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Efficacy of individual counseling versus group program in promoting healthier lifestyle behaviours among… Koh, Jiak Chin 2004

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E F F I C A C Y OF INDIV IDUAL C O U N S E L I N G VERSUS GROUP P R O G R A M IN P R O M O T I N G H E A L T H I E R L IFESTYLE BEHAVIOURS A M O N G C H I L D R E N (SEVEN TO 11 YEARS OLD) WHO A R E O V E R W E I G H T by Jiak Chin Koh B.Sc. (Hon.) Memorial University of Newfoundland, 1996 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF T H E REQUIREMENTS FOR T H E D E G R E E OF MASTER OF SCIENCE in T H E FACULTY OF GRADUATE STUDIES H U M A N NUTRITION GRADUATE PROGRAM We accept this thesis as conforming to the required standards T H E UNIVER$TY OF BRITISH COLUMBIA January 2004 @Jiak Chin Koh, 2004 Library Authorization In presenting this thesis in partial fulfillment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Name of Author (please print) Date (dd/mm/yyyy) Title of Thesis: ^TTIO^CM ° f Ind iv idua l CoiK^s&.\>nc] VtrsuS. Department of )-|IUT)AK) N)uj/giTJ-or^ The University of British Columbia Vancouver, BC Canada A B S T R A C T The prevalence of childhood obesity has increased dramatically in Canada in recent decades. Despite this, treatment services are often limited, and when available, traditional weight control approaches have been criticized for unrealistic goals, possible adverse effects, and ultimately lack of long-term success. It is hypothesized that a group program focused on promoting healthier lifestyle behaviours for overweight children and their families in a fun, friendly and supportive. environment aimed at improving eating behaviour, physical activity, self-efficacy, and self-esteem would be more effective than individual counseling sessions despite a similar message. Forty-six children aged seven to 11 years with body mass index > 85 t h percentile were randomized with gender stratification to either a group program involving eight weekly two-hour sessions or a single one hour individual counseling session with a half-hour follow-up session two months later. Both groups were followed up 12 months after the initial session. Drop-out was high with only five and seven children respectively finishing the study, limiting its power. At 12 months, there were no differences between groups in change in body mass index (BMI) or triceps skinfold (TSF), although TSF (p=0.012) but not BMI fell in both groups. Questionnaire-measured physical activity level, self-efficacy and self-esteem did not differ between groups. This study concludes that, at least in the short term, a widely-focused group program for the management of childhood obesity is no better than individual nutritional counseling sessions with a similar message. Longer term studies are needed to investigate the effectiveness of a healthful lifestyle approach in children, irrespective of the mode of delivery. T A B L E O F C O N T E N T S ABSTRACT ii T A B L E OF CONTENTS iii-v LIST OF TABLES vi A C K N O W L E D G E M E N T S vii CHAPTER I INTRODUCTION 1.1 Background 1 1.2 Purpose and Objectives 2 1.3 Null Hypotheses 4 CHAPTER II L ITERATURE REVIEW 2.1 Introduction 5 2.2 Assessment of Childhood Obesity 6 2.2.a Growth Charts 8 2.2.b Body Mass Index 9 2.2.c Triceps Skinfold Measurements 12 2.3 Prevalence of Childhood Obesity 13 2.4 Factors Contributing to Obesity in Children 17 2.5 Health Consequences of Childhood Obesity 22 2.6 Management of Childhood Obesity 26 2.7 Summary 36 CHAPTER III M E T H O D O L O G Y 3.1 Research Design 38 3.2 Subject Recruitment 39 3.2.a First Session 39 3.2. b Second Session 39 3.3 Sample Size 40 3.3. a First Session 40 3.3.b Second Session 40 3.4 Inclusion and Exclusion Criteria 41 3.5 Ethical Approval 42 3.6 Description of Programs 42 in 3.6.a Individual Counseling Program 42 3.6. b Group Program 43 3.7 Anthropometric Measurements 44 3.7. a Body Mass Index .44 3.7. b Triceps Skinfold 45 3.8 Survey Instruments 45 3.8. a First Session 45 3.8.a.i Questionnaire for the Children 46 3.8.a.ii Questionnaire for the Parents 46 3.8.b Second Session 46 3.8.b.i Questionnaires for the Children 47 A. Food Frequency Questionnaire 47 B. Fruit and Vegetable Intake Self-Efficacy 48 C. Physical Activity Questionnaire 49 D. Physical Activity Self-Efficacy Scale 50 E. Self-Perception Profile 50 3.8.b.ii Questionnaire for the Parents 51 3.9 Statistical Analysis 53 CHAPTER IV RESULTS 4.1 Recruitment 55 4.2 Subjects' Characteristics 56 4.2.a Baseline Surveys Variables for the Children...... 57 4.2. b Baseline Surveys Variables for the Parents 60 4.3 Outcome Measurements 62 4.3. a Anthropometric Measurements 62 4.3.b Food Frequency Questionnaire and Fruit and Vegetables Intake Self-Efficacy 64 4.3.c Physical Activity and Physical Activity Self-Efficacy 67 4.3.d Self-Perception Profile 70 4.3.e Family Eating and Activity Habits Questionnaire 72 CHAPTER V DISCUSSION 5.1 Overview 77 5.2 Design of this Study 77 5.3 Anthropometric Measurements 78 5.4 Reported Dietary Intakes 80 iv 5.5 Physical Activity 82 5.6 Self-Perception Profile 83 5.7 Family Eating and Activity Habits 85 5.8 Overall Findings of this Study 85 5.9 Limitations 87 5.10 Implications of Findings 89 5.11 Avenues for Future Research 90 5.12 Concluding Remarks 91 REFERENCES 93 APPENDIX A: Letter to Health Professionals 112 APPENDIX B: Announcement in Newspapers 114 APPENDIX C: Poster in Community Centers 115 APPENDIX D: Weight Changes in the Children (First Session) 116 APPENDIX E: Parental Informed Consent Form 117 APPENDIX F: Certificates of Ethical Approval 119 A P P E N D r X G: Educational Materials for Both Programs 121 APPENDIX H: Outline for Counseling Program 137 APPENDIX I: Schedules for Group Program " F U N T R E K " 138 APPENDIX J: Rosner's Body Mass Index Tables. 146 APPENDIX K: Skinfolds Percentile Table 150 APPENDIX L: First Session- Questionnaire for the Children 151 APPENDIX M: First Session- Questionnaire for the Parents 154 APPENDIX N: Second Session- Food Frequency Questionnaire 158 APPENDIX O: Second Session-Fruit and Vegetables Intake Self-Efficacy Questionnaire 170 APPENDTX P: Second Session- Physical Activity Questionnaire 172 APPENDIX Q: Second Session- Physical Activity Self-Efficacy Questionnaire 176 APPENDIX R: Second Session- Self-Perception Profile 178 APPENDIX S: Second Session- Family Eating and Activity Habits Questionnaire 183 APPENDIX T: Equations for Estimated Energy Requirements 188 L IST O F T A B L E S Number Page 1. Global Increases in Prevalence of Childhood Obesity 15 2. Subjects' Baseline Characteristics 57 3. Survey Variables at Baseline for Children 59 4. Survey Variables at Baseline for the Parents 61 5. Repeated-Measures A N O V A - Anthropometric Measures 63 6. Repeated-Measures A N O V A — Food Frequency Questionnaire 65 7. Repeated-Measures A N O V A - Fruit and Vegetables Intake Self-Efficacy Questionnaire 66 8. Repeated-Measures A N O V A - Physical Activity Questionnaire 68 9. Repeated-Measures A N O V A - Physical Activity Self-Efficacy Questionnaire 69 10. Repeated-Measures A N O V A - Self-Perception Profile 71 11. Repeated-Measures A N O V A - Family Eating & Activity Habits Questionnaire 73 vi A C K N O W L E D G M E N T S I would like to thank my thesis supervisor, Dr. Ryna Levy-Milne for her guidance, support and understanding throughout my Masters program. Sincere gratitude goes to my advisory committee members, Dr. Susan Barr, Debbie Zibrik, and Karol Traviss for reviewing the thesis and providing me with valuable feedback. I appreciated and enjoyed the insightful questions from my external examiner, Dr. James Frankish. Thank you to Dr. Gwen Chapman for chairing my thesis oral defense. Sincere thanks go to my manager, Frances Johnson and my colleagues for their understanding and help when I had to take time off from work to write my thesis. Doreen Yasui and Claudia Dow were instrumental in facilitating the programs. Many thanks go to the student volunteers from UBC who contributed their time and talents. This study would not be possible without the participation of the families. Special thanks go to Stuart for convincing me "not to give up" and for his amazing support in many ways. Finally, I wish to thank my family for their unwavering support and encouragement. vn Chapter I I N T R O D U C T I O N 1.1 B A C K G R O U N D In Canada, as elsewhere in the world, the prevalence of overweight1 in children has increased dramatically during the last two decades. Between 1981 and 1996, the prevalence of Canadian children aged seven to 13 who were overweight, defined as greater than 85 th percentile body mass index (BMI) for age, rose from 15% to 35.4% in boys and 15% to 29.2% in girls. The prevalence of obesity, defined as over the 95 th percentile BMI for age also increased from 5.0% to 16.6% and from 5.0% to 14.6% in boys and girls respectively (Tremblay and Willms, 2000). Obesity in children is associated with both physiological and psychological health problems, including abnormal lipid profiles, future risk for cardiovascular and metabolic diseases, body image distortion, depression, and potentially lowered self-esteem (Schwartz and Puhl, 2003; Wile and Mclntyre, 1993). As well, the chance of becoming an obese adult increases with increased age of obesity (i.e., an overweight teenager is at higher risk than an overweight toddler), increased degree of obesity, and increased number of obese family members (Logan, 1994; Maffeis et al., 1998). Total direct cost of obesity in Canada in 1997 was estimated to be approximately $1.8 billion, which corresponded to 2.4% of the total health care expenditures for all disease in Canada (Birmingham et al., 1999). Therefore, reducing the prevalence of obesity 1 The Centers for Disease Control and Prevention (CDC) (2000) defined children whose BMI-for-age at 85th percentile to less than 95th percentile as at risk of overweight and those with BMI-for-age more than 95* percentile as overweight (based on data from five national health examination surveys). However, different researchers, practitioners and the media have used different criteria and terms referring to the same BMI cut-points. During the time of the initiation of this study, the term overweight was defined as equal to or greater than 85*1 to less than 95th percentile and obesity as above 95th percentile, therefore, these terms will be used as such in this thesis. 1 is not only crucial from a national health perspective, but would also result in significant cost savings to the health care system. There is a general emphasis on promoting preventive programs for children. However, there are limited services available for overweight children. Even though the prevalence of childhood obesity is increasing in British Columbia, the number of services and resources available to these children is not keeping pace. Obese children are not seen for counseling at British Columbia's Children's Hospital unless they are suspected of having or are diagnosed with an endocrine disorder. Thus, the majority of families are left without guidance. A number of approaches have been advocated for weight management, for instance the Vitality Message (Health Canada, 1992), the Play Approach (Rickard, 1995), and the Trust Paradigm (Satter, 1996) (these will be discussed later in the section of management of childhood obesity) and various factors have been hypothesized to lead to success. However, whether these approaches are more successful in a group or individual context is not known. 1.2 P U R P O S E A N D OBJECTIVES The overall purpose of this study was to compare the effectiveness of individual counseling with a group program on changing anthropometric measurements and promoting healthier lifestyle behaviours in overweight children (aged seven to 11 years) and their families. The individual nutritional counseling and the group program were designed based on the Vitality Message (Health Canada, 1992), the Play Approach (Rickard, 1995) and the Trust Paradigm (Satter, 1996). The two groups were provided with similar messages and educational materials. The mode of delivery differed, in that one group was provided with individual counseling 2 sessions while the other group was involved in a more widely focused group program. In addition, the contact time also differed. The participants in the counseling sessions were seen for a total of 1 Vz hour each (one hour of initial session and a half hour follow-up two months later) compared with the group sessions where there was a total of 16 hours (eight two-hour sessions) of contact time. The specific objectives for this study were: 1. to develop frameworks for individual counseling program and group program that were suitable for children aged seven to 11 years of age using the Vitality Message, the Play Approach, and the Trust Paradigm; thus focused on healthy eating, an active lifestyle and improving self-esteem. 2. to assess the children participating in the study at the initial, two month and 12 month visits and assess the effects of the interventions on self-efficacy and behaviours regarding nutrition and physical activity habits, self-esteem and anthropometric variables (height, weight, BMI and skinfold measurements). 3. to follow the parents in the study for one year and assess the effects of the interventions on family eating and activity habits. 3 1.3 N U L L H Y P O T H E S E S Compared to baseline measurements before intervention, at two and 12 months after the first individual counseling session or group program, the groups will not differ in terms of mean changes in: 1. anthropometric measurements 2. macronutrients intakes 3. physical activity 4. self-efficacy on physical activity 5. self-efficacy on fruit and vegetables intakes 6. self-esteem Compared to baseline measurements before interventions, at two and 12 months after the first counseling session or group program session, the groups of parents also will not differ in terms of their changes in family eating and activity habits. 4 Chapter II LITERATURE REVIEW 2.1 INTRODUCTION Childhood obesity is one of the most complex and least understood clinical syndromes in pediatric medicine (Must et al., 1992). It is also one of the most common metabolic and nutritional disorders in children (Ball and McCargar, 2003; Coates and Thoresen, 1978; Dietz and Robinson, 1993). Overweight is usually defined as a BMI above the 85 th percentile for age and obesity as a BMI above the 95 th percentile for age (Proimos and Sawyer, 2000). However, as later illustrated, these definitions have not always been used by all authors and groups, making cursory comparisons potentially difficult. Childhood obesity is, in the final analysis, the obligatory result of energy intake exceeding energy expenditure and the energy required for growth. It can be contributed by certain genetic and /or endocrine disorders or environmental factors (Hill and Trowbridge, 1998). Some of the medical complications associated with obesity in children include cardiovascular disease, hypercholesterolemia, diabetes mellitus, gallbladder disease and musculoskeletal disorders (Dietz and Robinson, 1993; Hill and Trowbridge, 1998). As well, these children often experience a broad range of social and psychological problems such as discrimination and alienation from peers. Their body size may give them a clumsy self-image and other poor self-concepts (e.g.: poor at sports). In addition, it has been shown that about 30% (Keller and Stevens, 1996) and possibly over half (Proimos and Sawyer, 2000) of obese children will become obese adults. Despite this, Epstein et al. (1998) suggested that efforts to deal with 5 childhood obesity may be more cost-effective and successful than efforts to treat adult obesity. Therefore, treatment early in life is crucial. This review will focus on the assessment, prevalence, contributing factors, consequences and treatments of pediatric obesity. 2.2 ASSESSMENT OF CHILDHOOD OBESITY An ideal time for initial clinical evaluation of children's weight status and overall cardiovascular disease risk profile is after the age of two years (prior to then, pregnancy and birth weight related issues are also major players) and preferably before entering school, at age five or six years (Williams et al., 2001). The preschool period is preferable because lifestyle habits contributing to development of risk factors are begun during these early years, especially habits related to diet and physical activity. In addition, habits of shorter duration should be easier to change than those of long duration; thus intervention aimed at younger children may be more likely to succeed. Finally, this is also when young parents are eager for advice on child care and visits to the pediatrician for immunizations and check-ups are more frequent, providing opportunities for assessment and early intervention if needed (Williams et al, 2001). There are a number of assessment tools available to assess obesity. However, not all of them are suitable to be used in children. Currendy available assessment measures of obesity range from relatively simple weight measurements to the more sophisticated hydrostatic weighing. Each tool has inherent advantages and limitations. For instance, hydrodensitometry is considered a reference method for body fat determination in adults, but it is unsuitable for use in young children as it 6 requires underwater weighing (Goran, 1998; Reilly et al., 2000; Roche, 1993). Application of magnetic resonance imaging and computed tomography, two additional established methods for pediatric body composition research, is limited by high cost, and in the case of computed tomography (CT) considerable exposure to ionizing radiation (Pietrobelli et al., 1998). Some of the more common tools currendy used in pediatric research and clinical settings such as growth charts, body mass index, and triceps skinfolds are discussed later in this section. There has been long-standing debate regarding the best indicator to use for assessing obesity in children. Several criteria should be considered when selecting a measure of adiposity. Ideally,.an indicator should be accessible, individual, reliable, and valid. Several convenient indicators (i.e. skinfold thicknesses, weight-for height, BMI, Ponderal index (weight 0 3 3 /height), Rohrer index (weight/height3) and circumferences have all been used to assess overweight and obesity status. While no single indicator satisfies all of the above criteria, BMI is the measure that is generally recommended to define overweight and obesity in children (Cole et al., 2000; Pietrobelli et al., 1998; troiano and Flegal, 1998). The BMI is an accurate and valid indicator of weight status in children, is significandy correlated with total body fatness, and measurements of height and weight are easy and convenient to perform in most settings (Ball and McCargar, 2003). It is widely agreed that BMI is the most practical measure of fatness at the moment. The International Obesity Task Force has recommended the use of BMI-determined international cut-offs for overweight and obesity in children (Gibson, 2002), 7 2.2.a Growth Charts Most growth charts available for children relate height (length) and weight to age, weight to height, and head circumference to length and weight. Unlike the adult desirable height and weight tables which are based on longevity data collected by life insurance companies (i.e. Metropolitan Life Insurance Company), the child and adolescent growth charts do not indicate "ideal" weights for children of the same sex, age, and height (Roche, 1993). Instead, percentiles are used to show the distribution of body weights and other variables (i.e., height, skinfolds) based on a national sample of children and adolescents. A child's age, sex, and weight must be considered together when using normative tables to assess a child's obesity status. In general, body measurements between the 25th and 75th percentiles represent normal growth; children with values below the 10th or above the 90th percentiles require additional assessment (Rotatori, 1979). Growth charts for children and adolescents must be used carefully and by trained professionals. Even when used appropriately, these charts have inherent limitations. For example, they do not take into consideration the relative proportions of body weight that is accounted for by lean body mass versus adipose tissue (fat). Consequently, a large-framed heavy and tall child with little adipose tissue could be considered as obese by the tables. Thus, it should be noted that weight-for-height, and similar measures such as BMI, however defined, do not measure fatness as such, but only a general index of weight status (Power et al., 1997; Troiano and Flegal, 1998). In order to overcome this limitation, additional assessment such as skinfold measurements can be done to predict body fat. The United States Centers for Disease Control and Prevention (CDC) growth charts consist of a set of charts for infants, birth to 36 months of age and a set of charts for children and adolescents from ages two to 20 years. These charts were developed based on data from five national health examination surveys. These charts were initially released in the year 2000 and detailed report of how the 8 charts were developed was only recently released in the year 2002 (National Center for Health Statistics, 2002). Therefore, it has only been recendy that these charts have been favourably used by health care practitioners. The charts for children and adolescents include weight-for-age, stature-for-age, and body mass index (BMI)-for-age-curves. The BMI-for-age charts represent a relatively new tool that can be used by health care providers for the early identification of children who are at risk for becoming overweight (National Center for Health Statistics, 2002), and accounts for the normal changes in BMI that occur during childhood and in relation to puberty. 2.2.b Body Mass Index The body mass index (BMI) is probably the best simple method for evaluating obesity in adults as it has a number of advantages over other available measures of adiposity. Weight and height are simple and direct indexes of body size and easy to measure, cheap and highly reproducible in field, clinical and research settings (Abrantes et al., 2002; Troiano et al., 1995). Body mass index provides a guideline based on weight and height to determine underweight or overweight status. BMI is not an exact measure of fatness per se, as levels of fatness among children will vary at any given BMI (Williams et al., 2001). This is true because BMI reflects frame size and leg length, in addition to the amount of lean and fat tissue. However, even though BMI correlates less well with percent of body weight that is fat compared with other more direct measures of fat such as triceps skinfold thickness, the large measurement error associated with triceps skinfold measurements (especially at high levels of fatness) and the more readily available weight and height data make BMI a more useful tool for assessment of overweight as a proxy for fatness (William et al., 2001). 9 Pietrobelli et al. (1998) recently conducted a validation study which showed that BMI was a valid measure of fatness in groups of children and adolescents. However, the researchers stressed that caution should be used when comparing BMI across different age groups or using it to predict an individual's total body fat (TBF) or percent body fat (PBF). Dual-energy x-ray absorptiometry (DEXA) is an accurate method of quantifying fatness in both small animals and children (Gutin and Manos, 1993; Pietrobelli et al., 1998). TBF (in kilograms) and PBF were estimated using D E X A in 198 healthy Italian children and adolescents (aged five to 19 years). BMI was strongly associated with TBF (coefficient of determination [R2] = 0.85 for boys and 0.89 for girls) and PBF ([R*j = 0.63 for boys and 0.69 for girls). Specifically, BMI independently explained 85% and 89% of between-individual differences in TBF and 63% and 69% of the variance in PBF for boys and girls, respectively (Pietrobelli et al., 1998). Therefore although BMI is useful as an approximate classification of obesity status, and strongly related to more precise measures of fatness, it cannot be used to accurately predict specific individual's TBF or PBF. Rosner et al. (1998) provided normative data for the distribution of BMI in children and adolescents in the United States. Standardized measurements of height and weight from nine large epidemiological studies including 66,772 children (aged five to 17 years) were used to develop the age-, race- and gender-specific tables for the distribution of BMI values. Data from the National Health and Nutrition Examination Surveys (NHANES) II (1976-1980) and III (1988-1991) were included in this study. In addition, differences in BMI by gender and ethnicity were described. These BMI values and percentiles are consistentiy higher than those based on data from NHANES I (1971-1974) by Must et al. (1991), particularly the 95 th percentiles. The first NHANES data were derived from only 1754 white and 546 black male subjects and 1763 white and 585 black female subjects, aged six to 19 years. Rosner et al. (1998) commented that the 10 sample size was too small to adequately demonstrate ethnic differences in BMI. The small sample size also made the data inaccurate when comparing the 85 th and 95 t h percentiles of BMI, which were traditionally used to define children at risk of overweight and obesity, respectively. Increases in mean BMI range up to 9% for some percentiles in boys and 10% in girls. The Expert Committee on Clinical Guidelines for Overweight in Adolescent Preventive Services (Himes and Dietz, 1994) suggested that BMI > 95 t h percentile for age and sex, or > 30 (kg/m2), whichever is smaller, should be considered overweight in adolescents (ages 11-21 years). However, no consensus exists on the application of BMI to younger children (under 11 years of age). This is due in part to the lack of data on the validity of the BMI as a measure of adiposity; the absence of a reference population; the lack of agreement on which cutoff point to use; and limited data on sensitivity, specificity and predictive value of the persistence of obesity or the development of its complications (Dietz and Bellizzi, 1999). Obesity frequently is defined as the age- and sex-specific 85 t h percentile of BMI or triceps skinfolds (Obarzanek, 1993). However, Obarzanek (1993) argued that this may result in overestimation of obesity at younger ages because young children at the 85 th percentile of a population reference standard are unlikely to be obese. Alternatively, Himes and Dietz (1994) proposed the 95* percentile of BMI to define obesity and the 85 th percentile of BMI for overweight. The Centers for Disease Control and Prevention (CDC) defined children with BMI-for-age at 85 t h percentile to <95* percentile as at risk of overweight and those with BMI-for-age of >95* percentile as overweight (National Center for Health Statistics, 2002). The International Obesity Task Force (IOTF) proposed the adult cut off points of 25 kg/m 2 for overweight and 30 kg/m 2 for obesity to be linked to BMI-centiles for children to provide child cut off points (Cole et al., 2000). 11 In conclusion, BMI is generally viewed as the best measure of weight status. It has reasonable correlation with the percentage of body fat measured by dual energy X-ray absorptiometry in both girls and boys. Moreover, weight and height, from which it is obtained, are easily measured with a good level of inter- and intra-operator reliability. Finally, obtaining measurements is not costiy or intrusive (Maffeis and Tato, 2001). 2.2.c Triceps Skinfold Measurements Triceps skinfold measurements predict percent body fat by assessing the thickness of the underlying subcutaneous adipose tissue. The site for taking triceps measures is the midpoint between the tip of the acromion process (back of shoulders) and the olecranon process (at the elbow). For children, the value obtained is compared to the table of triceps skinfold measurements for corresponding age from six months to 19 years of age (National Center for Health Statistics, 1987). A triceps skinfold measurement in excess of the 85th percentile was considered evidence of obesity in the 1981 Canada Fitness Survey (Limbert et al., 1994). In children, measurement of two or more skinfolds at different sites (i.e.: triceps, subscapular) has a high correlation with body fatness as estimated by underwater weighing, which is widely viewed as the gold standard (Keller and Stevens, 1996). Thus, skinfold measurements are considered valid estimates of body fat. Furthermore, the triceps skinfold measures body fat is unaffected by the frame size (Dietz and Robinson, 1993). However, as with any measure of obesity, triceps skinfold measurements have their limitations. The distribution of body fat varies with the developmental age and sex of children. An even greater problem with it relates to reproducibility. Even well-trained personnel may find it difficult to reproduce measurements of 12 the triceps skinfold, particularly among fatter children (Limbert et al., 1994). Reproducibility between observers is a challenge. Thus, both intraobserver and interobserver reproducibility for triceps skinfold thickness measurements are difficult to establish as body fat increases. Nonetheless, it is still useful in clinical settings as a direct measure of body fat and is useful to confirm that an increased BMI reflects an increase in fat rather than an increase in frame size or muscle mass (Dietz and Robinson, 1993). 