School-Based "Pathways" Intervention Reveals Need for More Intense Tools to Combat Childhood Obesity

Children who participated in Pathways, an obesity prevention program involving 41 elementary schools in seven American Indian communities, had just as much body fat at the end of the three-year study period as children who did not participate in the intervention (40.3 percent versus 40 percent). The study, led by Benjamin Caballero, MD, PhD, director of the Center for Human Nutrition at the Johns Hopkins Bloomberg School of Public Health, sought to prevent or reduce excess weight gain in children during their third, fourth, and fifth grade years by reducing fat in school meals, increasing their physical activity, teaching them about healthy lifestyles, and involving their parents so that messages learned in school would be reinforced at home. The final results from the Pathways study appear in the November 1, 2003, issue of the American Journal of Clinical Nutrition. 

American Indian children are almost twice as likely to be obese as the rest of U.S. children combined, according to national health surveys. Data on American Indian adults indicate that 34 percent of men and 40 percent of women are obese compared to 24 percent and 25 percent respectively for the all race national averages. Children who are overweight are more likely to be obese and develop chronic diseases as adults. Primary prevention programs, like Pathways, target at-risk children in an attempt to thwart these trends.

“Pathways was the largest and longest primary obesity prevention program to date, and it worked on multiple levels within the schools,” said Dr. Caballero. “The results suggest that it may take longer than three years to demonstrate changes in body composition in this age group.  A combination of school and community programs may also enhance the overall impact on obesity rates.”

Although the project failed to reduce body fat, it succeeded in several other measures.  Observational data and analysis of school menus showed that the kids in intervention schools consumed less fat from school meals than those in the schools who did not participate in the intervention (28 percent versus 32 percent). The school food service personnel were extensively trained in techniques for preparing lower-fat school meals. The Pathways meal plans did not restrict calories, but focused on less energy dense foods by adding fresh fruit and vegetables and reducing fat in commonly consumed foods such as milk and ground meats.

The Pathways classroom curriculum also produced positive results. The lesson plans incorporated the American Indian mode of learning through storytelling to convey messages about diet and physical activity and reinforced the healthful aspects of the indigenous cultural heritage. The children who received this instruction over the three years showed significant improvement in knowledge and behaviors relating to health.

The physical education component of the program did not produce a substantial increase in physical activity as investigators had hoped, but the data showed a trend of increasing activity in the intervention schools over the three years. Investigators believe that a longer intervention may further this trend and succeed at reducing body fat in this vulnerable group.

“Pathways: a school-based, randomized controlled trial for the prevention of obesity in American Indian schoolchildren” was written by Benjamin Caballero, Theresa Clay, Sally M. Davis, Becky Ethelbah, Bonnie Holy Rock, Timothy Lohman, James Norman, Mary Story, Elaine J. Stone, Larry Stephenson and June Stevens for the Pathways Study Research Group.

Funding for this research study was provided by the National Institutes of Health/NHLBI.

Photographs of Benjamin Caballero are available upon request.