Wellness Cascade Milestone Steps:
Following the wellness cascade approach, we tracked progress and outcomes of all available students ( program effectiveness) as well subset of students with a BMI>85th %ile (cascade effectiveness). We approached 601 students who were registered and eligible for screening at the MMCC afterschool program between 2016 to 2018. Of the students, 403 had demographic data and were assessed (n=198 were absent on health screening days). Three hundred and twenty-four had screening BMI data over the three school years, and of those, 180 had a BMI>85th%ile (56% of those with BMI screening data) (Step 1 - see Figure 1). A total of 79 students assented and enrolled ( 56 with BMI>85th%ile) (Step 2) in B’N Fit POWER by registering in both SBHC and MMCC. A total of 76 students attended at least one clinic and one afterschool session and thus engaged (55 with BMI>85th%ile) (Step 3) in the B’N Fit POWER program. A total of 65 students participated at all three clinic visits and completed the program ( 48 had BMI>85th %ile) (Step 4). Finally, 24 students (21 with BMI>85th%ile) demonstrated either maintenance or an improvement in BMI z-score (Step 5).
Baseline Student Characteristics
Table 1 summarizes the demographic and baseline anthropometric information of the B’N Fit POWER students that were engaged in three academic years (N=76). Students were predominantly Hispanic/Latino (62%), and 46% of students were girls. A majority (80%) were overweight or obese, and over half (53.6%) were obese or severely obese. At baseline, average BMI Z-score was 1.4 (0.8). Overall, there was low attainment of target behaviors at baseline, with 32% of students eating breakfast and lunch daily, 53% eating 2-3 servings of fruit daily and 29% eat 3-6 servings of vegetables daily, 29% drinking 8 cups of sugar-free beverages daily, 75% sleeping at least 8 hours a night, 21% participating in at least 7 hours of physical activity weekly, 25% eating no more than one unhealthy snack or fast food meal weekly. The overall target behavior composite score was 2.5 (SD=1.1). Comparison of baseline target behaviors by grade, demonstrates that while not significant due to limited sample size, there was a trend of a 5% -10% decline in target attainment of lunch consumption, sugar-free beverage consumption, sugary beverage consumption, unhealthy snack food consumption and fast food consumption from age 11 to 13 years.
Table 1
B’N Fit POWER 2016-2018 Baseline Student Characteristics
|
B’N Fit POWER
All Students
(N=76)
|
B’N Fit Power
Cascade Target students (≥85th %ile)
(N=55)
|
Demographics
|
2016
|
35
|
30
|
2017
|
27
|
17
|
2018
|
14
|
8
|
Age, yrs (SD)
|
12.4 (1.0)
|
12.5 (1.1)
|
Sex, Female, %
|
35 (46.1)
|
25 (45.5)
|
Ethnicity
|
Black (Non-Hispanic)
|
19 (25)
|
14 (25)
|
Hispanic/Latino
|
47 (61.8)
|
32 (58)
|
White (Non-Hispanic)
|
3 (3.9)
|
3 (5)
|
Anthropometrics: x̅ + SD
|
BMI, kg/m2
|
24.7 (3.8)
|
26.2 (2.3)
|
BMI percentile, %
|
86.7 (20.1)
|
95.1 (3.6)
|
BMI Z-score
|
1.4 (0.8)
|
1.7 (0.3)
|
Obesity category
|
BMI (5- 84.9%ile) Healthy weight
|
14 (20.3)
|
0 (0)
|
BMI (85-94.9%ile) Overweight
|
18 (26.1)
|
18 (32.7)
|
BMI (95-98.9%ile) Obesity
|
33 (47.8)
|
33 (60)
|
BMI ( >99%ile) Severe obesity
|
4 (5.8)
|
4 (7.3)
|
Baseline Attainment of Target behaviors (%)
|
Breakfast daily
|
34 (45.3)
|
25 (46.3)
|
Lunch daily
|
43 (57.3)
|
29 (53.7)
|
Breakfast and Lunch daily
|
24 (32)
|
17 (31.5)