2.3 P R E V A L E N C E OF C H I L D H O O D OBESITY Direct comparison of different studies on the prevalence of obesity in North America is difficult because of methodological and definition concerns. However, there is agreement on the substantial magnitude of the problem. Tremblay and Willms (2000) reported that the prevalence of obesity has increased dramatically in Canadian children in the last two decades. Between 1981 and 1996, the prevalence of overweight (BMI > 85 th percentile for age) rose from 15% to 35.4% in boys aged seven to 13, and from 15% to 29.2% in girls in the same age range using the Canada Fitness Survey (CFS) and National Longitudinal Survey of Children and Youth (NLSCY) as the reference population. Obesity (BMI >95th percentile) also increased from 5.0% to 16.6% and from 5.0% to 14.6% in boys and girls, respectively. Ball et al. (2001) reported an overweight prevalence of 20.3% and 17.9% in a sample of mostiy Caucasian six to 10 year-old boys and girls, respectively, using the sum of five skinfolds (triceps, biceps, subscapular, suprailiac and medial calf) > 85 th percentile as the criterion to determine overweight. Hill and Trowbridge (1998) reported that at least 11% and possibly 25% of U.S. children and adolescents are overweight depending on the criteria used. Results from the 1999-2000 National Health and Nutrition Examination Survey (NHANES) indicated that 15% of children aged six to 11 years are 13 \ overweight as defined by > 95 t h percentile of age-and sex-specific BMI (National Center for Health Statistics, 2002). There is a lack of international agreement on classification of obesity in children and adolescents. The International Obesity Task Force has recommended the use of cut off points for BMI in childhood that are based on international data and linked to the widely accepted adult cut off points of a body mass index of 25 kg/m 2 and above as overweight and 30 kg/m 2 and above as obese. The Centers for Disease Control and Prevention (CDC) (2000), on the other hand, defined children whose BMI-for age at 85* percentile to less than 95 t h percentile as at risk of overweight and those with BMI-for-age more than 95 t h percentile as overweight (based on data from five national health examination surveys). Therefore, it is not possible to precisely compare rates of childhood obesity with other countries in the world. The World Health Organization (1998) indicated that childhood obesity is increasing worldwide, in developing countries as well as industrialized ones. Emerging data from both industrialized and developing countries suggest that the increase in childhood obesity is both global and pandemic. Table 1 shows the global increases in the prevalence of childhood obesity. 14 Table 1: Global Increases in Prevalence of Childhood Obesity Country Age of Children. (Years) T i m e Intervals Prevalence of Obesity Obesity Criterion Reference England 4-11 1984 to 1994 0.6 to 2.6% Age-adjusted BMI>30 Chinn and Rona, 2001 Scotiand 4-11 1984 to 1994 0.9 to 3.2% Age-adjusted BMI>30 Chinn and Rona, 2001 China 6-9 1991 to 1997 10.5 to 11.3% Age-adjusted BMI>25 Wang et al., 2002 Japan 10 1970 to 1996 4 to 10% >120% standard weight Murata, 2000 Australia 7-15 1985 to 1995 1.2 to 5.5% Age-adjusted BMI>30 Magarey et al., 2001 Egypt 0-5 1978 to 1996 2.2 to 8.6% Weight-for-height >2 standard deviation from median DeOnis and Blossner, 2000 Ghana 0-3 1988 fo 1994 0.5 to 1.9% Weight-for-height > 2 standard deviation from median DeOnis and Blossner, 2000 Brazil 6-9 1974 to 1997 4.9 to 17.4% Age-adjusted BMI>25 Wang et al., 2002 15 Childhood obesity is a global concern affecting wealthy, middle-income and lower-income countries (Styne, 2001). Shifts in the trends of diet and physical activity may be implicated for the increase in the prevalence of obesity (Doak et al., 2002; Popkin, 1994). The major shifts in diet that seem to be occurring on a worldwide basis especially in lower-income countries include an increase in the consumption of vegetable oils, a shift away from coarser grains to more refined ones, and a shift toward a more diverse diet that includes more meats and eggs (Popkin and Doak, 1998). Physical activity is decreased due to the increase use of transportation to school and more passive leisure activities (e.g. television, video games) (Popkin and Doak, 1998). In developed countries, the urban poor is especially vulnerable because of a poor diet and limited opportunities for physical activity (James et al., 1997). Conversely, childhood obesity is most frequent in upper socioeconomic strata of developing nations, possibly due to adoption of an increasingly Western lifestyle (Doak et al., 2002). It has been shown that the chances of becoming an obese adult increase with increased age of obesity (i.e.: an overweight teenager is at a higher risk than an overweight toddler), increased degree of obesity, and increased number of obese family members (Logan, 1994). The risk is more than doubled if the parents are obese (Birch and Fisher, 2000; Maffeis and Tato, 2001) and is equal to or more than three times higher for a young child with one as compared to no parent who is obese (Birch and Fisher, 2000). Whitaker et al. (1997) found obese children under three years of age without obese parents are at low risk for obesity in adulthood, but among older children above three years of age, obesity is an increasingly important predictor of adult obesity. Similarly, Proimos and Sawyer (2000) found that after the age of three, the likelihood of obesity persisting into adulthood increases with the advancing age of the child and is higher in children with severe obesity at all ages. After age six, the probability of obesity persisting into adulthood exceeds 50%; 70-80% of obese adolescents will become obese 16 adults (Proimos and Sawyer, 2000). Parental obesity more than doubled the risk of adult obesity among both obese and non-obese children under 10 years of age (Whitaker et al., 1997). In addition, Wiecha and Casey (1994) found that children from lower socioeconomic families are at higher risk of being obese than children from more affluent families (Wiecha and Casey, 1994). 2.4 FACTORS CONTRIBUTING TO OBESITY IN CHILDREN Obesity is a complex health problem influenced by genetic, metabolic, biochemical, and environmental variables (Epstein et al., 1998). Williams et al. (1993) reported that endocrine and genetic disorders such as, Cushing's syndrome, hypothyroidism, and Prader-Willi, are responsible for less than 10% of the obesity seen in children. Obesity necessarily results from an imbalance between energy intake and expenditure. However, it should be acknowledged that there are strong genetic influences that can affect the energy balance (Hill and Trowbridge, 1998), and while true genetic disorders are rare, polygenetic influences are near-universal. In addition, even genetic influences require a permissive environment for their effects to be expressed. On the other hand, twin and adoption studies have consistently shown that 20-50% of the variation in body fat cannot be explained by genetic factors (Proimos and Sawyer, 2000). From a practical standpoint, the environmental component appears to be of greater relevance and may have greater potential for modification than the genetic one. The two major environmental factors that contribute to obesity among children are the increase in consumption of energy-dense foods and the decline in the amount of physical activity (Hill and Trowbridge, 1998). It is, therefore, important to understand how and when children's preferences for high-fat, energy-dense foods develop and how they can 17 be modified at different stages of development. Birch and Fisher (1998) suggested that children's food preferences are shaped by early experience with food and their eating environment. It has been found that children whose parents ate high amounts of saturated fatty acids were 5.5 times more likely to eat high amounts of saturated fatty acids than controls (White Ray and Klesges, 1993). In addition, parents and care providers may exert different types of influences over children's eating. Some examples are: (1) verbal prompting or control during mealtime; (2) nonverbal influences, such as presentation of foods at mealtime; (3) the influence of parents' eating behaviours; and (4) the use of foods for non-nutritious purposes, such as rewarding (White Ray and Klesges, 1993). Verbal prompting at mealtime has been shown to increase the likelihood that a child will consume food. Klesges et al. (1983) found that parental food offers were significantly correlated with the child's weight and parents of overweight children gave more encouragements to eat and more total food prompts than parents of normal weight children. Hertzler (1983) stated that greater attentiveness to children's refusals to eat (e.g. providing negative feedback) may result in less desirable eating behaviours and lowered preferences for certain foods, especially vegetables. Therefore, Hertzler (1983) recommended parents to stop the practice of forcing food, to allow children to eat what they wanted to in a reasonable amount of time, to offer a good variety of food without coaxing or threats, to remove uneaten foods without comments and to refrain from offering any more food until the next meal. Aside from verbal prompts at mealtime, parents also exert nonverbal mealtime influences over eating behaviour of children through their presentations of foods at mealtime. Waxman and Stunkard (1980) noted that mothers of obese boys served them larger portions than they served their non-obese brothers. This practice of larger portions for the obese child generalized to the school environment where the obese boys were observed loading their plates with food and eating far more than their non-obese peers at 18 lunch (Waxman and Stunkard, 1980). Hertzler (1983) noted that parental eating behaviour influenced the eating behaviour of children in that children are more likely to eat a food when they see parents eating it, rather than when the food was simply being offered to them. The final area of parental influences on eating behaviour in children is the use of food for non-nutritious purposes, such as in the form of rewards. Birch and Fisher (1998) found that instrumental consumption of food such as making a child eat fruit in order to engage in play activity, could adversely affect the child's preference for that fruit. The past few decades have witnessed enormous changes in the eating patterns and lifestyles of children and their families. Nielsen et al. (2002) examined the trends of energy intake in the United States between 1977 and 1996. Nationally representative data were taken from the 1977 and 1978 Nationwide Food Consumption Survey and the 1989 to 1991 and 1994 to 1996 Continuing Survey of Food Intake by Individuals. The sample size consisted of 63,380 individuals aged two and above. They found that more than two thirds of mothers with children work outside of the home, and prefer the time-saving advantages of ready-made foods and take-out dinners. Typically, these meals are higher in energy, fat, saturated fat, and sodium than foods prepared from raw ingredients at home. In addition, families now eat fewer meals together than ever. This is a regrettable trend because a cross-sectional study of 14,402 children (nine to 14 years old) of participants in the Nurses' Health Study II by Gillman et al. (2000) found that eating family dinner together was associated with healthful dietary intake patterns, including more fruits and vegetables (at least five servings /day), less fried food and sodas. Snacking patterns of children have also changed dramatically over the past few decades. Jahns et al. (2001) studied the prevalence of snacking among US children from 1977 to 1996. Data were obtained from the 1977-78 Nationwide Food Consumption Survey (NFCS77), 1989-91 Continuing Survey of Food Intake by 19 Individuals (CSFII89), and 1994-96 (CSFII96). The sample consisted of 21,236 individuals aged two to 18 years. They found that more children snack now than before (90% versus 80%), with the greatest increase seen in the past decade. Average energy intake from snacks has increased from 450 to 600 calories per day, and now accounts for 30% of daily energy intake. In addition, the energy density of children's snack has increased significantiy from 1.35 to 1.54 kcal/g. This finding is significant because research suggests that, small increases in the energy density of foods consumed can lead to large increases in total energy intake. Thus, current snacking trends are very likely contributing to the increase in childhood obesity (Jahns et al., 2001). Pastime choices are also doubtlessly a factor. Recent studies have confirmed that children are spending a substantial amount of their time watching television and playing video and computer games (Hill and Trowbridge, 1998; Myers et al., 1996; Taubes, 1998). These studies have suggested that the increase in the amount of time spent in these sedentary activities may lead to less time spent in more physical endeavors. Although the amount of television viewing has not been shown to be specifically associated with decreased levels of physical activity, viewing hours certainly reduce the opportunity to be active (DuRant et al., 1994; Kohl and Hobbs, 1998). It has been shown that the percentage of time spent outdoors is strongly related to physical activity. Since television-viewing reduces the opportunity to be outdoors, it follows that it also reduces the opportunity for physical activity. Watching television while eating meals and snacks may become conditioned cues for some children, so that even when not hungry, watching television will cue eating (Williams et al., 2001). In addition, Coon and Tucker (2002) and Taras et al. (1989) reported that time spent viewing television and being influenced by its commercials correlated positively with children's requests for and parents' purchase of foods as well as children's dietary intakes. In addition, with the urbanization of society, many parents are increasingly 20 concerned about their children's safety while playing outdoors (Gutin and Manos, 1993). Television is also possibly indirectly at fault here as well, as there is evidence that it is not so much crime that is increasing, but the media's reporting of it. Regardless, this parental fear combined with the factors mentioned above to lower the opportunity for children to play outdoors. Decreased physical education during school hours, increased sedentary free-time activities such as watching television, playing video and computer games, and the Internet, increased bussing of children to schools, and the lack of safe play areas for children in urban, and suburban areas all contribute to fewer opportunities for physical activity for children, and a greater risk of obesity (Williams et al., 2001). Levels of physical activity among children are highly variable (Lindquist et al., 1999). There are four levels of determinants which influence children's physical activity patterns: the physiological level, including factors such as maturation and growth; the psychological level, including motivation, self-efficacy, and sense of control; the sociocultural level, including family characteristics, sociodemographics, and role models; and the ecological level, including the availability of facilities for activity, physical safely, and climate (Lindquist et al., 1999). As one would expect, there appears to be a parental influence on physical activity. Kohl and Hobbs (1998) and Hill and Trowbridge (1998) found that active parents tend to have more active children. This suggests an area for intervention in the family environment and parenting practices. These researchers found success in increasing physical activity by providing flexible choices of lifestyle activities that are easily incorporated into the family's routine. For instance, it was easier to encourage a family to start taking a regular walk around the neighborhood rather than promoting the idea of going to the pool as a family on a regular basis. Schools can also play an important role in increasing children's physical activity levels and habits (Basdevant et al., 1999; Styne, 1999; Troiano and Flegal, 1998). 21 Styne (1999) stressed that a nationwide population-based approach to the prevention of childhood obesity is essential. Increasing physical activity through education in schools or through extracurricular programs should be emphasized. However, due to financial constraints, many schools are eliminating physical education programs or do not make the investment to hire certified physical education specialists (Kohl and Hobbs, 1998; Luepker, 1999). It is therefore clear that many schools view physical education as being of secondary importance, allowing these financial issues to potentially have significant adverse effects on the activity levels of their pupils. 2.5 H E A L T H C O N S E Q U E N C E S O F C H I L D H O O D O B E S I T Y The onset of obesity in children not only affects growth, but also has various physiological and psychological consequences. During the last three decades, it has been estimated that childhood obesity accounts for approximately 30% of all adult obesity (Golan et al., 1998b). Furthermore, reports suggest that even before reaching adulthood, overweight and obese children already experience medical and psychological effects related to being overweight (Dietz, 1998; Hill and Trowbridge, 1998). A variety of common medical conditions has been associated with childhood obesity. They include insulin resistance, abnormal lipids and lipoproteins, and elevated blood pressure (Bao et al., 1996; Berenson et al., 1993; Clarke, 1986; Dietz, 1998; Harlan, 1993; Hill and Trowbridge, 1998; Parsons et. al., 1999; Pi-Sunyer, 1993; Rosner et al., 1998). Some of the less common medical problems associated with childhood obesity include orthopedic problems, sleep apnea, 22 pseudotumor cerebri, and gallbladder disease (Davis and Christoffel, 1994; Dietz, 1998; Suskind et al., 1993). Childhood-onset obesity is associated with higher rates of morbidity and mortality in adulthood regardless of later weight status. Most prospective studies on obesity in relation to mortality have been limited to middle-aged cohorts being followed from adolescence. In a 55-year follow up (Must et al., 1992), overall mortality rate was found to be higher (relative risk 1.8, 95% confidence interval, 1.2 to 2.7; p=0.004) in men who were obese during adolescence compared with those who were lean during adolescence. A higher morbidity rate for chronic illness was also found in both males and females who were classified as obese during adolescence (Lauer and Clarke, 1989). The risk for cardiovascular disease in relation to childhood obesity has been studied extensively. In a five-year longitudinal study (Freedman et al., 1985), children who were aged five to 12 initially were followed to see if there was a relationship between changes in triceps skinfold and changes in serum lipids and lipoproteins. Results indicated that obesity was direcdy and significandy associated with total cholesterol, triglycerides, V L D L cholesterol and L D L cholesterol, and inversely associated with FfDL cholesterol. Obesity is therefore suggested to be a major cardiovascular risk factor in children. Dietz and Gortmaker (2001) reported that 60% of overweight five to 10 year-old children already have one associated cardiovascular disease risk factor, such as hyperlipidemia, elevated blood pressure, or hyperinsulinemia, and over 20% have two or more adverse cardiovascular risk factors. Type 2 diabetes, until recendy thought to be almost exclusively an adult-onset disease, is now routinely diagnosed in children and has even been referred to as an epidemic (Dietz and Gortmaker, 2001). 23 In terms of growth and development, obese children tend to be taller than their non-obese peers, and have advanced bone ages (Dietz and Robinson, 1993; Lowrey, 1986). Longitudinal study by Forbes (1977) of children who became overweight has shown that height gain accelerates or follows shortly after excessive weight gain. Early menarche in obese girls is often observed, and may be confused with other causes of premature puberty in some cases (Dietz and Robinson, 1993). Childhood obesity also takes a toll on mental health, with reported negative effects on self-esteem and peer relationships (Gibson, 2002). Wilkins et al. (1998) found that obese children tend to have a negative self-image, lower self-esteem, and delayed psychosocial development and are often socially isolated. The major problem for obese children is often not only the excess weight and their self-image, but also how they are perceived by others. Overweight children are often taller than their peers and are often mistaken as older than their actual age. This may lead to frustration or a sense of failure on the part of the children when they cannot perform at the expected level (Proimos and Sawyer, 2000). The bias against obesity is expressed by children as young as six years of age. In a study conducted by Dietz and Robinson (1993), children at six years of age associated negative stereotypes with obese children. The children ranked drawings of obese children as less likable than those of handicapped children. Adjectives like lazy, stupid and dirty were frequently attributed to the obese body type (Almen et al., 1992; Dietz, 1998; Must and Strauss, 1999). In another study, Richardson et al. (1961) found that 10 to 11-year-old children preferred physically-challenged children as friends more so than obese children, and ranked obese children among those with whom they would least like to be friends. Not surprisingly, teasing is among the most frequent complaints of obese children (Dietz and Robinson, 1993). In order to avoid teasing, many obese children tend 24 to withdraw themselves from their peer groups, or they may choose younger children as friends (Dietz and Robinson, 1993). Chronic illnesses that are associated with obesity inflict a substantial burden of illness on society. The total direct cost of obesity in Canada in 1997 was estimated to be over $1.8 billion with hypertension, type 2 diabetes, and coronary heart disease being the largest contributors. This corresponded to 2.4% of the total health care expenditures for all diseases in Canada in 1997 (Birmingham et al., 1999). As for the United States, the economic costs of obesity were estimated to be $69 billion in 1990 (about 8% of total health care costs) (Hill and Trowbridge, 1998) and $100 billion in 1995 (Maffeis and Tato, 2001). Thus, reducing the incidence of these illnesses would result in significant cost savings to the health care system. Obesity is also associated with increased pharmaceutical costs (Thompson and Wolf, 2001). Narbro et al. (2002) found that obese individuals were more likely to take medications associated with diabetes mellitus, cardiovascular disease, non-steroidal anti-inflammatory and pain and asthma medications (risk ratios ranging from 2.3-9.2) than non-obese individuals. Economic consequences of obesity go beyond the health care system. In the United States at least 30 billion dollars are thought to be spent on diet foods, products and programs to lose weight (Kiess et al., 2001). There has been a dramatic surge in the number and variety of weight-loss programs (Spielman et al., 1992; Swinburn at al., 1997). A parallel surge has occurred in the cost of these weight-loss programs with a wide variation in personal expenditure. Spielman et al. (1992) noted that the cost of a 12-week outpatient commercial weight-loss program ranged from $108 to $2,120 in the United States in the early 1990's. Therefore, one can speculate that the costs for these programs are probably even more expensive now. If one is to calculate the costs of obesity that have started at an early age, the cumulative financial costs are even higher. 25 2.6 MANAGEMENT OF CHILDHOOD OBESITY There has been a lot of interest in developing effective treatments for childhood obesity. The major components of most treatment programs include dietary, activity, and/or behavioural components. Epstein et al. (1998) suggested that the goals for treating pediatric obesity should be regulating weight through adequate nutrition for growth and development. This is important to prevent the interruption of linear growth (a concern not present in the management of adult obesity), minimize loss of lean body tissue, and prevent endocrine disturbances such as pubertal problems. In addition, Epstein et al. (1998) stated that ideal treatments should be associated with positive outcomes with regards to both physiologic and psychologic issues. Treatments should modify eating and exercise behaviours along with the factors that affect these behaviours so that the new healthier behaviours persist throughout development and later life. Hill and Trowbridge (1998) stated that attempts to deal with childhood obesity may be more successful and cost effective than treating adult obesity. This is because at a young age, children have generally engaged in unhealthy behaviours for less time than adults, thus, it may be easier to modify their behaviours. In addition, the treatment of pediatric obesity can take advantage of growth and increases in lean body mass. Furthermore, instead of shrinking adipose cells, treatment at an early age prevents the development of excess adipose cells (Epstein et al., 1998). The treatment goals according to the Centers for Disease Control and Prevention in the United States should be based on the age of the child, the degree of obesity, and the presence or absence of complications or comorbidities. Weight loss is recommended for all obese children over seven years of age who have a BMI greater than the 95 t h percentile (whether or not complications are present). Weight loss is also recommended for children over seven years of age who are at 26 risk of obesity (BMI between 85 t h to 94* percentile) if complications are present. The amount of weight loss recommended and the schedule for weight-loss goals vary depending on the severity of obesity and the nature and severity of the complications. Children with potentially life-threatening complications, such as sleep apnea or obesity hypoventilation syndrome, are candidates for more rapid weight loss. Limited research data are available, however, to suggest a safe rate at which children and adolescents may lose weight without deceleration of growth velocity (Williams et al., 2001). There have been a number of reports on approaches to reduce caloric intake and improve eating habits. One approach is to provide individualized dietary intervention (Hill and Parker, 1988). However, in a controlled study on exercise, no weight loss was observed for preadolescents (n=10) who were provided with individualized dietary recommendations for 16 weeks without exercise (Hill and Parker, 1988). Another approach was the traffic-light diet, which was used for preschool and preadolescent children (Epstein et al., 1998). The traffic-light diet assigns food into categories: green foods (go) may be consumed in unlimited quantities, yellow foods (caution) have average nutritional value and red foods (stop) contain high fat or simple carbohydrate content. Interventions using the traffic-light diet as part of a comprehensive treatment approach had some success in decreasing the level of obesity in children (Epstein et al., 1985; Valoski and Epstein, 1990) but the diet was restrictive and lacked emphasis on the concept that all foods can be incorporated into a healthy diet. Some studies have included both diet and aerobic exercise. Hills and Parkers (1988) found differences in skinfold changes but not in weight (due to increase in lean body mass) in preadolescent children who were provided with a diet plus weekly supervised exercise sessions and three or four times per week home aerobic activity program versus the children who were provided a diet alone. Another approach used the diabetic exchange system, with a caloric level 27 calculated to produce one pound of weight loss per week (Becque et al., 1988). Using this approach, Becque et al. (1988) found that a diet plus exercise program was associated with a better physiologic outcome than the no-treatment control group (n=36). Another type of exercise program that has been studied is lifestyle exercise, which attempts to increase energy expenditure in flexible, regular daily activity as well as during structured or unstructured exercise (Gutin and Monos, 1993). Lifestyle exercise programs attempt not only to increase caloric expenditure, but also to build activity into a child's lifestyle (e.g. children are encouraged to walk to school, play weekend "pick-up" games with friends such as hockey or baseball). These programs maximize choice and perceived control over exercise behaviour, and may increase adherence when compared to more structured aerobic exercise programs (Epstein et al., 1996). They also focus on creating environments that prompt activity, and reducing environments that encourage sedentary behaviours. Environments that can be targeted include the home, school, and community recreation centers. In a study by Epstein et al. (1985), lifestyle exercise plus diet was found to be more effective in weight control than aerobic exercise plus diet after two years. In a later study by Epstein et al. (2000), they found that targeting either decreased sedentary behaviours or increased physical activity was associated with significant decreases in percent overweight and body fat and improved aerobic fitness in eight to 12 years old obese children after two years. In order to have a lasting effect, it has been suggested to include behaviour therapy in the treatment of childhood obesity. Behaviour therapy is designed to teach new behaviours and it would be expected that families who have received intense behavioural intervention might do better than families who received less behavioural treatment. Indeed, Israel et al. (1985) found that at one-year follow up, children whose parents had participated in a short course in general behaviour management had significantly better weight loss than children in an intervention 28 that focused only on weight reduction. In another study by Braet and Van Winckel (2000), cognitive behavioural treatment was used to promote dietary change and aerobic exercise. Decrease in proportion overweight at 4.6 years among 109 of 136 children available for follow-up was greater in response to behavioural treatment (15%) compared with only advice (7%), but most children remained substantially obese. One aspect to consider in the treatment of childhood obesity is the motivation for change for the child, parents and the family as a whole. If it is determined that there is not sufficient motivation for behavioural change, then change may not happen. Epstein et al. (1998) suggested that the use of motivational interviewing may be helpful for enhancing motivation. The Social Cognitive Theory implicates self-efficacy, the belief in one's ability to perform a certain task, as a pivotal construct in understanding