Preventing Risk for Obesity by Promoting Self-Regulation and Decision-Making Skills: Pilot Results...

PROGRAMME PAPER

Translating evidence based violence and drug useprevention to obesity prevention: development and

construction of the Pathways program

Kari-Lyn K. Sakuma1*, Nathaniel R. Riggs2 and Mary Ann Pentz2

1Prevention Research Center, College of Health and Human Development, The Pennsylvania State University, 402 Marion

Place, University Park, PA 16802, USA and 2Institute for Prevention Research, Department of PreventiveMedicine, University

of Southern California, 2001 N. Soto Street, MC 9239, Los Angeles, CA 90089 USA.

*Correspondence to: K. K. Sakuma. E-mail: [email protected]

Received on December 2, 2010; accepted on September 1, 2011

Abstract

Effective school-based obesity prevention pro-grams are needed to prevent and reduce the grow-ing obesity risk among youth. Utilizing theevidence-rich areas of violence and substance useprevention, translation science may provide an ef-ficient means for developing curricula across mul-tiple health behaviors. This paper introducesPathways toHealth, a school-based obesity preven-tion program that was developed by translatingfromevidence-based violence anddrug use preven-tion programs, Promoting Alternative THinkingStrategies and the Midwestern Prevention ProjectSTAR (STAR). We illustrate how a hypothesizedunderlying behavior change mechanism in twodomains of risk behavior, violence and substanceuse, can be applied to obesity prevention. A 4-steptranslational process is provided and may be rele-vant for use in developing other curricula to ad-dress multiple health risk behaviors. Practicalapplication and decision points are also provided.

Introduction

Obesity prevention programs are clearly warranted

with over a third of US youth aged 2 through 19 years

at or above the 85th percentile of body mass index

(BMI) for age [1]. School-based prevention programs

that target individual psychological mechanisms and

social and familial processes are needed as part of an

overall comprehensive approach toward reducing

obesity and obesity risk among youth. Studies on

school-based violence and substance abuse preven-

tion have shown success in reducing their respective

risk behaviors [2–8] and may serve as models in

designing programs for reducing obesity risk. These

different outcomes share common contributors,

which suggest translation of content across health

behaviors.

The primary aim of the Pathways to Health (Path-

ways) study was to utilize existing evidence-based

programs and translate the scientific rigor and theo-

retical constructs to other health behaviors in children,

specifically those with application to obesity preven-

tion. There are a number of evidence-based programs

in both the violence prevention and drug prevention

fields with rich theoretical and empirical findings to

draw from in translating for obesity prevention. Fur-

thermore, there is a large body of implementation re-

search to build upon within those fields to help design

a maximally effective school-based program. Build-

ing upon the successes of these evidence-based pro-

grams would potentially allow for efficiency in the

design of new programs targeting different health

behavior outcomes.

Pathways began with a hypothesis that dysregu-

lated behavior could be an underlying mechanism

contributing to the obesity epidemic. Inhibitory

control, emotional control, planning and organiza-

HEALTH EDUCATION RESEARCH

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tion and working memory are skills subsumed un-

der the term executive cognitive function (ECF) and

are necessary for regulating behaviors and decision

making in order to achieve goals [9, 10]. Prior re-

search suggests that self-regulation and decision

making as it relates to food consumption and phys-

ical (in)activity are important modifiable risk factors

for childhood obesity [11–15]. Low ECF has also

been directly linked to obese and overweight BMI

in adults [16–18] and youth [15, 19–22]. More spe-

cifically, individual ECF sub-skills may be asso-

ciated with the regulation of food intake. Inhibitory

control may allow an individual to inhibit

food-related thoughts and behaviors within an

environment or situation filled with cues for (over)-

consumption of snack foods [15, 20, 23]. Emotional

control may allow an individual to cognitively man-

age strong affect and behavioral impulses. Evidence

suggests that negative affective states have been

shown to increase food intake [24, 25].

ECF may also play a different role in consump-

tion depending on food type [26]. Among school-

aged children, ECF was found to have a negative

correlation with snack food intake [27]. There is

also evidence that suggests that highly palatable

snack foods may be extremely rewarding for chil-

dren and may activate reward circuitry making it

particularly difficult for some children to control,

similar to those produced by some drugs [22, 28,

29]. In comparison to snack foods, the lower palat-

ability and lower availability of vegetables and

fruits may require more goal-oriented problem-

solving skills to increase vegetable and fruit

consumption for healthful reasons.

ECF may also be directly related to physical activity

and sedentary behavior in similar ways to fruit and

vegetable intake. For a child, it may take organization

and future planning to be physically active, especially

if the environment is not conducive to unstructured

physical activity (e.g. access to playground, safe side-

walks and neighborhoods). Furthermore, for some

children, sedentary behaviors such as watching tele-

vision or playing video games may be their activity of

choice. It may take considerable cognitive effort

to inhibit these unhealthy behaviors and plan for

healthier physical activity.

