Middle schools see culture of health pays off in nationwide study

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Problem: Too many teens are developing type 2 diabetes, primarily from being dangerously overweight.

Solution: Middle schools intervene directly in students' eating and exercise habits for three years.

Outcome: The most at-risk students were 21 percent less likely to have moved into the danger zone than were students in the control schools.

Conclusion: School intervention works.

That's the good news coming out of the nationwide HEALTHY study, conducted in Pittsburgh and six other sites across the country. Funding came from the National Institutes of Health, which released the results last week.

Now it's up to school districts to run with the strategies, which are available free at www.healthystudy.org.

"It's all public domain," said principal investigator Marsha Marcus, chief of behavioral medicine at Western Psychiatric Institute and Clinic.

"Anybody could institute these things right now," Dr. Marcus said. "Schools would not have to reinvent the wheel, but they'd have to reorient it."

And pay for it. Michael Peck, director of food services for the Pittsburgh Public Schools, said the study covered the added costs for food, materials and technical assistance. In 2008, for example, the additional funding was $17,000 for the five Pittsburgh schools combined.

"The changes are certainly doable district-wide, but we don't have a source for the funding," he said.

The district already has made changes it could afford: adding whole grains; eliminating flavored milk for breakfast; offering only 1 percent and skim milk for lunch; taking control of vending machines that used to be the province of individual schools.

As of last year, 34 percent of Pennsylvania middle school students were overweight or obese, and only 38 percent got the recommended hour of exercise a day.

"The kids at highest risk [of long-term health problems related to excessive weight] are ethnic minorities and kids of lower socioeconomic status," Dr. Marcus said.

The study targeted middle schools with large proportions of high-risk children, meaning at least 50 percent minorities or 50 percent eligible for free or reduced price lunch. Schools were randomized for intervention or control.

Incoming sixth-graders whose families consented got in-depth assessments, including blood tests to check cholesterol levels, at the start of the study,

At the control schools -- South Hills Middle, Pittsburgh Classical Academy and Beaver Falls Middle -- screening results and information were sent home to parents and guardians, alerting them, for example, to a child's high blood pressure. But nothing beyond that was done.

The intervention schools -- Arsenal Middle, Allegheny Traditional Academy and Frick International Studies Academy -- took a multi-pronged approach to weight reduction school-wide.

Researchers worked with staff and students to change the school culture. They replaced high-fat, high-sugar food and drinks on the menu with things like whole wheat pizza and lower calorie snacks. They increased the amount of moderate to vigorous physical activity; explained the science of energy intake and output; and addressed social behavior and peer influence with student-designed PR campaigns.

"The HEALTHY intervention was very comprehensive in contrast to previous efforts to change the school environment," Dr. Marcus said.

"When we took away nachos from the snack line, there was definitely some complaining," said co-investigator Elizabeth Venditti, a psychologist in the psychiatry department of the University of Pittsburgh Medical School.

"But once it's gone, they forget about it."

The program instituted fresh salad and wrap bars, which she said proved very popular.

"It wasn't icky brown lettuce, it was colorful tortillas with an array of fresh vegetables they could choose themselves. That takes extra food service labor and reorienting how the lunch room works. It can't be shipped in an warmed up."

New foods were introduced with taste tests. Students also came up with their own slogans -- "Only you can move you" or "Friends help friends eat healthy" -- and made posters and wrote raps, songs and skits to perform at school assemblies.

As for PE class, Dr. Venditti said, "Some kids don't like moving so we tried to make it fun and engaging. In Pittsburgh the schools had pools so we made a special attempt to augment the swimming program with new suits, goggles and water games for kids who don't love swimming."

The study even attempted to revamp fund-raising activities.

"We had to work on how to raise money in non-food ways. For cash-strapped schools in low-income districts, it's hard to fund things like science trips without selling a $1 candy bar for $1.50. We moved to things like trinkets, school supplies, branded pencils and sponsoring roller rink parties. You have to look at whether educational opportunities come at the sake of their health."

All participating students were assessed again at the end of eighth grade, the study's conclusion.

Looking at the entire student population from thin and normal to overweight and obese, the outcomes were virtually identical. With or without the intervention, each school showed a 4 percent decrease in the number of overweight students.

"That was a surprise," said Dr. Marcus. "It could be that overall the rates of overweight and obesity are leveling off. We don't really understand that yet."

But looking only at the most at-risk half of the student body -- the primary target group -- the intervention results were significant. Students who started out the heaviest had 21 percent lower odds of being obese at the end of eighth grade than the same group in the control schools.

An economic analysis is underway to determine the cost per student of comprehensive intervention.

"If we're able to make this change in highest-risk kids in a cost-effective way, it would impact the rates of obesity and diabetes," said Dr. Venditti.

"It may take a while for this to trickle down into public policy, but the strategies are pretty evident and most schools already have the infrastructure that could support them."

Sally Kalson can be reached at skalson@post-gazette.com or 412-263-1610.


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