and modifying human behaviours. Self-efficacy was introduced by Bandura (1982) as a key concept in Social Cognitive Theory. Social Cognitive Theory attempts to predict and explain human behaviour (Bandura, 1986). This theory holds that the person, the person's environment, and the cognitive and emotional processes specific to that person all interact to determine behaviour; thus, behaviour can shape cognition and the environment just as cognition and the environment can shape. behaviour. Self-efficacy reflects a person's belief and confidence level in his or her ability to overcome the difficulties inherent in performing a specific task in a particular situation. Bandura argues that judgments of self-efficacy influence choices of behaviour people undertake, such as acquisition of new behaviours (e.g. learning a new computer program) and the inhibition of existing behaviours (e.g. decreasing high-fat food choices) (Bandura, 1982). People tend to pursue tasks they know they can accomplish and avoid those they believe exceed their capabilities. For example, if a person has high confidence in his or her ability to resist chocolate, then the likelihood of that person not consuming chocolate is increased. In addition, self-29 efficacy affects the amount of effort people will expend while adopting a new behaviour and their persistence in the face of obstacles. For example, high dietary efficacy predicts increased ability to lose weight and decreased attrition from weight-loss programs. To measure self-efficacy, persons are presented with a list of specific behaviours and/or tasks reflecting various levels of difficulty and are asked to indicate those tasks they believe they can accomplish. They, then, are asked to rate the strength of their belief in their ability to accomplish each task on a scale ranging from high uncertainty, to moderate levels of certainty, to complete certainty. Social cognitive theory has been used extensively in health behaviour research (AbuSabha and Achterberg, 1997; Chambliss and Murray, 1979; Parcel et al., 1995; Shannon et al., 1990; Sheeshka et al., 1993). Research on weight-control behaviour showed that subjects with relatively high self-efficacy have lower dropout and higher weight-loss rates than subjects with lower self-efficacy (Bernier and Avard, 1986; Chambliss and Murray, 1979). Parcel and colleagues (1995), as part of a pilot study to develop instrumentation for the Child and Adolescent Trial for Cardiovascular Disease, developed a self-efficacy scale for diet-related behaviours among elementary school children. Self-efficacy was measured using a three-point (not sure, a little sure, and very sure) 15-item questionnaire that specifically measured food choice behaviours (internal consistency standardized coefficient <x=0.84). In this study, self-efficacy was found to be strongly associated with the children's (n=l,127) food choices, accounting for 34% of the variation. The research conducted to date suggests that parental involvement is an important part of the treatment (Robinson, 1999). The family provides a major social learning environment for the child. Parental health behaviours and personal attitudes guide the development of both the child's self-image and health practices (Nader, 1993). Research on treatment of pediatric obesity has tested the 30 influence of including family members. Flodmark et al. (1993) and Epstein et al. (1981) independendy found that children in family therapy groups had significandy smaller increases in weight than did children in the conventional dietary counseling group at one-year and 10-year follow-up sessions, respectively. Flodmark et al. (1993) reported that children who received dietary counseling, encouragement to exercise, and family therapy for 14-18 months has a smaller increase in BMI than controls, who received no treatment (1.1 vs 2.8 kg/m2) one year after therapy stopped, though drop-out rate was substantial. Another study led by Israel et al. (1994) found that 34 children showed moderate deceases in weight after six-months' family intervention that used cue control and a reward system to foster behavioural change. However, at three-years' follow-up, the proportion of children who were overweight approached or exceeded baseline values. In possibly the only successful long-term intervention, Epstein and colleagues (1990) used behavioural strategies (contracting, self-monitoring, social reinforcement, modeling) with obese children and their parents to limit consumption of high calorie foods and increase aerobic exercise. A decrease in percent of overweight (7.5%) was noted at 10-years' follow-up in the experimental group compared with an increase in untreated controls (14.3%). However, individuals were selectively recruited based on motivation to change and likelihood of success, and less than half of the children in the experimental group maintained a 20% decrease in weight (Epstein et al., 1994). Thus, family involvement is critical in enhancing the effectiveness of programs for young children (Rickard et al., 1995; Satter, 1996). Whitaker et al. (1997) suggested that obese three to nine year olds may be ideal candidates for treatment because the parents still have the opportunity to influence their children's activity and diet in a positive manner. This is because parents can help to instill confidence in their children and model healthy eating and exercise habits. Thus, parenting skills are very important in the management of overweight children. 31 General parenting skills relevant to weight management include: being consistent and avoiding mixed messages, being aware and observant of children's behaviours so that desired behaviours are positively reinforced, offering direct praise on children's behaviour rather than on their personal attributes, modeling desired behaviours, including strategies for dealing with setbacks, and setting limits for behaviours when necessary (Proimos and Sawyer, 2000). The successful treatment of obesity in childhood may prevent severe diseases in later years (Basdevant et al., 1999). However, the "weight control approach" traditionally used to treat children with obesity has been under much scrutiny for reasons such as unrealistic goals, dependence of self-esteem on body image, possible development of eating disorders, loss of lean body mass and the possibility of delayed growth (Wile and Mclntyre, 1993). Children's self esteem often suffers and they may become resistant to change. There is also evidence that dieting may predispose a child to an eating disorder (Hill et al., 1994). Although many previous studies have successfully incorporated dietary, activity and behaviour components in the programs, they lack emphasis on assisting obese children in improving their self-esteem. Thus, this suggests that a new approach for youth is needed by offering a program that can offer a balance of the three main aspects of a healthy lifestyle; fitness, healthy eating and improved self-esteem. As well, Parham (1996) stressed that new approaches to treat childhood obesity should be evaluated not only by the weight loss criteria of traditional programs, but rather by the extent to which the program's unique goals have been achieved. For instance, the adoption of a more active lifestyle by a participant can be interpreted as a success instead of evaluating the efficacy of the treatment by using solely the amount of weight a participant lost. Different approaches have been proposed to be included in the design of weight management programs for children. These included the "Play Approach", the "Vitality Message", and the "Trust Paradigm". 32 Playing is an effective vehicle for promoting learning in young children. The "Play Approach" to learning focuses on the use of play as a medium for enhancing knowledge and skill in selecting healthful eating habits and fitness behaviours in the context of the family and the school (Rickard et al., 1995). This approach has been used in educational programs for obese children ranging in age from five to 10 years old. The learner effectively engages with the task and the environment. It is a process of learning that is enjoyable, motivated, and freely chosen. Through play, children learn to interact with others and gain a sense of competence and control over their lives. This approach allows children to make choices and take responsibility for their choices. The play approach to learning was used as the theoretical model for the design and implementation of the Healthy Bodies Wilshine Program for elementary schoolchildren considered obese and their families (DeVito et al., 1993). An interdisciplinary team designed and implemented the integrated nutrition and fitness program. Team members included dietitians, an elementary school physical education teacher, an expert in curriculum development, a developmental kinesiologist, an early childhood educator, and a pediatrician. The following were goals for the program: (a) explore and find joy and pleasure in a variety of movement activities, and taste and find joy and pleasure in eating a variety of foods from the different food groups; (b) experiment with combinations of movement activities, and experiment with new foods and methods for preparing and seasoning them; and (c) learn to change physical activities, food choices, and fitness, and well being. The program was designed to have children sample food, digest it, and say "wow!". When children had fun, they perpetuated the activities by adding new challenges and interesting complexities. During the program, family discovery times were focused on concepts such as partnerships, portions and parts, variety, choices, and life habits. 33 The Vitality Message (Health Canada, 1992) promotes enjoying healthy eating, being active and feeling good about oneself. Vitality is a concept that applies to everyone, all ages, all walks of life, all physical abilities. The Vitality message gets away from strict regimes and diets, and encourages people to be the best they can be by making healthy lifestyle choices. As well, reports from the National Academy of Sciences (2002) recommended that to maintain cardiovascular health, regardless of weight, adults and children should achieve a total of at least one hour of moderate intensity physical activity (e.g.: walking, jogging at four to five miles per hour) each day. Children generally participate in physical activity and sports when they are "having fun" and stop participating when they lose interest and feel they are no longer having fun. In preventing, as well as, treating obesity, it's important to determine what type of activities the child enjoys doing, and then develop a plan for incorporating these activities into the child's daily schedule. Parents should be encouraged to facilitate their child's physical activity, be a good role model by increasing their own activity, and plan family activities with this goal in mind (Goran et al., 1999). The "Trust Paradigm" was proposed by Ellyn Satter (1996) who suggests that children must be trusted to regulate their own energy intake and weight when they are given exposure to appropriate food choices. Satter (1996) stated that this "trust" applies to children who are fat and children who are slim. It assumes that body weight is primarily determined by genetic predisposition and fatness is normal for some people. The key is to develop the weight that is right for each individual. This approach suggests that the solution to obesity is to establish consistent and positive eating and activity behaviours. For example, parents should take the responsibility for providing wholesome and appealing food at predictable and pleasant times. However, once they have done their part, parents should trust children to pick and choose from the available foods. Parents should not criticize every individual food choice a child makes but should trust that the 34 overall diet for the day will be balanced. Satter states that a child who is trusted learns self-esteem and responsibility. This trust paradigm is supported by a study by Johnson and Birch (1994), in which young children whose mothers were more controlling of their children's food intake showed less ability to self-regulate energy intake. Satter (1996) further states that helping parents to raise an emotionally healthy fat child is a part of primary prevention, since fat children have a better chance of growing up to achieve a positive acceptance of their physical identity as a fat person if parents are accepting and supportive of them. As practitioners, Satter (1996) cautioned that we must understand and support the developmental needs of children and families, as well as develop practical treatment models that can be permanently and comfortably maintained. Achieving these goals is only possible when one is working from a stance of trust. Being trusting allows us to turn our attention from striving for a particular body weight and turn toward nurturing the whole child. In doing that, we can think about feeding children well, giving them opportunities to be active, providing for their emotional and social needs, and letting them grow up to develop the bodies that are right for them. Different approaches have been taken by Canadian health practitioners in the management of childhood obesity. Wray and Levy-Milne (2002) conducted a survey on Canadian dietitians' practices in childhood weight management. Of the 164 respondents, 65 reported that they provide an intervention program to overweight youth. Most dietitians used the healthful lifestyle approach (i.e.: healthy eating, movement, and self-esteem) via one-to-one consultation, including parents and involving professionals from two or more disciplines for the management of these children. More specifically, 65% of the respondents reported they used the Vitality approach and 27% used the Trust Paradigm in their practice. 35 2.7 Summary Childhood obesity is increasing at an alarming rate. This is even more concerning given that it is one of the most challenging and frustrating pediatric conditions with which we are faced. It is difficult to define the problem, difficult to understand its etiology, difficult to predict its natural history, and difficult to effectively prevent or treat it. The use of a variety of anthropometric indicators, cut-off points, and reference populations have worsened the problem by precluding direct comparisons between studies. Wide adoption of the International Obesity Task Force's (IOTF) recommendation of using age-specific absolute BMI cut-off points which correspond to obesity at age 18 which links the degree of obesity with health risks for definition would remedy this problem. Despite the above, it is clear that the prevalence of childhood obesity is both high and rising throughout the world. Both genetic and environmental factors are contributing to this crisis. The genetic influence, although quite strong, is except in rare circumstances, of a polygenetic nature, and thus not easily amenable to medical intervention. In addition, genetic influences alone do not explain the rapid increase in the prevalence of childhood obesity. Environmental factors include increased availability and consumption of high fat, energy-dense foods, increased snacking, changes in family eating patterns and lifestyles, and decreased opportunities for, as well as time spent partaking in physical activities. Parental and societal influences on all of these factors are considerable. The consequences of childhood obesity are both immediate and long term with respect to both physiologic and psychologic issues. Furthermore, the morbidities associated with overweight/obesity have significant health expenditure implications. Treatment for childhood obesity, although well-intentioned and often multi-faceted, has been associated with only limited benefits, especially in the long run. 36 Therefore, a healthful lifestyle approach, focusing on diet, activity and messages dealing with self-esteem may be more effective in inducing family-wide change. 37 Chapter III METHODOLOGY 3.1 RESEARCH DESIGN The aim of this study was to compare the effectiveness of individual counseling with a group program in promoting healthier lifestyle behaviours in overweight children (aged seven to 11 years) and their families. Participants in this project were recruited through referrals from health professionals, advertisements in local newspapers, and posters in community centers and health units. Parental informed consent was obtained in order to allow the children to participate in the study. The children were stratified according to gender and randomized into one of two groups. Although it was not expected that the difference in gender for preadolescent children would affect the results, the children were stratified to ensure a mixture of boys and girls in both groups. The two groups were provided with similar messages and educational materials that encouraged healthy eating, active living and enhancing self-esteem. The control group was provided with a one-hour individual nutritional consultation and two half-hour follow up sessions at two-months and twelve-months after the first session. The intervention group partook in an eight-week (i.e. two months) group program that dealt with the nutritional and non-nutritional messages (i.e. physical activities, discussions on self-esteem) in a much more in depth fashion including several "hands-on'Vpractical sessions. This group was followed-up a year after the initial group session. Two sessions of this project were conducted. Initially only one session was planned. However, due to insufficient recruitment of subjects in the first session, it was converted into a pilot study to help develop the study protocols and 38 modules for both the counseling and group programs. Through process and project evaluations involving the participants of the first session, modifications were made and included in the second session to ensure that the activities planned for the children were able to stimulate and maintain the children's interests. The first session of the project was held from late October to early December, 1998, involving seven children. The second session was held from early May to late June, 1999, with a 12-month follow-up in May of 2000. 3.2 SUBJECT R E C R U I T M E N T 3.2.a First Session The subjects were recruited through referrals from pediatricians, family physicians, dietitians, and public health nurses. A total of 430 letters were mailed to such health professionals in the Lower Mainland to inform them of this study (Appendix A). Only 16 referrals were obtained during the first recruitment session. 3.2.b Second Session Referrals from health professionals were continued to be accepted. However, since this recruitment method did not provide adequate referrals during the first session, other recruitment methods were employed in the second session. They included: • announcements in local newspapers (i.e. The Vancouver Sun, The Courier, The Georgia Strait) (Appendix B) 39 • posters displayed in community centers, health units and the University of British Columbia (Appendix Q Group assignment was performed in a random manual fashion (which means names were randomly hand-drawn) following gender stratification. 3.3 S A M P L E SIZE 3.3.a First session Of the total 16 referrals from health professionals, seven families agreed to have their children participate in the study. Four children were randomized to individual nutritional counseling and three to the eight-week group program. All four children in the individual nutritional counseling arm also completed the follow-up session two months after the initial nutritional consultation session. 3.3.b Second Session Calculation of target sample size was conducted based on the weight changes (Appendix D) of the children in the first session. It was determined that a total of at least 16 children were required in each group to achieve an 80% power in the study as shown by the calculation below: Calculated on the basis of power = 80% (8=0.8), p<0.05 (a=0.05, two-tailed) Standard deviation of weight changes in the counseling program, SD^ l .23 kg Standard deviation of weight changes in the group program, SD2=0.3786 kg 40 Mean weight change of counseling program, x t = + 0.55 kg Mean weight change of group program, x 2 = -1.47 kg Meaningful difference was ~ 1kg Z values were obtained from the z tables (two-tailed). n = (SD,2 + SU,2) x (Z t.p + Z W 2 ) 2 / ( x 2 - X l ) 2 n= (1.232 + 0.37862) x (0.84 + 1.96)2 / (1.47 - 0.55)2 n = 15.34 Therefore, 16 children were required in each group. 3.4 INCLUSION AND EXCLUSION CRITERIA The inclusion criteria were: • children aged seven to 11 years of age • above 85 th percentile of BMI for age and gender • at least one parent available to participate in the study 41 The exclusion criteria were: • inability to obtain informed, written parental consent (Appendix E) • children and /or parents unable to communicate in English • children with endocrine disorders or cardiac disease 3.5 ETH ICAL APPROVAL This project was funded by the Children's Hospital Foundation Innovations Fund. The original study proposal as well as the amendment in the recruitment method for the second session of the study were approved by the University of British Columbia and the Children's and Women's Hospital Research Ethics Committees. Certificates of approval are in Appendix F. 3.6 DESCRIPTIONS OF PROGRAMS 3.6.a Individual Counseling Group The control group (individual nutritional counseling arm) was provided with one hour of individual nutritional consultation and two half-hour follow-up sessions at two months and at twelve months after the initial session. An agreement was established with the BC Children's Hospital for a contracted dietitian, who was not involved in the group program, to facilitate the individual nutritional counseling at the hospital. The control group was provided with the same 42 messages and educational materials as the group program (Appendix G). The outline for the counseling session is included in Appendix H. 3.6.b Group Program The intervention group (group program) was involved in an eight-week group program (one two-hour session/week) focusing on healthy eating, active living, improving self-esteem and enhancing parental participation. The tide " F U N T R E K " was given to this program. The group program was facilitated by two dietitians (a coordinator and a graduate student (the author)) and senior dietetic students. The group sessions were held at the Mt. Pleasant Community Center in Vancouver, with whom a partnership was formed to provide a non-hospital environment to conduct the group program. Modules of activities and games that were used in the second session of the group program were developed and pre-tested (i.e. assessed for ability to stimulate and maintain the children's interests) in the first session of the program. The assessment was done through obtaining informal oral feedback from the children and parents. The nutritional activities included active experimentation with and discussions of a variety of foods from the four food groups, nutrition jeopardy, and attending a Shop Smart tour (Appendix I). The nutritional component of the program was based on Canada's Food Guide to Healthy Eating, and thus, the concept of "All Foods Can Fit". The children were encouraged to incorporate a variety of foods in their diets. Parents were encouraged to make healthier food choices available to their children, and to trust their children in regulating their energy intakes. The physical activity component of the program was based on Canada's Physical Activity Guide to Healthy Active Living. The children and parents were encouraged to incorporate physical activities into their daily routines. Some of the 43 games utilized to encourage the children and parents to be active included boxercise, soccer and nature trek. Activities to assist the children in improving their self-esteem included keeping a journal and inviting a community nurse to discuss self-esteem with the group. The resource binder "Promoting Healthy Body Image and Positive Self-Esteem" developed by the Fraser Valley Health Region's Community Nutrition Program (1999), was used as a resource. At least one parent or caregiver attended the program and they were encouraged to participate in games and activities. Special educational components such as learning to read nutritional information on product labels, sharing ideas on healthier snack foods and discussion about the Trust paradigm were designed for the parents. 3.7 A N T H R O P O M E T R I C M E A S U R E M E N T S Anthropometric measurements were determined for the children in both the individual counseling and group program at baseline, two and 12 months after baseline. 3.7.a Body Mass Index Height was measured following shoe removal to the nearest 0.1 cm using a vertical measuring tape positioned on a wall. Weight was measured in indoor clothing but without shoes using a balance scale. BMI was calculated using the formula of weight in kilograms divided by the square of height in meters. The "Percentiles of BMI for boys and girls" tables compiled by Rosner et al. (1998) 44 available at the time of this study were used as an approximate classification of obesity status (Appendix J). 3.7. b Triceps Skinfold Triplicate triceps skinfold measurements were done using Lange skinfolds calipers and appropriate measurement techniques were employed according to the provided operator's manual (Cambridge Scientific Instruments, Cambridge, MA, USA). The percentile table for triceps skinfolds based on the data of the National Health and Nutrition Examination Survey I was used to classify the obesity status of the children (Appendix K). The triceps skinfold measurements were consistentiy done by the dietitian assigned to each program (i.e. one for the counseling program and another one for the group program) and it was this same dietitian who did the measurements for each time period. 3.8 S U R V E Y I N S T R U M E N T S 3.8. a First Session The primary purpose for the first session was to help develop program modules for the second session. Two self-report questionnaires, one for the children and the other one for the parents, were developed by the author specifically for participants in this study. The questionnaires were developed based on reviewing relevant literature to identify factors that affect obesity and weight loss in children (Crocker et al., 1997; Parcel et al., 1995; Harter, 1982). The questionnaires were administered to the parents and children in the individual nutritional counseling and group programs at baseline (i.e., during the first individual nutritional counseling or group session), and again at two and 12 months. These questionnaires were not evaluated for their validity or reliability. 45 3.8.a.i Questionnaire For the Children The questionnaire for the children addressed three areas; lifestyle activities, attitude regarding nutrition and self-esteem (Appendix L). 3.8.a.ii Questionnaire For the Parents The questionnaire for the parents consisted of questions related to their attitude regarding nutrition, health and lifestyle activities (Appendix M). Both open and closed ended items were included to avoid eliciting biased responses. 3.8.b Second Session Validated questionnaires were chosen for the second session as per recommended by the advisory committee. Five questionnaires (Food Frequency Questionnaire (Rockett et al., 1995 and 1997) (Appendix N), Dietary Self-Efficacy Scale (Domel et al., 1996) (Appendix O), Physical Activity Questionnaire (Crocker et al., 1997) (Appendix P), Physical Activity Self-Efficacy Scale (Saunders et al., 1997) (Appendix Q) and the Self Perception Profile for Children (Harter, 1982) (Appendix R) were administered to the children. The Family Eating and Activity Habits Questionnaire (Golan and Weizman, 1998a) (Appendix S) was administered to the parents. Details about these questionnaires will be presented in sections 3.8.b.i (A-E) and 3.8.b.ii. The questionnaires were mailed to and completed by the children and parents a week prior to the start of the first individual counseling or group program session. As younger children have difficulty in recalling activity (Baranowski et al., 2000), parents were requested to assist the children in completing the questionnaires to help improve accuracy of reporting. During the initial individual 46 counseling or group program session, the researcher(s) reviewed the questionnaires with the child and the parent to clarify unclear answers and to ensure that the questionnaires were fully completed. These questionnaires were then re-administered at two and 12 months after the initial session. 