ECF may be a common contributor to multiple

health behaviors. Eating and physical activity patterns,

at its surface, appear to be very different from violence

and drug use patterns in youth. However, considering

that each of these behaviors may occur due to a dysre-

gulation of emotion and poor ECF, then the behavior

patterns begin to overlap [30–33]. Drugs and highly

palatable foods both activate a common reward

circuitry in the brain, circuitry which can become

dysregulated resulting in uninhibited appetitive

behaviors such as excessive food intake and drug

use [22]. Some types of violence, such as aggressive

and externalizing problem behaviors, may also be

viewed as the outcome of poor or dysregulated emo-

tion and impulsive behavior [34–37].

Pathways sought to capitalize on the prior work

in the fields of drug use prevention and violence

prevention and apply the concepts to obesity preven-

tion. Promoting Alternative THinking Strategies

(PATHS) is an internationally recognized evidence-

based blueprints model program and Substance Abuse

and Mental Health Administration (SAMHSA)

endorsed violence prevention program for youth [4,

6, 38–41]. PATHS was chosen as the base curriculum

model due to its underlying neurocognitive theoretical

model that addressed emotional regulation, impulse

control and ECF in children [6, 39, 41]. PATHS

targets the prevention of violence by addressing un-

derlying risk factors that arise from poor social and

emotional competence. PATHS was based on the

principles of emotion theory [42, 43] but more specif-

ically the Affective–Behavioral–Cognitive–Dynamic

(ABCD) model of development [4, 39]. The ABCD

model places primary importance on the developmen-

tal integration of affect, behavior, cognition and

emotion language.

Pathways also identified STAR, a nationally rec-

ognized evidence-based blueprints and SAMHSA

model drug prevention program [2, 44–46]. STAR’s

successes as a drug use prevention program were

attributable to several key components, including

the use of standardized teacher training for program

delivery, use of active social learning methods for

program delivery, targeted skills training and inter-

active homework activities with parents who com-

plement in-school program skills training [46]. In

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addition, the STAR parent component that involved

homework activities (e.g. rule-setting for health be-

havior, encouragement of family-based activities)

and parental skills training (i.e. parent–child commu-

nication and parental modeling) was used as a model

for the new Pathways parent night curriculum.

STAR was based on the Integrative Transactional

Theory (ITT), which posits that individual, social, sit-

uational and environmental factors interact to influ-

ence child behavior [44]. ITT incorporates social

learning and social cognitive factors of peer and parent

modeling, practice, self-efficacy and reinforcement;

social support and social norms for non-use and

broader environmental factors of policy change and

media influences. A number of STAR constructs were

applicable to Pathways, including resistance skills in

response to peer pressure, self-efficacy, counteracting

perceived social norms, healthy decision making

based on perceived consequences of behavior and

lessons involving parents (prevention communication,

rule setting, leisure and family physical activity).

The aim of this paper is to present a framework

for developing Pathways and illustrate the steps

we used to translate from the PATHS and STAR

programs to an obesity prevention program while

providing practical examples and methods for de-

signing a school-based curriculum for youth in the

fourth through sixth grades.

Translation steps

The translation and development model presented

here is based upon a well-established curriculum

development process that builds curriculum activi-

ties from information provided in the literature and

takes it through formative evaluations and formal

randomized controlled trials [47]. Pathways fol-

lowed this general process for building a curriculum

but special attention was given to applying ECF

constructs to obesity prevention using established

intervention trials in violence and substance use

fields and the associated literature base. The trans-

lation model consists of (i) conceptual mapping, (ii)

model building and refinement, (iii) pilot studies

and (iv) efficacy study (see Fig. 1).

Step 1: conceptual mapping

Pathways began with a theory-driven preconception

that dysregulation of affect or impulse control was an

important underlying risk factor for youth violence,

drug use and obesity in our target population [41,

48–51]. Thus, executive control, emotion regulation

and problem-solving skills were identified as potential

mediators to target [40, 48, 52]. Step 1 begins with

the first phase of conceptual mapping which uses

a theory-driven process to identify potential mediators.

The second phase of conceptual mapping was to

search for programs that addressed dysregulation and

operationalized the constructs in ways similar to how

Pathways aimed to address the constructs and target

the mediators. Evidence-based violence prevention

and drug use prevention programs were identified

and evaluated whether the programs had the same

hypothesized theoretical underpinnings and targeted

similar mechanism of behavior change.

Once PATHS and STAR were identified as can-

didate programs, the third phase of conceptual map-

ping was to deconstruct the programs and map the

theoretical concepts together to view any overlap-

ping constructs between the two programs and

search the literature for the new obesity-related

target risk factors (see Table I).

