Lytle LA, Murray DM, Perry CL, Story M, Birnbaum AS, Kubik MY, Varnell S. (2004). School-Based Approaches to Affect Adolescents' Diets: Results from the TEENS Study. Health Education & Behavior, 31, 270-287.
Designed to increase the consumption of fruits, vegetables, and lower-fat foods among seventh and eighth graders, this school-based intervention consists of a 10-lesson classroom component teaching self-monitoring, goal setting, snack preparation, and skills for choosing healthy foods; a school-wide component to increase the offering and promotion of healthy foods; and a family component providing newsletters with tips for healthy eating and shopping. The study showed increases in intentions to select lower-fat foods and in the proportion of healthy foods offered a la carte in cafeterias.
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Unhealthy dietary choices puts adolescents at an increased risk for immediate and chronic disease, including cancer. Low intake of fruits, vegetables, whole grains, and calcium and excessive intake of fat, saturated fat, and sodium can lead to obesity, Type 2 diabetes, low bone mass, and various adult-onset chronic diseases. Eating more vegetables and fruits has been linked to a lower risk of lung, oral, esophageal, stomach, and colon cancer. School-based interventions are an effective way to access youth because of the amount of time youth spend in school and the influence of physical, social, and normative environments within the school. The early adolescent period is particularly critical to health; adolescents face new challenges in making healthier choices as their physical and social environments change due to school transitions and as they become more autonomous in their food choices.
Teens Eating for Energy and Nutrition at School (TEENS) is a school-based intervention intended to increase students' intake of fruits, vegetables, and lower-fat foods. The theory-based program consists of classroom, school-wide, and family components implemented in the seventh and eighth grades. The classroom component includes 10 nutrition education lessons for grade 7 and another 10 lessons for grade 8. The lessons focus on self-monitoring, goal setting, hands-on snack preparation, and skill development for choosing healthy foods and for overcoming barriers to making healthful choices. Trained peer leaders are used in the first year to help deliver segments of the curriculum, and in the second year the program includes activities to show students the connection between cues, reinforcements, and eating behavior.
The school-wide component involves working with food service managers and staff to increase offerings and promotion of fruits and vegetables and healthier snacks and to create an environment where healthy food choices are easier and more accepted.
The family component of the intervention includes three newsletters and sets of behavioral coupons delivered in conjunction with the classroom lessons for each grade. Each newsletter includes a short lead article and tip sheets for eating more fruits, vegetables, and lower-fat snacks. The behavioral coupons have simple, specific messages such as "Buy pretzels instead of potato chips the next time you shop". Parents of students participating in the study were offered an incentive for complying with the coupons.
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The time required varies among the three components used to deliver the intervention. For the classroom component, the TEENS curriculum is delivered in 10 classroom sessions each year for two years. Each lesson is approximately 45 minutes. Teachers are also required to attend a full day of training each year, and seventh-grade peer leaders attend a full-day training the first year. For the family component, time required for parents varies according to the extent to which they follow the advice of the newsletters and behavioral coupons (e.g., preparing and serving a fruit or vegetable with dinner) to foster healthier eating habits. Participants involved in the school-wide component (e.g., school administrator, food service staff) should meet monthly to work on policies related to improving the availability of providing healthier foods in the school as well as ways to promote healthier food choices.
The intended audiences for this program are seventh- and eighth-grade students, their parents, district food service directors, and local school food service managers and staff.
The intervention is suitable for implementation in the school and home. It is recommended that the classroom component be implemented in family and consumer science, home economics, health, or science classes.
The TEENS seventh- and eighth-grade teacher training manuals, TEENS video and audiotapes, and TEENS Peer Leader Manual are required. Information on costs associated with the program is not provided. Teachers are required to attend a one-day training each year.
About the Study
Sixteen middle schools in Minnesota were matched in pairs based on the proportion of seventh graders expected to receive the TEENS curriculum and the proportion receiving free or reduced-price school lunches. The schools were then randomly assigned to TEENS or to a wait-list control condition. Students completed surveys at baseline (fall of the seventh-grade school year) and posttest (spring of the eighth-grade school year). To gauge students' usual food choices and eating patterns, the survey presented nine pairs of food choices (one healthier choice and one less healthy choice) and asked students to indicate which item they would choose from each pair most of the time. A random sample of parents from both the intervention and control conditions completed a parent survey at posttest that included a 43-item "home-shelf" inventory that asked parents to indicate if they had specific food items in their home at the time they completed the survey. The parent survey also presented nine pairs of food choices (one healthier choice and one less healthy choice) and asked parents to indicate which item they would buy at the grocery store. The food choice pairs were based on the behavioral coupons used in the family intervention component, which gave suggestions for substituting lower-fat choices for higher-fat choices when shopping.
