1. health and fitness
2. disorders

ARTICLE
School-Based Overweight Preventive Intervention
Lowers Incidence of Disordered Weight-Control
Behaviors in Early Adolescent Girls
S. Bryn Austin, ScD; Juhee Kim, ScD; Jean Wiecha, PhD; Philip J. Troped, PhD, MS;
Henry A. Feldman, PhD; Karen E. Peterson, ScD
Objective: To determine the effect of a school-based intervention to promote healthful nutrition and physical
activity on disordered weight-control behaviors (selfinduced vomiting or use of laxatives or diet pills to control weight) in early adolescent girls and boys.
Design: Using a group-randomized, controlled-trial de-
sign, we randomly assigned middle schools to an intervention or control condition. Multivariate logistic regression analyses were used to assess the effect of the
intervention on the odds of reporting a new case of disordered weight-control behaviors at follow-up, adjusting for sex, school-level prevalence of disordered weightcontrol behaviors at baseline, and school clusters. Students
reporting these behaviors at baseline were excluded from
the analyses.
dex for Physical Activity and Healthy Eating: A SelfAssessment and Planning Guide, Middle/High School Version) was implemented during 2 school years, from
November 2002 through May 2004.
Main Outcome Measure: Self-reported disordered
weight-control behaviors in last 30 days at follow-up.
Results: At follow-up in girls, 3.6% (15 of 422) in control schools compared with 1.2% (4 of 327) in intervention schools reported engaging in disordered weightcontrol behaviors (P=.04). Multivariate analyses indicated
that the odds of these behaviors in girls in intervention
schools were reduced by two thirds compared with girls
in control schools (odds ratio, 0.33; 95% confidence interval, 0.11-0.97). No intervention effect was observed
in boys.
Setting: Thirteen middle schools.
Participants: At baseline, 749 girls and 702 boys in
grades 6 and 7.
Conclusions: Results add compelling support for the effectiveness of an interdisciplinary, school-based obesity
prevention intervention to prevent disordered weightcontrol behaviors in early adolescent girls.
Intervention: The 5-2-1 Go! intervention (Planet Health
obesity prevention curriculum plus School Health In-
E
Author Affiliations are listed at
the end of this article.
Arch Pediatr Adolesc Med. 2007;161(9):865-869
ATING DISORDERS HAVE SUB-
stantial negative consequences on the health of affected adolescents, including
fluid and electrolyte imbalances, menstrual and gastrointestinal dysfunction, cardiomyopathy, and premature death.1-3 Disordered weight-control
behaviors, including self-induced vomiting or use of laxatives or diet pills to control weight, often precursors to eating disorders, also have been positively associated
with overweight in adolescents as antecedents, correlates, and sequealae.4-10 The
rising obesity epidemic in children and
adolescents11,12 and its associated health
consequences13-16 and economic costs to
individuals and society17-19 add urgency to
the need to identify effective strategies for
the prevention of maladaptive methods of
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865
weight control in youth. Interventions that
can prevent both overweight and disordered weight-control behaviors may have
the potential to be most efficient and
safe.5,20-22
A recent analysis of the efficacy of the
Planet Health obesity preventive intervention23 in a randomized controlled trial conducted in middle school students found
that the interdisciplinary curriculum had
an unanticipated but beneficial effect, halving girls’ risk of reporting disordered
weight-control behaviors after 2 school
years in intervention schools compared
with control schools (odds ratio [OR],
0.41; 95% confidence interval [CI], 0.220.75).24 Planet Health had previously been
found effective in reducing obesity prevalence in girls.23 To our knowledge, the
Planet Health protective effect on the on-
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16 Middle schools group
randomized (school is
unit of randomization)
8 Schools assigned to
5-2-1-Go! intervention
8 Comparison schools
2 Schools drop out
1 School drops out
6 Schools with 808 eligible
students
7 Schools with 1158 eligible
students
54 Students do not provide
data
73 Students do not provide
data
Baseline data collected from
754 students in fall 2002
Baseline data collected from
1085 students in fall 2002
55 Students lost to follow-up
120 Students lost to follow-up
Follow-up data collected from
699 students in spring 2004
640 Students with complete
data for analyses
Follow-up data collected from
965 students in spring 2004
868 Students with complete
data for analyses
Figure. Flowchart of schools and students through 5-2-1 Go! intervention
during 2 school years.
