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Education and feeding project (EDAL): promoting health in primary-school to reduce obesity.
 

Education and feeding project (EDAL): promoting health in primary-school to reduce obesity.

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Lucía Tarro, Faculty of Medicine and Health Sciences URV

Lucía Tarro, Faculty of Medicine and Health Sciences URV

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  • Good Morning, I’m Lucía, I’m a nutritionist, and a school teacher, and I’m working on education and health promotion. I’m going to talk about EdAl Program, A Primary-school-based study to reduce prevalence of childhood obesity in Catalunya (Spain) – EDAL- Educació en alimentació
  • In this Europe map, we can observe overweight and obesity prevalence in children. In red, we can see the countries where obesity is more prevalent. If we focus in Spain, we can see that the children’s OB prevalence is increasing in the last years. Since overweight status and obesity in adulthood are predicated on childhood and adolescent weight, obesity prevention should start early in life.
  • The elements that have to be involved in comprehensive strategies to prevent childhood obesity are: administration, industry, community and social environment such as family, children and school. In our programme we chose the school environment. This preventive intervention will be effective when: It starts during childhood It’s devéloped in school The family and social institutions actively take part in it The study is longitudinal
  • For this reason, EdAl program focused on health-promotion in schools because: - Schools provide an environment where almost all children can be reached repeatedly and continuously. - and, where health education can be combined with health-promoting environmental changes. But… Teachers are very busy
  • Teachers are very busy with the school’s academic activities, and their time is taken-up with new challenges arising from multiculturalism and schooling conditions of new citizens. So… Who and how can do it?
  • To solve this problem we thought of using Health Promoting Agents. HPAs were young students from medical and health science departments who would receive health education could be applied in school-based interventions. What is known as “service learning”.
  • So, our hypothesis is And the aims are
  • EdAl program is randomized, controlled, parallel study applied to primary school. We offered the program to all schools both public and private. We considered two clusters, the first cluster involved 24 schools from Reus it is the intervention group and the second involved 14 schools from surrounding towns Cambrils, Salou and Vilaseca it is the control group combined in order to obtain comparable groups. All strategies are focused on children aged between 7 and 8 years old. All children that took part in the study had parental consent. Other data that we needed from the children were their weight and height.
  • The study’s protocol was approved by the ethics Committee of Hospital Universitari Sant Joan de Reus. The anthropometrics measures were weight, height, waist and hip circumference. They were made each year of study (3 times in total). Questionnaires regarding eating habits, physical activity and parental education level developed by Serra-Majem. This questionnaire was answered with children’s parents twice during the study, at the first and at the last year. We established underweight, normal weight, overweight and obesity by Cole.
  • This research project has been supported by different institutions private and public.
  • This was the statistical analysis, which it performed by the statistic of Technological Centre of Nutrition and Health.
  • So that the students could become Health Promoting Agents, they had to pass two subjects: the first one was a Methodological basis for the promotion of community health. In this subject the students designed a health program. The second subject was interdisciplinary application of health education in the community. Students trained during the lessons. When they were standardized, they did some practice in the schools. And when they completed this learning process, they became health-promoting agents.
  • First, the students learned theory and methodological basis. Afterwards they designed different activities for children and then, teachers and tutors evaluated the students’ work. Next, university professors and primary school teachers chose and standardized the activities. And finally, the trained students acted as HPAs and performed the intervention in school.
  • We defined 8 nutritional aims to prevent OB that were chosen for scientific evidence to improve consumption of some food. Physical activity is present in all nutrition aims. The activities designed by the students were based on this nutritional aims, and they used a programming unit, which is the tool of primary school teachers.
  • On the first year of study we focused on 4 objectives. The remaining/other 4 were covered during the 2nd year. And during the last year we did 4 activities to promote all 8 objectives. So, in total edal program has 12 standardized activities (4 per year) that allowed children taste different foods.
  • This is an example of the activity done in objective 3.. First, the students explained the benefits of vegetables with a funny lecture, then they did an experimental activity: prepared a salad with the shape of a clown's face: legumes, carrots, tomatoes, olive, lettuce. Next, they evaluated the activity, and finally students gave to the children a reminder of what they had learned to repeat it at home.
  • This is an example of the activity done in objective 3.. First, the students explained the benefits of vegetables with a funny lecture, then they did an experimental activity: prepared a salad with the shape of a clown's face: legumes, carrots, tomatoes, olive, lettuce. Next, they evaluated the activity, and finally students gave to the children a reminder of what they had learned to repeat it at home.
