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APPLES: A SCHOOL-BASED
INTERVENTION TO REDUCE OBESITY RISK FACTORS
P Sahota, MCJ Rudolf, R Dixey,
AJ Hill, JH Barth, J Cade.
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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
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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
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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
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APPROACH
• Population Approach
• Health Promoting School Philosophy
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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
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APPLES ACTIVITIES
Topic work
Dietitian visits to class
Practical cooking sessions
Tuck shops
PE lessons Playground activities
Health fairs
School meals
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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?
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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
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Teachers Evaluation
• Training extremely useful 43%
very useful 32%
useful 25%• Resources
yes, will use again 100%• Benefits
increased awareness in children 100%
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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%
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IMPACT ON THE SCHOOL
• Action plans
• School meals
• Focus groups
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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
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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
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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
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WAS THE INTERVENTION EFFECTIVE?
• Growth
• Diet - 3 day diaries, 24 hr recall
• Physical activity - diaries and recall
• Psychological well being
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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
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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
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OTHER OUTCOMES:no significant difference between intervention
and comparison schools
• Dietary: fat
sugar
fruit intake
• Physical activity
• Psychological measures
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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
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Reflections and implications for Health Services Research
Study Design
• Sample size
• Length of intervention
• Outcome measures
• Complexity of the intervention
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FutureFuture
• Research officer post funded
• Refine intervention
• conduct a multi-centre RCT
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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)
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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
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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
* **
**
** **
**
** **
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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
** **
**
** ** ** ** **
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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.