set of disordered weight-control behaviors has been evaluated in only a single trial conducted a decade ago, and
potential effects for boys are unknown. We undertook
the present study to determine the effect of Planet Health
implemented in a randomized effectiveness trial25 on incidence of disordered weight-control behaviors in middle
school girls and boys. This study extends beyond the previous research on Planet Health by including a larger
sample, more recent data, and data for boys.
METHODS
From November 2002 to May 2004, the Massachusetts Department of Public Health carried out the 5-2-1 Go! study using a
2-arm, group-randomized design in 13 Massachusetts middle
schools. The intervention arm was designed to promote healthful nutrition and physical activity and reduce overweight, and
included 2 tools, the Planet Health curriculum23,26 and the School
Health Index for Physical Activity and Healthy Eating: A SelfAssessment and Planning Guide, Middle/High School Version
(SHI).27 The Planet Health curriculum includes health messages focused on physical activity, television viewing, and consumption of fruits, vegetables, and fats that are provided in the
major subject area and physical education classes. The SHI is
a tool developed by the Centers for Disease Control and Prevention to assist schools in assessing their physical activity and
nutrition policies and programs.27 The SHI consists of multiple modules to help schools address nutrition and physical
activity in various domains of the school such as nutrition services, physical education, and school policies and environment.27
All study procedures were approved by the institutional review boards of the Massachusetts Department of Public Health
and Harvard School of Public Health, Boston. Schools were re-
cruited from 289 Massachusetts middle schools taking part in
the Massachusetts Department of Public Health Enhanced School
Health Services Program. All schools were contacted through
letters and telephone calls, and the 16 schools that indicated
they wanted to participate were enrolled in 5-2-1 Go! The study
used a group-randomized design in which middle schools were
the unit of randomization and students were the unit of analysis.28 The 16 schools were stratified by type (parochial vs public), and public schools were further stratified by racial/ethnic
composition (ⱖ75% or ⬍75% white). Schools within each group
were then randomly assigned to the intervention, which included both Planet Health and the SHI, or the control condition. Control schools were asked to work with only module 1
of the SHI, focused on school policies and environment, and
to make an action plan and prepare a report on their progress
on the plan at the end of year 2 of the study. Subsequent to
randomization and before the baseline assessment, 2 intervention schools and 1 control school dropped out, leaving 6 intervention and 7 control schools in the study. Additional details about 5-2-1 Go! methods have been published previously.29
All students from the 13 schools who were in the sixth and
seventh grades at baseline were eligible to participate. Informed consent was obtained before assessment. A total of 1839
students completed the baseline assessment. Students completed self-report questionnaires on physical activity, sedentary behaviors, diet, and disordered weight-control behaviors
at baseline in November 2002 and at follow-up in May 2004.
Disordered weight-control items (self-induced vomiting or use
of laxatives or diet pills to lose or control weight in the last 30
days) were adapted from the Centers for Disease Control and
Prevention Youth Risk Behavioral Surveillance System survey30; we created a binary variable representing disordered
weight-control behaviors if students reported engaging in at least
1 of the behaviors. A validation study with girls examining a
disordered weight-control measure closely adapted from the
Youth Risk Behavioral Surveillance System items used in 5-2-1
Go! found that the measure had a sensitivity of 0.93 and a specificity of 0.86.31 To characterize the social environment, we computed the prevalence of disordered weight-control behaviors
in each school at baseline. We used this variable as a schoollevel covariate to adjust for the social environment relating to
disordered weight-control behaviors of students in the school,32,33
along with a random effect for school within intervention group
to capture any additional unmeasured school-level influences.
