A school based intervention designed to positively impact preschool children's weight status by improving fundamental movement skills and food consumption patterns, and by reducing the amount of unhealthy snack items consumed.
Blueprints: Inconclusive Evidence
Jillian Adams
Population Health, Planning and Performance Directorate, North Coast Area Health Service
The Tooty Fruity Vegie program employed a mix of intervention strategies aimed at encouraging healthy eating, physical exercise, and community involvement. To encourage healthy food consumption, the program employs strategies at the environment level (posters, drinking water access), parent level (workshops, newsletters), and child level (food games, practical exercises in fruit and vegie growing and cooking). To improve children's engagement in physical activities, a games-based fundamental movement skills program (FunMoves) is used twice a week during school hours. A final program component aims at capacity building and community participation through the formation of project management committees, which involve parents, staff, and health professionals. The Tooty Fruity Vegie program is designed to be implemented over a period of one academic year.
The Tooty Fruity Vegie program employed a mix of intervention strategies aimed at encouraging healthy eating, physical exercise, and community involvement.
Healthy eating strategies: The program employs strategies at the environment, parent, and child level to encourage health behavior patterns. For example, environmental modifications include hanging up posters to raise parents' awareness of healthy and unhealthy lunchbox items and to improve access to drinking water in schools. At the parent level, workshops and newsletters are used to raise attention toward the risks posed by poor eating and low levels of physical activity. Parents are provided with practical advice to modify eating and activity behaviors to reduce these risks. At the child level, positive and consistent messages regarding healthy food choices are communicated through playful intervention activities administered by health professionals. These activities involve sorting foods into 'sometimes' and 'everyday' categories, food taste testing, growing fruit and vegetables in gardens, and simple healthy cooking classes.
Physical activity strategies: To improve children's engagement in physical activities, a games-based fundamental movement skills program (FunMoves) is used. The "FunMoves" program consists of two terms of 10 sessions. Each session is repeated twice per week and each term is repeated twice per year. Each session has a five minute warm-up session at the beginning, which included movements that increase stability and balance. After this, children are assigned to small groups (about five to eight children) and use equipment and games to develop a particular skill. After three activities (each lasting about five minutes) the children return to a central spot for a cool down transition time. In addition to the school-based intervention, parents are educated of how to design and use fun games to play with their children at home.
Community involvement: A final program component aims at capacity building and community participation. In each preschool, project management committees (PMCs) are formed with parents, staff, and health professionals. The PMCs are responsible for overseeing the program implementation and to ensure sustainability of the program.
The Tooty Fruity Vegie program demonstrated the following significant program effects among pre-school children compared to a control group at posttest:
The study employed a clustered randomized controlled trial design. Thirty preschools of the North South Wales (NSW) North Coast area (student n=560) were randomly assigned to the intervention (n=18) or control group (n=12). The Tooty Fruity Vegie program was administered over a period of 10 months during the academic year of 2006/2007 in intervention preschools. Control schools were put on a waitlist to receive the intervention one year later. Assessments were conducted at the beginning (pretest), and at the end of the school year (posttest).
No information regarding the racial composition of the sample was provided. However, a gender effect was observed for fundamental movement skills. In the intervention group, girls improved their movement skills significantly more than boys. No gender difference was observed on the other 4 outcome measures under study (fruit and vegetable items in lunch box, energy-dense nutrient-poor food items, BMI z-scores, and waist circumference).
Source: Washington State Institute for Public Policy
All benefit-cost ratios are the most recent estimates published by The Washington State Institute for Public Policy for Blueprint programs implemented in Washington State. These ratios are based on a) meta-analysis estimates of effect size and b) monetized benefits and calculated costs for programs as delivered in the State of Washington. Caution is recommended in applying these estimates of the benefit-cost ratio to any other state or local area. They are provided as an illustration of the benefit-cost ratio found in one specific state. When feasible, local costs and monetized benefits should be used to calculate expected local benefit-cost ratios. The formula for this calculation can be found on the WSIPP website.
Jillian AdamsPopulation Health, Planning and Performance Directorate, North Coast Area Health ServicePO Box 498Lismore, New South Wales 2480Australia(02) 6622-2151jillian.adams@ncahs.health.nsw.gov.au
A school based intervention designed to positively impact preschool children's weight status by improving fundamental movement skills and food consumption patterns, and by reducing the amount of unhealthy snack items consumed.
The program targets preschool children age 3 to 6 years.
No information regarding the racial composition of the sample was provided. However, a gender effect was observed for fundamental movement skills. In the intervention group, girls improved their movement skills significantly more than boys. No gender difference was observed on the other 4 outcome measures under study (fruit and vegetable items in lunch box, energy-dense nutrient-poor food items, BMI z-scores, and waist circumference).