  • The Communication between schools and the university was: First, the research team meets all schools from Reus. Afterwards, each school decided whether they would take part in the study, or not. Then, directors of Edal Program explained the devélopment of the EdAl activities, and the anthropometric measures. Next, EdAl’s coordinator arranged a meeting with every school. Finally, HPA students performed the activities. And, in control group, should be similar.
  • In total Two thousands, five hundred and sixty-four (2564) children enrolled in the study. And we analyzed seven hundred and seventeen (717) in control group, and one thousand two hundred and twenty two (1222) in intervention group.
  • This table shows the classification of obesity prevalence according to Cole, comparison between populations and gender at the end of the study. We can observe that the boys of the intervention group have reduced two point thirty-six per cent (2.36%) obesity prevalence, and the ones in the control group have increased two point ou three per cent (2.03%). Control group CAMBRILS, SALOU and VILASECA 
  • This diagram shows us the prevalence of OB in boys, girls, and both together. Wang predicted that in Spain the prevalence of children’s OB would increase 0.5% each year from 2006 to 2010. So, if our study lasted 3 years, the increase should have been of 1.5% in total. We can observe that in our control group, boys’ OB prevalence increased up to 2%. We don’t observe this in girls. And if we focus on the intervention group, we see that OB prevalence in boys dramatically decreased, which makes a total difference of for point thirty-nine per cent (4.39%) between control and intervention group in boys. In girls it has also decreased, but the difference with the control group is not significant.
  • I will just expose the results that were significant. In the lifestyle evaluation we observe that in the intervention group the percentage of pupils having a cereal breakfast, consuming vegetables and performing physical activity, increased. The percentage of pupils consuming pastry before setting-off for school and in the mid-morning break has decreased.
  • In the control group, the percentage of legumes and pastries consume decreased while the consumption of fruit or natural juice increased.
  • This figure summarizes the odds ratio of obesity related to some of the more relevant dietary habits. For example, fish consumption was found to be a protective factor against obesity whereas fast-food consumption more than once a week increased the risk of obesity.
  • Apart from the intervention in the schools, we trained 60 HPAs, who designed the 12 standardized activities used in this study.
  • From this study we can draw several conclusions. Regarding to innovative communication practice:… Achift=achieved
  • From this study we can draw several conclusions. Regarding to innovative communication practice:… Achift=achieved
  • And with regards to obesity prevalence in our population we can conclude that

Education and feeding project (EDAL): promoting health in primary-school to reduce obesity. Education and feeding project (EDAL): promoting health in primary-school to reduce obesity. Presentation Transcript

  • COMMUNICATING FOOD FOR HEALTH BENEFITS NEW FOOD TRENDS AND MEANINGS  PROFESSIONAL IDENTITIES AND FOOD COMMUNICATION  INNOVATIVE PRACTICES IN COMMUNICATION 8th – 9th November, 2012TARRAGONAA primary-school-based study to reduce prevalence ofchildhood obesity in Catalunya (Spain) - EDAL-Educació en alimentació: study protocol for arandomized controlled trialRegister International Standard Randomized Controlled Trial NumberISRCTN29247645
  • Prevalence of Overweight and Obesity in EuropeINTRODUCTION Children (7-11 years old) Evolution of OB prevalence in Spain ALADINO ENKID Since overweight and obesity status in adulthood are PAIDOS predicated on childhood and adolescent weight, obesity prevention should start early in life. 1984 2000 2011 Reinehr T, Wabitsch M. Childhood obesity. Curr Opin Lipidol 2011; 22:21-5. Spanish studies Moreno, Pigeot, Ahrens (eds.): Epidemiology of overweight and obesity in children and adolescents. Springer, New York 2011 Estrategia NAOS. Estudio ALADINO (Alimentación, Actividad física, Desarrollo Infantil y Obesidad). 2011.
  • Elements have to be involved in comprehensive strategies to preventINTRODUCTION childhood obesityADMINISTRATION Community and social INDUSTRY environment -Product formulation -Investigation -Publicity environment -Labelling Family -Consumer information School Children -Health promotion Catering Preventive intervention will be effective when: It starts during childhood It is developed in school The family and social institutions actively take part in it The study is longitudinal
  • EDAL program focused on a health- promotion in schoolsINTRODUCTION Schools provide an environment where: usy - almost all children can be very b reached repeatedly and are ers continuously. Te ach - health education can be combined with health- promoting environmental changes.Giralt M, Albaladejo R, Tarro L, et al. (Editor Submitted). A Primary-School-Based Study to Reduce the Prevalence of Childhood Obesity: A randomizedcontrolled trial.