3.8.b.i Questionnaires for the Children A total of five validated questionnaires were administered to the children in this study. They included a Food Frequency Questionnaire (Rockett et al., 1997), Physical Activity Questionnaire (Crocker et al., 1997), Dietary Self-Efficacy Scale (Domel et al., 1996), Physical Activity Self-Efficacy Scale (Saunders et al., 1997) and the Self Perception Profile for children (Harter, 1982). A. Food Frequency Questionnaire The "Youth / Adolescent Food Frequency Questionnaire" was developed based on the Nurses' Health Study Food Frequency Questionnaire (FFQ) by Helaine Rockett and colleagues (1995) (Appendix N). This FFQ which contains 131 food items was tested for its reproducibility by Rockett et al. (1997). A multiethnic sample of 179 youths (ages nine to 18) completed the questionnaire twice, one year apart (Rockett et al., 1997). Reproducibility for nutrients ranged from 0.26 for protein and iron to 0.58 for calcium. For foods, it ranged from 0.39 for meats to 0.57 for soda. Mean reproducibility was higher among girls than boys for energy and nutrients and for foods. No consistent pattern was observed for age. The validity of the questionnaire was evaluated in a study with 261 youths (ages nine to 18) (Rockett et al., 1997). The form was administered twice at an approximate interval of one year and three 24-hr dietary recalls were collected during this period. After correction for within-person error, the average correlation coefficient was 0.54. Thus, Rockett et al. (1997) suggested that the 47 FFQ had a reasonable ability to assess the eating habits of older children and adolescents. For the purpose of this study, which necessitated the FFQ to be administered three times a year (initial session, two and twelve months after the initial session), the children were asked to recall what they ate in the past month instead of a year as specified on the original FFQ. The completed FFQ were then mailed to the Channing Laboratory in Boston, MA, USA to be analyzed for macronutrient intakes. B. Fruits and Vegetables Intake Self-Efficacy A self-efficacy questionnaire for fruit and vegetable consumption (Appendix O) developed by Domel and colleagues (1996) was used in this study. A self-efficacy questionnaire for fruit and vegetable consumption was chosen for use in this study based on a few reasons. Self-efficacy judgments are specific to a particular task and situation in which the task occurs, therefore, the instrument chosen should pertain to a certain health behaviour studied. One of the main focuses in the activities (e.g. snacks provided to the group program) and information (educational handouts for both groups) provided in study was on promoting fruits and vegetables intake. Therefore, the fruit and vegetable intake self-efficacy questionnaire was chosen to measure the outcome expectations for fruit and vegetable consumption. In addition, most dietary approaches for obesity treatment or prevention attempt to limit intake of high-fat, low nutrient dense foods. This may be perceived as a dietary restriction by people who find these foods reinforcing. The perceived restriction can lead to increases in preference for these foods, thereby increasing the probability of relapsing to previous eating habits when structured interventions are removed (Fisher and Birch, 1999). An alternative approach would be to teach children to increase intake of healthy high-nutrient dense foods, such as fruits and vegetables, which has been the 48 target of large health interventions (Domel et al., 1993) and has been found to decrease the consumption of high fat, high-sugar foods (Epstein et al, 2001). The self-efficacy questionnaire for fruits and vegetables intake consists of 24 items with two subscales: (1) shopping and asking and (2) selection. We also added a third subscale consisting of four questions for measuring self-efficacy for choosing lower fat food choices. These questions originated from Parcel et al. (1995) Child Dietary Self-Efficacy Scale from the Child and Adolescent Trial for Cardiovascular Health (CATCH). C. Physical Activity Questionnaire The "Physical Activity Questionnaire for Older Children" (PAQ-Q was developed by Peter Crocker and colleagues (1997) (Appendix P). It is a self-administered seven-day recall measure designed to assess general physical activity levels of children grades four and higher and not meant to be used to estimate caloric expenditure. The PAQ-C was designed to be relatively quick (< 20 min) to complete, to be inexpensive, to have low staff burden (self-administered), and to be easy to understand. The questionnaire consists of nine items which are scored on a five-point scale and used to derive a total activity score. There is also a question to assess whether sickness or other events prevented the child from doing his or her regular activity in the last week. One-week test-retest reliability of the PAQ-C was found to be r = 0.75 for males and r = 0.82 for females from Grades four to eight with a total of 84 students (Crocker et al., 1997). Another study was done to examine the relationship between the PAQ-C and other measures of physical activity and children's test of aerobic fitness (Kowalski et al., 1997). The PAC-C was found to be moderately related to the Leisure Time Exercise Questionnaire (r=0.41), a Caltrac motion sensor (r=0.39), a seven-day physical activity recall interview (r=0.46), and a step test of fitness (r=0.28). The 49 above findings supported PAQ-C as a promising self-administered physical activity measure for school-age children. D. Physical Activity Self-Efficacy Scale The "Physical Activity Self-Efficacy Scale for Children" by Ruth Saunders and colleagues (1997) containing 17 items was also administered to the children in this study (Appendix Q). Three factors emerged from analysis of this questionnaire: support seeking, barriers, and positive alternatives. The internal consistency reliabilities for the support seeking, barriers, and positive alternatives scales were 0.71 (n=319), 0.71 (n=323), and 0.54 (n=321), respectively. The test-retest reliability for the scales were 0.76, 0.82, and 0.61, respectively (Saunders et al., 1997). The questionnaire was chosen in this study to measure the influences on activity and the children's perceived self-efficacy, or confidence in their ability to be successful at being physically active. E. Self-Perception Profile The "Self-Perception Profile for Children" by Susan Harter (1982) was developed for children aged eight and over (Appendix R). This instrument has six domains: scholastic competence, athletic competence, peer acceptance, physical acceptance, behavioural conduct and global self-worth. The scale contains 36 items (six items per domain) with a response format, which Harter (1982) proposed would offset the tendency to give socially desirable responses. The format involves asking children to choose what sort of child typifies their own behaviours (e.g. "some kids forget what they learn, but other kids can remember things easily") and then asking whether the statement is only sort of true or really true for him or her. The scales proved to be reliable over an interval of nine months, and scores on the test exhibited convergent validity with teacher and peer ratings (Harter, 1982). 50 The content of each domain is as follow: 1. Scholastic competence — the child's perception of his/her competence or ability within the realm of scholastic performance. 2. Social acceptance — the degree to which the child perceives that he/she is accepted by peers or his/her popularity. The items do not measure competence directiy in the sense that they do not refer to social skills. Rather, the items measure the degree to which one has friends, how one feels about his/her popularity and acceptance by other kids. 3. Athletic competence — content relevant to sports and outdoor games. 4. Physical appearance — the degree to which the child is happy with the way he/she looks, ones's height, weight, body, face and hair. 5. Behavioural conduct - the degree to which the children like they way they behave, do the right thing, act the way they are supposed to, avoid getting into trouble, and do the things they are supposed to do. 6. Global self-worth — the extent to which the child likes oneself as a person, is happy the way one is leading one's life, and is generally happy. 3.8.b.ii Questionnaires For the Parents A validated questionnaire, The Family Eating and Activity Habits Questionnaire, (Appendix S) was administered to the parents in the second session of the study. Golan and Weizman (1998a) developed and validated this questionnaire that was divided into four scales; activity level, stimulus exposure, eating related to hunger, and eating style. It was designed to be completed by one of the parents of a child 51 aged six to 11 years. Four subscales in the questionnaire refer to the responding parent, his/her spouse, and the child, as follows: 1. Activity level (four items) - frequency with which the parent, spouse and child engage in physical and sedentary activity. 2. Stimulus exposure (eight items) - presence and visibility of snacks, sweets, cakes and ice-cream in the home; boundaries of child's autonomy in buying or eating these foods. 3. Eating related to hunger (four items) - person in family who initiates eating; eating and hunger. They were also asked what they would do and what they would suggest the child should do if they are not hungry during meal time; eating (during mealtimes) when not hungry. 4. Eating style (13 items) - eating while standing at the open refrigerator or from the pot, while watching television or doing homework or reading, following stress (anger, frustration, boredom), and between meals, second helpings; parental presence when the child is eating. Scores were calculated separately for the child, the responding parent and the spouse. Each scale was rated and scored differently. Responses to the first scale were given in hours. Responses to the second scale were either a quantitative measure (number of items circled) or a frequency measure (using a five-point Likert Scale). The third and fourth scales were also scored by summing the numbers circled for each item. Higher scores reflected less appropriate eating patterns (Golan and Weizman, 1998a). Golan and Weizman (1998a) evaluated the content validity of the questionnaire using a team of ten experts. Cronbach's a was calculated to test whether individual response to each item was consistent with the remaining items on the 52 scale. The questionnaire was internally consistent with a mean r=0.83. Pearson's correlation coefficients were computed between test and retest scores for individual items in a population of 40 mothers, which were found to range from 0.78 to 0.90. Therefore, Golan and Weizman (1998a) concluded that the Family Activity and Eating Habits Questionnaire was a reliable and internally consistent tool for identifying the patterns of eating and activity in families. 3.9 S T A T I S T I C A L A N A L Y S I S Statistical analyses were performed using SPSS for Windows, Version 7.5 (SPSS Inc., Chicago, IL). Data were entered, then manually verified against source data. Errors were corrected prior to conducting statistical analyses. Despite the small sample size, parametric tests were conducted as recommended by three independent statisticians as parametric tests are robust to violation of normality. The following analyses were performed: • Descriptive statistics were used for baseline characteristics. Differences between the counseling and group program in baseline characteristics were assessed using independent t-tests. • The General Linear Model (GLM) repeated measures procedure was used to compare the effects of the intervention on the two programs. The G L M repeated measures procedure performs analysis of variance (ANOVA) to analyze the effect of within subjects factor (i.e. time) and between subject factors (i.e. group) on the outcome measures. For data that did not satisfy the assumption of sphericity, an adjusted F value was reported. Thus, this procedure was used to test the null hypothesis that there is no statistical difference between the individual program and the 53 group program on dependent variables (BMI, triceps skinfold, and survey variables). All comparisons were made at a significance level of p<0.05. 54 Chapter IV RESULTS 2 4.1 RECRUITMENT Forty-six children and their families agreed to participate. Thus, 23 children were initially randomized into each group. Eighteen showed up at the initial counseling session while 14 attended the initial group session. The reason given by most of the families who could not participate in the study after randomization was inflexibility in the parents' work schedules to allow them to take time off to participate in the study. This reason was especially apparent in those who were randomized into the group program due to inability in allowing flexible meeting times as in the counseling group. A n attempt was made to accommodate as many families as possible in the group program by holding the sessions on late Tuesday afternoon. Weekend sessions might have enabled more families to participate in the group program but unfortunately the community center could not accommodate the group on weekends. Eleven families attended at least two out of the three counseling sessions and nine families attended at least four out of the eight group sessions. However, a complete set of data (all anthropometric measurements and questionnaires) from all three time points (baseline, two and 12 months after initial session) was only successfully obtained from seven participants in the nutritional counseling group and five from the group program. Numerous attempts such as rescheduling 2 Only results from the second session will be presented here. The results from the first session were not analyzed and discussed in this thesis as the primary purpose for the first session was to help develop program modules for the second session. 55 nutrition counseling follow-up sessions to accommodate the families' schedules and home visits by the researcher from the group program to those who could not attend the one year group follow-up session were made to increase the likelihood of obtaining complete sets of data from as many families as possible. However, such attempts were not always successful as some families either did not respond to our phone and written requests for rescheduling or were unable to commit for follow-up a year later. Analyses were performed on data of participants (seven in the counseling program and five in the group program) who were able to provide complete set of data (i.e.;.anthropometric measurements and questionnaires all three times). 4.2 S U B J E C T S ' C H A R A C T E R I S T I C S As shown in Table 2, age and body mass index (BMI) at recruitment were not significantly different between the children in the two programs. As a group, the average age was 9.7 ±1.5 years. The ratio of girls to boys was comparable in both groups with more girls in both groups. As a group, the mean BMI was 28.5 ± 4.5 and all children were above the 85 th percentile of BMI for age. The average triceps skinfold, as a group was 35.8 ± 11.3 mm with the majority of children (10 out of 12) above the 95* percentile for TSF. The average triceps skin folds were significantly different (p=0.006) at recruitment between the counseling program and group program. 56 Table 2: Subjects' Baseline Characteristics Counseling Program n=7 mean (+SD) Group Program n=5 mean (±SD) t(p) Age at Recruitment (years) 9.4 (1.7) 10.2 (1.1) -0.878 (0.401) Boy 2 1 -Girl 5 4 -Body Mass Index (BMI) (kg/m2) 28.7 (4.3) 28.3 (5.3) 0.152 (0.882) Body Mass Index Percentile 2 (> 85 th percentile) 5 (>95th percentile) 2 (>85th percentile) 3 (>95th percentile) -Average Triceps Skinfold (mm) 42.6 (6.7) 26.4 (9.7) 3.450 (0.006)* Triceps Skinfold Percentile 7 (> 95 th percentile) 1 (> 50th percentile) 1 (>75* percentile) 1 (>90th percentile) 2(>95th percentile) * Significant at p < .05 4.2.a Baseline Surveys Variables for the Children Table 3 illustrates the comparison of the survey variables (Food Frequency Questionnaire, Fruit and Vegetable Intake Self-Efficacy, Physical Activity Questionnaire, Physical Activity Self-Efficacy, and Self-Perception Profile) of the children in the two programs at baseline. There was no significant difference in any of the variables, demonstrating the two groups were comparable at baseline. From the Food Frequency, the children in the counseling program consumed an average of 2100 kcal/d with 16% of total calories from protein, 30% from fats and 54% from carbohydrates. The children in the group program consumed an 57 average of 1700 kcal/d with 16% of total calories from protein, 32% from fats and 52% from carbohydrates. Higher scores on the Fruit and Vegetable Intake Self-Efficacy subscales indicated higher confidence in performing each of the specific tasks on the list. It appeared that the children in the two programs were fairly confident in asking their parents to shop for their favorite fruit and vegetables. However, they seemed to be less confident in making healthier and lower fat food choices. Children in the group program were reportedly more active, but not significantiy so compared with children in the counseling program at baseline. Children in both of the programs were similarly confident in seeking support and choosing positive alternatives to be physically active. They were, however, less confident in overcoming barriers (e.g. lots of homework, feeling tired) to be physically active. As for the Self-Perception Profile, the children in both programs ranked themselves reasonably high on scholastic competence, social acceptance, behavioural conduct and global self-worth scales. However, they rated themselves lower on the athletic competence scale and the physical appearance scale, indicating they were less happy with their looks. 58 Table 3: Survey Variables at Baseline for Children Survey Variable Unit or -Maximum Possible Counseling Program Group Program t(p) Value n = 7 Mean(± SD) n = 5 Mean(+ SD) Food Frequency Questionnaire Calories Intake Kcal 2102 (860.2) 1678 (443.8) i 1.001 (0.340) Protein Gram 86.0 (32.5) 70.3 (23.3)' 0.923 (0.378) Animal Fats Gram 37.3 (21.4) 28.4 (9.9) 0.856 (0.412) Vegetable Fats Gram 34.9 (15.9) 31.5 (8.7) 0.430 (0.677) Carbohydrates Gram 284.0 (109.6) 219.6 (62.5) 1.174 (0.267) Fruit and Vegetable Intake self-Efficacy Shopping and Asking 32 29.3 (2.4) 29.3 (2.6) -0.010 (0..992) Selection 64 54.0 (4.9) 50.4 (6.5) 1.047 (0.320) Lower Fat Choices 16 12.9 (1.8) 10.6 (6.1) 0.946 (0.366) Physical Activity Questionnaire 4.2 2.6 (0.5) 3.3 (0.6) -2.150 (0.057) Physical Activity Self-Efficacy Support Seeking 7 6.6 (0.5) 6.6 (0.9) 0.108 (0.916) Barriers 4 2.0 (1.2) 2.0(1.2) 0.000 (1.000) Positive Alternatives 6 5.0 (1.5) 5.0 (1.2) 0.000 (1.000) Self-Perception Profile Scholastic Competence 4 3.2 (0.6) 3.1 (0.7) 0.235 (0.806) Social Acceptance 4 3.3 (0.7) 3.4 (0.9) -0.309 (0.763) Athletic Competence 4 2.4 (0.7) 3.1 (0.9) -1.493 (0.166) Physical Appearance 4 2.7 (0.7) 2.3 (0.4) 1.104 (0.295) Behavioural Conduct 4 3.3 (0.3) 3.0 (0.9) 0.964 (0.358) Global Self-worth 4 3.5 (0.5) 3.0 (1.0) 1.069 (0.310) 59 4.2.b Baseline Survey Variables for the Parents As shown in Table 4, at baseline, there were no significant differences in all variables in the Family Eating and Activity Survey except for the mothers' eating styles. The mothers in the counseling group had higher scores indicating less appropriate eating style (p=0.007). The mothers in the counseling group also had a higher score on activity level, indicating that they were less active but not significantly so (although approaching significance at p =0.056) compared with the mothers in the group program. Stimulus exposure relates to the presence and visibility of snacks, sweets, cakes and ice cream in the home, thus, indicating the boundaries of the member in the family's autonomy in buying and taking these foods. Higher stimulus exposure score would indicate more temptations and opportunities to have access to snack foods. The parents and children in the two programs did not differ at baseline on this scale. 60 Table 4: Survey Variables at Baseline for the Parents Survey Variable Unit or Maximum Possible Value Counseling Program n = 7 Mean(± SD) Group Program n = 5 Mean(± SD) t(p) Family Eating and Activity Survey Activity Level -Mother Higher value indicates less active 10.2 (10.6) -0.6 (3.8) 2.164 (0.056) Activity Level -Father 5.5 (5.9) 5.7 (4.9) -0.042 (0.968) Activity Level -Child 6.2 (9.7) 4.3 (11.7) 0.894 (0.763) Stimulus Exposure - Mother Higher value indicates more stimulus exposure 6.9 (3.2) 6.0 (1.2) 0.228 (0.589) Stimulus Exposure - Father 7.5 (3.0) 5.7 (1.5) 0.505 (0.365) Stimulus Exposure — Child 9.7 (4.7) 9.4 (1.8) 0.074 (0.891) Eating Related to Hunger - Mother Higher value indicates eating less related to hunger 3 1.7 (1.1) 0.8 (1.3) 0.870 (0.220) Eating Related to Hunger - Father 3 0.8 (1.0) 1.7 (1.2) 0.838 (0.292) Eating Related to Hunger - Child 7 3.5 (1.3) 2.8 (1.5) 0.936 (0.410) Eating Style -Mother Higher value indicates less appropriate eating style 51 21.1 (4.4) 12.4 (4.3) 3.407 (0.007)* Eating Style -Father 51 17.1 (8.2) 8.7 (2.5) 1.676(0.138) Eating Style - Child 59 25.1 (6.6) 22.8 (6.7) 0.587 (0.570) * Significant at p < .05 61 4.3 Outcome Measurements 4.3.a Anthropometric Measurements Table 5 illustrates that there was no significant difference in body mass index (BMI) between and within the two programs over time. The children in both programs appeared to maintain their BMIs over the course of the study. Average triceps skinfolds (TSF) was significantly different between the two groups, with the counseling group having higher values. Average TSF decreased significantiy over time. There was a 13% decrease in TSF for the children in counseling program from the initial visit compared with the 12-month follow-up. The children in the group program had a 16% decrease in TSF over the same time period. 62 Table 5: Repeated-Measures ANOVA - Anthropometric Measures (Time = Within subject factor, Group = Between subject factor) Variable Counseling Program n=7 Group Program n=5 F(P) Initial Visit 2-month Follow-up 12-month Follow-up Initial Visit 2-month Follow-up 12-month Follow-up Group Effect Time Effect Group X Time mean (±SD) mean (±SD) mean (±SD) mean (±SD) mean (+SD) mean (±SD) F (P) F (P) F (P) Body Mass Index (kg/m2) 28.7 (4.3) 29.0 (4.4) 28.6 (4.7) 28.3 (5.3) 28.4 (4.9) 28.4 (6.2) 0.019 (0.892) 0.245 (0.708) 0.138 (0.799) Body Mass Index Percentile 2 ( > 8 5 * percentile) 5 (>95 t h percentile) 2 f ^ S S * percentile) 5 (>95* percentile) 2 r ^ s s * percentile) 5 (>95 t h percentile) 2 percentile) 3 (>95* percentile) 1 (>85* percentile) 4 (>95* percentile) 2 (>85* percentile) 3 (>95* percentile) - — — Average Triceps Skinfold (mm) 42.6 (6.7) 41.2 (5.7) 37.0 (5.0) 26.4 (9.7) 25.0 (8.9) 22.2 (3.7) 15.053 (0.004)* 6.879 (0.012)* 0.591 (0.912) Triceps Skinfold Percentile 7 (>95 t h percentile) 7 (>95 t h percentile) 7 (>95 t h percentile) 1 ( > 5 0 * percentile) 1 (>75 t h percentile) 1 (>90 t h percentile) 2 ( ^ S * percentile) 1 ^ s o * percentile) 1 (>75 t h percentile) 2 (>90 t h percentile) 1 (>95 , h percentile) 4 (>75 t h percentile) 1 (>95* percentile) — — * Significant at p<.05 63 4.3.b Food Frequency Questionnaire and Fruit and Vegetable Intake Self-Efficacy There were no significant changes in the macronutrient intakes between and within the two programs over the course of the study (Table 6). Therefore, the macronutrient intakes were averaged over the course of the study (i.e. average of the intakes from initial, two-month and 12-month). The children in the counseling group consumed an average of 1800 kcal/d with 16% of total calories from protein, 29% from fats and 55% from carbohydrates. The children in the group program also consumed an average of 1800 kcal/d with 16% from protein, 30% from fats and 54% from carbohydrates. The group and time interaction for protein intake was significantly different for the two programs, with the counseling program having a decreased protein intake during the two-month follow-up followed by a slight increase in protein intake at the 12-month follow-up, but did not return to baseline (Table 6). The group program, on the other hand, had an increased protein intake during two-month follow-up and returned to baseline at 12-month follow-up. No other significant differences were observed between and within the groups over time for total caloric and macronutrients intakes. Table 7 shows that there were no significant differences between and within the groups over time for the variables in the Fruit and Vegetable Self-Efficacy Questionnaire. The children in both programs appeared to be relatively confident in the shopping and asking for fruit and vegetables scale but less so on the selection and lower fat choices scales. 64 Table 6: Repeated Measures ANOVA - Food Frequency Questionnaire Variable Counseling Program n=7 Group Program n=5 F(P) Initial 2-month 12-Month Initial 2-month 12-month Group Time Group X Visit Follow-up Follow-up Visit Follow-up Follow-up Effect Effect Time mean mean mean mean mean mean F F F (±SD) (±SD) (±SD) (±SD) (±SD) (±SD) (P) (P) (P) Energy Intake 2102 (860) 1722 (617) 1726 (512) 1678 (444) 2011 (156) 1606 (130) 0.088 1.711 3.614 (kcal) (0.773) (0.215) (0.062) Protein 86.0 (32.5) 69.2 (29.0) 74.3 (24.2) 70.3 (23.3) 86.4 (15.0) 66.7 (17.8) 0.025 1.669 5.912 (gram) (0.879) (0.242) (0.023)* Animal Fats 37.3 (21.4) 28.5 (13.2) 26.9 (10.6) 28.4 (9.9) 34.7 (7.8) 24.9 (2.9) 0.053 2.960 3.045 (gram) (0.822) (0.092) (0.087) Vegetable Fats 35.0 (16.0) 29.0 (10.1) 25.9 (12.6) 31.5 (8.7) 30.0 (3.6) 27.0 (6.4) 0.006 2.707 0.368 (gram) (0.938) (0.120) (0.702) Carbohydrates 284.0 238.2 244.2 219.6 278.2 224.8 0.162 1.178 3.202 (gram) (109.6) (84.7) (62.6) (62.5) (42.7) (22.9) (0.696) (0.351) (0.089) 65 Table 7: Repeated-Measures ANOVA - Fruit and Vegetable Self-Efficacy Questionnaire Variable Maximum Counseling Program Group Program F Possible n=7 N=5 (P) Value Initial 2-month 12- Initial 2-month 12- Group Time Group X Visit month Visit month Effect Effect Time mean mean mean mean mean mean F F F (±SD) (±SD) (±SD) (+SD) (±SD) (±SD) (P) (P) (P) Shopping 32 29.3 26.6 29.1 29.3 30.8 29.2 0.651 0.095 1.727 and Asking (2.4) (7.2) (3.6) (2.6) (0.8) (3-6) (0.438) (0.911) (0.232) Selection 64 53.9 53.1 55.3 50.4 49.2 55.4 0.349 1.778 0.444 (4-9) (10.5) (9.3) (6.5) (9.1) (7.9) (0.568) (0.223) (0.655) Lower Fat 16 12.9 11.7 13.4 10.6 12.4 13.4 0.080 1.771 1.307 Choices (1.8) (4-4) (2-0) (6-1) (3-8) (3.6) (0.783) (0.205) . (0.291) 66 4.3.c Physical Activity Questionnaire and Physical Activity Self-Efficacy There were no significant differences between and within the groups over time in the physical activity level as shown in Table 8. As for the Physical Activity Self-Efficacy Questionnaire, there were no significant differences between and within the two groups over time for all variables in this questionnaire (Table 9). They appeared to be confident in seeking support and choosing positive alternatives to be physically active but less so on overcoming barriers to be physically active. 67 Table 8: Repeated-Measures ANOVA - Physical Activity Questionnaire Variable Maximum Possible Value Counseling Program n=7 Group Program n=5 F (P) Initial 2-month 12- Initial 2-month 12- Group Time Group X Visit month Visit month Effect Effect Time mean mean mean mean mean mean F F F (±SD) (±SD) (±SD) (±SD) (±SD) (±SD) (P) (P) (P) Physical Activity Questionnaire 4.2 2.6 (0.5) 2.5 (0.3) 3.1 (1.1) 3.3 (0.6) 3.3 (0.9) ' 3.2 (0.5) 2.949 (0.117) 0.337 (0.722) 0.789 (0.483) 68 Table 9: Repeated-Measures ANOVA - Physical Activity Self-Efficacy Questionnaire Variable Maximum Counseling Program Group Program F Possible n=7 N=5 (P) Value Initial 2-month 12- Initial 2-month 12- Group Time Group X Visit month Visit month Effect Effect Time mean mean mean mean mean mean F F F (±SD) (±SD) (±SD) (±SD) (±SD) (±SD) (P) (P) (P) Support 7 6.6 7.0 6.4 6.6 6.4 7.0 0.008 0.132 2.618 Seeking (0-5) (0) (1-0) (0.9) (0-5) (0) (0.930) (0.878) (0.127) Barriers 4 2.0 2.4 2.4 2.0 2.6 2.8 0.132 2.401 0.180 (1.2) (1.1) (1.0) (1.2) (l.D (1-3) (0.724) (0.146) (0.838) Positive 6 5.0 5.3 5.3 5.0 4.6 5.2 0.120 0.638 0.521 Alternatives (1-5) (1.3) (1.1) (1-2) (2.2) (1.8) (0.736) (0.550) (0.611) 69 4.3.d Self-Perception Profile There were no significant differences between and within the two groups over time for all variables (scholastic competence, social acceptance, athletic competence, physical appearance, behavioural conduct and global self-worth) in the Self-Perception Profile (Table 10). The children in both groups rated themselves fairly high on scholastic competence, social acceptance, behavioural conduct and global self-worth scales. Both groups rated themselves lower on the physical appearance scale, indicating they were less happy with the way they look. 70 Table 10: Repeated-Measures ANOVA - Self-Perception Profile Variable Maximum Counseling Program Group Program F Possible n=7 N=5 (P) Value Initial 2-month 12- Initial 2-month 12- Group Time Group X Visit month Visit month Effect Effect Time mean mean mean mean mean mean F F F (±SD) (iSD) (±SD) (±SD) (±SD) (+SD) (P) (P) (P) Scholastic 4 3.2 3.0 3.4 3.1 3.3 3.4 0.082 2.001 1.575 (0.7) (0.7) (0.5) (0.7) (0.6) (0.4) (0.781) (0.191) (0.259) Social 4 3.3 3.0 2.9 3.4 3.4 3.6 1.101 0.308 0.660 Acceptance (0.7) (0.7) (1.1) (0-9) (0.6) (0.6) (0.319) (0.743) (0.540) Athletic 4 2.4 2.4 2.9 3.1 3.0 3.2 1.213 1.763 0.651 (0.7) (0.9) (0.9) (0.9) (1.0) (0.9) (0.297) (0.207) (0.495) Physical 4 2.7 2.7 2.8 2.3 2.9 2.3 0.444 1.108 1.478 Appearance (0.7) (0.9) (0-9) (0.4) (1.0) (0.6) (0.520) (0.371) (0.279) Behavioural 4 3.3 3.6 3.8 3.0 3.0 3.2 3.688 2.936 0.169 Conduct (0-3) (0.4) (0-3) (0-9) (0-8) (0.5) (0.084) (0.104) (0.847) Global Self- 4 3.4 3.3 3.3 3.0 3.5 3.1 0.224 0.943 1.453 Worth (0.5) (1.0) (0-9) (1.0) (0-6) (0-5) (0.646) (0.425) (0.284) 71 4.3.e Family Eating and Activity Habits Questionnaire As shown in Table 11, there was a significant difference in the mothers' eating style between the two programs, with the mothers in the group program having lower score, indicating better eating styles. In addition, there was a significant increase in the hunger scale over time for children in both programs. There was an 11% increase for the counseling program and a 64% increase in the group program, indicating eating less related to hunger. The scores for the children's eating style decreased significantiy over time with the counseling program having a 15% decrease and a 9% decrease for the group program, indicating improvements in eating styles. Other variables in this questionnaire did not differ significantly between the two programs. 