|
Fruit (2-3 servings/day)
|
40 (53.3)
|
29 (53.7)
|
Vegetable ( 3-6 servings/day)
|
22 (29.3)
|
16 (29.6)
|
Sugarfree Beverages ( 8 cups a day)
|
21 (28.8)
|
15 (28.8)
|
Sugary Beverages (<1 cup a day)
|
20 (26.7)
|
15 (27.8)
|
Sugarfree and Sugary Beverages (8 cups & <1 cup a day)
|
7 (9.3)
|
5 (9.3)
|
Sleep ( at least 8 hours a night)
|
56 (74.7)
|
41 (75.9)
|
Physical activity (≥1 hour of physical activity/day)
|
16 (21.3)
|
12 (22.2)
|
Unhealthy snacks ( no more than weekly)
|
20 (27)
|
16 (29.6)
|
Fast foods ( no more than weekly)
|
53 (70.7)
|
37 (68.5)
|
Unhealthy snack and fast foods ( no more than weekly)
|
19 (25.3)
|
15 (27.8)
|
Composite score (SD), range: 0-7
|
2.5 (1.1)
|
2.5 (1.1)
|
Afterschool Program and Clinic Attendance
The overall afterschool leadership and physical activity attendance following one academic year was 63.7 (+23.6) hours and 67.9 (+39.3) hours, respectively. That is, the students participated less than expected– 1.8 hours per week in leadership (80% of expected 2.25 hours) and 1.9 hours per week in physical activity (45% of expected 4.25 hours). Participation at the clinic visits was high, with 85.5% (65/76) attending all three visits. Yet, participation in all three clinic visits and at least 75% attendance at leadership and physical activity was low at 15.8% (12/76).
BMI Z-score and Composite Target Behavior Score Changes After Participation in B’N Fit POWER
Comparing baseline and 4th visit, students engaged in the B’N Fit POWER program showed negligible change in BMI Z-score of 0.02 (SE=0.03, p=0.29). Multiple imputation (MI) showed a similar result of -0.04 (SE=0.15). Similarly, we did not observe any significant change in composite score over time (mean change=0, SE=0.21, p=0.96) (Figure 2). The BMI Z-score change in the cascade target students was 0.01 (SE: 0.04, p=0.49), while not statistically significant, the change in composite score was -0.22 (SE: 0.24, p=0.47) suggesting a potential narrowing of uptake of expected negative behaviors.
Assessment of changes in each individual target behavior showed progress in some target behaviors (Figure 3): fruit and vegetable consumption, combined increased consumption of sugar-free beverages with decreased sugary beverages, and improved unhealthy snack food consumption following participation in the program. Students, however, lacked progress in breakfast, lunch (p=0.05), fast food, sugary beverage consumption, and target sleep hours. Similarly, multiple imputation result suggested a marginally significant increase in vegetable consumption (p=0.07), a decrease in breakfast consumption (p=0.09) and increase in eating fast food (p=0.05). Individual behavioral changes in the cascade target students suggested a similar positive progress in percentages as in the total program students. (Supplementary Figure 1)
As target behaviors were measured four times over the academic year, we assessed the trajectory in behavior changes using the repeated measures with similar results. A non statistically significant trend in composite score over time showed that students demonstrated progress in vegetable and fruit consumption, sugar free and sugary beverage consumption, physical activity, and unhealthy snack consumption. (Supplementary Table 1). Multiple imputation results showed similar magnitudes in the forementionned target behaviors except for the composite score, fruit consumption, and physical activity.
