Tackling Obesity with Afterschool Programs
By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
- In all, 75 middle school students from the Bronx, NY, enrolled in an initiative to add nutrition education and physical activity requirements to afterschool programming. They were followed for one year between 2016 and 2018 to determine if participation in the afterschool portion of a comprehensive wellness program improved targeted health behaviors (including eating breakfast and lunch daily and reducing unhealthy snacking) and weight.
- The comprehensive wellness program, B’N Fit Power, was integrated into the school-based health center and included a leadership program, cooking class, and physical activities led by on-site afterschool staff.
- Height, weight, and self-reported target behavior status was collected four times yearly.
- Out of the 65 students completing the program, 24 showed maintenance and/or improvement of body mass index Z-score and, although not statistically significant, students with higher attendance at the program had a higher tendency to improve target behaviors.
SYNOPSIS: This prospective study following 75 low-income middle school students found that adding nutrition education and physical activity requirements to afterschool programming may enhance gains in some health behaviors and weight management.
SOURCE: Rieder J, Moon J-Y, Joels J, et al. Trends in health behavior and weight outcomes following enhanced afterschool programming participation. BMC Public Health 2021;21:672.
Obesity in the United States is not an equal-opportunity disorder. Data from before the COVID-19 pandemic tells part of the story. In 2014, the prevalence rate of obesity in children was 17% to 20%. However, the risk of obesity was 1.35 times higher in children of low socioeconomic status than in children of higher status.
There were significant racial differences as well; Hispanic children had a 25.6% prevalence rate of obesity, and non-Hispanic Black children had an obesity prevalence rate of 24.2%. Meanwhile, the corresponding values for non-Hispanic white and Asian children were 16.1% and 8.7%, respectively.1,2 Notably, the risk of developing chronic diseases associated with child obesity, such as type-2 diabetes, hypercholesterolemia, and hypertension, is significant for any affected child.1-3
We are just starting to understand the effect of the COVID-19 pandemic and associated lifestyle changes on childhood obesity. The findings of a recent large study of children (ages 2-19 years) are cause for alarm, since the results indicate the rate of body mass index (BMI) increase during the COVID-19 pandemic was nearly double that of the prepandemic period.4 This makes the need to address childhood obesity even more pressing. Rieder et al conducted their investigation in the prepandemic years of 2016-2018. They noted the U.S. Preventive Services Task Force (USPSTF) recommendation to refer obese children and adolescents to moderate-high intensity comprehensive, behavioral interventions was difficult and perhaps impractical to follow in areas not served by highly specialized treatment centers. The goal of this group was to concentrate efforts to fight obesity in the most at-risk groups, which they defined as “low socioeconomic minority youth living in a low-income urban environment.”
The Bronx Nutrition and Fitness Initiative for Teens (B’N Fit Power) is a comprehensive wellness program originally developed in 2005 as a hospital and community-based program to treat obesity in low-income adolescents. While the program had success in meeting some weight-loss goals, feedback from stakeholders emphasized the need to bring the program to a more convenient setting and time to increase attendance and decrease stigma.5,6
Rieder et al piloted implementation of this program within a middle school setting, incorporating both a school-based health center and an afterschool component. This study was designed to determine if adding nutritional education and physical activity requirements to the existing afterschool programming was effective in changing the trajectory of weight gain among the participants and if there was an association between attending the afterschool program and attaining improvement in specific targeted health behaviors. Those targeted health behaviors were:
- Eat breakfast and lunch daily;
- Consume two to three servings of fruit daily;
- Consume more than three servings of vegetables daily;
- Drink 8 cups of water daily and < 1 cup of sugary beverages daily;
- Sleep at least eight hours nightly;
- Be physically active more than one hour daily;
- Decrease unhealthy snack foods and fast foods to less than once weekly.
The afterschool component of the program was intensive, with leadership training, cooking classes, and physical activity all included. The programming was implemented by existing school staff with some additional training specific to the goals of B’N Fit Power.
Staffing determined program size, with enrollment capped to 40 students in year 1 and 2 and 20 students in year 3. Weight and height were collected four times yearly via school data, and target behaviors were assessed via self-reported questionnaires. Over the three years, a total of 601 students were eligible for participation in the program. Out of this group, 79 students enrolled, 76 students attended at least one afterschool session, and 65 completed the program. Out of the final group of 65, 48 had a BMI > 85th percentile.
BMI Z-scores were calculated for the students. BMI Z-score is a relative adjustment of a BMI score taking into consideration the age and sex of the child.7 At baseline, 14 (20.3 %) of the participating students had a BMI Z-score below the 85th percentile.
Comparing fourth visit data to baseline, the change in mean BMI Z-score was not statistically significant, with a mean change of 0.002 (P = 0.29) in children participating in B’N Fit Power. In total, 44% of the students maintained or decreased BMI while participating in the program. Further results are summarized in Table 1.
