Impact of a Diabetes Prevention Program on Body Size, Physical Activity, and Diet Among Kanien'kehá:ka (Mohawk) Children 6 to 11 Years Old:
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《小儿科》
Direction de Santé Publique de Montréal and Division of Preventive Medicine, McGill University Health Center, Montreal, Quebec, Canada
Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
Kahnawake Schools Diabetes Prevention Project Centre for Research and Training, Kahnawake, Quebec, Canada
School of Physical and Health Education, Queen's University, Kingston, Ontario, Canada
Department of Family Medicine, McGill University, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
Groupe de Recherche Interdisciplinaire en Santé, Université de Montréal, Montreal, Quebec, Canada
Department of Nutrition, Université de Montréal, Montreal, Quebec, Canada
Research and Evaluation Inc, Montreal, Quebec, Canada
ABSTRACT
Objectives. Report the 8-year impact on body size, physical activity, and diet of a community-based diabetes prevention program for elementary-school children in a Kanien'kehá:ka (Mohawk) community in Canada.
Methods. Follow-up (1994–1996) of subjects in the intervention and comparison community and repeat cross-sectional measurements in the intervention community alone from 1994 to 2002. Measures included triceps and subscapular skinfold thicknesses, body mass index (BMI), weekly number of 15-minute episodes of physical activity, run/walk test times, television watching, and consumption of sugared foods, fatty foods, and fruits and vegetables.
Results. The longitudinal data of 1994–1996 showed some early positive effects of the program on skinfold thickness but not on BMI, physical activity, fitness, or diet. Repeat cross-sectional measures from 1994 to 2002 showed increases in skinfold thickness and BMI. Physical activity, fitness, and television watching showed favorable trends from 1994 to 1999 that were not sustained in 2002. Key high-fat and high-sugar foods consumption decreased, as did consumption of fruits and vegetables.
Conclusions. Although early results showed some successes in reducing risk factors for type 2 diabetes, these benefits were not maintained over 8 years.
Key Words: prevention diabetes children community Indians North American community-based participatory research
Abbreviations: KSDPP, Kahnawake School Diabetes Prevention Project
The increasing prevalence of childhood obesity and the appearance of type 2 diabetes during adolescence and in particular among Aboriginal youth is a major public health concern.1,2 Aboriginal children have a higher prevalence of overweight, obesity, and diabetes than non-Aboriginal children.3 Aboriginal leaders, Aboriginal community elders, and many authors have argued that primary prevention of diabetes for Aboriginal children and youth is the only solution to a foreseen public health disaster as the adverse outcomes associated with diabetes and other cardiovascular risk factors become evident with the maturation of these populations.2,4–6
Several primary prevention programs for diabetes and its risk factors in Aboriginal and other high-risk populations have been initiated successfully, many taking advantage of the opportunities to reach children, families, and communities through their schools.2,7–11 Evaluations of some of these programs have shown improvements in diabetes knowledge and behavior-specific self-efficacy,12 as well as in diet, including reduced dietary fats and increased consumption of fruits and vegetables9 and reduced soft-drink consumption.10 Although prevention programs for non-Aboriginal children have shown some positive impacts on physical activity and physical fitness,13,14 no study has yet reported on the impact of primary prevention of diabetes risk factors in North American Aboriginal children.15
This study reports the impact on body size, physical activity and fitness, and diet of the Kahnawake School Diabetes Prevention Project (KSDPP), a diabetes prevention program for elementary-school children, reinforced by community interventions and conducted in a Kanien'kehá:ka (Mohawk) community in Québec, Canada. As described elsewhere, the intervention used a participatory approach, emphasizing community ownership16–18 and community decision-making about the research.19–21
METHODS
Intervention
The Kanien'kehá:ka community of Kahnawake, with a population of 6746 in 1994, is located 12 miles southwest of Montreal, Canada. In the early 1980s, an observed rate of type 2 diabetes in adults twice that of the general population and high rates of ensuing macrovascular complications combined with a perceived increase of obesity in children led to requests from community leaders and elders for a diabetes primary prevention program focusing on elementary-school children, their families, and the entire community.
The KSDPP intervention program and evaluation designs have been described in detail22 and are only summarized below. The objectives of the program are to reduce the prevalence of obesity, high-calorie and high-fat diets, and physical inactivity among Kahnawake elementary-school children. The intervention model combines elements from the social learning theory,23 the Precede-Proceed model,24 the Ottawa Charter for Health Promotion,25 and traditional learning styles of native children.26,27
The main program components include a health education curriculum delivered in grades 1 through 6 in the community's 2 elementary schools (ten 45-minute lessons per year for each grade). The curriculum includes topics on type 2 diabetes, healthy nutrition (including traditional foods), physical activity and fitness, and other healthy lifestyles. Community activities include regular use of the local newspaper and radio for advertisement, press coverage of events and reporting of results back to the community, promotional events such as contests and family activities (treasure hunts, snow sculpture contests, harvest fair, food tasting, cyclothons, walking clubs, line-dancing clubs, figure skating, etc), and collaborations with other community organizations including the Youth Center, the Kahnawake Combined Schools Committee, the Band Council, and the local health and social services agency, among others. Finally, the program supports the development of capacity (training of native staff and volunteers as well as community members) and promotes healthier environments and stronger social norms for healthy behaviors, especially nutritional choices and physical activity. Environmental and policy changes supported by the KSDPP include the school nutrition policy (ban of junk foods sold on or brought onto school premises) and the construction of a walking and cycling path in the community. Process evaluation showed that the intervention resulted in increases in healthy food choices at school, classroom diabetes prevention–related activities, ecological changes such as the school nutrition policy and the community walking path, and strong community agreement with project objectives.18,28,29
Evaluation Design
The outcome evaluation used a mixed cross-sectional and longitudinal design with a nonequivalent comparison group of children in the single school of a second Kanien'kehá:ka community 200 miles southwest of Kahnawake. Baseline assessments were conducted in the fall of 1994 on all elementary-school (grades 1–6) children in the intervention and comparison communities for whom a parent or guardian had provided written informed consent. Follow-up cross-sectional measurements were conducted in the intervention community in the fall of 1995, 1996, 1998, 1999, and 2002 and in the comparison community in 1995 and 1996. A diabetes prevention program was started in the comparison community in 1996, precluding additional data collection in its elementary school.
