From NIH to Texas schools: policy impact of the Coordinated Approach to Child Health (CATCH) program in Texas

Editor's Note: Active Living Research has awarded the third annual Translating Research to Policy Award to the Michael and Susan Dell Center for Advancement of Healthy Living's Coordinated Approach to Child Health (CATCH) program.?The purpose of the award is to recognize innovative teams or individuals representing research, policy, and/or advocacy who have had success in catalyzing policy or environmental change of relevance to youth physical activity, sedentary behavior, and obesity prevention. The goal is to celebrate achievements, understand how success occurs, and share these stories so others will be inspired to use or adapt new and effective approaches. The commentary that follows describes the work that is being recognized by the Award. Active Living Research commends the awardees on their success in changing policy, and we commend this as a model to others.     

Adoption and institutionalization of the Child and Adolescent Trial for Cardiovascular Health (CATCH) in El Paso, Texas

One goal of national health-promotion research is to disseminate and institutionalize experimentally tested programs in local communities. In 1997, the national Child and Adolescent Trial for Cardiovascular Health (CATCH) was chosen by the Paso del Norte Health Foundation as their first community-wide preventive health initiative for the El Paso, Texas/Juárez, México border region. With help from researchers at the University of Texas at Houston, evaluators from the University of Texas at El Paso, and the Region 19 Educational Services Center, CATCH was implemented in 18 Title I pilot schools. Known as the Coordinated Approach to Child Health 5 years later, the El Paso CATCH program has been embraced by the border community and reaches 108 elementary schools from New Mexico to West Central Texas. There are also plans to implement CATCH in Juárez. This article describes the institutionalization of CATCH in a predominately Hispanic, low income border region.     

Dissemination and adoption of the Child and Adolescent Trial for Cardiovascular Health (CATCH): a case study in Texas.

The total impact of a health promotion program can be measured by the efficacy of the intervention multiplied by the extent of its implementation across the target population. The Child and Adolescent Trial for Cardiovascular Health (CATCH) was a school-based health promotion project designed to decrease fat, saturated fat, and sodium in children's diets, increase physical activity, and prevent tobacco use. This article describes the dissemination of CATCH in Texas, including the theoretical framework, strategies used, and lessons learned. To date (Fall 2000), CATCH materials have been adopted by more than 728 elementary schools in Texas.     

A Complementary Ecological Model of the Coordinated School Health Program

BACKGROUND: A complementary ecological model of the coordinated school health program (CSHP) reflecting 20 years of evolved changes is proposed. Ecology refers to the complex interrelationship between intrapersonal factors, interpersonal processes and primary groups, institutional factors, community factors, and public policy. METHODS: Public health and child development theories that incorporate the influence of personal and social environments on health behavior, along with models that incorporate the influence of ecology, were consulted. RESULTS: Concepts from several models were combined with the 8 components of CSHP to formulate an ecological model involving 6 program and services components in an inner circle surrounded by 4 concentric rings representing the healthy school environment, essential structures of CSHP, local school district governance, and family and community involvement. CONCLUSION: This complementary ecological model is intended to serve as an additional conceptual approach to CSHP practice, evaluation, and research, and should prove especially useful to practitioners and researchers who already have a fundamental understanding of CSHP.     

Factors influencing implementation of the Community Health Fund in Tanzania

Although prepayment schemes are being hailed internationally as part of a solution to health care financing problems in low-income countries, literature has raised problems with such schemes. This paper reports the findings of a study that examined the factors influencing low enrollment in Tanzania's health prepayment schemes (Community Health Fund). The paper argues that district managers had a direct influence over the factors explaining low enrollment and identified in other studies (inability to pay membership contributions, low quality of care, lack of trust in scheme managers and failure to see the rationale to insure). District managers' actions appeared, in turn, to be at least partly a response to the manner of this policy's implementation. In order better to achieve the objectives of prepayment schemes, it is important to focus attention on policy implementers, who are capable of re-shaping policy during its implementation, with consequences for policy outcomes.     

