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Promoting Physical Activity and aHealthful Diet among Children:Results of a School-BasedIntervention Study

A B S T R A C T Bruee G. Simons-Morton, EdD, MPH , G uy S. Parcel, PhD,Tom Baranowski, PhD, Ronald Forthofer, PhD, Nancy M . O Hara, Ph D

Background: National heaithobjectfves call for improved diet andmore regular physical activity amoi^children. We tested the effects of a

school-based program to improvestudents' diet and physical activitybehavior at school.

Methods: Two of the four ele-mentary schools in one Te?as schooldistrict were afffiigned to interventionMid two to control conditions. Thethree intervention components wereclassraom health education, vigorousphysical education, and tower fat,lower sodium school lunches- Nutri-ents from school lunches and the totalday and the amount of physical activ-

i ^ students obtained during physicaJeducation were assessed as outcome.

Results: Analysis of schoollunches showed declines from baseline to po sttest in the two interventionschools of 15.5% and 10.4% for totalfat, 31.7% and 18.8% fw saturated fat,and 40.2% and 53.6% for sodium;posttest values were lower in the in-tervention schools. Observation ofph>«ical activity during physical edu-cation clas ses indicated an increase inthe intervention sch ools from baselineto posttest in the percent of time chil-dren engaged in moderate-to-vigorousphysical activity from less than 10% ofclass time at baseline to about 40% ofclass time at posttest; posttest valueswere higher in the interventionschools than in the control schtwls.

Conclusions: TTiis efficacy studydemonstrates the feasibility of sub-stantially modifying schooJ lunchesand school phj^iai education to im-prove children 's diet and physical ac-tivity behavior at school. (A' J Pub-l Health. 199i;81;986-991)

Introduction

Childhtxxi diet and physical activitymay lead to increased risk for cardiovas-cular disease {CVD) in adulthood.' Pro-moting a healthful diet and regular vigor-ous physical activity among children is anational public health objective.^ Schoolis an ideal setting in which to promotehealthful diet and physical activity be-cause these topics usually are part of thehealth education curriculum, and feder-ally supported food services and state-mandated physical education {PE) arewidespread.^ School food services pro-vide nutritious m eals for 73.4^( of all USpublic school students,"^'^^ but the high fat

and sodium content is a concern.^ An es-timated 97% of first hrough fourth-gradechildren in U S public schools are enrolledin school PE programs for an average of100 minutes per week.^ However, the fre-quency and duration of PE classes and theamount of moderate to vigorous physicalactivity {MVPA) children obtain duringPE may be less than recommended."''

This study was designed to influencethe school environment in terms of affecton student diet and physical activity atsch(X5l. The Go For Health {GFH) pro-

gram included a be haviorally-based healtheducation curriculum, fitness-orientedPE, and lower fat and sodium schoollunches. We report the effects of the pro-gram on children's dietary intake andphysical activity during school.

Methods

Design and Study Population

The Texas City Independent SchoolDistrict (TCISD) was selected for thestudy because it is conveniently close tothe university, it has an ethnic m ix of stu-

dents, and it has curriculum, school lunchand PE compo nents. The district particpated in the US Department of Agricuture school lunch program, and eacschool had its own on-premises kitchencafeteria, and focxl preparation staff. Thirdand fourth graders had PE daily, taught bPB specialists. Facilities at each schooinclude a modem gymnasium and largoutdoor playground area. The populatioof students was 62.3% Anglo-America20.9% Mexican-American, and 14.8%Afro-American. The ethnic distributionwere comparable for both treatment ancontrol conditions.

Two of the four elementary school{kindergarten through fourth grade) weassigned to intervention and two to control additions. Third and fourth gradewere assessed annually during threspring data collection periods.

Intervention

The three GFH intervention components, based on social cognitive theo ry,were the Go For Health Curriculum, Chdren 's Act ive Physical Educat io{CAPE), and the New School Lunc{N SL) ." Following the model of Chart

Bruce G. Simons-Morton, Guy S. Parcel, Ronald Forthofer, and Nancy M. O'Hara are witthe School of Public Health of the University ofTexas Health Science Center, Houston, TXTom Baranowski is with the Georgia Prevention Institute, M edical College of G eorgia, Agusta, Ga.

