Transcript Start Strong Walking and Breakfast Program Presentation as part of Public Health Nutrition.

Start Strong Walking and
Breakfast Program
Presentation as part of
Public Health Nutrition
Outline
 Background
to school breakfast and
walking programs
 Start Strong program description
 Results and discussion
 Conclusions and recommendations
Background
What is the Need for School Interventions
in Nutrition and Physical Activity?

Past 30 years, the obesity rate for 6-11 year olds has tripled
 At least 15% of US children are overweight
 Childhood obesity influenced by many factors (IOM):
 Reduced access and affordability of nutritious foods in
communities
 Decreased opportunity for physical activity to and from as
well as at school
 Food insecurity
• 10% of all American children experience food deprivation


Certain populations at highest risk for obesity:
 Boys – Hispanic-American
 Girls – African-American
Long-term health risks associated with childhood obesity
Significance of nutrition in schools

Improvement in academic performance
 Improvement in psychosocial functioning
 Emphasis of healthy body image
 Promotion of healthy body weight
 Promotion of long-term health outcomes
 Development of optimal lifelong eating habits
Importance of School Breakfast
- determined by SBP data


SBP a low-cost health intervention
Affect of breakfast consumption on total energy intake



Association of food insecurity and obesity


Breakfast skippers are more likely to be overweight
Higher dinner intake increases risk of overweight
Decrease in overweight among food-insecure participants
Affect of school breakfast consumption:


Fewer hungry children, nurse visits, disciplinary problems
Improvement in academic performance, body image, healthy
eating practices, and translates to better family eating habits
School Breakfast Program
Need and Utilization

Offered more in low-income vs. high income
neighborhoods
 Targets groups with free/reduced cost meals
 Addresses issue of breakfast-skipping




¼ of students fail to eat breakfast
Race – black and hispanic adolescents highest rate
Age – older age groups more likely to skip
Gender – girls more likely to skip than boys
School Breakfast Program Barriers
 Time
 Late
buses, school arrivals or long commutes
 Students not hungry in the morning
 Stigma associating the SBP with poverty
Importance of Physical Activity in School

½ of 6-17 year-olds go without daily physical activity
 40% decrease in active commuting since the 1970s
 Only 5% of children walk or bike to school
 Walking or biking to school is associated with an
average of 24 minutes of increased daily exercise
Physical Activity in School Associated With:

Increased physical activity outside of school
 Decreased BMI
 Decreased incidence of chronic disease
 Improved cardiovascular fitness
 Decreased TV screen-time
 Decreased consumption of high-fat snacks
 Improved academic performance
School Walking Programs and
Active Transportation


Improve the health and physical fitness of individuals
 Increase metabolism and circulation
 Decrease illness and absenteeism
 Improve concentration and learning
 Encourage an overall increase in physical activity
Support the health of the community
 Limit traffic pollution and congestion
 Encourage parent/teacher involvement
 Reallocate school transportation resources
Utilization of Active Transportation Programs
Demographic disparities:
 Low SES is a determinant for low overall
physical activity
 Participants of programs are more likely to
have lower SES
 Gender differences

Boys more active than girls
Barriers to Active Transportation
 Unsafe
neighborhoods
 Inclement weather
 Traffic and congestion
 Lack of sidewalks and crosswalks
 Suburban sprawl
Start Strong Program
Description
Purpose of Start Strong
 Start
Strong is a program working to
combine walking to school with healthy
breakfasts in order to enhance student
health and build community involvement in
your elementary school.
Program Objectives
 Decrease
potential for student injury
 Increase number of students walking to
school
 Increase number of students consuming a
healthy breakfast
 Improve school breakfasts
Logic Model
Inputs
Outputs
Resources
Activities
Grant money
Focus
Groups
Staff
Promotions
Volunteers
Nutrition Ed
Taste Tests
Short Term
Outcomes
Intermediate
Outcomes
Increased # of
students
walking to
school
Add to
evidence base
for breakfast
and Walk to
School
Activities
Increased
participation in
school lunch
program
+ changes in
school
breakfasts
Great
evaluation
Improved
knowledge
Healthier
students
Increased
student
academic
success
Develop health
champions
within schools
Long Term Outcomes
Decreased
Obesity Rates
District Wide
Policy Change
Breakfast
changes
District Wide
+ changes in
Nutrition
Services due
to increased
revenue
Walk to School
expansion
Program Schools

Maple Elementary:


Dearborn Park Elementary


77% participating in free/reduced program,
46% breakfast participation
Wing Luke Elementary


75% participating in free/reduced program,
21.6% breakfast participation
Emerson Elementary


64.5% participating in free/reduced program,
12.9% breakfast participation
72% participating in free/reduced program,
24.4% breakfast participation
Beacon Hill (control)
Intervention

