APPLES :

1. APPLES: A SCHOOL-BASED INTERVENTION TO REDUCE OBESITY RISK FACTORS P Sahota, MCJ Rudolf, R Dixey, AJ Hill, JH Barth, J Cade.

2. Aim of The APPLES Project • To develop a school based programme to improve the diet and activity levels of primary school children and so reduce obesity risk factors

3. Aim of The APPLES Project • To develop a school based programme to improve the diet and activity levels of primary school children and so reduce obesity risk factors

4. STUDY DESIGN: GROUP RANDOMISED CONTROLLED TRIAL • 10 schools involving 700 children aged 7-11 years • analysis by cluster • schools paired for size, ethnicity and FSMI and then randomised baseline 12 mths 24 mths Schools A-E Schools F-J INTERVENTION Schools A-E Schools F-J COMPARISON

5. APPROACH • Population Approach • Health Promoting School Philosophy

6. The APPLES PROGRAMME • Teachers Training Days • Resource Dissemination • Formulation of School Action Plans • Continuous Support and Monitoring • Anthropometric, diet, physical activity, psychological data collected pre and post intervention

7. APPLES ACTIVITIES Practical cooking sessions Topic work Health fairs Dietitian visits to class Tuck shops PElessons Playgroundactivities Schoolmeals

14. THE EVALUATION PROCESS • How successful was the implementation process? • What impact did APPLES have on the school? • What effect did it have on the individual child?

15. HOW SUCCESSFUL WAS THE IMPLEMENTATION? • All 10 schools completed • The teachers’ evaluations • 85 action points developed (6 -14 per school) • Response rates for data collection 64%-97% • Uptake of support offered by the Team

16. Teachers Evaluation • Trainingextremely useful 43% very useful 32% useful 25% • Resources yes, will use again 100% • Benefits increased awareness in children 100%

17. Change Suggested by Parents Results of questionnaire ( 64% response rate) • playground activities 43% • break-time snacks 40% • school dinners 33% • games and sports 29% • packed lunches 16 % • no change 20%

18. IMPACT ON THE SCHOOL • Action plans • School meals • Focus groups

19. Some Activities in the Action Plans - 89% achieved Schools • Nutrition education in curriculum 10 • Healthy eating sessions by dietitian 10 • Fit is Fun programme in P.E 10 • Improved playground facilities 6 • Policy changes in break-time snacks 5 • Healthy tuckshops 4

20. Changes in School Meals No. of Schools beforeafter • jacket potatoes 1 10 • fresh fruit - daily 8 10 • mash potatoes 4 6 • salad vegetables - daily 4 7 • vegetarian options poor good

21. FOCUS GROUPS Intervention school children reported: • Better understanding • More sophisticated ideas • Higher self reported behaviour change • Higher recollection of activities related to diet and activity

23. WAS THE INTERVENTION EFFECTIVE? • Growth • Diet - 3 day diaries, 24 hr recall • Physical activity - diaries and recall • Psychological well being

25. BMI

26. VEGETABLE INTAKE

27. OTHER OUTCOMES:no significant difference between intervention and comparison schools • Dietary: fat sugar fruit intake • Physical activity • Psychological measures

28. SUMMARY OF THE FINDINGS • APPLES was successful in its implementation • APPLES had an evident impact on the schools • Behavioural changes in the children were disappointing

29. Reflections and implications for Health Services Research Study Design • Sample size • Length of intervention • Outcome measures • Complexity of the intervention

30. Future • Research officer post funded • Refine intervention • conduct a multi-centre RCT

31. Publications • Mary CJ Rudolf, Tim J Cole, Aaron J Krom, Pinki Sahota, Jenny Walker. (2000) Growth of primary school children: a validation of the 1990 references and their use in growth monitoring. Archives of Disease in Childhood, 83:298 – 301. • R. Dixey, P Sahota, S Atwal, A Turner. (2001) Children talking about healthy eating: data from focus groups with 300 9-11 year olds.Nutrition Bulletin, British Nutrition Foundation, 26 (1): 71-79. • Rachael Dixey, Pinki Sahota, Serbjit Atwal , Alex Turner. (2001) “Ha ha, you’re fat, we’re strong”; a qualitative study of boys’ and girls’ perceptions of fatness, thinness, social pressures and health using focus groups. Health Education,101(5): 206 – 216. • Mary CJ Rudolf, Pinki Sahota, Julian H Barth, Jenny Walker. (2001) Increasing prevalence of obesity in primary school children: cohort study. British Medical Journal 322: 1094 - 1095 • Pinki Sahota, Mary CJ Rudolf, Rachael Dixey, Andrew J. Hill, Julian H Barth, Janet Cade. (2001) Evaluation of implementation and effect of school based intervention to reduce risk factors for obesity.British Medical Journal, 323: 1027 – 1029. • Pinki Sahota, Mary CJ Rudolf, Rachael Dixey, Andrew J. Hill, Julian H Barth, Janet Cade. (2001) Randomised controlled trial of primary school based intervention to reduce risk factors for obesity. British Medical Journal, 323: 1029 – 1032. • Rudolf MCJ, Greenwood DC, Cole TJ, Levine R, Sahota P, Walker J, Holland P, Cade J, Truscott J (2003) Rising Obesity and Expanding Waistlines In School Children: A Cohort Study. Archives of Disease in Childhood (in press)

32. Prevalence of Overweight and Obesity by Year

35. CONCLUSIONS • Primary schools can implement changes into the school with little in the way of extra resources • Behavioural changes are harder to measure and achieve • Obesity is reaching epidemic proportions in the UK • Urgent need for good quality evaluative research.