Cradock AL, Barrett JL, Giles CM, Lee RM, Kenney EL, deBlois ME, Thayer JC, Gortmaker SL. (2016). Promoting Physical Activity With the Out of School Nutrition and Physical Activity (OSNAP) Initiative: A Cluster-Randomized Controlled Trial. JAMA The Journal of the American Medical Association Pediatrics, 170 (2), 155-162.
Designed to increase physical activity and improve dietary habits among children aged 5-12, this out-of-school intervention consists of learning collaborative sessions during which staff learn about OSNAP’s physical activity and nutrition goals, assess their own policies and practices, develop action plans, and share implementation successes and challenges. The study showed an increase in physical activity.
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Currently in the United States, 13.7 million children and adolescents are living with obesity. Many health-related conditions are linked to obesity, including heart disease, stroke, type 2 diabetes, and certain types of cancer. Obesity can be prevented through healthy eating habits and physical activity. Out-of-school programs can have a unique impact on a child’s health and learning. To improve overall child health, the Centers for Disease Control and Prevention (CDC) recommends that out-of-school programs create healthy environments by establishing physical activity and nutrition programs. Out-of-school interventions that encourage nutrition and physical activity among children are vital to decrease rates of obesity and related health problems.
The Out of School Nutrition and Physical Activity (OSNAP) Project is an after-school (“out-of-school”) intervention that promotes physical activity and healthy nutrition among children aged 5 to 12. Based on the social ecological model, which targets multiple levels of change, the program aims to affect the school district, out-of-school site, family, and child. The bulk of the intervention is delivered through learning collaborative sessions that include directors and support staff from multiple out-of-school programs. The learning collaborative sessions are based on the Institute for Health Care Improvement’s Breakthrough Series collaborative model and the social cognitive theory.
A trained coordinator facilitates three 3-hour learning collaborative sessions with out-of-school program staff to help them develop action plans that address physical activity and nutrition and implement them throughout the school year. The sessions are typically held in the fall, winter, and spring and occur 2 months apart.
During session 1, out-of-school program staff learn about the goals, scientific rationale, and evidence base for the OSNAP Project. The OSNAP Project’s physical activity goals are to provide all children with at least 30 minutes of moderate physical activity each day, offer 20 minutes of vigorous physical activity (VPA) three times per week, eliminate use of commercial broadcast and cable TV and movies, and limit computer and digital device use to homework or instructional only. Nutrition goals include offering a fruit or vegetable option every day at snack, limiting 100% juice servings to no more than 4 ounces per day, serving water as a drink at snack every day, removing foods with trans fats (e.g. partially hydrogenated oils), and increasing servings of whole-grain foods.
Also during this session, program staff and the coordinator score and review the 5-day practice assessment that program staff complete prior to the session. The assessment helps program staff identify the areas in which their program’s current policies and practices meet or fall short of the intervention’s nutritional and physical activity goals. Based on the results, staff then choose two to four goals in need of improvement to be the focus for the school year, and they work in teams to develop action plans with practice, policy, and communication action steps to work toward those goals.
Session 2 begins with reviewing action plans and discussing the successes and challenges program staff have experienced with implementation to date. The coordinator teaches resources for developing nutrition and physical activity policies, methods for promoting healthy eating and drinking, strategies for communicating with foodservice staff, and creative ways to get kids moving. Additionally, participants identify areas for policy change at their site and learn how to write and implement nutrition and physical activity policies. The session ends with participants revising their action plans.
In the final session, participants share their successes and implementation challenges, work on healthy staff role modeling and family engagement, brainstorm strategies for healthy celebrations and rewards. The coordinator teaches strategies to sustain the physical activity and nutrition efforts, including hiring and training staff.
Staff from multiple out-of-school programs work in teams during the sessions and are encouraged to share promising practices with each other. Program staff have access to technical assistance and free tools on the OSNAP Project’s website (e.g., policy-writing guide, whole grain tip sheet, fruit and vegetable decision aide, guide to working with food service).
Program staff also attend a one-hour training to learn to implement the Food and Fun curriculum that reinforces the OSNAP goals through child and parent learning and skill development.
Community Preventive Services Task Force Finding
-- 6 hours to conduct the coordinator training
-- 10 hours to train the out-of-school staff through three learning collaborative sessions & one Food and Fun training
-- Approximately 10 hours for the coordinator to provide technical assistance, send reminders via email and telephone, and prepare newsletters
The intervention is intended for children aged 5 to 12 who attend an out-of-school program.
This intervention is intended to be implemented in out-of-school settings.
Required resources to implement the program include the following:
-- The OSNAP Guide: A Step by Step Process for Improving Nutrition and Physical Activity in Out of School Settings
-- OSNAP Learning Collaborative Facilitation Handbook
-- Out of School Nutrition and Physical Activity Observational Practice Assessment Tool (OSNAP-OPAT)
-- OSNAP Project website
For costs associated with this program, please contact the developer, Rebekka Lee. (See products page on the EBCCP website for developer contact information.)