72 Table 11: Repeated-Measures ANOVA - Family Eating and Activity Habits Questionnaire Variable Maximum Possible Value Counseling Program n=7 Group Program N=5 F (P) Initial Visit 2-month 12-month Initial Visit 2-month 12-month Group Effect Time Effect Group X Time mean (±SD) mean (±SD) mean (±SD) mean (±SD) mean (±SD) mean (±SD) F (P) F (P) F (P) Activity Level (Mother) Higher value indicates less active 10.2 (10.6) 4.5 (15.5) 3.4 (16.4) -0.6 (3.8) -0.9 (4.0) -1.9 . (7.8) 0.914 (0.364) 1.065 (0.389) 0.279 (0.763) Activity Level (Father) (Unlimited maximum possible value) 5.5 (5.9) 7.0 (12.8) 4.7 (10.4) 5.7 (4.9) 10.0 (9.0) 1.5 (8.0) 0.162 (0.701) 0.289 (0.761) 0.050 (0.952) Activity Level (Child) 6.2 (9.7) 1.9 (6.0) 0.7 (11.4) 4.3 (11.7) 6.4 (7.4) 11.0 (11.6) 1.278 (0.287) 0.776 (0.492) 3.425 (0.084) 73 Table 11 (Continued): Repeated-Measures ANOVA - Family Eating and Activity Habits Questionnaire Variable Maximum Possible Value Counseling Program n=7 Group Program N=5 F (P) Initial Visit 2-month 12-month Initial Visit 2-month 12-month Group Effect Time Effect Group X Time mean (±SD) mean (±SD) mean (±SD) mean (±SD) mean (±SD) mean (±SD) F (P) F (P) F (P) Stimulus Exposure (Mother) Higher value indicates more stimulus exposure 6.9 (3.2) 6.4 (2.1) 6.6 (2.1) 6.0 (1.2) 7.0 (5.4) 7.9 (4.4) 0.029 (0.869) 0.561 (0.592) 0.808 (0.479) Stimulus Exposure (Father) (Unlimited maximum possible value) 7.5 (3.0) 7.1 (0.8) 6.9 (2.1) 5.7 (1.5) 6.7 (6.7) 7.0 (5.2) 0.002 (0.962) 0.731 (0.527) 1.675 (0.278) Stimulus Exposure (Child) 9.7 (4.7) 9.5 (1.8) 10.3 (3.4) 9.4 (1.8) 9.4 (6.0) 9.2 (4.9) 0.074 (0.791) 0.046 (0.955) 0.140 (0.871) 74 Table 11 (Continued): Repeated-Measures ANOVA - Family Eating and Activity Habits Questionnaire Variable Maximum Possible Value Counseling Program n=7 Group Program N=5 F (P) Initial Visit 2-month 12-month Initial Visit 2-month 12-month Group Effect Time Effect Group X Time mean (±SD) mean (±SD) mean (±SD) mean (±SD) mean (±SD) mean (±SD) F (P) F (P) F (P) Eating Related to Hunger (Mother) Higher value indicates eating less related to hunger 1.7 (1.1) 1.6 (1.1) 1.3 (1.0) 0.8 (1.3) 1.0 (1.4) 1.2 (1.1) 0.969 (0.351) 0.818 (0.417) 0.057 (0.877) Eating Related to Hunger (Father) (Maximum possible value for parents: 3) 0.8 (1.0) 0.8 (0.8) 1.3 (1.2) 1.7 (1.2) 1.7 (1.2) 1.7 (1.2) 1.733 (0.240) 0.411 (0.688) 1.839 (0.271) Eating Related to Hunger (Child) 7 3.5 (1.3) 3.8 (2.0) 3.9 (1.8) 2.8 (1.5) 4.6 (1.7) 4.6 (2.0) 0.086 (0.775) 3.999 (0.046)* 1.796 (0.200) * Significant at p<.05 75 Table 11 (Continued): Repeated-Measures ANOVA - Family Eating and Activity Habits Questionnaire Variable Maximum Possible Value Counseling Program n=7 Group Program N=5 F (P) Initial Visit 2-month 12-month Initial Visit 2-month 12-month Group Effect Time Effect Group X Time mean (±SD) mean (±SD) mean (±SD) mean (±SD) mean (±SD) mean (±SD) F (P) F (P) F (P) Eating Style (Mother) Higher value indicates less appropriate eating style 21.1 (4.5) 17.9 (3.8) 17.4 (4.3) 12.4 (4.3) 14.5 (6.0) 10.5 (3.7) 9.020 (0.015)* 2.332 (0.159) 2.554 (0.139) Eating Style (Father) (Maximum possible value for parents: 51) 17.1 (8.2) 14.2 (9.5) 12.5 (5.2) 8.7 (2.5) 14.0 (3.0) 12.3 (4.2) 0.322 (0.595) 0.675 (0.559) 1.777 (0.280) Eating Style (Child) 59 25.1 (6.6) 20.7 (5-4) 21.3 (8.3) 22.8 (6-7) 16.1 (3-7) 20.6 (7.1) 0.526 (0.485) 8.120 (0.010)* 1.204 (0.344) * Significant at p<.05 76 Chapter V DISCUSSION 5.1 OVERVIEW The purpose of this study was to compare the effectiveness of individual nutritional counseling with a group program on promoting healthier lifestyle behaviours for overweight children (aged seven to 11 years) and their families. Results showed that there was no difference in most of the outcome measures between the two interventions. Results also showed minimal effects of either program on most outcome measures. This suggests that one strategy is not necessarily better than the other, at least in the short term, as this study only assessed outcome up to one year. In this chapter, study findings are discussed in relation to other studies in the literature on childhood obesity. Study limitations, implications of the findings, avenues for future research and conclusions are oudined. 5.2 DESIGN OF THIS STUDY Several issues with regards to the design of this study are noteworthy. The choice of control group in this study was not a straightforward one. Nutritional counseling for overweight children in British Columbia was not easily available during the time of this study. However, many would consider it unethical to have a true placebo arm (i.e. no intervention) in a study where such a placebo is considered less than standard of care, simply because this standard is communally 77 unavailable, as the study clearly had the capabilities of providing such services. On the other hand, in the management of childhood obesity, while nutritional counseling may be generally viewed as standard of care, it is not clear that it is actually any better than no intervention. There is limited literature direcdy comparing the results of individual and group interventions. Most studies on children were focused on group programs. Some of the arguments for group programs include that they are more efficient and less expensive to administer, and that they foster beneficial interactions between group members. Both parents and children often report learning from other group members and enjoying the support and interaction provided by the group setting (Robinson, 1999). Approaches endorsed by other group members may also have more credibility than when solely promoted by a clinician. Steps were taken to prevent group contamination and researchers' biases in this study. There was no interaction between participants in the two groups. The two groups were facilitated by different dietitians to reduce researchers' biases. On the other hand, this opened the possibility that one dietitian could be more effective than the other. 5.3 A N T H R O P O M E T R I C M E A S U R E M E N T S In terms of anthropometric measurements, body mass index (BMI) did not differ between and within the two groups at baseline or at the completion of the study. BMI did not increase during the course of the study, indicating that the weight status in the children at least did not worsen. The fact that weight status did not 78 deteriorate in either group might be viewed as a partial success, as such is the natural history of obesity. This negative result may be viewed as the primary outcome of this study. The intervention in this study was not direcdy targeted at weight status in that there was no systematic attempt to ensure a relative caloric deficit in the subjects. Nevertheless, the primary outcome measure, BMI, is indeed a measure of weight status, and it was indirecdy targeted through behavioural and environmental means. The triceps skinfold (TSF), on the other hand, differed significantly between the two groups even at baseline. This was most likely due to the large inter-observer variability (all measurements were taken by a single individual in the counseling group, and all by another in the group program) that exists in measurement of TSF (Power et al., 1997). Unfortunately, the two individuals who performed the triceps skinfold measurements did not conduct trial measurements on the same individuals prior to the study. Therefore, the inter-and intra-observer variabilities could not be established. Triceps skinfold did decrease significandy in both groups over time. This effect occurred in parallel, and thus there was no between group difference. This finding is likely to be accurate as intra-observer variability in TSF measurements is less of a problem. This brings up an alternate interpretation of the study's findings. In the age range studied, both BMI and TSF tend to increase slighdy over time as the individual approaches puberty (Wells et al., 2002). One would expect BMI and TSF percentiles to correct for this and therefore to be the better measure in these age groups. Neither differed over time in either arm of this study. However, the published tables for these measures are insensitive to small changes in that they only list six to seven levels (percentiles 5, 15, 50, 75, 85, 95 for BMI and 5, 10, 25, 50, 75, 90, 95 for TSF). Therefore, if an individual whose levels dropped failed to cross one of these "landmark" numbers, no change would be detected. This appears to have 79 occurred here. This argument is very similar to the one put forward by Rotatori (1979) in relation to growth charts and their insensitivity for assessing change in very obese children. The fact that the children in both of the programs had a drop in absolute TSF (the better measure of fatness) and maintained their absolute BMI over the course of this study can be viewed as positive effects on weight and fat status especially during a time when both are normally slighdy rising as children are approaching puberty. 5.4 R E P O R T E D D I E T A R Y INTAKES Over the course of the study, the children in the counseling program reported an average intake of 1800 kcal/d with 16% of total calories from protein, 29% from fat and 55% from carbohydrates. The children in the group program reported an intake of 1800 kcal/d with 16% of total calories from protein, 30% from fats and 54% from carbohydrates. Therefore, there was no significant difference in the reported macronutrients intakes between the two programs. Williams et al. (2001) reported that the average nine to 10 year-old child consumes about 2000 kcal/day and data from NHANES III (1988 to 1994) indicated that American children on average consume 33% to 34% of their calories as fat, compared with the recommended level of 20-35% from fat (National Academy of Sciences, 2002). When the estimated energy requirements of children in this study were calculated based on the equations proposed by the National Academy of Sciences (2002) (Appendix T) for overweight children aged three to 18 years, the mean energy requirements were estimated to be 2400 kcal/d and 2200 kcal/d for the children in the counseling and group program, respectively. Therefore, the children in this study had reported a lower energy intake than the estimated requirement. As a 80 group, our subjects consumed an average of 1800 kcal/d with about 30% of energy intake from fats. Therefore, on the whole, our subjects did not appear to differ significantiy from average children nor did they exceed the estimated requirements in terms of their energy consumption. However, it should be noted that dietary intake is very difficult to measure in children (Hills and Parker, 1988) and the resultant error possibly accounts for the between group difference in total intake, which is unlikely to be real given that the children in the two groups were of similar size and had similar energy expenditures but had no difference in weight change. At first glance, one may find it surprising that the subjects in this study did not have above-average calorie intake despite being clearly overweight. However, most studies assessing this issue in children had similar findings. Klesges et al. (1995) and Maffeis et al. (1998) found that there was no relationship between energy intake and fatness in eight to 12 year olds. Deheeger et al. (1996) and Roland-Cachera et al. (1995), found no relationship between energy intake and fatness in four to six year olds. Five studies looked at the percentage of energy from fat; four found no influence on fatness in five to 12 year olds (Maffeis et al., 1998; Nicklas et al., 1988; Roland-Cachera et al., 1995; Shea et al , 1993), and one found a positive association in six year olds (Klesges et al., 1995). Percentage energy intake from carbohydrate was examined in four studies, none found a relationship with fatness in two to 12 year olds (Klesges et al., 1995; Maffeis et al., 1998; Nicklas et al., 1988; Roland-Cachera et al., 1995). Three studies investigated the effect of percentage energy intake from protein; two studies found no influence on fatness at four or seven years of age (Nicklas et al., 1988) or in 12 year olds (Maffeis et al., 1998) respectively, and one found a positive association with fatness at eight years of age (Roland-Cachera et al., 1995). The above information can be interpreted in two ways. If one accepts the majority findings as being correct, then it would necessarily have to follow that 81 the principal cause of overweight status in children would be lower than average energy expenditure. On the other hand, as mentioned above, measures of caloric intake tend to be inaccurate in children. This is confirmed in a study by O'Connor et al. (2001) where they compared measurements of energy intake (El) from diet records and total energy expenditure (TEE) by the doubly labeled water (DLW) method to investigate misreporting of energy intake. Forty seven children aged six to nine years old were recruited from 25 schools in western Sydney, Australia. Total Energy Expenditure (TEE) was measured by D L W over 10 days and EI by use of three-day food records. They found that the mean level of misreporting was 4%, indicating that there was a slight tendency to overestimate EI. The most significant predictor of misreporting was dietary fat intake, with a higher fat intake being associated with over-reporting. Misreporting was not associated with sex or body composition of the children. However, in another study on the influence of body composition on the accuracy of reported energy intake in children four to 11 years old, Fisher et al. (2000) found that under-reporting tended to occur among heavier children who have higher body fat content and relative weight. Therefore, accurately assessing the dietary intake of children is a fundamental challenge in understanding the role of nutrition in preventing obesity. 5.5 PHYSICAL ACTIVITY Physical activity did not differ over time between or within the two groups. However, the children in the group program reported slightly, though not significantly, higher activity levels. There were no significant differences between and within the two groups over time for all the variables (support seeking, 82 barriers, and positive alternatives) in the physical activity self efficacy scale. Williams et al. (2001) reported that obese children had lower levels of physical activity self-efficacy, were involved in fewer community organizations promoting physical activity and had fathers who were less physically active than controls. Children will be more likely to continue being active if they have the opportunity to choose the types of activities they participate in (Robinson, 1999) Recent evidence suggests that decreasing sedentary activities, rather than promoting physical activity levels may be more effective in promoting weight loss. For instance, children should be encouraged to reduce time spent on television watching and playing computer and video games. 5.6 S E L F P E R C E P T I O N P R O F I L E • There were no significant differences between and within the two groups over time for all variables (scholastic, social acceptance, athletic, physical appearance, behavioural conduct and global self-worth) in the Self-Perception Profile. The children in both groups rated themselves fairly high on scholastic competence, social acceptance, behavioural conduct and global self-worth scales. Both groups rated themselves lower on the athletic competence scale and the physical appearance scale, indicating that they were less happy with the way they look. French et al. (1995) reviewed 35 studies examining self-esteem and obesity in children. Thirteen of 25 cross-sectional studies demonstrated lower self-esteem in obese youth. Two prospective studies assessing the relationship between self-esteem and obesity had conflicting findings. On the other hand, six of eight treatment studies showed improved levels of self-esteem among overweight 83 children who participated in weight loss treatments. Inappropriate control groups and small sample sizes make it difficult to establish a clear relationship but, at least among the cross-sectional studies, obesity in children is inversely related to self-esteem. Similarly, a more recent study by Stradmeijer et al. (2000) reported lower self-esteem among overweight 10-16-year-old girls. Although self-esteem may change during some interventions, this change is not consistently associated with decreases in weight status. For example, in school-based interventions designed for prepubertal children, increases in self-esteem occurred in the absence of weight change (Sherman et al., 1992), and equivalent improvements in self-esteem were demonstrated for both experimental and control groups (Foster et al., 1985). Although disappointing that a decrease in weight has not been demonstrated, it is important to remember that improving self-esteem has benefits beyond this. Prevention and treatment of obesity ultimately involves eating less and being more physically active (Ebbeling, 2002). Though this sounds simple, long-term weight loss has proven exceedingly difficult to achieve. The intellectual and psychological immaturity of children and their susceptibility to peer pressure present practical obstacles to the successful treatment of childhood obesity (Ebbeling, 2002). Much press has been devoted to the importance of a component designed to maintain overweight children's self-esteem in the face of their condition and their being singled out for a targeted intervention. Nevertheless, it is inevitable that such will have only limited success given the nature of our society's biases outside the protected environment and the child's ability to read and interpret such, as well as the knowledge that there is a reason why they are being targeted for intervention. A child's self-esteem may be better protected once we come to view today's society as being fundamentally at fault rather than the individual. 84 5.7 FAMILY EATING AND ACTIVITY HABITS Mothers in the two groups differed in their eating styles at baseline. The mothers in the counseling program had a less appropriate eating style but the difference disappeared over time with improvement (although short of statistical significance) in eating style in both groups. Interestingly, it was also noted that the mothers in the counseling program were less physically active (approaching significance, p=0.056) at baseline compared with mothers in the group program. Over time, the mothers in both groups were more physically active, but the improvement was not significant within or between the two groups. It is not clear how this baseline difference would be expected to influence the results. One could hypothesize that the children in the nutrition counseling program would be at a disadvantage due to their mothers' poor eating pattern and more sedentary nature, or alternatively that such would translate into more room for easy improvement. The fathers in both groups did not differ in their physical activity levels at baseline and did not appear to have improvement over time. 5.8 OVERALL FINDINGS OF THIS STUDY The overall results of this study (i.e. the lack of differences in outcome measures between the two groups and minimal impact on outcome measures in either group) can be interpreted in several ways. The participants in the counseling program arm received a rather advanced level of intervention where in addition to nutritional counseling, discussions on physical activity and self-esteem were incorporated in the sessions. This could have positively impacted the outcome on this arm, which may account for the lack of difference seen in the outcome measures between the counseling and group programs. On the other hand, the 85 intensity of intervention in the group program might not have been strong enough versus any degree of counseling to make a detectable difference in the outcome measures between the two groups. The simplest interpretation, of course, is that a group setting is of no added benefit in the management of childhood obesity. Another plausible explanation for the lack of noticeable difference in the two groups lies with the inherent weaknesses of this study, i.e.: small sample size and short duration of intervention. Yet the former seems unlikely given the lack of even a trend towards between-group differences. With regards to the latter, the questionnaires did not uncover any evidence to suggest that there was any reason for differences to emerge with more time. This brings one back to the viewpoint that the group setting itself is of no extra benefit in this condition. Merely giving information and instructions about diet and exercise in any setting is not enough. Even with highly motivated families it is difficult to make long-term adjustments in life-style (Gibson, 2002). This difficulty was illustrated in a study by Flodmark et al. (1993) which assessed the effects of family therapy on treatment of obesity in 10-and 11-year-old children. At the end of 14 months, neither group showed decreases in obesity, but children in the family therapy group had significantly smaller increases in BMI than did children in the conventional dietary counseling group. However, the difference disappeared one year later. Successful interventions must include behavioural treatments that address eating and physical activity. Frequent follow-up and empathetic support from health professionals may help the child and family to continue making small, sustainable changes in lifestyle. It is imperative to note that eating and activity habits are deeply ingrained and highly resistant to change. However, we must endeavor to help children we care for to develop their own personal coping strategies to protect their health in a world where over-consumption and inactivity have become endemic (Laing, 2002). In the short term, any change will 86 be difficult to measure, and a long term approach to arresting the worrying rise of childhood obesity has to be a strategic goal for the society (Epstein et al., 1998). The WHO report "Obesity" produced in 1997 stated: "Obesity cannot be prevented or managed solely at the individual level. Committees, governments, the media and the food industry need to work together to modify the environment so that it is less conducive to weight gain" (Gibson, 2002). 5.9 L IMITATIONS This study had several limitations. The most important is the small sample size, involving a total of only 12 subjects (seven in the nutritional counseling group and five in the group program). The reason given by most of the families who could not participate and complete the study after randomization was inflexibility in the parents' work schedules to allow them to take time off to participate in the study. This reason was especially apparent in those who were randomized into the group program due to the inflexibility of meeting times, unlike the counseling group. An attempt was made to accommodate as many families as possible in the group program by holding sessions late in the afternoon. Weekend sessions might have enabled more families to participate in the group program but unfortunately the community center could not accommodate the group on weekends. It is, however, crucial to recognize that this bilateral problem of scheduling inflexibility was not specific to this study, but is instead inherent to the nature of group programs and especially those requiring more than one family member to attend. It is an additional consideration that must be factored in by any health authority or practitioners when deciding on the nature of an intervention program. Numerous attempts such as rescheduling nutrition counseling follow-up sessions to accommodate the families' schedules and home visits by the researcher from 87 the group program to those who could not attend the one year group follow-up session were made to increase the likelihood of obtaining a complete set of data from as many families as possible. However, such attempts were not always successful as some families either did not respond to our phone and written requests for rescheduling or were unable to commit to follow-up a year later. Therefore, the major limitation of this study was the high dropout rate (70% for the counseling program and 78% for the group program) resulting in a small sample size. The high dropout rate in nutrition intervention studies involving weight control, though is not uncommon.. For instance, one multicenter study on obesity using a nutrition intervention with more than 1300 children had a dropout rate of 90% (Pinelli et al., 1999). Dropout rates of this magnitude could justifiably lead one to question the validity of the results obtained in any such study, including this one. However, this is much more of a problem for studies with positive results, as it can be reasonably hypothesized that the characteristics leading individuals to stay in the study select for those most likely to benefit from it (potentially by as direct a mechanism as their realizing the improvements and therefore continuing onwards). Therefore, such positive results may not apply to the group as a whole. On the other hand, in studies on weight control with high dropout and negative results such as this one, it would seem very unlikely that those who left would have been anymore successful (and one might cynically wonder if they were doing worse) than those who stayed on. Therefore, the high dropout rate can be seen as essentially reinforcing the negative results. Questionnaires were chosen to be used in this study to assess the subjects' nutrition and lifestyle behaviours. Questionnaires are easy to administer, practical, non-invasive, and are cost-effective. However, the limitations of questionnaires must be recognized. Questionnaires often ignore an individual's context or have the potential to be too standardized. In addition, children's ability to understand the questions and to recall accurately present practical obstacles. The 88 questionnaires likely suffered more from sample size issues than did the anthropometric measures due to the multiple questions and insensitivities of each individual measure. A questionnaire that would incorporate the individual subsections into one or several overall scores may be more appropriate for similar studies in the future. 5.10 I M P L I C A T I O N S O F F I N D I N G S The prevalence of childhood obesity has increased in Canada over the years and it brings with it important health and social implications. The successful treatment of childhood obesity may prevent severe diseases in later years. Conventional dietary interventions have generally failed to affect the prevalence and treatment of childhood obesity. Many tend to view group programs as being inherently advantageous. However, from this study, group programs did not appear to be better than counseling to any degree. Furthermore, as discussed elsewhere, group programs inherently suffer from scheduling inflexibilities, thus potentially limiting accessibility for many families. Especially should these findings be confirmed in longer term studies, allocation of health care funds for childhood obesity should be based on economic concerns and program availability without any preference towards group programs. On the other hand, given the equivocal findings of this study, one may wonder if health care dollars should be allocated to the treatment of childhood obesity and certainly such an opinion is worthy of debate. 89 5.11 A V E N U E S F O R F U T U R E R E S E A R C H The locus of responsibility for childhood obesity needs to shift away from individuals and towards the environment (Schwartz and Puhl, 2003). Places that are intended to protect children, such as schools, need to become involved in proactive ways. "Unhealthful" foods such as soft drinks, candies, and high-fat snacks should be removed from schools (Story et al., 1996). Physical education should be a required part of each child's school day (Kann et al., 1995). Advertising unhealthful foods to children should be limited and advertising healthful foods should be subsidized. In addition, parents, teachers and others who work with children need to take on the challenges of educating children not only about nutrition but also about the importance of treating each other with respect and tolerance despite physical differences in size and shape (Berg et al., 2003). On the federal level, legal steps to prohibit size discrimination and limit advertising of unhealthful products to children are necessary. Prevention of childhood obesity would be better than cure, although there is unfortunately little evidence about what preventive measures are effective (Gibson, 2002). The aim should be to help children develop healthy life-styles which can be continued throughout life. We need to make healthy choices easier to make. Health professionals can help with information and education about nutrition, physical activity and parenting. Schools are of critical importance in implementing effective obesity prevention programs for children. Children spend a large proportion of their day in schools. They are educated and influenced by their teachers and peers. They usually eat lunch at school, and sometimes breakfast and snacks. The frequency, intensity, and duration of their physical activity are strongly influenced by the school's physical education, sports, and after school programs. The presence of 90 appropriately trained staff and the availability of adequate gyms, playgrounds, equipment, and educational resources are also critical (Williams et al., 2001). Recent treatment modalities with more promising outcomes have been oriented towards family-based behavioural modification programs (Gibson, 2002). The unique characteristic of this study was that it offered a program that provided a supportive environment to children who are overweight and their families to enable them to develop and maintain healthy eating and lifestyle behaviours. There is a lack of evidence on the effectiveness of interventions on which to base national strategies or to inform clinical practice. Many of the randomized controlled trials have methodological problems such as small sizes and high rates of drop out, leading to low statistical power and potential bias. Future research must be of good methodological quality, involve large numbers of participants in appropriate settings and needs to be of longer duration and intensity (Wilson, 2003). 5.12 C O N C L U D I N G R E M A R K S The problem of childhood obesity in Western society has been widely recognized for at least two decades now. Today, given widespread media attention, it is possible that every North American school-aged child is aware of the problem. Despite this it continues to increase in prevalence from survey to survey. The implications for our society are clear: we are not doing an adequate job of tackling this problem. Some of the interventions discussed have seen short-term success, but evidence for long term positive results have been less than impressive. In this study a two months intensive multi-modal group approach was not better than 91 individual counseling. When one carefully considers the nature of the problem we are addressing this is not surprising. Viewed teleologically the body's tendency towards greater caloric intake and conservation is easy to understand in terms of survival of the fittest during times of food scarcity. Such times would of course encompass all of pre-recorded and much of recorded human history. In fact, the genes involved in such behaviour and metabolism doubtlessly antedate the emergence of our species, and would at the very least be expected to be present in all animal species. Therefore this complement of genes have clearly had ample generations of evolutionary environmental pressures to hone their previously much-valued skills. It is only during the last several decades of extreme caloric abundance and availability that these long beneficial but inherently neutral genes have turned against us and begun resulting in diseases of the plenty. When viewed from this perspective it is easy to see why the tendency to gain weight comes so easily to many of us and our children. It also makes it easy to see why well-meaning and seemingly intense, well-designed interventions routinely fall short of their goals. 