From the baseline cohort of 1839 students, 1664 completed the follow-up questionnaire and were included in the
longitudinal cohort (90.5% of baseline). From the longitudinal cohort, we excluded respondents if there was missing information on sex or disordered weight-control behaviors at baseline or follow-up (n=156), leaving 1508 students (90.6% of the
longitudinal sample and 82.0% of the baseline sample) (Figure).
We further excluded students who reported disordered weightcontrol behaviors at baseline (n=57; 3.8% [26 of 775] of girls
and 4.3% [31 of 733] of boys; 3.7% from control vs 4.2% from
intervention schools with P=.71) from statistical analyses; thus,
our total analytic sample was 1451 students (749 girls and 702
boys) who did not report disordered weight-control behaviors
at baseline. At baseline, control and intervention schools did
not differ by grade (P=.23), race/ethnicity (P=.21), or overweight (defined here as body mass index [calculated as weight
in kilograms divided by height in meters squared] ⱖ85th percentile for age and sex; P=.93) (Table 1), indicating that randomization resulted in a satisfactory balance of student characteristics across the intervention conditions.
We used multivariate logistic regression models with generalized estimating equation methods34 to estimate ORs and 95%
CIs that account for the clustered sampling design. All models
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Table 1. Characteristics of Middle Schools at Baseline and of Analytic Sample of Participants in 5-2-1 Go! Intervention Trial a
All Schools
(N = 13)
Characteristic
Public, ⱖ 75% white students
Public,⬍ 75% white students
Parochial
Disordered weight-control behavior, % at baseline
Total No. of Students c
Sex
Male
Female
Grade
6
7
Race/ethnicity
White
African American
Hispanic
Other
Overweight d
Control Schools
(n = 7)
Intervention Schools
(n = 6)
P Value b
6
2
5
3.9
1451
3
2
2
3.7
837
3
0
3
4.2
614
...
...
...
.71
...
702 (48)
749 (52)
415 (50)
422 (50)
287 (47)
327 (53)
.15
...
818 (56)
633 (44)
420 (50)
417 (50)
398 (65)
216 (35)
.23
...
693 (83)
46 (5)
67 (8)
31 (4)
274 (33)
570 (93)
6 (1)
24 (4)
14 (2)
194 (32)
.21
...
...
...
.93
1263
52
91
45
468
(87)
(4)
(6)
(3)
(32)
Abbreviation: ellipses, not applicable.
a Values are given as number (percentage) unless otherwise indicated.
b Comparing control and intervention conditions with generalized estimating equations.
c Students reporting purging or diet pill use at baseline were excluded from follow-up analysis.
d Body mass index (calculated as weight in kilograms divided by height in meters squared) greater than or equal to the 85th percentile for age and sex.
Table 2. Effect of 5-2-1 Go! Intervention on 2-Year Incidence of Disordered Weight-Control Behaviors in Middle School Children a
Intervention vs Control Schools b
Covariate Adjustment
Covariate Effect b
Boys
Girls
Student characteristic
Grade 6 vs grade 7
Nonwhite vs white
Overweight at baseline c
All of the above
...
0.72 (0.32-1.58)
0.65 (0.24-1.80)
1.15 (0.53-2.46)
...
0.91 (0.27-3.13)
0.86 (0.26-2.88)
1.04 (0.27-4.06)
0.98 (0.26-3.62)
0.97 (0.25-3.75)
0.33 (0.11-0.97)
0.32 (0.10-1.02)
0.36 (0.11-1.14)
0.33 (0.11-1.01)
0.34 (0.10-1.21)
Abbreviation: ellipses, not applicable.
a Values are given as odds ratio (95% confidence interval). Students reporting disordered weight-control behaviors at baseline were excluded.