Measures and Procedures
One community research nurse conducted all anthropometric measurements in each community during school hours. Weight was obtained in light indoor clothing without shoes or extra sweaters. All measures were taken by using the same numeric scales (SECA Model 770 Alpha, SECA Co, Columbia, MD) to the nearest 0.1 kg. The weight of standard clothing was not subtracted from the observed weight. The scale was tested periodically for accuracy and calibrated by using a set of standard weights. Height was measured with a portable wooden infant/child height-measuring board (Irwin J. Shorr, Olney, MD), and measurement was recorded to the nearest millimeter (0.1 cm). Children were asked to remove their shoes and to stand straight with their head in the Frankfurt horizontal plane. BMI was calculated as weight (kg)/height (m2). Triceps and subscapular skinfold thicknesses were measured 3 times each on the right side by using a Lange caliper (Beta Technology, Santa Cruz, CA) and the method described by Lohman et al.30 The precision was 0.1 cm. Children stood with their feet together and arms at their sides, and clothing was lifted to expose the measurements sites. Reliability indices for these measures, previously reported, were very high.22
Questionnaires collected data on sociodemographic and lifestyles variables. Parents completed the questionnaire at home for students in grades 1 to 3, and children in grades 4 to 6 completed the questionnaires in class. Physical activity was measured with a 7-day recall adapted from an instrument developed by Sallis et al,31 which assesses the number of 15-minute episodes of 25 sports and other physical activities during and outside of school hours. Sedentary behaviors were assessed with questions on the frequency of television watching and video playing on weekdays and on Saturday. Physical fitness was measured by using the run/walk test.32 In groups of 60, children in grades 4 to 6 were asked to run or walk 1 mile on a paved road as quickly as possible, and their individual scores were recorded. The same procedure was used for children in grades 1 to 3 except that the distance covered was half of a mile. The run/walk test was repeated 1 week later, and the better of the 2 times was used in the analyses. A research coordinator and a community research assistant conducted all the run/walk tests in each community. In 2002, the run/walk test was replaced by a shuttle run.
Nutrition data were collected by a 7-day food-frequency questionnaire adapted from previous research33 to include foods commonly eaten in the community. Children or their parents were asked to indicate how often children ate 51 different foods. For the present article, 3-item subscales based on factor analysis and validation against 24-hour recall data34 were used to create indicators of key high-sugar food consumption (soft drink, candy, and sugared cereal), key high-fat food consumption (hot dogs, fries, chips), and fruit and vegetable consumption (including fruit and vegetable juices).
Data Analyses
Data for 1995 were not included in the analyses because of concerns about the quality of the anthropometric measures. Two types of analyses of the impact of the intervention program on all the risk factor measures were performed. First, the changes in outcome variables in the intervention relative to the comparison community were assessed in the longitudinal cohort by repeated measures analyses of covariance (with age and gender as covariates) with time (1994 vs 1996) and community (intervention versus comparison) as independent variables. In these analyses, the time by community interactions tested the intervention impact.
Second, changes over time (1994–2002) were assessed cross-sectionally in the risk-factor variables among the children in the intervention community only. Because of the repeated observations per subjects over time, these analyses were conducted by using a generalized estimating equation (GEE) to account for the correlated nature of the data. Age- and gender-adjusted odds ratio and their 95% confidence intervals were determined for each individual outcome, comparing each follow-up year relative to the 1994 baseline. For these analyses, measures of skinfold thickness and BMI were regrouped into quintiles, measures of physical activity and fitness into quartiles, and measures of diet into tertiles.
RESULTS
Analyses Comparing the Intervention and Comparison Communities:1994–1996
The slower increase in skinfolds did not translate in a lower rate of increase in BMI in the intervention compared with the comparison community children (Table 2). The age- and gender-adjusted mean BMI increased from 17.24 to 19.04 among Kahnawake children compared with 17.76 to 19.80 in the comparison community.
In both communities the frequency of self-reported episodes of at least 15 minutes of physical activity increased by 23% (Table 2). However, children in the intervention community reported a significant decrease in frequency of gym class at school, from 2.84 to 1.85 times per week between 1994 and 1996, compared with children in the comparison community, who reported an increase from 1.71 to 2.18 times per week over the same time period (F[1220] = 24.81; P < .01). This is consistent with the result showing that children in the comparison community improved their performance on the run/walk test (8% improvement in average time to complete the run/walk test), compared with children from Kahnawake, who had worse performances in 1996 than in 1994 (22% deterioration in average time). On school days, television viewing decreased marginally in Kahnawake children relative to the comparison community (F[1189] = 2.67; P = .10), but there were no overall changes in television watching on Saturdays (F[1189] = 1.34 [not significant]). Finally, there were no significant changes between intervention and comparison communities from 1994 to 1996 for indices of consumption of sugar, fat, or fruits and vegetables.
Cross-Sectional Analyses in the Intervention Community: 1994–2002
In contrast, the mean number of physical activities increased significantly in 1998 and 1999 but returned to the baseline level in 2002. Similarly, the fitness measure improved significantly in 1999 and television and video watching decreased from 1994 to 1999, but those improvements were lost in 2002. Significant decreases in key high-sugar and high fat food items intake were consistently noted from 1996 onward, with 65% to 70% reductions in the risk of consumption of these food items in 2002. However, fruit and vegetable consumption also decreased significantly over the same period.
DISCUSSION
Prevention of the occurrence of risk factors for diabetes in children should be a major public health objective for populations at high risk, including Aboriginal peoples of North America. However, because of their unique cultural, social, and political fabric, Aboriginal populations offer the opportunity for innovative approaches to health-promotion program planning. KSDPP is one of the first community-based, primary prevention programs for diabetes evaluated in an Aboriginal population. It distinguishes itself from other programs by its focus on participatory research, community ownership, and true grass-root participation at all levels of program planning, delivery, and evaluation.16–22,28,35 The evaluation design of KSDPP includes both follow-up of a cohort of elementary-school children in the intervention and comparison communities for 2 years from 1994 to 1996 and repeat cross-sectional surveys of the elementary-school children in the intervention community in 1994, 1996, 1998, 1999, and 2002.
Despite local community control and efforts to implement culturally appropriate, healthy lifestyle interventions, the primary study objective to reduce the prevalence of obesity was not achieved. Early results from the longitudinal 2-year contrasts suggested that, although BMI was unaffected, both skinfold measures increased less rapidly in the intervention compared with the comparison community. If skinfolds are more sensitive to changes in energy balance, then these results would support early benefits from the program. However, the repeat cross-sectional assessments showed constant progression of skinfolds (except the 1998 and 1999 triceps skinfold values, which show discrepancies possibly caused by measurement error) and BMI across all years with concomitant increases in the risk of higher skinfolds and BMI over time. The risk of having a higher BMI over baseline was increased by 37% in 2002.
These increases in body fatness occurred despite improvements in measures of physical activity, fitness, and television and video watching reported over most of the study period (1994–1999) but were not maintained in 2002. In addition, results from the cross-sectional analyses were not supported by the early longitudinal contrasts (Table 2), which failed to show improvements in physical activity and television watching and showed significant decreases in fitness in the intervention community, compared with the comparison community. Although the introduction of satellite television in the community may have negatively influenced television-viewing habits, this variable was not assessed either through environmental assessment or self-report. Additional explanations for the increase in adiposity, which were suggested by residents in a series of local meetings to return research results to the community, include increased overall community wealth and disposable income over the past decade combined with increasing availabilities of fast-food restaurants in the areas surrounding the reserve, increased proportion of families in which both parents work and are less available for supervision of children's meals and leisure activities, and the perceived importance within the community of computer literacy for youth. The longitudinal results for physical fitness are congruent with a reported decrease in physical education classes in 1 of the 2 schools in the intervention community during the period of 1994–1996 and are reflected in the significant decrease in frequency of gym classes at school (Table 2). The decrease in physical education classes occurred because of cuts in the education budget and not as a result of changes in KSDPP interventions.