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Prevalence of overweight among children and adolescents: United States, 1999. http: //www.dcd.gov.nchs/products/pubs/pubd/hestats / oveweight99.htm 104 National Center for Health Statistics. 2002. http:/Ayww.cdc.gov/growmcharts/ Nicklas TA, Farris RP, Smoak CG, Frank GC. Srinivasan SR, Webber LS, Bereson GS. Dietary factors related to cardiovascular risk factors in early life. Bogalusa Heart Study. Arteriosclerosis 1988;8:193-199. Nielsen SJ, Siega-Riz A M , Popkin BM. Trends in energy intake in U.S. between 1977 and 1996: similar shifts seen across age groups. Obes Res 2002;10(5):2002. Obarzanek E. methodological issues in estimating the prevalence of obesity in childhood. Ann NY Acad Sci 1993;699:278-279. O'Connor J, Ball EJ, Steinbeck FCS, Davies PSW, Wishart C, Gaskin KJ, Baur LA. Comparison of total energy expenditure and energy intake in children aged 6-9 y. Am] Clin Nutr 2001;74:643-649. Parsons TJ, Power C, Logan S, Summerbell CD. 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Suskind RM, Sothern MS, Farris RP, von Almen TK, Schumacher H, Carlisle L, Vargas A, Escobar O, Loftin M, Fuchs G, Brown R Udall JN . Recent advances in the treatment of childhood obesity. Ann NY Acad Sd 1993;699:181-199. Swinburn B, Ashton T, Gillespie J, Cox B, Menon A, Simmons D, Birkbeck J. Health care costs of obesity in New Zealand. Int J Obes Relat Metab Disord 1997;21(10):891-896. Taras HF, Sallis JF, Patterson TX, Nader P R Nelson JA. Television's influence on children's diet and physical activity. Dev Behav Pediatr 1989;10:176-180. Taubes G. As obesity rates rise, experts struggle to explain why. Sdence 1998;280(May 29): 1367-1368. Thompson D, Wolf AM. The medical-care cost burden of obesity. Obes Rev 2001 £(3): 189-197. 109 Tremblay MS, and Willms JD. Secular trends in the body mass index of Canadian children. Can Med Assoc J 2000;163:1429-1433. (Published erratum appears in CMAJ 164:970). Troiano RP, Flegal K M . Overweight children and adolescents: description, epidemiology, and demographics. Pediatrics 1998;101(3 Part 2 of 2):497-504. Troiano RP, Flegal K M , Kuczmarski RJ, Campbell SM, Johnson CL. Overweight prevalence and trends for children and adolescents. Arch Pediatr Adolesc Med 1995(149):1085-1091. Valoski A, Epstein L H . Nutrient intake of obese children in a family-based behavioural weight control program. Int J Obes 1990;14:667-677. Wang Y, Monteiro C, Popkin BM. Trends of obesity and underweight in older children and adolescents in the United States, Brazil, China and Russia. Am J Clin Nutr 2002;75:971-977. Waxman M, Stunkard AJ. Caloric intake and expenditure of obese boys. / Pediatr 1980;Feb 96(2): 187-193. Wells JCK, Coward WA, Cole TJ, Davies PSW. The contribution of fat and fat-free tissue to body mass index in contemporary children and the reference child. Int J Obes 2002;26:1323-1328. Whitaker RC, Wright JA, Pepe MS, Seidel K D , Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997;337(13):869-873. 110 White Ray J, Klesges RC. Influences on the eating behaviour of children. Ann NY Acad Sci 1993;699:57-69. WHO Consultation on Obesity: Global prevalence and secular trends in obesity. In Obesity — Preventing and Managing the Global Epidemic. Geneva: WHO; l 998:17-40. Wiecha JL, Casey VA. High prevalence of overweight and short stature among Head Start children in Massachusetts. PublicHealth Rep 1994;109(6):767-773. Wile H, Mclntyre L. The management of childhood obesity. Can J Ped 1993; 5(1): 188-196. Wilkins SC, Kendrick OW, Stitt KR, Stinett N, Hammarlund VA. Family functioning is related to overweight in children. JADA 1998;98(5):572-574. Williams CL, Bollella M, Carter BJ. Treatment of childhood obesity in pediatric practice. Ann NY Acad Sci 1993;699:207-219. Williams CL, Gulli MT, Deckelbaum RJ. Prevention and treatment of childhood obesity. Current Atherosclerosis Reports 2001;3:486-497. Wilson P. Tackling childhood obesity. Prof Nurse 2003;18(6):310. Wray S. Levy-Milne R. Weight management in childhood. Can J Diet Prac Res 2002;63:130-133. I l l APPENDIX D: WEIGHT CHANGES IN T H E CHILDREN (FIRST SESSION) Baseline Two Months Counseling Program 82.7 kg 85.2 kg 36.6 kg 35.3 kg 40.9 kg 41.1 kg 75.8 kg 76.6 kg Group Program 70.7 kg 68.8 kg 45.6 kg 44.3 kg 45.5 kg 43.6 kg 116 APPENDIX G: EDUCATIONAL MATERIALS FOR B O T H PROGRAMS How Can I Help My Child Who Is Overweight? Help Your Child Develop Good Attitudes About Eatino As a parent, be a role model about eating healthy. Meal planning, grocery shopping and food preparation for the family should focus on well-balanced meals and snacks in daily eating. Ellyn Satter, author of "How To Set Your Child To Eat. But Not Too Much" summarizes the message that it is the parents' job to provides a selection of nutritious foods and it is the child's job to decide what and how much of the food to eat. Don't restrict your child's food intake or put him / her in a low-calorie diet. To promote proper growth, development and prevent overweight, parents should offer a wide variety of foods from each of the food groups in Canada's Food Guide to Healthy Eating: Cut back on the amount of fat in your family's food. Use low fat or nonfat dairy products, lean meats and skinless poultry, or naturally fat free or low fat breads and cereals. Make gradual changes for a more low fat way to eat and to prevent excess weight gain in children. Use sweets or treats in moderation only. Although these foods are high in fat, salt and sugar, there still is a place for these foods. Do not have them available in the house all the time as you will always be trying to hide the food or arguing as to whether your child can have them and how much. Eat meals together as a family as often as possible. Try to make mealtimes pleasant and not a time for scolding or arguing. Children may try to eat faster and leave the table sooner if mealtimes are unpleasant. This creates negative association with eating. Encourage your child to eat slowly. A child can detect when he is getting full when eating slowly. Please Turn Over -> 121 Have regular meals and planned snacks as part of the family's routine. Unintentional overeating can lead to overweight when meals and snacks are at irregular times. Children can regulate their food intake better if they are fed regularly. They can eat until they are satisfied without overeating. It also teaches them to feel secure about being fed, so they won't worry about the possibility of being deprived of food when they are hungry-Help your child with snack choice. If your child is often nibbling on candy, cookies, chips, ice cream, nuts and soft drinks, this is overeating and leading to poor eating habits. Make other foods such as vegetable sticks, fruits, and low fat crackers available and, help your child make better choices. Involve children in food shopping and meal preparation. This can provide an opportunity to teach children about nutrition and also provide children with the feeling of accomplishment. Children are also more willing to eat or try foods they help prepare. Don't allow eating meals and snacks while watching TV. This habit can make it difficult for children to pay attention to whether they are full and may cause overeating. There may also be the association that whenever children watch TV, they want to eat. Try not to use food to punish or reward your child. Withholding food for punishment or rewarding with sweets gives.mixed messages about foods to children. For example, sending a child to bed without dinner for bad behavior may cause worry that he / she will be hungry. The child may then try to eat whenever he / she gets a chance. On the other hand, when foods such as sweets are offered as a reward for eating vegetables for example, this is giving the wrong message about vegetables. Last, but not least important, intense preoccupation with the child's food, eating and exercising is to be avoided since this approach to managing weight can take its toll on self-esteem and sense of self worth. Healthy Lifestyle Project May, 1999 Doreen Yasui 122 The Overweight Child: Guidelines for Parents Diet for Dietitian/Nutritionist Telephone Date By following these guidelines your child will develop lifestyle habits designed to achieve and maintain a healthy body weight. Planning Meals 1. Encourage your child to eat a variety of foods from the major food groups every day. 2. Focus on what to eat, not what not to eat. 3. Focus on earing fewer high-fat and high-sugar foods. 4. Serve small portions and ask your child to wait a little while before asking for a second serving. 5. Serve meals and snacks at regular times each day. Behaviour Changes 1. Encourage active play every day, rather than passive activity like watching television. 2. Encourage your child always to eat in the same place. The child should not eat while doing something else, for example while watching television. 3. Slow your child's rate of eating by having conversations at mealtimes. 4. Do not insist that your child's plate be cleaned at each meal. Instead, allow your child to de-cide how much to eat and when to stop eating. 5. Do not use food for bribery, punishment or reward. 6. Remember to provide opportunities for activi-ties like bicycling, swimming, walking, hiking and active playing. Attitudes 1. Set a good example yourself. 2. Encourage family members and friends to be supportive. 3. Be realistic with your child about a suitable weight goal and body image. 4. Share the responsibility with your child for the child's eating habits. 5. Do not treat your child as different from others simply because of the child's weight. Suggested Reading 1. Satter, E. How to Gel Your Kid to Eat...But Not Too Much. Palo Alto, CA: Bull Publ Co 1987. 2. Lanski, V. Fat Proofing Your Children... So They Never Become Diet Addicted Adults. Toronto: Bantam Books 1988. 3. Department of Nutrition Services. The Ready Set Go Elastic Band Program. Vancouver. BC Children's Hospital 1988. BCDNA Manual of Nutritional Care 123 1*1 Health and Welfare Sante et Bien-etre social Canada Canada Grain Products Choose whole grain and enriched products more often. Canada Vegetables & Fruit Choose dark green and orange vegetables and orange fruit more often. Milk Products Choose lower-fat milk products more often. Meat & Alternatives Choose leaner meats, poultry and fish, as well as dried peas, beans and lentils more often. © 124 T O H E A L T H Y E A T I N G FOR PEOPLE F O U R Y E A R S A N D O V E R Different People Need Different Amounts of Food The amount of food you need every day from the 4 food groups and other foods depends on your age, body size, activity level, whether you are male or female and if you are pregnant or breast-feeding. That's why the Food Guide gives a lower and higher number of servings for each food group. For example, young children can choose the lower number of servings, while male teenagers can go to the higher number. Most other people can choose servings somewhere in between. Grain Products 5 - 1 2 SERVINGS PER DAY 1 Serving 2 Servings 1 Slice 1 Bagel, Pita or Bun 1 cup Vegetables & Fruit 5 - 1 0 SERVINGS PER DAY 1 Serving Fresh, Frozen or Canned Vegetables or Fruit 1 Medium Size Vegetable or Fruit Salad Juice 125 mL -- ' 1/2 cup Milk Products SERVINGS PER DAY Qtkmi-1 ( B i M To.* 10-14 yrari: 3-4 Attic 1-4 fnparftl Wmc3-4 1 Serving Meats, Alternatives 2 - 3 SERVINGS PER DAY Cheese 2 Slices 50 g 1 Serving Meat, Poultry or Fish 50-100g 1-2 Eggs 100 g Peanut 1/3 cup Butter 30 mL 2 tbsp Taste and enjoy-ment can also come from other foods and bever-ages that are not part of the 4 food groups. Some of these foods are higher in fat or Calories, so use these foodsln moderation. Enjoy eating well, being active and feeling good about yourself. That's VfTALIT^ © Minister ot Supply and Services Canada 1992 Cat. No H39-252/1992E No changes permitted. Reprint permission not required i r rm n.fifio.iofidH-1 125 Snacks Believe it or not, kids usually need snacks, between meals to give them a boost of energy and round out their nutrient needs for the day. What you choose to eat as snack foods is important to give your body what it needs, things like vitamins A and C and minerals like calcium and iron and fiber. Choose snacks that are low in fat. Keep serving sizes small at snack times. Here are some healthy snack food suggestions: Fresh fruits - apples, grapes, kiwi, pears, banana, cantaloupe, honeydew melon, orange, berries, papaya, pineapple, watermelon, persimmon, mango Are there any fruits on this list you haven't tried? Did you know... fruit juice is full of natural sugar and has no fiber so fresh fruit is preferable. Fresh Vegetables - carrot sticks, turnip sticks, cucumber wedges, cauliflower, broccoli, cherry tomatoes, celery sticks, green, yellow, orange or red pepper slices, fennel stalks or asparagus stalks Which of these veggies do you like? Which ones can you try next? Fresh fruit and vegetables are full of vitamins, minerals and fiber and they are low in fat. Bread and grain products - plain bread sticks, whole grain breads, rice cakes, flat bread, rye crisps, melba toast, pita bread, flour tortillas, popcorn, crackers and plain cookies (look for low fat ones), cereals (high fiber, low sugar) This group of foods gives you carbohydrate energy and if you choose wisely you can get some fiber and vitamins. Remember that putting butter, margarine, peanut butter or cheese with these breads can add a lot of unwanted fat. If you do use fats with breads and grains use it in small amounts. 126 Milk and milk products - skim or 1 % milk, yogurt with fruit, cheese sticks, cottage cheese served with fruit, frozen yogurt, ice cream. With dairy choices, always try to choose the low fat option. Milk has calcium and is vitamin D fortified. Kids need these nutrients to grow and make strong bones. Treat foods! - The following foods could be used as treat foods. Use these only sometimes or for special occasions: They don't give a lot of nutrients to keep you healthy or to help you grow, so use these in limited amounts. Cakes, cookies, pies, muffins, croissants, pastries, sweet baked desserts, potato chips, corn chips, nacho chips, slushies, Slurpees, french fries, candies, pop, sweet drinks like fruit punches. To Everything, there is a Season Apples August - June Marjoram June - October Apricots July - August Melons Aug. - September Basil July - September Mushrooms Year Round Beets July - October Nectarines July - August Blackberries August - October Onions, Green June - September Blueberries July - September Onions, Red October - January Broccoli July - October Onion, Yellow September - March Brussels Sprouts Oct. - December Parsley May - October Cabbage July - February Parsnip Oct. - March Carrots July - November Peaches July - September Cauliflower June - November Pears August - April Celery July - October Peas June - July Cherries June - July Peppers July - October Chinese Vegetables June- September Plums Aug. - September Chives r Apr. - October Potatoes June - October Cilantro June - October Radish May October Corn August - October Raspberries July - September Cranberries October Rhubarb April - July Cucumbers July - September Rosemary Year Round Currants Aug. - September Sage Year Round Dill Mid July - Sept. Salad Greens June - October Garlic July - October Shallots Aug. - September Grapes Sept. - October Spinach April - September Green Beans July - September Strawberries June - September Hazelnuts Sept. - October Summer Squash July - August Kale Mid- Aug. - Nov. Swiss Chard July - October Kiwi October - February Tomatoes July - October Lavender June - October Thyme June - November Leeks July - November Turnips May - February Lettuce June - October Winter Squash Mid Sept. - Dec. Reference: East Vancouver Farmers / Community Market Pamphlet. Remember that frozen, dried (no added sugar) and canned (water / light syrup-packed) fruits and vegetables are also good choices when fresh fruits and vegetables are not available. 128 Tips for Eating Out Eating out is fun and allows one to try new foods that you might not have at home. But making healthy choices isn't always easy when you're tempted by so many delicious foods. Also each one of us has individual nutrition goals and restrictions to keep in mind when ordering at a restaurant. Whether our food needs to be low fat, low cholesterol, low salt, vegetarian or milk-free, selections can be made wisely. Here are some considerations for making heaithy choices... 1. Carefully choose which restaurant you will eat out at - fast food or dining out -what will the food selection be? 2. Make wise menu selections. Start with the main course and then you can decide from there if you will need bread, a starter or an appetizer and wait to decide on dessert later. You may be too full to want dessert at all! 3. Make special requests when ordering. For example: no mayo, no sauces, salad dressing on the side, no bacon bits on baked potatoes or low fat milk. 4. Watch out for the fats and deep fat fried foods. Fats that aren't healthy are the saturated variety and these tend to come with cholesterol in foods as well. Fats • make food taste good but pack a lot of calories as well, so learning to ID which foods are high in fat is a good thing to know. Then try to have these less often - like french fries, fried chicken, fried fish as in fish and chips. 5. Practice controlling serving size. Most restaurants give you more than you really need, but once it's in front of you it's hard to resist eating it all. Learn to share an order with someone else. Don't be afraid to ask for a doggy-bag for the leftovers. Choose the regular size serving rather than "jumbo", "super jumbo", "whopper" or "giant" etc. You'll probably be quite full with the regular size without feeling stuffed. Try to eat until you are satisfied, until your stomach feels full, without being overfull and uncomfortable. You can get a little snack later if you get hungry. 6. Eat slowly when the food is served. Take your time, chew your food. Did you know it takes about 20 minutes for the brain to get the message after you've eaten that you've had enough? If you gobble your food quickly, you're on seconds before your brain knows you've had enough. By then you've eaten enough to feel "stuffed". Stop to talk to your family, have a sip of water, put your fork down and relax between mouthfuls of food. Enjoy the whole meal time. Another consideration is how often your family "eats out", "takes out" or "orders in". For example pizzas, lasagna, hamburgers, fried chicken and fries. Try to use these fast-foods as occasional treats. Try using these suggestions the next time you eat out to make healthy choices and have funl 129 Physical Activity Guide to Healthy Active Living Physical activity improves health. Every little bit counts, but more is even better - everyone can do it! Get active your way -build physical activity into your daily life... • at home • at school • at work • at play • on the way ...thafs active living! Increase Endurance Activities Health Sante Canada Canada C*M» Canadian Society for j^j^ PE Exercise Physiology 130 Choose a variety of activities from these three groups: Endurance 4-7 days a week Continuous activities for your heart, lungs and circulatory system. Flexibility;' 4-7 days aweek ^ ^ | Gentle reaching, bending £ iandrstretehing'activities.:to;i . keepsyoursmusclesfrelaxed'*", W *~ 4 ,' and i^oints mobile * *- Strength fc- ' i v , 2-4 days a weekt r / s " ' sActivities against resistance «io;strengtHen imuseies^ 'nd" *ibones;and;improve,j|Kture^ Starting slowly is very safe for most people. Not sure? Consult your health professional. For a copy of the Guide Handbook and more information: 1-888-334-9769, or www.paguide.com Eating well is also important. Follow Canada's Food Guide to Healthy Eating to make wise food choices. Get Active Your Way, Every Day-For Life! Scientists say accumulate 60 minutes of physical activity every day to stay healthy or improve your health. As you progress to moderate activities you can cut down to 30 minutes, 4 days a week. Add-up your activities in periods of at least 10 minutes each. Start slowly... and build up. Very Light Effort • Strolling • Dusting Time needed depends on effort Light Effort Moderate Effort Vigorous Effort 60 minutes 30-60 minutes 20-30 minutes •Light walking • Brisk walking •Volleyball's-.^ , • Biking • Easy gardenings* Raking leaves • Stretching>«s«.«;Swinirnirig' • Dancing ' j \ • Water aerobics • Aerobics • Joqging • Hockey • Basketball stsvrimming S,Fast?8aTlciiui Range needed to?sta'ylHealth"y4 Maximum Effort • Sprinting • Racing You Can Do It - Getting started is easier than you think Physical activity doesn't have to be very hard. Build physical activities into your daily routine. • Walk whenever you can - get off the bus early, use the stairs instead of the elevator. • Reduce inactivity for long periods, like watching TV. • Get up from the couch and stretch and bend for a few minutes every hour. • Play actively with your kids. • Choose to walk, wheel or cycle for short trips. Start with a 10 minute walk-gradually increase the time. 1 Find out about walking and cycling paths nearby and use them. ' Observe a physical activity class to see if you want to try it. 1 Try one class to start, you don't have to make a long-term commitment. 1 Do the activities you are doing now, more often. 'Senefits^jnf regular'^ risks of inactivity: • better health • premature death • improved fitness • heart disease • better posture and balance • obesity • better self-esteem • high blood pressure • weight control • adult-onset diabetes • stronger muscles and bones • osteoporosis • feeling more energetic • stroke • relaxation and reduced stress • depression • continued independent living in • colon cancer later life rAcn\r. LIVING No changes permitted. Permission to photocopy this document in its entirety not required. Cat. No. H39-429/1998-1E ISBN 0-662-B6627-7 131 The handbook for Canada's Physical Activity Guide to Healthy Active Living (Health Canada) and Active Children Healthy Children (Health Canada, 1996) were also provided to the families in both programs. 132 All About Anger Lively songs, thought-provoking graphics and a variety of situations close to young students' experience demonstrate constructive ways ot dealing with anger. Grades 2-4 Audio-visual JAV 186.1 SUN 1996 I'm So Frustrated Program oilers easy to team strategies students can use lo solve their problems without resorting to inappropriate or destructive behaviour. Grades K-2 Audio-Visual JAV 186.1 . VAN 1994 More About Teasing: Strategies children can use to turn the tables on the teaser - 90 mins A lecture by psychologist Don Ross which talks about leasing among children. She oilers advice that is designed to help those bei ng teased develop strategies lo deal with their teasers. Ross. Dorothea Audio-Visual AV109 ROS No More Teasing Presents effective strategies kids can use to protect themselves against teasing t bullying. With help ol the 'No More Teasing Team'-peer hosts who introduce common teasing situations and oiler solutions- students can change their own behaviour to lessen teasing or bullying's impact. Gr. 2-4 Audio-Visual JAV 109ROB 1995 No one quite like me . . .or you Audio-Visual J AV 120 MAZ 1992 Peace on the Playground Hosted by a lather and son. Provides lips lor parents on how to monitor violence on TV. Shows kids how to deal with their own anger. A cartoon character suggests ways ol defusing violent situation. (27 minutes) Audio-Visual AV 109.1 FHC 1998 Stop Teasing Me Helps the youngest students understand how teasing atlects other people's feelings. Grades K-2 Audio-Visual JAV 109VAN 1995 Teasing And How To Stop It. A home based program teaches children aged 6-12 years how to end verbal abuse by taking charge ol the situation. Demonstrates correct body language and oilers a variety ot verbal responses to undermine theeffons of the children who are doing the teasing. 20:22 mins. Durbach. Edna Audio-Visual AV109DUR 1993 When You're Mad, mad, mad-dealing with anger Reassuring students that anger is normal, program helps them differentiate between angry feelings and angry behaviour. Shows viewers that they can learn to handle anger by controlling how they act, suggests positive steps they can take. Grades 5-9 Audio-Visual JAV 186.1 GRE 1993 Youth Violence: What's Out There Alter viewing dramatic recreations ol various tense situations, a studio audience ol adolescents discuss each threat, and what might be done to avert the situation. A host, acting as a group facilitator, guides the teens through the discussion toward conclusions that make sense and can save lives. 48 min. Audio-Visual Y AV 109.1 RL 1997 A Volcano in my Tummy: Helping Children Handle Anger Resource guide for parents and teachers ot 6 to 15 year olds includes worksheets, sections on what adults can do when a child is angry, troubleshooting and developing a program on anger management.. 77 pp. Book 186 WH11996 Battling the school-yard bully. Learn to stop the cycle ol bullying through friendly parent to parent advice. The child is taught how to become neither a bully nor a victim. 200pp Zarzour.Kim Book 1092 ZAR 1994 Beast. When a young boy's life Is disturbed by a classroom bully and a recurring nightmare, he is helped by the understanding of his young sister. A book lor the older child.' 93pp Wild, Margaret Book J109 WIL1992 But Names Will Never Hurt Me. Alison Wonderland grapples with the teasing she encounters until she learns how she got her name. 32pp Waber, Bernard Book J109WAB 1980 Childhood Bullying and Teasing: What School Personnel, Other Professionals, and Parents Can Do Described are the factors that support bully/victim problems, and strategies tor educators and parents to dramatically decrease these behaviours, pp. 223 Ross, Dorothea M. Book 109.2 ROS 1996 Helping Children Cope With Bullying This book aims to provide parents with the background, inlormation and support they need to tackle bullying conlidently and effectively, whatever form it takes and wherever it takes place, pp. 108 Lawson, Sarah Book 109.2 LWS 1994 Keys to Dealing with Bullies Bullying: what is it: who are bullies; who are victims: what parents can do; what schools can do. Helping victims and bullies. McNamara, BE . Book 109 McN 1997 Kidscape Stop Bullying! The signs and symptoms ot bullying are described. Methods ol dealing with bullying are suggested. Book 109.2 KDS 1993 My name is not Dummy. A book designed to help children solve common social problems by presenting a conlllct and several different ways a child could respond to it. pp. 29. Craiy, Elizabeth Book J109 MYN 1983 No one to play with; the social side of learning disabilities. Deals with the social'side ol learning disabilities & why the handicapped child is isolated trom his peer group. Why he doesn't 'lit in. 'Suggests ways that parents, teachers. & caregivers can help a child with his academic & social problems pp i2H Osman, Betty Book 181.3 OSM 1982 Nobody likes me: Helping your Child Make Friends The author looks at why some children struggle lor tiiends; how parents can help a child develop friendship skills: what social skills can be learned; and provides tilty activities tm practicing Iriendship in the home. McEwan, Elaine Book 125 MCE 1996 Family Fact Sheet Self-image and Self-esteem Self-image is the way people see themselves, both inside (feelings, dreams, confidence level) and outside (how they look, how they get along with others, how they do in school sports). Self-esteem relates to how worthwhile a person feels in all of these areas. Providing your children with love and encouragement are the most important ways that you can help your child feel worthwhile. The high cost of low self-esteem Children begin to develop their sense of self-esteem at a very young age. People who spend time with them—parents, grandparents, teachers, babysitters and others—affect how they feel about themselves. Children with low self-esteem • tend to worry more and feel sad more often • are more likely to be shy and to conform to social pressure (for example, to start smoking) • are not confident about their abilities in school and other activities • tend to have problems with peers and family members Q are more likely to feel unhappy about the way they look Q exhibit negative self-talk Children with high self-esteem • believe in their ability to succeed • feel worthy of love and respect • tend to be popular • are more likely to resist pressures to smoke and use alcohol or other drugs • are more likely to feel comfortable with their bodies and to be accepting of other people's differences Adapted from Getting There is Half the Fun! Reprinted with permission. All rights reserved. 1997. 16 „ . ^ J , i—U i> iri'i^ fmw l/alu-H *t>'H1 , a T ' c 135 How can family members help children build positive self esteem? Q Give your children chances to succeed and let them know when they do. Q Respect your children. Allow some individual action, but set clearly defined limits and rules. • Offer unconditional love. When a child misbehaves, dislike the behaviour, not the child. • Offer positive encouragement, praise and recognition. • Help your children appreciate people with different backgrounds or looks. • Show how you love them. Hug your children. Tell them they are terrific. Spend time together. • Take their ideas and feelings seriously. Don't say "You'll grow out of it." • Tell your children about the physical and emotional changes they will experience as they grow up. Ask your child's teacher for books or videos that can help you talk about difficult subjects. • Listen carefully when your children talk. • Give your children responsibility. They will feel more useful and valued. Adapted from Getting There is Half the Fun! Reprinted with permission. All rights reserved. 1997. 