A school-based intervention improved dietary intake outcomes and reduced waist circumference in adolescents: a cluster randomized controlled trial

Angélica Ochoa-Avilés, Roosmarijn Verstraeten, Lieven Huybregts, Susana Andrade, John Van Camp, Silvana Donoso, Patricia Liliana Ramírez, Carl Lachat, Lea Maes, Patrick Kolsteren, Angélica Ochoa-Avilés, Roosmarijn Verstraeten, Lieven Huybregts, Susana Andrade, John Van Camp, Silvana Donoso, Patricia Liliana Ramírez, Carl Lachat, Lea Maes, Patrick Kolsteren

Abstract

Background: In Ecuador, adolescents' food intake does not comply with guidelines for a healthy diet. Together with abdominal obesity adolescent's inadequate diets are risk factors for non-communicable diseases. We report the effectiveness of a school-based intervention on the dietary intake and waist circumference among Ecuadorian adolescents.

Methods: A pair-matched cluster randomized controlled trial including 1430 adolescents (12-14 years old) was conducted. The program aimed at improving the nutritional value of dietary intake, physical activity (primary outcomes), body mass index, waist circumference and blood pressure (secondary outcomes). This paper reports: (i) the effect on fruit and vegetable intake, added sugar intake, unhealthy snacking (consumption of unhealthy food items that are not in line with the dietary guidelines eaten during snack time; i.e. table sugar, sweets, salty snacks, fast food, soft drinks and packaged food), breakfast intake and waist circumference; and, (ii) dose and reach of the intervention. Dietary outcomes were estimated by means of two 24-h recall at baseline, after the first 17-months (stage one) and after the last 11-months (stage two) of implementation. Dose and reach were evaluated using field notes and attendance forms. Educational toolkits and healthy eating workshops with parents and food kiosks staff in the schools were implemented in two different stages. The overall effect was assessed using linear mixed models and regression spline mixed effect models were applied to evaluate the effect after each stage.

Results: Data from 1046 adolescents in 20 schools were analyzed. Participants from the intervention group consumed lower quantities of unhealthy snacks (-23.32 g; 95% CI: -45.25,-1.37) and less added sugar (-5.66 g; 95% CI: -9.63,-1.65) at the end of the trial. Daily fruit and vegetable intake decreased in both the intervention and control groups compared to baseline, albeit this decrease was 23.88 g (95% CI: 7.36, 40.40) lower in the intervention group. Waist circumference (-0.84 cm; 95% CI: -1.68, 0.28) was lower in the intervention group at the end of the program; the effect was mainly observed at stage one. Dose and reach were also higher at stage one.

Conclusions: The trial had positive effects on risk factors for non-communicable diseases, i.e. decreased consumption of unhealthy snacks. The program strategies must be implemented at the national level through collaboration between the academia and policy makers to assure impact at larger scale.

Trial registration: ClinicalTrial.gov-NCT01004367 .

Keywords: Andes; Cluster randomized controlled trial; Dietary intake; Health promotion.

Conflict of interest statement

Ethics approval and consent to participate

The study protocol was approved by the ethics committees of the University Central in Quito-Ecuador (CBM/cobi-001 - 2008/462) and the Ghent University Hospital Belgium (FWA00002482). The study was registered at ClinicalTrial.gov with identifier NCT01004367. The CONSORT guidelines were followed to report the results of the study [49]. Only adolescents with a signed written consent from their parents/guardians (response rate 90%) and an informed assent signed by themselves (response rate 85%) were included in the final sample. Students were excluded prior and during the intervention if they were pregnant or suffered from a chronic medical or physical disorder, which may have interfered with a normal diet or physical activity performance, e.g. Crohn’s Disease or severe physical disability.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flow chart of progress
Fig. 2
Fig. 2
Description of the intervention development process. IM: Intervention mapping, CPPE: Comprehensive and Participatory Planning and Evaluation
Fig. 3
Fig. 3
Timeline and measurements of the ACTIVITAL trial. ●Activities performed in both, intervention and control schools. ○ Activities performed in the intervention schools only