The 2-year longitudinal contrast failed to show any differences between intervention and control communities on dietary indicators, which suggests that, in the short-term, KSDPP was not effective in influencing eating practices of elementary-school children. Repeat cross-sectional analyses, which provide longer-term insight into the effect of the program, show improvements in important aspects of dietary behaviors such as decreased consumption of key high-fat and high-sugar foods as well as reduced soft-drink consumption as noted in a previous study on a subsample of the children.34 The school nutrition policy may have supported such a change. Favorable dietary changes in sugar and fat, however, were accompanied by the less healthy effect of decreased fruit and vegetable consumption. Although there is no clear explanation for this finding, television advertising may be a contributing factor. Content analysis of Saturday morning children's programming estimates that the average child viewer may be exposed to 1 food commercial every 5 minutes.36 One study found that for each additional hour of television viewed per day there was a decline in fruit and vegetable consumption among adolescents.37 Exposure to television food advertising also has shown to negatively influence children's identification of a healthy food choice from a series of paired items.38,39
Over the same period that KSDPP was being implemented, all segments of North American society experienced strong secular increases in excess body fat.40 The prevalence of obesity among Canadian children 7 to 13 years old increased from 2% to 10% from 1981 to 1996.41 Our findings suggest that secular forces of increasing obesity throughout North America are strong and may require more intense and comprehensive efforts than those contained in a single local health-promotion program. Findings from primary prevention interventions targeting changes in both diet and physical activity have not resulted in significant reductions in average body weight or adiposity,13,42,43 with the exception of 1 study reporting a significant reduction in obesity for girls only.44 These studies, however, were successful in achieving positive changes in diet,45 diet and television watching,44 and diet and physical activity,13,43 among other self-reported psychosocial variables. Of particular interest and relevance is the randomized, controlled school-based trial in American Indian communities, which found that the percentage body fat among elementary-school children was essentially identical at the end of a 3-year intervention period for intervention and control schools despite a significant reduction in the percentage of energy derived from fat and total energy intake (by 24-hour recall) in the intervention schools.42,45 In addition, experimental schools were more physically active than control schools, although the overall difference between the 2 groups (10%) was not statistically significant.46 A separate study on the same population of children found that the percentage of children with a BMI >95th percentile was consistently higher than the national averages in all communities studied and for both girls and boys.47 With children overweight by the time they reach elementary school, intervening at the elementary-school level may be too late.
The main limitations of this study are the small sample sizes in both the intervention and comparison communities, as well as the lack of follow-up data from the comparison community after 1996. In addition, a differential degree of reporting completeness might have resulted, because parents completed at home the questionnaire of children in grades 1 through 3. The absence of a gold standard to measure fitness in children in a community setting led to the selection of the 1-mile run/walk test, which can be influenced by children's motivation to complete the run as quickly as possible and used a half-mile distance for younger children.
Qualitative analysis of 31 semistructured interviews conducted with classroom teachers over the course of this study suggests that teachers implemented the curriculum and enforced the nutrition policy to varying degrees. Some teachers implemented all 10 lessons per year, whereas others implemented relatively few lessons. Similarly, the nutrition policy was enforced to varying degrees, with some teachers not permitting any unhealthy food or beverage in the classroom even on special occasions. Although we can not systematically determine individual or classroom-level exposures of children to these components of the KSDPP intervention, qualitative findings suggest the presence of variation in exposure and thus intervention intensity.
KSDPP is an effectiveness trial conducted in a real-life setting and not in the artificial conditions created by true randomized experiments, which in many cases have also failed to find strong unequivocal evidence of preventive impact.48 Policy and environmental changes and behavior modifications for nutrition and physical activity at a community-wide level are difficult to achieve in the short term in real-life situations, because they are influenced by a complex web of very strong and pervasive social, cultural, and political factors that act at numerous and various societal levels and are often beyond the control of a local program such as KSDPP. For example, children are exposed to an estimated 20000 to 40000 food commercials annually,49 commercials which tend to promote foods high in fat and sugar by using aggressive marketing strategies and enormous financial resources.36,50
Although it is likely that much longer intervention periods, more intensive programs, and possibly different types of interventions are needed to achieve lasting lifestyle changes, they are much more likely to occur and be sustained over the long term as a result of community mobilization and participation, which is a hallmark of KSDPP.18,35 This ongoing project has been strengthened by incorporating the reported research results into the planning of new interventions. A series of 16 community meetings was held to return the results reported here to the population of Kahnawake, to generate community input in the interpretation of the results, and to solicit suggestions for the future directions of the project. Additional data will be collected in the intervention community for at least 10 years from program implementation. Although these results show some successes in reducing risk factors for diabetes among elementary-school children, it is clear that many challenges remain.
ACKNOWLEDGMENTS
This research was supported by Health Canada through the National Health Research and Development Program (grants 6605-4188-ND and 6605-4187-ND) and the Canadian Institutes for Health Research, the Kahnawake community, and private foundations. Drs Lévesque and Cargo were supported by fellowships from the Medical Research Council of Canada (now the Canadian Institutes for Health Research), and Dr Potvin is a Canadian Foundation for Health Services Research chair.
We thank Dr Louis T. Montour (deceased), Edward J. Cross, Chantal Saad-Haddad, Serge Desrosiers, Treena Delormier, Tracee Diabo, Amy Ing, Ida Labillois-Montour, Geraldine Sky, and Ashley Ross and the Kahnawake Schools Diabetes Prevention Project Community Advisory Board, the school principals, teachers, students and their parents for their contributions.
FOOTNOTES
Accepted Jun 30, 2004.
No conflict of interest declared.
