Step Ahead Intervention School Worksite Weight Gain Prevention

Obesity is associated with increased risk of cancers of the esophagus, breast (post-menopausal), endometrium (the lining of the uterus), colon and rectum, kidney, pancreas, thyroid, gallbladder, and possibly other cancer types, according to the National Cancer Institute. Obesity also puts people at higher risk for coronary heart disease, stroke, high blood pressure, diabetes, and a number of other chronic diseases. Obesity results in profound economic costs, including the costs of medical care and lost productivity related to being absent from work. The workplace can be a supportive environment in which to encourage healthy lifestyle choices and minimize or prevent weight gain. Because public and private schools throughout the United States employ more than seven million teachers and other personnel, schools hosting weight gain prevention interventions have the potential to reach a large proportion of the U.S. workforce. Further, school facilities, such as tracks and gymnasiums, can provide opportunities for school staff to engage in physical activity.

Step Ahead is a 2-year, multi-component school worksite intervention designed to help school employees be more active, eat better, feel better, and maintain a healthy weight. Step Ahead is guided by social ecological principles. In a school environment, these principles suggest that behavior change among employees is more likely if school-wide strategies are put in place targeting the physical environment and school policy, social environment, and individual. The intervention is guided within each school by staff members who serve as the Step Ahead coach or a member of the Employee Advisory Group (EAG). The coach, who has a background in health (e.g., school nurse, physical education instructor), serves as a champion for the program, recruits and convenes EAG members, and functions as a liaison to school leadership. The coach receives additional compensation for the time needed to carry out these responsibilities. The EAG, which consists of 12-15 school employees representing the array of school staff, provides overall direction to the intervention.

The intervention is designed to be implemented beginning in the fall semester. In the spring preceding implementation, the coach conducts planning activities, including soliciting feedback on proposed activities from school employees through surveys, focus groups, and environmental scans. Step Ahead activities are also guided by the Centers for Disease Control and Prevention's Community Health Assessment and Group Evaluation (CHANGE) tool (including the Worksite Sector subscales). The coach and EAG use the CHANGE tool in the formulation, implementation, and modification of the school's activities. During the school year, the coach convenes the EAG every few months to select, plan, and implement intervention activities, which may include the following:

-- Physical environment and school policy (organizational level): Creating policies at the school to affect the physical environment, such as providing access to fitness facilities and locker rooms, removing sugar-sweetened drinks from vending machines, and arranging for healthy lunch options for staff

-- Social environment (interpersonal level): Organizing group activities that build on or create relationships among staff, such as staff games, group walking, and healthy potlucks

-- Individual: Providing access to health information and tools that can be readily used, such as the Step Ahead website, self-weighing programs, and pedometers

School employees are encouraged to participate in program activities during or after their work hours. Because the school's physical environment may support or impede the adoption of healthy behaviors, a detailed facility assessment is recommended to help inform policy interventions at the organizational level.

-- Approximately 3 hours per week for 4 months during the spring semester (prior to implementation in the fall) for the coach to plan for implementation

-- Approximately 3 hours per week during the school year for the coach to recruit and convene the EAG and implement the intervention

-- Approximately 1 hour every 2-3 months (or more frequently) during the school year for the EAG to meet to plan and implement intervention activities

Step Ahead targets school employees, such as principals, teachers, counselors, school nurses, administrative staff, food service workers, and maintenance staff.

The intervention is intended for use in schools.

Materials required for implementation include:

-- Step Ahead program website

-- Step Ahead Intervention Manual School Worksite Weight Gain Prevention

-- Step Ahead Intervention Timeline

-- Employee Resource Book 2010-2012

-- Potluck Booklet

-- Sample 5K poster

-- Posters

-- Recipe books

-- Health Promotion Displays

For costs associated with this program, please contact: Barbara Estabrook. (See products page on the EBCCP website for contact information.)

The study was conducted in 12 public high schools in Massachusetts. Superintendents, principals, and school nurses of all 114 public high schools within 50 miles of Worcester, Massachusetts, were approached to gauge their interest in participating in the study. Representatives from 32 schools responded, and these schools were stratified into 3 groups based on school size and urbanicity (i.e., large urban school, small urban school, rural school). Within each stratum, four schools were randomly assigned to the intervention condition (two) or the materials-only comparison condition (two), so that there were six schools in each condition. The primary outcomes were change in weight and body mass index (BMI) at 12-month and 24-month follow-up.

The 782 study participants ranged in age from 21 years to 65 years and older, and two-thirds (67.0%) were female. The sample was 95.9% White, 3.4% Hispanic or Latino, 1.3% Asian, 0.7% American Indian, 0.7% Black, and 0.1% Pacific Islander. In addition, 54.7% of the sample were teachers, and 65.3% reported that they were currently trying to lose weight. Lastly, 35.8% had a baseline BMI of 25.0-29.9, and 29.0% had a baseline BMI ≥30, in the overweight and obese range, respectively, according to Centers for Disease Control and Prevention guidelines.

Study participants completed a self-administered survey and underwent anthropometric assessments at baseline and at 12 and 24 months. The 30-minute survey asked questions about experiences trying to lose weight; medical history; eating habits; school environment; work habits; work satisfaction, and relationships with school colleagues, family, and friends. The anthropometric assessments, conducted by trained staff, included measurements of weight using portable digital scales with readings to the nearest 2/10th pound and measurements of height using portable stadiometers that measured to the nearest 1/8th inch. Weight and height measurements were converted to the metric scale, and BMI was calculated as weight in kilograms divided by height in meters squared (kg/m²). Intention-to-treat analyses were conducted using the baseline sample of 782 employees to assess changes in weight and BMI. The difference in mean weight change (the mean pre-to-post weight change of the intervention group subtracted from the mean pre-to-post weight change of the comparison group) and difference in mean BMI change (the mean pre-to-post BMI change of the intervention group subtracted from the mean pre-to-post BMI change of the comparison group) were calculated using linear mixed models with and without covariates.

Each of the six intervention schools selected and implemented a variety of physical environment and policy (organizational), social environment (interpersonal), and individual strategies. Site-level implementation and participation in activities were documented through staff logs and meeting minutes, and participants self-reported the specific individual-level strategies in which they were engaged.

• At baseline, the average weight was the same in both conditions (173.9 lbs). From baseline to 24-month follow-up, weight decreased among intervention group participants (173.2 lbs at 12 months and 172.6 lbs at 24 months) and increased among comparison group participants (175.9 lbs at 12 months and 176.1 lbs at 24 months).

• At 24-month follow-up, the net change in weight was significant between the intervention and comparison groups (-3.03 lbs, p=.04). The net change in weight between the intervention and comparison groups at 12-month follow-up was not significant (-1.27 lbs, p=.24).

• At 24-month follow-up, the net change in BMI was significant between the intervention and comparison groups (-0.48 kg/m², p=.05). The net change in BMI between the intervention and comparison groups at 12-month follow-up was not significant (-0.20 kg/m², p=.32).

Additional Findings

• The difference in weight change from baseline to 24-month follow-up was significant between intervention and comparison groups among participants aged 35 to 44 (-5.4 lbs, p=.05) but not among participants aged 21 to 34 or those aged 45 and older.

• All intervention schools successfully implemented at least 11 of the 17 intervention strategies examined in the study. Employees reported participation in many of the intervention components at the 12-month and 24-month follow-up. The proportion of intervention participants using information resources (an individual strategy) increased from year 1 to year 2. Examples include using the employee resource book (63.3% vs. 71.5%), visiting the Step Ahead website (23.8% vs. 32.2%), and reading the Step Ahead newsletters (59.7% vs. 65.5%).