When examining how target behavior trajectory change over time differed with afterschool attendance, though not statistically significant, assuming the baseline risks are the same between groups, students with >75% afterschool attendance at leadership (which included nutrition education and cooking classes) and physical activity had higher tendency for target behavior improvement, including a 3.6 fold increase in fruit consumption and a 4.2 fold increase in drinking less surgary beverages, compared to students with lower afterschool attendance (<75%) (Table 2). Mulitple imputation result showed similar results. The cascade target students who had higher after school attendance showed progress in BMI Z-score, fruit (OR: 5.93, 95%CI: 0.85, 41.46) and vegetable (OR: 1.62, 95% CI: 0.11, 23.02) consumption. They also showed improved progress in physical activity and eating less unhealthy snacks target behavior attainment. ( Supplemental Table 2)
Table 2
Target behavior change for Low (<75%) and High (>75%) Afterschool Attendance*
|
Afterschool Attendance
|
|
Low
N= 56 (78%)
|
High
N= 16 (22%)
|
Mean attendance
(3.1 hrs/week)
|
Mean attendance
(5.7 hrs/week)
|
Outcome
|
β
|
95% CI
|
P-value
|
β
|
95% CI
|
P-value
|
Composite Score*
|
0.07
|
(-0.37-0.51 )
|
0.745
|
0.16
|
(-0.65-0.97)
|
0.700
|
BMI Z-score
|
0.00
|
(-0.05-0.06)
|
0.923
|
0.02
|
(-0.08-0.12)
|
0.632
|
Behavior
|
OR
|
95% CI
|
P-value
|
OR
|
95% CI
|
P-value
|
Breakfast
|
0.80
|
(0.23-2.77)
|
0.728
|
0.96
|
(0.12-7.69)
|
0.969
|
Lunch
|
0.37
|
(0.11-1.24)
|
0.108
|
0.00
|
(0-0.1)
|
0.001
|
Breakfast & Lunch
|
0.88
|
(0.26-2.9)
|
0.828
|
0.30
|
(0.03-3.48)
|
0.334
|
Fruit
|
0.98
|
(0.42-2.28)
|
0.965
|
3.55
|
(0.65-19.29)
|
0.143
|
Vegetable
|
2.07
|
(0.67-6.37)
|
0.204
|
2.22
|
(0.24-20.79)
|
0.484
|
Sugar Free Beverage
|
1.09
|
(0.35-3.32)
|
0.886
|
0.90
|
(0.12-6.73)
|
0.922
|
Sugary Beverage
|
0.63
|
(0.2-1.91)
|
0.411
|
2.64
|
(0.31-22.59)
|
0.376
|
Sugar-Free and Sugary Beverage
|
1.13
|
(0.25-5.09)
|
0.877
|
1.83
|
(0.12-28.91)
|
0.669
|
Sleep
|
0.83
|
(0.25-2.75)
|
0.762
|
0.24
|
(0.03-1.92)
|
0.179
|
Physical activity
|
1.09
|
(0.28-4.22)
|
0.905
|
1.59
|
(0.15-16.35)
|
0.698
|
Unhealthy snacks
|
1.25
|
(0.46-3.4)
|
0.660
|
1.55
|
(0.21-11.6)
|
0.668
|
Fast Food
|
0.55
|
(0.19-1.58)
|
0.268
|
0.38
|
(0.07-2.19)
|
0.281
|
Unhealthy Snack and Fast Food
|
0.77
|
(0.27-2.18)
|
0.627
|
0.82
|
(0.07-9.33)
|
0.870
|
*- 4 students were missing afterschool attendance data
Associations Between Target Behavior Change and BMI Z-score
Although not significant, improvements in individual target behaviors and composite score showed progress in BMI Z-score reduction. This was seen especially in those students who had accomplished the target sleep hours with a statistically significant decrease in BMI Z-score (β= -0.05, 95% CI -0.1 – -0.003, p=0.038) (Table 3). Cascade target students showed similar trends as whole program participants especially with respect to eating breakfast, which showed a significant reduction in BMI Z score (β: -0.06, 95% CI: -0.11, -0.01, p=0.02). (Supplemental Table 3)
Table 3
Association Between Target Behavior Attainment as an Exposure and BMI Z-score
Exposure
|
β
|
95% CI
|
P-value
|
Composite score*
|
-0.01
|
(-0.03, 0.01)
|
0.367
|
Breakfast
|
-0.04
|
(-0.09, 0.02)
|
0.196
|
Lunch
|
-0.02
|
(-0.07, 0.03)
|
0.416
|
Breakfast & lunch
|
-0.01
|
(-0.07, 0.04)
|
0.635
|
Fruit
|
0
|
(-0.04, 0.04)
|
0.99
|
Vegetable
|
-0.03
|
(-0.08, 0.02)
|
0.248
|
Sugar free beverage
|
-0.02
|
(-0.07, 0.03)
|
0.352
|
Sugary beverage
|
0.02
|
(-0.03, 0.07)
|
0.519
|
Sugar free and sugary beverage
|
0.04
|
(-0.03, 0.11)
|
0.284
|
Sleep
|
-0.05
|
(-0.1, -0.003)
|
0.038
|
Physical activity
|
-0.03
|
(-0.08, 0.03)
|
0.374
|
Unhealthy snacks
|
0.04
|
(-0.01, 0.08)
|
0.13
|
Fast Food
|
0.02
|
(-0.02, 0.07)
|
0.32
|
Unhealthy snack and fast food
|
0.04
|
(-0.01, 0.09)
|
0.132
|