SNaX is an evidence-based program that increases healthy eating. In a randomized study comparing five schools that received the program and five that did not, SNaX had significant effects on students’ healthy eating at school, including increasing the number of students served lunch as part of the National School Lunch Program and served fruit in the cafeteria, and decreasing the number of students who bought snacks (e.g., cookies) from the school store. After their school implemented SNaX, students also reported that they drank water more often, had more positive attitudes about the cafeteria and about water, and showed improved knowledge about healthy eating and physical activity.
The following academic articles detail the evidence base for SNaX (click title for description):
A Randomized Controlled Trial of Students for Nutrition and eXercise (SNaX): A Community-Based Participatory Research Study. Journal of Adolescent Health. 2014.
To conduct a randomized controlled trial of Students for Nutrition and eXercise , a 5-week middle-school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education.
We randomly selected schools (five intervention, five wait-list control) from the Los Angeles Unified School District. School records were obtained for number of fruits and vegetables served, students served lunch, and snacks sold per attending student, representing an average of 1,515 students (SD=323) per intervention school and 1,524 students (SD=266) per control school. A total of 2,997 seventh-graders (75% of seventh-graders across schools) completed pre- and post-intervention surveys assessing psychosocial variables. Consistent with community-based participatory research principles, the school district was an equal partner, and a community advisory board provided critical input.
Relative to control schools, intervention schools showed significant increases in the proportion of students served fruit and lunch and a significant decrease in proportion of students buying snacks at school. Specifically, the intervention was associated with relative increases of 15.3% more fruit served (p=.006), 10.4% more lunches served (p<.001), and 11.9% fewer snacks sold (p<.001) than would have been expected in its absence. Pre-to-post intervention, intervention school students reported more positive attitudes about cafeteria food (p=.02) and tap water (p=.03), greater obesity-prevention knowledge (p=0.006), increased intentions to drink water from the tap (p=.04) or a refillable bottle (p=.02), and greater tap water consumption (p=.04) compared with control school students.
Multi-level school-based interventions may promote healthy adolescent dietary behaviors.
Preliminary Healthy Eating Outcomes of SNaX, A Pilot Community-Based Intervention for Adolescents. Journal of Adolescent Health. 2011.
We used principles of community-based participatory research to develop and pilot test a 5-week intervention for middle school students, Students for Nutrition and eXercise (SNaX). SNaX aimed to translate school obesity-prevention policies into practice with peer advocacy of healthy eating and school cafeteria changes.
A total 425 seventh graders (63% of all seventh graders) in the intervention school were surveyed at baseline regarding cafeteria attitudes and sugar-sweetened beverage consumption; of the 425 students, 399 (94%) were surveyed again at 1-month post-intervention. School cafeteria records were obtained from two schools: the intervention school and a nonrandomized selected comparison school with similar student socio-demographic characteristics.
A total of 140 students in the intervention school were trained as peer advocates. In the intervention school, cafeteria attitudes among peer advocates significantly improved over time (approximately one-third of a standard deviation), whereas cafeteria attitudes of non-peer advocates remained stable; the improvement among peer advocates was significantly greater than the pre-post-change for non-peer advocates (b = .71, p < .001). Peer advocates significantly reduced their sugar-sweetened beverage intake (sports and fruit drinks), from 33% before intervention to 21% after intervention (p = .03). Cafeteria records indicated that servings of fruit and healthier entrées (salads, sandwiches, and yogurt parfaits) significantly decreased in the comparison school and significantly increased in the intervention school; the magnitude of changes differed significantly between the schools (p < .001).
As compared with the non-peer advocates, peer advocates appeared to benefit more from the intervention. Future research should consider engaging parents, students, and other key community stakeholders to determine acceptable and sustainable cafeteria changes.
Increasing the Availability and Consumption of Drinking Water in Middle Schools: A Pilot Study. Preventing Chronic Disease. 2011.
Although several studies suggest that drinking water may help prevent obesity, no US studies have examined the effect of school drinking water provision and promotion on student beverage intake. We assessed the acceptability, feasibility, and outcomes of a school-based intervention to improve drinking water consumption among adolescents.
The 5-week program, conducted in a Los Angeles middle school in 2008, consisted of providing cold, filtered drinking water in cafeterias; distributing reusable water bottles to students and staff; conducting school promotional activities; and providing education. Self-reported consumption of water, non-diet soda, sports drinks, and 100% fruit juice was assessed by conducting surveys among students (n = 876), pre-intervention and at 1 week and 2 months post-intervention, from the intervention school and the comparison school. Daily water (in gallons) distributed in the cafeteria during the intervention was recorded.
After adjusting for socio-demographic characteristics and baseline intake of water at school, the odds of drinking water at school were higher for students at the intervention school than students at the comparison school. Students from the intervention school had higher adjusted odds of drinking water from fountains and from reusable water bottles at school than students from the comparison school. Intervention effects for other beverages were not significant.
Provision of filtered, chilled drinking water in school cafeterias coupled with promotion and education is associated with increased consumption of drinking water at school. A randomized controlled trial is necessary to assess the intervention’s influence on students’ consumption of water and sugar-sweetened beverages, as well as obesity-related outcomes.
Perceptions about Availability and Adequacy of Drinking Water in a Large California School District. Preventing Chronic Disease. 2010.
