APPLES: A SCHOOL-BASED

INTERVENTION TO REDUCE OBESITY RISK FACTORS

P Sahota, MCJ Rudolf, R Dixey,

AJ Hill, JH Barth, J Cade.

Aim of The APPLES Project

• To develop a school based programme to improve the diet and activity levels of primary school children and so reduce obesity risk factors

Aim of The APPLES Project

• To develop a school based programme to improve the diet and activity levels of primary school children and so reduce obesity risk factors

STUDY DESIGN: GROUP RANDOMISED CONTROLLED TRIAL

•10 schools involving 700 children aged 7-11 years

Schools F-J

Schools A-E

INTERVENTION

COMPARISON

Schools F-J

Schools A-E

baseline 12 mths

24 mths

•schools paired for size, ethnicity and FSMI and then randomised

•analysis by cluster

APPROACH

• Population Approach

• Health Promoting School Philosophy

The APPLES PROGRAMME

• Teachers Training Days

• Resource Dissemination

• Formulation of School Action Plans

• Continuous Support and Monitoring

• Anthropometric, diet, physical activity, psychological data collected pre and post intervention

APPLES ACTIVITIES

Topic work

Dietitian visits to class

Practical cooking sessions

Tuck shops

PE lessons Playground activities

Health fairs

School meals

THE EVALUATION PROCESS

• How successful was the implementation process?

• What impact did APPLES have on the school?

• What effect did it have on the individual child?

HOW SUCCESSFUL WAS THE IMPLEMENTATION?

• All 10 schools completed

• The teachers’ evaluations

• 85 action points developed (6 -14 per school)

• Response rates for data collection 64%-97%

• Uptake of support offered by the Team

Teachers Evaluation

• Training extremely useful 43%

very useful 32%

useful 25%• Resources

yes, will use again 100%• Benefits

increased awareness in children 100%

Change Suggested by Parents Results of questionnaire ( 64% response rate)

• playground activities 43%• break-time snacks 40%• school dinners 33%• games and sports 29%• packed lunches 16 %• no change 20%

IMPACT ON THE SCHOOL

• Action plans

• School meals

• Focus groups

Some Activities in the Action Plans - 89% achieved

Schools• Nutrition education in curriculum 10• Healthy eating sessions by dietitian 10• Fit is Fun programme in P.E 10• Improved playground facilities 6• Policy changes in break-time snacks 5• Healthy tuckshops 4

Changes in School Meals

No. of Schools

before after

• jacket potatoes 1 10

• fresh fruit - daily 8 10

• mash potatoes 4 6

• salad vegetables - daily 4 7

• vegetarian options poor good

FOCUS GROUPS

Intervention school children reported:

• Better understanding

• More sophisticated ideas

• Higher self reported behaviour change

• Higher recollection of activities related to diet and activity

WAS THE INTERVENTION EFFECTIVE?

• Growth

• Diet - 3 day diaries, 24 hr recall

• Physical activity - diaries and recall

• Psychological well being

W E IG H T E D M E A N D IF F E R E N C E F O R T H E 5 IN T E R V E N T IO NS C H O O L S R E L A T IV E T O T H E IR P A IR E D C O M P A R IS O NS C H O O L

in d ica tes low e r B M I sd score in d ica tes h igh er B M I sd score in th ein th e In terven tion S ch oo ls In terven tion S ch oo ls

W eigh ted M ean d if f .-.34 0 .34

% W eig h t W eig h ted M ean d if f . (95 % C I)

-0 .04 (-0 .1 5 ,0 .0 8 ) 1 25 .8

0 .06 ( -0 .10 ,0 .2 1 ) 2 18 .0

0 .07 ( -0 .06 ,0 .2 0 ) 3 22 .5

-0 .12 (-0 .2 7 ,0 .0 3 ) 4 19 .8

-0 .15 (-0 .3 4 ,0 .0 4 ) 5 13 .9

-0 .03 (-0 .1 1 ,0 .0 5 ) O vera ll (95 % C I)

BMI

W E I G H T E D M E A N D IF F E R E N C E F O R T H E 5 I N T E R V E N T I O NS C H O O L S R E L A T I V E T O T H E I R P A I R E D C O M P A R I S O NS C H O O L S

W eig h te d M e a n d if f .- .7 2 0 .7 2

% W eig h t W e ig h te d M e a n d if f . (9 5 % C I)