REFERENCES
Fagot-Campagna A, Burrows N, Williamson D. The public health epidemiology of type 2 diabetes in children and adolescents: a case study of American Indian adolescents in the Southwestern United Sates. Clin Chim Acta. 1999;286(1–2) :81 –95
Story M. School-based approaches for preventing and treating obesity. Int J Obes Relat Metab Disord. 1999;23(suppl 2) :S43 –S51
Jackson M. Height, weight and body mass index of American Indian school children, 1990–1991. J Am Diet Assoc. 1993;93 :1136 –1140
Young T, Reading J, Elias B, O'Neil J. Type 2 diabetes mellitus in Canada's First Nations: status of an epidemic in progress. Can Med Assoc J.163 :561 –566
Burrows N, Geiss L, Engelgau M, Action K. Prevalence of diabetes among Aboriginal Americans and Alaska Aboriginals, 1990–1997: an increasing burden. Diabetes Care. 2000;23 :1786 –90
Broussard B, Sugarman J, Bachman-Carter K, et al. Toward comprehensive obesity prevention programs in Aboriginal North American communities. Obes Res. 1995;3(suppl 2) :289S –297S
Helitzer D, Davis S, Gittleson J, Going S, Murray D, Snyder P, Steckler A. process evaluation in a multi-site primary obesity-prevention trial in American Indian schoolchildren. Am J Clin Nutr. 1999;69(4 suppl) :816S –824S
Davis S, Going S, Helitzer D, et al. Pathways: a culturally appropriate obesity-prevention program for American Indian schoolchildren. Am J Clin Nutr. 1999;69(4 suppl) :796S –802S
Trevino R, Pygh J, Hernandez A, Menchaca V, Ramirez R, Mendoza M. Bienstar: a diabetes risk-factor prevention program. J Sch Health. 1998;68 :62 –67
Teufel N, Ritenbaugh C. Development of a primary prevention program: insight gained in the Zuni Diabetes Prevention Program. Clin Pediatr (Phila). 1998;37 :131 –141
Hood V, Kelly B, Martinez C, Shuman S, Secker-Walker R. A Native American community initiative to prevent diabetes. Ethn Health. 1997;2 :277 –285
Holcomb J, Lira P, Kingery P, Smith D, Lane D, Goodway J. Evaluation of Jump Into Action: a program to reduce the risk of non-insulin dependent diabetes mellitus in school children on the Texas-Mexico border. J Sch Health. 1998;68 :282 –288
Luepker R, Perry C, McKinlay S, et al. Outcomes of a field trial to improve children's dietary patterns and physical activity: the Child and Adolescent Trial for Cardiovascular Health. CATCH Collaborative Group. JAMA. 1996;275 :768 –776
Harrell J, Gansky S, McMurray R, Bangdiwala S, Frauman A, Bradley C. School-based interventions improve heart health in children with multiple cardiovascular disease risk factors. Pediatrics. 1998;102 :371 –380
Satterfield DW, Volansky M, Caspersen CJ, et al. Community-based lifestyle interventions to prevent type 2 diabetes. Diabetes Care. 2003;26 :2643 –2652
Macaulay A, Commanda L, Freeman W, et al. Participatory research maximizes community and lay involvement. BMJ. 1999;319 :774 –778
McComber AM, Macaulay AC, Kirby R, Desrosiers S, Cross EJ, Saad-Haddad C. The Kahnawake Schools Diabetes Prevention Project: community participation in a diabetes primary prevention research project. Int J Circumpolar Health. 1998;57(suppl 1) :370 –374
Cargo M, Lévesque L, Macaulay AC, et al. Community governance of the Kahnawake Schools Diabetes Prevention Project. Health Promot Int. 2003;18 :177 –187
Potvin LP, Cargo M, McComber AM, Delormier T, Macaulay AC. Implementing participatory intervention and research in communities: lessons from the Kahnawake Schools Diabetes Prevention Project. Soc Sci Med. 2003;56 :1295 –1305
Macaulay AC, Delormier T, McComber A, et al. Participatory research with native community of Kahnawake creates innovative code of research ethics. Can J Public Health. 1998;89 :105 –108
Delormier T, Cargo M, Kirby R, McComber A, Rice J, Potvin L. Activity implementation as a reflection of living in balance. The Kahnawake Schools Diabetes Prevention Project. Pimatziwin. 2003;1 :145 –163
Macaulay A, Paradis G, Potvin L, et al. The Kahnawake Schools Diabetes Prevention Project: intervention, evaluation and baseline results of a diabetes primary prevention program in an Aboriginal community in Canada. Prev Med. 1997;26 :779 –790
Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84 :191 –215
Green LW, Kreuter MW. Health Promotion Planning: An Educational and environmental Approach. 2nd ed. Mountain View, CA: Mayfield; 1991
Ottawa Charter for Health Promotion. Can J Public Health. 1986;77 :425 –430
More AJ. Native Indian learning styles: a review for researchers and teachers. J Am Indian Educ. October 1987:17 –29
Sawyer D. Native learning styles: shorthand for instructional adaptations. Can J Native Educ. 1991;18 :99 –105
Lévesque L, Guilbault G, Delormier T, Potvin L. Unpacking the black box: a deconstruction of the programming approach and physical activity interventions implemented in the Kahnawake Schools Diabetes Prevention Project. Health Promot Pract. 2005;6 :64 –71
Macaulay AC, Paradis G, Potvin L, et al. Primary Prevention of Diabetes Type II in First Nations: Experiences of the Kahnawake Schools Diabetes Prevention Project. Can J Diabetes Care. 1998;22 :44 –49
Lohman T, Roche A, Martorell R, eds. Anthropometric Standardization Reference Manual. Champaign, IL: Human Kinetics; 1988
Sallis J, Strikmiller P, Harsha D, et al. Validation of interviewer and self-administered physical activity checklists for fifth grade students. Med Sci Sports Exerc. 1996;28 :840 –851
Chun DM, Corbin CB, Pangrazi RP. Validation of criterion-referenced standards for the mile run and progression aerobic cardiovascular endurance tests. Res Q Exerc Sport. 2000;71 :125 –134
O'Loughlin J, Paradis G, Renaud L, Meshefedjian G, Gray-Donald K. Prevalence and correlates of overweight among elementary schoolchildren in multiethnic, low income, inner-city neighbourhoods in Montreal, Canada. Ann Epidemiol. 2000;8 :422 –432
Jimenez M, Receveur O, Trifonopoulos M, Kuhnlein H, Paradis G, Macaulay AC. Evaluation of dietary change among children (grades 4–6) from the Kahnawake Schools Diabetes Prevention Project. J Am Diet Assoc. 2003;103 :1191 –1194
American Academy of Pediatrics, Committee on Native American Child Health; Committee on Community Health Services. Ethical considerations in research with socially identifiable populations. Pediatrics. 2004;113 :148 –151
Kotz K, Story M. Food advertisements during children's Saturday morning television programming: are they consistent with dietary recommendations J Am Diet Assoc. 1994;94 :1296 –1300
Boynton-Jarret R, Thomas TN, Peterson KE, Wiecha J, Sobol AM, Gortmaker SL. Impact of television viewing patterns on fruit and vegetable consumption among adolescents. Pediatrics. 2003;113 :1321 –1326
Signorielli N, Staples J. Television and children's conceptions of nutrition. Health Commun. 1997;9 :281 –301
Signorielli N, Lears M. Television and children's conceptions of nutrition: unhealthy messages. Health Commun. 1992;4 :245 –257
Strauss RS, Pollack HA. Epidemic increase in childhood overweight, 1986–1998. JAMA. 2001;286 :2845 –2848
Tremblay MS, Katzmarzyk PT, Willms JD. Temporal trends in overweight and obesity in Canada, 1981–96. Int J Obes Relat Metab Disord. 2002;26 :538 –543
Caballero B, Clay T, Davis SM, et al. Pathways: a school-based, randomized controlled trial for the prevention of obesity in American Indian schoolchildren. Am J Clin Nutr. 2003;78 :1030 –1038
Nader PR, Stone EJ, Lytle LA, et al. Three-year maintenance of improved diet and physical activity: the CATCH cohort. Arch Pediatr Adolesc Med. 1999;153 :695 –704
Gortmaker SL, Peterson K, Wiecha J, et al. Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Arch Pediatr Adolesc Med. 1999;153 :409 –418
Himes JH, Ring K, Gittelsohn J, et al. Impact of the Pathways intervention on dietary intakes of American Indian schoolchildren. Prev Med. 2003;37(suppl 1) :S55 –S61
Going S, Thompson J, Cano S, et al. The effects of the Pathways Obesity Prevention Program on physical activity in American Indian children. Prev Med. 2003;37(6 pt 2) :S62 –S69
Caballero B, Himes JH, Lohman T, et al. Body composition and overweight prevalence in 1704 schoolchildren from 7 American Indian communities. Am J Clin Nutr. 2003;78 :308 –312
Wilson P, O'Mears S, Summerhall C, Kelley S. The prevention and treatment of childhood obesity. Qual Saf Health Care. 2003;12 :65 –74
American Academy of Pediatrics, Committee on Communications. Children, adolescents, and advertising. Pediatrics. 1995;95 :295 –297
Story M. Food advertising and marketing directed at children and adolescents in the US. Int J Behav Nutr Phys Act. 2004;1 :3(Gilles Paradis, MD, Lucie)
Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
Kahnawake Schools Diabetes Prevention Project Centre for Research and Training, Kahnawake, Quebec, Canada
School of Physical and Health Education, Queen's University, Kingston, Ontario, Canada
Department of Family Medicine, McGill University, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
Groupe de Recherche Interdisciplinaire en Santé, Université de Montréal, Montreal, Quebec, Canada
Department of Nutrition, Université de Montréal, Montreal, Quebec, Canada
Research and Evaluation Inc, Montreal, Quebec, Canada
ABSTRACT
Objectives. Report the 8-year impact on body size, physical activity, and diet of a community-based diabetes prevention program for elementary-school children in a Kanien'kehá:ka (Mohawk) community in Canada.
