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School-based obesity prevention in Chilean
primary school children: Methodology and
evaluation of a controlled...

Article in International Journal of Obesity · May 2004
DOI: 10.1038/sj.ijo.0802611 · Source: PubMed


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6 authors, including:

Juliana Kain Ricardo Uauy
University of Chile London School of Hygiene and Tropical Medi…


Cecilia Albala Brevis Bárbara Leyton
University of Chile University of Chile


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Chile. aware of the conse- include an increased urbanization and rising incomes that quences of present trends in NR-CDs (obesity.0001 for each test). tion activities are centered on five conditioning factors: healthy diet. anthropometry. leaving little profile of the population. International Journal of Obesity advance online publication. A differential effect in BMI Z was observed according to baseline nutritional status. Casilla 138-11.2 Albala1. The (INTA). disease. and 2 Public Health Nutrition.2 large shifts in diet and physical activity (Vida Chile) and defined goals for physical activity and patterns have occurred in low. has Chile is facing a progressive rise in obesity with the corres. revised 11 December 2003. coronary heart disease) and related burden of and trans fats as well as to a progressive sedentary behavior. children. have led to a drastic change in fat PEDIATRIC HIGHLIGHT School-based obesity prevention in Chilean primary school children: methodology and evaluation of a controlled study J Kain1*.and moderate-income obesity throughout the life course. Santiago. behavioral PA program and active recess. Specific health promo- developing countries in the last 20 y. 2141 in intervention and 945 in control schools. UK OBJECTIVE: To assess the impact of a 6 months nutrition education and physical activity intervention on primary school children through changes in adiposity and physical fitness. The ‘western diet’. Casilla 138-11.1 The most probable causes The Ministry of Health of Chile.d. the large income disparity and rise in particularly obesity.3 prevalence has been the greatest. established in 1997 a Health Promotion Program As stated by Popkin. while both physical fitness parameters increased significantly in both boys (Po0. Santiago. 1–11 & 2004 Nature Publishing Group All rights reserved 0307-0565/04 $25. WHO/NCHS 1977) among schoolchildren in January 2004 first grade from 16% (year 2000 baseline) to 12% by year . A sustained increase in risk factors space for parks and recreational areas to facilitate an active for nutrition-related chronic diseases (NR-CDs) has occurred. Chile.0802611 Keywords: obesity prevention. rapidly replaced traditional diets. International Journal of Obesity (2004).nature. the workplace and community life. which although has affected all age number of cars have compromised personal safety in the groups. 2 March 2004. the rise in street. so children can no longer play in public places. Institute of Nutrition and Food Technology focusing on schools. tobacco control. Santiago. ‘healthier’ kiosks. Santiago. especially saturated hypertension. R Uauy1.001 for each test) and girls (Po0. Also.001 for BMI Z). psychosocial and healthy environment. An action plan has been defined *Correspondence: J Kain. triceps skinfold thickness (TSF). in preschool and school age children. CONCLUSIONS: This intervention showed a robust effect on physical fitness in both genders and decreased adiposity only in Received 3 September 2003. In addition. DESIGN: Longitudinal school-based controlled evaluation study. 90 min of additional physical activity (PA) weekly. R Cerda1 and B Leyton1 1 Institute of Nutrition and Food Technology (INTA). accepted 18 height 42 s. SUBJECTS: Children from 1st to 8th grade.ijo. London. physical activity. BMI Z-score. F Vio1. life in the city. physical fitness Introduction which is high in saturated fat. U.00 www. RESULTS: Positive effect on adiposity indices (except TSF) was observed in boys (Po0. London School of Hygiene and Tropical Medicine. the present ponding consequences in the epidemiological and nutrition urban environment favors motorized vehicles. INTERVENTION: Nutrition education for children and parents. goal for childhood obesity is to reduce obesity (weight for E-mail: jkain@inta. sugar and low in fiber. diabetes. of Chile. doi:10.1038/sj. University of Chile. waist circumference and physical fitness (20 m shuttle run test and lower back flexibility). MEASUREMENTS: Adiposity indices (BMI.

