Children's Health, Activity and Nutrition: Get Educated! (CHANGE!)

Currently in the United States, 13.7 million children and adolescents are obese. Many health-related conditions are linked to obesity, including heart disease, stroke, type 2 diabetes, and certain types of cancer. Obesity can be prevented through regular physical activity and healthy dietary habits. Children and adolescents should participate in daily physical activity, such as bike riding; walking; running; dancing; and playing tag, soccer, and basketball. They are also encouraged to consume a diet of foods and beverages that help to maintain a healthy weight. Schools can serve as an environment that is supportive of physical activity and healthy eating, and they are a prime setting in which to teach youth about exercise and diet and encourage an active lifestyle. School-based interventions that encourage physical activity and healthy eating among children and adolescents are critical to reduce rates of obesity.

Children's Health, Activity and Nutrition: Get Educated! (CHANGE!) is a school-based intervention that targets nutrition and physical activity among 10- and 11-year-olds to promote healthy weight. The CHANGE! curriculum is built upon social cognitive theory, which focuses on the interaction between social and environmental factors on behavior. Trained teachers deliver the intervention, which is integrated into a school's pre-existing standardized health education curriculum, in 20 weekly, 60-minute lessons promoting different components of a healthy lifestyle. Students discuss, explore, and learn the meaning and practicalities of physical activity and nutrition.

The physical activity lessons, with the message ''move more, sit less,'' aim to increase activity and reduce sedentary behavior. Rather than promote specific types of physical activity, the lessons encourage students to stay active. Topics include the basics about physical activity (intensities, fitness, guidelines for health, finding local opportunities to be active); setting goals and monitoring physical activity using a diary or pedometer; the impact of technology (screen time) on activity levels; and fitness as it relates to heart health, muscle health, and body composition.

The lessons on nutrition address energy (calorie) balance, macronutrients, and eating behaviors. Specifically, students learn about the components of food (e.g., carbohydrates, fat, sugar), food labels, and healthy beverage consumption, as well as including fruits and vegetables in their diet, eating a healthy breakfast, making good snack choices, and eating a variety of foods. Students also learn about local and worldwide food production and food access.

Lesson plans are aided with the use of worksheets and other resources. Additionally, students receive homework assignments focused on food and physical activity that reinforce the lessons and require regular family involvement (e.g., performing taught exercises as a family unit).

-- 2 hours to train teachers
-- 60 minutes to deliver each of 20 lessons on physical activity and nutrition
 

CHANGE! targets children aged 10-11.

This intervention is intended to be implemented in school-based settings.

Required resources to implement the program include the following:

-- CHANGE! Curriculum

Costs associated with the program's implementation are not provided.

A cluster randomized controlled trial compared CHANGE! with a usual care comparison condition among school-aged children in northwest England, UK. Within each of six geographical areas in one municipality, one school of high socioeconomic status (SES) and one of low SES were randomly selected. The 12 selected schools were then stratified and randomized by equal division into the intervention condition (6 schools) or comparison condition (6 schools). One intervention school withdrew from the study and did not complete all the follow-up data collection. All grade 6 students, 420, were invited to participate, and 318 participated. The comparison group received normal instruction, which included some concepts related to healthy eating and exercise as part of regular school lessons.

In the intervention group, the average age of participants was 10.6 years, the average height was 1.4 m, and the average body mass index (BMI) was 17.9 kg/m²; 79.9% of intervention group students were at normal weight. In the comparison group, the average age was 10.7 years, the average height was 1.4 m, and the average BMI was 18.1 kg/m²; 78.3% of these students were at normal weight.

The main outcomes- waist circumference, BMI z-scores, and light intensity physical activity (LPA) were measured at baseline, post-intervention (20 weeks), and follow-up (30 weeks). Waist circumference was measured to the nearest 0.1 cm at the narrowest point between the bottom of the ribs and iliac crest (part of the pelvis) using a non-elastic anthropometric tape. BMI was calculated as weight (kg)/height² (m²), and a BMI z-score was determined. A z-score is a population value that represents the number of standard deviations a score is away from the mean. The BMI z-scores, measures of relative weight adjusted for child age and gender, were calculated relative to UK reference data. Light intensity physical activity was assessed for 7 consecutive days using ActiGraph GT1M accelerometers. (LPA is defined as greater than 100 and up to 2,159 counts per minute.) Students also completed a log to distinguish between sleep and active time. The monitor was worn from morning to night and was removed for showering, swimming, and playing contact sports. The outcome was measured as the number of minutes of LPA per day.

• Relative to students in the comparison group, students in the intervention group had a smaller increase in waist circumference from baseline to post-intervention (p<.001). This group difference was no longer significant at follow-up. Results are adjusted for group, baseline value of the outcome measure, gender, socioeconomic status, and weight status group (normal weight or overweight/obese).

• Relative to students in the comparison group, students in the intervention group had a significant decrease in BMI z-scores from baseline to follow-up (p=.04). This group difference was not significant at post-intervention. Results are adjusted for group, baseline value of the outcome measure, gender, socioeconomic status, and weight status group (normal weight or overweight/obese).

• Relative to students in the comparison group, students in the intervention group had a significant increase in LPA from baseline to follow-up (p=.01). This group difference was not significant at post-intervention. Results are adjusted for group, baseline value of the outcome measure, gender, socioeconomic status, weight status group (normal weight or overweight/obese), school playground area, and average weekly temperature and rainfall at baseline.

Additional Findings

• Within the intervention group, overweight students had a greater decrease in waist circumference compared with normal weight students at post-intervention (p<.001).