From organizing after-school team sports programs for elementary school children to encouraging lifestyle changes in adolescents, two NHLBI-funded studies are using a variety of tactics to address the childhood obesity epidemic. Both studies are part of a research consortium on childhood obesity prevention and treatment.
The Stanford Family, Community, and Clinic Collaboration to Treat Overweight and Obese Children (Stanford GOALS) is a three-year randomized controlled intervention trial for overweight and obese 7 to 11 year olds in low-income, primarily Latino families and neighborhoods in Northern California. The study has recruited 240 children to participate in either an intervention arm or a community health education program.
The intervention arm includes a community-based after school team sports program, a home-based family intervention component, and a primary care provider behavioral counseling component.
The community-based after school team sports, referred to as Team GOALS, is designed specifically for overweight and obese children and includes supervised physical activity in a supportive environment up to five days per week. The Team GOALS’ coaches are trained to create a safe environment on the sports field that encourages high levels of motivation for the participants. The children determine how often they participate. The program’s flexibility and supportive environment have resulted in high participation rates compared with typical community sports programs that attract a self-selected group.
The home-based family intervention – GOALS@home – includes five modules spread throughout the three-year study. In the first module, a study expert visits the families’ homes and shows them how to reduce portion sizes by providing smaller bowls, plates, mugs, glasses, and serving utensils. Other modules teach families how to make behavioral and environmental changes in their eating, physical activity, and TV watching habits. For example, in the physical activity module, children learn how to categorize, monitor, and set physical activity goals using an activity point system. Body weight and height are measured and body mass index is calculated annually throughout the intervention along with physical activity, dietary patterns, screen time, blood pressure, and related biological measurements.
In contrast, the community health education group receives two home counseling visits two times per year. During the visits, a health educator teaches the families healthy nutrition principles using standard education materials from both federal agencies and professional associations. Families are invited to participate in at least three ‘Family Fun Nights’ per year that consist of health education lectures and activities on topics such as choosing healthy foods and tips for reducing screen time.
Families in the community health education group are invited to participate in at least two additional health-related social and educational activities per year – such as field trips to sporting events – to build community and promote participation. Children and parents also receive separate monthly newsletters about nutrition education topics.
“Back in the early 1990s, as I looked at the many complex forces driving the emerging obesity epidemic, along with the somewhat limited effectiveness of prior approaches to prevent and treat it, it seemed like [childhood obesity was] the most difficult and important challenge I could try to help solve,” explained Thomas Robinson, M.D., M.P.H., principal investigator for Stanford GOALS and professor and director of the Center for Healthy Weight at Stanford University School of Medicine and Lucile Packard Children's Hospital at Stanford. “That is what brought me to childhood obesity research.”
The IMPACT (Ideas Moving Parents and Adolescents to Change Together) trial is a collaborative effort between multiple research and policy centers at Case Western Research University. The multi-level behavioral trial works collaboratively with community partners – parents, students, teachers, The Greater Cleveland YMCA, and the Cleveland Metropolitan School District – to implement the interventions.
“Childhood obesity is a complex problem that requires complex solutions,” said Shirley Moore, R.N., Ph.D., FAAN, co-principal investigator for the IMPACT trial and professor of nursing and associate dean for research at the Case Western Reserve University School of Nursing in Cleveland. “We have learned that change is interdependent on the people you live with and your environment. In the IMPACT trial we aim to change families’ patterns.”
The trial seeks to reduce body mass index in adolescents by helping them to change lifestyle behaviors such as diet, physical activity, sedentary behavior, sleep, and stress management. The trial has enrolled 360 economically challenged minority middle school urban youth from the Cleveland Metropolitan School District who are overweight or obese who were randomized to participate in one of two family-based behavior change groups or an education-only group. In addition to the family interventions, the trial includes a school-based program that tracks student participation in the YMCA-led “We Run This City” youth marathon program, offered by approximately half of the Cleveland schools.