Understanding the underlying theoretical foun-

dation of each respective program was imperative

prior to developing the curriculum lessons. More

information on the principles underlying PATHS

and STAR programs for the integration between

the original programs and the new obesity preven-

tion curriculum was needed in order to address and

test the proposed hypotheses. Thus, a literature re-

view was done in the following areas: PATHS and

STAR outcomes, mediation analyses and theories;

Emotional intelligence, social and emotional com-

petence, neurocognitive circuitry of emotional/so-

cial development, ECF and impulse control and

obesity prevention constructs, methods and theories

for application in children.

Step 2: activity building and refinement

The purpose of Step 2 in the translational process

was to carefully construct lessons in light of the

Pathways obesity prevention program

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empirical evidence in the literature, the theories

used in the original evidence-based programs and

new data gathered through formative evaluations.

Formative evaluations were conducted using inter-

views, focus groups and class assessments with

teachers, parents and students. Results from forma-

tive evaluations conducted during this step helped

to refine the activities, define target mediators more

Table I. Sample program mediators across behavioral outcomes

Program mediators Violence prevention Substance use prevention Obesity prevention

Food choice Physical (in)activity

Inhibitory controla,c x x x

Emotion languagea,c x x

Emotion regulationa,c x x

Decision makinga,b,c x x x x

Planninga,b,c x x x x

Parent modelingb,c x x x

Skill practicea,b,c x x x x

Self-efficacyb,c x x x

Social normsb,c x

Resistance skillsb,c x

Communicationa,b,c x x x x

Rule settingb,c x

Family leisure timeb,c x x

aPATHS.bSTAR.cPathways.

Fig. 1. Translation and development process.

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precisely and direct development of the overall cur-

riculum. Step 2 also includes assessment of the

original programs for programing logistics such as

delivery structure, sequencing, age-appropriate con-

tent and teacher training.

The Pathways program underwent two phases of

development prior to formal pilot testing of the full

curriculum [50]. The first phase consisted of iden-

tifying core components from the PATHS curricu-

lum and modifying to target attitudes toward food

intake and physical activity for fifth graders. Five

representative lessons focusing on self-control, emo-

tional language, communication and problem-

solving were chosen for evaluation. Each component

had a tool to help convey the lesson to the children.

For example, self-control used a Control Signals

Poster (CSP) which looked like a stop light. In

PATHS, children are taught to imagine the CSP

when they have a really strong emotion so they

can stop before they act, think about the situation

and say how they feel and why. In keeping with the

translational process, this tool was used in Pathways

as it was presented in PATHS. However, situations in

which a child would apply this tool in Pathways were

expanded to include where affect may not be strong,

such as boredom and mindless or repetitive actions

like watching television for an hour or consuming an

entire bag of chips. The CSP was a strong visual cue

so children were able to remember the concept readily

within the classroom. Generalizability to other situa-

tions and contexts was also critical. Therefore, study

personnel developed products such as mini posters,

magnets and stickers and tested it for appeal, cost

and use outside of the classroom. Furthermore,

teachers were queried if they felt comfortable with

the material, found the concepts easy to teach with

minimal or no training and whether or not they

would endorse and support the concepts outside of

those lessons. The information gathered from teach-

ers and students drove the second iteration of the

activity development and a second phase and forma-

tive evaluation was completed (See Table II).

The Pathways study needed a structured curricu-

lum that was standardized in number of class

sessions and length of delivery to more readily assess

teacher fidelity and provide a minimum level of

programing to evaluate students. Curriculum special-

ists and teachers in the school districts who were

involved at the start of the study requested that the

lessons be provided as packages and training be pro-

vided to teachers on delivering the content. Most

conveyed the need for the lessons to be set as a mod-

ule to be able to quickly integrate within the teachers’

limited schedules. Given the goals of Pathways study

and requests from our school partners, restructuring

of the PATHS lessons in content and number was

necessary and was done based on existing theory and

research. PATHS core theoretical constructs were

included in the current Pathways program (i.e.

emotion, impulse control and problem solving), but

they were used specifically as they relate to making

healthy choices on diet and physical activity. There

were three initial decisions that needed to be made

prior to lesson planning:

Standardization of lessons

PATHS was designed to be delivered by elementary

classroom teachers in grades K-6. Typically, these

lessons would be taught three times a week for a min-

imum of 20–30 min per day for a total of 131 les-

sons. Grade-specific lessons were also developed for

Grades 3–5 that focused on developmentally appro-

priate interpersonal cognitive problem-solving skills.

The Grade 3 curriculum was chosen to be the foun-

dation for the Pathways program in order to capital-

ize on the fundamental concepts presented at that

level. This set of 46 lessons consisted of 10 dedicated

to getting started, 16 feelings and relationship

lessons, 17 cognitive problem-solving lessons and

3 relationships and social competence lessons.

