DEGREE (if

applicable)

Completion Date

MM/YYYY FIELD OF STUDY

San Diego State University, San Diego, CA

California State University, San Marcos, CA

B.S.

Teaching credentials

BSN

MSN

12/1995

5/1996

5/2009

5/2016

Biology

Life Sciences & Chemistry

Nursing

Family Nurse Practitioner

A. Personal Statement

Jennifer has the background, training, expertise, and motivation required to accomplish the proposed study. Her background in education as well as nursing makes her particularly suitable to this project. She has worked with children in classrooms as an educator and understand the complexities of having a viable appropriate curriculum. She has worked as a team teacher and is able to communicate the need for the proposed intervention to staff. After raising her own children she returned to school and completed her nursing degree. This gives her insight into understanding the perspective from the role of the instructor as well as a parent. As a nurse she has seen the co morbidities caused by obesity in adults and understand the necessity to address obesity at the pediatric level. As a new nurse she cared for long term critically ill patients with multi-system failure, who were ventilator dependent and promoted education and support to those patients and their families. She became a wound care nurse in addition to working on the floor. She has worked as part of collaborative health care team, providing compassionate, quality care to patients and their families. As an Urgent Care nurse she performs triage and assessment of patients with emergent conditions. This position requires the ability to communicate and assist providers and other staff with necessary patient care.

B. Positions and Honors Positions

Telemetry, Stepdown Unit and Wound Care RN Promise Hospital San Diego 2009-2011 Telemetry and Medical Surgical RN Scripps Mercy San Diego 2011 Urgent Care RN Sharp Rees-Stealy San Diego 2011-present

Honors and Activities

Wound Care Champion Dean’s List, California State University San Marcos, 2006-2009 Founding member of CSUSM National Student Nurse Association Student Nurse Association Board Member – Fundraising Co-Chairman Athletic Scholarship to Northeastern Illinois University (Tennis) Most Valuable Player (Tennis) at Northeastern Illinois University San Diego Mesa Garden Club Scholarship California Public Health Nurse ACLS PALS




NAME: Linnea Axman


POSITION TITLE: Statistical Consultant



DEGREE (if

applicable)

Completion Date


Hurley Medical Center School of Nursing

University of Michigan

University of Kentucky

The George Washington University School of Medicine and Health Sciences

RN

BSN

MSN

DrPH

1977

1981

1992

2003

Nursing

Nursing

Family Nurse Practitioner Public Health




NAME: Deborah Bennett


POSITION TITLE: Faculty Mentor



DEGREE (if

applicable)

Completion Date


Washington State University PhD Nursing

Deborah Bennett has been a nurse educator for over twenty years and a nurse clinician for thirty years. She is a

generalist with specialties in pediatrics and primary care. As a nurse educator she has taught in associate degree

nursing programs and is currently employed at California State University San Marcos (CSUSM) where she

teaches Nursing Care for Children, precepts students in a pediatric community clinic, and is CSUSM’s Nursing

Simulation Director. At present she co-chairs the San Diego Simulation Collaborative. Deborah obtained a PhD

from Washington State University in August 2015. The area of research was instrument development for

pediatric medication administration competencies through simulation which was found to be reliable and valid.


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Appendix ASchool-Based Intervention on BMI Z scores in 5th Grade StudentsStudent Assent

We are doing a study to learn about how nutrition and exercise in school can affect your BMI. BMI is a measure using height and weight to estimate body fat. We will look at the BMI in relation to other kids BMI’s that are your age. We are asking you to help because we would like to see if including instructions as part of your science and PE lessons might cause a change in your average BMI. If you agree to be in our study, we will measure your height and weight 2 times. Once before we start the study and once after we finish the study. The measurements will be done privately and no one outside you and the researchers will know your height or weight. The study will be included as part of your regular science and PE for 9 weeks. It will also include some time spent in the school garden area. Being part of this study may help to show whether school is the place to help kids learn how to decrease their BMI into a healthy range. There are some risks associated with this study. The risks in this study are similar to the risks that you have in your regular day at school. The exercise portion of this activity is similar to what you might have in a regular PE class for physical injury associated with exercise like falling or having an asthma attack. The garden activity may expose you to soil which can contain germs which can cause infection. Being weighed in front of others can be stressful and may cause psychological distress. You can decline to be in this study at any time. If you decide at any time not to finish, you can tell us you want to stop. The lessons plans will be the same for all students whether or not you decide to be in the study. The only difference will be that your measurements will not be taken for the study. Your measurements have no effect on your grade and your teacher will not know your measurements. If you don’t want to be in the study, don’t sign this paper. Being in the study is up to you, and no one willbe upset if you don’t sign this paper or if you change your mind later.

