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Citation:

Moore JB, Pawloski LR, Goldberg P, Kyeung MO, Stoehr A, Baghi H. Childhood obesity study: a pilot study of the effect of the nutrition education program Color My Pyramid. J Sch Nurs. 2009 Jun;25(3):230-9. Epub 2009 Apr 10.


PubMed ID: 19363107
Study Design:
Group Nonrandomized Trial
Class:
C - Click here for explanation of classification scheme.
NEUTRAL: See Research Design and Implementation Criteria Checklist below.
Research Purpose:

To determine the effect of the nutrition education program Color My Pyramid on the nutrition knowledge, nutrition self-care practices, physical activity and nutrition status of school-age children.

Inclusion Criteria:
  • Fourth or fifth grade student attending two of Washington DC schools
  • Signed informed consent by parent
  • Assent provide by student.
Exclusion Criteria:
  • Not a fourth or fifth grade student attending two particular Washington DC schools
  • No signed informed consent by parent or assent by student provided.

 

 

Description of Study Protocol:

Recruitment

  • All fourth and fifth grade students from two Washington DC schools were invited to participate

Design:  Group nonrandomized trial

  • Pre and post tests were administered to measure children's nutrition knowledge, nutrition self-care practices, physical activity and nutrition status
  • Both schools received the education and activity content with six classes over three months but the experiential learning implemented in the schools differed
  • School one students received a more didactic presentation on playing the Blast-Off Game and the students at school two used individual computers to evaluate their diets in small groups

Blinding used (if applicable):  implied with measurements

Intervention

  • Method of experiential learning implemented regarding Blast-Off Game

Statistical Analysis

  • Analysis of variance (ANOVA), independent t tests and dependent t tests used to determine differences between schools and pretest and posttest scores for nutrition knowledge
  • Statistical significance reported using p values and effect size reported using Cohen's d.

 

Data Collection Summary:

Timing of Measurements

  • Physical assessment including height, weight, and blood pressure measurements measured pretest and posttest
  • Body mass index (BMI), weight-for-age percentiles, height-for-age percentiles and BMI-for-age percentiles generated from physical assessment data pre and post test
  • Children's nutrition knowledge, self-care practices, and physical activity were measured by a test given prior to and after the intervention 

Dependent Variables

  • Nutrition knowledge
  • Self-care practices
  • Level of physical activity
  • Blood pressure
  • Percentiles for height, weight and BMI

Independent Variables

  • Method of experiential learning implementation of Color My Pyramid and Blast-Off Game

 Control Variables

  • Age
  • Gender
  • Ethnicity
  • Health problems
  • Sports participation
  • Age of guardian
  • Education level of guardian
  • Participation in school breakfast program.

 

Description of Actual Data Sample:

Initial N: Not described

Attrition (final N): 126 students (46 male, 80 female, 35% participation rate)

Age: nine to 11 years

Ethnicity: 113 African American, 8 other

Other relevant demographics

  • No significant differences between groups
  • Age of guardian
    • 33.3% of guardians <30 years of age
    • 45.7% of guardians 31 to 40 years of age
    • 21% of guardians >41 years of age
  • Highest level of education of guardian
    • 6.5% did not complete high school
    • 34.3% with high school diploma
    • 28.7% with some college education
    • 24% with college degree
    • 6.5% with graduate school attendance
  • 50.4% of students were in the school breakfast program

Anthropometrics:

  • No significant differences in body mass index (BMI) between two schools at baseline

Location: Washington, DC.

 

Summary of Results:

 Key Findings

  • Significant difference in nutrition knowledge between school one and school two from pre to post test with school one making the greatest gains (F=4.916, p=0.029)
  • When data from both schools combined, there was no significant improvement between pretest and posttest scores for nutrition knowledge (t=0.92, p=0.279)
  • Combined score of two schools showed significant improvement between pretest and posttest scores for self-care practices (t=1.981, p=0.05)
  • No significant difference in change scores between schools although school 1 made the most improvement (F=1.1852, p=0.279)
  • Nutrition education program had a small effect on behavior (d=0.261)
  • Significant increase in activity time pre and post the intervention (t=3.779, p<0.001) with no significant differences in activity between schools
  • Intervention had medium effect size on activity (d=0.598)
  • Significant decreases in systolic blood pressure (t=5.85, p<0.001) but not in diastolic blood pressure (d=0.578)
  • Increases in the height-for-age percentiles and decreases in weight-for-age and BMI percentiles were not significant
  • No significant differences in scores of pretest knowledge, posttest knowledge, pretest practices, posttest practices by either gender, grade or school breakfast program

Variables

Pretest

Posttest

T value

Effect size

Knowledge

16.6+5.3

17.4+4.5

0.92

0.163

Behavior

154.8+31.8

162.1+23.6 

1.98 

0.261

Activity

(minutes per day)

31.4+37

60.1+69.6

3.779

0.598
Height for age percentile 69.3+25.2 72.4+23.9 0.500 0.126
Weight for age percentile 77.9+24.5 79.5+23 0.313 0.067
BMI for age percentile 77+26.2 77.3+25.7 1.378 0.011
Systolic blood pressure (mmHg) 113.9+9.8 108+10.6 5.85 0.578
Diastolic blood pressure (mmHg) 68.4+8.2 67.6+6.2 1.40 0.110

 

Other Findings

  • No significant differences between schools regarding gender, grade or school breakfast program.

 

Author Conclusion:

Children in this study increased their activity levels and improved their eating behaviors showing that Internet interventions can lead to improvement in children's nutrition and activity behaviors. The program demonstrated moderate effectiveness of a short-term nutrition education program. 

Reviewer Comments:
  • Subjects from narrow sample of population (35% participation rate)
  • More than half of subjects from families with low socioeconomic status, limiting generalizability
  • Physical activity levels based on self report.

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?
???
  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?
Yes
  2.2. Were criteria applied equally to all study groups?
Yes
  2.3. Were health, demographics, and other characteristics of subjects described?
Yes
  2.4. Were the subjects/patients a representative sample of the relevant population?
No
3. Were study groups comparable?
Yes
  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?
Yes
  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?
N/A
  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?
Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?
Yes
  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.)
Yes
  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?
No
  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?
Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately?
Yes
  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?
N/A
  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)?
N/A
  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?
N/A
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
 
 

Copyright American Dietetic Association (ADA).