Background: Approximately one-third of U.S. children are overweight or obese, which is concerning due to the detrimental effects on physical and mental health and academic success. A window of risk has emerged for inappropriate childhood weight gain – the summer months. Data indicate that school-age children, particularly economically disadvantaged and racial/ethnicity minorities, experience unhealthy gains in BMI two to three times as fast during the summer versus academic months. While there are limited data on the causal factors, it has been hypothesized that a loss of the protective effect of schools (i.e., reduced daily access to healthy foods (through school-based federal child nutrition programs) and safe play, and a lack of daily structure) is a major contributing factor. The USDA offers the Summer Food Service Program (SFSP) to address this problem of reduced access to healthy foods during the summer, however the program is highly underutilized, in part due to a lack of quality (engaging) programming for children. Unfortunately, few research efforts have been invested in designing and testing evidence-based programming that might boost participation in the SFSP and offset this negative trend in child weight status during the summer months.
Study Design: Camp NERF 2015 was a citywide scale up of an 8-week, multi-component (nutrition, physical activity (PA), and mental health), theory-based program for disadvantaged school-age children in grades K-5 coupled with the USDA SFSP. Twelve eligible elementary school sites were randomized to 1 of 3 programming groups: 1) Active Control (non-nutrition, PA, or mental health); 2) Standard Care (nutrition and PA); or 3) Enhanced Care (nutrition, PA, and mental health) programming. Caregiver and Youth Mentor social support components were also pilot tested as part of the Enhanced Care group. The primary objective of the Camp NERF intervention was to determine efficacy of implementation on child nutrition, physical activity, psychosocial, and weight status outcomes. Following the completion of the Camp NERF intervention, Project SWEAT (Summer Weight and Environmental Assessment Trial) was developed to further explore the potential protective effect of participation in structured programming on unhealthy gain during the summer months. Project SWEAT is a multi-state, prospective observational study. Two elementary schools in low-income neighborhoods of Columbus, OH were recruited. At the end of the 2016-17 school year, families with pre-K-5th graders were invited to participate. The primary objective of the Project SWEAT study was to determine if and to what extent routine engagement in structured programming during the summer protects against inappropriate weight gain among economically disadvantaged, racial/ethnic minority school-age children.
Outcomes: The Camp NERF child participants were assessed pre- and post-intervention. A survey consisting of validated nutrition, PA, and social support questionnaires was administered. Diet was assessed via 24-hr recall methodology. Height, weight, and waist circumference (WC) were measured. Project SWEAT child participant anthropometric data – height, weight, and WC - were obtained from children at the end of the School Year 1 and the beginning of School Year 2. To assess child attendance at structured program, each week throughout the summer between School Years 1 and 2, caregivers received the following text: “Hi from Project SWEAT! How many days did your child attend a summer camp/program this week? Respond with a number from 0 to 5 with “0” meaning no days, “1” meaning 1 day, etc.” Non-responders receive a follow-up text and phone call.
Statistical Analyses: For Camp NERF child participants, program efficacy was determined by assessing mean group change in outcomes of interest using mixed effects linear and logistic regression model analyses. For Project SWEAT, the potential protective effect of structured programming was tested by comparing mean change in zBMI and zWC from School Year 1 to School Year 2 using mixed effects linear regression model analyses with structured programming attendance as the primary predictor.
Results: Camp NERF: Eighty-seven child-caregiver dyads consented to the Camp NERF study and 81 completed post-intervention assessments (93% retention rate). Among child participants, approximately 56.2% (n=49) were female and 89% (n=77) were Black. There was no intervention effect on Camp NERF child zBMI; however, the overall mean change in zBMI from baseline to post-intervention was -0.07. Non-black participants significantly decreased zBMI compared to Black participants (-0.87 ± 0.24; p<0.001). Project SWEAT: At the end of School Year 1, 113 children representing 79 families enrolled in Project SWEAT. Among child participants, 53.10% were female and 79.65% were Black. BMI z-score from the end of School Year 1 to the beginning of School Year 2 increased significantly for the entire sample (0.15 ± 0.03, p<0.001) and by school (School: 0.15 ± 0.04, p=0.001; School 2: 0.15 ± 0.05, p=0.009). Significant effects of attendance at structured programming on child zBMI and zWC were not observed (zBMI: ¿=-0.003, p=0.28; zWC: ¿=-0.003, p=0.25); however, the directionality and large effect sizes (zBMI: -1.50; zWC: -1.00) indicate a strong relationship.
Conclusions: Results from the Camp NERF study indicate that engagement of disadvantaged school-age children in structured programming – of any type (nutrition, PA, mental health, other) – over the summer months that offers access to healthy foods and safe play, as well as a child-appropriate curriculum prevents unhealthy weight gain during non-academic months. To confirm these findings from Camp NERF, a study design with a true negative control (i.e., observation of child counterparts who do not participate in summer programming) was warranted and developed – Project SWEAT. Based on the preliminary findings from Project SWEAT, it appears that there is a strong relationship between child attendance in structured programming and child health status during the summer months. Results from this research have direct implications for policy reform related to child food and nutrition programs.