Methods. Follow-up (1994–1996) of subjects in the intervention and comparison community and repeat cross-sectional measurements in the intervention community alone from 1994 to 2002. Measures included triceps and subscapular skinfold thicknesses, body mass index (BMI), weekly number of 15-minute episodes of physical activity, run/walk test times, television watching, and consumption of sugared foods, fatty foods, and fruits and vegetables.
Results. The longitudinal data of 1994–1996 showed some early positive effects of the program on skinfold thickness but not on BMI, physical activity, fitness, or diet. Repeat cross-sectional measures from 1994 to 2002 showed increases in skinfold thickness and BMI. Physical activity, fitness, and television watching showed favorable trends from 1994 to 1999 that were not sustained in 2002. Key high-fat and high-sugar foods consumption decreased, as did consumption of fruits and vegetables.
Conclusions. Although early results showed some successes in reducing risk factors for type 2 diabetes, these benefits were not maintained over 8 years.
Key Words: prevention diabetes children community Indians North American community-based participatory research
Abbreviations: KSDPP, Kahnawake School Diabetes Prevention Project
The increasing prevalence of childhood obesity and the appearance of type 2 diabetes during adolescence and in particular among Aboriginal youth is a major public health concern.1,2 Aboriginal children have a higher prevalence of overweight, obesity, and diabetes than non-Aboriginal children.3 Aboriginal leaders, Aboriginal community elders, and many authors have argued that primary prevention of diabetes for Aboriginal children and youth is the only solution to a foreseen public health disaster as the adverse outcomes associated with diabetes and other cardiovascular risk factors become evident with the maturation of these populations.2,4–6
Several primary prevention programs for diabetes and its risk factors in Aboriginal and other high-risk populations have been initiated successfully, many taking advantage of the opportunities to reach children, families, and communities through their schools.2,7–11 Evaluations of some of these programs have shown improvements in diabetes knowledge and behavior-specific self-efficacy,12 as well as in diet, including reduced dietary fats and increased consumption of fruits and vegetables9 and reduced soft-drink consumption.10 Although prevention programs for non-Aboriginal children have shown some positive impacts on physical activity and physical fitness,13,14 no study has yet reported on the impact of primary prevention of diabetes risk factors in North American Aboriginal children.15
This study reports the impact on body size, physical activity and fitness, and diet of the Kahnawake School Diabetes Prevention Project (KSDPP), a diabetes prevention program for elementary-school children, reinforced by community interventions and conducted in a Kanien'kehá:ka (Mohawk) community in Québec, Canada. As described elsewhere, the intervention used a participatory approach, emphasizing community ownership16–18 and community decision-making about the research.19–21
METHODS
Intervention
The Kanien'kehá:ka community of Kahnawake, with a population of 6746 in 1994, is located 12 miles southwest of Montreal, Canada. In the early 1980s, an observed rate of type 2 diabetes in adults twice that of the general population and high rates of ensuing macrovascular complications combined with a perceived increase of obesity in children led to requests from community leaders and elders for a diabetes primary prevention program focusing on elementary-school children, their families, and the entire community.
The KSDPP intervention program and evaluation designs have been described in detail22 and are only summarized below. The objectives of the program are to reduce the prevalence of obesity, high-calorie and high-fat diets, and physical inactivity among Kahnawake elementary-school children. The intervention model combines elements from the social learning theory,23 the Precede-Proceed model,24 the Ottawa Charter for Health Promotion,25 and traditional learning styles of native children.26,27
The main program components include a health education curriculum delivered in grades 1 through 6 in the community's 2 elementary schools (ten 45-minute lessons per year for each grade). The curriculum includes topics on type 2 diabetes, healthy nutrition (including traditional foods), physical activity and fitness, and other healthy lifestyles. Community activities include regular use of the local newspaper and radio for advertisement, press coverage of events and reporting of results back to the community, promotional events such as contests and family activities (treasure hunts, snow sculpture contests, harvest fair, food tasting, cyclothons, walking clubs, line-dancing clubs, figure skating, etc), and collaborations with other community organizations including the Youth Center, the Kahnawake Combined Schools Committee, the Band Council, and the local health and social services agency, among others. Finally, the program supports the development of capacity (training of native staff and volunteers as well as community members) and promotes healthier environments and stronger social norms for healthy behaviors, especially nutritional choices and physical activity. Environmental and policy changes supported by the KSDPP include the school nutrition policy (ban of junk foods sold on or brought onto school premises) and the construction of a walking and cycling path in the community. Process evaluation showed that the intervention resulted in increases in healthy food choices at school, classroom diabetes prevention–related activities, ecological changes such as the school nutrition policy and the community walking path, and strong community agreement with project objectives.18,28,29
Evaluation Design
The outcome evaluation used a mixed cross-sectional and longitudinal design with a nonequivalent comparison group of children in the single school of a second Kanien'kehá:ka community 200 miles southwest of Kahnawake. Baseline assessments were conducted in the fall of 1994 on all elementary-school (grades 1–6) children in the intervention and comparison communities for whom a parent or guardian had provided written informed consent. Follow-up cross-sectional measurements were conducted in the intervention community in the fall of 1995, 1996, 1998, 1999, and 2002 and in the comparison community in 1995 and 1996. A diabetes prevention program was started in the comparison community in 1996, precluding additional data collection in its elementary school.
Measures and Procedures
One community research nurse conducted all anthropometric measurements in each community during school hours. Weight was obtained in light indoor clothing without shoes or extra sweaters. All measures were taken by using the same numeric scales (SECA Model 770 Alpha, SECA Co, Columbia, MD) to the nearest 0.1 kg. The weight of standard clothing was not subtracted from the observed weight. The scale was tested periodically for accuracy and calibrated by using a set of standard weights. Height was measured with a portable wooden infant/child height-measuring board (Irwin J. Shorr, Olney, MD), and measurement was recorded to the nearest millimeter (0.1 cm). Children were asked to remove their shoes and to stand straight with their head in the Frankfurt horizontal plane. BMI was calculated as weight (kg)/height (m2). Triceps and subscapular skinfold thicknesses were measured 3 times each on the right side by using a Lange caliper (Beta Technology, Santa Cruz, CA) and the method described by Lohman et al.30 The precision was 0.1 cm. Children stood with their feet together and arms at their sides, and clothing was lifted to expose the measurements sites. Reliability indices for these measures, previously reported, were very high.22
Questionnaires collected data on sociodemographic and lifestyles variables. Parents completed the questionnaire at home for students in grades 1 to 3, and children in grades 4 to 6 completed the questionnaires in class. Physical activity was measured with a 7-day recall adapted from an instrument developed by Sallis et al,31 which assesses the number of 15-minute episodes of 25 sports and other physical activities during and outside of school hours. Sedentary behaviors were assessed with questions on the frequency of television watching and video playing on weekdays and on Saturday. Physical fitness was measured by using the run/walk test.32 In groups of 60, children in grades 4 to 6 were asked to run or walk 1 mile on a paved road as quickly as possible, and their individual scores were recorded. The same procedure was used for children in grades 1 to 3 except that the distance covered was half of a mile. The run/walk test was repeated 1 week later, and the better of the 2 times was used in the analyses. A research coordinator and a community research assistant conducted all the run/walk tests in each community. In 2002, the run/walk test was replaced by a shuttle run.