Breakfast taste tests

Walking School Bus

Monthly walk and breakfast promotions

October 2006 start, planned through June 2007
Data Collection

Hands-up Surveys (at Dearborn Park,
Emerson, and Beacon Hill)


Parent interviews (at Dearborn Park,
Emerson, Maple, and Wing Luke)


Questions about where/if students ate breakfast
and how they traveled to school
Questions about opinions on breakfast and
walking, perceptions of program, and possible
barriers to participation
Teacher/staff interviews (at Dearborn Park,
Emerson, Maple, and Wing Luke)

Questions about perceptions of program,
participation, and evaluation of effects
Analysis of Hands-Up Survey Data

Proportion calculated for each breakfast and
transportation category
 Used a two-sample proportion hypothesis test to
compare each intervention school to the control
school
 Significance was defined as a two-sided p-value
<.05
Analysis of Key Informant Interviews
 Yes/No
questions analyzed quantitatively
 Qualitative questions analyzed by
grouping answers into main themes
 Relevant responses were quoted in the
qualitative results
 Statistical analysis could not be performed
due to small sample sizes
 Results presented explicitly as fractions
Hands Up Survey Results
and Discussion
Hands Up Student Breakfast
and Transportation Survey
“Please enter the number of students who raise their hand for
each of the following”:
Car
Ate breakfast
both at home
and school
School
Bus
Walked
with an
adult
Ate breakfast
just at home
Walked
without
an adult
Ate breakfast
just at school
Bicycle
Ate breakfast
somewhere
else
Other
Did not eat
breakfast
Hands-Up Survey:
Where did you eat breakfast today?
All Students Surveyed
8%
2%
16%
At Home and at School
Only at Home
19%
Only at School
Someplace else
No breakfast
55%
Hands Up Survey:
“Where did you eat breakfast today?”
Dearborn Park
(n = 265)
Emerson
(n = 180)
Beacon Hill
(n = 335)
38 (14%)
56 (31%)*
31 (9%)
Only at home
135 (51%)*
61 (34%)*
230 (69%)
Only at school
59 (22%)*
52 (29%)*
38 (11%)
Someplace else
6 (2%)
6 (3%)
7 (2%)
26 (11%)
5 (3%)
29 (9%)
At home and at
school
No breakfast
* Significant compared to control (p<.05)
Hands-Up Survey:
How did you get to school today?
All Students Surveyed
6%
7%
Car or carpool
School Bus
City Bus
49%
37%
Walked with an Adult
Walked without an Adult
Bicycle
Other
Hands Up Survey:
“How did you get to school today?”
Dearborn Park
(n = 271)
Emerson
(n = 177)
Beacon Hill
(n = 330)
Car or carpool
119 (44%)
87 (49%)
181 (55%)
School bus
125 (46%)*
65 (37%)*
95 (29%)
Walked with an
adult
11 (4%)
6 (3%)
34 (10%)
Walked without
an adult
15 (6%)
17 (10%)*
14 (4%)
Walked >2
blocks
24 (10%)
27 (15%)*
26 (8%)
* Significant compared to control (p<.05)
Hands Up Survey Limitations
 Unequal
counts between walking and
breakfast questions
 Some children (especially younger ones) did
not understand the question about walking
more than 2 blocks to school
 Many classes were taking a field trip that day
 At Emerson, day care across the street
affected children’s answers
Parent/Guardian Interview Results
and Discussion
Parent Interviews
 32%
participation rate (8 of 25)
 All the parents had heard of Start Strong
 7 of 8 had met other parents
 6 of 8 had met teachers
 5 of 8 had helped with nutrition homework
Parent Responses - Breakfast
 Eating
breakfast is very important to all the
parents
 3 of 8 have children eating breakfast at
school
 5 parents knew that parents can come to
school breakfast, but only 3 have done it
 Half the parents like the breakfast served
 Half the parents think communication has
improved
Qualitative Breakfast Data
 Breakfast



Provides energy
Improves learning
1st meal of the day
 Breakfast



is important
at home
Family eats together
Late bus arrival
Food isn’t good enough at school
How to Improve Breakfast
Participation
 Parents



More nutritious food
More organic food
Better quality food
 Don’t


would participate if
participate because
Time constraints
Lack of trust
Parent Responses - Walking
 All
the parents support the walking
program
 3 of 8 parents said their children walk to
school and 2 responded that they
sometimes walk
 All the parents think the walking program
is safe
 Results were mixed if it improves
communication (5 of 8 said yes)
Qualitative Responses Walking
 Parents
think walking is important for
themselves and their children
 They think walking



