School-Based Obesity Prevention: One Piece of the Puzzle

SAN ANTONIO – School-based interventions for reducing obesity and diabetes risk can have a positive impact, but should be viewed as just one piece of the puzzle, according to Gary Foster, Ph.D.

Findings from the HEALTHY study provide some insight into how and why this is so, Dr. Foster said at the annual meeting of the Obesity Society.

As an investigator on that cluster design, multicomponent, school-based trial, he saw firsthand how school-based interventions can make a difference, but the overall results of that trial, which were published in the New England Journal of Medicine in 2010, underscore the importance of a more comprehensive approach for combating childhood obesity and the development of diabetes, he said.

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In more than 4,600 6th grade students from 42 schools that participated in the 3-year randomized, controlled trial, an "incredibly comprehensive and robust intervention" that addressed nutrition, physical activity, behavioral knowledge and skills, and communications and social marketing did not lead to a significant difference between the intervention and control groups with respect to the combined prevalence of overweight and obesity. However, on the obesity measure alone, the difference between the intervention and control groups approached significance, with those in the intervention group having a 19% lower odds of being obese at the end of the study, compared with the students in the control schools (odds ratio, 0.81), the investigators reported (N. Engl. J. Med. 2010;363:443-53).

Also, students in both groups who were overweight or obese at baseline (about 50% of the study population) had about a 16% decrease in the prevalence of overweight and obesity at the end of the study.

The intervention schools also had significantly greater improvements on several secondary outcomes, including body mass index (BMI) z score, insulin, and percentage of students with waist circumference at or above the 90th percentile – "a big deal from a public health point of view," said Dr. Foster, director of the center for obesity research and education at Temple University, Philadelphia.

Why does moving students from the obese to the overweight category make such an impact – perhaps even more of an impact than moving them from the overweight to the healthy category?

"The data are quite compelling," he said, explaining that in this study population, only 2% of students in the healthy range, and only 6% in the overweight range, had elevated insulin levels.

"But a whopping 35% in the obese range had elevated insulin levels ... so if you can modify insulin levels by moving from the obese to the overweight range ... boy, what an impact that would have on diabetes," he said.

Similarly, glucose levels increased with weight range, although the differences were less pronounced. Still, there was a "pretty sharp uptick" in the obese versus the overweight and healthy groups, he noted.

"It’s very troubling that 30% of kids going to school are already obese in 6th grade," Dr. Foster said, but the successes seen in the HEALTHY trial – including the improvement of measures of adiposity that could affect diabetes outcomes, are encouraging, he noted.

Also encouraging was the fact that all schools completed the study, attesting to the value of the cluster design of the trial, and the innovative approach that targeted numerous factors that could contribute to obesity and diabetes risk – from nutritional goals to activity levels to food-based school fundraisers.

Although some resistance was encountered (removing French fries from school lunches didn’t always go over well, Dr. Foster noted), schools, for the most part, were able to effectively enact change.

Programs should take care, however, to avoid targeting only overweight and obese students (and to instead target appropriate outcomes) as it remains important to work to decrease the stigma and discrimination associated with obesity, he said.

School-based programs can indeed be of benefit, although results are mixed, he said, adding that it "really is a comprehensive approach that’s needed."

"Schools are just one piece of this, and there are a lot of pieces to the puzzle," he said.

Dr. Foster disclosed that he is an adviser for Con Agra, United Health Group, Medtronic, and Nutrisystem. The complete list of disclosures for HEALTHY trial investigators is available with the full text of the article at NEJM.org.

SAN ANTONIO – School-based interventions for reducing obesity and diabetes risk can have a positive impact, but should be viewed as just one piece of the puzzle, according to Gary Foster, Ph.D.

Findings from the HEALTHY study provide some insight into how and why this is so, Dr. Foster said at the annual meeting of the Obesity Society.

As an investigator on that cluster design, multicomponent, school-based trial, he saw firsthand how school-based interventions can make a difference, but the overall results of that trial, which were published in the New England Journal of Medicine in 2010, underscore the importance of a more comprehensive approach for combating childhood obesity and the development of diabetes, he said.

Thinkstockphotos.com

In more than 4,600 6th grade students from 42 schools that participated in the 3-year randomized, controlled trial, an "incredibly comprehensive and robust intervention" that addressed nutrition, physical activity, behavioral knowledge and skills, and communications and social marketing did not lead to a significant difference between the intervention and control groups with respect to the combined prevalence of overweight and obesity. However, on the obesity measure alone, the difference between the intervention and control groups approached significance, with those in the intervention group having a 19% lower odds of being obese at the end of the study, compared with the students in the control schools (odds ratio, 0.81), the investigators reported (N. Engl. J. Med. 2010;363:443-53).

Also, students in both groups who were overweight or obese at baseline (about 50% of the study population) had about a 16% decrease in the prevalence of overweight and obesity at the end of the study.

The intervention schools also had significantly greater improvements on several secondary outcomes, including body mass index (BMI) z score, insulin, and percentage of students with waist circumference at or above the 90th percentile – "a big deal from a public health point of view," said Dr. Foster, director of the center for obesity research and education at Temple University, Philadelphia.

Why does moving students from the obese to the overweight category make such an impact – perhaps even more of an impact than moving them from the overweight to the healthy category?