In PATHS, lessons were designed for flexibility

in delivery. PATHS has a specific developmental

order in which to present the lessons but teachers

were able to decide which lessons they would like

to teach at any given point during the day or

throughout the week and infuse them within other

standard curriculum (e.g. math, social studies). Les-

sons varied in the amount of delivery time (i.e. 5–30

min) and contained different stop points allowing

teachers to stop a lesson if they run out of time or

chose to continue on a different day. In contrast,

Pathways lessons were standardized to be a 30- to


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Table II. PATHS lessons with application to obesity

Title Focus Application to obesity Translational step

Grade 4

1 Class rules Peer relationships Step 2: formative evaluation 1

2 PATHS kid Peer relationships Step 2: formative evaluation 1

3 CSP Self-control Impulsive eating Step 2: formative evaluation 1, 2

4 Introduction to feelings Affective understanding Emotions and eating Step 3: pilot

5 Recognizing and controlling feelings Self-control Impulsive eating Step 2: formative evaluation 1, 2

6 Feelings dictionary Affective understanding Emotions and activity Step 2: formative evaluation 1, 2

7 Feelings intensity Self-control Impulsive eating Step 2: formative evaluation 1, 2

8 Making good decisions 1 Self-control resisting peer pressure Peers and food choices Step 3: pilot

9 Making good decisions 2 Decision-making skills thinking ahead Problem-solving skills,

eating and activity

Step 3: pilot

10 Problem identification 1 Emotions associated with identifying

problems

Emotions and identifying

health food/activity

Step 2: formative evaluation 2

11 Problem identification 2 Self-regulation while

identifying problems

Regulating intake and

identifying food

Step 2: formative evaluation 1, 2

12 Setting positive goals Goal-directed behavior Health goals Step 2: formative evaluation 1, 2

13 Reaching our goals Goal-directed behavior Health goals Step 3: pilot

14 Generating solutions Solution generation Problem-solving/activity Step 2: formative evaluation 2

15 Thinking takes time Self-regulation solution generation Regulating intake and problem

solving/food

Step 3: pilot

Grade 5

16 PATHS jeopardy review Positive peer relationships Peers and food choice Step 3: pilot

17 Feelings review Positive peer relationships Peers and activity choice Step 3: pilot

18 CSP review Self-control Impulsive eating Step 3: pilot

19 Managing our feelings Emotional control Emotion, impulse and food/activity Step 3: pilot

20 Making good decisions Decision-making skills Problem solving and food Step 3: pilot

21 Identifying Problems, feelings, goals and

solutions

Problem-solving skills Problem-solving and food activity Step 3: pilot

22 Consequences: what might happen next Evaluation of consequences Consequences of food/activity Step 2: formative evaluation 2

23 Trying out your plan refusal skills Plan initiation/refusal skills Health plans for food/activity Step 2: formative evaluation 2

24 Making a good plan Planning and sequencing Plans for food/activities Step 3: pilot

25 Trying again: obstacles Persistence/evaluation Evaluate healthy plans Step 3: pilot

Grade 6

26 Problem-solving review Social competence Problem solving and food Step 3: pilot

27 Making a good decisions Social competence Healthy decisions Step 3: pilot

28 Getting help from others Social competence Peers and food/activity Step 3: pilot

29 Conflict resolution styles Social competence Conflict and food/activity Step 3: pilot

30 Resolving conflict Social competence Conflict and food/activity Step 3: pilot

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45-min packaged session. Teachers could choose

the days they would deliver each session but they

must be delivered in consecutive order and must

be done in the complete format so that students

received a minimum amount of intended program-

ing (see Fig. 2). Additional ideas and optional ac-

tivities that allowed the teacher to infuse the

program beyond the minimum sessions were also

written into the plan and encouraged but not made

compulsory. Furthermore, each session was struc-

tured so students had clear expectations of learning

objectives and included a standard order from in-

troduction, through several activities/discussions,

and a closing to provide consistency for ease of

learning by students and delivery by teachers.

Classroom activity level

The PATHS curriculum relied primarily on socratic

discussions and cooperative learning principles

to illustrate points to students. The level of classroom

activity was constrained to individual activity sheets,

feeling face boxes and class or group discussions/

demonstrations. Pathways, with consent and consul-

tation from the PATHS developer, increased class-

room activity level and included more dynamic and

visual teaching modalities. For example, in PATHS,

students are asked ‘why is it important to pay atten-

tion?’ and teachers encouraged active discussion

within the classroom. The Pathways lesson starts

students with a standard color–word Stroop task

[53], in which students must name the color they

see and not the word they read. The task itself is

geared so that students will answer incorrectly when

done quickly. Then the discussion uses the task to

illustrate the point that if they do not stop and pay

attention, they will make mistakes. This activity still

maintains the construct being addressed, encourages

active socratic class discussions and creates the

illusion of a game.

Lesson content

The PATHS program teaches youth to recognize

;55 affective states in addition to varying degrees

of those states (e.g. angry, upset, furious). Labeling of

affective states is a fundamental component of

PATHS; thus, many of the earlier lessons are dedi-

cated to recognition and labeling. For Pathways, the

content and mode of delivery had to be changed

dramatically to accommodate time constraints. The

number of affect states was limited to 39 of those that

could be directly linked to physical activity or dysre-

gulated eating behaviors (e.g. angry, bored, guilty,

happy, humiliated, rejected, satisfied, tired, uncom-

fortable, worried). This decision was based, in part,

on literature that identified categories of emotional

eating or provided evidence of a relationship between

specific emotional states and dysregulated eating.

Step 3: pilot studies

We have defined pilot studies here as testing a sub-

set or full set of lessons with the intent to evaluate

content, sequencing, delivery modality, feasibility

and impact on targeted mediators. We also aimed to

assess whether the program was well received by

the students, teachers and administers and no un-

intended consequences occurred that would nega-

tively impact students.

A pilot study was conducted with a full version of

the fourth grade Pathways curriculum which consisted

of fifteen 30- to 45-min lessons. The pilot study fo-

cused broadly on the content and sequencing of the

lessons. Teachers were queried whether the conceptual

level of the lessons was too young or too mature for

their students, whether the language and examples was

age appropriate and culturally relevant and whether

they observed any spontaneous use of the curriculum

tools or skills outside of the lesson. Focus groups were

Fig. 2. Structure of Pathways curriculum. Note: This figure isjust an example and does not map the full curriculum. Sessionsare specific activities that are packaged together into 30- to 45-min blocks intended to be delivered together. Activities(abbreviated as Act) are separate tasks targeting a specificconstruct or learning objective.


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conducted with teachers, parents and students at the

conclusion of the pilot study. Observers in the class-

room were also used to monitor the fidelity with which

teachers completed each lesson and whether timing of

the lessons was estimated correctly.

PATHS was a comprehensive program that began

teaching students about emotions and empathy at an

earlier age than the Pathways students. Thus, the

Pathways research team specifically assessed sequen-

ces of lessons by looking for stages of understanding

around different emotions (e.g. Could students define

jealousy, do they understand subtle differences

between angry and frustration) and whether introduc-

ing the concept of empathy early in the set of lessons

would produce greater understanding of emotions

than introducing it later. Empathy was found to be

critical to the program sequence because many of the

lessons ask the child how they might feel within

a given scenario and then asks them to relate to

how another child might feel. Empathy, as a construct

in these programs, was used as a way to demonstrate

different emotions that people may have in the same

scenario and to link an individual’s actions with emo-

tional consequences (e.g. If I hit Joey, then Joey will

be sad and I will feel guilty versus only focusing on

me hitting Joey because I was angry). Empathy

allows for the program to extend beyond just a child’s

feelings and provides an opportunity for them to look

for social and emotional cues in others and prevent

impulsive behavior by building on the CSP, thinking

through how others might feel, and considering con-

sequences of their actions. A specific example from

Pathways asks students how they feel and the prob-

lems they may face in a vignette describing a thanks-

giving dinner, a student stuffed full of food and then

a beloved grandmother bringing out her dessert in

which she insists everyone must partake. Teachers

prompt students for their internal feeling states, how

others might feel, a behavioral choice students could

make and the consequences as a result of that choice.

A child might impulsively grab a piece of dessert and

ignore how full he or she was from dinner and in

doing so may make the grandmother feel happy. An-

other child might turn down the dessert and disregard

the grandmother’s feelings. This complex scenario

relies on the culmination of several preceding lessons

but takes students beyond just feeling full or wanting

a palatable dessert to incorporating other social cues

(e.g. how the grandmother might feel or the social

expectation to eat food that is offered) and how chil-

dren might negotiate the situation in a way that they

can make healthy decisions.

Using empirical and focus group data, we found

that students in fourth grade were generally able to

distinguish between the different emotions, includ-

ing higher order or complex emotions such as jeal-

ousy, but empathy needed to be introduced across

a few lessons after majority of the students had the

practice of saying how they felt out loud. We spec-

ulate that the students needed to be comfortable

identifying their ‘own’ feelings and that expressing

them was a safe and appropriate activity to do in

front of their teacher and classmates. So the lessons

were sequenced to first establish a safe social envi-

ronment for students to label how they felt before

addressing the concept of empathy.

The intent of Pathways was not to teach students

about nutrition or exercise but to give them the tools to

regulate affect and control behaviors in order to make

healthy choices regarding nutrition and physical activ-

ity. However, developmentally, students in the Path-

ways age groups needed very concrete examples of

what constitutes a healthy choice in terms of food

and activity. Class activities and homework activities

were structured so that broad concepts were paired

with concrete examples so students were able to un-

derstand the objectives of the lesson, how and where to

apply the skills they learned and generalize beyond the

example provided. Examples could not be all inclu-

sive; thus, special attention was given to developing

a wide range of situations in order to be as relevant

to each student as possible and cover the gamut of

potential circumstances for further generalization.

Physical activity can be categorized relatively

easily as a healthy behavior (e.g. vigorous exercise

>30 min per day) and physical inactivity (i.e. video

games, television, computer time) as a generally

unhealthy behavior; however, food choices and

how to discuss them in a universal program was

not so clear. We can teach students to make the

healthy decision but we cannot expect them to do

so without telling them ‘what’ is considered healthy

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Table III. Fourth grade pilot Pathways session and activities and applications

Session Activity Title Mediating construct Applicationa

Physical activity Sugar Fiber

1 Control signals

1 Don’t blink Affect awareness

2 Introduction to Pathways Affect language X

3 Introduction to feeling faces Affect language

2 Intro to feelings

1 All feelings are OK Affect language

2 When have you had this feeling Affect awareness

HW When have you had this feeling-

parent interview

Affect awareness and language

3 Describe that feeling

1 Stoplight review Affect awareness X X

2 Blank faces Affect language and regulation

4 How would you feel

1 Feeling faces Affect awareness

2 How would you feel if . Affect awareness and empathy

(language)

5 What are these feelings?

1 Breathe Affect regulation

OPT ACT Red light/green light Affect awareness and regulation X

2 New feelings Affect language

3 When is enough enough? affect language and regulation

6 What is healthy?

1 Stoplight review Affect regulation X X X

2 What is health? Knowledge

3 Healthy nutrition Knowledge X X

4 Sugar bad or good? Knowledge X X

5 Hiding sugar Knowledge X X

7 Behaviors

OPT ACT Eating mindfully Awareness X X

1 Sugar sugar everywhere Knowledge X X

2 OK and not OK behaviors Affect awareness and regulation

3 After school Affect awareness

HW Food finds Knowledge X X

8 Problem identification

1 Cool tool Affect regulation

Path

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Table III. Continued

Session Activity Title Mediating construct Applicationa

Physical activity Sugar Fiber

2 Identifying problems Problem-solving skills

3 Problem identification practice Problem-solving skills

9 Problem identification 2

1 Is there a problem/goal setting Problem-solving skills

2 Finding our goals Problem-solving skills X X X

10 Solution generation

1 Lateral thinking Problem-solving skills

2 Solution generation Problem-solving skills X X X

3 On your own Problem-solving skills X X X

11 Making good decisions

1 Consequences Problem-solving skills

2 Freddie and alberto Problem-solving skills

3 On your own Problem-solving skills X X X

12 Making good decisions 2

1 Green light Planning

2 Try try again Planning

3 Science corner Knowledge X

4 Storyboard Planning X X X

13 Negotiation

OPT ACT Food choices Problem-solving skills X X

1 Exercise your brain Impulse control

2 Negotiating decisions Problem-solving skills X X X

3 Communication Affect language X X X

HW Skill development Problem-solving skills X X

14 Setting a positive future

1 Goal-setting review Problem-solving skills

2 Long-term goal setting Planning X X X

3 Roadblocks and speed bumps Problem-solving skills X X X

4 Walk your path Planning X X X

15 On the right path

1 Storyboard play Affect language X X X

2 Own story, own goals, own health Planning X X X

aApplication: More than one demarcation indicates that specified activity was pilot tested with variation on Physical activity, Sugar, and/or fiber as marked. HW, Homework; OPTACT, Optional Activity.

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or at the very least how to judge for themselves

whether or not something is healthy.

There were two major ‘camps’ or philosophies

identified in the literature on how to effectively in-

tervene on food-type consumption that would result

in measurable differences in BMI. We have dubbed

these camps as the ‘sugar camp’ and the ‘fiber camp’.

These camps are not mutually exclusive but provide

a challenge in framing messages to students regard-

ing their food choices.

The sugar camp focuses on the unhealthy con-

sumption of sugar-laden and/or high-fat foods, often

found in junk foods, sodas and other processed items.

The philosophy behind the sugar camp is to teach

students to look for the hidden sugars in processed

items, read nutrition labels and ingredient lists to

identify the various disguises of sugar and avoid eat-

ing those items when possible. To further concretize

the lessons, students were taught to avoid items

where any type of sugar was listed as one of the

top three ingredients or restrict their diet to no >50

grams of sugar a day, which represents ;10% of

their daily diet based on recommendations by the

World Health Organization [54].

The fiber camp is essentially the 5-a-day cam-

paign by the Centers for Disease Control and Pre-

vention. The philosophy behind the fiber camp is to

introduce and encourage eating a wide range of fresh

fruits and vegetables to reach the 5-a-day serving

guidelines. By eating at least five servings of fruits

and vegetables a day, it will help provide vitamins

and nutrients necessary for good health and the fiber

to help satiety and thereby indirectly reducing con-

sumption of low-nutrient foods. An extension of this

philosophy is to have students seek foods that con-

tain a high amount of fiber (>3 grams per serving)

and/or avoid those with low amounts of fiber as

noted on their nutrition labels.

Four variations of specific Pathways lessons were

written and piloted to identify which of these camps’

messages was more salient to students and would

most likely result in changes in behavior. Variation

1 was to test whether physical activity messages (i.e.

increase physical activity and decrease sedentary ac-

tivity) were salient enough for students to recall them

and change their behaviors. Variation 2 emphasized

the sugar camp philosophy while Variation 3 empha-

sized the fiber camp philosophy. Variation 4 did not

emphasize any one camp but all three messages (i.e.

physical activity, sugar reduction and fiber increase)

were distributed in equal amounts across the lessons.

For example, ‘session 6: What is Healthy?’ had ac-

tivities that focused on defining health. In the physical

activity variant, the focus was on feeling energized

and seeking fun activities that raise their heart rate for

an extended period of time. For the sugar camp var-

iant of session 6, the context of health and knowledge

taught students to find snacks that they currently eat

and look for the different types of sugar in the in-

gredient list. For the fiber camp variant of session 6,

the context of health and knowledge taught students

to seek different fruits and vegetables and look for

high-fiber snacks. These variations in the curriculum

helped us to empirically disentangle what is important

to students at this age and further concretize examples

used to deliver message of healthy choice and help

students to apply them directly to their behaviors.

Sequencing of these health behaviors was also an

important finding from this pilot study. Students un-

derstand that exercise is healthy and important but in

fourth grade, they may be too young to control their

free time choices and may not have the planning

skills or problem-solving skills to enable them to seek

healthy environments or activities (e.g. asking mom

for a ride to the park). In contrast, given food choices,

perhaps between fruit and cookies lying around the

home, a fourth grader would be able to apply the

healthy decision-making skills learned in Pathways.

Hence, emphasis on increasing physical activity/de-

creasing sedentary behaviors and how to plan for

them were not added until the fifth grade booster

program. Table III represents the Pathways fourth

grade pilot curriculum with applications mapped

on to each activity. If more than one application is

marked with an ‘X’, it indicates that more than one

variation was pilot tested as described above.

Step 4: efficacy study

The goal of the development work done here to

translate evidence-based violence and drug use pre-

vention programs for application to obesity preven-

tion was to prepare a curriculum for a school-based


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randomized control trial with teacher delivery.

A randomized control trial will enable us to test

whether the Pathways prevention program will be

effective in changing our targeted mediators and re-

sult in the ultimate outcome of differences in over-

weight and adiposity between our treatment group

and the control group. The final Pathways curriculum

consisted of thirty 45-min sessions with 15 sessions

delivered during the fourth grade, 10 booster sessions

delivered during the fifth grade and 5 booster ses-

sions in the sixth grade. Parent night activities were

also delivered during the fifth and sixth grade terms.

The current landscape of school-based prevention

is challenging due to time and economic constraints

and Pathways was not immune to some of these chal-

lenges. After a year of curriculum development in

partnership with a school district, budget deficits

had led to district-wide lay-offs of teachers and

administrators. At the request of the school district,

the partnership was dissolved and new partnerships

were formed with other school districts in order to

conduct the efficacy study portion of Pathways. Path-

ways also had to face two-school closings due to the

budget shortfall and again recruitment for new part-

ners had to occur. We were able to face these chal-

lenges with the help of a high-level champion. In most

cases, we had buy-in from a supporting school super-

intendant. Meetings with school principals and teach-

ers or curriculum specialists were also necessary to

gain the support of the program and the resources

necessary for implementation. What appeared to be

the strongest influencing factor in adopting the re-

search study was that Pathways was based on estab-

lished evidence-based prevention programs in which

schools were already familiar and that the materials

were designed for easy administration by the teachers.

The Pathways curriculum is currently being imple-

mented in a randomized control trial in school districts

in the southern California region.

Discussion

Obesity is a highly complex issue that requires the

integration across individual, family, environment

and population-level factors in order to successfully

address the burgeoning problem facing our nation’s

health [55, 56]. Integrating behavioral and environ-

mental prevention efforts are important, even critical,

to the success of obesity prevention. Individuals are

embedded within these environments and therefore

must make healthy choices, given those environ-

ments. There is no doubt that multi-level efforts, such

as changing school policies that limit student access

to competing calorie-dense foods or mandating

increased physical activity in classes, together with

healthy home environments that limit sedentary

screen time, safe neighborhood environments that

provide green space and individual-level prevention

programs would likely be more effective in producing

health behavior change than any one intervention tar-

geting just one level [55–57]. The Pathways project

aimed to strengthen the individual level by interven-

ing with children and developing their ECF and im-

proving their healthy decision making within contexts

that are challenging (e.g. a home with limited fresh

fruit and vegetables to snack on after school, neigh-

borhoods that are dense with high fast food establish-

ments). Furthermore, the Pathways program was not

intended to stand alone in its efforts to prevent and

reduce childhood obesity risk. Efforts to influence the

home environment through homework activities and

family nights with parents and school officials were

part of the initial design of Pathways. Pathways also

asked students and teachers to critically examine their

school environment for areas they would most likely

need to use their skills (e.g. near vending machines).

This may fall short of the need to change school

policies and environments; however, the link to other

school programs and initiatives such as the Network

for a Healthy California (http://healthedcouncil.org/

network/index.html) that do aim for those changes

are natural and encouraged. The efficacy trial of the

Pathways program will help determine its ability to

influence obesity-related factors and contribution to

the overall goal of reducing obesity risk. Future devel-

opments of school-based obesity prevention program-

ing may benefit by including policies that aim to

provide healthier home and school environments.

School-based intervention programs that do not

take into account the setting-level contextual factors

[58, 59], like socioeconomic status of the families

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or political environment within the school district,

may show short-term successes in behavioral out-

comes but may never be adopted and disseminated

outside of funded research [60]. Pathways began by

including curriculum specialists at the district level,

teachers, parents and students as partners in the de-

velopment process. These contributors were valuable

in allowing the program to mitigate and address po-

tential barriers. The design of the Pathways program

also utilized teachers as the implementers of the pro-

gram, instead of specially trained health educators or

research assistants, and built the curriculum to fit the

teachers’ needs in terms of structure (e.g. full compo-

nents, delivered within one class period) and level of

expertise. Pathways also looked for other natural

translatable opportunities. For example, ECF skill

applications were designed to address other common

issues that teachers face in education, specifically

children’s ability to calm down, sit still and concen-

trate. Pathways built lesson plans to address those

needs but also provided optional exercises to help

students and teachers manage anxiety and help with

focus on standardized testing. As teachers and admin-

istrators accepted the value of the Pathways program

and as teachers experienced visible changes in their

students’ behaviors, they looked for other ways

to incorporate other programs available through the

school’s nutrition network and change the classroom

environment. For example, a student chided her

teacher for eating three small bags of chips without

using the CSP. The teacher was so surprised to realize

that she had eaten under stress that she had the

students help institute classroom rules about eating

and helping each other use the CSP. Other research-

ers and curriculum developers are encouraged to de-

sign programs that are easily assessable by the target

implementers and audience and one that can be easily

disseminated from the research setting to real-world

settings [59]. A model that may be useful to guide this

work is the RE-AIM framework developed by

Glasgow, Vogt and Boles [61, 62].

Obesity is a multi-faceted problem and school-

based interventions that target individual affective,

cognitive and behavioral change is just one piece

of the puzzle needed in facing the challenge of

reducing obesity and obesity risk among youth

[46, 56]. Translating the successes of already

established evidence-based prevention programs

may be a viable way to combat the rapid increase

in obesity prevalence among our youth. Transla-

tion and application from existing evidence-based

programs is an arduous process but the benefit

of this process is the ability to capitalize on the

fieldwork already completed by evidence-based

programs while testing new hypotheses without

starting from scratch.

This paper describes the initial processes needed

to translate a primary prevention program from the

area of violence and drug use to obesity prevention

in youth. We presented the steps we used to orga-

nize the translational process and described some

of the practical applications, challenges and deci-

sions we have faced in developing Pathways.

These steps are intended to guide other researchers

who may choose an interdisciplinary route in de-

veloping their school-based curriculum and take

advantage of fieldwork in other areas. The Path-

ways prevention trial is underway and future anal-

yses will be able to shed light on the applicability

of translation to a new health outcome but also on

multiple outcomes. The current Pathways pro-

gram, although primarily an obesity prevention

program, introduces drug use prevention concepts

during the fifth grade booster sessions and expands

during the sixth grade booster sessions. Empirical

evidence is needed to confirm whether the trans-

lation between these health behaviors was appro-

priate. Future directions should include whether

a true universal program that targets multiple

behaviors (e.g. violence, drug use and obesity pre-

vention) would be just as effective as a program

aimed at only one health outcome [63, 64]. The

implications of such a program may facilitate

greater adoption by school systems resulting in

greater public health impact [65]. Currently, vol-

untary prevention programing in school settings

are threatened with the economic challenges that

face states and school districts as well as the

stresses of academic testing. A well-designed, uni-

versal health promotion program targeting multiple

health outcomes may be necessary for school-based

programs in our future.


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Funding

National Institute of Child Health and Human De-

velopment; National Institute of Drug Abuse at the

National Institutes of Health (grant number R01-

HD052107).

Acknowledgements

The authors would like to thank Drs Mark Greenberg,

Donna Spruijt-Metz, Kim Reynolds and Chih-Ping

Chou for their contributions to the development of

the Pathways curriculum and to Anna Solmeyer for

reviewing and editing drafts of the manuscript. They

would also like to thank Cecilia Portugal, Elizabeth

Hoyt, Jacqueline Corvan, study staff and the partici-

pating schools and teachers for their contributions to

the Pathways project.

Conflict of interest statement

None declared.

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