Requests for reprints should be sent Bruce G. Simons-Morton, E dD, M PH, Centfor Health Promotion Research and Develoment, School of Public Health, University Texas Health Science Center, PO Box 20f8Houston, TX 77225.

This paper was submitted to the journ

September \X 1990, and accepted w ith revsions April 23, 1991.



CtiUdren's Diet and Physicai Activity

TABLE —Average N utrients per Luncii N = 12 Meais per School} at Baseline, Mkttest, and Po sttest, with 95% C onfidence Intervais:Go for l ealth Recipe A nalysis

Treatment condition

BaselineMeanLower 95% C iUpper 95% C i

MidtestMeanLower 95% CIUpper 95% CI

PosttestMeanLower 95% CIUpper 95% CI

Baseline^MeanLower 95% C IUpper 95% C i

Midtest

MeanLower 95% C IUpper 95% CI

PosttestMeanLower 95% CIUpper 95% CI

BaselineMeanLower 95% CtUpper 95% Ct

MidtestMeanLower 95% C IUpper 95% C I

Posttest e n

Lower 95% CIUpper 95% CI

BaselineMeanLower 95% CIUpper 95% C I

MicftestMeanLower 95% CIUpper 95% CI

PosttestMeanLower 95% CIUpper 95% C I

Energy(kcal)

1049.21014.31084.1

997.5949.3

1045.8

B98.2870.4926.0

1049,21014.31084.1

1038.3996.4

1080.3

943.5918.6968.4

1077,51037,81117.1

890.4856.3924.5

849.3816.8881,8

1021.0856.6985.4

887.3856.6918.0

840.9800,7

881,1

Protein(g)

38.337.439.2

36.235.237.3

35.334,436,2

38.337.439.2

37.135.738.4

37.136.138.0

37.336.338.3

37.736.438.9

35.034.435.7

39.337.940.6

33.832.734.8

35.735.036,4

CartMjhydrate(g)

Controi school 1

115.1112.7117.3

107.7104.5111.0

100.498.2

102.4Controi school

115,1112.7117.1

114.9112,4117.8

103.6102,2105,3

Intervention school 3

117,8114,9120.6

105.3102.5108.1

100.897.8

104.0intervention school 4

112.2110.4114.4

108.2106.1110,3

96,993.0

100.6^Baseiine tor cwitrof schools imputed from the average of the intervention s dio ds .

Fat(g)

48,446.050,9

46.943,450.3

39.537.841.3

48.446.050,9

47,844,950,6

42.340.643.9

50.848.153.5

35.433.437.4

34,032.035.9

46.143.648.5

35.533.537.5

34.532.1

37.0

Cholesterol(mg)

123.8116.5131.1

113.2104.5121.6

94,690,498.7

123.8116.5131.1

112.2104.2120.2

111.7103.4119.9

137,7129,8145,6

98.191.6

104.7

79.076.881.1

110,0101.8118.1

83,578,288,7

79.377,181,4

Vitamin A(lU)

2722.72291,03154.4

2985,32301,43669.2

2071.51738.32404.7

2722.72291.03154.4

2418.62019.62817,7

2106,01756,42455.5

2809.42365.63253.1

3559.63020.84098.4

3393.02916.73869.3

2636,02210,93061,0

3430,82903,03958,6

3907,63305.2

4509,9

Calcium(mg)

535.5516.4554.6

537.2510.5564.0

480,3461,4499.3

535,5516,4554,6

539.9507.9572.0

511.7488.7534.7

544.0522.3565.6

514.5496,2532,7

474.7462,1487.2

527-0508.3545.7

501.5481.3521.7

469.5452,4

486.6

and Joncs, '^ we em ployed a four-step ap-proach to program implementation and in-stitutionalizatioti.'^ To foster quality im-plementation, the GFH staff providedample training, consultation, and techni-cal support to both teachers and food ser-vice staff.

