Childhood obesity is an emerging epidemic with long-lasting health risks. Many communities lack adequate education and guidance about healthy nutrition and exercise for children and families. Our intent was to improve the obesity-associated health risks of participants using a community based participatory approach. The Power-Up pilot program was successful in showing the beneficial effects of a family focused nutrition and exercise program in the after-school environment. Our results demonstrate a significant lowering of BMI z
scores among African American school children over the 14-week program. Boys overall showed a trend toward greater mean BMI z
score reduction than girls; however, this finding was driven primarily by changes among normal weight boys and was not associated with decreased prevalence of overweight/obesity among boys. We hypothesize that girls may be more self-conscious about their appearance and weight than boys even during the pre-adolescent years, driving the trend toward greater effect among overweight girls. Children’s attitudes toward healthy diet and physical activity showed significant improvement when pre- and post- questionnaires were com pared; participants reported intention to eat more fresh fruit and vegetables and to participate more in sports. These attitudes are predictive of positive behavior change, which could be studied further through longitudinal follow-up of behavioral outcomes. The Power-Up pilot experience adds to the growing literature on addressing childhood obesity in school based settings. Power-Up shares some features with other recent research efforts such as the HEALTHY study,22
in that it utilized social marketing and environmental changes within the school setting to promote healthy nutrition and physical activity. The major difference and new contribution is that Power-Up is situated in the after-school setting, which lessens competition for academic time, and it builds on the strengths of the community school model, to enhance the likelihood of sustainability. We have shared our findings and pilot experience with the Power-Up project in academic and community venues. We participated in the year-end “All School Festival,” in which project experience was reviewed and celebrated with WCS students, parents, teachers, and school leadership. Project experience, outcomes, and subsequent plans were shared with the UC Community Advisory and Review Council, a body of local community leaders and representatives which interacts with research faculty to review and help shape our community-based research agenda broadly. Other local community and academic presentations have occurred, and two of us (LM and DB) co-presented the Power-Up pilot experience at a national meeting of the Society of General Internal Medicine.
Our study has several limitations. Because this was a pilot study to assess feasibility, we worked with a small group of students recruited from one school on Chicago’s South Side, did not employ a control condition, and were not able to follow participants beyond 14 weeks. Children enrolling in the Power-Up program may have differed from others within WCS with respect to BMI, level of motivation, and other characteristics. Results may not generalize to other after-school school settings. Self-reported behavioral and attitudinal responses are subject to social desirability bias; we chose to use simple self-report methods for assessing diet, physical activity, and attitudes to minimize participant burden for children of various ages in the after-school setting. Because this was a multicomponent intervention (environmental changes, curriculum addressing nutrition and physical activity, parent outreach component), it is not clear which aspects were essential for program success. Larger, more detailed studies could illuminate these issues.
One of the practical challenges we encountered was the inconsistent engagement of families. Parents found it difficult to attend the discussion groups regularly. This was not surprising; these parents have their children in the after-school program to provide day care while they are busy with other activities. We did send family materials home with children, but we would have preferred to have regular interactions with more of the parents. Alternative approaches for engaging parents are under consideration for future studies, including outreach through cell phones and text messaging, as well as evening parent events held in conjunction with scheduled PTA meetings. The after-school teachers greatly appreciated the training from our social psychologist, Dr. Michael Quinn; they found his material so helpful they invited him to speak with parents about behavior change. This parent session was specially advertised and was well attended. The after-school teachers requested more training on health topics; we are working to incorporate American Heart Association training for teachers for future studies.
We learned powerful lessons about the importance of building strong relationships with school and community leaders, parents, and teachers. We were able to successfully integrate Power-Up into school activities and culture through the active support of the WCS Principal and other school leaders, presentations at parent–teacher events, and participation in the annual All School Festival at the end of the school year. The WCS security guard became an unexpectedly important ally in terms of practical logistics; his strong relationships with WCS families and his literal keys to various rooms and resources proved invaluable throughout the program. The time and effort involved in building relationships are significant, but are crucial to successful integration of a program and study. The CBPR approach helped tremendously with the success of this project, and also greatly enhances its sustainability through lasting changes in school culture and environment. School staff and families see this work as their own. The lead after-school teacher described their on-going efforts:
Woodlawn Community School has continued to try to stay on the healthy track. We have added an agriculture component to our after school program. Here, we concentrate on life cycle of fruit, vegetables, and livestock. Because of the Power-Up program, we have continued to stay healthy and have purchased a greenhouse. We have started growing our own vegetables. Since Power-Up, we partnered with the Greater Chicago Food Depository. The program is called “Nourishment for Knowledge.” Every Thursday, the after-school kids get healthy nutritional snacks along with three different pieces of fruit. We also have a “Fruit and Veggie” program that targets the entire school. Every Tuesday and Thursday students are given a piece of fruit or a vegetable; a vegetable or fruit is also designated monthly in the school newsletter containing a fun recipe to try at home.
The physical or built environment has come to the forefront of public health research with a growing body of evidence linking aspects of the built environment to obesity.46
As a result of the Power-Up program, WCS installed a “Fun Hoop” (AAA State of Play, Indianapolis, IN) to provide interactive fun and encourage physical activity on the playground appropriate for all ages. Studies have shown that the availability of equipment and permanent activity structures in school play areas is associated with higher physical activity.47,48
The school has begun participating in a local community garden, is planning to install a greenhouse that was purchased with funding from this collaborative project to foster healthy nutrition, and is exploring a WCS farmers market. Improved access to fresh fruits and vegetables and healthier snack choices are other continuing benefits within the WCS after-school program.
WCS has demonstrated behavioral and environmental changes necessary through strategies recommended by the Institute of Medicine and the Centers for Disease Control and Prevention through promoting healthier eating habits and physical activity.49,50
The after-school setting proved to be a feasible venue for the Power-Up intervention, with promising changes in BMI z
score for children. Children, parents, teachers, and school personnel enjoyed the Power-Up program and have worked to sustain program principles and practices beyond the research project. The Power-Up program has significant potential to improve the health of participants by introducing sustainable lifestyle and environmental changes. University investigators have continued working with WCS staff and families beyond the period of this pilot project to share findings and interpretations from this study, to identify and build relationships with other schools on Chicago’s South Side, and to develop a proposal for a larger, randomized trial of the Power-Up after-school intervention involving multiple sites. As the community school concept and availability of after-school care are increasing locally and nationally,24,51
obesity prevention programs like Power-Up could be implemented in various schools throughout Chicago and the nation.