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Citation:

Hopper CA, Gruber MB, Munoz KD, MacConnie, S. School based cardiovascular exercise and nutrition programs with parent participation. Journal of Health Education. 1996; 27: S32-39.

Study Design:
Cluster Randomized Trial
Class:
A - Click here for explanation of classification scheme.
NEUTRAL: See Research Design and Implementation Criteria Checklist below.
Research Purpose:

To examine the efficacy of school-based exercise and nutrition programs with parent components. 

Inclusion Criteria:
  • Study one: Participants must be enrolled in fifth or sixth grade elementary school
  • Study two: Participants must be enrolled in second or fourth grade elementary school.
Exclusion Criteria:

None stated.

Description of Study Protocol:

Design

  • Study one: Parents completed a demographic and medical questionnaire. Six classes of students were randomly assigned to three different treatment conditions, including control, school only and school-and-home groups. Packets were sent home with the school-and-home groups weekly, with a points system used to evaluate learning activities completed. Incentives were provided to encourage continued compliance. Pre- and post-test physical measurements were obtained on all groups. Nutrition data were also collected. 
  • Study two: 97 second and fourth grade students were randomly divided into two groups (school-and-home and control). Parents completed a demographic and medical history questionnaire. Pre- and post-tests were given one week prior to and one week after completion of the program. 

Dietary Intake/Dietary Assessment Methodology

  • Study one: 24-hour dietary recall by interview; 20-item multiple choice test given to administer nutrition knowledge 
  • Study two: 24-hour dietary recall on weekday diets; evaluated using Food Processor II computer program.

Intervention 

  • Study one: Weekly packets were given to the school-and-home group to teach families about healthy nutrition and exercise habits. Children in both experimental groups were given two half-hour nutrition education sessions per week for six weeks. 
  • Study two: In the school-and-home group, children were given additional in-class instruction and activities relating to developing healthy nutritional and exercise habits. Parents of the experimental participants were asked to participate in home activities. Weekly packets were sent home to all experimental participants with suggestions for nutrition and fitness activities. The home program lasted 10 weeks. 

Statistical Analysis

  • Study one: MANOVA followed by pairwise comparisons to compare the three groups on their change scores; multivariate effect size was calculated using the method provided by Tabachnick and Fidell (1993); ANOVA was used to further examine difference among groups
  • Study two: ANCOVA, MANOVA, ANOVA.
Data Collection Summary:

Timing of Measurements

  • Study one: Pre-test prior to randomization; 24-hour recall collected post-intervention period (time not specified)
  • Study two: Pre-test one week prior to program initiation; post-test given one week after program conclusion.

Dependent Variables

  • Study one:
    • Canonical function based on:
      • Height
      • Weight
      • Skinfold
      • Sit-and-reach
      • Sit-ups
      • Mile run time
    • Exercise knowledge
    • Saturated fat intake
    • Percentage kcal intake from carbohydrates
    • Nutrition knowledge
  • Study two:
    • Height
    • Weight
    • Sum of skinfolds
    • Mile run time
    • Fitness knowledge
    • Nutrition knowledge
    • Protein intake
    • Carbohydrate intake
    • Cholesterol intake
    • Total fat intake
    • Saturated fat intake.

Independent Variables

  • Study one: Program participation
  • Study two: Program participation

Control Variables 

  • Study one:
    • Age
    • Gender
  • Study two:
    • Age
    • Gender.
Description of Actual Data Sample:
  • Initial N:
    • Study one: N=132 (45 in school-and-home group, 43 in school only group, 44 in control group)
    • Study two: N=97 (48 in experimental, 49 in control)
  • Mean age:
    • Study one: 
      • 11.6 years (SD=0.7) for children
      • 37.8 years (SD=6.8) for adults
    • Study two: 
      • 8.9 years (SD=1.18) for children
      • 36.9 years (SD=4.31) for parents.
Summary of Results:

Key Findings

  • Study one:
    • Study was pre- and post-test design with three separate treatment groups measured on 12 variables
    • The MANOVA on the subjects' change scores showed that the three groups differed significantly, F(24,236)=2.91, P<0.001, η2=0.40, on one canonical function or combination of change scores
    • The variables that correlated stronger than 0.20 with the canonical function (correlations) were exercise knowledge (0.68), nutrition knowledge (0.46), skinfold (-0.31), sit-and-reach flexibility (0.23), height (0.22), weight (0.23) and percentage of calories from fat (-0.23)
    • The standardized mean scores on the canonical function were 0.56 for the school-and-home group, 0.36 for the school-only group and -0.92 for the control group
    • Pair-wise contrasts showed the school-and-home and school-only groups each scored significantly higher on this canonical function than the control group (P<0.05)
    • Duncan post-hoc comparisons showed that the school-and-home group (M±SD), 14.4±3.38 and school-only group, 14.9±3.3 were significantly higher (P<0.05) than the control group, 11.7±3.3
    • Post-test nutrition knowledge scores for school-and-home group (11.2±2.6) but not school-only group (10.2±3.0) was significantly higher than control (8.8±3.1), P<0.05
    • Post-test calories from fat scores for school-and-home group (33.9±6.3) and school-only group (34.2±6.2) each showed significantly lower than control (37.7±5.78), P<0.05
    • Post-test sit-and-reach flexibility scores for school-and-home group (31.7±6.6), but not school-only group was significantly higher than control (28.6±6.5), P<0.05
    • The school-and-home group showed a higher mean improvement than the school-only group, but these two groups' means were not significantly different from each other. Examining single variables, however, the school-and-home group scored significantly higher than the control group on post-test nutrition knowledge and flexibility, whereas the school-only group did not.
  •  Study two:
    • Groups differed significantly on measures at post-test [F=(8,88) 2.96; P<0.01, η2=0.21]
    • Children in the treatment group scored higher than the children in the control group on post-test in fitness and nutrition knowledge [F=(1,87)=14.76; P<0.001; η2=0.15]
    • Treatment group scored higher than control group on post-test vegetable and fruit servings [F(1,79)=4.5; P<0.05]
    • No significant (NS) differences found on any other measures
    • Treatment group demonstrated greater improvements on fitness/nutrition knowledge [F=(1,87)=18.63; P<0.001; η2=0.18]
    • Treatment group demonstrated significantly greater increase in fruit and vegetable servings [F=(1,79)=3.85; P<0.05; η2=0.05]
    • NS group differences were found for change scores on any of the other measurements
    • Significant negative correlation between family team points and pre-test mile run times [r(44)=-0.34, P<0.05], indicating that children who initially took longer to run a mile had less family participation during the program
    • Significant correlation between number of family team points earned and higher amounts of post-test grain and cereal servings [r(43)=-0.32, P<0.05], indicating that children with greater family involvement were consuming more grain and cereal and less cholesterol at post-test than children with little or no family involvement
    • The same result were observed for saturated fat [r(40)=-0.30, P<0.05], cholesterol [r(40)=-0.30, P<0.05]. 