The purposes of the classroom healtheducation, which consisted of six, bchav-

ioral ly based modules, were to teach

knowledge and skills essential to lifelongperformance of the target diet and physi-cal activity behaviors and foster the trans-fer of learning about these behaviors fromschool to out-of-school environments. '

The NS Lw as designed to provide low-er-fat, lower-sodium lunc hes within the a m -text of the existing school lunch program.Food purchasing, menus, recipes,, and food

preparation practices were modified.

CAPE, which consisted of five, 6- to8 week units, was designed to encourageenjoyable MVPA among children duringPE classes. Each unit included two orthree main cardiovascular fitness activi-ties, such as dancing, running, aerobicgames, jump rope, and obstacle courses.Each class session consisted of warmup,fitness development, cool down, and skill

development or game activities.



Simons Mortun et al.

School 3 SchoiilINTERVENTION

FIGURE —Means and 95 Confi-dence Intervals for TotalFat and Saturated Fat asa Percent of Calories inSchooi Lunches {N = 12meals per school) inControl and InterventionS c h o o l s a t B a s e i i n e(Pre), after 1 Year (Mid),and after 2 Years (Post).

easures and Procedures

Program effects were assessed by an-alyzing the nutrient contents of lunches,conducting 24-hour dietary recalls, andobserving stud ents ' physical activity dur-ing FE.

Nutrient Analysis of School LunchesThe identical menu w as repeated in Marchand April each year of the study. At base-line, 12 meals were selected randomly fromthe March and April menus and analyzedfor nutrient content. Recipe analyses, basedon detailed interviews with each cook in theintervention schools at baseline and in all

four schools at midtest and posttest, werectinducted by trained staff nutritionists andanalyzed by the Nutrition Coding Center

Diet Recall The 24-hour dietary re-call interview w as administered at po sttestto random , cross-sectional subsamples ofchildren, stratified by study school. Inter-viewers were trained according to NCCprocedures and followed the NCC proto-col for diet interviews. Each child was in-terviewed at home in the compan y of oneparent, who was asked about ingredients,food preparat ion, and other i tems asneeded.

Physical Activity The time {in min-utes) of MVPA performed by childrenduring physical education w as assessed bytrained observers using the Children 'sPhys ica l Act iv i ty Observa t ion Form{CPAOF). ^ Study schools were observedon randomly selected days over a 2-monf hperiod each spring; all third- and fourth-grade classes were observed. Observersrecorded on a m inutc-by-minute basis thetype {e.g., basketball, jump rope) and in-tensity of physical activity. The CPAOFintensity categories have been validatedagainst heart rate,'^ and the average heartrate for MVPA was 172.2 (SD = 21.2)beats per minute. Interobserver agree-ment was 97.0% {n = 57 paired observa-tions).

Analysis

For energy and selected nutrients ofpotential concem in this age group, wecalculated the mean s and 9 5% confidenceintervals {CIs) of the repeated samples ofschcxjl lunches in each school. For eachseparate treatment condition, we calcu-lated the mean nutrient intakes from the24-hour dietary interviews for selected nu-trients and examined the contribution ofschool and bag lunches to total daily nu-trient intakes.

For each school at each reporting pe-riod, we calculated the MVPA means,standard deviations, medians, and 95%CIs for the medians. ' The median is themost appropriate statistic for purposes ofcomparing treatment effects because in-creases in the amount of MVPA on thepart of only a few stu den ts could affect th emean value, obscuring true program ef-fects. P ercent of class time is preferable tominutes as an outcome becau se the sched-uled length of PE classes varied so mew hatfrom year to year, and the effective classtime available for PE teachers and stu-dents, although similar in each school fora given year, varied somewhat fromschool to school due to local scheduling.