Nutrition data were collected by a 7-day food-frequency questionnaire adapted from previous research33 to include foods commonly eaten in the community. Children or their parents were asked to indicate how often children ate 51 different foods. For the present article, 3-item subscales based on factor analysis and validation against 24-hour recall data34 were used to create indicators of key high-sugar food consumption (soft drink, candy, and sugared cereal), key high-fat food consumption (hot dogs, fries, chips), and fruit and vegetable consumption (including fruit and vegetable juices).
Data Analyses
Data for 1995 were not included in the analyses because of concerns about the quality of the anthropometric measures. Two types of analyses of the impact of the intervention program on all the risk factor measures were performed. First, the changes in outcome variables in the intervention relative to the comparison community were assessed in the longitudinal cohort by repeated measures analyses of covariance (with age and gender as covariates) with time (1994 vs 1996) and community (intervention versus comparison) as independent variables. In these analyses, the time by community interactions tested the intervention impact.
Second, changes over time (1994–2002) were assessed cross-sectionally in the risk-factor variables among the children in the intervention community only. Because of the repeated observations per subjects over time, these analyses were conducted by using a generalized estimating equation (GEE) to account for the correlated nature of the data. Age- and gender-adjusted odds ratio and their 95% confidence intervals were determined for each individual outcome, comparing each follow-up year relative to the 1994 baseline. For these analyses, measures of skinfold thickness and BMI were regrouped into quintiles, measures of physical activity and fitness into quartiles, and measures of diet into tertiles.
RESULTS
Analyses Comparing the Intervention and Comparison Communities:1994–1996
The slower increase in skinfolds did not translate in a lower rate of increase in BMI in the intervention compared with the comparison community children (Table 2). The age- and gender-adjusted mean BMI increased from 17.24 to 19.04 among Kahnawake children compared with 17.76 to 19.80 in the comparison community.
In both communities the frequency of self-reported episodes of at least 15 minutes of physical activity increased by 23% (Table 2). However, children in the intervention community reported a significant decrease in frequency of gym class at school, from 2.84 to 1.85 times per week between 1994 and 1996, compared with children in the comparison community, who reported an increase from 1.71 to 2.18 times per week over the same time period (F[1220] = 24.81; P < .01). This is consistent with the result showing that children in the comparison community improved their performance on the run/walk test (8% improvement in average time to complete the run/walk test), compared with children from Kahnawake, who had worse performances in 1996 than in 1994 (22% deterioration in average time). On school days, television viewing decreased marginally in Kahnawake children relative to the comparison community (F[1189] = 2.67; P = .10), but there were no overall changes in television watching on Saturdays (F[1189] = 1.34 [not significant]). Finally, there were no significant changes between intervention and comparison communities from 1994 to 1996 for indices of consumption of sugar, fat, or fruits and vegetables.
Cross-Sectional Analyses in the Intervention Community: 1994–2002
In contrast, the mean number of physical activities increased significantly in 1998 and 1999 but returned to the baseline level in 2002. Similarly, the fitness measure improved significantly in 1999 and television and video watching decreased from 1994 to 1999, but those improvements were lost in 2002. Significant decreases in key high-sugar and high fat food items intake were consistently noted from 1996 onward, with 65% to 70% reductions in the risk of consumption of these food items in 2002. However, fruit and vegetable consumption also decreased significantly over the same period.
DISCUSSION
Prevention of the occurrence of risk factors for diabetes in children should be a major public health objective for populations at high risk, including Aboriginal peoples of North America. However, because of their unique cultural, social, and political fabric, Aboriginal populations offer the opportunity for innovative approaches to health-promotion program planning. KSDPP is one of the first community-based, primary prevention programs for diabetes evaluated in an Aboriginal population. It distinguishes itself from other programs by its focus on participatory research, community ownership, and true grass-root participation at all levels of program planning, delivery, and evaluation.16–22,28,35 The evaluation design of KSDPP includes both follow-up of a cohort of elementary-school children in the intervention and comparison communities for 2 years from 1994 to 1996 and repeat cross-sectional surveys of the elementary-school children in the intervention community in 1994, 1996, 1998, 1999, and 2002.
Despite local community control and efforts to implement culturally appropriate, healthy lifestyle interventions, the primary study objective to reduce the prevalence of obesity was not achieved. Early results from the longitudinal 2-year contrasts suggested that, although BMI was unaffected, both skinfold measures increased less rapidly in the intervention compared with the comparison community. If skinfolds are more sensitive to changes in energy balance, then these results would support early benefits from the program. However, the repeat cross-sectional assessments showed constant progression of skinfolds (except the 1998 and 1999 triceps skinfold values, which show discrepancies possibly caused by measurement error) and BMI across all years with concomitant increases in the risk of higher skinfolds and BMI over time. The risk of having a higher BMI over baseline was increased by 37% in 2002.
These increases in body fatness occurred despite improvements in measures of physical activity, fitness, and television and video watching reported over most of the study period (1994–1999) but were not maintained in 2002. In addition, results from the cross-sectional analyses were not supported by the early longitudinal contrasts (Table 2), which failed to show improvements in physical activity and television watching and showed significant decreases in fitness in the intervention community, compared with the comparison community. Although the introduction of satellite television in the community may have negatively influenced television-viewing habits, this variable was not assessed either through environmental assessment or self-report. Additional explanations for the increase in adiposity, which were suggested by residents in a series of local meetings to return research results to the community, include increased overall community wealth and disposable income over the past decade combined with increasing availabilities of fast-food restaurants in the areas surrounding the reserve, increased proportion of families in which both parents work and are less available for supervision of children's meals and leisure activities, and the perceived importance within the community of computer literacy for youth. The longitudinal results for physical fitness are congruent with a reported decrease in physical education classes in 1 of the 2 schools in the intervention community during the period of 1994–1996 and are reflected in the significant decrease in frequency of gym classes at school (Table 2). The decrease in physical education classes occurred because of cuts in the education budget and not as a result of changes in KSDPP interventions.