17 136 APPENDIX H: OUTLINE FOR COUNSELING PROGRAM Scheduling initial appointments by telephone with participants in the counseling program. Informed consent. Collect and review questionnaires (please check that all questions were answered) which have been completed at home: Children (with parents' assistance): 1. Food Frequency Questionnaire 2. Fruit and Vegetable Intake Self-Efficacy 3. Physical Activity Questionnaire 4. Physical Activity Self-Efficacy 5. Self-Perception Profile Parents: 1. Family Eating and Activity Habits Questionnaire Obtain height, weight, and triceps skinfold measurements Obtain diet history (including portion sizes, meal frequency, environment during mealtimes). Find out re: lifestyle activities. Topics to discuss: 1. Healthy eating based on Canada's Food Guide to Healthy Eating 2. Physical activity based on Canada's Physical Activity Guide to healthy Active Living 3. Self-esteem based on family fact sheet in "Getting There is Half the Fun" Handouts: similar to those given to " F U N T R E K " group program. Schedule follow-up in two months time. Charting on form provided. 137 A P P E N D I X I: S C H E D U L E S F O R G R O U P P R O G R A M " F U N T R E K " F U N T R E K Schedule for Today - Tuesday. May 11,1999 Time (min) Activity Facilitator / Volunteer 3:30 - 3:50 20 • Registration & collect completed questionnaires • Name Tags • Snacks Adrienne, Laura, Mubina, Nicole, and Tamar 3:50-4:15 25 • Introduction Doreen 4:15 - 5:00 45 • Parental Informed Consent • Questionnaires (2) Jiak 5:00-5:30 30 • Games - Team Colored Water Relay A l l 138 FUNTREK Schedule for Today - Tuesday. May 18.1999 Time (min) Activity Facilitator / Volunteer 3:30 - 3:50 20 • Snacks • Brief discussion re: Snacks Ideas A l l Doreen 3:50 - 4:30 40 Parents: Doreen • Discussion re: Learning Objectives • Food Track 40 Kids: • Making photo frames • Height / Weight / Skinfold Measurements • Discussion re: Canada's Food Guide Jiak Volunteers 4:30-5:15 45 • Parachute • Soccer A l l 139 FUNTREK Tuesday. AAav 25.1999 Time (min) Activity Facilitator/ Volunteer 3:30 - 3:50 20 • Snacks All 3:50 - 4:45 (55) Parents: • Discussion re: Healthy Eating Habits • Discussion re: Label Reading Doreen (55) Kids: • Discussion re: Canada's Food Guide • Nutrition Bingo • Measurement: Triceps Skinfold • Soccer Game Adrienne Mubina and Nicole Jiak 4:45 - 5:15 30 • Colored Water Relay • Al l . 140 F U N T R E K Tuesday. June 1.1999 Time (min) Activity Facilitator / Volunteer 3:30 - 4:00 30 • Snacks • Photo Frame All 4:00-4:30 30 Children: • Guest Speaker - Pat Ward (Community Nurse) Parents: • Brief discussion re: Physical Activity Pat Ward Jiak 4:30-5:00 30 Parents: • Guest Speaker - Pat Ward Children: • Games Pat Ward 5:00-5:20 20 • Games: • "Ship to Shore" • "Octopus" All 141 F U N T R E K Tuesday. June 8.1999 Time (min) Activity Facilitator / Volunteer 3:30 - 4:00 30 • Snacks • Follow-up re: self-esteem session with Pat Ward All 4:00 - 4:30 30 • Guest Speaker - Rosalin Hanna, Assistant Fitness Programmer, Mt. Pleasant Community Center "Physical Activities" Rosalin Hanna 4:30-5:00 30 • Relaxation Session -David Garfinkle David Garfinkle 5:00-5:20 20 • Games: • "Ship to Shore" • "Octopus" Jiak 142 Tuesday June 15,1999 • Shop Smart Tour was conducted at Save-on-Foods store at Metrotown, Burnaby. 143 FUNTREK Tuesday. June 22.1999 Time (min) Activity Facilitator / Volunteer 3:30 - 4:00 30 • Snacks • Nutrition Jeopardy • Package - surveys to be completed at home All Mubina and Nicole Jiak 4:00-4:45 45 Parents: • Guest speaker - "Effective Parenting" Children: • Games • Measurements - Ht, Wt, and TSF Mary Kay, BCCH Tamar and Adrienne Jiak 4:45-5:15 30 • Boxercise Session Laura 144 Tuesday, June 29,1999 - Last session of F U N T R E K (2-month): Anthropometric measurements were done. Collected surveys and reviewed to ensure that all questions were answered. 145 A P P E N D I X J : R O S N E R ' S B O D Y M A S S I N D E X T A B L E S T H E JOURNAL of PEDIATRICS Volume 132. Number 2 Table V. Percentiles of BMI for boys 5 to 17 years of age ROSNER ET A L Age (y> Xile Asian Black Hispanic 10 15 5 15 50 75 85 95 5 15 50 75 85 95 5 15 50 75 85 95 5 15 50 75 85 95 5 15 50 75 85 95 5 15 50 75 85 95 5 15 50 75 85 95 5 15 50 75 85 95 5 15 50 13.2 14.0 15.0 15.3 15.5 17.1 13.3 H. l 15.0 15.5 157 173 13.5 143 15.2 15.8 16.1 18.8 137 14.5 15.6 16.4 16.9 202 13.9 147 16.0 17.2 175 7T7 14.1 15.0 16.6 18.0 19.1 23.2 14.4 15.4 17.1 185 20.0 24.3 143 16.0 17.8 19.6 207 25.1 15.4 16.6 18.4-13.7 14.4 15.5 16.2 16.8 18.1 13.8 14.4 15.5 16.4 17.0 18.8 14.0 14.6 153 167 17.4 195 14.2 143 16.1 17.3 183 21.3 14.4 15.1 16.5 18.1 19.4 22.9 14.6 15.4 17.1 19.0 20.6 24.4 14.9 15.8 177 19.9 21.6 25.5 153 163 183 20.6 22.3 26.3 155 17.0 19.0 13.8 14.6 155 17.2 18.0 19.4 133 147 16.0 17.4 18.2 20.2 14.0 14.9 16.2 177 18.6 21.2 14.2 15.1 16.6 183 19.5 22.7 14.4 15.4 17.0 19.1 207 24.4 147 15.6 17.6 20.0 215 255 15.0 16.1 18.1 205 225 27.1 15.4 16.6 183 217 23.6 275 155 173 19.5 White US. weighted mean (A) NHANES 1(B) % Difference* 13.7 137 — -14.4 14.4 - — 15.5 15.6 - — 16.4 16.5 - — 17.1 17.2 - — 18.1 18.3 — — 133 133 125 67 14.4 143 13.4 75 15.6 15.6 143 77 16.6 167 — — 17.3 17.4 16.6 43 18.9 19.0 18.0 5.5 135 135 13.2 5.6 14.6 147 139 53 153 15.8 15.1 4.9 165 17.0 — — 177 173 17.4 2.1 195 20.0 19.2 4.4 14.1 14.1 13.6 35 145 145 143 4.0 16.2 \&2 15.6 37 17.5 173 — — 18.6 18.6 18.1 27 21.4 213 203 5.8 143 143 14.0 23 15.1 15.1 14.7 23 16.6 16.6 16J 27 183 18.4 — — 197 197 185 4.4 23.0 23.1 213 7.4 14.6 14.6 14.4 13 15.4 15.4 15.2 13 17.1 17.2 167 2.8 19.2 19.2 — — 205 205 19.6 67 24.5 24.6 22.6 83 145 145 143 0.7 153 153 15.6 13 177 173 . 173 27 20.1 20.1 — — 215 215 20.4 7.4 25.6 257 23.7 8.6 153 153 15.2 03 163 163 16.1 1.5 18.4 18.4 175 23 203 20.9 — — 22.6 22.6 21.1 73 26.4 263 245 63 155 155 157 1.0 17.0 17.0 16.6 2-4 19.1 19.1 183 3.2 •IA - BVB) x 100%. 146 ROSNER ET AL THE JOURNAL OF PEDIATRICS FEBRUARY 1998 TabU V (continued). Percentiles <->f BMI for boys 5 to 17 years of ??e 15 16 17 Unweighted mean (A) * NHANES X AsJari Black Hispanic White 1(B) Difference* 75 20.2 Wk 21.2 22-8 22.3 24-2 21.5 p i hzi 21.9 S3 M 26.9 28.5 27.0 27.1 25.9 4.6 I 16.0 16.5 16.6 16.5 16.5 16.2 1.9 l7 i . 17.7 18.0 177 177 { 17.2 2.9 50 19-2 19.7 20.2 19.8 19.8 19.i 32 76 20\ 21.9 23.0 • 2ti 22.1 — — & 2M 23.4 24.8 237 22.8 4.1 95 26 J 27.6 29.2 27.6 27.8 26.9 32 6 16-7 17.2 17.3 17.2 17.2 16.6 37 15 18.0 18.3 18.6 18J 18.4 17.8 3.1 50 19i 20.5 21.0 20.5 20.6 195 3.3 7S 2L5 22.5 23.6 22.8 22.8 — • — 85 22* 24.1 25.6 24.5 24.5 23.6 3.9 95 274 28.5 30.1 28.5 28.7 27.8 3.2 5 17S 17.9 18.0 17.9 17.9 17.0 5.1 15 1.8.6 18.9 19.2 18.9 19.0 18.3 3.6 50 2b¥ 21.2 21.7 21.3 21.3 20.6 3.3 75 22.2 23.3 24.4 23.6 23.6 — — 85 23.4 25.1 26.5 25.4 25.4 24.5 3.9 95 28.2 29.6 31.2 29.6 29.8 28.5 4.5 5 17.8 18.4 18.4 18.3 18.3 17.3 6.0 15 19.2 19.6 19.9 19.6 19.6 18.7 4.9 50 21.2 21.7 22.3 21.8 21.8 21.1 3.5 75 22.9 23.9 25.1 242 24.2 — ..— 85 23.8 25.5 27.0 25.9 25.9 25.3 2.3 95 28.6 29.9 31.6 30.0 30.1 29.3 2.8 •[(A-B)/B]xl00%. 147 •CHE JOURNAL OF PEDIATRICS Volume 132, Number 2 ROSNER ET A L TabU VI. Percentiles of BMI for girls 5 to 17 years of age Age (y) 12 13 %ile Asian Black Hispanic White 5 13.0 13.3 13.5 13.0 15 13.6 14.0 14.3 13.7 50 14.5 15.4 15.5 14.9 75 15.2 16.6 17.1 15.8 85 | 15.7 17.7 18.1 16.5 95 | 16.6 19.8 19.6 18.1 5 13.3 13.6 13.8 133 15 13.8 14.2 14.5 14.0 50 14.6 15.5 15.6 15.0 75 15.5 17.0 17.5 16.1 85 16.1 18.1 18.5 16.9 95 17.4 20.7 20.5 18.9 5 13.4 13.8 13.9 13.5 15 14.0 14.4 14.7 14.1 50 14.9 15.8 15.9 153 75 16.1 17.5 18.0 167 85 16.7 18.8 19.2 17.6 95 18.4 21.8 21.6 20.0 5 13.5 135 14.0 133 15 14.2 14.6 14.9 14.3 50 15.3 16.2 16.3 157 75 16.8 18.3 18.8 17.4 85 17.7 19.8 20.2 18.6 95 19.6 23.1 22.9 21.2 5 13.6 14.0 14.1 13.6 15 14.4 14.8 15.1 14.5 50 15.8 16.7 16.9 16.2 75 17.7 19.2 19.7 183 85 18JL 21.0 21.4 197 95 20.9 24.5 243 22.6 5 13.9 14.2 14.4 13.9 15 ' 14.8 15.2 15.5 14.9 50 16.5 17.4 17.6 16.9 75 18.7 20.2 20.8 193 85 20.0 22.3 22.7 21.0 95 22.4 26.1 25.8 24.1 5 14.3 14.7 14.9 14.4 15 15.4 15.8 16.1 153 50 173 183 18.4 177 75 19.7 21.3 21.9 20.4 85 21.2 23.5 24.0 22.2 95 23.8 27.6 27.4 26.6 5 15.0 15.4 15.5 15.0 15 16.1 16.6 16.9 163 50 18.2 19.2 193' 18.6 75 20.7 22.4 22.9 21.4 85 22.2 24.6 25.1 23.2 95 25.2 29.1 28.9 27.0 5 15.8 16.1 163 15.8 15 1619 17.4 17.7 17.1 50 193 20.0 20.2 19.4 U.S. weighted mean (A) NHANES 1(B) X Difference* 13.1 13.8 15.1 16.1 16.9 18.5 13.4 14.1 15.2 16.4 17.2 193 13.6 143 15.4 17.0 175 20.4 13.6 14.4 15.8 177 18.9 21.7 137 14.6 16.4 18.6 20.1 23.0 14.0 15.0 17.1 19.6 21.4 24.5 143 15.6 17.9 20.7 22.6 26.1 15.1 16.4 18.8 217 23.6 27.5 155 17.2 19.6 12.8 13.4 143 16.2 173 13.2 13.8 15.0 17.2 18.9 133 14.2 157 18.2 20.4 13.9 147 163 19.2 21.8 14.2 15.1 17.0 20.2 23.2 14.6 153 . 177 21.2 24.6 15.0 16.0 18.4 22.2 26.0 15.4 16.4 19.0 4.9 4.9 6.0 63 103 23 33 23 43 8.0 1.0 1.6 07 3.9 62 -1.1 -03 0.4 4.6 57 -13 -0.4 0.4 57 53 -0.8 03 1.1 63 6.0 1.0 2.4 2.1 6.4 5.8 33 5.0 3.2 • IA-BVB]X100%. 148 ROSNER ET AL. THE JOURNAL of PEDIATRIC; FEBRUARY 1996 Jhilr 17 itontimui). Ptaxentiles of BMI for gtris 5 lo 17 years of age Aje US. weighted NHANES X Asian Bhck Hispanic White mean (A) I (B) Difference* 76 21.6 • J > 23.2 23.8 22.2 22.6 86 23.0 25.4 26.9 24.0 24.4 23.1 6.6. 96 26.3 303 30.0 28.1 28.6 27.1 6.7 14 6 16.5 163 17.0 \6f 16.6 167 6.8 15 177 18.1 18.5 173 18.0 163 65 60 19.6 207 203 20.1 20.2 193 76 22.1 233 243 22.8 23.1 — — 86 23.6 255 26.4 243 24.9 23.9 4.2 96 26.9 51.0 307 28.8 29.3 28.0 4.7 1« 6 17.0 17.4 173 17.0 17.1 16.0 7.0 16 18.1 18.6 }9.0 183 18.4 17.2 7.2 60 20A 21.1 21.2 20.6 20.6 197 43 76 223 24.0 24.6 23.1 23.4 - — 86 23.8 2W 267 24,8 26.2 243 3.7 96 27.2 313 31.0 29:1 29.6 283 3.9 16 6 17.2 17.6 17.8 17i 17.4 16.4 6.1 16 18.4 18.9 19.2 18.6 18.7 173 6.6 60 20.2 213 21.4 20.7 20.9 20.1 3.8 76 22.6 24.2 24.8 23.2 233 — — • 86 24.0 26.6 27.0 25.1 26.5 24.7 3.1 96 27.6 31.6 31.4 29.4 29.9 29.1 2.9 17 6 17.5 17.9 18.1 17.6 17.7 16.6 6.6 16 18.6 19.1 193 183 185 173 6.3 60 20.6 21.6 21.8 21.0 21.2 20.4 4.0 75 23.0 24.7 253 237 24.1 — — 86 24.6 265 273 263 26.9 26.2 3.0 96 28.8 33.0 32.8 30.8 31.3 297 6.4 1(A-B>/U|x|00*. 149 APPENDIX K: SKINFOLDS PERCENTILE TABLES Age Triceps Skinfold Percentiles (mm) (yr) 5 10 25 50 75 90 95 . Males 1-1.9 6 7 8 10 12 14 16 2-2.9 6 7 8 10 12 14 15 3-3.9 6 7 8 10 11 14 15 4-4.9 6 6 8 9 11 12 14 5-5.9 6 6 8 9 11 14 15 6-6.9 5 6 7 8 10 13 16 7-7.9 5 6 7 9 12 15 17 8-8.9 5 6 7 8 10 13 16 9-9.9 6 6 7 10 13 17 18 10-10.9 6 6 8 10 14 18 21 11-11.9 6 6 8 11 16 20 24 12-12.9 6 6 8 11 14 22 28 13-13.9 5 5 7 10 14 22 26 14-14.9 4 5 7 9 14 21 24 15-15.9 4 5 6 8 11 18 24 16-16.9 4 5 6 8 12 16 22 17-17.9 5 5 6 8 12 16 19 18-18.9 4 . 5 6 9 13 20 24 19-24.9 4 5 7 10 15 20 22 25-34.9 5 6 8 12 16 20 24 35-44.9 5 6 8 12 16 20 23 45-54.9 6 6 8 12 15 20 25 . 55-64.9 5 6 8 11 , 14 19 22 65-74.9 . 4 6 8 11 15 19 22 Females 1-1.9 6 7 8 10 12 14 16 2-2.9 6 8 9 10 12 15 16 3-3.9 7 8 9 11 12 14 15 4-4.9 7 8 8 10 12 14 16 5-5.9 6 7 8 10 12 15 18 6-6.9 6 6 8 10 12 14 16 7-7.9 6 7 9 11 13 16 18 8-8.9 6 8 9 12 15 18 24 9-9.9 8 8 10 13 16 20 22 10-10.9 •7 8 10 12 17 23 27 11-11.9. 7 8 10 13 18 24 28 12-12.9 8 9 11 14 18 23 27 13-13.9 8 8 12 15 21 26 30 14-14.9 9 10 13 16 21 26 28 15-15.9 8 10 12 17 21 25 32 16-16.9 10 12 15 18 22 26 31 17-17.9 10 12 13 19 24 30 37 18-18.9 10 12 15 18 22 26 30 19-24.9 10 11 14 18 . 24 30 34 25-34.9 10 12 16 21 27 34 37 35-44.9 12 14 18 : 23 29 35 38 45-54.9 12 16 20 25 30 36 40 55-64.9 12 16 20 25 31 36 38 65-74.9 12 14 18 24 29 34 36 Appendix A 12.28: Percentiles for triceps skinfolds (mm) by age for U.S. white persons aged one to seventy-five years. Data from the NHANES I (1971-1974) survey. Date from Frisancho (1981). © Am. J. Clin. Nutr. American Society for Clinical Nutrition. 150 Name: APPENDIX L: FIRST SESSION- QUESTIONNIARE FOR T H E CHILDREN Age: Please circle: Boy or Girl Date: This is NOT a test and there are no right or wrong answers. Please answer all the questions as honestly and as accurately as you can. In the Previous Week,. 1. During your PHYSICAL EDUCATION (PE) classes, how often were you active (playing hard, running, jumping, throwing)? i a. I don't do PE b. Hardly ever c. Sometimes d. Quite often e. Always , 2. What did you do most of the time at R E C E S S ? a. Sat down (talking, reading, doing school work) b. Stood around or walked around c. Ran or played a little bit d. Ran around and played quite a bit e. Ran and played hard most of the time 3. What did you normally do AT LUNCH (besides eating lunch)? a. Sat down (talking, reading, doing school work) b. Stood around or walked around c. Ran or played a little bit d. Ran around and played quite a bit e. Ran and played hard most of the time 151 \ \ 4. On how many days R IGHT A F T E R S C H O O L did you do sports, danced, or played games? a. None b. 1 day last week c. 2 days last week d. 3 days last week e. 4 days last week f. 5 days last week 5. On how many E V E N I N G S did you do sports, danced, or played games? a. None b. 1 day last week c. 2-3 days last week d. 4-5 days last week e. 6-7 days last week 6. O N T H E L A S T W E E K E N D , how many times did you do sports, danced, or played games? a. None b. 1 time c. 2 - 3 times d. 4 - 5 times e. 6 or more 7. How often do you do activities such as playing sports, playing games, dancing, hiking with members of your family? a. None b. A little bit c. Somewhat often d. Often e. Very often 8. How often do you talk to your parents about health? a. None b. A little bit c. Somewhat often d. Often e. Very often 152 9. When I choose foods, good taste is most important to me. 10. I watch carefully the foods I choose at every meal. 11. I am not concerned about the kinds of food I eat everyday. 12. I believe i f I skip breakfast, I wil l not be able to concentrate well in class during morning session. 13. I think what I eat may affect my health. Strongly Disagree Not sure Agree Strongly Disagree Agree • • - • • • • • • • • • • • • • • • • • • • • • • • • 14. When I choose a snack, I usually choose: (Please list at list 3 kinds of food you usually choose for snacks) W H A T I A M L I K E : Not True for Me 15. Some kids are happy with they way the look. 16. Some kids have a lot of friends. 17. Some kids like their body the way it is. 18. Some kids like the kind of person they are. • • • • 19. In games and sports, some kids usually play rather C than just watch. 20. Some kids are happy with the way they do a lot of 0 things. 153 Sort of True for M e • • • • • • Really True for Me • • • • • • APPENDIX M: FIRST SESSION-QUESTIONNAIRE FOR T H E PARENTS Questionnaire - For Parent / Guardian Name: Ch i l d ' s Name: . Date: Please c i rc le : Father or Mother Th is set of questions relate to your diet, l ifestyle, and health. 1. During the past month, how healthy were the foods you ate in general? a. Not healthy at all b. Not so healthy c. Not sure d. Moderately healthy e. Very healthy 2. In general, compared to other people your age, would you say your health is .... a. Poor b. Fair c. Good d. Very good e. Excellent 3. During *he past month, did you think that your diet affects your health? a. Not at all b. Not very much c. Not sure d. Yes, very much so e. Yes, definitely so 4. Are your food habits influenced by your cultural or ethnic background? a. Yes If yes, which group b. No c. Don't know 154 Please identify if any of the following factors are challenges for you in relation to food. Strongly Disagree Not sure Agree Strongly Disagree Agree 5. When I choose foods, good 0 taste is most important to me. • • • • 6. I watch carefully the foods I choose at every meal. • • • • • 7. I am not concerned about the kinds of food I eat everyday. • • • • • 8. I believe if I skip breakfast, 0 I will not be able to concentrate well in the morning. 9. I mink what I eat may affect 0 my health. 10.1 find it hard to shop for healthy 0 foods in the grocery stores. • • • • • • • • • • • • 11.1 find it difficult to know what LZ3 foods are nutritious • • • • 12.1 find it takes to much time to 0 prepare healthy meals. • • • • 13.1 find it easy to change my eating 0 when I know it is good for my health. • • • • 155 15. Compared with other people you know, how would you describe your usual activity level? a. Very Low b. Low c. Medium d. High e. Very High 16. Which statement best describes how you feel about regular physical activity? a. I am not very active, I don't exercise and I don't plan to start. b. I have been tlunking about being more active but just can't get started. c. I exercise once in a while, but I could do more. d. I have started exercising regularly but it is tough to keep up. e. I exercise regularly and enjoy it. 17. Do you think that getting more exercise would improve your health? a. Not at all b. A little c. Not sure d. A moderate amount e. A great deal 18. How often do you do activities such as playing sports, playing games, dancing, hiking with members of your family? a. None b. A little bit c. Somewhat often d. Often e. Very often 19. How often do you talk to you kids about health? a. None b. A little bit c. Somewhat often d. Often e. Very Often 156 20. What is your current marital status? a. Single (Never married) b. Married (and not separated), or living common law c. Separated d. Divorced e. Widowed 21. Which of the following best describes your employment status now? a. Employed full-time b. Employed part-time (less than 30 hours/week) c. Self-employed d. Unemployed e. Retired f. Stay Home Parent g. Student 22. What is the highest grade or level of education you have completed? 23. What is your best estimate of the total income, before taxes of all household members from all sources in 1998? a Less then 10, 000 b. 10, 000 - 19,999 c. 20, 000 - 29,999 d. 30,000 - 39,999 e. 40,000 - 49,999 f. 50,000 - 59,999 g. 60,000 and above Thank you for your time in completing this questionnaire 157 A P P E N D I X N : S E C O N D SESSION-FOOD F R E Q U E N C Y Q U E S T I O N N A I R E P A G E O N E E A T I N G S U R V E Y K-95-1 H A R V A R D M E D I C A L S C H O O L ! M A R K I N G I N S T R U C T I O N S • Use a NO. 2 PENCIL only. • Do not use ink or ballpoint pen. • Darken in the circle completely. • Erase cleanly any marks you wish to change. • Do not make any stray marks on this form. The RIGHT way to mark your answer! The WRONG way to mark your answersl e>®o© fVl»/ne » 1. What is your AGE? • Less than 9 0 1 3 C 9 C 1 4 O 1 0 C 1 5 G 1 1 C 1 6 0 1 2 0 1 7 O l 8 o r older 2. Are you: :) Male O Female 3. Your Height FEET HCHES I © ®© © ©© © © © © © © © © © © 4. Your Waight (tx) © © © ft © © © © © © © © © © © © © © •} © © # © Questionnaire refers to what you ate over the past y«r. 5. Do you now take vitamins (like Fllntstones, Ons-A-Day, etc.)? -'No C Yes — ^ If yes) 4. a) How many vitamin pills do you take a weak? O 2 or less G 3 - 5 0 6 - 9 0 1 0 or more b) For how many years havs you b«an taking them? O 0 -1 years © 2 - 4 © 5 - 9 0 1 0 + years 9b 6. How many teaspoons of sugar do you ADD to your beverages or food each day? •< None/less than 1 teaspoon per day J 1 - 2 teaspoons per day O 3 - 4 teaspoons per day O 5 or more teaspoons per day 8. Where do you usually eat breakfast? C At home C At school O Don't eat breakfast C Other Copyright© 1985 Bdgham and Worrwn'i Ho*piul. AH ngnti r » M r v M worldwide. 7. Which cold breakfast cereal do you usually eat? C Never eat cold breakfast cereal » . i i 1 ** a » »i • ' '1 *• *, *1 i i • ». • I 7' 7, • •': • I » • M 9. How many times each week (including weekdays and weekends) do you usually eat breakfast prepared awav from home? 0 Never or almost never 0 1 - 2 times per week 0 3 - 4 times per week O 5 or more times per week • •V 29528 158 10. How many times each week (including weekdays and weekends) do you usually eat lunch prepared away from home? ' • Never or almost never . 1 - 2 times per week ... 3 - 4 times per week . 5 or more times per week 11. How many times each week do you usually eat after-school snacks or foods prepared away from home? Never or almost never ' , 1 - 2 times per week .' 3 - 4 times per week 5 or more times per week 12. How many times each week (weekdays and weekends) do you usually eat dinner prepared awav from home? . Never or almost never . 1 - 2 times per week 3 - 4 times per week ..." 5 or more times per week 13. How many times per week do you prepare dinner for yourself (and/or others in your house)? •'. Never or almost never Less than once per week • 1 - 2 times per week 3 - 4 times per week 5 or more times per week 14. How often do you have dinner that is ready made, like frozen dinners, Spaghetti-O's, microwave meals, etc. ; Never/less than once per month 1 - 2 times per week 3 - 4 times per week 5 or more times per week 15. How many times each week (including weekdays and weekends) do you eat late night snacks prepared away from home? ••' ; Never/less than once per month 1 - 2 times per week 3 - 4 times per week 5 or more times per week 16. How often do you eat food that is fried at home, like fried chicken? Never/less than once per week . 1 - 3 times per week . 4 - 6 times per week '"' Daily 17. How often do you eat fried food away from home (like french fries, chicken nuggets)? • .'' Never/less than once per week ; . 1 - 3 times per week 4 - 6 times per week I Daily DIETARY INTAKE How often do you eat the following foods: E1. Diet soda Example If you drink one can of diet soda 2-3 (1 can or glass) times per week, then your answer should look Never l i k e t h l s : 1 - 3 cans per month 1 can per week • 2 - 6 cans per week 1 can per day 2 or more cans per day 159 B E V E R A G E S FILL OUT ONE BUBBLE FOR EACH FOOD ITEM 18. Diet soda (1 can or glass) ' Never/less than 1 per month r1 - 3 cans per month . 1 can per week . 2 - 6 cans per week ~ 1 can per day 2 or more cans per day 19. Soda-not diet (1 can or glass) Never/less than 1 per month 1-3 cans per month 1 can per week ' 2 - 6 cans per week A 1 can per day 2 or more cans per day 20. Hawaiian Punch, lemonade, Koolaid or other non-carbonated fruit drink (1 glass) C Never/less than 1 per month C 1 - 3 glasses per month J 1 glass per week 0 2 - 4 glasses per week C 5 - 6 glasses per week ( 1 glass per day '".' 2 or more glasses per day 21. Iced Tea - sweetened 22. Tea (1 cup) (1 glase, can or bottle) "Never/less than 1 per month ' ~j 1 - 3 glasses per month " 1 - 4 glasses per week . / 5 - 6 glasses per week 0 1 or more glasses per day _ Never/less than 1 per month 1 - 3 cups per month . 1 - 2 cups per week j 3 - 6 cups per week "j 1 or more cups per day 23. Coffee - not decaf. (1 cup) 0 Never/less than 1 per month 0 1 - 3 cups per month 0 1 - 2 cups per week 3 - 6 cups per week C 1 or more cups per day py, 24. Beer (1 glass, bottle or can) ~"i Never/less than 1 per month C 1 - 3 cans per month C 1 can per week O 2 or more cans per week 3 24- .16 25. Wine or wine coolers (1 glass) C Never/less than 1 per month C 1 - 3 glasses per month ~ 1 glass per week ' 2 or more glasses per week 26. Liquor, like vodka or rum (1 drink or shot) C Never/less than 1 per month C 1 - 3 drinks per month 0 1 drink per week O 2 or more drinks per week Example H you eat 3 pats of margarine on toast 1-2 pats of margarine on sandwich 1 pat of margarine on vegetables 5 - 6 pats total all day then answer this way E2. Margarine (1 pat) • butter not O Never 0 1 -'3 pats per month 0 1 pat per week O 2 - 6 pats per week Q1 pat per day G 2 - 4 pats per day # 5 or more pats per day DAIRY PRODUCTS 27. What TYPE of milk do you usually drink? "J Whole milk C 2% milk O 1% milk C Skim/nonfat milk C Don't know C Don't drink milk 28. Milk (glass or with cereal) L Never/less than 1 per month C 1 glass per week or less ?. 2 - 6 glasses per week ~ 1 glass per day 2 -3 glasses per day 4+ glasses per day 29. Chocolate milk (glass) C Never/less than 1 per month 0 1 - 3 glasses per month C 1 glass per week C 2 - 6 glasses per week C, 1 - 2 glasses per day '7 3 or more glasses per day 29528 160 3 0 . Instant Breakfast Drink (1 packet) Never'less than 1 per month 11 - 3 times per month Once per week 2 - 4 times per week 5 or more times per week 3 1 . Whipped cream ~ Never/less than 1 per month 1-3 times per month Once per week 2 - 4 times per week 5 or more times per week 32. Yogurt (1 cup) - Not frozen ' Never/less than 1 per month 1 - 3 cups per month 1 cup per week 2 - 6 cups per week • 1 cup per day 2 or more cups per day 33. Cottage or ricotta cheese Never/less than 1 per month . 1 - 3 times per month Once per week 2 or more times per week 34. Cheese II slice) Never/less than 1 per month ' . . 1 -3 slices per month . 1 slice per week . 2 - 6 slices per week 1 slice per day . 2 or more slices per day 35. Cream cheese Never'less than 1 per month 1 - 3 times per month Once per week 2 or more times per week 36. What TYPE of yogurt, cottage cheese & dairy products (besides milk) do you use mostly? Nontat ' Lowfat ' Regular '.. Don't know 37. Butter |1 pat) -NOT margarine ' Never/less than 1 per month '.. 1 -3 pats per month . 1 pat per week . 2 - 6 pats per week 1 pat per day 2 - 4 pats per day 5 or more pats per day 38. Margarine (1 pat) - NOT butter '. Never/less than 1 per month 1 - 3 pats per month 1 pat per week 2 - 6 pats per week _ 1 pat per day . 2 - 4 pats per day 5 or more pats per day 39. What FORM and BRAND of margarine does your family usually use? None Stick '".•Tub Squeeze (liquid) WHAT SPECIFIC BRAND ANO TYPE (LIKE "PAP.KAY CORN OIL SPREAD")? 40. What TYPE of oil does your family use at home? Canola oil Corn oil , ' Safflower oil . .'• Olive oil '. Vegetable oil ".' Don't know Leave blank If you don't know. M A I N D I S H E S 41. Cheeseburger (1) 42. Hamburger (1) 43. Pizza (2 slices) ' Never/less than 1 per month C Never'less than 1 per month Never/less than 1 per month 1 - 3 per month O 1 - 3 per month 1 - 3 times per month One per week .One per week '. Once per week 2 - 4 per week . 2 - 4 per week 2 - 4 times per week 5 or more per week 5 or more per week ' 5 or more times per week 44. Tacos/burritos (1) Never/less than 1 per month i . 1 - 3 per month i "' One per week i . 2 - 4 per week i " 5 or more per week 45. Which taco filling do you usually have: '.'. Beef & beans Beef '.. Chicken .. Beans 46. Chicken nuggets (6) Never/less than 1 per month 1 - 3 times per month Once per week 2 - 4 times pe r week 5 or more times per week 47. Hot dogs (1) Never/less than 1 per month ._) 1 - 3 per month O One per week O 2 - 4 per week 5 or more per week 48. Peanut butter sandwich (1) (plain or with jelly, fluff, etc.) . Never/less than 1 per month 1 - 3 per month . One per week 2 - 4 per week 5 or more per week 49. Chicken or turkey sandwich (1) C Never/less than 1 per month '.. 1 - 3 per month O One per week C 2 or more per week 50. Roast beef or ham sandwich (1) O Never/less than 1 per month O 1 - 3 per month '.J One per week O 2 or more per week 51. Salami, bologna, or other deli meat sandwich (1) '." Never/less than 1 per month 1 - 3 per month . One per week .1 2 or more per week 52. Tuna sandwich (1) C Never/less than 1 per month O 1 - 3 per month C One per week ... 2 or more per week 53. Chicken or turkey as main dish (1 serving) J Never/less than 1 per month 0 1 - 3 times per month C Once per week O 2 - 4 times per week •' , 5 or more times per week 54. Fish sticks, fish cakes or fish sandwich (1 serving) O Never/less than 1 per month . ; 1 - 3 times per month Once per week 2 or more times per week 55. Fresh fish as main dish (1 serving) 'J Never/less than 1 per month C 1 - 3 times per month C Once per week i. 2 - 4 times per week 1. 5 or more times per week 56. Beef (steak, roast) or lamb as main dish (1 serving) O Never/less than 1 per month O 1 - 3 times per month (j Once per week O 2 - 4 times per week O 5 or more times per week 57. Pork or ham as main dish (1 serving) " Never/less than 1 per month C 1 - 3 times per month ' Once per week 2 - 4 times per week O 5 or more times per week 58. Meatballs or meatloaf (1 serving) C Never/less than 1 per month Q 1 - 3 times per month C Once per week 0 2 - 4 times per week C 5 or more times per week 59. Lasagna/baked ztti (1 serving) O Never/less than 1 per month O 1 - 3 times per month O Once per week O 2 or more times per week 60. Macaroni and cheese (1 serving) J Never/less than 1 per month Ol - 3 times per month O Once per week 2 or more times per week 61. Spaghetti with tomato sauce (1 serving) C Never/less than 1 per month O l - 3 times per month O Once per week 0 2 - 4 times per week O 5 or more times per week 62. Eggs (1) 0 Never/less than 1 per month 01 - 3 eggs per month O One egg per week .) 2 - 4 eggs per week • I 5 or more eggs per week 63. Liver: beef, calf, chicken or pork (1 serving) Never'less than 1 per month Less than once per month Once per month . 2 - 3 times per month . Once per week or more 64. Shrimp, lobster, scallops (1 serving) T Never/less than 1 per month 1 - 3 times per month O Once per week 2 or more times per week • 29528 162 65. French toast (2 slices) Never'less than 1 per month '. 1 - 3 times per month Once per week 2 or more times per week 66. Grilled cheese (1) Never/less than 1 per month ".. 1 - 3 times per month Once per week ')2 or more times per week 67. Eggrolls (1) Never/less than 1 per month 1 - 3 times per month . Once per week 7 2 or more times per week M I S C E L L A N E O U S F O O D S 68. Brown gravy Never'less than 1 per month Once per week or less ' 2 - 6 times per week : ':• Once per day , 2 or more times per day 69. Ketchup Never/less than 1 per month 1 - 3 times per month Once per week . 2 - 4 times per week 5 or more times per week 70. Clear soup (with rice, noodles, vegetables) 1 bowl ~ Never'less than 1 per month . 1 - 3 bowls per month C 1 bowl per week 2 or more bowls per week 71. Cream (milk) soups or 72. Mayonnaise 73. Low calorie/fat salad dressing chowder (1 bowl) r N e v e r / t e s s t n a n 1 p e r month Never/less than 1 per month Never'less than 1 per month . 1 - 3 times per month 1 - 3 times per month . 1 - 3 bowls per month '. Once per week : Once per week ' 1 bowl per week - 2 - 6 times per week . 2 - 6 times per week 2 - 6 bowls per week Once per day Once or more per day 1 or more bowls per day 74. Salad dressing (not low calorie) , , Never/less than 1 per month ~. 1 - 3 times per month ~ Once per week V 2 - 6 times per week Once or more per day 75. Salsa ... Never/less than 1 per month " 1 - 3 times per month Once per week 2 - 6 times per week C Once or more per day 76. How much fat on your beef, pork, or lamb do you eat? O Eat all L Eat some C Eat none C Don't eat meat 77. When you have chicken or turkey, do you eat the skin? ' . Y e s . No Sometimes 163" B R E A D S & C E R E A L S 78. Cold breakfast cereal (1 bowl) N r v c / l e s s than 1 per month 1 - 3 bowls per month 1 bow ! per week 2 - 4 bowls per week 5 - 7 bow's per week 2 or more bowls per day 81. Dark bread (1 slice) Never- ' less than 1 per month 1 sl ice per week or less 2 - 4 s l ices per week 5 - 7 s l ices per week 2 - 3 s l ices per day 4+ s l ices per day 79. Hot breakfast cereal, like oatmeal, grits (1 bowl) Never ' less than 1 per man 1 - 3 bowls per month 1 bowl per week 2 - 4 bowls per week 5 - 7 bowls per week 2 or more bowls per day 80. White bread, pita bread, or toast (1 slice) Never - less than 1 per mont> 1 s l ice per week or less 2 - 4 s l ices per week 5 - 7 s l i ces per week 2 - 3 s l ices per dny 4+ s l ices per day 82. English muffins or 83. Muffin (1) bagels (1) Never/ less than 1 per month 1 - 3 per month . 1 per week 2 - 4 per week 5 or more per week Never / less than 1 per month 1 - 3 muffins per month 1 muffin per week 2 - 4 muffins per week 5 or more m u f i n s per week 84. Cornbread (1 square) Never ' l ess than 1 per month 1 - 3 t imes per month O n c e per week 2 - 4 t imes per week 5 o r more per week 85. Biscuit/roll ID Never/ less than 1 per month 1 - 3 per month 1 per week 2 - 4 per week ' 5 or more per week 86. Rice Never / less than 1 per m c n ' h 1 - 3 t imes per month O n c e per week 2 - 4 t imes per week 5 or more t imes per week 87. Noodles, pasta Never ' l ess than 1 per month 1 - 3 t imes per month O n c e per week 2 - 4 t imes per week 5 or more t imes per week 88. Tortilla - no filling (1) Never/ less than 1 per month . 1 - 3 per month 1 per week 2 - 4 per week 5 or more per week 89. Other grains, like kasha, couscous, bulgur Neve r ' l ess than 1 per month 1 - 3 t imes per month O n c e per week 2 or more t imes per week 90. Pancakes (2) or waffles (1) Never / less than 1 per month 1 - 3 t imes per month O n c e per week 2 or more t imes per week 91. French fries (large order) Never / less than 1 per month 1 - 3 orders per month 1 order per week 2 - 4 orders per week 5 or more orders per week 92. Potatoes - baked, boiled, mashed Neve r ' l ess than 1 per month 1 - 3 t imes per month O n c e per week 2 - 4 t imes per week 5 or more t imes per week l9f a 164 F R U I T S & V E G E T A B L E S 93. Raisins (small pack) '.' Never/less than 1 per month ~. 1 - 3 times per month 1 per week 2 - 4 times per week . 5 or more times per week 96. Cantaloupe, melons (1/4 melon) 0 Never/less than 1 per month 0 1 - 3 times per month . 1 per week 2 or more times per week 94. Grapes (bunch) 0 Never/less than 1 per month O 1 - 3 times per month Once per week O 2 - 4 times per week • J 5 or more times per week 97. Apples (1) or applesauce 0 Never/less than 1 per month 0 1 - 3 per month O1 per week 2 - 6 per week O 1 or more per day 99. Oranges (1), grapefruit (1/2) 100. Strawberries Never/less than 1 per month 1 - 3 per month 1 per week 2 - 6 per week 1 or more per day 102. Orange juice (1 glass) Never/less than 1 per month . 1 - 3 glasses per month 1 glass per week 0' 2 - 6 glasses per week O 1 glass per day v 2 or more glasses per day 105. Tomato/spaghetti sauce '• ". Never/less than 1 per month ' v 1 - 3 times per month . Once per week 2 - 4 times per week ' . 5 or more times per week Never/less than 1 per month 0 1 - 3 times per month J Once per week J 2 or more times per week 103. Apple juice and other fruit juices (1 glass) C Never/less than 1 per month O 1 - 3 glasses per month C 1 glass per week 0 2 - 6 glasses per week O 1 glass per day O 2 or more glasses per day 95. Bananas (1) . Never/less than 1 per month 1 - 3 per month '. 1 per week 0 2 - 4 per week O 5 or more per week 98. Pears (11 '.. Never/less than 1 per month O 1 - 3 per month O 1 per week T 2 - 6 per week O 1 or more per day 101. Peaches, plums, apricots (1) 0 Never/less than 1 per month 0 1 - 3 per month I) 1 per week O 2 or more per week 104. Tomatoes (1) O Never/less than 1 per month '. J1 - 3 per month O 1 per week O 2 - 6 per week O 1 or more per day 106.Tofu O Never/less than 1 per month 0'1 - 3 times per month O Once per week 0 2 - 4 times per week ._' 5 or more times per week 107. String beans . ; Never/less than 1 per month O 1 - 3 times per month 0 Once per week O 2 - 4 times per week O 5 or more times per week 29528 165 108. Beans/lentils/soybeans 109. Never'less than 1 per month Once per week or less 2 - 6 times per week Once per d a / Broccoli '. Never/less than 1 per month 1 - 3 times per month Once per week . , 2 - 4 times per week 5 or more times per week 110. Beets (not greens) Never/less than 1 per montn Once per week or less 2 or more times per week 111. Corn 112. Never/less than 1 per month 1 - 3 times per month Once per week 2 - 4 times per week 5 or more tines per week Peas or lima beans 113. '. Never/less than 1 per month 1- 3 times per month Once per week 2 - 4 times per week 5 or more times per week Mixed vegetables Never/less than 1 per month 1 - 3 times per month Once per week 2 - 4 times per week 5 or more times per week 114. Spinach 115. Never'less than 1 per month 1 - 3 times per month Once a week ' 2 - 4 times per week 5 or more times per week Greens/kale '' .• Never/less than 1 per month ,1-3 times per month Once per week . 2 - 4 times per week 5 or more times per week 116. Green/red peppers Never/less than 1 per month ' 1-3 times per month . Once a week 2 - 4 times per week 5 or more times per week 117. Yams/sweet potatoes (11 Never'less than 1 per month 1 - 3 times per month Once a week 2 - 4 times per week 5 or more times per week 118. Zucchini, summer squash, eggplant Never/less than 1 per month 1 - 3 times per month ' , Once per week 2 -4 times per week 5 or more times per week 19. Carrots, cooked Never'less than 1 per month 1 - 3 times per month Once per week 2 - 4 times per week 5 or more times per week 120. Carrots, raw 121. Celery 122. Lettuce/tossed salad Never'less than 1 per month 7 Never'less than 1 per month Never'less than 1 per month 1 -3 times per month 1 - 3 times per month 1 - 3 times per month Once p e r week ' , Once per week \ Once per week 2 - 4 times per week . 2 - 4 times per week 2 - 6 times per week 5 or more times per week 5 or more times per week '.. One or more per day 123. Coleslaw Never'less than 1 per month 1 - 3 times per month Once per week 2 or more times per week 124. Potato salad '.' Neve''less than 1 per month 1-3 times per month Once per week 2 or more times per week 166 Think about your usual snacks. How often do you eat each type of snack food. Example H you eat poptarts rarely (about 6 per year) then your answer should look like this: E3. Poptarts (1) 9 Never/less than 1 per month 1 - 3 per month 1 - 6 per week 1 or more per day S N A C K F O O D S / D E S S E R T S 125. Fill in the number of snacks (food or drinks) eaten on school , i „ , „ „ J / days and weekends/vacation days. gf s n , e J r S -for +ht f»«T WW Snacks Between breakfast and lunch After lunch, before dinner After dinner School Daya NONE 1 2 3 4 OR MORE f j Vacation/Weekend Days NONE 1 2 3 4 OR MORE '-126. Potato chips (1 small bag) 127. Never/less than 1 per month 1 - 3 small bags per month _ One small bag per week . 2 - 6 small bags per week 1 or more small bags per day Corn chips/Doritos (small bag) Never/less than 1 per month 1 - 3 small bags per month One small bag per week 2 - 6 small bags per week 1 or more small bags per day 128. Nachos with cheese (1 serving) Never/less than 1 per month 1 - 3 times per month . Once per week 2 or more times per week 129. Popcorn (1 small bag) 130. Never/less than 1 per month 1 -3 small bags per month 1 -4 small bags per week 5 or more small bags per week Pretzels (1 small bag) 131. Never/less than 1 per month 1 - 3 small bags per month '. 1 small bags per week 2 or more small bags per week Peanuts, nuts (1 small bag) ' Never/less than 1 per month • \ 1 -3 small bags per month ' 1 - 4 small bags per week 5 or more small bags per week 132. Fun fruit or fruit rollups (1 pack) Never/less than 1 per month 1 - 3 packs per month 1-4 packs per week 5 or more packs per week 133. Graham crackers Never/less than 1 per month . 1 - 3 times per month , 1 - 4 times per week 5 or more times per week 134. Crackers, like saftines or wheat thins Never/less than 1 per month ' 1 -3 times per month . ' 1 - 4 times per week 5 or more times per week 29528 167 135. Poptarts (1) 136. Cake (1 slice) 137. Snack cakes, Twinkies (1 package) Ntver/less than 1 pet month Never'less than 1 per month Never/less than 1 per month 1 - 3 poptarts per month .1-3 slices per month 1 - 3 per month 1 - 6 pop'arts per week 1 slice per week Once per week 1 or more poptarts per day 2 or more s ' i c e s per week 2 - 6 per week 1 or more per day 138. Danish, sweetrolls, pastry (1) Never'less thai 1 per month 1 - 3 per month 1 per week 2 - 4 per week 5 or more per week 139. Donuts (1) 140. Cookies (1) Never/less than 1 per month 1 - 3 donuts per month 1 dor.ut per /.eek 2 - 6 donuts per week 1 or more donuts per day Never/less than 1 per month 1 - 3 cookies per month 1 cookie per week 2 - 6 cookies per week 1 - 3 cookies per day 4 or more cookies per day 141. Brownies (1) Never/less than 1 per month 1 - 3 per month 1 per week 2 - 4 per week 5 or more per week 142. Pie 11 slice) . Never/less than 1 per month 1 -3 slices pe' month 1 slice per week 2 or more s'ices per week 143. Chocolate (1 bar or packet) like Hershey's or M & NTs . Never/less than 1 per month 1 - 3 per month 1 per week 2 - 6 per week 1 or more per day 144. Other candy bars (Milky Way, Snickers) Never'less than 1 per month 1 - 3 candy bars per month 1 candy bar per week 2 - 4 candy bars per week 5 or more candy bars per week 145. Other candy without chocolate (Skittles) (1 pack) 146. Jello Never'less than 1 pe r month 1 - 3 times per month Once per week 2-4 times per week 5 or more times per week Never/less than 1 per month 1 - 3 times per month Once per week 2 - 4 times per week 5 or more times per week 147. Pudding Never/less than 1 per month 1 - 3 times per month Once per week 2 - 4 times pe r week 5 or more t :mes per week 148. Frozen yogurt Never/less than 1 per month 1 - 3 times per month Once per week ' 2 - 4 times per week 5 or more times per week 149. Ice cream Never'less than 1 per month 1-3 times per month Once per week •2-4 times per ween .' 5 or more times per week 150. Milkshake or trapped) 151. Never'less than 1 per month 1 - 3 pe r month 1 per week 2 or more per week Popsicles Never/less than 1 per month '•[. 1 - 3 popsicles per month 1 popsicle per week 2-4 popsicles per week . 5 or mere popsicles per week 152. Please list any other foods that you usually eat at least once per week that are not listed (for example, coconut, hummus, falafel, chili, plantains, mangoes, etc...) FOODS HOW OFTEN? b) c) d) b) c) d) a Li. c 0 (2; . '3, y ,4. .4; 5 5' ,6 A 7 J « a 6 9 C 0 , ° iV 2; '2 •?-' •:V. 4 • t e. 7 .'7 B « THANK YOU FOR COMPLETING THIS SURVEY! Mark fl efl«K* by NCS EM-20T 370-1:654 Printed In U S A 1 2 3 4 S « 7 B « 1 0 1 1 12 U 94 « 96 97 98 M • •• • •• ••• 29528 • I B • 1 6 9 A P P E N D I X O : S E C O N D S E S S I O N - F R U I T A N D V E G E T A B L E S I N T A K E S E L F - E F F I C A C Y Q U E S T I O N N A R E Dietary Self-Efficacy Questionnaire Name: • This questionnaire is to be completed by your son / daughter, with assistance from you. • Please bring the completed questionnaire with you to the follow-up nutrition counseling session or final group session. • If you have any questions, please contact Jiak Chin at tel: 222-0553. Thank you. Special Instructions for the Children: ** We want to know how sure you are that you can do things to eat more fruits and vegetables. ** There are no right or wrong answers, just your opinion. ** For each question, put an X in one of the boxes that best describe what you think. I think I can I Disagree Very Much I Disagree A Little I Am Not Sure I Agree A Little I Agree Very Much 1. write my favourite fruit or vegetable on the family's shopping list? 2. ask someone in my family to buy my favourite fruit or vegetable? 3. go shopping with my family for my favourite fruit or vegetable? 4. pick out my favourite fruit or vegetable at the store and put it in the shopping basket? 5. ask someone in my family to make my favourite vegetable dish for dinner? 6. ask someone in my family to serve my favourite fruit at dinner? 7. ask someone in my family to have fruits and fruit juices out where 1 can reach them? 8. ask someone in my family to have vegetable sticks out where I can reach them? At breakfast, I think I can 9. drink a glass of my favourite juice? 10. add my favourite fruit to my favourite cereal? I Disagree Very Much I Disagree A Little I A m Not Sure I Agree A Little i . . .v. I Agree Very Much 11. eat a vegetable that's served? _ 12. eat a fruit that's served? F n r lunrh n t hnnrift*. T t h i n k I CSI1 • • • » T - -13. eat carrots or celery sticks instead of chips? 14. eat my favourite fruit instead of my usual dessert? 15 my favourite fruit instead of my favourite cookie? -16. my favourite fruit instead of my favourite candy bar? . 17. my favourite raw vegetable with dip instead of my favourite cookie? 18. my favourite raw vegetable with dip instead of my favourite candy UuX . ^ _________——^_-—_—— ___—_— 19. my favourite raw vegetable with dip instead of chips? IT/\f H i r i n g * * n f c n n n p r . I t h i n k T CfMl 20. eat a casserole with vegetables? — 21. eat my favourite fruit instead of my usual dessert? I think I can — •" * ' - ' 22. eat 2 or more servings of fruit or juice each day? . 23. eat 3 or more servings of vegetables each day? 24. eat 5 or more servings of fruits and vegetables each day? 7S pat rprt*a] i ns tead of a donut? _ _ i _ _ _ _ _ _ _ „ jfi. . . V - . . 26. take off and not eat the skin of the chicken? 27. ask for frozen yogurt instead of ice cream? 28. eat a baked potato instead of french fries? II Thank you for completing this questionnaire !! 171 Physical Activity Questionnaire (Elementary School) Name:_ Age:_ Sex: M F Grade: Teacher: cf f\pnl 10-I6J We are trying to find out about your level of physical activity from the last 7 days (in the last week). This includes sports or dance that make you sweat or make your legs feel tired, or games that make you breathe hard, like tag, skipping, running, climbing, and others. Remember: A. There are no right and wrong answers — this is not a test. B. Please answer all the questions as honestly and accurately as you can — this is very important. 1. Physical activity in your spare time: Have you done any of the following activities in the past 7 days (last week)? If yes, how many times? (Mark only one circle per row.) 7 times No 1-2 3-4 5-6 or more O o o o o Rowing/canoeing o o o o o o o o o o Tag o o o o o Walking for exercise o o o o o o o o o o Jogging or running o o o o o Aerobics o o o o o Swimming o o o o o Baseball, softball o o o o o Dance o o o o o Football o o o o o Badminton o o o o o Skateboarding , o o o o o Soccer „ o o o o o Street hockey o o o o o Volleyball o o o o o Floor hockey o o o o o Basketball o o o o o Ice skating o o o o o Cross-country skiing o o o o o o o o o o Other: o o o o o o o o o o 173 2. In the last 7 days, during your physical education (PE) classes, how often were you very active (playing hard, running, jumping, throwing)? (Check one only.) I don't do PE O Hardly ever O Sometimes O Quite often , O Always O 3. In the last 7 days, what did you do most of the time at recess? (Check one only.) Sat down (talking, reading, doing school work)... O Stood around or walked around O Ran or played a little bit O Ran around and played quite a bit O Ran and played hard most of the time O 4. In the last 7 days, what did you normally do at lunch (besides eating lunch)? (Check one only.) Sat down (talking, reading, doing schoolwork)... O Stood around or walked around O Ran or played a little bit O Ran around and played quite a bit O Ran and played hard most of the time O 5. In the last 7 days, on how many days right after school, did you do sports, dance, or play games in which you were very active? (Check one only.) None O 1 time last week O 2 or 3 times last week O 4 times last week O 5 times last week O 6. In the last 7 days, on how many evenings did you do sports, dance, or play games in which you were very active? (Check one only.) None O 1 time last week Q 2 or 3 times last week O 4 or 5 last week Q 6 or 7 times last week Q 174 7. On the last weekend, how many times did you do sports, dance, or play games in which you were very active? (Check one only.) None O 1 time O 2 — 3 times O 4 — 5 times O 6 or more times O 8. Which one of the following describes you best for the last 7 days? Read all five statements before deciding on the one answer that describes you. A. A l l or most of my free time was spent doing things that involve little physical effort O B. I sometimes (1 — 2 times last week) did physical things in my free time (e.g. played sports, went running, swimming, bike riding, did aerobics) O C. I often (3 — 4 times last week) did physical things in my free time O D. I quite often (5 — 6 times last week) did physical things in my free time O E. I very often (7 or more times last week) did physical things in my free time ... O 9. Mark how often you did physical activity (like playing sports, games, doing dance, or any other physical activity) for each day last week. Little Very None bit Medium Often often O O O 3 O O o o O O o o o 3 o o o o O o o o o O o o o o O o o o o 3 o Monday Tuesday , Wednesday Thursday.... Friday Saturday 10. Were you sick last week, or did anything prevent you from doing your normal physical activities? (Check one.) Yes O No O If Yes, what prevented you? 175 Please circle the answer that best describe what you think 8. I think I can be physically active no matter how busy my day is. Y E S N O 9. I think I can be physically active no matter how tired I may feel. Y E S N O 10. I think I can be physically active even if it is hot or cold outside. Y E S N O 11. I think I can be physically active even if I have a lot of homework. Y E S N O 12. I think I can be physically active after school even if I could watch TV or play video games instead. Y E S N O 13. I think I can be physically active even if I have to stay at home. Y E S N O 14. I think I can be physically active even when I'd rather be doing something else. Y E S N O 15. I think I can be physically active even if my friends don't want me to. Y E S N O 16. I lliink I can be physically active after school even if my friends want me to do something else. Y E S N O 17. I think I can be physically active at least three times a week for the next two weeks. Y E S N O Thank you for completing this questionnaire!! 177 What I A m Like LQQ Birthday G r o u p . Name —— _ Boy or Girl (circle which) SAMPLE SENTENCE Really Sort of S o r l o f R e a j | , T r u e , T r u e True True forme forme { o r m e f o f m e (a) j 1 I j Some kids would rather Other kids would rather , play outdoors in their BUT watch T.V. 1 I I I I spare time j •. , Some kids feel that they Other kids worry about . . j 1 are very good at their BUT whether they can do the school work school work ass.gned to I 1 I 1 them. 2 . • • • • • • Some kids find it hard to make friends Some kids do very we// at all kinds of sports Some kids are happy with the way they look Other kids find it's pretty BUT easy to make friends. Other kids don't feel that BUT they are very good when it comes to sports. Other kids are not happy BUT with the way they look. • • • • • • 5. • • Some kids often do not Other kids usually like like the way they behave BUT the way they behave. • • • • S o m e kids are often Other kids are pretty unhappy with themselves BUT pleased wi th themselves. 7. • S o m e kids feel l ike they are just as smart as as other kids their ega Other kids aren't so sure BUT and wonder if they are as smart. • • • • Some kids have alot of friends BUT Other kids don't have very many fr iends. 179 Heally Sort ol True True for me for me 10. 11. 12. 13. 14. 15. • • • • • • • • • • • • • • Some kids wish they could be alot better at BUT sports Some kids are happy with their height and BUT weight Some kids usually do the fight thing BUT Some kids don't like the way they are leading BUT their life Some kids are pretty slow in finishing their BUT school work Some kids would like to have alot ruore friends BUT Some kids think they could do well at just BUT about any new sports activity they haven"t tried before Other kids feel they are good enough at sports. Other kids wish their height or weight were dilterent. Other kids often don't do the right thing. Other kids do like the way they are leading their life. Other kids can do their school work quickly. Other kids have as many friends as they want. Other kids are afraid they might not do well at sports they haven't ever tried. 16. • • Some kids wish their body was different Other kids like their BUT body the way it is. 17. 18. 19. 20. • • • • • • • • Some kids usually acr the way they know they BUT are supposed to Some kids are happy with themselves as a person BUT Some kids often forget what they learn 8UT Some kids are always doing things with alot BUT Of W;ic?S Other kids often don't act the way they are supposed to. Other kids are often not happy with themselves. Other kids can remember things easily. Other kids usually do things by themselves. Sort of Really True True for me for me • • • • • • • • • • • • • • • • • • • • • • • • 180 Reilly Sort of True True (or me lor me 21. • • Some kids feel that they Other kids don't feel are tetter than others BUT they can play as well, their age at sports 22. • • Some kids wish their Other kids like their physical appearance (how BUT physical appearance the they look) was different way it is. 23. • • Some kids usually get in //-oi/o/e-because of things they do Other kids usually don't BUT do things that get them in trouble. 24. • • ° Some kids like the kind f person they are Other kids often wish BUT they were someone else. 25. 26. 27. 28. 29. • • • • • • • • • • Some kids do very well at their classwork Some kids wish that more people their age liked them In games and sports some kids usually watch instead of play Some kids wish something about their face or hair looked different Some kids do things they know they shouldn't do Other kids don't do BUT very well at their classwork. Other kids feel that most BUT people their age do like them. Other kids usually play BUT rather than just watch. Other kids like their face BUT and hair the way they are. Other kids hardly ever BUT do things they know they shouldn't do. 30. •j | Some kids are very happy being the way BUT I I they are Other kids wish they were different. 31. • • B Some kids have trouble Other kids almost ng out the answers BUT always can figure out hool the answers. 32. • • Some kids are popular with others their age Other kids are not verv B U T popular . Sort of True for me Real ly True for me • • • • • • • • • • • • • • • • • • • • • • • 181 Really Sort of True (or me True (or me True for me fleaHy True (or me 33. 34. 35. 36. • • • • • • • Some kids don't do well at new outdoor games BUT Some kids think that they are good looking BUT Some kids behave themselves very well BUT Some kids are not very happy with the way they BUT do alot of things O t h e r kids are good at new games right away. Other kids think that they are not very good looking. Other kids often find it hard to behave themselves. Other kids think the way they do things is tine. • • • • • • • • Susan Harter, Ph.D., University of Denver, 1985 182 Family Eating and Activity Habits Questionnaire Please refer your answers to questions 1-4 to yourself, your spouse (if applicable)and your 7-11 year child. 1. How many hours per week on average do you watch television and/or play computer games? Mother: Father: Child: 2. How many hours per week on average do you engage in the following activities? Mother Father Child Ride bicycles Take walk Swim Do gymnastics Dance Play tennis Other 3. How many times per week on average to you attend leisure time classes (Including exercise classes)? (If none, write 0) Mother: Father: Child: 4. When you are alone and are not busy, do you get bored? (Place the number of your answer in the appropriate column.) Mother Father Child 0 never 1 almost never 2 sometimes 3 frequently 4 always In modern society, people often skip meals, do with snacks instead of proper meals or eat irregularly or depending on their mood. The following questions are related to the types of foods you and your family eat, and your eating behavior. 5. How many of the following snacks are usually found in your home? (Circle all applicable items) Chitos, Pret_els, Potato Chips, Ruffles, Popcorn, Sunflower seeds, Peanuts, Almonds, Pistasios, Nuts, and Other - please specify . 6. How many of the following types of sweets are usually found in your home? (Circle all applicable items) Chocolate and chocolate bars, Candy, Wafers, Cookies, Jam, and Other - please specify . 7. How many types of cake are usually found in your home? 8. How many types of ice-cream and popsicles are usually found in your home? 9. During the weekend, do you add more of the foods listed in 5-8? 0 Don't add 1 Add 10. You usually keep the snacks and sweets in your honfe in 0 A hiding place 1 Known but not seen place 2 Reachable place 11. To what degree can your child eat snacks and/or sweets without your permission? 0 Never 1 Almost never 2 Sometimes 3 Frequently 4 Always 12. How frequently does your child buy his/her own sweets? 0 Never 1 Almost never 2 Sometimes 3 Frequently 4 Always 13. When your child asks to eat, does he/she claim to be hungry? 0 Yes 1 No 14. Usually when the child eats: 1 He/she asked for it. 2 The food was offered by the mother/father. 184 15. If it is meal time and your child is not hungry, how would you respond? 0 You suggest that the child will eat later. 1 You suggest that the child sit at the table with the rest of the family but would not eat. 2 You suggest that the child sit at the table with the rest of the family but would eat less. 3 You convince the child to eat with the rest of the family. 4 This is an irrelevant question, the child is always hungry. 16. When it is meal time and you are not hungry what would you do? (Both parents, if applicable) Mother: Father: 0 Not eat 0 Not eat 1 Eat less 1 Eat less 2 Eat the same 2 Eat the same 3 It never happens 3 It never happens Frequently, we just grab something to eat, or eat under certain conditions or moods. (Please refer your answer to questions 17-20 to yourself, your spouse (if applicable) and your child.) 17. How frequently do the following behaviors occur for each family member: Mother Never 0 Almost never 1 Sometimes 2 Frequently 3 Always 4 Eat while standing Eat straight from the pot / baking pan / bowl / frying pan Eat while watching television, reading, working Eat when bored Eat when angry or in other negative mood states Eat in disorderly way during the afternoon Eat late in the evening or at night Father Never 0 Almost never 1 Sometimes 2 Frequently 3 Always 4 Eat while standing Eat straight from the pot / baking pan / bowl / frying pan Eat while watching television, reading, working Eat when bored Eat when angry or in other negative mood states Eat in disorderly way during the afternoon Eat late in the evening or at night Child Never 0 Almost never 1 Sometimes 2 Frequently 3 Always 4 Eat while standing Eat straight from the pot / baking pan / bowl / frying pan Eat while watching television, reading, working Eat when bored Eat when angry or in other negative mood states Eat in disorderly way during the afternoon Eat late in the evening or at night Please Turn Over to the Next Page 185 In many houses eating is not limited to the dining room or kitchen. 18. How often do you eat in the following rooms? (If you do not have such a room in the house, please mark with —) Mother Never Almost Never Sometimes Frequently Always Living Room / TV Room Bedroom Office Father Never Almost Never Sometimes Frequently Always Living Room / TV Room Bedroom Office Child Never Almost Never Sometimes Frequently Always Living Room / TV Room Bedroom 19. Compared to other people you age, how would you rate your eating pace: Mother: 1 - Slow 2 - Average 3 - Fast Father: 1 - Slow 2 - Average 3 - Fast Child: 1 - Slow 2 - Average 3 - Fast 20. How often do you customarily ask for or take a second helping? Mother: 0 Never 1 Almost never 2 Sometimes 3 Frequently 4 Always Father: 0 Never 1 Almost never 2 Sometimes 3 Frequently 4 Always Child: 0 Never 1 Almost never 2 Sometimes 3 Frequently 4 Always 21. How often do you or your spouse eat with the child? Breakfast: 0 Always 1 Frequently 2 Sometimes 3 Almost never 4 Never Lunch: 0 Always 1 Frequently 2 Sometimes 3 Almost never 4 Never Afternoon snack: 0 Always 1 Frequently 2 Sometimes 3 Almost never 4 Never Dinner: 0 Always 1 Frequently 2 Sometimes 3 Almost never 4 Never 22. What is your current marital status? a. Single (Never married) b. Married (and not separated), or living common law c. Separated d. Divorced e. Widowed Please Turn Over to the Next Page 186 23. Which of the following best describes your employment status now? a. Employed full time b. Employed part time (less than 30 hours / week) c. Self-employed d. Unemployed e. Retired f. Stay home parent g. Student 24. What is the highest grade or level of education you have completed? 25. What is your best estimate of the total income, before taxes of all household members from all sources in 1997? a. Less than 10, 000 b. 10,000-19,999 c. 20,000 - 29,999 d. 30,000 - 39,999 e. 40,000 - 49,999 f. 50,000 - 59,999 g. 60,000 and above Thank you for completing this questionnaire I! 187 A P P E N D I X T : E Q U A T I O N S F O R E S T I M A T E D E N E R G Y R E Q U I R E M E N T S Equations proposed by National Academy of Sciences (2002), based on doubly labeled water database for overweight and obese boys and girls: Basal Energy Expenditure ( B E E ) : Boy : B E E (kcal/d) = 419.9-33.5 x Age (y) + 418.9 x Height (m) + 16.7 x Weight (kg) Gi r l : B E E (kcal/d) = 515.8-26.8 x Age (y) + 347 x Height (m) + 12.4 x Weight (kg) Physical activity factors used: Boy: Age 3-8: 1.42 Age 9-13: 1.52 Gi r l : Age 3-8: 1.45 Age 9-13: 1.63 Tota l Energy Expenditure ( T E E ) : T E E = B E E x Physical Activity Factor 188 

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