The annual surveys are presented sepa-rately for each grade because most of oneyear 's third graders became the nextyear's fourth graders; hence the data foreach grade are not independent acrossyears.

sults

Diet

Recipe Analysis Table 1 includesthe means and the 95% CIs for total en-ergy {in ki localories[l kcal =4 .2 kJ ]) an dsix nutrients in the 12 meals served in

each study school each year. Baselinevalues for the control schools, whichwere not collected directly, were estimated by averaging the values of the twin te rvent ion schools . Dec l ines f rombaseline to posttest in each school foprotein, carbohydrates, total fat, cholesterol, and calcium are the product of declines in energy. The decline in calorieserved in the intervention schools appears to have been due mainly to a reduction in the amount of fat and carbohydrates. Despite the declines in energyvitamin A and calcium did not declineand posttest values for all schools exceeded the USDA school lunch requirements for each nutrient. For example, aevery reporting the average intake of energy in each school exceeded 33 % of thtotal daily requirement for energy, whichis 6(K) to 7(X) kcal per m ca l.'^

Shown in Figure I for each school ithe average total fat and saturated fat as percent of kcal served in the sample of 1lunches. For both intervention sch ools thupper CIs of the posttest mean s were lesthan the pr etest m ean s, and in schcx)l 3 thupper and lower CI values did not overlapThe mean percent fat declined in school by 15.5%, from 41.3% to 35.6% of calories, and in schoo l 4 by 10.3%, from 39 .7%to 35.6% of calorics. Average percent saturated fat declined in school 3 by 31.7%from 16.1 % to 11.0% of calorics , and ischool 4 by 18.8%, from 13.8%' to 11.0% ofcalories. The means for percent total faand saturated fat at posttest in the controschool were within the imputed pretes95% CIs .

Figure 2 shows that the sodium content in the school f(X)d declined from baseline to posttest in schooi 3 by 53.6% from2141.1 mg to 993.0 mg, and in schtw l 4 b40 .2%, from 1730.0 mg to 1034.5 mgThese differences remained after controling for kcals served. Sodium in the control schixils did not decline from the imputed baseline value.

Dietary Recall Table 2 shows theanalysis of the posttest 24-hour recalls fothe nutrients of interest. Students in thintervention group, compared with students in the control group, reported fewecalories {2094 vs 2135 [1 calorie = 4.2 Jand less total fat (77 g vs 90 g), saturatedfat {29 g vs 34 g), and sodium (2873 mg v3378 mg) for the total day. In comparisowith control group students, interventiogroup students reported consuming lestotal fat, saturated fat, and sodium in bottray and bag lunches.



ChUdren*s Diet and Physical Activity

Physical ctivity

Table 3 shows m edians, means, andstandard deviations for minutes of MVPAfor observed students in grades three andfour at each study school at baseline,midtest, and posttest. At baseline, meanMVPA for third and fourth graders wasless than 3 minutes at each school; medi-ans were 2.0 minutes or lower. At post-test, mean minutes had increased inschool 3 to 11.7 (third grade) and 15.0(fourth grade and in school 4 to 16.2 (thirdgrade) and 16.1 (fourth grade) per class.

Median m inutes as a percent of classtime and 95% CIs around the medians areshown for third and fourth g rade in Figure3. For both grades, the median percent ofclass time in MVPA at baseline was zeroin three schools and less than 10 inschool 3. At posttest, the control schoolmedians were still no greater than 5 % ofclass time. In the intervention schools,however, the posttest m edians w ere sub-stantially higher, 28 of class time forthird graders in school 3, and 39% of classtime or greater for the other Interventiongroups. Except for fourth g rade in school3, the upper and lower 95% CI values donot overlap with the baseiine m eans.

Discussion

The results show strong positive pro-gram etfects on children's diet and phys-ical activity at school. At posttest, school

lunches in the intervention schools pro-vided less energy, fat, and sodium com-pared with baseline and with the controlschools, white adequate levels of other es-sential nutrients were maintained. Simi-larly, children 's physical activity in the in-tervention schools was much higher atposttest than at baseline and in compari-son with the control schools.