At baseline and followup, TEENS evaluation staff collected data over a 5-day period on the number of food and beverage items that were offered and sold on a la carte lines (available in the cafeteria and not offered as part of the meal pattern lunch). Data were summarized into categories of "foods to promote" (e.g., snacks with 5 or less grams of fat, 100% fruit juice, water and low-fat milk, fruits and vegetables, and other lower-fat versions of popular entrees such as pizza or pretzels with cheese) and "foods to limit" (e.g., snacks with more than 5 grams of fat, fruit drinks, and higher-fat popular entrees such as regular pizza or nachos).
Analyses were based on 2,929 students who had both baseline and followup student survey data and 343 parents who completed the parent survey at posttest. Students were 51% male and 72.9% White, 8.0% African American, 6.4% Asian or Pacific Islander, 5.1% Multiracial, 3.9% Other, 2.5% Hispanic/Latino, and 1.2% Native American.
Effects on Students' Food Choices
- Students in intervention schools had higher scores on the food choice survey, indicative of making lower-fat choices, compared to students in control schools (p<.05).
- A random sample of students completed a self-report 24-hour recall survey. There were no significant differences between students in the TEENS condition and students in the control condition on intake of fruits, vegetables, and energy from fat.
Effects on Parents' Food Choices
- At Posttest, parents whose children received the TEENS intervention more often indicated they would select the lower-fat choice from a shopping pair compared to parents of children who did not receive the TEENS intervention (p=.01).
- There were no significant differences between TEENS intervention and control conditions in the mean number of high-fat items, fruits, and vegetables parents reported being in their house at the time of the posttest survey.
Effects on Cafeteria Items Offered
- At the end of the intervention, the proportion of healthier foods ("foods to promote") offered a la carte in intervention schools had more than doubled, and offerings of less healthful choices ("foods to limit") had declined. Although control schools also had improvements, the change at the intervention schools was significantly greater (p=.04).
- While a la carte offerings showed a significant positive effect, there was no significant difference between conditions in the percentage of foods actually sold, although there was a trend toward significance (p=.07).
Birnbaum AS, Lytle LA, Murray DM, Story M, Perry CL, Boutelle KN. (2002). Survey Development for Assessing Correlates of Young Adolescents' Eating. American Journal of Health Behavior, 26(4), 284-295.
Birnbaum AS, Lytle LA, Story M, Perry CL, Murray DM. (2002). Are Differences in Exposure to a Multicomponent School-Based Intervention Associated with Varying Dietary Outcomes in Adolescents? Health Education & Behavior, 29(4), 427-443.
Janega JB, Murray DM, Varnell SP, Blitstein JL, Birnbaum AS, Lytle LA. (2004). Assessing the Most Powerful Analysis Method for School-Based Intervention Sutdies with Alcohol, Tobacco, and Other Drug Outcomes. Addictive Behaviors, 29 (3), 595-606.
Birnbaum AS, Lytle LA, Hannan PJ, Murray DM, Perry CL, Forster JL. (2003). School Functioning and Violent Behavior among Young Adolescents: A Contextual Analysis. Health Education Research, 18 (3), 389-403.
Boutelle KN, Birnbaum AS, Lytle LA, Murray DM, Story M. (2003). Associations between Perceived Family Meal Environment and Parent Intake of Fruit, Vegetables, and Fat. Journal of Nutrition Education and Behavior, 35 (1), 24-29.
Story M, Lytle LA, Birnbaum AS, Perry CL. (2002). Peer-Led, School-Based Nutrition Education for Young Adolescents: Feasibility and Process Evaluation of the TEENS Study. Journal of School Health, 72 (3), 121-127.
Schmitz KH, Lytle LA, Phillips GA, Murray DM, Birnbaum AS, Kubik MY. (2002). Psychosocial Correlates of Physical Activity and Sedentary Leisure Habits in Young Adolescents: The Teens Eating for Energy and Nutrition at School Study. Preventive Medicine, 34, 266-278.
Boutelle KN, Lytle LA, Murray DM, Birnbaum AS, Story M. (2001). Perceptions of the Family Mealtime Environment and Adolescent Mealtime Behavior: Do Adults and Adolescents Agree? Journal of Nutrition Education, 33, 128-133.
Lytle LA, Perry C. (2002). Applying Research and Theory in Program Planning: An Example from a Nutrition Education Intervention. Health Promotion Practice, 2, 68-80.
Murray DM, Phillips GA, Birnbaum AS, Lytle LA. (2001). Intraclass Correlation for Measure from a Middle School Nutrition Intervention Study: Estimates, Correlates, and Applications. Health Education & Behavior, 28, 666-679.
Lytle LA, Birnbaum A, Boutelle K, Murray DM. (1999). Wellness and Risk Communication from Parent to Teen: The "Parental Energy Index". Health Education, 5, 207-214.