Your signature: _________________________________________ Date _____________

Your printed name: ______________________________________ Date _____________

Signature of person obtaining consent: _______________________ Date _____________

Printed name of person obtaining consent: _____________________ Date _____________


Appendix B School-Based Intervention on BMI Z scores in 5th Grade Students

Consent to Participate in Research Jennifer Burgess, a Doctoral student at California State University San Marcos (CSUSM), is conducting a study to see if there will be a significant change in BMI z scores, ofchildren who receive an educational and physical activity intervention. BMI is a measure used toassess body fat. A BMI z score the standard deviation of the children’s BMI from the average BMI. Study Objectives. This research seeks to answer the question “Can a school based intervention of physical activity and nutrition education in 5th grade students’ effect their BMI z scores?” Procedures The intervention will incorporate into the curriculum, Nutrition to Grow On, which was developed by the California Department of Education (CDE) and the United States Department of Agriculture (USDA). The lesson plans have been developed by the CaliforniaDepartment of Education and the USDA. These lesson plans fit with the requirements of the board of education. Nutrition to Grow On curriculum includes 9 lesson plans that incorporate a weekly 1 hour lesson with a ½ hour outdoor gardening activity. The curriculum was developed by the CDE and fits California curriculum standards. The physical activity portion of the intervention will be incorporated as part of the physical education of the students as a dailyrunning program. Risks and Inconveniences. There are minimal risks to participating in this study. The risks inthis study are comparable to the risks that the child has with their daily school activities. The physical activity presents a risk for possibility physical injury associated with exercise, like fallsand exacerbation of medical conditions like asthma. The garden activity may expose children to soil which can contain pathogens that may cause infection. There may be a psychological risk tothe child being weighed in front of others. Children can be very sensitive regarding their weightand being weighed can cause psychological distress. Safeguards. To help ensure confidentiality, all data will be collected privately. Students’ heightand weight will be assessed in a curtained area for privacy. All data collected will be kept confidential. Student numbers will be used as identifiers to help insure confidentiality. All data collected will be encrypted and stored on a computer with a HIPAA compliant drive and kept ina secured area. Voluntary Participation. Participation in this study is entirely voluntary, and may be withdrawn by you at any time. There are no consequences if you decide not to participate. Benefits. Participation in this research may increase knowledge regarding nutrition and increase your child’s physical activity. These have the potential to improve the health and well-being ofyour child through participation in this study. Participation in this study may also benefit others by increasing our knowledge base regarding school based interventions for obesity.

A GRANT PROPOSAL FOR A SCHOOL-BASED INTERVENTION ON BMI 37

Questions. This study has been approved by the CSUSM Institutional Review Board (IRB). Ifyou have questions about the study, you may direct those to the researcher, Jennifer Burgess RN, MSN at 858-848-5023. If you have questions about your rights as a research participant these should be directed to the IRB at [email protected], or (760) 750‐4029. You will be given a copy ofthis form to keep for your records.

Statement of Consent: I have read the above information, and have received answers to anyquestions I asked. I consent to take part in the study.

Your Signature ___________________________________ Date ________________________

Your Name (printed) _________________________________ Date _____________________

Signature of person obtaining consent______________________Date_____________________

Printed name of person obtaining consent ____________________Date ___________________

mailto:[email protected]

a research grant proposal

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