The 2-year longitudinal contrast failed to show any differences between intervention and control communities on dietary indicators, which suggests that, in the short-term, KSDPP was not effective in influencing eating practices of elementary-school children. Repeat cross-sectional analyses, which provide longer-term insight into the effect of the program, show improvements in important aspects of dietary behaviors such as decreased consumption of key high-fat and high-sugar foods as well as reduced soft-drink consumption as noted in a previous study on a subsample of the children.34 The school nutrition policy may have supported such a change. Favorable dietary changes in sugar and fat, however, were accompanied by the less healthy effect of decreased fruit and vegetable consumption. Although there is no clear explanation for this finding, television advertising may be a contributing factor. Content analysis of Saturday morning children's programming estimates that the average child viewer may be exposed to 1 food commercial every 5 minutes.36 One study found that for each additional hour of television viewed per day there was a decline in fruit and vegetable consumption among adolescents.37 Exposure to television food advertising also has shown to negatively influence children's identification of a healthy food choice from a series of paired items.38,39
Over the same period that KSDPP was being implemented, all segments of North American society experienced strong secular increases in excess body fat.40 The prevalence of obesity among Canadian children 7 to 13 years old increased from 2% to 10% from 1981 to 1996.41 Our findings suggest that secular forces of increasing obesity throughout North America are strong and may require more intense and comprehensive efforts than those contained in a single local health-promotion program. Findings from primary prevention interventions targeting changes in both diet and physical activity have not resulted in significant reductions in average body weight or adiposity,13,42,43 with the exception of 1 study reporting a significant reduction in obesity for girls only.44 These studies, however, were successful in achieving positive changes in diet,45 diet and television watching,44 and diet and physical activity,13,43 among other self-reported psychosocial variables. Of particular interest and relevance is the randomized, controlled school-based trial in American Indian communities, which found that the percentage body fat among elementary-school children was essentially identical at the end of a 3-year intervention period for intervention and control schools despite a significant reduction in the percentage of energy derived from fat and total energy intake (by 24-hour recall) in the intervention schools.42,45 In addition, experimental schools were more physically active than control schools, although the overall difference between the 2 groups (10%) was not statistically significant.46 A separate study on the same population of children found that the percentage of children with a BMI >95th percentile was consistently higher than the national averages in all communities studied and for both girls and boys.47 With children overweight by the time they reach elementary school, intervening at the elementary-school level may be too late.
The main limitations of this study are the small sample sizes in both the intervention and comparison communities, as well as the lack of follow-up data from the comparison community after 1996. In addition, a differential degree of reporting completeness might have resulted, because parents completed at home the questionnaire of children in grades 1 through 3. The absence of a gold standard to measure fitness in children in a community setting led to the selection of the 1-mile run/walk test, which can be influenced by children's motivation to complete the run as quickly as possible and used a half-mile distance for younger children.
Qualitative analysis of 31 semistructured interviews conducted with classroom teachers over the course of this study suggests that teachers implemented the curriculum and enforced the nutrition policy to varying degrees. Some teachers implemented all 10 lessons per year, whereas others implemented relatively few lessons. Similarly, the nutrition policy was enforced to varying degrees, with some teachers not permitting any unhealthy food or beverage in the classroom even on special occasions. Although we can not systematically determine individual or classroom-level exposures of children to these components of the KSDPP intervention, qualitative findings suggest the presence of variation in exposure and thus intervention intensity.
KSDPP is an effectiveness trial conducted in a real-life setting and not in the artificial conditions created by true randomized experiments, which in many cases have also failed to find strong unequivocal evidence of preventive impact.48 Policy and environmental changes and behavior modifications for nutrition and physical activity at a community-wide level are difficult to achieve in the short term in real-life situations, because they are influenced by a complex web of very strong and pervasive social, cultural, and political factors that act at numerous and various societal levels and are often beyond the control of a local program such as KSDPP. For example, children are exposed to an estimated 20000 to 40000 food commercials annually,49 commercials which tend to promote foods high in fat and sugar by using aggressive marketing strategies and enormous financial resources.36,50
Although it is likely that much longer intervention periods, more intensive programs, and possibly different types of interventions are needed to achieve lasting lifestyle changes, they are much more likely to occur and be sustained over the long term as a result of community mobilization and participation, which is a hallmark of KSDPP.18,35 This ongoing project has been strengthened by incorporating the reported research results into the planning of new interventions. A series of 16 community meetings was held to return the results reported here to the population of Kahnawake, to generate community input in the interpretation of the results, and to solicit suggestions for the future directions of the project. Additional data will be collected in the intervention community for at least 10 years from program implementation. Although these results show some successes in reducing risk factors for diabetes among elementary-school children, it is clear that many challenges remain.
ACKNOWLEDGMENTS
This research was supported by Health Canada through the National Health Research and Development Program (grants 6605-4188-ND and 6605-4187-ND) and the Canadian Institutes for Health Research, the Kahnawake community, and private foundations. Drs Lévesque and Cargo were supported by fellowships from the Medical Research Council of Canada (now the Canadian Institutes for Health Research), and Dr Potvin is a Canadian Foundation for Health Services Research chair.
We thank Dr Louis T. Montour (deceased), Edward J. Cross, Chantal Saad-Haddad, Serge Desrosiers, Treena Delormier, Tracee Diabo, Amy Ing, Ida Labillois-Montour, Geraldine Sky, and Ashley Ross and the Kahnawake Schools Diabetes Prevention Project Community Advisory Board, the school principals, teachers, students and their parents for their contributions.
FOOTNOTES
Accepted Jun 30, 2004.
No conflict of interest declared.