Other Findings

  • Study one:
    • 25 (80.6%) parents reported they were under care of a physician
    • Six (19.4%) parents reported no current physician medical care
    • Two (6.5%) parents reported history of premature death from cardiovascular disease in their immediate family
    • 29 (93.5%) participants reports no history of premature death from cardiovascular disease in their immediate family
    • 16 (51.6%) parents reported regular exercise
    • 15 (48.4%) parents reported no regular exercise
  • Study two:
    • Five (18.5%) parents were currently under physician care
    • 22 (81.5%) parents were not currently under physician care
    • 25 parents (92.6%) smoked
    • Two parents (7.4%) did not smoke
    • Two parents (7.4%) reported history of premature death from cardiovascular disease in their immediate family
    • 25 parents (92.6%) reported no history of premature death from cardiovascular disease in their immediate family
    • 19 parents (70.4%) reported regular exercise
    • Eight parents (29.6%) reported no regular exercise
    • Parents who reported exercise spent 2.8 hours per week on exercise
    • Children's grade, age in months and gender did not differ significantly between groups
    • Fourth grade had significantly higher pre-test and post-test height, weight, knowledge scores and faster run time compared to second graders
    • Second grade children had significantly greater pre-test to post-test changes in height and weight compared to fourth grade children.
Author Conclusion:
  • In both studies, children who received parental support and participation improved their knowledge of nutrition and exercise. These findings are consistent with previous research and indicate that the school-home groups increased their awareness and understanding of fitness and nutrition knowledge, but did not change physical fitness performance levels.
  • A limitation of the study is the classroom social traits are not identical. Parent involvement may have different among classrooms. 
Reviewer Comments:

None.


Research Design and Implementation Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)
Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?
Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to nutrition or dietetics practice?
Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies)
Yes
 
Validity Questions
1. Was the research question clearly stated?
Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?
Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated?
Yes
  1.3. Were the target population and setting specified?
Yes
2. Was the selection of study subjects/patients free from bias?
No
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?
No
  2.2. Were criteria applied equally to all study groups?
Yes
  2.3. Were health, demographics, and other characteristics of subjects described?
No
  2.4. Were the subjects/patients a representative sample of the relevant population?
???
3. Were study groups comparable?
???
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)
Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?
???
  3.3. Were concurrent controls used? (Concurrent preferred over historical controls.)
Yes
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?
N/A
  3.5. If case control or cross-sectional study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable. Criterion may not be applicable in some cross-sectional studies.)
N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?
N/A
4. Was method of handling withdrawals described?
???
  4.1. Were follow-up methods described and the same for all groups?
Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)
No
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for?
???
  4.4. Were reasons for withdrawals similar across groups?
???
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study?
N/A
5. Was blinding used to prevent introduction of bias?
No
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?
N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)
No
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?
N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status?
N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results?
N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?
Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied?
Yes
  6.2. In observational study, were interventions, study settings, and clinicians/provider described?
N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?
Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured?
Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described?
Yes
  6.6. Were extra or unplanned treatments described?
N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?
Yes
  6.8. In diagnostic study, were details of test administration and replication sufficient?
N/A
7. Were outcomes clearly defined and the measurements valid and reliable?
Yes
  7.1. Were primary and secondary endpoints described and relevant to the question?
Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern?
Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur?
Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?
Yes
  7.5. Was the measurement of effect at an appropriate level of precision?
Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes?
Yes
  7.7. Were the measurements conducted consistently across groups?
Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators?
No
  8.1. Were statistical analyses adequately described and the results reported appropriately?
No
  8.2. Were correct statistical tests used and assumptions of test not violated?
Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals?
Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?
Yes
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?
Yes
  8.6. Was clinical significance as well as statistical significance reported?
Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error?
Yes
9. Are conclusions supported by results with biases and limitations taken into consideration?
Yes
  9.1. Is there a discussion of findings?
Yes
  9.2. Are biases and study limitations identified and discussed?
Yes
10. Is bias due to study’s funding or sponsorship unlikely?
Yes
  10.1. Were sources of funding and investigators’ affiliations described?
Yes
  10.2. Was the study free from apparent conflict of interest?
Yes