We held two meetings with owners 2375. during the 6. county educational authorities. given and activities completed by the children by tion school drawn from Santiago included 821 children occasional spot-checks. All tions are absolutely necessary in order to develop effective teachers in the intervention schools received on-site training programmatic actions. obesity prevention signment to intervention or control school was made by and to reinforce national food-based dietary guidelines. reduce sedentary behavior in those 15 y of age and director to accept a research study. The ‘Healthy School’ initiatives have minimal evaluation providing training to school teachers.month intervention period. The implementation of school-based programs plays an Intervention program important role in promoting lifelong physical activity and A trained nutritionist and physical education (PE) teacher healthy eating in children. Cities were providing information on healthy diets and potential selected by the research team to represent urban commu. The program was initiated with 4th Participants grade students since the dietary assessment question- Five schools were selected from three different cities: for naires to be completed by the children required them to Santiago (large city. healthy included 707 and 495 children. but was part of the initiative called ‘Healthy Schools’. sugar (school C). body mass index (BMI) and other adiposity indices compared with (i) Educational program for children from fourth to eighth controls. This included: show a significant difference in physical fitness. (8:30–16:30). They are privately owned and pay a monthly rent number of children who were intervened amounted to to the school. (school A). responsible for collecting anthropometric and dietary data. Children were expected to (medium-size city. from Curico 350 (school B) and Casablanca 1204 (ii) Kiosks: Schools have kiosks that sell mostly high fat. respectively. As. for Casablanca (small city. An activity that International Journal of Obesity . only one school met the selection research nutritionists checked if contents were being criteria and was assigned to the intervention. children with full-day school attendance items could be sold and still remain profitable.4 Vida Chile has developed an obesity. Control schools from Santiago and Curicó and salty snacks. population 245 000). some of the physical activity workshops for children. program. we describe the dietary and physical grades: We implemented a shorter version of a specially activity interventions and provide results of anthropometric designed child-friendly classroom nutrition education and physical fitness outcomes. Thus. considering their perception (iv) In addition. They were an active lifestyle. attitudes and behavior. tobacco control and healthy environment). The goals of the intervention following criteria: primary level public schools (1st–8th were also explained giving ideas on what healthier food grades only). supporting them components and are focused exclusively on process indica. around 5 million people) and Curico be able to read and write. which consists in im. The emphasis of these programs (one of each per intervention school) were responsible for should be on developing knowledge. plementing actions addressing simultaneously three of the five risk factors for NR-CDs. and a comparison school were chosen. We hypothesized that children exposed to a diet/nutrition and physical activity intervention during 6 months would Diet and Nutrition Intervention.5 by the research team PE teacher for about 4 months. The population 22 000). and physical education teacher to support their role in It is important to note that there are virtually no controlled educating the children. we developed and implemented a for 2 days to provide them with general information on the controlled school-based obesity prevention intervention. involved received additional training from the nutritionist physical activity. and conducting tors. low socioeconomic status (approximately (iii) Parental involvement: Two meetings were held with 35% of children receiving School Lunch Program) and no parents of children from 4th to 8th grades and were previous participation in health promotion programs. an experimental and receive approximately 8–11 h from 4th to 6th grade. in an attempt to influence what was nities of different size. These activities took in the case of intervention studies on obesity prevention in developing the nutritionist approximately 1 h per day and 2 h per week countries. The interven. In this paper. Since evaluations of efficacy under controlled condi. The intervention schools older from 91 to 84% and reduce tobacco use among eighth were thus potentially biased for increased prevalence of graders from 27 to 20%. which was recently developed by INTA and FAO6 with the objective of introducing food and nutrition contents for the curricula of Latin American Methods primary schools. the foods. healthy snacks. preconditions defined by the educational authorities. some teachers developed special activities of overweight prevalence and the willingness of the school in support of the educational program. Those directly included actions addressing four risk factors (diet/nutrition. and in much smaller quantities. implementing the diet/nutrition education and physical al skills needed to establish and maintain healthy eating and activity program and evaluating the process. It nature and significance of the intervention. mainly directed at healthy eating. 5–6 h for 7th and 8th grades over the 6 months. Schools were eligible if they met the being offered to children. Obesity prevention in Chilean children J Kain et al 2 2010. while those in the comparison group 1202. this was an inherent limitation.