References

    1. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, Mullany EC, Biryukov S, Abbafati C, Abera SF. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the global burden of disease study 2013. Lancet. 2014;384:766–781. doi: 10.1016/S0140-6736(14)60460-8.
    1. Biro FM, Wien M. Childhood obesity and adult morbidities. Am J Clin Nutr. 2010;91:1499S–1505S. doi: 10.3945/ajcn.2010.28701B.
    1. Juhola J, Magnussen CG, Berenson GS, Venn A, Burns TL, Sabin MA, Srinivasan SR, Daniels SR, Davis PH, Chen W. Combined effects of child and adult elevated blood pressure on subclinical atherosclerosis the international childhood cardiovascular cohort consortium. Circulation. 2013;128:217–224. doi: 10.1161/CIRCULATIONAHA.113.001614.
    1. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, AlMazroa MA, Amann M, Anderson HR, Andrews KG, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the global burden of disease study 2010. Lancet. 2012;380:2224–2260. doi: 10.1016/S0140-6736(12)61766-8.
    1. Mente A, de Koning L, Shannon HS, Anand SS. A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease. Arch Intern Med. 2009;169:659–669. doi: 10.1001/archinternmed.2009.38.
    1. Mozaffarian D, Appel LJ, Van Horn L. Components of a Cardioprotective diet: new insights. Circulation. 2011;123:2870–2891. doi: 10.1161/CIRCULATIONAHA.110.968735.
    1. Ortega F, Ruiz J, Castillo M, Sjöström M. Physical fitness in childhood and adolescence: a powerful marker of health. Int J Obes. 2007;32:1–11. doi: 10.1038/sj.ijo.0803774.
    1. Instituto Nacional de Estadísticas y Censos. Anuario de Estadísticas Vitales - Nacimientos y Defunciones 2014. 2014. . Accessed 29 Nov 2017.
    1. Freire WRM, Belmont P, Mendieta M, Silva M, Romero N, Sáenz K, Piñeiros P, Gómez L, Monge R. Resumen Ejecutivo Tomo I. Encuesta Nacional de Salud y Nutrición del Ecuador. 2013.
    1. Ochoa-Avilés A, Andrade S, Huynh T, Verstraeten R, Lachat C, Rojas R, Donoso S, Manuel-y-Keenoy B, Kolsteren P. Prevalence and socioeconomic differences of risk factors of cardiovascular disease in Ecuadorian adolescents. Pediatric Obesity. 2012;7:274–283. doi: 10.1111/j.2047-6310.2012.00061.x.
    1. Ochoa-Aviles A, Verstraeten R, Lachat C, Andrade S, Van Camp J, Donoso S, Kolsteren P. Dietary intake practices associated with cardiovascular risk in urban and rural Ecuadorian adolescents: a cross-sectional study. BMC Public Health. 2014;14:939. doi: 10.1186/1471-2458-14-939.
    1. Jamison DT, Summers LH, Alleyne G, Arrow KJ, Berkley S, Binagwaho A, Bustreo F, Evans D, Feachem RGA, Frenk J, et al. Global health 2035: a world converging within a generation. Lancet. 2013;382:1898–1955. doi: 10.1016/S0140-6736(13)62105-4.
    1. Verstraeten R, Roberfroid D, Lachat C, Leroy JL, Holdsworth M, Maes L, Kolsteren PW. Effectiveness of preventive school-based obesity interventions in low- and middle-income countries: a systematic review. Am J Clin Nutr. 2012;96:415–438. doi: 10.3945/ajcn.112.035378.
    1. Story M, Nanney MS, Schwartz MB. Schools and obesity prevention: creating school environments and policies to promote healthy eating and physical activity. Milbank Q. 2009;87:71–100. doi: 10.1111/j.1468-0009.2009.00548.x.