  • EDAL program focused on a health- promotion in schoolsINTRODUCTION Teachers are very busy School’s academic activities it ? do can is taken-up their time how and W ho new challenges arising from multiculturalism and schooling conditions of new citizens
  • “Health Promoting Agents (HPAs)”INTRODUCTION “Service learning” academic coursework Young students from medical and health- science departments are trained as “Health Promoting Agents” Children listen to HPAs with enthusiasm because Age of HPAs is nearer to children.Butin DW. (2006). Special Issue Introduction: Future Directions for Service Learning in Higher Education. Int Journ Teach Learn Higher Ed, 18, 1-4.Giralt M, Albaladejo R, Tarro L, et al. (Editor Submitted). A Primary-School-Based Study to Reduce the Prevalence of Childhood Obesity: A randomizedcontrolled trial.
  • HYPOTHESIS AND AIMS HYPOTHESIS A regular systematic educational intervention in primary school improves lifestyle choices and reduces obesity. AIMS 1) To evaluate the effects of a 3-year school-based program of lifestyle improvement, including diet and physical activity, on the obesity prevalence. 2) To design a health promotion program implemented by HPAs in primary schools.
  • Randomized, controlled, parallel study applied to schoolMETHODOLOGY STUDY POPULATION Intervention group: 24 schools (n=1550) Control group: 14 schools (n=800) All type of Schools: Offered degree 2 or 3 (7 – 8 years old) INTERVENTION GROUP Whole class participated: boys and girls of different ethnicity Criteria: Name and surname, gender, date of birth, weight and height Sample Size = 700 Rate of parental consent = 91.65% CONTROL GROUP Giralt M, Albaladejo R, Tarro L, Moriña D, Arija V, Solà R. A primary-school-based study to reduce prevalence of childhood obesity in Catalonia (Spain) – EDAL- Educació en Alimentació: Study protocol for a randomized controlled trial. Trials. 2011;12:54.
  • Anthropometrics and habits evaluationMETHODOLOGY Ethics Committee CEIC Hospital Universitari Sant Joan de Reus (reference 08-07-24/7aclproj1) Anthropometrics measures Anthropometric Standardization Referente Manual Abridged Edition, 1991. Rapid test Krece PlusValidated survey of EnKid Serra-Majem Ll Study et al., 2003; EnKid Krece Plus., 2003 Survey of healthy habits Validated survey of AVall Study (Llargués E et al., 2009)Establish underweight, normal weight, overweight and obesity Cole et al., 2000, 2007Giralt M, Albaladejo R, Tarro L, Moriña D, Arija V, Solà R. A primary-school-based study to reduce prevalence of childhood obesity in Catalonia (Spain) –EDAL- Educació en Alimentació: Study protocol for a randomized controlled trial. Trials. 2011;12:54.
  • This research project has been supported by:METHODOLOGY  Fundació Privada Reddis, Reus  Ajuntament de Reus – Institut Puericultura Dr Frias  Direcció General de Salut Pública  Departament de Salut, Generalitat de Catalunya  Departament Educació, Generalitat de Catalunya  Hospital Universitari Sant Joan de Reus  Diputació de Tarragona  Assaig Agència Salut Pública del Baix Camp  Centre Tecnològic de Nutrició i Salut (CTNS, CT09-1-0019)
  • Statistical analysis Performed byMETHODOLOGY Continuous variables: Mean, standard deviation and confidence interval 95%  Categorical variables: percentage All losses are attributable to chance, so the analysis was always performed using all available cases.  Continuous variables are used the Mixed Models analysis.  The evolution of continuous parameters in time analysis is used Mixed Model Repeated Measures.  Compare a categorical variable on another is the analysis used Generalized Linear Models.  Analysis to compare categorical variables used Fishers exact test.  Statistical significance: p <0.05  The tables and lists are made by using the SAS version 9.1.3 Service Pack 2, (SAS Institute Inc., Cary, NC, USA).
  • Health-promoting agents’ universityMETHODOLOGY training European Dietetic Benchmark Statement or EDBS Skills and competencies Methodological basis for the Interdisciplinary application of promotion of community health. health education in the community. Theory and methodological basis to Develop an activity from a nutritional aim, perform tasks of health-promoting agent. which would go to school. Giralt M, Albaladejo R, Tarro L, Moriña D, Arija V, Solà R. A primary-school-based study to reduce prevalence of childhood obesity in Catalonia (Spain) – EDAL- Educació en Alimentació: Study protocol for a randomized controlled trial. Trials. 2011;12:54.
