Start Strong Walking and Breakfast Program

Start Strong Walking and Breakfast Program

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 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 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 Walke d with an adult Ate breakfast just at home Walked without an adult

Ate breakfast just at school Bicycl e 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 Only at School Someplace else No breakfast 19%

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 7% 6% 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 childrens 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 is important

Provides energy Improves learning 1st meal of the day Breakfast at home Family eats together Late bus arrival Food isnt good enough at school How to Improve Breakfast Participation Parents would participate if

More nutritious food More organic food Better quality food Dont 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 non- response 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

Ask, Anne S. Changes in dietary pattern in 15 year old adolescents following a 4 month dietary intervention with school breakfast, Nutrition Journal 2006, 5:33.

Berrigan et al. Active transportation Increases Adherence to Activity Recommendations. American Journal of Preventative Medicine. 2006: 31 (3). Bickel G, Carlson S, Nord M: Household Food Security in the United States 19951998; Advanced Report. Alexandria/Va, Food and Nutrition Service, United States Department of Agriculture, 1999 Carter, The Impact of Public Schools on Childhood Obesity. JAMA 2002. Cooper, R, et al, Active travel to school and cardiovascular fitness in Danish children and adolescents. Med Sci Sports Exerc. 2006 Oct;38(10):1724-31) Cooper, A.R. et al. Physical Activity Levels of Children who walk, cycle, or are driven to school. American Journal of Preventative Medicine. 2005: 29 (3) 179-184. Center for Disease Control and Prevention (CDC): Obesity: Healthy School Program: Crepinsek, M.K. et. al., J Am Diet Assoc. 2006;106:1796-1803 Eisenmann JC, Physical activity, TV viewing, and weight in U.S. youth: 1999 Youth Risk Behavior Survey. Obes Res. 2002 May;10(5):379-85). Evenson, K.R. et al. Girls perception of physical environmental factors and transportation: reliability and

association with activity and active transport to school. International Journal of Behavioral Nutrition and Physical Activity. 2006; 3:28. Erickson, SJ et al, Are overweight children unhappy?: Body mass index, depressive symptoms, and overweight concerns in elementary school children. Arch Pediatr Adolesc Med. 2000 Sep;154(9):931-5). FRAC websites: FRAC Wellness Guide 2006: 2006.pdf FRAC USBP Pilot Summary FRAC School Breakfast Program References

Fulton JE, Shisler JL, Yore MM, Caspersen CJ. Active transportation to school: findings from a national survey. Res Q Exerc Sport. 2005;76:3527. Injury Free Coalition For Kids of Seattle: Breakfast and child obesity: Whats the link? IOM Fact sheet Childhood obesity in the United States (2004). Available at: Master/22/606/FINALfactsandfigures2.pdf. Accessed 3-1-07. Kids Count: State-level data online. Available at: Accessed 3-1-07. Kleinman RE, Murphy JM, Little M, Pagano,M, Wehler CA, Regal K, Jellinek MS: Hunger in children in the United

States: Potential behavioral and emotional correlates. Pediatrics 1998;101:100111. Miech, R.A et al. Trends in the association of poverty with overweight among US adolescents, 1971-2004. JAMA 2006. Position of the ADA: Local Support For Nutrition Integrity In Schools. J Am Diet Assoc. 2006;106:122-133. Safe Routes To School: Radcliffe, B et al. The Queensland School Breakfast Project: A health promoting schools approach. Nutr Diet 2005; 62:33-40. Recommendations for Strengthening Community Programs for Youth. New York, NY: Carnegie Corporation of New York, 1994. M. Sharma et al, School-based interventions. The International Association for the Study of Obesity. Obesity Reviews 7, 261-269 (2006). Sirard JR, Ainsworth BE, McIver KL, Pate RR. Prevalence of active commuting at urban and suburban elementary schools in Columbia, SC. Am J Public Health. 2005;95:23640. Sirard JR, Riner WF Jr, McIver KL, Pate RR. Physical activity and active commuting to elementary school. Med Sci Sports Exerc. 2005 Dec; 37(12):2062-9. Tudor-Locke C, Ainsworth BE, Popkin BM. Active commuting to school: an overlooked source of childrens physical activity? Sports Med. 2001;31:309 13.

References Tudor-Locke, C, et al. Omission of active commuting to school and the prevalence of children's health-related physical activity levels: the Russian Longitudinal Monitoring Study. Child Care Health Dev. 2002 Nov;28(6):507-12). United States Department of Agriculture (USDA): USDA Nutrition Insights: Eating school breakfast greatly improves schoolchildrens diet quality. USDA School Breakfast Program. USDA SBP Fact Sheet:

US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000]. document/HTML/Volume2/19Nutrition.htm Walking School Bus:

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