Several studies have demonstratedthat sodium reductions can be accom-plished by intervention directed at schoolmeals.' '^^ However, no studies have re-

ported systematic reductions in fat and so-dium in school lunches. In the GFH inter-vention schools, sodium content wasreduced to target levels, saturated fat re-ductions of 31.7% and 18.8% occurred,and posttest values approached the targetgoal of 10% of kcals served. Total fat re-ductions were modest, 15.5% and 10.3%,and the target goal of 30% of kcals was notreached, indicating that it is easier, even ininstitutional settings, to substitute fat typ ethan to reduce the amount of fat.

The 24-hour dietaiy recall data indi-cate that the changes in nutrients served in

26

24

22

2

8

6

4

2

8

6

0

Sodium (mg)

pre mid post pre mid postSchool 1 School 2CONTROL

pre mid post pre mid postSchool 3 School 4INTERVENTION

FIGURE 2—Means and 95% Confidence Intervals for Sodium in Scho ol Lunches (N =12 Meals per School) in Control and Intervention Sch ools at B aseline (Pre),after Year (Mid), and after 2 Years (Post).

T ^ U E 2~-Means and % % Con fld«ice Intervals of Selected Nutrients from B ag or TrayLunc h B ased on 24-4Hour Diet Recalls in the Intervention and Con troi S choo ls

Variables Energy (kcal) Total fat (g) Saturated fat (g) Sodium (mg)

ControlTotal day (n = 68)

MeanLower 95% CIUpper 95% 01

Tray lunch (n = 49)MeanLower 95% CUpper 95% CITotal day avwage (%)SE

Bag und i (n = 19)MeanLower 95% CIUpper 95% CITotal day average (%)SE

Total day (n = 67) e n

Lower ^ % CIUpper 95% CI

Tray lundi (n = 48)MeanLower 95% CIUpper 95% 01Ttrtal day average (%)SE

Bag lunch (n = 19)MeanLower 95% CtUpper 95% CITcrtai day average (%)SE

2135.31978.32292.3

806.9730.7883.0

37.81.8

681.4568.8794.1

35.72.e

2094.51922.62266.5

790.2676.9903.4

36.51.9

657.7516.8798.6

36.12.7

90.080.899.1

34.830.838.840.1

2.4

27.321,533,034.4

2,7

Intnvent lon78.670,087.2

29.725.633.838.0

2.2

25.118.831.337.2

2.8

33.930.337.6

13.811.915.840.7

2.4

9.06.9

11,032.5

3.4

28.525.032.0

10.08,3

11.635.4

2.3

7.85.6

10.032.63,2

3377,63044.13711.0

1283.41137.21429.6

39.72.3

966.0794,8

1137.333.42.7

2872.62554,23190,7

909.1756.6

1052.732,5

2.0

789.5645.5933.5

31.32.4



Simons-Morton ct al.

TABL£ 3—Average Tinie (in Minutes) of MVPA Obs«ved during Physical Education

Tre^mentCondition

Bas^ine

MidpantPosttestSchool 2

eline

MidpointPosttest

Schoot3Bas^neMidpointPosttest

School 4Bas^ineMidpointPosttest

N

32

2737

342436

313438

323858

Third Grade

Median

0.0

1.02.0

0.01,02.0

2.01.5

10 5

0 04.5

16.0

Mean

0.4

2.82.9

0.52.03.5

2.02.6

11 7

2.84.9

16.2

SD

Control

0.9

5.03.5

1.12.23.9

Intervention

1.42.67.5

5.04.37.8

N

41

3635

261051

452426

362449

in Control and intervention Schoois

Fourtii Grade

Median

0.0

0.51.0

0.00.01.0

2.02.5

20.0

0.07.0

16.0

Mean

0.3

1.11.5

0.42.24.5

2.46.8

15.0

1.98.0

16.1

SD

0.7

1.51.9

0.93.45.9

1.97.4

10.6

3.64.47.4

THIRD GRADEMedian Class Time in MVPA during PE

11

FOURTH GRADE

\I

1

School Scliool CONTROL

RGURE 3—Medians and 95 Con fi-dence intervais for Per-centage of Physical Ed-ucation Class Time inModerate to VigorousPhysicai Activity (MVPA)

in Control and Interven-tion Schools at Baseline(Pre), after 1 Year (Mid),and after 2 Years (Post);Third and Fourth Grade.

school lunch contributed to improve-ments in total daily dietary intake of cal-ories, total fat, saturated fat, and sodium.Children did not make up in other mealsfor reductions of fat and sodium in schoollunches. Energy, calcium, and vitamin Aremained adequate at posttest in allschools, suggesting that reductions in fat

can be accomplished without undue re-ductions in other essential nutrients.