8 which. we provided basic sports equipment. normal (BMI P 10–85). those children who (TSF) and waist circumference (WC) were measured on all collected the most stickers received a physical activity- children by the three study nutritionists. while the endurance run to those children between 4th ing to the schools’ facilities.13 such as soccer balls. This included three aspects: coefficient (r-value) and one-way ANOVA (Bartlett’s test (i) Canadian active living challenge (CALC): CALC is a for equal variances). Obesity prevention in Chilean children J Kain et al 3 was successfully adopted in all schools over the second beginning of the school year (March/April 2002) in both half of the intervention was a contest called ‘Healthy intervention and control schools and repeated at the end of Snack’. basketball boards and ping-pong tables. consisting in giving once a week a sticker to 15 the school year (November). Secondary outcome measures. and averaged. hula hoops. has by the classroom teacher. basket balls. so children were aerobic capacity by running at an increasing speed back encouraged to dance. This program was Children were classified as underweight (BMIopercentile selected based on the recommendation of technical or P 10). basketball or and forth a distance of 20 m. respectively.1 kg with a portable digital scale and active living as well as encourage children to (Seca model 840).9 WC was possible to train the teachers. They were collected at the was completed by the children from fourth to eighth International Journal of Obesity . as part Sports Promotion Agency. using the equipment provided a speed of 8. overweight (BMI P 85–95) cooperation given by the University of Toronto’s Center and obese BMIZP 95. Weights were The objectives of this ‘hands-on’ tool is to build taken without shoes or belts and with light clothing. TSF was determined with Lange calipers to (ii) Provision of an extra 90 min per week of physical the nearest 1 mm. These were based on the 0. These included a selected sively used during recess time. European Test of Physical Fitness (Eurofit). respectively. months: These were mainly oriented toward a certain  Physical fitness: We applied two health-related tests: the sport (soccer.7 ANOVA were 0. intra.982.11 The flexibility test was applied to all children.9995 and 0. The subjects start running at volleyball as recreation.and interobserver reliability were determined for TSF and WC by intraclass correlation Physical activity intervention. The reference utilized was NCHS/ for Health Promotion to the Chilean Health Promotion CDC 2000 Growth Charts. the iliac crest. volley balls. children picked randomly eating a healthy snack during  Anthropometry: Weight. These included anthropometric food consumption survey of key food items. At the end of the school year. and 8th grades.2 of types of activities to be undertaken.69– those planned originally.5 km/h. based on their inclusion in the of this intervention. They were exten. but the actual score is the last (iv) Extra program: During the implementation of the PE half-stage fully completed before the subject drops out. because among younger children results were found to be less reliable. approximately 3 months. made of several shuttle runs. while P-values from the healthy and active lifestyle for children aged 6–18 y. although was devel- program. basketball and volleyball) and were first one assesses flexibility of the lower back by reaching conducted by the school PE teacher/classroom teacher as far as possible from a standing position. They were related item as a prize. while the other or research team PE teacher. program. and knowledge about the benefits and importance of health recorded to the nearest 0. stadiometer (Seca model 720) and recorded with a preci- CALC was translated into Spanish and adapted in terms sion of 1 mm. dietary assessment. during the second half of which gets progressively faster. triceps skinfold thickness recess.87). The survey and physical fitness parameters. Leger and Lambert test). trained thoroughly. Heights were measured with a standing increasingly incorporate activity into every-day life.92 and 0. the research team promoted activities beyond This test has been found to be reliable (test–retest r ¼ 0. it was not been endorsed by the Chilean Pediatric Society. one is the endurance 20 m shuttle run test (20 m SRT or (iii) Active recess: During one daily recess (15 min per day). Intraclass r-values for practical behavioral resource designed to instill a TSF and WC were 0.94. This activity was implemented for accordance with the pace dictated by a sound signal. but in this case. The BMI was calculated as Wt/Ht (m). height.12 Application of these tests The PE equipment for the participating schools was was recommended by specialists from the Government inadequate to support the needs of the study: thus. Each stage of the test is the intervention period. three consecutive times in the mid- activity to children from 3rd to 8th grades during 6 point of the left arm hanging straight. then increase at various stages in by the study. individual interest of the PE teacher and varied accord. play ping-pong.10 which indirectly determines music was played at recess time. This program is intended to be applied daily oped to evaluate the nutritional status of US children. so the research PE teacher measured standing with a nonelastic tape that was applied was responsible for its application and could only do it horizontally midway between the lowest rib margin and once a week on the children from 1st to 8th grade. attitudes and behavior towards healthy eating and physical activity Measures  Selected dietary assessment questionnaire consisted in a Primary outcome measures.

treatment and recess on a given day near the middle of the month. from 1st to 8th. the program as planned and the support given by the We decided to determine frequency rather than actual nutritionist. Mann–Whitney tests were conducted to assure comparabil- ity of anthropometric and fitness measurements between Data collection related to process groups at baseline.d. experimental subjects per one control. we also assessed changes over time intervention and their perception of possible changes within each group (differences between schools) in response in diet and/or physical activity observed during the to the intervention. This calculation assumed that BMI in the intervention Questionnaires were pilot tested before the study was schools would remain unchanged. seeds and dry fruits. energy-dense Also.16.8. estimation considering an effect of at least 0.05.1 s. We based the power only questions related to fruits and salads were investi.14. based on consump. were not normally distributed. engagement and liking priori.15 A total of 14 questions related to physical activity (attitudes. they (26 of 40 total) provided through a structured snacks (high in fat/sugars processed foods). high-sugar questionnaire (14 questions) and one open question beverages. while that of control begun in children of similar SES attending summer schools schools would increase by approximately 0. BMI Z score. we were tional data. With respect to healthy eating. we assessed power and significance that resulted from of vigorous physical activity. We found that about 15% was obtained from existing information on children of of children who would be entering 4th grade had difficulty similar age in Chile and is consistent with other interna- in reading and writing.d. willingness to increase consumption and (approximately 0. healthy foods (fruits. Statistical analysis They included the number of ‘active and sedentary’ Although the number of schools included was defined a activities performed after school. as well as fast foods. All analyses International Journal of Obesity . The questionnaires were modified until all questions months. WC) and physical fitness indices (20 m SRT scores and  Attitudes and behavior related to healthy eating and flexibility) measured on all the children before and after physical activity: These were assessed on children from the 6-month intervention period. time spent in implementing each of the programmed tion of the previous 24 h. and perceived ability to a total sample size of 3086 subjects with a ratio of two engage in physical activity. The effect of the program was analyzed  Kiosks: We monitored the monthly sales of food items using a mixed model analysis of covariance. It included questions related to physical contribute to a better understanding of the effects on activity and healthy eating. We examined height/age Z-score (HAZ) to see if  Parents: Data were collected in November on a sample there were differences in this parameter at baseline and of parents (one class per grade. school and baseline status. We designed specific ques- primary outcomes.14. the analyses for those The following items were considered healthy: dairy variables were performed using natural log transformed products. Obesity prevention in Chilean children J Kain et al 4 grade on two different days (a weekday and the corre. estimating the relative changes both in intervention and control schools. which have used this methodology to gather outcome variables in intervention and control schools. using the procedure mentioned 329 parents) about their general opinion regarding the above. the difficulty in applying differences in consumption between weekday and Sunday. The s. A total of 16 items.) difference between the two groups perception if amount consumed was adequate) with an alpha of 0. We interaction. to calculate the sample size in both groups were understood by most children.  Teachers: They recorded the approximate amount of sponding Monday) of the same week.3 BMI units.17 prepared to provide special assistance to those with difficul- t-Tests for independent samples and nonparametric ties during the actual study. served to assess frequency their opinion regarding the educational program. These will be reported in greater detail tions and selected others from research carried out in the elsewhere. values. who would enter fourth to eighth grade the following school which is the expected increase in children of this age over 6 year. In addition. vegetables and dairy). information regarding food consumption in large popula- These include anthropometric indices (BMI. The comparative analysis of changes was school year. around explore change over time. intake. over the 6-month study period. Based on this observation. As TSF measures and the 20 m SRT scores (stages) then determined the proportion of ‘healthy foods’ sold. adjusting for bought by the children during the mid-morning recess gender and baseline value.35 BMI units gated (liking. fruits. nutritionist registered all sales for the corresponding The two-way model tested the effect of time. including activities of the diet/nutrition educational program. behavior. the of food consumption and also to determine if there were type of activities proposed. tions of children. sandwiches. after reviewing recent studies in Europe and the This manuscript will solely present results of the primary USA. The research observed in the two groups. adjusted by school effect where appropriate. USA and Europe based on children’s ability to understand them.15 TSF. Secondary questionnaire on a day different from that of food outcomes and process indicators will be informed when they consumption. the post hoc power estimated was 0. perception and barriers). and changes observed 4th to 8th grade and consisted in a self-registered according to sex.

8 (6. 2002. significantly affected by the intervention.)) P-value* F-value** BMI (kg/m2) I 19. HAZ decreased in Table 2 Change in anthropometric and physical fitness variables at follow-up in boys from intervention and control schools Variables Group Baseline (mean (s. % BMI ZP95 CDC 15 11.8 C 0.3) 19.6)b o0.6 y for Table 2 shows these effects in boys.4 (1. International Journal of Obesity .2 C 3. HAZ in Age 10. it % Boys 53.5 (3.1)b BMI Z-score I 0.7 (2) 5.3) a Denotes significant differences between intervention and control schools at baseline.2 (1.’s in control schools.5 (3.001 33.3 U. Obesity prevention in Chilean children J Kain et al 5 were performed using the SAS statistical package (SAS release and control schools were found in mean values for weight.6) declined in the intervention group by a mean of 0.14 C 12. Both physical Triceps skinfold (mm) 14 (6.8) 3.9 (3.8) 19.3) 65.3) 12. as expected for this age over 6 months.91) o0.) unless stated otherwise) The BMI Z-score declined significantly in the intervention Intervention Control schools.0001).4) 13. The main reason for missing data a clear bias favoring greater obesity in the experimental was child’s absence from school on days of measurements.5)a of group  time were noted (Po0. bControl significantly greater For girls (Table 3).96 (1.6) boys was significantly lower in control schools at baseline.96 (1.9 (13. TSF Weight (kg) 39 (13.3) 23. the proportion of boys was slightly higher in unchanged in the intervention group over time. while in both groups.8 (9.9)b o0.5 (14.2.6 (8.2 (3.12 C 18.9)a 22 (6. bDenotes significant differences between the delta change of intervention and that of control schools from baseline to follow-up.7 (27)a Waist circumference (cm) 66. the N 2141 945 group  time interaction was significant (Po0.0001 20. SAS Institute. in the comparison schools. Table 1 shows the baseline based on changes in the values of anthropometric and characteristics of 2141 children in the intervention and 945 physical fitness indices between baseline and follow-up.d.6 (9.9 cm. The proportion of obese children was significantly higher in the experimental group.3% of the total sample.6 (2.001 112.5) 138.46 (0.001 94. adjusting for the baseline value. and control groups.d. Fitness variables were taken on subsamples of total popula- The effect of the intervention over time was evaluated tion as detailed under Methods.7) dropped nonsignificantly over time in both groups.5) 10. height.05 s. Canada).8) 64.3 while in controls it increased by the same amount.2 (26) 63. No significant differences between intervention control schools it increased by 0.5 (5.6 (2. Average BMI remained both sexes.59 (0.81) HAZ I 0.44 (0.5 48 while the mean dropped by 0. while in control schools it remained unchanged. that is.5 52 remained unchanged over time in intervention schools.98) TSF (mm) I 12. schools.54 (0. Baseline and follow-up with a nonrandom assignment of schools to experimental values for anthropometry were collected in 3086.2 (3.5) o0.45 (0.1) 0. BMI and TSF.9)a 66.94) 0.3 (6.48 (0.5) 37. BMI Results percentile and WC. **F-value for interaction (group  time) calculated from mixed model analysis of covariance values in intervention and control schools.92)a significant group effect and a highly significant interaction BMI percentile 68.3) 23.7)a 19.d.6 (3.51 (0.8 (14.4 (5. there was 86.4) fitness parameters improved significantly in the intervention Lower back flexibility (cm) 22 (7.8)a 3.001 15.001). while in the control group the 20 m SRT 20 m SRT (stages) 3.7 (6. a Intervention significantly greater than control.5 (9. The analysis shows that this change was significantly affected by the interaction between group Table 1 Characteristics of the sample at baseline in intervention and control assignment and time.7 C 23. The average age was 10.7 C 64.97 C 0. 8.2 (10.7 (6.3 (7.63 (0.6) WC (cm) I 67. BMI and BMI Z scores were not than intervention. WC BMI (kg/m2) 19.94)b o0.d. Concordantly with the higher obesity prevalence.001).0 (1. schools (values are mean and (s. % Girls 46.6)b remained unchanged and flexibility declined.3 (5. physical fitness indices were worse (lower values) The baseline sample included 3577 children from both in the experimental schools.0001 73.48 (0.6) o0.92)a 0.9) 20 m SRT (stages) I 3.1)b group (Po0. after adjusting for baseline BMI values.93) 0. *P-value for interaction (group  time) calculated from mixed model analysis of covariance.4 (10. a BMI Z score 0. differences were also noted for mean values in BMI Z-score.)) Follow-up (mean (s.63 (0.9) 11. As explained under Methods. These results are consistent intervention and control schools.98) 0.3) Height (cm) 138.9) Lower back flexibility (cm) I 21.5 (8.97)a 0.

we observed a small but significant difference obese.61 (0. but effect of age was found when assessing the interaction of age.07 Z individual time and group effect. bDenotes significant differences between the delta change of intervention and that of control schools from baseline to follow-up.3) Lower back flexibility (cm) I 22.6 (1.9 (9. mixed model of covariance.6 C 0. boys and girls in each of the three intervention schools while they declined in control schools (P&lt.49 C 0.5) 20 m SRT (stages) I 2.3 (6. of them.9) 20.0. **F-value for interaction (group  time) calculated from mixed model analysis of covariance values in intervention and control schools.4) a Denotes significant differences between intervention and control schools at baseline. These findings are unique and of key significance between schools at baseline (P ¼ 0.06 for girls.9 (9. For girls.1 (6.4 (3. suggesting an independent effect of pubertal related to program implementation in order to illustrate maturation. TSF and this case is difficult to interpret.up. interaction.2) 0.and overnourished at follow-up.8) 0.7) 66 (9.53 (0.2) 3. the group  time interaction was highly population. The mean BMI Z scores for bility improved significantly in the intervention schools. adjusting for the baseline value.94) 0. to 0.9 (7.9 (1.0 (3. normal children lost 0. No group  time interaction was observed. (delta BMI Z) was homogenous and independent of baseline BMI Z scores declined significantly over time in each BMI Z-score. an important improvement occurred. group  time interaction was highly ignificant.4)b o0.92)b o0. we evaluated this change for obese. in contrast to boys. For the control group. BMI Z in those younger than 12 y of age. significant differences In order to examine if the effect of the intervention among intervention schools were noted at baseline.9) HAZ I 0.40 (0. In all intervention for developing countries that must face the challenge schools.1 (10. overweight.92) 0. For combined sexes. both the 20 m SRT scores and flexi.07 for the underweight. However. for at follow-up.6) 0.6 (1.03 for the boys.7 (7. respectively. their potential impact on the main outcomes reported in this Table 3 Change in anthropometric and physical fitness variables at follow-up in girls from intervention and control schools Variables Group Baseline (mean (s. if both control schools had a significant decline in 20 m SRT scores control and intervention groups were examined jointly. in contrast to boys. for ranged from þ 0.)) P-value* F-value** BMI (kg/m2) I 19.59 (0.48 (0.0001 109.92)a 0.05 4. In this case.8) BMI Z score I 0. is independent of the intervention. this group and time of measurement (baseline and at follow-up).7 C 24.3)a 2.e. while in control schools these remained un- normal weight and underweight.06 for control schools combined are shown in Figure 2.2) 65. there was no effect in terms of The mean 20 m SRT scores for boys and girls in each of the observed BMI Z over the 6 months of study. School effects on changes in main outcomes between There was a significant effect of the intervention on baseline and follow-up