0 .1 5 ( -0 .0 7 ,0 .3 7 ) 1 2 5 .5

0 .4 3 ( 0 .1 6 ,0 .7 0 ) 2 1 8 .2

0 .3 0 ( 0 .0 7 ,0 .5 3 ) 3 2 3 .0

0 .4 3 ( 0 .1 4 ,0 .7 2 ) 4 1 6 .0

0 .1 4 ( -0 .1 3 ,0 .4 1 ) 5 1 7 .4

0 .2 8 ( 0 .1 6 ,0 .4 0 ) O v er a l l ( 9 5 % C I )

in d ic a te s lo w e r in ta k e in th e in d ic a te s h ig h e r in ta k e in th e In te rv e n t io n sc h o o ls In te rv e n t io n S c h o o ls

VEGETABLE INTAKE

OTHER OUTCOMES:no significant difference between intervention

and comparison schools

• Dietary: fat

sugar

fruit intake

• Physical activity

• Psychological measures

SUMMARY OF THE FINDINGS

• APPLES was successful in its implementation

• APPLES had an evident impact on the schools

• Behavioural changes in the children were disappointing

Reflections and implications for Health Services Research

Study Design

• Sample size

• Length of intervention

• Outcome measures

• Complexity of the intervention

FutureFuture

• Research officer post funded

• Refine intervention

• conduct a multi-centre RCT

Publications• Mary CJ Rudolf, Tim J Cole, Aaron J Krom, Pinki Sahota, Jenny Walker. (2000) Growth of primary school

children: a validation of the 1990 references and their use in growth monitoring. Archives of Disease in Childhood, 83:298 – 301.

• R. Dixey, P Sahota, S Atwal, A Turner. (2001) Children talking about healthy eating: data from focus groups with 300 9-11 year olds. Nutrition Bulletin, British Nutrition Foundation, 26 (1): 71-79.

• Rachael Dixey, Pinki Sahota, Serbjit Atwal , Alex Turner. (2001) “Ha ha, you’re fat, we’re strong”; a qualitative study of boys’ and girls’ perceptions of fatness, thinness, social pressures and health using focus groups. Health Education,101(5): 206 – 216.

• Mary CJ Rudolf, Pinki Sahota, Julian H Barth, Jenny Walker. (2001) Increasing prevalence of obesity in primary school children: cohort study. British Medical Journal 322: 1094 - 1095

• Pinki Sahota, Mary CJ Rudolf, Rachael Dixey, Andrew J. Hill, Julian H Barth, Janet Cade. (2001) Evaluation of implementation and effect of school based intervention to reduce risk factors for obesity. British Medical Journal, 323: 1027 – 1029.

• Pinki Sahota, Mary CJ Rudolf, Rachael Dixey, Andrew J. Hill, Julian H Barth, Janet Cade. (2001) Randomised controlled trial of primary school based intervention to reduce risk factors for obesity. British Medical Journal, 323: 1029 – 1032.

• Rudolf MCJ, Greenwood DC, Cole TJ, Levine R, Sahota P, Walker J, Holland P, Cade J, Truscott J (2003) Rising Obesity and Expanding Waistlines In School Children: A Cohort Study. Archives of Disease in Childhood (in press)

Prevalence of Overweight and Obesity by Year

N Mean ageYrs.

Overweight %

Obese%

1996 613 8.39 17.5 8.9

1997 596 9.39 21.3 10.9

1998 577 10.35 25.5 13.9

0

5

10

15

20

25

30

35

40

% Children

7 8 9 10 11 total

Age yrs.

Prevalence of Overweight according to age

GirlsBoys

85th Centile

Frequencies significantly different from expected values of 15% (overweight) at * p < 0.01 ** p < 0.001

* **

**

** **

**

** **

Prevalence of Obesity according to age

0

5

10

15

20

25

7 8 9 10 11 totalAge yrs.

% Children

Girls

Boys

95th Centile

Frequencies significantly different from expected values of 5% (obesity) at * p < 0.01 ** p < 0.001

** **

**

** ** ** ** **

CONCLUSIONS• Primary schools can implement changes into the

school with little in the way of extra resources

• Behavioural changes are harder to measure and achieve

• Obesity is reaching epidemic proportions in the UK

• Urgent need for good quality evaluative research.