REFERENCES
Fagot-Campagna A, Burrows N, Williamson D. The public health epidemiology of type 2 diabetes in children and adolescents: a case study of American Indian adolescents in the Southwestern United Sates. Clin Chim Acta. 1999;286(1–2) :81 –95
Story M. School-based approaches for preventing and treating obesity. Int J Obes Relat Metab Disord. 1999;23(suppl 2) :S43 –S51
Jackson M. Height, weight and body mass index of American Indian school children, 1990–1991. J Am Diet Assoc. 1993;93 :1136 –1140
Young T, Reading J, Elias B, O'Neil J. Type 2 diabetes mellitus in Canada's First Nations: status of an epidemic in progress. Can Med Assoc J.163 :561 –566
Burrows N, Geiss L, Engelgau M, Action K. Prevalence of diabetes among Aboriginal Americans and Alaska Aboriginals, 1990–1997: an increasing burden. Diabetes Care. 2000;23 :1786 –90
Broussard B, Sugarman J, Bachman-Carter K, et al. Toward comprehensive obesity prevention programs in Aboriginal North American communities. Obes Res. 1995;3(suppl 2) :289S –297S
Helitzer D, Davis S, Gittleson J, Going S, Murray D, Snyder P, Steckler A. process evaluation in a multi-site primary obesity-prevention trial in American Indian schoolchildren. Am J Clin Nutr. 1999;69(4 suppl) :816S –824S
Davis S, Going S, Helitzer D, et al. Pathways: a culturally appropriate obesity-prevention program for American Indian schoolchildren. Am J Clin Nutr. 1999;69(4 suppl) :796S –802S
Trevino R, Pygh J, Hernandez A, Menchaca V, Ramirez R, Mendoza M. Bienstar: a diabetes risk-factor prevention program. J Sch Health. 1998;68 :62 –67
Teufel N, Ritenbaugh C. Development of a primary prevention program: insight gained in the Zuni Diabetes Prevention Program. Clin Pediatr (Phila). 1998;37 :131 –141
Hood V, Kelly B, Martinez C, Shuman S, Secker-Walker R. A Native American community initiative to prevent diabetes. Ethn Health. 1997;2 :277 –285
Holcomb J, Lira P, Kingery P, Smith D, Lane D, Goodway J. Evaluation of Jump Into Action: a program to reduce the risk of non-insulin dependent diabetes mellitus in school children on the Texas-Mexico border. J Sch Health. 1998;68 :282 –288
Luepker R, Perry C, McKinlay S, et al. Outcomes of a field trial to improve children's dietary patterns and physical activity: the Child and Adolescent Trial for Cardiovascular Health. CATCH Collaborative Group. JAMA. 1996;275 :768 –776
Harrell J, Gansky S, McMurray R, Bangdiwala S, Frauman A, Bradley C. School-based interventions improve heart health in children with multiple cardiovascular disease risk factors. Pediatrics. 1998;102 :371 –380
Satterfield DW, Volansky M, Caspersen CJ, et al. Community-based lifestyle interventions to prevent type 2 diabetes. Diabetes Care. 2003;26 :2643 –2652
Macaulay A, Commanda L, Freeman W, et al. Participatory research maximizes community and lay involvement. BMJ. 1999;319 :774 –778
McComber AM, Macaulay AC, Kirby R, Desrosiers S, Cross EJ, Saad-Haddad C. The Kahnawake Schools Diabetes Prevention Project: community participation in a diabetes primary prevention research project. Int J Circumpolar Health. 1998;57(suppl 1) :370 –374
Cargo M, Lévesque L, Macaulay AC, et al. Community governance of the Kahnawake Schools Diabetes Prevention Project. Health Promot Int. 2003;18 :177 –187
Potvin LP, Cargo M, McComber AM, Delormier T, Macaulay AC. Implementing participatory intervention and research in communities: lessons from the Kahnawake Schools Diabetes Prevention Project. Soc Sci Med. 2003;56 :1295 –1305
Macaulay AC, Delormier T, McComber A, et al. Participatory research with native community of Kahnawake creates innovative code of research ethics. Can J Public Health. 1998;89 :105 –108
Delormier T, Cargo M, Kirby R, McComber A, Rice J, Potvin L. Activity implementation as a reflection of living in balance. The Kahnawake Schools Diabetes Prevention Project. Pimatziwin. 2003;1 :145 –163
Macaulay A, Paradis G, Potvin L, et al. The Kahnawake Schools Diabetes Prevention Project: intervention, evaluation and baseline results of a diabetes primary prevention program in an Aboriginal community in Canada. Prev Med. 1997;26 :779 –790
Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84 :191 –215
Green LW, Kreuter MW. Health Promotion Planning: An Educational and environmental Approach. 2nd ed. Mountain View, CA: Mayfield; 1991
Ottawa Charter for Health Promotion. Can J Public Health. 1986;77 :425 –430
More AJ. Native Indian learning styles: a review for researchers and teachers. J Am Indian Educ. October 1987:17 –29
Sawyer D. Native learning styles: shorthand for instructional adaptations. Can J Native Educ. 1991;18 :99 –105
Lévesque L, Guilbault G, Delormier T, Potvin L. Unpacking the black box: a deconstruction of the programming approach and physical activity interventions implemented in the Kahnawake Schools Diabetes Prevention Project. Health Promot Pract. 2005;6 :64 –71
Macaulay AC, Paradis G, Potvin L, et al. Primary Prevention of Diabetes Type II in First Nations: Experiences of the Kahnawake Schools Diabetes Prevention Project. Can J Diabetes Care. 1998;22 :44 –49
Lohman T, Roche A, Martorell R, eds. Anthropometric Standardization Reference Manual. Champaign, IL: Human Kinetics; 1988
Sallis J, Strikmiller P, Harsha D, et al. Validation of interviewer and self-administered physical activity checklists for fifth grade students. Med Sci Sports Exerc. 1996;28 :840 –851
Chun DM, Corbin CB, Pangrazi RP. Validation of criterion-referenced standards for the mile run and progression aerobic cardiovascular endurance tests. Res Q Exerc Sport. 2000;71 :125 –134
O'Loughlin J, Paradis G, Renaud L, Meshefedjian G, Gray-Donald K. Prevalence and correlates of overweight among elementary schoolchildren in multiethnic, low income, inner-city neighbourhoods in Montreal, Canada. Ann Epidemiol. 2000;8 :422 –432
Jimenez M, Receveur O, Trifonopoulos M, Kuhnlein H, Paradis G, Macaulay AC. Evaluation of dietary change among children (grades 4–6) from the Kahnawake Schools Diabetes Prevention Project. J Am Diet Assoc. 2003;103 :1191 –1194
American Academy of Pediatrics, Committee on Native American Child Health; Committee on Community Health Services. Ethical considerations in research with socially identifiable populations. Pediatrics. 2004;113 :148 –151
Kotz K, Story M. Food advertisements during children's Saturday morning television programming: are they consistent with dietary recommendations J Am Diet Assoc. 1994;94 :1296 –1300
Boynton-Jarret R, Thomas TN, Peterson KE, Wiecha J, Sobol AM, Gortmaker SL. Impact of television viewing patterns on fruit and vegetable consumption among adolescents. Pediatrics. 2003;113 :1321 –1326
Signorielli N, Staples J. Television and children's conceptions of nutrition. Health Commun. 1997;9 :281 –301
Signorielli N, Lears M. Television and children's conceptions of nutrition: unhealthy messages. Health Commun. 1992;4 :245 –257
Strauss RS, Pollack HA. Epidemic increase in childhood overweight, 1986–1998. JAMA. 2001;286 :2845 –2848
Tremblay MS, Katzmarzyk PT, Willms JD. Temporal trends in overweight and obesity in Canada, 1981–96. Int J Obes Relat Metab Disord. 2002;26 :538 –543
Caballero B, Clay T, Davis SM, et al. Pathways: a school-based, randomized controlled trial for the prevention of obesity in American Indian schoolchildren. Am J Clin Nutr. 2003;78 :1030 –1038
Nader PR, Stone EJ, Lytle LA, et al. Three-year maintenance of improved diet and physical activity: the CATCH cohort. Arch Pediatr Adolesc Med. 1999;153 :695 –704
Gortmaker SL, Peterson K, Wiecha J, et al. Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Arch Pediatr Adolesc Med. 1999;153 :409 –418
Himes JH, Ring K, Gittelsohn J, et al. Impact of the Pathways intervention on dietary intakes of American Indian schoolchildren. Prev Med. 2003;37(suppl 1) :S55 –S61
Going S, Thompson J, Cano S, et al. The effects of the Pathways Obesity Prevention Program on physical activity in American Indian children. Prev Med. 2003;37(6 pt 2) :S62 –S69
Caballero B, Himes JH, Lohman T, et al. Body composition and overweight prevalence in 1704 schoolchildren from 7 American Indian communities. Am J Clin Nutr. 2003;78 :308 –312
Wilson P, O'Mears S, Summerhall C, Kelley S. The prevention and treatment of childhood obesity. Qual Saf Health Care. 2003;12 :65 –74
American Academy of Pediatrics, Committee on Communications. Children, adolescents, and advertising. Pediatrics. 1995;95 :295 –297
Story M. Food advertising and marketing directed at children and adolescents in the US. Int J Behav Nutr Phys Act. 2004;1 :3(Gilles Paradis, MD, Lucie)