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

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

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

4. STUDY DESIGN: GROUP RANDOMISED CONTROLLED TRIAL 10 schools involving 700 children aged 7- 11 years Schools F-J Schools A-E INTERVENTION COMPARISON Schools F-J Schools A- E baseline12 mths 24 mths schools paired for size, ethnicity and FSMI and then randomised analysis by cluster

5. APPROACH Population Approach Health Promoting School Philosophy

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

7. APPLES ACTIVITIES Topic work Dietitian visits to class Practical cooking sessions Tuck shops PE lessons Playground activities Health fairs School meals

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

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

16. Teachers Evaluation Training extremely useful 43% very useful 32% useful25% Resources yes, will use again 100% Benefits increased awareness in children 100%

17. Change Suggested by Parents Results of questionnaire ( 64% response rate) playground activities43% break-time snacks40% school dinners 33% games and sports29% packed lunches 16 % no change20%

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

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

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

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

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

25. BMI

26. VEGETABLE INTAKE

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

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

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

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

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

32. Prevalence of Overweight and Obesity by Year

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