"The data are quite compelling," he said, explaining that in this study population, only 2% of students in the healthy range, and only 6% in the overweight range, had elevated insulin levels.

"But a whopping 35% in the obese range had elevated insulin levels ... so if you can modify insulin levels by moving from the obese to the overweight range ... boy, what an impact that would have on diabetes," he said.

Similarly, glucose levels increased with weight range, although the differences were less pronounced. Still, there was a "pretty sharp uptick" in the obese versus the overweight and healthy groups, he noted.

"It’s very troubling that 30% of kids going to school are already obese in 6th grade," Dr. Foster said, but the successes seen in the HEALTHY trial – including the improvement of measures of adiposity that could affect diabetes outcomes, are encouraging, he noted.

Also encouraging was the fact that all schools completed the study, attesting to the value of the cluster design of the trial, and the innovative approach that targeted numerous factors that could contribute to obesity and diabetes risk – from nutritional goals to activity levels to food-based school fundraisers.

Although some resistance was encountered (removing French fries from school lunches didn’t always go over well, Dr. Foster noted), schools, for the most part, were able to effectively enact change.

Programs should take care, however, to avoid targeting only overweight and obese students (and to instead target appropriate outcomes) as it remains important to work to decrease the stigma and discrimination associated with obesity, he said.

School-based programs can indeed be of benefit, although results are mixed, he said, adding that it "really is a comprehensive approach that’s needed."

"Schools are just one piece of this, and there are a lot of pieces to the puzzle," he said.

Dr. Foster disclosed that he is an adviser for Con Agra, United Health Group, Medtronic, and Nutrisystem. The complete list of disclosures for HEALTHY trial investigators is available with the full text of the article at NEJM.org.

SAN ANTONIO – School-based interventions for reducing obesity and diabetes risk can have a positive impact, but should be viewed as just one piece of the puzzle, according to Gary Foster, Ph.D.

Findings from the HEALTHY study provide some insight into how and why this is so, Dr. Foster said at the annual meeting of the Obesity Society.

As an investigator on that cluster design, multicomponent, school-based trial, he saw firsthand how school-based interventions can make a difference, but the overall results of that trial, which were published in the New England Journal of Medicine in 2010, underscore the importance of a more comprehensive approach for combating childhood obesity and the development of diabetes, he said.

Thinkstockphotos.com

In more than 4,600 6th grade students from 42 schools that participated in the 3-year randomized, controlled trial, an "incredibly comprehensive and robust intervention" that addressed nutrition, physical activity, behavioral knowledge and skills, and communications and social marketing did not lead to a significant difference between the intervention and control groups with respect to the combined prevalence of overweight and obesity. However, on the obesity measure alone, the difference between the intervention and control groups approached significance, with those in the intervention group having a 19% lower odds of being obese at the end of the study, compared with the students in the control schools (odds ratio, 0.81), the investigators reported (N. Engl. J. Med. 2010;363:443-53).

Also, students in both groups who were overweight or obese at baseline (about 50% of the study population) had about a 16% decrease in the prevalence of overweight and obesity at the end of the study.

The intervention schools also had significantly greater improvements on several secondary outcomes, including body mass index (BMI) z score, insulin, and percentage of students with waist circumference at or above the 90th percentile – "a big deal from a public health point of view," said Dr. Foster, director of the center for obesity research and education at Temple University, Philadelphia.

Why does moving students from the obese to the overweight category make such an impact – perhaps even more of an impact than moving them from the overweight to the healthy category?

"The data are quite compelling," he said, explaining that in this study population, only 2% of students in the healthy range, and only 6% in the overweight range, had elevated insulin levels.

"But a whopping 35% in the obese range had elevated insulin levels ... so if you can modify insulin levels by moving from the obese to the overweight range ... boy, what an impact that would have on diabetes," he said.

Similarly, glucose levels increased with weight range, although the differences were less pronounced. Still, there was a "pretty sharp uptick" in the obese versus the overweight and healthy groups, he noted.

"It’s very troubling that 30% of kids going to school are already obese in 6th grade," Dr. Foster said, but the successes seen in the HEALTHY trial – including the improvement of measures of adiposity that could affect diabetes outcomes, are encouraging, he noted.

Also encouraging was the fact that all schools completed the study, attesting to the value of the cluster design of the trial, and the innovative approach that targeted numerous factors that could contribute to obesity and diabetes risk – from nutritional goals to activity levels to food-based school fundraisers.

Although some resistance was encountered (removing French fries from school lunches didn’t always go over well, Dr. Foster noted), schools, for the most part, were able to effectively enact change.

Programs should take care, however, to avoid targeting only overweight and obese students (and to instead target appropriate outcomes) as it remains important to work to decrease the stigma and discrimination associated with obesity, he said.

School-based programs can indeed be of benefit, although results are mixed, he said, adding that it "really is a comprehensive approach that’s needed."

"Schools are just one piece of this, and there are a lot of pieces to the puzzle," he said.

Dr. Foster disclosed that he is an adviser for Con Agra, United Health Group, Medtronic, and Nutrisystem. The complete list of disclosures for HEALTHY trial investigators is available with the full text of the article at NEJM.org.