b Odds of disordered weight-control behaviors in indicated group vs other, with 95% confidence interval. From logistic regression analysis adjusted for school
clustering, individual-level covariates as indicated, school-level prevalence of disordered weight-control behaviors at baseline, sex, and a intervention
condition ⫻ sex interaction term. The school-level covariate and all individual-level covariate effects (grade, race/ethnicity, and overweight) were nonsignificant
(P ⬎ .30) in all models. Similar results were obtained when regression was adjusted for all covariates simultaneously.
c Above or equal to vs less than the body mass index (calculated as weight in kilograms divided by height in meters squared).
included intervention condition, school-level baseline prevalence of disordered weight-control behaviors, sex, and an intervention condition⫻sex interaction term. Additional models also controlled for grade, race/ethnicity, and overweight. All
statistical analyses were performed using SAS software (version 9.1; SAS Institute Inc, Cary, NC).
RESULTS
At follow-up, a sizable protective effect of the intervention on disordered weight-control behaviors was observed for girls. After 2 school years, 3.6% (15 of 422) of
girls in control schools compared with 1.2% (4 of 327) of
girls in intervention schools reported new disordered
weight-control behaviors. The multivariate odds of adopting disordered weight-control behaviors were reduced by
two thirds in girls in intervention schools compared with
girls in control schools (OR, 0.33; 95% CI, 0.11-0.97)
(Table 2). In subsequent multivariate models that also
controlled for grade, race/ethnicity, and overweight, the
magnitude of the effect estimate associated with the intervention for girls remained stable, changing less than 10%,
but the CI widened to include the null value of 1.0. No added
covariates were statistically significant. No protective effect
of the intervention was observed for boys. At follow-up,
2.7% (11 of 415) of boys in control schools compared with
2.4% (7 of 287) of boys in intervention schools reported
new disordered weight-control behaviors (Table 2).
COMMENT
The results of the 5-2-1 Go! trial provide encouraging
evidence that a middle school–based intervention that
has been shown to be effective in reducing obesity in early
adolescent girls23 can also prevent adoption of disor-
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dered weight-control behaviors. The risk of reporting selfinduced vomiting or use of laxatives or diet pills to control weight at follow-up after 2 school years was reduced
by two thirds in girls in the intervention schools compared with the control schools. The present study expands on previous work to evaluate the Planet Health intervention effect24 by including a larger number of schools
(13 vs 10) and girls (749 vs 480) and more recently collected data (2002-2004 vs 1995-1997). In addition, the
Massachusetts Department of Public Health oversaw both
the implementation protocol and conduct of 5-2-1 Go!;
thus, the findings suggest more generalized effectiveness of the intervention model in school settings. The magnitude of risk reduction in the 5-2-1 Go! trial is comparable to that found for girls participating in the first
evaluation of Planet Health24 (OR, 0.41; 95% CI, 0.220.75), a robust protective effect that has held up in 2 rigorously designed randomized controlled trials.
Findings from other studies may provide some insight into the protective effect documented in our intervention. In a small randomized controlled trial in 8- to
10-year-old girls that assessed the effect of an intervention to promote dance and reduce television viewing for
overweight prevention, Robinson et al35 found that girls
in the intervention arm experienced a reduction in weight
and shape concerns, although 2 other nutrition and physical activity interventions in adolescent girls and boys did
not find an intervention effect on body dissatisfaction and
weight concerns36 or body image.37 In an eating disorders prevention randomized controlled trial conducted
in 14- to 19-year-old high school and college female students with moderate body dissatisfaction, an arm of the
intervention that focused on healthful nutrition and physical activity was associated with reduced body dissatisfaction and bulimic symptoms compared with the assessment-only arm, and reduced risk of obesity onset in
female students who were not obese at baseline.38 It is
possible that our Planet Health24 and 5-2-1 Go! findings
of a protective effect on disordered weight-control behaviors in early adolescent girls may be achieved through
a reduction in unhealthful weight concerns and body dissatisfaction, but further research will be needed to identify the mechanism of the observed protective effect.
The present study has several limitations. The 5-2-1
Go! trial may not have been sufficiently powered to detect differences in intervention effect on the addition of
multiple covariates to regression models. The observations that grade, race/ethnicity, and overweight did not
differ across intervention conditions at baseline after randomization and that the effect estimate associated with
the intervention changed little (⬍10%) on the introduction of these covariates are reassuring and suggest that
our results are not likely to be substantially confounded. 39 We could not examine possible race/
ethnicity differences in intervention effects, but because
eating disorders affect all racial/ethnic groups,40-43 further study will be critical. While the measure of disordered weight-control behaviors used in our study has high
sensitivity and specificity in girls,31 it is not known whether
measure performance is comparable in boys.
In 2004, the National Institutes of Health called for
pioneering research collaborations between the eating dis-
orders and obesity prevention fields.44 The present study
adds novel empirical evidence in support of the viability
of integrating obesity and eating disorders prevention initiatives. New research efforts will need to identify protective strategies for early adolescent boys also and to understand the mechanism of Planet Health and other
strategies in school settings that integrate obesity and eating disorders prevention.
Accepted for Publication: April 5, 2007.
Author Affiliations: Division of Adolescent and Young
Adult Medicine (Dr Austin) and Clinical Research Program (Dr Feldman), Children’s Hospital Boston; Harvard Prevention Research Center (Drs Austin and
Wiecha), Department of Society, Human Development,
and Health (Drs Austin and Peterson), and Program in
Public Health Nutrition, Department of Nutrition (Drs
Kim and Peterson), Harvard School of Public Health, Boston, Massachusetts; Department of Kinesiology and Community Health, University of Illinois at UrbanaChampaign (Dr Kim); and Department of Health and
Kinesiology, Purdue University, West Lafayette, Indiana (Dr Troped).
Correspondence: S. Bryn Austin, ScD, Division of Adolescent and Young Adult Medicine, Children’s Hospital,
300 Longwood Ave, Boston, MA 02115 (bryn.austin
@childrens.harvard.edu).
Author Contributions: Dr Austin had full access to all
the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Austin, Wiecha, Troped, and
Peterson. Acquisition of data: Wiecha, Troped, and
Peterson. Analysis and interpretation of data: Austin, Kim,
Wiecha, Troped, Feldman, and Peterson. Drafting of the
manuscript: Austin, Kim, Troped, and Feldman. Critical
revision of the manuscript for important intellectual content: Austin, Kim, Wiecha, Troped, Feldman, and Peterson. Statistical analysis: Austin, Kim, and Feldman. Obtained funding: Wiecha and Peterson. Administrative,
technical, and material support: Kim, Wiecha, Feldman,
and Peterson. Study supervision: Austin. Design and implementation of the 5-2-1 Go! intervention trial: Wiecha,
Troped, and Peterson.
Financial Disclosure: Drs Wiecha and Peterson
receive royalties as coauthors of the Planet Health curriculum.
Funding/Support: This study was supported by the Leadership Education in Adolescent Health project, Maternal and Child Health Bureau, Health Resources and Service Administration grant 6T71-MC00009-15-01 from the
US Department of Health and Human Services (Dr Austin); by the Berkowitz Family Legal Sea Foods Fellowship in Public Health Nutrition at the Harvard School of
Public Health (Dr Kim); and by a subcontract from the
Massachusetts Department of Public Health (MDPH) under Centers for Disease Control and Prevention Cooperative Agreement U48/CCU115807 with MDPH.
Disclaimer: The authors are not employees of the MDPH,
which is not responsible for the accuracy of the reported results or the views expressed by the authors.
Additional Contributions: Maria Bettencourt, MPH;
Vanessa Cavallaro, MS, RD; Kathleen Grattan, MPH;
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Solomon Mezgebu, MSc; Wee Lock Ooi, ScD; and Julie
Robarts, MPH, RD, at the MDPH participated in the
design and implementation of 5-2-1 Go! and Daniel
Finkelstein, PhD, contributed to the data analyses.
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