EAL

NGHC: Childhood Nutrition and Lifestyle Factors (2013)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

The purpose of this paper is to describe a primary prevention curriculum administered to fourth-grade through sixth-grade students and discusses implication of the results and reflects on the need for future efforts to prevent body image, eating and weight concerns.

Inclusion Criteria:

Schools were included if they gained administrative approval.

Exclusion Criteria:

Schools were excluded if they did not gain administrative approval.

Description of Study Protocol:

Recruitment

In the fall of 1999, an invitation to participate in the project was mailed to nine schools.

Design

Non-randomized controlled trial.

Intervention

11-lesson "Healthy Body Image: Teaching Kids to Eat and Love Their Bodies Too!" curriculum for grades four through six
Curriculum includes age-appropriate activities incorporating prevention principles.

Blinding

Not used.

Statistical Analysis

All statistical analysis were completed using the Statistical Package for the Social Sciences (SPSS)
Descriptive statistics were calculated by frequencies and percentages
Continuous scale scores were analyzed using univariate analysis of variance (ANOVA)
A two-tailed level of significance with P<0.05 was used throughout
Due to significant differences at baseline by school, school code was controlled for in all analysis
All analysis were conducted separately for girls, boys, and grade level
Multivariate analysis were conducted for girls and boys using one between group and one within time factor, controlling for school code and grade level, to assess interaction effects.

Data Collection Summary:

Timing of Measurements

Administrators from each school approved the study protocol and parents were informed by a letter from their child's teacher that the lessons would be taught and they were invited to raise questions or concerns
Classroom teachers administered the pre-test and post-test to ensure student comfort and written instructions were read to each class describing the survey purpose, students read the surveys and answered the questions for themselves
Control group instructions were identical to those given to the intervention group
The pre-test and post-test were administered to intervention and control groups within one week prior to introduction of the curriculum and again within one week following the final lesson
Following the pre-test, the curriculum was implemented on a schedule at the teacher's discretion
In all cases, lessons were completed within a 10-week period during the fall term of the 1999-2000 school year.

Dependent Variables

Body image, weight and eating concerns measured by a survey that included six scales such as body image, knowledge, body size prejudice, lifestyle behaviors, self-image and media awareness

The survey used in the project was developed following an extensive review of existing questionnaires and discussions with experts in the field of body image
Six body image experts reviewed the survey to establish face validity
After careful consideration, 103 questions were selected by consensus.

Independent Variables

Assignment to Healthy Body Image (HBI) Curriculum or Control group (no exposure to curriculum)

11-lesson "Healthy Body Image: Teaching Kids to Eat and Love Their Bodies Too!" curriculum for grades four through six
Curriculum includes age-appropriate activities incorporating prevention principles.

Description of Actual Data Sample:

Initial N

415 boys and girls (209 boys, 206 girls).

Attrition (Final N)

415 boys and girls (209 boys, 206 girls)

357 in HBI Group
58 in Control Group.

Age

Range was from fourth to sixth grade:

44% fourth graders
19% fifth graders
37% sixth graders.

Ethnicity

95% Caucasian
2.5% Asian American
1.2% Native American
0.7% African-American
0.5% Hispanic
Ten participants did not indicate ethnic background

Other Relevant Demographics

Not reported.

Anthropometrics

There were significant differences in pre-test data related to gender, grade, school and between intervention and control groups at baseline.

Location

Urban and rural school districts within Minnesota.

Summary of Results:

Key Findings

In girls receiving the intervention, significant positive changes were found in five of six scales from pre-test to post-test
Significant changes were noted in questions pertaining to Knowledge (P<0.001) and Media Awareness (P<0.001)
Scores for intervention group girls improved notably for Body Size Prejudice (P=0.048), Self-Image (P=0.048) and in endorsement of desirable Lifestyle Behaviors (P=0.037) compared to pre-test scores
In boys receiving the intervention, significant positive differences were found in five of six scales from pre-test to post-test
Boys in the intervention condition had significantly improved scores in regard to Knowledge (P<0.001), Media Awareness (P<0.001), Body Size Prejudice (P<0.001) and Lifestyle Behaviors (P<0.001)
Multivariate analysis of covariance (MANCOVA) controlling for school code and grade level were conducted separately by gender to evaluate interaction effects between group. For girls, results indicate significant Group X Time interaction for the Knowledge (F=72.66, P<0.001) and Media (F=11.29, P<0.001) scales.
Interactions were not found for girls' scores on the Body Image, Body Size Prejudice, Lifestyle Behavior and Self-Image scales.

Author Conclusion:

Overall, the intervention had a positive effect at least in the short-term. This result supports the belief that children can acquire a knowledge base as they enter the critical and often more vulnerable middle school years and as they face increasing unhealthy pressures about appearance weight and eating.
As part of this approach, adults need to assume more responsibility to institutionalize policies and traditions that improve the context of children's lives while simultaneously promoting life skills such as media literacy that empower healthy cultural resistance.

Funding Source:

Other:

Not indicated

Reviewer Comments:

There were significant differences in pre-test data related to gender, grade, school and between intervention and control groups at baseline. The authors did identify some limitations to the study:

First, the time between pre-test and post-test was insufficient to assess long-term changes and future studies should incorporate a follow-up survey
Second, a larger control group should have been included to provide a more representative population base sample
Finally, the study population should have been more ethnically diverse.

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	Yes
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	Yes

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		No
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	Yes
	2.2.	Were criteria applied equally to all study groups?	Yes
	2.3.	Were health, demographics, and other characteristics of subjects described?	Yes
	2.4.	Were the subjects/patients a representative sample of the relevant population?	No
3.	Were study groups comparable?		No
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	Yes
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	No
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	Yes
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	N/A
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		Yes
	4.1.	Were follow-up methods described and the same for all groups?	Yes
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	Yes
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	Yes
	4.4.	Were reasons for withdrawals similar across groups?	Yes
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		No
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	No
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	No
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	N/A
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	Yes
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	N/A
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	Yes
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	Yes
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	Yes
	6.6.	Were extra or unplanned treatments described?	Yes
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	Yes
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		Yes
	7.1.	Were primary and secondary endpoints described and relevant to the question?	Yes
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	Yes
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	Yes
	7.5.	Was the measurement of effect at an appropriate level of precision?	Yes
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	Yes
	7.7.	Were the measurements conducted consistently across groups?	Yes
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	N/A
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes