A Nurse-Led and Teacher-Assisted Adolescent Healthy Weight Program to Improve Health Behaviors in the School Setting

Abstract

Adolescents with overweight and obesity are at risk for future health problems. The purpose of this study was to examine the feasibility and initial efficacy of a weight management intervention to help adolescents develop healthy nutrition and physical activity behaviors and improve their anthropometrics. This study used a single-group repeated measures design in a small school in Durham, North Carolina (NC). The intervention consisted of a nurse-led and teacher-assisted nutrition and physical activity education and exercise classes that met twice each week for 45–60 minutes for 7 weeks. Data were collected at Time 1 (baseline), Time 2 (after intervention completion), and Time 3 (after 3 months on their own). Interview feedback, low cost, and successful completion of all planned activities indicated that all stakeholders found the project beneficial and suitable for their school. This study suggests that a weight management intervention for adolescents was feasible in the school setting.

Keywords

adolescent high school nurse teacher weight management community partnership

Overweight and obesity in adolescents is a national public health concern. In the last 30 years, overweight and obesity have increased dramatically in adolescents living in the United States (Centers for Disease Control and Prevention [CDC], 2015). Adolescents who are overweight or obese are at a greater risk of developing physical, behavioral, and social health problems compared with their average weight peers (Black, Zhou, Takayanagi, Jacobsen, & Koebnick, 2013; Park, Falconer, Viner, & Kinra, 2012; Pulgaron, 2013). Despite interventions developed at the state (Balvanz et al., 2016; Benjamin Neelon et al., 2015) and national (Ho et al., 2013) level, decreasing overweight and obesity remains a challenge. Individual, environmental, and cultural barriers to healthy eating and physical activity create obstacles that make it challenging for adolescents to achieve a healthy weight (Sallis & Glanz, 2006; Strasburger, Jordan, & Donnerstein, 2010).

Adolescents who are overweight or obese are at an increased risk of developing prediabetes, type 2 diabetes mellitus, hypertension, cardiovascular disease, asthma, poor dental health, orthopedic disorders, and sleep apnea (American Diabetes Association [ADA], 2017; Black et al., 2013; Mozaffarian et al., 2016; Park et al., 2012; Pulgaron, 2013). Overweight and obesity in adolescence tracks into adulthood with an increased incidence of early diabetes and cardiovascular disease (CDC, 2015; Tirosh et al., 2011). In addition, adolescents who are overweight or obese often struggle with behavioral health issues such as low body satisfaction, decreased self-esteem, increased anxiety, increased risk of substance abuse, and more depressive symptoms compared to their average weight peers (Cortese et al., 2009; Loth, Mond, Wall, & Neumark-Sztainer, 2011; Petry, Barry, Pietrzak, & Wagner, 2008). Compared to average weight adolescents, an increased risk of depression and suicide was found in adolescents with obesity and extreme obesity, with a slightly lower risk for adolescents who were overweight (Boutelle, Hannan, Fulkerson, Crow, & Stice, 2010; Hoare, Skouteris, Fuller-Tyszkiewicz, Millilar, & Allender, 2014; Zeller, Reiter-Purtill, Jenkins, & Ratcliff, 2013). Further evidence demonstrated that the higher the body mass index (BMI) category, the higher the risk for poor overall health, prevalence of chronic conditions, sleep problems, and difficulties with behavioral health (Wake et al., 2013).

Social health concerns for adolescents who are overweight or obese involve an elevated risk of body dissatisfaction with an increased related risk of unhealthy eating behaviors (Puhl & Latner, 2007). In a study by Danielsen and colleagues (2012), children who were overweight reported lower levels of confidence and self-assurance related to appearance, athletic ability, and social status. The combination of social and internal pressures likely contributes to decreased feelings of self-worth among adolescents who are overweight. In addition, adolescents who are obese tend to be subjected to more bias, stereotyping, discrimination, and ridicule than their average weight peers (Puhl & King, 2013). Nearly half of adolescents who are overweight or obese reported being bullied or called derogatory names because of their weight, and these adolescents were subjected to regular criticism and experienced anxiety while eating, trying on clothes, and during social activities (Wills, Backett-Milburn, Gregory, & Lawton, 2006). These findings suggest that such repetitive denigration could result in poor outcomes for adolescents’ self-concept and confidence. Therefore, implementing interventions that promote healthy eating behaviors and exercise may decrease the risk of developing obesity, eating disorders, suicide, negative body image, and other social distress (Han, Lawlor, & Kimm, 2010; Penedo & Dahn, 2005; Stathopoulou, Powers, Berry, Smits, & Otto, 2006; Wake et al., 2013).

A review of dietary patterns contributing to poor weight management demonstrated that unhealthy eating patterns, such as high-calorie foods and low consumption of fruits and vegetables, have an adverse impact on adolescent weight management (Office of the Surgeon General, 2010; Sallis & Glanz, 2006). Sedentary behaviors were also found to be negatively associated with fruit and vegetable consumption and positively associated with energy-dense snacks and increased fast-food consumption (Pearson & Biddle, 2011).

Low levels of regular physical activity and increased sedentary behaviors, including playing video games and watching television, have been found to increase adolescents’ risk of becoming overweight or obese (Office of the Surgeon General, 2010; Sallis & Glanz, 2006; Strasburger et al., 2010). Short 30-minute interruptions of sedentary activity each day improve metabolic function; additionally, experiential learning has been shown to be effective in promoting positive changes in both nutrition knowledge and behaviors in adolescents (Belcher et al., 2015; Dudley, Cotton, & Peralta, 2015). Therefore, an intervention able to increase adolescents’ physical activity at least 30-minutes daily with a theory-based nutrition education component may reduce barriers to achieving a healthy weight.

The school setting has been shown to be an effective environment for adolescent weight management and overweight prevention (ADA, 2006; Brown & Summerbell, 2009; Katz, O’Connell, Njike, Yeh, & Nawaz, 2008; Kelishadi & Azizi-Soleiman, 2014; Kriemler et al., 2011; Sun et al., 2013; Tucker & Lanningham-Foster, 2015). Wang and colleagues (2015) conducted an extensive systematic review and meta-analysis and found that overall the strength of evidence was very high for both physical activity interventions with involvement in the home and nutrition and physical activity interventions with home and community involvement.

Partnership with the school offers the advantage of providing an expected meeting location, having trusted adults, being part of an established daily routine, and supplying material resources (Smith & Petosa, 2016). In addition, the teachers can offer professional teaching expertise and insight into their students’ needs and personalities.

Theoretical Framework

Developmental theory (Erikson, 1994), ecological systems theory (Bronfenbrenner, 1979), and experiential learning theory (Kolb, 1984) provided the guiding frameworks for this study. Healthy behaviors and weight control are often influenced by the current developmental stage of adolescents, making developmental theory an essential consideration when evaluating the problem and developing an intervention (Salvy, De La Haye, Bowker, & Hermans, 2012). Social influences, mainly perceived as cultural norms for eating and physical activity, affecting adolescents’ diet and activity levels are high during adolescence, and interventions with popular culture references promote interest and participation in learning (Patino, Kalcheva, & Smith, 2011; Petrone, 2013; Salvy et al., 2012). These influences supported the use of an engaging intervention that worked to change the adolescents’ group opinions, dietary choices, and physical activity within their school setting.

Ecological systems theory describes the impact of different environmental systems on child development (Bronfenbrenner, 1979). This theory facilitated an understanding of how environmental contexts may influence adolescents struggling with weight management and assisted researchers with identifying key environmental contributors (Bloonpleng et al., 2013; Davison & Birch, 2001). A fundamental component of this theory is the five nested environments (Bronfenbrenner, 1979). The nested environments concept works well to explain the various environments and how they affect adolescent weight management.

Kolb’s (1984) experiential learning theory provides a strong foundation for designing interventions to reduce overweight and obesity in adolescents. The experiential learning model focuses on how individuals learn through their personal experimentation, experience, reflection, and conceptualization (Kolb, 1984). This type of learning requires an actively involved participant to explore and self-reflect, while instructors function as a facilitator (Kolb, 1984). Experiential learning has been proven to be an effective method to promote positive changes in nutrition knowledge and behaviors in adolescents (Dudley et al., 2015). This theory guided the creation and implementation of the interactive classes.

Adolescents within the United States are at increased risk of various health problems associated with overweight and obesity due to environmental influences and poor dietary and physical activity choices (Black et al., 2013; Office of the Surgeon General, 2010; Park et al., 2012; Pulgaron, 2013; Sallis & Glanz, 2006; Strasburger et al., 2010). Research suggests that school-based interventions may be the best approach for adolescent obesity management, but few study designs have used a nurse- and teacher-led, evidence-based intervention (American Dietetic Association, 2006; Brown & Summerbell, 2009; Katz et al., 2008; Kelishadi & Azizi-Soleiman, 2014; Kriemler et al., 2011; Sun et al., 2013; Tucker & Lanningham-Foster, 2015). This study used a school partnership to rapidly implement an efficient and sustainable intervention that was evidence-based and developmentally appropriate to help adolescents develop and maintain healthy nutrition and physical activity behaviors and improve their weight management.

Study Purpose and Aims

The purpose of this study was to examine the feasibility and initial efficacy of a healthy nutrition and physical activity intervention to improve weight management in adolescents using an evidence-based and developmentally appropriate intervention in the school setting while partnering with educators to produce immediate implementation and sustainability.

Method

Study Design and Institutional Review Board (IRB) Approval

This feasibility study used a one group repeated measures design. The study was approved by the University of North Carolina at Chapel Hill IRB.

Recruitment and Enrollment

Two weeks before the enrollment period, the researcher and school administrator distributed a letter and a flyer to adolescents and their parents explaining the classes along with parental consent forms and adolescent assent forms. The letter explained the study, the intervention classes, and the need for both parental consent and adolescent assent to participate in the study. During an open meeting at the school, the study was explained to the students and parents, risks and benefits of participation were explained, and all questions were answered. All parents and adolescents volunteered, parents signed the consent forms, and adolescents signed the assent form signifying their agreement to participate in the study.

Setting and Participants

The Just Right Academy (2015), located in Durham, NC, is a small private school for children who need more structure, consistency, positive reinforcement, and other learning strategies that are difficult to accommodate in the public school system. The researchers met with the school administrator and teachers to plan the intervention for rapid implementation and minimal disruption to the students’ routine. To accomplish this, the intervention was designed for integration into the existing health class by meeting educational objectives that would have been covered in an alternative format.

Inclusion criteria included participants being from 14 to 18 years of age and able to speak, write, and read in English. There were 15 students in the one classroom that was targeted, and all 15 students agreed to participate. All 15 students participated in the full intervention series, and the participation rate was 85% of the classes. However, only 12 students completed all three data collections. Three students moved out of town over the summer and could not be contacted.

Intervention Classes

The intervention class series was developed using evidence indicating that healthy eating and exercise are essential to adolescent weight maintenance and that it should be fun and engaging (Han et al., 2010; Schneider & Cooper, 2011; Schneider, Dunn, & Cooper, 2009). The intervention classes were developed with all of the authors providing suggestions and feedback. The healthy eating and exercise education classes for the study were interactive and used food models, cooking, games, and popular culture references to engage the adolescents (Table 1). The classroom sessions lasted approximately 45–60 minutes and began and ended with goal setting. The intervention content was designed to accommodate an appropriate developmental level with consideration for the unique learning needs of each participant.

Table 1.

Nutrition and Exercise Education Classes for Adolescents.

Classes	Topics	Activities
Exercise education
This class provided exercise ideas and hobbies that adolescents may perceive as fun to encourage physical activity such and swimming, dance, martial arts, team sports, and walking with friends	Exercise can be fun	Walking challenge Physical activity tracking Recess walk and run Goal setting
Nutrition education
This class was designed to teach students how to pack a healthy lunch focused on avoiding high sugared beverages and high calorie snacks	Packing a power lunch	Review ChoseMyPlate.gov National Dairy Council’s food model cards Goal setting
Exercise education
This class uses an outdoor scavenger hunt format that was compared to the “Amazing Race” competition	Just Right Academy fitness Outdoor challenge	Scavenger hunt Goal setting
Nutrition education
This class was designed to follow a cooking show format to teach a simple recipe and identify unprocessed foods and food groups used in the recipe	Just Right Academy chef Tasty and healthy cooking	Preparation of a meal Goal setting
Exercise education
This class was designed to take into consideration that adolescents may have differing activity preferences and are willing to increase their exercise time and engage in regular physical activity they find pleasurable	Just Right Academy fitness Field day	Mummy relay race Balloon sidesteps game Tug-of-war Group activity games Goal setting
Nutrition education
This class was designed to discuss how to make healthier food and drink choices when grocery shopping and at restaurants	Try this…not that…jeopardy	Jeopardy game Nutrition labels Goal setting
Exercise education
This class was designed to reduce sedentary activity at home by providing fun indoor physical activities	Just Right Academy fitness Indoor challenge	Team building yoga Shuttle run Goal setting
Nutrition education
This class was designed to help students build sugar board displays to encourage interactive and participative learning to understand how much sugar was in certain foods and drinks	Sugar? No thanks, I’m sweet enough	Sugar displays Goal setting
Nutrition education
This class was designed to use a cooking competition to encourage teams to creatively combine healthy ingredients into a meal they would enjoy	Just Right Academy chef Fruit and vegetable competition	Group activity Goal setting
Exercise education
This class was designed to develop a routine to present in front of a panel of judges and then a scavenger hunt in teams	Video presentations/field day II	Video Talent show Goal setting
Exercise education
This class was designed to develop a routine to present in front of a panel of judges and then a scavenger hunt in teams	Talent show/scavenger hunt	Team building Talent show Goal setting
Nutrition education
This class was designed as a nutrition review class and students brought in their favorite recipe to share with the class for lunch	Just Right Academy chef Potluck and nutrition review	Review Goal setting

This project was designed with a “train-the-trainer” component to provide a system model that was sustainable and translatable for the school personnel. The classes were led by a certified pediatric registered nurse with experience in nutrition and exercise education and co-taught with three high school teachers at Just Right Academy. This provided an inclusive environment where the registered nurse simultaneously taught the classes while training the three high school teachers how to teach the classes. The three high school teachers will then teach other teachers in the school. The classroom teachers and administrators were consulted during the design of the classes and prior to the beginning of each class to discuss the lesson plans and adjust instructions, groups, and other components of the activities to best meet the students’ needs. The total time each week with the nurse and three high school teachers included 30 minutes before class, 45–60 minutes for the class, and 30 minutes for feedback and fine-tuning the class for a total of 105–120 minutes per week. Weekly feedback from students and teachers was used to adjust the design of the intervention classes to accommodate class schedules, behavioral needs, and the school’s teaching philosophy throughout the project.

Outcome Measures and Instruments

Demographic data

Demographic data were collected at baseline using a standardized demographic data questionnaire. Information collected on adolescents and parents included age, race/ethnicity, gender, parents’ employment, income, and marital status, highest level of education attained, birth order, health concerns, and decision-making regarding dietary and physical activity choices.

Anthropometric measures

All measurements were taken in a private area of a room. The adolescents’ height was measured twice, while they wore street clothes without shoes, using a stadiometer, which was calibrated in 1/8-cm intervals and averaged. Weight was measured twice on adolescents in street clothes without shoes to the nearest 0.1 kg using a Tanita WB-110A digital scale and averaged. The WB-110A self-calibrates to 0 before each weight. BMI was then calculated by computer. BMI percentile was calculated using the online CDC BMI Percentile Calculator for Children and Teens.

Triceps, subscapular, and waist circumferences were measured by researchers who were trained in the procedure. To measure triceps and subscapular skinfolds, each participant was asked to stand erect on both feet. Skinfolds were measured 3 times on the right side of the body using Lange skinfold calipers and averaged. The triceps site was determined using a tape measure to locate the midpoint between the acromion and olecranon processes with the elbow bent at 90°. The subscapular measurement was taken diagonally 1 cm below the inferior angle of the scapula, following the natural fold of the skin. The skinfold was measured to the nearest 1 mm while the fingers continued to hold the skinfold for approximately 3 seconds after the caliper tension was released. The measurements were taken 3 times and averaged according to the National Health and Nutrition Examination Survey (NHANES) Procedures (McDowell & National Center for Health Statistics, 2008).

To measure waist circumference, the researcher stood on the adolescent’s right side and placed the measuring tape around the trunk in a horizontal plane at the level equal to the opposite side of the trunk. The researcher ensured that the tape was parallel to the floor and was snug and did not compress the skin. The measurement was taken at the end of normal expiration and was measured to the nearest 0.1 centimeter. All measurements were performed 3 times and averaged according to the NHANES Procedures (McDowell & National Center for Health Statistics, 2008).

The Child Health Behavior Survey

The Child Health Behavior Survey was used to collect information on usual dietary intake (Department of Health and Human Services, 2004). This survey is a self-reported, 20-item questionnaire that asks children to quantify different choices of food they make in a typical day. Topics include how much soda and sweetened beverages are consumed and the size of the beverage consumed each time. Adolescents were asked how many glasses of milk and water they drink each day, the type of milk they drink, and what they drink when they were thirsty; how many servings of vegetables and fruit they ate each day and how many times they ate French fries or chips daily; how many times each week they ate fast food, whether they supersized fast food and drinks, and how often; what they ate for a snack and how often they bought extra food or drinks at school; how many days a week they ate breakfast, what type of bread and what type of cold cereal they ate, and if they ate fried food at home and how often; and how often they ate home-baked goods. Answers were scored from 0 (none) to 5 (on most or all days of the week). All answers were recoded as a 1 to reflect a healthy choice or a 2 as an unhealthy choice.

Cost, school accommodation, and sustainability

Costs for teaching materials and students’ supplies associated with the study were tracked using receipts. The school’s willingness to accommodate the researcher was determined by weekly informal post intervention debriefings with students and interviews with teachers. After completion of the study, parents were interviewed to gather information about the intervention’s strengths and challenges. The sustainability of the project was indicated by the changes adopted at the school and classroom levels. Interviews with the teachers and school administration in the immediate post intervention period and 3-months post intervention determined which changes were maintained.

Data Management and Analysis

All data were entered into an SPSS database, checked for inaccuracies, and corrected against raw data. Descriptive statistics were calculated. Paired t tests were run on nutrition and physical activity data from Time 1 to Time 2 and Time 1 to Time 3 to examine differences across time. Only 12 students completed the study; therefore, effect sizes were not calculated.

A researcher conducted the interviews over the telephone. Twelve parent, 12 student, and 4 teacher interviews were conducted using a standard interview guide prepared for the study. Interviews took approximately 10–15 min to conduct. All interviews were transcribed, and content analysis was conducted.

Results

Data were collected from March 2016 through October 2016. The sample consisted of African American, non-Hispanic White, and bilingual Hispanic adolescents enrolled at the Just Right Academy in Durham, NC (Table 2). The students’ mean age was 15.83 (SD = ±1.19) years old. The majority were male (75.0%), non-Hispanic White (91.7%), and the firstborn child (50.0%). The majority were male since that was the makeup of the particular class the administrator chose to allow the feasibility study to be conducted. The class had a total of 15 students and all 15 students chose to participate; however, only 12 students completed the final data collection and were included in the study. The other three students moved out the school district over the summer and could not be contacted for follow-up. The most common education level was ninth grade (50.0%). All of the students lived with their parents.

Table 2.

Demographics.

Parent’s demographics (N = 12)
Age in years
Range (M, SD)	37–59 (48.67, ±6.69)
Gender	Percentage	Frequency
Female	66.7	8
Male	33.3	4
Marital status
Married	66.7	8
Widowed	8.3	1
Divorced/separated	8.3	1
Living with significant other	16.7	2
Employment
Full-time	41.7	5
Part-time	41.7	5
Homemaker	8.3	1
Unemployed	8.3	1
Education level
Completed high school or General education diploma	8.3	1
Completed some college or associate’s degree	33.3	4
Completed baccalaureate degree	16.7	2
Completed graduate or professional degree	41.7	5
Ethnicity
Hispanic or Latino	25.0	3
Not Hispanic or Latino	75.0	9
Race
Black or African American	16.7	2
White	83.3	10
Annual income
US$20,000–US$39,000	50.0	6
US$40,000–US$59,000	8.3	1
US$60,000–US$79,000	8.3	1
US$80,000–US$99,000	8.3	1
≥US$100,000	16.7	2
Do not wish to respond	8.3	1
Health status
Excellent	8.3	1
Good	58.3	7
Fair	33.3	4
Biological parent
Yes	83.3	10
No	16.7	2
Adolescent’s demographics (N = 12)
Age in years
Range (M, SD)	14–18 (15.83, ±1.19)
Gender	Percentage	Frequency
Male	75.0	9
Female	25.5	3
Education level
8th Grade	8.3	1
9th Grade	50.0	6
10th Grade	25.0	3
11th Grade	16.7	2
Ethnicity
Hispanic or Latino	8.3	1
Non-Hispanic or Latino	91.7	11
Race
Black or African American	16.7	2
White	83.3	10
Birth order
First born	50.0	6
Second born	16.7	2
Third born	8.3	1
Fourth born	16.7	2
Other	8.3	1
Lives with parents
Yes	100.0	12
Parents make decisions about food purchased and served?
Yes	91.7	11
No	8.3	1
Parent’s make decisions how much physical activity the adolescent participates in daily?
Yes	75.0	9
No	25.0	3

Note. M = mean; SD = standard deviation.

In this small sample of 12 adolescents, 1 (8%) was categorized as underweight, 4 (33%) were normal weight, 2 (17%) were overweight, and 5 (42%) were obese. There was no significant decrease in BMI percentile (Table 3) from Time 1 to Time 2 (p = .105) or Time 3 (p = .140), nor was there any significant decrease in triceps skinfolds from Time 1 to Time 2 (p = .255) or Time 3 (p = .579). In addition, there was no significant decrease in subscapular skinfolds from Time 1 to Time 2 (p = .915) or Time 3 (p = .843). However, there was a significant decrease in waist circumference at both Time 2 (p = .003) and Time 3 (p = .008). The Child Health Behavior Survey demonstrated no significant changes from Time 1 to Time 2 for any of the variables.

Table 3.

Anthropometric Measurements.

	Time 1	Time 2	T	Time 3	T
	N = 12	N = 12	(p)	N = 12	(p)
BMI percentile	M = 78.12 (SD = ±28.34)	M = 79.73 (SD = ±26.73)	−1.76 (p = .105)	M = 80.07 (SD = ±28.39)	9.76 (p = .140)
Triceps skinfolds (mm)	M = 13.37 (SD = ±3.61)	M = 13.17 (SD = ±3.86)	1.20 (p = .255)	M = 13.22 (SD = ±4.18)	0.57 (p = .579)
Subscapular skinfolds (mm)	M = 13.68 (SD = ±4.56)	M = 13.66 (SD = ±4.71)	0.11 (p = .915)	M = 13.64 (SD = ±4.56)	0.20 (p = .843)
Waist circumference (cm)	M = 92.99 (SD = ±11.42)	M = 90.50 (SD = ±11.95)	3.87 (p = .003)	M = 90.75 (SD = ±12.49)	3.21 (p = .008)

Note. M = mean; SD = standard deviation; mm = millimeters; cm = centimeters; BMI = body mass index.

Cost, School Accommodation, and Sustainability

The cost of the project was minimal, with the only expenses being the cost of printing (US$30) and teaching materials (US$20). There were no costs for the local school, parents, or students.

The students expressed their acceptance of the project by describing the activities as fun and displaying enthusiasm during activities. The teachers stated that many of the parents were pleased with the classes. The teachers also reported that the students learned new concepts and enjoyed the activities. The parents described their adolescents’ new interest in nutrition information, a desire to eat healthier foods, and seeking recognition when they ate healthier foods.

The school has exhibited a continued commitment to a healthier culture by encouraging fun physical activity and promoting a healthier school environment. School leadership made systemic changes over the course of the study that have continued beyond the end of the project. These changes included tracking and rewarding students’ physical activity with positive reinforcement and nonfood rewards, the initiation of a “salad club” for teachers, teachers losing weight, and the adaptation of this intervention into their regular curriculum.

Discussion

This intervention tested whether a healthy nutrition and physical activity intervention to improve weight management in adolescents using an evidence-based and developmentally appropriate intervention in the school setting was feasible and showed initial efficacy. The findings of this initial study suggest that the intervention may need adjustments to result in significant weight management improvements. However, it was well received in the school setting with positive systemic school changes, a strong researcher and school partnership, and a strong potential for sustainability.

Interventions that are evidence-based, rapidly deployable, low cost, designed to be fun, and able to be implemented in a school setting with minimal disruptions are needed to promote healthy weight management in adolescents (Schneider et al., 2009). Few recent studies fit most of these criteria, despite the prevalence of many wide-ranging school-based studies.

There were no significant decreases in BMI percentile, triceps, or subscapular skinfolds. This was not surprising since this was a feasibility study with a small sample and examined one group over a short period of time. In addition, the Time 3 data collection fell immediately after summer vacation. This is consistent with existing evidence indicating that adolescents typically have increased weight gain over summer breaks, with the greatest gains seen in overweight adolescents (Baranowski et al., 2014; Franckle, Adler, & Davison, 2014). Summertime weight management interventions in youth with a higher risk for weight gain can lead to significant trends toward improved BMI (Barr-Anderson, Singleton, Cotwright, Floyd, & Affuso, 2014; George, Schneider, & Kaiser, 2016). However, there was a significant decrease in waist circumference at both Time 2 and Time 3. Recent evidence suggests that adiposity may be a better indicator for evaluating excessive weight in children compared to BMI (Kolotourou et al., 2013). In the future, it may be beneficial to consider an intervention to maintain and build upon the positive changes made in the postintervention period throughout the summer.

There were no significant changes in the Child Health Behavior Survey. This was also not surprising with a small sample, and we examined one group over a short period of time. Studies examining this effect suggest that summer weight gain may be caused by increases in sedentary behavior, decreased time doing light and moderate physical activity, unstructured schedules, and increased access to unhealthy snacks over summer breaks (Franckle et al., 2014; McCue, Marlatt, Sirard, & Dengel, 2013; Moreno, Johnston, & Woehler, 2013).

The acceptance of the students, parents, and school staff of the intervention was very positive. Developing a trusting relationship between the school and researchers was important (Schoeppe, Oliver, Badland, Burke, & Duncan, 2014; Smith & Petosa, 2016). Prior research showed that a trusting relationship between the researcher and partners in the local school helped create sustainable outcomes, potential spin-off projects, and systemic changes (Jagosh et al., 2015).

The low cost of the project was beneficial in enabling the local school, parents, and students to incur no cost. The use of an in-class physical activity session compared to after school was one way that expenses and disruption to normal school function were minimized by preventing teachers or volunteers from having to stay after regular hours (Babey, Wu, & Cohen, 2014). Low cost also increases the chances that components of the intervention will be sustained, as they will require fewer resources to maintain (Grow et al., 2013). A study finding on school partnerships with researchers recommended building trust with the local school, minimizing disruptions to normal school function, and demonstrating a degree of sustainability beyond the short-term project to prevent the partnership from being seen as one-sided and unfavorable for the school (Smith & Petosa, 2016). This study was able to partner with a school to quickly implement a health education program that met the needs of the researchers and the school.

There were several sustainable positive changes and spin-off developments within the school system following this study. The design of these classes did not require any advanced training in health care and was constructed with the intent of continued use beyond the end of this project. The school administration and teaching staff embraced the healthy nutrition and physical activity intervention and began working on a healthier school culture. A study examining partnerships between researchers and communities suggests that the likely reason for the positive acceptance was the partnership and communication between researchers and school that produced a culturally appropriate project that considered the school’s desires, needs, and logistics (Jagosh et al., 2012). Specific sustainable changes included adaptation of the nutrition and physical activity intervention for their routine curriculum and tracking and rewarding students’ physical activity with nonfood rewards. In addition, the salad club and personal decision of several of the teachers to lose weight provided good role models for the adolescents.

Current research on school-based interventions indicates that modification and intended future use of the intervention are essential to the sustainability of the project, which is often desired by school stakeholders in partnership with researchers (Smith & Petosa, 2016). These sustainable changes made within the school showed the acceptance, successes, and sustainability of the project in this setting. In addition, at the end of the intervention, the teachers were provided detailed lesson plans and educational resources created during this study.

Implications for School Nursing

The partnership with the school resulted in sustainable, healthy systemic changes. Even without the improvements in weight management and body composition, the acceptance by the school staff, students, and parents as well as healthy changes within the school suggests that the intervention had a positive impact. School nurses are in a unique position, as school employees and health-care professionals, to lead similar interventions. The school nurse benefits from existing relationships with school administration and many of the students. In addition, the school nurse is aware of the population’s needs and norms regarding health behaviors. School nurses should seek to collaborate with administration and teachers to lead projects that will improve their population’s health while minimizing disruptions to the existing routines. This could be accomplished by designing the intervention to meet academic standards or satisfying other reporting needs with integration into existing health or physical education classes (Smith & Petosa, 2016). This study demonstrated that the concept was possible with clear communication and active involvement of teachers and administration throughout the process of the study.

Limitations and Recommendations

Limitations of this study included the sample being restricted to a majority homogeneous (non-Hispanic White) population, with the majority being male adolescents aged 14–18. This study was also limited to a single private school for children who needed more structure and positive reinforcement due to various behavioral challenges and consequently utilized a small sample size. Also, the intervention materials were designed to be developmentally appropriate for adolescents in a school setting.

In the future, the intervention design will be revised to reflect changes realized following the discussions with the teachers, feedback from the students, and lessons learned from the pilot study. However, it is important to consider how these changes will affect the partnership with the school and families to try to avoid imposing more time on the school day and home environment. Considering the level of feasibility and acceptability of the pilot intervention, a potential next step would be to try testing the efficacy with a larger sample size and more time.

Conclusions

This study found that using an evidence-based and developmentally appropriate intervention to improve weight management in the school setting was clearly accepted and feasible for teachers, students, and researchers. This finding is not surprising, considering the multitude of studies done in school settings to improve child and adolescent weight management. This study also demonstrated that this intervention could be done in a nontraditional private school for children with special behavioral support needs.

Footnotes

Authors’ Note

All authors made substantial contributions in the conception and design of the study, acquisition of data, and analysis of data. In addition, all the authors worked on revising the manuscript critically for important intellectual content and read and approved the final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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