Improvements in middle school student dietary intake after implementation of the Texas Public School Nutrition Policy

Objectives. We assessed the effect of the Texas Public School Nutrition Policy on middle school student lunchtime food consumption.Methods. Three years of lunch food records were collected from middle school students in southeast Texas: baseline (2001–2002), after local district changes (2002–2003), and 1 year after implementation of the Texas Public School Nutrition Policy (2005–2006). Students recorded amount and source of foods and beverages they consumed. Analysis of variance and covariance and nonparametric tests were used to compare intake after the policy change with intake during the 2 previous years.Results. After implementation of the nutrition policy, student lunch consumption of vegetables, milk, and several nutrients increased (protein, fiber, vitamins A and C, calcium, and sodium), and consumption of less desirable items (sweetened beverages, snack chips) decreased, as did percentage of energy from fat. Most of the desired nutrients and foods (vegetables and milk) were obtained from the National School Lunch Program meal. Fewer sweetened beverages, candy, chips, and dessert foods were purchased and consumed, but more of these items were brought from home and purchased from the snack bar.Conclusions. Overall, state school nutrition policies can improve the healthfulness of foods consumed by students at lunch.Public health efforts to reduce the increasing rates of childhood obesity1 have recently focused on school food environments.2 Although regulations exist for National School Lunch Program (NSLP) meals, there are no federal rules for competitive foods sold elsewhere in the school such as in snack bars and vending machines, except for foods of minimal nutritional value (e.g., soda).3 This has become an issue because the school environment influences dietary behavior.4 For example, middle school students with access to snack bar and a la carte foods consumed more sweetened beverages and french fries, and fewer fruit and vegetables compared with elementary school students without snack bars.5^,6 The number of snack vending machines was negatively related to daily fruit consumption among middle school youth.7 In high schools where soft drink machines were turned off during lunch, students purchased fewer soft drinks compared with students in schools where these machines were on during lunch.8 Improving types and portion sizes of foods available in school snack bars and a la carte could reduce the source of kilojoules available for student purchase and possibly improve energy balance.9States, school districts, and individual schools have enacted laws and policies regarding foods and beverages available in school food environments.10 The beverage industry also developed a voluntary beverage vending policy for schools.11 Such changes are controversial, and barriers to improving school food environments exist. These include the revenue generated from vending and snack bar and a la carte sales,12 school staff, student and parent attitudes toward types of foods expected in schools,13 and the concern that limiting access to these foods at school will not improve overall student dietary intake.14 Critics suggest that if these items are not available in schools, students will compensate by increasing consumption of desired foods in out-of-school environments.14Few data exist for the effect of policy changes on actual food consumption by students at school. One recent study documented significant improvements in food consumption by Texas middle school students (more milk, calcium, and vitamin A; fewer sweetened beverages) after a local school district enacted a snack bar food policy change.15 Consumption of chips purchased from the snack bar declined, but consumption of chips from vending machines increased, because the school administration, which was responsible for vending machines, made no changes. These results suggest that all school food sources have to make similar changes to favorably influence consumption.The Texas Public School Nutrition Policy, an unfunded mandate to promote a healthy school environment for Texas students, was implemented statewide in the fall of 2004. The guidelines apply to all school food sources, including vending machines.16 For middle schools, the policy restricts the portion sizes of high-fat and sugar snacks (limits vary by food group), sweetened beverages (≤ 12 oz), and the fat content of all foods served (≤ 28 grams of fat per serving no more than 2 times per week). It also sets limits on the frequency of serving high-fat vegetables such as french fries (3 oz per serving no more than 3 times per week). We report the results of a naturalistic study that assessed the effect of the Texas Public School Nutrition Policy on lunch consumption of middle school students in southeast Texas. Student lunch consumption data for 2 previous years were available for comparison.15     

Evaluation of a social policy program: the Maternal and Child Health and Nutrition Program

This study is based on an evaluation of the Maternal and Child Health and Nutrition Program (PROMIN) targeting pregnant women and their children under five years of age. The objective was to identify the conditioning factors for the Program's implementation in Rosario, Argentina. There were three levels of analysis: the organizational environment as perceived by the Executive Directors of the Health and Child Development Centers; management of interventions by the health teams; and the community's perception of the program's accessibility and acceptability. Two centers were chosen for the year 1998. Empirical evidence was obtained through quantitative and qualitative procedures. The results suggest that the two centers' respective organizational environments influenced the intervention strategies. The goal for coverage had been set at 80%. Documentation of the interventions by the two teams shows a partial and heterogeneous implementation. In terms of accessibility, mothers recognize the institutions by their reputation, quality of services, and extra services beyond the PROMIN basics. Acceptability is expressed as the provision of supplementary nutrition.     

Nutrient Intakes of Third Graders: Results from the Child and Adolescent Trial for Cardiovascular Health (CATCH) Baseline Survey

The purpose of this article is to report on baseline intakes of 1874 third-grade children representing a subsample of the Child and Adolescent Trial for Cardiovascular Health (CATCH) cohort. Intakes were assessed using a single, food record-assisted, 24-hour recall. The sample is unique in that it is drawn from four states and includes students from various ethnic backgrounds. Nutrients of interest include total energy, sodium, dietary cholesterol, and percent of energy from total fat and saturated fat. At baseline, third-grade students were consuming above nationally recommended levels of energy from fat, saturated fat, and sodium. The CATCH findings show a mean energy intake of 2031 kcal with significant differences by sex. Significant differences by site were seen for percent of energy from total fat, saturated fat, and dietary cholesterol. Children from Minnesota consumed the lowest proportion of energy from total fat and saturated fat while children from Texas had the highest proportion of energy from total fat and saturated fat. Intake of dietary cholesterol was lowest in Minnesota and highest in Louisiana. Nutrient differences by ethnic group were seen only for energy, with African Americans having the highest energy intake and Hispanics having the lowest energy intake. The number of meals consumed from school food service significantly influenced children's nutrient, intake; children consuming two meals from school food service had significantly greater intakes of energy, saturated fat, and dietary cholesterol compared to students consuming one or no meals from school food-service. The results are compared to other national nutritional surveys of children.     

Reliability and Validity of the Child and Adolescent Trial for Cardiovascular Health (CATCH) Food Checklist: A Self-report Instrument to Measure Fat and Sodium Intake by Middle School Students

OBJECTIVE: To develop a scoring algorithm and evaluate the reliability and validity of scores from the Child and Adolescent Trial for Cardiovascular Health (CATCH) Food Checklist (CFC) as measures of total fat, saturated fat, and sodium intake in middle school students. DESIGN: Randomized, controlled trial in which participants were assigned to 1 of 3 study protocols that varied the order of CFC and 24-hour dietary recall administration. Criterion outcomes were percent energy from total fat, percent energy from saturated fat, and sodium intake in milligrams. SUBJECTS/SETTING: A multiethnic sample (33% ethnic and racial minorities) of 365 seventh-grade students from 8 schools in 4 states. STATISTICAL ANALYSES: Multivariable regression models were used to calibrate the effects of individual food checklist items; bootstrap estimates were used for cross-validation; and kappa statistics, Pearson correlations, t tests, and effect sizes were employed to assess reliability and validity. RESULTS: The median same-day test-retest reliability kappa for the 40 individual CFC food items was 0.85. With respect to item validity, the median kappa statistic comparing student choices to those identified by staff dietitians was 0.54. Test-retest reliability coefficients ranged from 0.84 to 0.89 for CFC total nutrient scores. Correlations between CFC scores and 24-hour recall values were 0.36 for total fat, 0.36 for saturated fat, and 0.34 for sodium; CFC scores were consistent with hypothesized gender differences in nutrient intake. APPLICATIONS/CONCLUSIONS: The CFC is a reliable and valid tool for measuring fat, saturated fat, and sodium intake in middle school students. Its brevity and ease of administration make the CFC a cost-effective way to measure middle school students' previous day's intake of selected nutrients in school surveys and intervention studies.     

Vitamin supplement intake is related to dietary intake and physical activity: The Child and Adolescent Trial for Cardiovascular Health (CATCH)

OBJECTIVE: To explore the relationship of multiple-vitamin supplement use with selected food groups, physical activity, lifestyle behaviors, and weight status. SUBJECTS AND METHODS: Two thousand seven hundred sixty-one adolescents in the 12th grade who participated in the fourth Child and Adolescent Trial for Cardiovascular Health study had height and weight measured and completed health behavior survey and food frequency questionnaires. Logistic regression models were used to determine the likelihood of supplement use with health and activity behaviors and dietary intake. RESULTS: Prevalence of multiple-vitamin supplement use among adolescents was 25% and varied by sex and race/ethnicity. Supplement users had higher mean daily intakes of most food groups, but lower intakes of total fat and saturated fat than nonusers. Higher food index scores were positively associated with the likelihood of using multiple-vitamin supplements. Supplement users were more likely to be physically active, participate in team and organized sports, and less likely to be overweight and to watch more than an hour of television per day. CONCLUSIONS: Adolescents who use multiple vitamin supplements have more healthful dietary and lifestyle behaviors than nonusers. Further study on supplement use by adolescents, including other types of supplements used and reasons for use, is warranted.     

中国／WHO“以营养教育为重点的学校健康促进”项目效果评价

目的评价中国/WHO“以营养教育为重点的学校健康促进”项目的干预效果。方法采用对照实验研究的方法,对目标人群实施项目综合干预前后的营养相关知信行调查。结果试点学校学生喜欢学校提供的午餐的比例,小学生提高了12.2%(P<0.01),中学生提高了27.3%(P<0.01);饮食卫生知识知晓率,小学生提高了17.8%,中学生提高了20.3%;试点学校学生健康相关知识掌握情况有明显提高,学生对营养与健康的态度明显转变,健康行为形成率显著提高,身体素质状况有所改善。结论“以营养教育为重点的学校健康促进”项目的干预效果显著,应加以应用和推广。