    1. Cunha DB, BdSNd S, Pereira RA, Sichieri R. Effectiveness of a randomized school-based intervention involving families and teachers to prevent excessive weight gain among adolescents in Brazil. PLoS One. 2013;8:e57498. doi: 10.1371/journal.pone.0057498.
    1. Marshall SJ, Simoes EJ, Eisenberg CM, Holub CK, Arredondo EM, Barquera S, Elder JP. Weight-related child behavioral interventions in Brazil: a systematic review. Am J Prev Med. 2013;44:543–549. doi: 10.1016/j.amepre.2013.01.017.
    1. Kain J, Cordero SH, Pineda D, de Moraes AF, Antiporta D, Collese T, de Oliveira Forkert EC, González L, Miranda JJ, Rivera J. Obesity prevention in Latin America. Curr Obes Rep. 2014;3:150–155.
    1. Martínez R. Hambre y desigualdad en los países andinos: la desnutrición y la vulnerabilidad alimentaria en Bolivia, Colombia, Ecuador y Perú. Santiago de Chile: United Nations Publications; 2005.
    1. Guerrero AL, Gallucci SS, Michalijos P, Visciarelli S. Países Andinos: aportes teóricos para un abordaje integrado desde las perspectivas geográfica y turística. 2011.
    1. Sparks M. The changing contexts of health promotion. 2013. p. 28.
    1. Andrade S, Lachat C, Ochoa-Avilés A, Verstraeten R, Huybregts L, Roberfroid D, Andrade D, Van Camp J, Rojas R , Donoso S, et al. A school-based intervention improves physical fitness in Ecuadorian adolescents: a cluster-randomized controlled trial. Int J Behav Nutr Phys Act. 2014;11:153.
    1. Sistema Nacional de Información. Indicadores de Educación []. Accessed 29 Nov 2017.
    1. Hayes R, Bennett S. Simple sample size calculation for cluster-randomized trials. Int J Epidemiol. 1999;28:319–326. doi: 10.1093/ije/28.2.319.
    1. Verstraeten R, Van Royen K, Ochoa-Avilés A, Penafiel D, Holdsworth M, Donoso S, Maes L, Kolsteren P. A conceptual framework for healthy eating behavior in Ecuadorian adolescents: a qualitative study. PLoS One. 2014;9:e87183. doi: 10.1371/journal.pone.0087183.
    1. Bartholomew LK, Parcel GS, Kok G, Gottlieb NH, Fernandez ME. Planning health promotion programs: an intervention mapping approach. San Francisco: Wiley; 2011.
    1. Ndirangu M, Perkins H, Yadrick K, West JR, Bogle ML, Avis-Williams A, Santell R, Connell CL. Conducting needs assessment using the comprehensive participatory planning and evaluation model to develop nutrition and physical activity interventions in a rural community in the Mississippi Delta. Prog Community Health Partnersh. 2007;1:41–48. doi: 10.1353/cpr.0.0005.
    1. Bartholomew LK, Parcel G, Kok G, Gottlieb N. Intervention mapping: designing theory--and evidence-based health promotion programs. 2001.
    1. Abraham C, Michie S. A taxonomy of behavior change techniques used in interventions. Health Psychol. 2008;27:379. doi: 10.1037/0278-6133.27.3.379.
    1. Willett W. Nutritional epidemiology. New York: Oxford University Press; 2012.
    1. Greenfield H, Southgate D. Food composition data. Production, management and use. Barking: Elsevier Applied Science; 2003.
    1. Welsh JA, Sharma AJ, Grellinger L, Vos MB. Consumption of added sugars is decreasing in the United States. Am J Clin Nutr. 2011;94:726–734. doi: 10.3945/ajcn.111.018366.
    1. Fried E, Simon M. The competitive food conundrum: can government regulations improve school food? Duke Law J. 2007:1491–539.