Several studies have demonstratedthat it is possible to modify PE to improvecardiorespiratory fitness.^"^^ Our resultsindicate that it is possible to increase timedevoted to MVPA from less than 10% tomore than 40% of available class time. Atposttest, the typical student in the inter-vention schools obtained about 16 min-utes of MVPA p er daily P E period, or 80minutes of MVPA per week. It must benoted that these modest results were ob-tained after 2 years of intervention thatinvolved one staff person virtually fulltime in the provision of intensive trainingof PE teachers. Because PE accounts fornearly half of children's total daily physi-cai activity,^ the extremely low level ofMVPA observed in all schools at baselineis a cause for concem, particularly if fu-ture research determ ines that low levels ofactivity during PE are prevalent in Amer-ican schools.

This is the first US study to demon-strate the potential of altering the schoolenvironment to promote a more healthfuldiet and more vigorous physical activity mong children, although at least one suc-cessful European study has been report-ed.'^" Strengths of the present stucty in-clude planned implementation of theory-based individual and organizationalinterventions, two intervention and twocontrol schools within the same district,and objective measures of diet and phys-ical activity. Limitations of the study in-clude the lack of baseline recipe data forthe control schools, nonrandom assign-

ment of schiK)ls to treatment conditionsand the small number of study scho ols.

The results of this efficacy study sug-gest that school is a potentially importansite for improving children's diet andphysical activity nd that such changes arepossible. In our experience, howeverschools do not change readily, and substantial staff training should accompanypolicy changes regarding healthful schoolunch and vigorous physical educationBefore widespread implementation ofthese changes txxu rs, effectiveness studies with larger numbers of schtwis areneeded to determine the ability to generalize these approaches and to assess coseffectiveness. D

AcknowledgmentsThis research was funded by NHLBI Gran33376. We gralefuily acknowledge the admin-istrators, teachers, and staff of the Texas CityIndependent Schtx) District for their supporand ctxjperation. Aiso, we thank Renee Fleishman for data preparation and Ids Huang fostatistical analyses.

This research was presented at the annualmeeting of the Amedcan Public Heaith Association held in New Y ork City Septem ber 30 tOctober 4, 1990.

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National Primary Care Nurse ractitioner Symposium Issuing Call forAbstracts

The 17th National Primary Care Nurse Practitioner Sym-

posium is accepting abstracts of research, innovative clinicalpractice/models and roles, and other professional papers re-lating to primaiy eare nursing. Abstracts are being accepted forpresentat ion plenary) or poster sessions. This symposium,sponsored by the University of Colorado Health SciencesCenter School of Nursitig, will be held July/early August, 1992,in a Colorado mountain resort.

Please send three ^ e d copies 300 words or fewer), lim-

ited to one page, single spaced, with l-i/4 inch margins. Ab-stracts must be photocopy-ready and include title. A separatepage with author contact information may be used. Formatincludes title, brief statement of purpose, methods, conclu-

sions, and clinical application s) or, if not a re.search abstract,

brief summary of project/paper. Include author vita and indi-cate interest in presentation plenary) and/or poster session.

Preference will be given to abstracts with strong clinicalapplicability, innovative role development models and papers

with future-oriented perspective.

Presentera are provided tuition waiver for registration the

day of their presentation, but are responsible for their owntravel and expenses. Deadline is October 14. 1991.

Contact Ellen Lemberg, RN,C, MS, Nurse PractitionerSymposium Offits, School of Nursing, University of ColoradoHealth Sciences Center, 4200 East 9th Avenue, Box C287,Denver, Colorado 80262. Tel: 303/270-7436.

promoting phyical activty among chlidren

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