Encourages socialization
Benefits health
Improves concentration
 More
students walk to school when it is
“Walking Wednesday”
Barriers to Walking Participation
 Distance
– Biggest barrier
 Safety
 Weather
 Lack
of sidewalks and construction
Parents’ Suggestions
 All
would like to participate
 Ride the bus with child
 Designate a point to drop off children at
the walking school bus
 Better communication with promoters of
the program
 Better communication between parents
 Parents need more time to participate
Limitations
 Low
participation because of nonresponse
 Possibility of misinterpreting questions
 Disconnected numbers
 Short timeframe for conducting interviews
 Questions were sometimes vague and
confusing to the parents
Teacher/Staff Interview Results
and Discussion
Teacher/Staff Interviews
 48%
(17/35) staff members participated in
survey
 Of those who participated in survey:





All 17 were familiar with the program
All 17 had students participate in the program
All 17 believed the program was beneficial for
students
13 conducted classroom interventions on
health, nutrition, and/or exercise
7 had parents/guardians involved in students’
class work
Teacher/Staff Responses Breakfast
 12
of 17 thought parents were participating
 5 of 17 thought that communication was
improved with parents
 10 of 16 thought students’ knowledge of
healthy eating changed
 9 of 17 thought students’ attitude towards
breakfast eating had changed
 12 of 17 thought students doing better
academically because of breakfast
Qualitative Breakfast Data
 Kids
liked the taste tests
 More likely to try new foods introduced
 Enjoy variety
 New foods healthier
 Kids eat more fruit when it is offered
 Kids more alert when eat breakfast
 Kids more aware of what healthy eating
means
How to Improve Breakfast
Participation
 Implement
more frequent taste tests
 Getting kids back to class on time
 Permanent nutrition program aside from
PE instruction
Teacher/Staff Responses Walking
7
of 17 thought it improved school
communication and trust
 9 of 15 believed the walking program is safe
 12 of 17 believed students more aware of
health benefits of walking
 7 of 17 believed students’ attitude towards
walking had changed
 4 of 17 thought children doing better
academically
Qualitative Walking Data
 Parent
participation declined in the winter
 More opportunities to interact with parents
during a walk
 Making a connection is hard
 Program is too small to make a difference
 Kids are excited about the program
 Prizes and incentives help
 Program considered safe with adult
supervision
How to Improve Walking
Participation
 Staff
participation is currently keeping the
walking program afloat
 Get more parents to participate
 Staff is overburdened and want this to be
parents’ responsibility
Barriers to Walking Participation
 Bad
weather
 Lack of crosswalks
 Lack of neighborhood street safety
 Confusion about responsibility
 Too much burden placed in teachers
 Too much burden/expectation placed on
adults who volunteered at the start
Teacher/Staff Suggestions
 Use
school assemblies for nutrition ed
 Receive materials from Start Strong to
build a curriculum
 Sending letters home ineffective
 Materials should be multilingual
 Dedicated trails contribute to safety and
ease
 More incentives
Limitations
 52%


of staff members did not participate
Scheduling conflicts
Feeling they had nothing to contribute
 More
staff than teachers interviewed
 Questions about academic performance
not relevant to all interviewed
 Difficulty in assessing cognitive
improvement from breakfast
Discussion
Discussion of Limitations
 Ideal
study design would be an RCT
 Assumption that control and intervention
schools were identical in:



Student populations
Family SES
Surrounding physical environments
 Limited


timeframe for conducting:
Hands-up surveys
Key informant interviews
Potential Sources of Error

Observers not blinded toward control or
intervention schools
 Self-reported data
 Students may not have understood survey
questions
 Parents may not have understood questions
 Self-selection of key-informant interviewees
Conclusions and
Recommendations
Conclusions

Start Strong program positively impacts:





Students’ breakfast consumption habits and attitudes toward
healthy eating
Students’ attitudes toward walking to school
Built environment must be conducive for students to walk
to school (weather, distance, safety, cross-walks)
Further research required to determine the impact of this
program on the community
Research will help support school policies and programs
that can further positively impact the healthy eating
behavior and physical activity of children
Recommendations: Future
Research
 Establish
larger sample sizes
 Collect data at multiple time points
 Longer timeframe for data collection
 Consideration of weather and distance in
assessing feasibility of walking programs
Recommendations
 Improve
teacher/staff and parent
participation
 Offer more opportunities for incentives
 Clarify roles for teachers/staff and parents
 Improve communication
 Relationship-building opportunities
 Implement walking program during a warmer
season
 Create drop-off points for walking school bus
 Conduct school bus weekly rather than
monthly
Acknowledgments
 Donna
Johnson
 Mary Podrabsky
 Katie Busby
 Mollie Greves
 Kirsten Frandsen
Questions?
References
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