    1. Sistema Integrado de Indicadores Sociales del Ecuador S. Necesidades Básicas Insatisfechas. Ecuador: Siise: Sistema Integrado de Indicadores Sociales del Ecuador; 2012.
    1. Instituto Nacional de Estadísticas y Censos . Encuesta de Estratificación del Nivel Socio-Económico. Ecuador: INEC; 2011.
    1. Fitzmaurice GM, Laird NM, Ware JH. Applied longitudinal analysis. Hoboken: Wiley; 2012.
    1. Hellevik O. Linear versus logistic regression when the dependent variable is a dichotomy. Qual Quant. 2009;43:59–74. doi: 10.1007/s11135-007-9077-3.
    1. World Health Organization JC, FAO Expert . Diet, nutrition and the prevention of chronic diseases. 2003. p. 916.
    1. Knai C, Pomerleau J, Lock K, McKee M. Getting children to eat more fruit and vegetables: a systematic review. Prev Med. 2006;42:85–95. doi: 10.1016/j.ypmed.2005.11.012.
    1. Thomson CA, Ravia J. A systematic review of behavioral interventions to promote intake of fruit and vegetables. J Am Diet Assoc. 2011;111:1523–1535. doi: 10.1016/j.jada.2011.07.013.
    1. Jaime PC, Lock K. Do school based food and nutrition policies improve diet and reduce obesity? Prev Med. 2009;48:45–53. doi: 10.1016/j.ypmed.2008.10.018.
    1. Vandongen R, Jenner DA, Thompson C, Taggart AC, Spickett EE, Burke V, Beilin LJ, Milligan RA, Dunbar DL. A controlled evaluation of a fitness and nutrition intervention program on cardiovascular health in 10-year-old to 12-year-old children. Prev Med. 1995;24:9–22. doi: 10.1006/pmed.1995.1003.
    1. Lytle LA, Murray DM, Perry CL, Story M, Birnbaum AS, Kubik MY, Varnell S. School-based approaches to affect adolescents’ diets: results from the TEENS study. Health Educ Behav. 2004;31:270–287. doi: 10.1177/1090198103260635.
    1. Clarke J, Fletcher B, Lancashire E, Pallan M, Adab P. The views of stakeholders on the role of the primary school in preventing childhood obesity: a qualitative systematic review. Obes Rev. 2013;14:975–988. doi: 10.1111/obr.12058.
    1. Van Lippevelde W, Bere E, Verloigne M, van Stralen M, De Bourdeaudhuij I, Lien N, Vik F, Manios Y, Grillenberger M, Kovacs E, et al. The role of family-related factors in the effects of the UP4FUN school-based family-focused intervention targeting screen time in 10- to 12-year-old children: the ENERGY project. BMC Public Health. 2014;14:857. doi: 10.1186/1471-2458-14-857.
    1. Eldridge S, Ashby D, Bennett C, Wakelin M, Feder G. Internal and external validity of cluster randomised trials: systematic review of recent trials. BMJ. 2008;336:876–880. doi: 10.1136/bmj.39517.495764.25.
    1. Van Royen K, Verstraeten R, Andrade S, Ochoa-Aviles A, Donoso S, Maes L, Kolsteren P. Factors affecting physical activity in Ecuadorian adolescents: a focus group study. J Phys Act Health. 2015;12:340–348. doi: 10.1123/jpah.2013-0288.
    1. Larrea C, Warnars L. Ecuador's Yasuni-ITT initiative: avoiding emissions by keeping petroleum underground. Energy Sustain Dev. 2009;13:219–223. doi: 10.1016/j.esd.2009.08.003.
    1. Singal AG, Higgins PD, Waljee AK. A primer on effectiveness and efficacy trials. Clin Transl Gastroenterol. 2014;5:e45. doi: 10.1038/ctg.2013.13.
    1. Campbell MK, Elbourne DR, Altman DG. CONSORT statement: extension to cluster randomised trials. BMJ. 2004;328:702–708. doi: 10.1136/bmj.328.7441.702.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren