Teaching children self-care for chronic disease prevention: Obesity reduction and smoking prevention

92

TEACHING CHILDREN SELF-CARE FOR CHRONIC DISEASE PREVENTION: OBESITY REDUCTION AND SMOKING PREVENTION C. L. WILLIAMS, M.D., and C. B. ARNOLD, M.I). Health Maintenance Institute, American Health Foundation, New York, New York

ABSTRACT A general health education program was developed for 1,252 students in six New York city area school districts. The purpos e of the three-year project was to: reduce the prevalence of risk factors associated with increased cardiovascular and cancer risk in adults. The curriculum included nutrition, antitobacco, and hypertension-control materials. A smaller, experimental intensive health behavior program was also developed for obese children (weight >_ 120% ideal for height, age, and sex). A smoking prevention program was offered to children with the aim of discouraging new smokers. Findings show that: 1) such a schoolbased primary disease prevention program is feasible and highly acceptable; and 2) reduction of obesity and new cigarette smoking occurred with intensive intervention involving small groups of students. On the other hand, a general health education itself had little effect in the total population in reducing the incidence of extreme clinical values (such as physical inactivity, high blood pressure, as well as smoking and obesity) for their age and sex. It is recommended that future programs for higher risk children concentrate on behavioral change rather than on general education. SPECIFIC AlMS Tlais project had three main objectives. The first was to determine by screening the longitudinal prevalence of risk factors in children that relate to adult chronic disease, specifically cigarette smoking and obesity. Second, through a general health education program tailored to these risk factors, systematic efforts were made to increase knowledge levels and awareness in children about the need for lifelong personal surveillance over these health indicators.

Finally, two selected intensive behavioral change programs were implemented, one to reduce obesity and one to prevent smoking. Their effectiveness was evaluated. BACKGROUND Some elevated clinical values in children are thought to increase the risk of major chronic disease (coronary heart disease, cancer, and stroke) in later life. Studies 1-1o among children and adolescents have found in general that: 1. Smoking, elevated blood lipids, hypertension, and physical inactivity are prevalent in childhood populations. 2. Their prevalence seems to have public health significance (for example, 30 to 60% have one such elevated value depending on age and determination of critical levels). Moreover, by age 13 some 10% of children smoke cigarettes daily or almost daily. 3. Tracking phenomena occur, in that children tend to maintain their position relative to their peers over time with respect to blood pressure level, relative weight, and serum cholesterol, for example, so that values in the highest quartile tend to remain there over time. 4. Lifestyle habits that contribute to the development of increased risk status (such as cigarette smoking and overeating) are generally established in childhood. 5. Early pathologic arterial lesions of atherosclerosis can be identified in young children and adolescents. Based on these observations it has been suggested that childhood presents the most effective period in which to begin measures aimed at the primary prevention of major chronic disease. Questions regarding the feasibility, acceptability, safety, and effectiveness of various approaches to risk-factor reduction in childhood stimulated the following project. In this paper we shall report the results of a 24-month project in which children were screened annually and educated about

DATIENT COUNSELLING A N D HEALTH EDUCATION

93 chronic disease risk in order to determine whether a general education program could help decrease the prevalance of obesity and smoking in children. METHOD In 1976, 2,977 students aged 10 to 14 years in six New York metropolitan area junior high or intermediate schools were screened in a "Know Your Body" program. Three schools were designed for intervention and three for control (Table I). The three schools in each group represented lower, middle, and upper socioeconomic levels. Students in all six schools were offered a limited screening examination conducted in school by a medical team to determine the following clinical indices: height, weight, triceps skinfold, blood pressure, total cholesterol, modified Harvard step test, smoking status, health knowledge, and family health history. A nonfasting blood glucose test and a microhematocrit were done during the first two years. High-density lipoprotein levels were determined in the third year. Only the results of obesity control and cigarette smoking are reported in this paper. Program Evaluation Criteria

It was assumed for program evaluation purposes that the effect of the health education program should be detectable in children in whom extreme clinical values were found. Table II summarizes the critical value cut-off points that were used for program evaluation. Each cut-off point was selected by taking the upper level of clinical values found in population surveys of children by age and sex. The serum cholesterol level (180 mg/100 ml) was selected because it is approximately one standard deviation above the mean levels found in this study as well as in Bogaloosa iz (and by the NCHS in the HANES project 1_~). Blood pressure critical values were in the 95th percentile findings in Table I.

llealth Education program Summary

After screening, students received their results, excluding smoking status, either in class or by mail sent to their homes. In all cases parents and physicians also received results by mail, again excluding smoking status. Any health education in the schools began after the screening results were distributed. General program evaluation utilized the data on health indicator status on annual health profile evaluations. Intervention strategies were conducted on two levels: 1) an optional curriculum enrichment health education program, for use by teachers in class with all students, was provided to study schools; 2) h~tensire small group programs were conducted on a limited basis in the area of smoking prevention and obesity control. These methods have been reported in more detail elsewhere. 1c-is

Proportion of students participating in the health profile evaluation by school and year.

Year 1 (1975-76) School

the NHLBI Task Force Report a3 on pediatric blood pressure. Weight-to-height norms were the levels found in the HANES project 1, and published in 1976. Cigarette smoking was determined by self-report on a questionnaire identifying the child by number only. The questionnaire was completed in a secluded area and deposited by the child through a slot into a box. Confidentiality of responses was emphasized. Physical activity status was measured by a one-step test using criteria established by the Harvard group 15 for the two-step test. The results for the one-step test sufficiently paralleled those for the two-step test to be deemed usable. This adaptation seems to under-_ estimate the proportion of individuals in the lowest (poores0 group, but this problem was equal for all groups in the study. In subsequent papers from this project, we shall report data on mean values with confidence limits for observed changes that may have been induced by the program.

Category

A Experimental 1 B Control 1 C Experimental 2 D Control 2 E Experimental 3 F Control 3 All experimental All control All schools

Year 2 (1976-77)

year 3 (1977-78)

Number screened

Percentage screened

Number screened

Percentage screened

Number screened

800 329 260 448 648 492 1708 1269 2977

86% 66% 67% 54% 88% 57% 86% 58% 72%

487 334 262 468 564 508 1313 1310 2623

60.2% 70.2% 83.2% 59% 83% 70% 72% 66% 69%

485 332 170 209 434 404 1089 945 2034

Percentage screened 62.5% 9 78.8% 87% 55% 62.8% 57% 66% 63% 64%

94

Table II. Evaluation criteria Critical value levels

Noncritical values

>__120% weight for height, age, and sex Daily or almost every day

119% or less

Factor Relative weight

Cigarette smoking

Nonsmoker

Supplemental educational activities in the study schools consisted of parent meetings, teacher training workshops, parent and study advisory committees, parent school lunch committees, special athletic events, poster contests, and science projects. Semiannual monitoring of all health education activities in study and control schools was used to evaluate actual changes in health education teaching practices and related activities.

Participation Screening Participation in the screening required annual written parental consent. Rates of participation varied from 54 to 88% and tended to be lowest in the inner-city, disadvantaged schools and highest in the upper socioeconomic, largely professional communities. Figure 1 summarizes screening participation rates for control and study schools during the three years of the project. While every attempt was made to treat all schools equally with respect to prescreening and screening procedures, certain confoufading influences affecting participation rates could not be controlled. District A, for example, was embroiled in a bitter job action dispute between the teachers union and the administration during the second year of the study. In addition, the junior high school had three different principals in the three school years, only two of whom gave unqualified support to this project. In Districts C and f'l

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D (inner city) only half the students were followed up the third year because of the wide dispersal of students from those junior high schools to 12 high schools within New York City. Thus the transition to high school posed logistical problems for follow-up. Overall participation rates in the screening declined from 72 to 64% over the 24 months. This was attributed to the difficulty in maintaining the transition from junior high to high school. For students not making the transition to high school or another building, the participation rates increased rather than declined. Teachers and principals were encouraged to participate in the screening as well and did so to such an extent they had to be limited eventually. RESULTS

Evaluation of Health Education by Screening Data If behavioral change were to occur over the 24 months because of educational intervention, it was assumed that these changes would be reflected in a reduction of elevated clinical values. The study schools were hypothesized to achieve greater reduction if the health education program had a population effect. Knowledge change was also measured but is not reported here. A change in knowledge levels was not expected to be a positive factor in reducing obesity or new cigarette smoking.

Cigarette Smoking Both study and control schools reported similar cigarette smoking prevalence at the baseline and 24 months measures (Figure 2). The baseline rates were 5.8% and 5.9%, respectively. Two years later they were 11.9% and 9.0%. From the total smoking status data, the control schools reported that at 24 months there were fewer occasional smokers and more students who had never smoked. Clearly an overestimate of "never-smokers" exists for the control group, since logically they could not exceed their proportion reported at baseline. A data reliability/validity question exists about the control group's smoking data. In the study group blood cotinine levels were determined in a sample of 137 children: all self-reported smokers had detectable levels and no nonreported smokers did. We inferred the questionnaire to be valid in the study group, aa

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The reported daily smoking prevalence was examined by sex and by race (white and black). Except for boys in the control group, the results showed rates doubling between the first screen and 24 months. The highest

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Figure 4. Percent daily cigarette smokers in children by race for study and comparison schools. reported prevalence was in girls, where the study group had 18% smokers after two years. After 24 months, the reported rates of boys were approximately 35% of that of girls in both the study and control schools (Figure 3). Although the numbers were very small, black children reported a higher prevalence of smoking than did white children after two years, even though initially both had the same rates (Figure 4).

Weight Loss Over the 24 months there was a comparable reduction in the proportion of children in both study and comparison schools with respect to weight exceeding 120% for height (Figure 5). This change can be attributed primarily to the early adolescent growth spurt children experience between 12 and 14 years. As

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Intensive Smoking Prevention The objective of this intervention was smoking prevention. Evaluation of program effectiveness compared new smoking rates among the experimental group with that of controls. The program consisted of 12 weekly one-hour sessions in which a behavioral. modification program was conducted. The frame of reference was to provide the students with improved control over their social environment, including smoking. The results indicated that fewer experimental students initiated smoking during the threemonth follow-up than did the control ( P < 0 . 0 1 ) . The apparent effectiveness of the antismoking program was inversely related to grade level: it was 100% among 8th graders, 77% among 9th graders, and 53% among 10th graders. This finding suggests9 that better results should occur when such programs are initiated earlier in life. A one-year follow-up is in progress.

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PATIENT COUNSELLINGAND HEALTHEDUCATION

97

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there was no difference in the results between the schools, we infer, in agreement with the literature, TM that teenage obesity does not easily yield to awarenessinducing or information-laden programs. Intensive Weight Loss Program

The objective of this 10-week nutrition intervention component was weight loss in obese children through alteration of eating and exercise behavior hypothesized as essential to the onset and maintenance of adolescent obesity. One hundred and nineteen study school students (20% or more above ideal weight for height, sex, and age) participated. Posttest measurements indicated that 51% of the experimental group had lost weight compared with 16% of the control group (X2=14.88, P<0.001). Figure 6 further compares the weight loss between these groups in terms of shifts from the obese category ( > 130% of ideal weight) in the pretest and posttest measurements. Again there was a significant shift from obese to nonobese in the experimental group (X2= 4.39, P < 0 . 0 5 ) , whereas the slight decline in the control group was not significant. Moreover, 70% of the experimental group had lower triceps skinfold measurements on posttest compared with 43 % of controls, also a significant difference (X:=9.29, P < 0 . 0 1 ) . A six-month follow-up study of these students is underway to evaluate maintenance of weight loss after cessation of the intervention. DISCUSSION Obesity and smoking prevalence can be reduced in adults through intense individualized clinical programs in almost any population. For children we have been

SECOND QUARTER/1980

less confident, although the data from this project of intensive interventions aimed at promoting self-responsibility are encouraging. A major issue for the future will be to decide on the most appropriate target groups for childhood intervention programs. We can agree for the present that cigarette smoking and obesity are reasonable targets to strive to reduce. Both are precursors to adult disease. We believe the most important lessons learned in this project concern the relationship of nonbehavioral education and behavioral change type programming. Both types are necessary for public health effects. They are not mutually exclusive, but we believe the balance should be struck with behaviorally oriented programs in schools outweighing the other. We have indicated in this paper the kind of programming that we believe will produce the most effective reduction for those children in the upper quartiles or quintiles for their age and sex. It is our intention to pursue this risk reduction effort energetically because of the implications it has for the future of American public health. CONCLUSIONS 1. We have estimated that approximately one third of children have risk factors in childhood that if tracked into adulthood would undoubtedly place them at elevated risk for chronic diseases such as atherosclerosis, nutrition- and tobacco-related cancers, and stroke. 2. The Know Your Body program described in this paper has proved to be both feasible in design and acceptable in approach to school-age children, educators, and parents. In all its phases we believe the program represents a model that could be duplicated in other environments with relatively little adjustment. Original contributions in the program's development include the prescreening and postsereening education with an interpretation of the results and a curriculum geared to the needs of teachers in several fields, including science, health, social studies, and domestic sciences. 3. Educational type intervention (including extracurricular activities) did not affect children in the upper levels for the various clinical measures we used. That is, the percentage of children who smoked and who were obese did not differ significantly between the study and control schools. 4. Behavioral modification programs concerning weight loss and cigarette smoking prevention did have a positive effect on two subset populations within the study group of schools. The smoking incidence was reduced by 75% in the study group, and weight loss was significantly different ( P < 0 . 0 5 ) in the study group contrasted with the controls.