were also analyzed using the physical fitness.04).6 (3. are shown in Figure 1. boys.6 C 19.28 for boys and 0. at follow.18 significant. but no group  time while those underweight gained þ 0. again. Obesity prevention in Chilean children J Kain et al 6 the intervention schools. For showed a significant effect of baseline BMI Z in both girls.8) 19. for control schools combined test).2)a 23 (6. those older than 12 y of age had a greater decline in We provide preliminary results on process indicators BMI Z.8) WC (cm) I 65. but.2) 15.18 C 64.d. this is an effect which WC were not significantly affected by the intervention.15 BMI Z.)) Follow-up (mean (s. There was a significant 0.89) 0.47 (0.3) 25.2) 16 (6.9)b o0.63 (0. The age effect in indicating a greater drop in the intervention group. changes three intervention schools compared to mean7s.62 (0. no change for overweight and þ 0. mean BMI Z scores that the obese and overweight dropped by 0. For normals.e. The results of this analysis changed.35 C 15.0 (6. although a slight increase was noted in both groups. there was a major improvement in this score of targeting a combination of under. the data demonstrated vention schools.15 BMI Z units. while in controls this score remained un- We also explored the effect of age on change in BMI Z in changed. while it remained unchanged the nearly significant interaction showed a greater drop in in control schools.0001 113. *P-value for interaction (group  time) calculated from mixed model analysis of covariance. No significant overall between intervention schools were noted at baseline. there was a group  time interaction. we also noted differences at baseline between inter- boys and girls.96) TSF (mm) I 15. In the case of girls for both groups combined.001 for each compared to mean7s.8 (6.8 C 2. For boys.d.3 (1. no differences both intervention and control groups.7 (3.16 and were not affected by the intervention. P-value was 0.94)a 0. International Journal of Obesity .

we school C and 80% in school A.2 h and spend only 1.2 h in moderate-to-vigorous physical activities. the proportion of healthy foods sold was 2. where it was around 90%. In school B.34% in control schools were nificantly with age and sex. At baseline. Later on. approximately 50%. the research PE teacher assumed this role. although reliably measured. TSF and WC are both simple up evaluation. changes sig- intervention schools and 0. Parental involvement based on participation in scheduled meetings was much lower in Santiago.24 while WC is associated with The provision of extra physical activity time was success. Discussion In Chile. showed increased consumption of energy-dense foods (snacks high Figure 2 Comparison of the 20m Shuttle Run Test scores between baseline and follow up in intervention and control schools according to gender. respectively.20 In addition. overall decrease for all schools during the 3-month observation was 60%. we could only assess subjectively the influence it had on overall physical activity based on observations by the research team and school teachers assigned to supervise the children during recess.17. the distribution of abdominal fat23 and consequently to the fully implemented in all schools. BMI. When no regular teacher was available insights into the rate of visceral fat accumulation during for this activity. A total of 83% of parents who provided Figure 1 Comparison of BMI Z scores between baseline and follow up in intervention and control schools according to gender. have been shown to The intervention had absolutely no effect in modifying the predict total fat content (measured against results from pattern of sales of healthy foods by the kiosks.21 The objective of this study was to evaluate in a controlled paper.5% of the total number of food items sold over a recess in cents. from 168 to 68. It can thus provide into the curriculum. At the follow. relative to Curico and Casablanca (smaller cities). a potential risk and 0%. teachers activity intervention on obesity and fitness among school- applied 100% of the planned educational activities vs 85% in aged children. In this study. In 6-y olds. the number of injuries related to accidents or fights decreased substantially. watch television 3.2% (weight for height 42 s. TSF. determined on similar children as the ones included in our study. because it was incorporated occurrence of the metabolic syndrome. so BMI values were also considered healthy as defined under Methods. for cardiovascular diseases.26 Pubertal stage has an International Journal of Obesity .22. Interestingly. The implementation of the nutrition education manner the effects of a diet/nutrition education and physical program did not occur fully as planned. NCHS) in the year 2000. To assess effectiveness (impact evaluation). Most teachers underwent a chose simple variables that have been demonstrated to short training and only about half of them were initially detect changes in body composition and physical activity willing to take the responsibility for this activity. All opinions coincided in concluding that most children enjoyed the music or were more active because they had more sports equipment available. in fat and sugars) and low consumption of energy-dilute foods (fruits and vegetables). the prevalence of obesity among children has risen sharply over the past two decades. A study conducted recently in a low-income neighborhood of Santiago showed that 10-y-old children during a regular school day. their general opinion on the intervention reported positive changes in their children both in dietary intake and/or physical activity. carry out light activities during 8 h. 66% said they themselves incorporated some aspects of what was discussed at meetings in their own lifestyle. that we included in our study. The anthropometric measurements the rest accepted the challenge.d. Obesity prevention in Chilean children J Kain et al 7 Active recess was also implemented successfully in all schools.25. expressed as Z scores. it increased from 7% in 1987 to 17. childhood and adolescence.23 BMI.6 h. sleep 11. on average. over short-term periods. underwater weighing or DEXA) in children and adoles- 3.19 Sedentary behavior among children is also increasingly prevalent. dietary patterns.6 measurements: TSF relates to total body fat.