In both family-level interventions – referred to as SystemCHANGE and HealthyChange – students receive information about the NHLBI’s DASH (Dietary Approaches to Stop Hypertension) eating plan, physical activity, sleep management, and stress management skills. Both behavior change groups receive identical information about the healthy living component; where the content differed is in the methods used to create lifestyle changes.
The HealthyCHANGE group stresses changing beliefs and thoughts so that change in behavior follows. Families are taught traditional approaches to behavior change such as confidence building, goal setting, problem solving barriers to change, diary keeping, and the use of rewards and incentives.
The SystemCHANGE group focuses on changing the environment so that families rely less on personal motivation, memory, or willpower to make changes. For example, families create new habits – such as less snacking on the way home from school – that support a healthy lifestyle. Families create a family ‘storyboard’ to document positive behavior changes.
Students in both the HealthyCHANGE and the SystemCHANGE groups participate in face-to-face small interactive group sessions and/or phone calls. They are weighed at each group session and one family member always participates in the session. Topics covered in the interactive group sessions include yoga, dancing, cooking classes, field trips to inner-city grocery stores, and creation of photos and presentations on healthy living by the children.
Learn about an 11-year-old’s experience with the IMPACT trial (see Chapter 4: Changing Habits and Environments): http://www.ideastream.org/health/young
Adolescents in the education-only group receive a one-hour personal counseling session with a registered dietician who discusses the DASH eating plan and the importance of physical activity. The dietician calls the participants twice each year to stay connected and a social event such as roller skating is organized once a year. No healthy living information is provided during these calls or events.
The school-based component of the trial supplements the “We Run The City” program (http://clevelandymca.org/community/marathon/ [Link no longer available]) by providing staff to encourage the IMPACT participants to enroll and stay with the program until race day. “We know that for children the home, school, and neighborhood all play a role in their health and behaviors,” said Elaine Borawski, Ph.D., co-principal investigator for the IMPACT trial, director of the Prevention Research Center, and professor in the school of medicine at Case Western Reserve University. “And so, one aim of our study is to determine the role of a supportive school environment, via participation in the youth marathon program, on the success and sustainability of the family-based interventions.”
The trial also is measuring the independent effects of the home, school and neighborhood food and physical activity environments to better understand their impact on body mass index (BMI), blood pressure, cardiovascular risk factors, and quality of life.
Learn about how the IMPACT trial is encouraging parents and adolescents to change together by watching this video: http://fpb.case.edu/News/teamscience.shtm
At the trial’s conclusion in 2015, researchers will determine which approach helped the most children lose the most weight.
“Everyone is part of the team in preventing childhood obesity: parents, pediatricians, teachers, friends, and community members. To effectively prevent and treat obesity we must reach children where they live, learn, and play, and the COPTR trials are doing just that,” said Charlotte Pratt, Ph.D., M.S., R.D., F.A.H.A., program director, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (NHLBI).
Recent articles about the COPTR trials:
- Forging a future of better cardiovascular health: addressing childhood obesity (Journal of the American College of Cardiology, 2014)
- Childhood Obesity Prevention and Treatment Research (COPTR): interventions addressing multiple influences in childhood and adolescent obesity (Contemporary Clinical Trials, 2013)
- IMPACT: a multi-level family and school intervention targeting obesity in urban youth (Contemporary Clinical Trials, 2013)
- IMPACT Cleveland: http://prchn.org/AboutImpact.aspx
- Growing Right Onto Wellness (GROW): a family-centered, community-based obesity prevention randomized controlled trial for preschool child-parent pairs (Contemporary Clinical Trials, 2013)
- NET-Works: Linking families, communities and primary care to prevent obesity in preschool-age children (Contemporary Clinical Trials, 2013)
- Family, community and clinic collaboration to treat overweight and obese children: Stanford GOALS-A randomized controlled trial of a three-year, multi-component, multi-level, multi-setting intervention (Contemporary Clinical Trials, 2013)
- NHLBI Working Group Report on Future Research Directions in Childhood Obesity Prevention and Treatment