Comprehensive School-Based Program Increases Positive Health Behaviors and Reduces Risk Factors for Type 2 Diabetes Among Mexican-American and Other At-Risk Youth

Problem Addressed

• High prevalence, with increases in type 2 diabetes, especially among Hispanics: Approximately 150,000 children and adolescents under the age of 18 years have diabetes.¹ Although no hard data are available, researchers estimate that type 2 diabetes accounts for between 8 and 45 percent of all new cases of childhood diabetes.¹ Type 2 diabetes is more common among Hispanic children than their non-Hispanic white counterparts.¹
• Obesity and inactivity a contributing factor: Obesity and lack of physical activity have been identified as major factors contributing to the increased prevalence of type 2 diabetes among school-aged children and adolescents.¹

Description of the Innovative Activity

• Health education: The health education component is administered in 45-minute sessions once a week over 13 weeks; sessions address nutrition, exercise, self-control, self-esteem, and diabetes.
• Physical education (PE): The PE component promotes physical activity through 32 moderate to vigorous physical activities administered in 45-minute sessions four times per week.
• Student health club: The student health club consists of a 1-hour meeting held 1 day per week after school for 26 weeks. The club is designed to reinforce classroom activities through physical activities, cooking classes, and crafts. Student participation is voluntary and parents are encouraged to attend.
• Family education: The family education component consists of quarterly newsletters and 1-hour meetings held with parents once every 2 months. Parent meetings consist of four kinds of activities: cooking demonstrations, dancing (e.g., salsa), a nutrition game (e.g., bingo), and an exercise game (e.g., "wheel of health").
• School cafeteria: The cafeteria component, which is designed to improve food service staff knowledge of diabetes and nutrition, includes seven lessons conducted in 30-minute increments; sessions are held once a month during break times. Topics covered include purchasing and preparing healthy food selections, improving presentation of healthy foods, and persuading students to make healthier choices (e.g., eat more fruits and vegetables and fewer fatty foods).

References/Related Articles

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Results

• First study finds increased fitness and fiber intake, reduced blood sugar levels: Twenty-seven inner-city San Antonio, TX, elementary schools serving primarily Mexican-American and economically disadvantaged fourth graders were randomly assigned to either intervention (n = 13) or control (n = 14). This study yielded the following results:
  • Lower blood sugar levels: Mean fasting capillary glucose levels for students in intervention group schools decreased (87.72 to 87.53), while levels increased (89.47 to 89.99) for students in control group schools.
  • Better fitness levels: Mean fitness scores significantly increased (63.90 to 65.71) for students in intervention group schools and declined (65.93 to 65.20) for those in control group schools.
  • More fiber intake: Mean dietary fiber intake significantly increased (11.15 to 11.53) for students in intervention group schools and declined (10.79 to 10.65) for those in control group schools.
  • No impact on fat intake and body fat: There was no significant difference between intervention and control group schools regarding body fat percentage and saturated fat intake.
• Second study shows increased fitness: Nine elementary schools serving 561 fourth-grade students from inner-city neighborhoods were randomly assigned to either intervention (n = 5) or control (n = 4). The study found a statistically significant increase (+2.9 points) in mean physical fitness scores for students in intervention group schools and a decrease (–.2 point) in mean physical fitness scores for students in control group schools.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Theoretical grounding: A review of diabetes and obesity literature suggested that knowledge-based approaches to weight reduction and healthy lifestyle promotion were not effective in sustaining desired behavioral changes (e.g., making healthy food choices). This realization led to the adoption of a social learning model with social systems approach, which is the cornerstone of the Bienestar program.
• Program modification based on pilot test and ongoing evaluation: The Bienestar program was piloted for 2 years with fourth grade students in two parochial schools in San Antonio's poorest school district. The program was modified based on the findings of this study and subsequent evaluations. The program is currently being evaluated in 20 Mexican elementary schools in Ciudad Victoria, Tamaulipas.

Resources Used and Skills Needed

• Staffing: The Bienestar program requires staff time comparable to other Texas Education Agency (TEA)–approved school health programs and generally does not require the hiring of additional staff. Existing PE teachers implement the health and physical education components, food service staff implement the cafeteria component, parent liaisons (usually school-level administrative staff) mail out the Parent Newsletter, and after-school caretakers implement the student health club component. Once adopted by a school, the program is institutionalized and sustain by existing school staff.
• Training: Half-day training is available for school administrators and school personnel (e.g., PE teachers, cafeteria managers) involved in implementation of any component of the program.
• Costs: Costs are minimal, consisting primarily of program materials, the cost of which depend on the format desired (e.g., consumable vs. non-consumable workbooks) and the number of students targeted. For example, the cost is $12 per student to purchase of the health education, PE, food service component workbooks, and family education newsletter.

Funding Sources

National Institute of Diabetes and Digestive and Kidney Diseases (U.S.); University Health System - Bexar County, TX; San Antonio Metropolitan Health District

Tools and Other Resources

Getting Started with This Innovation

• Secure buy-in from school and district leaders: Because student achievement in key academic areas takes precedence in most schools, it is essential to convince school and district leaders of the importance of targeted, structured health education and of the benefits of improving overall health as a complement to academic achievement. 
• Use available program materials: Although potential adopters may elect to develop their own materials and training approaches based on publicly available information, Bienestar program curricula and program-related materials are available through SHRC. 
• Arrange training for school personnel: Although not required, it is highly recommended that school personnel involved in the implementation of any component of the Bienestar program attend a half-day training session, which is available through SHRC.

Sustaining This Innovation

• Train new staff: New school personnel need to be trained before they can take over the program responsibilities of departing staff members. 
• Provide adequate preparation time: It is important to provide program personnel with adequate time to prepare for activities and distribute educational materials (e.g., newsletters).

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