The intra. groups were similar within each sex category. since the age distributions of intervened and control phenomenon. the program. the change in 20 m SRT was different between at follow-up. Obesity prevention in Chilean children J Kain et al 8 important effect on fat accumulation and distribution. as revealed by the higher F-value) and WC. in this case 41%. was in the opposite direction. BMI energy intakes of this magnitude. At baseline.3 kg/m2) on adiposity. no We chose cardiorespiratory fitness and flexibility. the higher the score the better the two schools. from the three intervention schools (75% answered the up. In fact. noninvasive differences in response to the intervention among schools and requires limited facilities. for girls. In examining the large groups of children since it is reliable. have a very limited knowledge in nutrition. no effect was noted schools despite generalized improvement.6 and training mined by BMI Z-scores in boys (Figure 1) was evident in all time was very short. Cardiore. because of time and personnel constraints.33 found students to be physically active for about not allow for a quantitative estimation of differences in 50–60% of the total recess time. but most probably to the procedures have to harmonize science with what different high variability in values. In girls. while in schools B to perform two. while the underweight gained We thus recognize this issue as a source of uncontrolled BMI Z. willing to accept. typical of children undergoing people involved propose to implement and recipients are pubertal changes. on adiposity. the BMI Z scores (the effect was stronger when expressed as smaller the enrollment. intervention schools despite the marked differences in The additional PE classes were sports oriented and well baseline values.and interobserver measure. teachers do not implement the experimental the study. there was a significant similarly in all three intervention schools in boys. only approximately 1/3 of the classes were cardiovascular function. the spiratory fitness was determined indirectly according to research PE teacher (who was highly motivated) was directly children’s performance on the endurance 20 m SRT through in charge of most of the additional PE classes. This in fact suggests that changes observed in the interven- this effect was not of major significance in the results of our tion group are not due to a regression to the mean study. with were in fact 0.10. thus would not pick up such a small difference. while the experimental group professionals hired by us to support the process. indicating a possible systematic regard to the control group. regular school curricula. The anticipated effect of mean BMI change between questionnaire). In contrast. All intervention schools exhibited major gains in 20 m SRT Field-based fitness tests for children include measures of scores. mean values ranged from 3. liked by the children according to the report of 44 teachers but in. these schools revealed differences (small) cardiorespiratory endurance. and C they improved 50 and 40%. Boys ance and flexibility. because school effect was observed. public school teachers in general The effect of the intervention on each school as deter. This field test is recommended for conducted by the research PE teacher.3 U over 6 months. variance in the anthropometric results. However. to the fact that school B was substantially smaller. even the best methods for age assumes equal maturation at a given age. BMI Z-scores dropped surprising that results differ according to school. due to concern over the BMI Z-score for the obese compared to those underweight children’s privacy expressed by the educational authorities. as in boys. assuming additional PE classes should be permanently a part of the that this weight (about 600 g) was entirely fat tissue. we were only able from school A improved on average 17%. the obese and overweight lost weight relative to size. The degree of implementation differed among schools.27 We were unable to collect It is notable that for the intervention group.65 to 3. the change in data on sexual maturation. In girls. As reported by Baranowski et al. The effect in boys was observed as crude BMI. In positive effect on all adiposity-related indices (except TSF) contrast. there were no changes in BMI Z.76.28 Of these measures. children are not active in recess: increased physical activity and/or decreased energy intake. In our schools the situation International Journal of Obesity . Additionally. It has been in the intervened group remaining unchanged in the established that a key issue in the ability to deliver a program controls. This change in energy balance could be due to activity level. so this factor is unlikely to explain the high curricula with substantial fidelity. active recess periods would correspond to a change in energy balance of around may have contributed to the overall increase in physical 26 kcal/day. In general. respectively. limited effect. In the other maximum aerobic power. increasing BMI motivation by teachers and also to the time devoted by the by 0. This is a highly desirable outcome and reflects the need to Our data indicate that at baseline. for boys only.7 y younger. In addition. valid. observational studies carried out in elementary schools in The methods to assess dietary intake used in our study do the USA32. It is not remained unchanged. remained practically unchanged at follow.30 neglects this source of variance. 80% of the teachers thought that the baseline and follow-up ( þ 0. We consider this to be due in part to individual The control group behaved as expected. effect of earlier maturation on obesity prevalence. contrast. values were also different at baseline. school B exhibited the these have been widely used in evaluations performed on greatest improvement.31 if for ment error in TSF was carefully controlled prior to starting example. desired changes may have variability.29 (Figures 1 and 2). the better the degree of adherence to Z-score. muscular strength and endur. The lack of effect on TSF values may be due successfully is that the components and implementation to the small change observed. This is probably due Chilean school children (published as reports). we observe that BMI Z-score behaved The results showed that in boys. the obese (all schools) examine the differential effect within the intervened. Concordantly.