98 REFERENCES I. Williams, C. L. and Wynder, E. L. (1976): A blind spot in preventive medicine. I. Am. ?,led. Assoc. 236, 2196-2197. 2. Williams, C. L., Arnold, C. B., and Wynder, E. L. (1977): Primary prevention of chronic disease beginning in childhood: The "Know Your Body" program--deslgn of study. Prey. Med. 6(2), 344-357. 3. Williams, C. L., Carter, B. J., and Eng, A. (1980): Know your body: A development approach to health education. Prey. bled. 9. In press. 4. Eng, A., Carter, B. J., and Williams, C. L. (1979): Personalizing primary cancer prevention education for students. Health Values 3(6), 304-309. 5. Williams, C. L. and Wynder, E. L. (1978): Motivating adolescents to reduce risk for chronic disease. Postgrad. Med. 1. 54, 212-214. 6. Williams, C. L., Arnold, C. B., and Wynder, E. L. (1979): Chronic disease risk factors among children: The "Know Your Body" study. 1. Chronic Dis. 32, 505513. 7. Williams, C. L., Carter, B. J., Wynder, E. L., and Blumenfeld, T. A. (1979): Selected chronic disease "risk factors" in two elementary school populations: A pilot study. Ant. 1. Dis. ChiM. 133, 704-708. 8. Yankelovich, S. and White, Inc. (1976): A study of cigarette smoking among teenage girls and young women. Conducted for the American Cancer Society, New York. 9. Rawbone, R. G., Keeling C. A., Jenkins, A., and Guz, A. (1978): Cigarette smoking among secondary school children in 1975. J. Epidemiol. Commun. Health 32, 53-58. 10. National Clearinghouse for Smoking and Health, Teen-

THE

11.

12. 13. 14.

15. 16. 17. 18. 19.

age Smoking, Natiot,al Patterns o/ Cigarette Smoking, Ages 12-18, 1968 and 1970. DHEW Publ. No. 72-7508 HSMHA. Washington, D.C., 1971. Frerichs, R. R., Srinivasan, S. R., Webber, I. S., and Berenson, G. S. (1976): Serum cholesterol and tri. glycerides in 3,446 children from a biracial community The Bogalusa Heart Study. Circulation 54, 302-308. Wilmore, J. H. and McNamara, J. J. (1974): Prevalence of coronary heart disease risk factors in boys, 8 to 12 years of age. 1. Pediatr. 84, 527-533. Report of the Task Force on Blood Pressure Control in Children. Pediatrics 59(5) (Suppl), May 1977. Height and Weight o] Children 6 to I1 and Youthj 12-17 Years. U.S. Vital and Health Statistics, U.S. De. partment of Health, Education and Welfare Series No. 104 and 124, 1970 and 1973. Youth Physical Fitness. President's Council on Physical Fitness and Sports. No. 4000-00297. U.S. Govt. Print. ing Office, Washington, D.C. 20402. September 1973. Botvin, G. J., Eng, A., and Williams, C. L. (1980): Preventing the onset of cigarette smoking through life skills training. Prey. Med. 9, 135-143. Carter, B. J., Eng, A., and Williams, C. L. (1980): A middle school health education project: The "Know Your Body" program. Middle School J. In press. Botvin, G. J., Cantlon, A., Carter, B. J., and Williams, C. L. (1979): Reducing adolescent obesity through a school health program. I. Pediatr. 95, 1060-1064. Williams, C. L., Eng, A., Botvin, G. J., et al. (1979): Validation of student's self-reported cigarette smoking status with plasma cotinlne levels. 1. Am. Publ. Health Assoc. 69, 1272-1274.

IDENTIFICATION AND TREATMENT OF SPOUSE ABUSE: THE ROLE OF COMMUNITY HEALTH AND MENTAL HEALTH AGENCIES

A o n e - d a y c o n f e r e n c e t h a t will offer health a n d m e n t a l h e a l t h professionals an o p p o r t u n i t y to share a n d e x a m i n e new perspectives a n d innovative a p p r o a c h e s to the identification a n d t r e a t m e n t of spouse abuse will be h e l d o n N o v e m b e r 21, 1980 in N e w Y o r k City. T h e tuition will b e $25.00. F o r f u r t h e r i n f o r m a t i o n contact: Continuing Education Coordinator Long Island Jewish-Hillside Medical Center N e w H y d e P a r k , N e w Y o r k 11042 (212) 470-2114

PATIENT COUNSEI.i.ING AND HEALTH EDUCATION