Table 1. Results of Specialized Afterschool Program on Obesity
Subgroup of children with highest afterschool attendance (> 75%) compared to those with the lowest attendance
No significant difference in body mass index (BMI) Z-score change was recorded, but there were trends toward some positive target behavior changes in higher attendees:
Association between target behavior change and BMI Z-score
Students attaining sleep > 8 hours by the fourth reporting period had a significant decrease in BMI Z-score (P = 0.038) compared to peers not reaching this goal.
This ambitious investigation had the goal of determining if bringing a comprehensive, intensive wellness program to a low-income middle school could begin to address the vexing health problem of childhood obesity. It is worth noting that almost 80% of the cohort began the study in the overweight to severe obesity category and that the study took place in the Bronx — one of the most impoverished counties in the United States, with high unemployment and school absenteeism rates.8
Although the results are not statistically powerful, Rieder et al pointed to several promising results as an indication of the relative success of this program. Specifically, the authors noted that, although 56% of the group had an increase in BMI Z-score over the year, 44% maintained or decreased this number. Notably, the control group in this study was the individual students (each was compared to baseline status), so we do not have a comparison with BMI Z-score trends for children not participating in this program. This may be an essential element to add in future such investigations.
Perhaps more importantly, Rieder et al noted that higher afterschool attendance was associated with a trend toward improved target behaviors and that the children who reported an increase in sleep to eight hours or more had a significant decrease in BMI Z-score independent of attainment of other target behaviors . This finding may have clinical relevance.
Interestingly, the children taking part in the program reported marginal decreases in eating breakfast and lunch and an increase in fast food consumption during the year in the program. The significance of these findings are unclear without seeing a comparison to a larger group of peers not taking part in the program. It may be that this is a trend common to middle school students as they become more independent consumers.
There are some clear limitations to generalization of these results. The parents who agreed to have children participate in this program were a self-selected (non-randomized) group, but the distinguishing features of this cohort are unknown. The motivation of the students was likewise unclear, and self-report of the target behaviors may be subject to individual interpretation. Finally, the number of children involved and relative homogenous socioeconomic status limits the ability to make recommendations based on this study.
Childhood obesity can have a long-lasting negative effect on health; reversing the trajectory of this insidious problem can protect against development of chronic diseases associated with obesity.1-4 While Rieder et al take care not to overstate the effect of the program, it is useful to closely examine the trends uncovered and move forward keeping these in mind. It may be that one year is an insufficient time to reverse lifelong habits, and that small, incremental changes in target behaviors are more meaningful than statistics would show. However, given the statistics quoted earlier regarding the upswing in BMI increase during the pandemic years and the medical implications of childhood obesity, developing evidence-based interventions for prevention and treatment of obesity for children must be considered a critical public health mission.
Clinicians can use this study to keep in mind the importance of comprehensive intervention when working with patient with obesity. Simply eating less or exercising more is rarely the answer, especially for children who may have multiple outside forces limiting and determining choices in such matters. Helping children and parents design a holistic wellness plan (and incorporating sleep as part of the plan) may be the first step in reversing and preventing obesity from becoming a lifelong health burden.
- Kumar S, Kelly AS. Review of childhood obesity: From epidemiology, etiology, and comorbidities to clinical assessment and treatment. Mayo Clin Proc 2017;92:251-265.
- Centers for Disease Control and Prevention. Children, obesity, and COVID-19. Last reviewed June 17, 2022. https://www.cdc.gov/obesity/data/children-obesity-COVID-19.html
- Inge TH, King WC, Jenkins TM, et al. The effect of obesity in adolescence on adult health status. Pediatrics 2013;132:1098-1104.
- Lange SJ, Kompaniyets L, Freedman DS, et al. Longitudinal trends in body mass index before and during the COVID-19 pandemic among persons aged 2-19 years — United States, 2018-2020. MMWR Morb Mortal Wkly Rep 2021;70-1278-1283. https://www.cdc.gov/mmwr/volumes/70/wr/mm7037a3.htm?s_cid=mm7037a3_w
- The Children’s Hospital at Montefiore. Bronx Nutrition and Fitness Initiative for Teens (B’N Fit). https://www.cham.org/programs-centers/bronx-nutrition-and-fitness-initiative-for-teens-b-n-fit
- Rieder J, Cain A, Carson E, et al. Pilot project to integrate community and clinical level systems to address health disparities in the prevention and treatment of obesity among ethnic minority inner-city middle school students: Lessons learned. J Obesity 2018;2018:6983936. https://www.hindawi.com/journals/jobe/2018/6983936/
- Must A, Anderson SE. Body mass index in children and adolescents: considerations for population-based applications. Int J Obes 2006;30:590-594.
- DiNapoli TP. An economic snapshot of the Bronx. Office of the New York State Comptroller. https://www.osc.state.ny.us/files/reports/osdc/pdf/report-4-2019.pdf
This prospective study following 75 low-income middle school students found that adding nutrition education and physical activity requirements to afterschool programming may enhance gains in some health behaviors and weight management.
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