One successful strategy was the contest dance per week. In fact one could consider that in Leeds. Studies have shown that most low. Sahota et al.38 Unfortunately. after 12 weeks of 150 min of basic services. while it remained unchanged or even declined consistent data resulted from improvement of physical in the control group. The review included only of specific food items more frequently and thus a combined data from randomized and nonrandomized trials with effect of changes in physical activity and food intake concurrent control groups published from 1985 till 1997. because school assignment to the targeting the whole school community including parents intervention group was intentionally made by the local and teachers. health promotion and/or fitness but also with a reduction in adiposity. while the lowest effects time is more active. Our kiosk intervention failed in the absence strated to be generally effective at impacting obesity rates. and schools need the revenues to pay some improved in both genders. sion criteria are not strictly comparable to our study. significant improvements across genders and schools in evaluations. also found a reduction of the For example. The main difference is educational authorities. ‘The the selection of low-fat milk. because The results of the ‘healthier’ kiosks intervention demon. which motivated children to eat preschool children. over 12 months.31 The major impact of this study school-based programs that target obesity. Boys responded more effectively to the activity intensity during PE classes as well as reduction of physical activity intervention (determined as cardiorespira. skinfolds and aerobic diture.6 weeks. Gifts and prizes have been daily regimen of exercise (20 min of walking plus 20 min used as incentives for adopting health-enhancing behaviors. and to increase physical Active program promoting lifestyle in schools (APPLES)’47 activity. Stolley and Fitzgibbon46 sought to compare a dietary they included carbonated soft drinks.40 achieve and potentially critical to influence the home School-based preventive strategies have not been demon. to acknowledge the outcomes. which included called ‘Healthy Snack’. a control group allowed us to assess the influence of This study reveals important pitfalls in achieving uniform confounding variables. Positive effects were observed more frequently physical fitness. Flores et al found that in a income children buy these foods at school. and consisted in delivering a specific a healthy food during recess. From a nutritional stand. Our data on other type of intervention that focused on diet. Jacob42 also reviewed children should increase. reported improvement at the school level. there have been interventions to promote obesity prevalence that nearly reached significance. one aimed at reducing TV time while the last one by point. BMI declined significantly in girls while fitness items. Teachers play a key role in successful implementa- baseline values. She concluded that in almost flexibility improved significantly in the intervention group all studies. the decreased adiposity found in boys is International Journal of Obesity .39 implemented in some schools in the UK is comparable to The main limitation of this study is that it is a non. most of them was on physical fitness: both the 20 m SRT scores and with a time frame over 2 y. education vs a physical activity intervention. such as age. better fitness para. but strated that the availability of foods of low nutritional two of them were only physical activity interventions. of clear incentives to provide healthier choices or regulations Resnicow and Robinson41 reviewed 16 major school-based to limit the availability of energy-dense snacks and sugar- cardiovascular prevention trials published from 1985 to rich drinks. Dealing with confounders is very important tion. the nature of these foods is of considerable concern. as documented by Gattas et al. chocolates. if recess for smoking and cognitive aspects. may offer a better explanation for the gender differential Although the four short-term studies that met their inclu- on BMI response.44.35–37 so probably boys engaged in more vigorous interpreted in relation to comparable short-term interven- activity during the additional PE classes.34 therefore. it is interesting candies and chips. sample of 10–13-y old African-American and Hispanic there is no regulation restricting the sale of these children. type of school and efficacy. Results from this controlled study should be boys. environment. It has been shown that girls are less active than capacity. Campbell et al5 assessed the effectiveness of long- associated not only with an improvement in physical and short-term educational. physical food frequency questionnaire will serve to explore if activity or other aspect related to lifestyle and were designed responders in terms of BMI changed consumption patterns to prevent obesity in childhood. it uses a population health promotion approach randomized trial. in achieving a reduction in BMI. Having schools. implemented the APPLES program in primary schools meters in control schools.47 who in intervention schools and conversely. not only were they randomized controlled studies. sex. fat content of school meals. knowledge and attitudes improved and more in both sexes. Obesity prevention in Chilean children J Kain et al 9 is similar. total daily physical activity among were observed for adiposity measures. This resulted in higher obesity rates the attempt to modify school meals. our study. cookies. On the positive side. but this would bias the results toward a no effect: in contrast. no changes in BMI in the children from intervention we found a significant impact of the intervention. and this was tions. Robinson43 on the other hand tory fitness): boys improved by 35% while girls by 26%. analyzing results through semiquantitative meta. of aerobics) for 29. The study by Mo-Suwan. parental involvement was shown to be quite difficult to in the statistical treatment of results. we were able to achieve 1995.45 value remained unchanged. We reports that ‘behavior change’ interventions instead of can hypothesize that fitness in this case relates to increased ‘health education’ interventions seem to be more successful physical activity and thus possibly increased energy expen.

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