Children's food and drink intake are influenced by risk factors such as exposure to foods and drinks, parental food preferences, role modeling, child parent interactions around food, parenting style, food security, genetic factors, perinatal effects and television viewing habits. In childcare and preschool settings, the key influences on children's food consumption patterns include nutrition policies, formal curriculum, food exposure, physical education and the knowledge attitudes and practices of staff.
*Risk/Protective Factor was significantly impacted by the program
The Tooty Fruity Vegie program employed a mix of intervention strategies aimed at encouraging healthy eating, physical exercise, and community involvement. To encourage healthy food consumption, the program employs strategies at the environment level (posters, drinking water access), parent level (workshops, newsletters), and child level (food games, practical exercises in fruit and vegie growing and cooking). To improve children's engagement in physical activities, a games-based fundamental movement skills program (FunMoves) is used twice a week during school hours. A final program component aims at capacity building and community participation through the formation of project management committees, which involve parents, staff, and health professionals. The Tooty Fruity Vegie program is designed to be implemented over a period of one academic year.
The Tooty Fruity Vegie program employed a mix of intervention strategies aimed at encouraging healthy eating, physical exercise, and community involvement.
Healthy eating strategies: The program employs strategies at the environment, parent, and child level to encourage health behavior patterns. For example, environmental modifications include hanging up posters to raise parents' awareness of healthy and unhealthy lunchbox items and to improve access to drinking water in schools. At the parent level, workshops and newsletters are used to raise attention toward the risks posed by poor eating and low levels of physical activity. Parents are provided with practical advice to modify eating and activity behaviors to reduce these risks. At the child level, positive and consistent messages regarding healthy food choices are communicated through playful intervention activities administered by health professionals. These activities involve sorting foods into 'sometimes' and 'everyday' categories, food taste testing, growing fruit and vegetables in gardens, and simple healthy cooking classes.
Physical activity strategies: To improve children's engagement in physical activities, a games-based fundamental movement skills program (FunMoves) is used. The "FunMoves" program consists of two terms of 10 sessions. Each session is repeated twice per week and each term is repeated twice per year. Each session has a five minute warm-up session at the beginning, which included movements that increase stability and balance. After this, children are assigned to small groups (about five to eight children) and use equipment and games to develop a particular skill. After three activities (each lasting about five minutes) the children return to a central spot for a cool down transition time. In addition to the school-based intervention, parents are educated of how to design and use fun games to play with their children at home.
Community involvement: A final program component aims at capacity building and community participation. In each preschool, project management committees (PMCs) are formed with parents, staff, and health professionals. The PMCs are responsible for overseeing the program implementation and to ensure sustainability of the program.
The Tooty Fruity Vegie intervention was motivated by the Health Belief Model and the Competence Motivational Theory and employed capacity building and community participation theories to guarantee sustainability of the program. The Health Belief Model and Competence Motivational Theory (CMT) were used to guide the choice of program components and activities. CMT, for example, suggests that children's motivation to participate in physical activity is influenced by their actual and perceived competence, social support, and enjoyment of the activities. As such, the activities for children were designed as games and parents were educated in providing the necessary social support. Finally, based on capacity building and community participation theories, project management committees (PMCs) were designed to actively engage parents, staff, and health professionals in the program design, monitoring and implementation process.
The study employed a clustered randomized controlled trial design. Thirty preschools of the North South Wales (NSW) North Coast area (student n=560) were randomly assigned to the intervention (n=18) or control group (n=12). The Tooty Fruity Vegie program was administered over a period of 10 months during the academic year of 2006/2007 in intervention preschools. Control schools were put on a waitlist to receive the intervention one year later. Assessments were conducted at the beginning (pretest), and at the end of the school year (posttest).
The Tooty Fruity Vegie program demonstrated a number of significant program effects among pre-school children compared to a control group. The intervention was associated with a significant decrease in both BMI z-scores (0.15 points) and waist circumference (0.8 cm or 0.3 inch) across the 10 month intervention period. Positive program effects were also observed for movement skills (13.45%) as well as for a change in lunch box content (e.g., more fruit and vegetables and less energy-dens nutrient-poor food items).
The Tooty Fruity Vegie program demonstrated the following significant program effects among pre-school children compared to a control group at posttest:
A formal mediator analysis was not conducted. However, the secondary outcome variables (e.g., physical activities, lunch box content) can be conceptually understood as intervening between the intervention and the primary outcomes (e.g., BMI, waist circumference).
Not reported.
The results can be generalized to preschool children in the New South Wales (NSW) North Coast region of Australia.
Blueprints: Inconclusive Evidence
Adams, J., Zask, A., & Dietrich, U. (2009). Tooty Fruity Vegie in preschools: An obesity prevention intervention in preschools targeting children's movement skills and eating behaviours. Health Promotion Journal of Australia, 20, 112-119.