  • Health-promoting agents’ university trainingMETHODOLOGY Structure of activities: Education project - A discussion with a playful approach Educational bases - experimentation with food Evidence-based nutrition - an interaction with the environment - An evaluation of the activity Evaluation and simulation - oral presentation Evaluators: class, teachers / - Simulation tutors, teachers - attitudes (empathy, creativity ...) Choice and standardization - different proposals Evaluation Committee: class, - final activity teachers / tutors, teachers - standardization Intervention in schools - 1 hour duration/activity Practice schools Giralt M, Albaladejo R, Tarro L, Moriña D, Arija V, Solà R. A primary-school-based study to reduce prevalence of childhood obesity in Catalonia (Spain) – EDAL- Educació en Alimentació: Study protocol for a randomized controlled trial. Trials. 2011;12:54.
  • Health-promoting agents’ universityMETHODOLOGY training Programming Unit ► We defined nutritional Nutritional aim: objectives to prevent OB To promote a eating in a set of healthy habits, such as physical 1. Healthy lifestyle: taste activity, to improve health and reduce the main nutritional risk in children, Obesity. 2. Healthy drinks 3. Vegetables and legumes Lesson 1: Healthy lifestyles Nutritional aim: 4. Candies and pastry To promote a eating in a set of healthy habits, such as physical activity, to improve health and reduce the main nutritional risk in children, Obesity. 5. Healthy habits 6. Fruit Secondary aims: To understand the importance of a varied diet for health. To Know the qualitative and quantitative adequacy of the diet. To understand that energy intake must be adequate to the demands of child 7. Dairy products rearing, preserving the ideal weight for their age. Specific aims: 1.1 To understand the reasons for a balance diet 8. Fish 1.2 To design a balance diet by food groups, servings and time distribution. 1.3 To understand the importance energy balance between food intake and energy expensive to keep body and physical activity. 1.4 To understand association between achievement of energy balance and maintaining a healthy weight. 1.5 To calculate the energy requirements regarding age, sex, weight and height of subjects. 1.6 To understand the need for physical activity regularly maintain good health and proper weight. 1.7 To know witch are toxic substance: alcohol and others. Physical Activity 1.8 To experiment with different tastes of food and meal. 1.9 To know and respect other culture’s food habit and accept different and similarities. 1.10 To learn express feelings and opinions (how to say yes or no).
  • YEAR1 Objective 1: Healthy lifestyles Objective 2: Healthy drinks Objective 3: Vegetables and including physical activity (Activity 2: To prepare and Legumes Objective 4: Candies and (Activity 1: To eat a healthy taste natural orange juice and (Activity 3: To taste pastry vs. nuts breakfast) fruit with yogurt) vegetables and legumes) (Activity 4: To taste nuts)YEAR2 Objective 5: Healthy habits within a set timetable (home meals, teeth-brushing, hand- Objective 6: Fruits: The fun world Objective 8: Fish: A sea of washing) and physical activity; of fruit! Objective 7: Dairy products benefits. (Activity 5: to do physical activity (Activity 6: To produce a tree using (Activity 7: To taste four (Activity 8: To prepare and taste and teeth-brushing) banana and kiwi) different cheeses) a tuna sandwich)YEAR3 Objectives; 5, 8 reinforced. Objectives: 2, 7 reinforced. Objectives: 3, 6 reinforced. Healthy habits, set meal- Objectives: 1, 4, 5 reinforced. Healthy drinks and dairy Vegetables, legumes and fruits timetables and fish Healthy life-styles and candies products. (Activity 10: To (Activity 11: Garden of (Activity 12: To prepare a (Activity 9: To taste nuts) taste honey with curd cheese) vegetables, legumes and fruit) crocodile image using tuna)
  • 3. Vegetables and legumes Example:METHODOLOGY Funny lecture Experimental activity Verdura: 2 vegades al dia Llegums: 2-3 vegades a la setmana Vull menjar verdures i llegums! Assessment of activity Activity developed for use at home
  • Y E A R Objective 1: Healthy Objective 2: Healthy Objective 3: VegetablesMETHODOLOGY 1 lifestyles including physical drinks and Legumes Objective 4: Candies and activity (Activity 2: To prepare (Activity 3: To taste pastry vs. nuts (Activity 1: To eat a and taste natural vegetables and legumes) (Activity 4: To taste healthy breakfast) orange juice and fruit nuts) with yogurt)
