Background
The study by Bogart et al. (2016) seeks to examine the long-term effects on BMI of obesity prevention and intervention program for middle schoolers which combines exercise, education, and school environmental changes. The study identifies the primary issue as adolescent obesity with more than 1/5th of children aged 12 to 19 years old in the United States being medically obese, with the Latino population especially affected (22.5% obesity in comparison to 19.6% for white) (Bogart et al., 2016). This issue is significant to nursing since adolescent obesity can have both short-term and long-term health consequences for the children, ranging from physical to mental, and the problem has become a national and global epidemic of obesity. There is no direct research question, but the authors indicate that their research is attempting to identify the effects of various obesity prevention interventions according to the baseline weight status and BMI.
Pbert et al. (2016) similarly identify the problem of a rapid increase of adolescent overweight and obesity, reaching 34% with physical and mental consequences. The significance to nursing is also highlighted, emphasizing that adolescent obesity is linked to health issues and obesity in adulthood and that this age provides an opportunity to make changes and promote healthy lifestyles before there are yet severe consequences. The purpose of the study was to evaluate the efficacy of a school-based intervention for obesity with the objective of improving diet, activity, and BMI among overweight and obese adolescents. No research question is given but it can be construed as what the effect of a 12-session school nurse-delivered cognitive counseling intervention plus school-based exercise program on the BMI of participants.
Nursing Practice Issue
Both studies directly relate to the PICOT question by introducing an intervention into schools which focuses on exercise and another element such as nutrition or cognitive-behavioral counseling that are expected to have an influence on BMI. The studies target the school-aged adolescents from middle and high-school grades. The research approach and results are highly similar to the nature of the PICOT question and outcomes that it is investigate. Therefore, conclusions can be drawn upon as supporting evidence to analyze and justify the intervention proposed in the PICOT question. Both studies have intervention groups and control groups which help more accurately to track the effect of interventions, the structure which is also undertaken in the PICOT intervention. However, the interventions in the studies are inherently more complex, going beyond a simple exercise program. These take expertise and resources but can potentially be more effective than physical activity alone by also addressing elements of mental health, social pressure, and dietary habits related to BMI.
Method of Study
The study by Bogart et al. (2016) utilized a randomized control trial method, splitting 10 schools in a Los Angeles district (primarily Latino population) into 5 intervention schools and 5 control schools. The schools of intervention and control were paired using stratified randomization so that the matched schools underwent the study simultaneously, 1 pair in the spring semester and 2 in the fall semester. Researchers collected medical data from school records from students whose families gave consent. The study by Pbert et al. (2016) similarly used a pair-matched cluster-randomized controlled trial. 8 public high schools in Massachusetts were randomized and paired, with one receiving the intervention of 12 school nurse-led cognitive behavioral sessions and exercise program while the control school received a standard nurse-led talk about facts and dangers of obesity.
Randomized controlled trials are typically considered the gold standard for research regarding effectiveness of an intervention. Randomization in this case provides two benefits of reducing bias while also providing a tool to examine a cause-effect relationship. This occurs since randomization balances participant characteristics (including observed and unobserved) between the groups, thus attributing the outcome differences to the study intervention which is not possible in any other type of design (Hariton & Locascio, 2018). However, there are disadvantages as well. For example, the block randomization such as occurring in these studies results in a predictable allocation of participants and selection bias since the groups are unmasked. In terms of statistics, power calculation may require vast sample sizes and multiple sites, which requires resources and difficulty to manage. Similarly, efficacy studies are not widely applicable, but trials that test for effectiveness are significantly larger.
Results of Study
The study by Bogart et al. (2016) found that the intervention did not have a significant effect on the BMI percentile overall. However, those students in the intervention that were classified as obese at baseline saw reductions in the BMI (-2.33) percentile two years after compared to control group students, which equals roughly 9 pounds lower expected body weight at mean height and age. Meanwhile, Pbert et al. (2016) found that in the follow up, students participating in the intervention had no difference in BMI, percent body fat or waist circumference compared to control schools. The only improvement was students reporting eating breakfast more commonly without changes in any other behaviors. The implication from these studies is that despite school-based programs being theoretically effective with high potential, in reality, they have little influence in reducing BMI or other obesogenic behaviors. The study by Pbert et al. (2016) was targeted at individual behavior, while Bogart et al. (2016) aimed at institutional and environmental changes as well, demonstrating effectiveness with obese individuals. Therefore, it is possible the interventions should be multifaceted and be aimed at not just individual behavior but providing environmental factors in the school (such as school meals and peer-led education) that contribute to participation and improving BMI for those at risk.
Outcomes Comparison
The expected outcome for the PICOT question is that a positive dynamic will be reflected via reduction of BMI levels in participants. This is supported by CDC recommendations of at least 60 minutes of physical activity for individuals aged 6-17, with the benefits of addressing obesity and energy imbalance. While the intervention only covers 30 minutes of physical activity, it is meant to target and aid the population not receiving enough exercise since only 24% of the school age group actually participates in 60 or more minutes of physical activity per day (CDC Healthy Schools, 2020). The effects may potentially be minor, but considering the intervention is aimed at long-term over the duration of the school year.
The studies demonstrated mixed outcomes as evident by the results above showing either no changes or minor ones to a specific group. This differs from the expected outcomes, which is concerning given that the studies have relatively large sample sizes and also adopt additional elements to the exercise program. This brings up the critical examination of whether just a small-scale physical activity program able to make a difference in outcomes. However, at the same time, it is possible that a sole focus on the physical activity aspect at a minor, non-overwhelming aspect of just 30 minutes, can have positive impacts. While from a medical perspective, dietary habits and cognitive aspects undoubtedly impact the physical BMI, it may be ambitious for an intervention to attempt mora than one behavior changes in school-aged children. Another aspect to consider is also the participating sample, as the studies focused on mostly older children, while the PICOT question is targeting all school aged children that may have better potential at improving BMI.
References
Bogart, L. M., Elliott, M. N., Cowgill, B. O., Klein, D. J., Hawes-Dawson, J., Uyeda, K., & Schuster, M. A. (2016). Two-year BMI outcomes from a school-based intervention for nutrition and exercise: A randomized trial. Pediatrics, 137(5), e20152493–e20152493. Web.
CDC Healthy Schools. (2020). Physical activity facts. Web.
Hariton, E., & Locascio, J. J. (2018). Randomised controlled trials – the gold standard for effectiveness research: Study design: Randomised controlled trials. BJOG: An International Journal of Obstetrics and Gynaecology, 125(13), 1716. Web.
Pbert, L., Druker, S., Barton, B., Schneider, K. L., Olendzki, B., Gapinski, M. A., Kurtz, S., & Osganian, S. (2016). A school-based program for overweight and obese adolescents: A Randomized controlled trial. Journal of School Health, 86(10), 699–708. Web.