Zask, A., Adams, J., Brooks, L. O., Hughes, D. F. (2012). Tooty Fruity Vegie: an obesity prevention intervention evaluation in Australian preschools. Health Promotion Journal of Australia, 23 (1), 10-15.
While the results of the program evaluation were reported by Zask et al. (2012), the recruitment process, intervention strategy, evaluation methods and instruments were described in Adams et al. (2009).
Design:
Recruitment /Sample size:
All preschools in the New South Wales (NSW) North Coast area (n=40) were informed about the Tooty Fruity Vegie program and asked to submit an expression of interest to participate. Thirty preschools volunteered and were randomized.
Study type/Randomization/Intervention:
The study employed a clustered randomized controlled trial design. The 30 preschools (student n=560) were randomly assigned to the intervention (n=18) or control group (n=12). It is hard to assess the individual-level sample size for both groups. The sample sizes at pretest seemed to have varied by outcome variables as evident in Table 2 (e.g., n= 498 [BMI z-scores]; n=520 [unhealthy food items in lunch box]; n=415 [movement skills]). There is also some confusing reporting regarding the control school sample size. At some places in the text the authors talk about 13 instead of 12 control preschools. The Tooty Fruity Vegie program was administered over a period of 10 months during the academic year of 2006/2007 in intervention preschools. Control schools were put on a waitlist to receive the intervention one year later.
Assessment/Attrition:
Assessments were conducted at the start of the school year (pretest) and at the end of the school year, 10 months after baseline (posttest). The authors point out that "data were collected from 80.7% and 67.2% of all children enrolled pre and post intervention respectively." Most of the missing data were due to children being absent on the day of testing or having left the preschool between consent and testing. About 6.9% and 5.7% of enrolled children's parents did not consent to participate at pre and post intervention.
Sample characteristics:
Only limited information on the sample characteristics is provided. The sample comprised of 51.7% boys and 48.3% girls in an age ranged of 2.4 years to 6.1 years (mean age of 4.2 years). No information regarding the socioeconomic or racial composition of the sample was provided.
Measures:
Validity of measurements:
All measures and scales have been used in prior published work and reliability and validity has been established. Paired observations were conducted to assess inter-rater reliability.
Primary outcomes:
Secondary outcomes (mediators):
Analysis:
The authors employed multi-level growth curve models run in MLwiN to account for the clustered data structure. Time (pretests, posttest) was nested within students who were nested within preschools. All models implicitly control for baseline measures of the outcome variable while the main analytical focus was on the time x group interaction. The authors point out that "both random intercept and random slopes models were fitted" (p. 11).
Intention-to-treat: It is unclear whether the study complied with the intent-to-treat principle. The authors mention that "waist circumference data were only available in 498 cases in 18 preschools (10 intervention and 8 control) as records in other preschools were deemed unreliable" (p. 12).
Outcomes
Implementation fidelity:
A project management committee (PMC), established in each school oversaw the program implementation and ensured sustainability of the program. The preschool staff, implementing the "Fun Moves" program, received a one-day training and was given a program kit with detailed instructions of how to implement the program components. The authors point out that process evaluation was undertaken to assess uptake of individual implementation strategies within each intervention preschool. A structured interview with preschool directors in December of the intervention year explored the reach, frequency, director's perception of the quality and perceived sustainability of each strategy using a structured scoring matrix. However, results from this evaluation were not presented.
Baseline Equivalence:
A test for baseline equivalence was not performed. After random allocation, the authors compared preschool localities' socioeconomic status to ensure the groups were matched and state that "no change in allocation was required."
Differential attrition:
No test for differential attrition was reported.
Post-test:
Primary outcomes: For both primary outcome measures (BMI z-scores, and waist circumference) significance tests confirm the effectiveness of the Tooty Fruity Vegie program. Compared to the control group, children in the intervention group showed significantly (p<.05) lower BMI z-scores (-0.15 points) at the end of the 10 month intervention. Although both groups witnessed an increase in waist circumference, this increase was significantly lower (-0.80 cm; p<.05) in the intervention compared to the control group. However, the intervention had no impact on the levels of overweight and obesity prevalence.
Secondary outcomes: The results show that children in intervention preschools improved their movement skills significantly more than those in control preschools (p<.001) with a relative improvement of 13.45% above baseline levels. Within the intervention group, girls developed their movement skills significantly more than boys (p<.05). The intervention was responsible for an increase in fruit and vegetables in lunch boxes by 0.61 servings or 32.7% (p<.001), relative to the control group. This improvement in lunch box content was also evident by 29.1% (p<.001) increase in children without any energy-dens nutrient-poor food items in their lunch box and a decrease by 24.5% (p<.001) of children with more than 2 of such items in their lunch boxes.
Long-term effects:
The study did not collect long-term, follow-up data and therefore was not able to demonstrate sustained effects.