  • Communication between schools and the universityMETHODOLOGY The Research team I meets all schools from N T Reus Cambrils, Salou and Vila-seca E C R Directors of EDAL O V Program explained the N E development of the T N R T EDAL activities, and O I the anthropometric L O measurements N G R G EDAL’s coordinator O R U O arranged a meeting P U with every school. P HPA students performed the activities, and students Students performed performed anthropometric anthropometric measurements measurements
  • Flow DiagramRESULTS and Enrollment Assessed for eligibility (n= 2564)DISCUSSION Excluded (n= 214) Not meeting inclusion criteria Randomized (n= 2350) Allocation Allocated to control (n= 800) Allocated to intervention (n= 1550) Follow-Up Lost to follow-up (give reasons) (n= 328) Lost to follow-up (give reasons) (n= 83) (Height and weight were not registered) (Height and weight were not registered) Analysis Analysed (n= 717) Analysed (n= 1222)
  • Classification of obesity prevalence according to Cole et al. and comparisonRESULTS andDISCUSSION between populations and gender at the end of study OBESITY PREVALENCE Gender First year Third year Difference p % n % n % Intervention group Boy 9.59% 58 7.23% 48 -2.36% a REUS Girl 8.46% 49 6.80% 43 -1.66% ns Total 9.04% 107 7.02% 91 -2.02% b Control group Boy 7.40% 25 9.43% 28 2.03% a CAMBRILS, SALOU and Girl 7.57% 28 6.54% 21 -1.03% ns VILASECA Total 7.49% 53 7.93% 49 0.44% b ns: not significant. a: boys difference, b: total difference p<0.05. Fisher exact test. *p<0,05. ns: not significant. a) boys difference b) total difference. Fisher exact test.
  • Wang’s prediction BOYSRESULTS andDISCUSSION 2,00% 1,50% * 1,00% Total difference -4.39% in boys 0,50% PREVALENCE of OB 0,00% -0,50% -1,00% -1,50% -2,00% -2,50% * 0.00% 0.00% 2.00% 2.00% Total GIRLS *p <0,05 WANGS PREDICTION CONTROL GROUP INTERVENTION GROUP Wang Y, Lobstein T. Worldwide trends in childhood overweight and obesity. Int J Pediatric Obesity. 2006; 1: 11-25
  • Lifestyle evaluationRESULTS and Quick testDISCUSSION krece plus INTERVENTION GROUP INTERVENTION GROUP Eat more than one vegetable a Cereal in breakfast? Eat one vegetable a day? day? * * (68% vs. 73%) (69% vs. 73%) * (26% vs. 32%) How many hours per week Eat pastry before leaving Eat pastry at break do extracurricular physical home? (midmorning)? activity? (3.87% vs. 2.41%) * (3.79% vs. 1.70%) * % pupils performed 5 or more * hours per week after-school physical activity *p <0.05
  • Lifestyle evaluationRESULTS and Quick testDISCUSSION krece plus CONTROL GROUP CONTROL GROUP Eat fresh fruit or Eat legumes more than Eat pastry at break natural juice at break one a week? (midmorning)? (midmorning)? (76.94% vs. 70.85%) * (4.08% vs. 2.22%) * (12.2% vs. 15.47%) * *p <0.05
  • Risk factors of childhood obesity RESULTS and DISCUSSION *p <0.05BreastfeedingPhysical ActivityTelevision BreakfastVegetables * FishLegumes Fruit * Fast-food Candies
  • University educationRESULTS andDISCUSSION 15 hours of practice 60 students trained as Health Promoting Agents (HPA) 12 standardized activities
  • COMMUNICATING FOOD FOR HEALTH BENEFITS INNOVATIVE PRACTICESCONCLUSION IN COMMUNICATIONWhat is an innovative communication practice in EDAL Study? In the EDAL study, a practical communication strategy was developed using standardized experimental activities to be implemented in primary schools. The activities were designed to be fun but informative as well, and focused on acquainting the study subjects of the concepts of a healthy lifestyle that can be achieved by improving diet and physical activity.
  • COMMUNICATING FOOD FOR HEALTH BENEFITS INNOVATIVE PRACTICESCONCLUSION IN COMMUNICATIONWhat is an innovative communication practice in EDAL Study? The EDAL study includes effective use of healthy lifestyle communication strategy, applied by university students acting as Health Promoting Agents in classrooms, in order to reduce childhood obesity.
  • Global conclusionCONCLUSION Our primary-school-based program performed by health promoting agents reduces, within 28 months, the prevalence of obesity in boys by 4.4%, but not in girls.
  • Thank you