Concerns about the influence of sugar-sweetened beverage consumption on obesity have led experts to recommend that water be freely available in schools. We explored perceptions about the adequacy of drinking water provision in a large California school district to develop policies and programs to encourage student water consumption.
From March to September 2007, we used semi-structured interviews to ask 26 California key stakeholders – including school administrators and staff, health and nutrition agency representatives, and families – about school drinking water accessibility; attitudes about, facilitators of, and barriers to drinking water provision; and ideas for increasing water consumption. Interviews were analyzed to determine common themes.
Although stakeholders said that water was available from school drinking fountains, they expressed concerns about the appeal, taste, appearance, and safety of fountain water and worried about the affordability and environmental effect of bottled water sold in schools. Stakeholders supported efforts to improve free drinking water availability in schools, but perceived barriers (e.g., cost) and mistaken beliefs that regulations and beverage contracts prohibit serving free water may prevent schools from doing so. Some schools provide water through cold-filtered water dispensers and self-serve water coolers.
This is the first study to explore stakeholder perceptions about the adequacy of drinking water in US schools. Although limited in scope, our study suggests that water available in at least some schools may be inadequate. Collaborative efforts among schools, communities, and policy makers are needed to improve school drinking water provision.
Community-Based Participatory Research: Partnering with Communities for Effective and Sustainable Behavioral Health Interventions. Health Psychology. 2009.
The present issue contains one of the first studies published in Health Psychology-by Resnicow and colleaguesthat uses elements of community-based participatory research (CBPR) (Resnicow et al., 2009). The authors engaged community partners (three health maintenance organizations or HMOs) to develop and implement a fruit and vegetable promotion intervention (Tolsma et al., 2009). African American HMO patients (the intervention targets) participated in formative work (i.e., focus groups) on survey items and intervention content and in survey pilot testing. A diverse group of researcher and nonresearcher expert stakeholders (e.g., African American health plan staff; consultants with expertise in Black identity theory, on which the intervention was based) was engaged in major project decisions regarding the measures and intervention design.
Using Community-Based Participatory Research to Identify Potential Interventions to Overcome Barriers to Adolescents’ Healthy Eating and Physical Activity. Journal of Behavioral Medicine. 2009.
Using a community-based participatory research approach, we explored adolescent, parent, and community stakeholder perspectives on barriers to healthy eating and physical activity, and intervention ideas to address adolescent obesity. We conducted 14 adolescent focus groups (n = 119), 8 parent focus groups (n = 63), and 28 interviews with community members (i.e., local experts knowledgeable about youth nutrition and physical activity). Participants described ecological and psychosocial barriers in neighborhoods (e.g., lack of accessible nutritious food), in schools (e.g., poor quality of physical education), at home (e.g., sedentary lifestyle), and at the individual level (e.g., lack of nutrition knowledge). Participants proposed interventions such as nutrition classes for families, addition of healthy school food options that appeal to students, and non-competitive physical education activities. Participants supported health education delivered by students. Findings demonstrate that community-based participatory research is useful for revealing potentially feasible interventions that are acceptable to community members.
School Site Visits for Community-Based Participatory Research on Healthy Eating. American Journal of Preventive Medicine. 2009.
School nutrition policies are gaining support as a means of addressing childhood obesity. Community-based participatory research (CBPR) offers an approach for academic and community partners to collaborate to translate obesity-related school policies into practice. Site visits, in which trained observers visit settings to collect multilevel data (e.g., observation, qualitative interviews), may complement other methods that inform health promotion efforts. This paper demonstrates the utility of site visits in the development of an intervention to implement obesity-related policies in Los Angeles Unified School District (LAUSD) middle schools.
In 2006, trained observers visited four LAUSD middle schools. Observers mapped cafeteria layout; observed food/beverage offerings, student consumption, waste patterns, and duration of cafeteria lines; spoke with school staff and students; and collected relevant documents. Data were examined for common themes and patterns.
Food and beverages sold in study schools met LAUSD nutritional guidelines, and nearly all observed students had time to eat most or all of their meal. Some LAUSD policies were not implemented, including posting nutritional information for cafeteria food, marketing school meals to improve student participation in the National School Lunch Program, and serving a variety of fruits and vegetables. Cafeteria understaffing and costs were obstacles to policy implementation.
Site visits were a valuable methodology for evaluating the implementation of school district obesity-related policies and contributed to the development of a CBPR intervention to translate school food policies into practice. Future CBPR studies may consider site visits in their toolbox of formative research methods.
Development and Implementation of a School-Based Obesity Prevention Intervention: Lessons Learned from Community-Based Participatory Research. Progress in Community Health Partnerships. 2009.
National, state, and local policies aim to change school environments to prevent child obesity. Communitybased participatory research (CBPR) can be effective in translating public health policy into practice.
We describe lessons learned from developing and pilot testing a middle schoolbased obesity prevention intervention using CBPR in Los Angeles, California.
We formed a community-academic partnership between the Los Angeles Unified School District (LAUSD) and the UCLA/RAND Center for Adolescent Health Promotion to identify community needs and priorities for addressing adolescent obesity and to develop and pilot test a school-based intervention.
Academic partners need to be well-versed in organizational structures and policies. Partnerships should be built on relationships of trust, shared vision, and mutual capacity building, with genuine community engagement at multiple levels.
These lessons are critical, not only for partnering with schools on obesity prevention, but also for working in other community settings and on other health issues.