About the Study
A randomized controlled trial compared children attending out-of-school programs participating in the OSNAP Project with those attending out-of-school programs that continued their usual physical activity and nutrition practices. Researchers recruited out-of-school programs in Boston, Massachusetts—such as Boys & Girls Clubs, the YMCA, and Boston Public Schools—that met the following eligibility criteria: They (1) served children 5 to 12 years old, (2) had at least 40 children registered in the program, and (3) ran continuously from mid-October through the end of May. Twenty out-of-school programs were enrolled in the study and were matched by the following characteristics: type of out-of-school program provider, type of snack provider (either the facility or an off-site provider), physical activity facilities, and school-level racial/ethnic and socioeconomic composition. The matched pairs were randomly assigned to the intervention group or a wait-list control group that was invited to participate in the intervention in the next school year. Data collection occurred from fall 2010 to spring 2011.
Of the 20 participating out-of-school programs, 10 were assigned to the intervention group (n=182 children) and 10 were assigned to the control group (n=220 children). The children in the study were in kindergarten through grade 6, and the average age was 7.7 years; 51.2% were female, 34.8% were Hispanic, 30.6% were Black, 23.9% were “other” or “unknown,” 7.5% were White, and 3.2% were Asian.
The primary outcome—physical activity—was measured using accelerometers. Data collectors visited out-of-school programs for 1 week (5 weekdays) at baseline and follow-up. Children were provided Actigraph accelerometers, and they continuously wore them on their hips for 5 school days while attending their out-of-school program. Accelerometers recorded the number of minutes spent in various levels of physical activity: overall moderate to vigorous physical activity (MVPA), bouts (short periods) of MVPA, overall vigorous physical activity (VPA), bouts of VPA, overall sedentary activity, bouts of sedentary activity, and total accelerometer counts. Accelerometer counts were collected in 1-minute epochs. The number of minutes spent in MVPA was determined by age using national surveillance data; the thresholds were 4 metabolic equivalent counts for MVPA and 6 metabolic equivalent counts for VPA. Having less than 100 accelerometer counts per minute was classified as sedentary behavior. Data collectors also observed the kind of physical activity that was provided at each program.
Secondary outcomes were water consumed with snacks, juice consumed per snack, trans fats consumed per snack, fruits and vegetables consumed per snack, beverage calories consumed per snack, total calories consumed per snack, and whole grains consumed per snack. Dietary outcomes were measured by direct observation at baseline and follow-up. Data collectors observed the type, size, and brand of all food and beverage items served by the out-of-school time programs over the course of one week. Snack intake data was collected on 2 days at each time period by estimating the proportion of snack components consumed by each child.
- While attending their out-of-school program, children in intervention programs had a significant increase in VPA per day relative to children in control programs (p < .001).
- While attending their out-of-school program, children in intervention programs increased bouts of VPA per day (p < .001) and total accelerometer counts per day (p = .005) relative to children in control programs.
- No significant between-group differences were observed in overall MVPA, bouts of MVPA, overall sedentary activity, or bouts of sedentary activity.
- While attending their out-of-school program, children in intervention programs had a greater increase in water consumption with snacks relative to children in control programs (p < .0001).
- While attending their out-of-school program, children in intervention programs had a significant reduction in juice consumed per snack (p = .02), trans fats consumed per snack (p = .002), beverage calories consumed per snack (p < .0001), and total calories consumed per snack (p < .0001) as well as a significant increase in whole grains consumed per snack (p = .02) relative to children in control programs.
Lee RM, Giles CM, Cradock AL, Emmons KM, Okechukwu C, Kenney EL, Thayer J, Gortmaker SL. (2018). Impact of the Out-of-School Nutrition and Physical Activity (OSNAP) Group Randomized Controlled Trial on Children's Food, Beverage, and Calorie Consumption among Snacks Served. 118 (8), 1425-1437.
Lee RM, Okechukwu C, Emmons KM, Gortmaker SL. (2014). Impact of implementation factors on children's water consumption in the Out-of-School Nutrition and Physical Activity group-randomized trial. 143, 79-101.
Lee RM, Emmons KM, Okechukwu CA, Barrett JL, Kenney EL, Cradock AL, Giles CM, deBlois ME, Gortmaker SL. (2014). Validity of a practitioner-administered observational tool to measure physical activity, nutrition, and screen time in school-age programs. 11 (145), 1-9.
Kenney EL, Giles CM, deBlois ME, Gortmaker SL, Chinfatt S, Cradock AL. (2014). Improving nutrition and physical activity policies in afterschool programs: results from a group-randomized controlled trial. 66, 159-166.
Giles CM, Kenney EL, Gortmaker SL, Lee RM, Thayer JC, Mont-Ferguson H, Cradock AL. (2012). Increasing water availability during afterschool snack: evidence, strategies, and partnerships from a group randomized trial. 43 (3 Suppl 2), S136-142.