Evaluation of a student participatory, low-intensity program to improve school wellness environment and students’ eating and activity behaviors

Abstract

Background:
Most schools have not fully implemented wellness policies, and those that have rarely incorporate meaningful student participation. The aim of the Fuel Up to Play 60 (FUTP60) program is to help schools implement wellness policies by engaging students in activities to improve access to healthful, good tasting food and drinks, and increase the number and type of opportunities for students to be physically active. The aim of this paper is to present initial student-level results from an implementation of FUTP60 in 72 schools, grades 6-9.

Methods:
The study used a non-controlled pretest/posttest with serial cross-sectional data. School process data and student-level data were collected in fall 2009 (pre-intervention) and spring 2010 (post-intervention). School wellness practices were captured during a baseline needs assessment survey. Validated self-administered questionnaires assessing dietary and physical activity (PA) behaviors were administered to students in grades 6-9 in the 72 pilot schools. Mixed-effects logistic regression controlling for clustering of schools and demographics was used to calculate odds ratios and confidence intervals to evaluate changes pre- and post- intervention.

Results:
All 72 schools implemented FUTP60 during the 2009-2010 school year. Action strategies most frequently chosen by the schools included increasing breakfast participation and new activities before and after school. Positive and significant changes in students' behaviors (n = 32,482 at pretest and 29,839 at post-test) were noted for dairy, whole grains, fruit, and vegetable consumption and PA levels pre- and post-intervention (OR 1.05 to 1.27). Students aware of the program at post-test were significantly more likely to report healthier eating and PA behaviors than students unaware of the program (OR 1.1 to 1.34).

Conclusions:
FUTP60 pilot findings indicate that a low intensity program focused on wellness policy implementation is associated with small positive changes in student behaviors, especially when students were aware of the program. Although these initial results are promising, a more rigorous controlled study is warranted as a next step.

Full text

R E S E A R C H Open Access
Evaluation of a student participatory,
low-intensity program to improve school
wellness environment and students’eating
and activity behaviors
Deanna M. Hoelscher
1*
, Alicia Moag-Stahlberg
2
, Karen Ellis
3
, Elizabeth A. Vandewater
1
and Raja Malkani
1
Abstract
Background: Most schools have not fully implemented wellness policies, and those that have rarely incorporate
meaningful student participation. The aim of the Fuel Up to Play 60 (FUTP60) program is to help schools implement
wellness policies by engaging students in activities to improve access to healthful, good tasting food and drinks, and
increase the number and type of opportunities for students to be physically active. The aim of this paper is to present
initial student-level results from an implementation of FUTP60 in 72 schools, grades 6–9.
Methods: The study used a non-controlled pretest/posttest with serial cross-sectional data. School process data and
student-level data were collected in fall 2009 (pre-intervention) and spring 2010 (post-intervention). School wellness
practices were captured during a baseline needs assessment survey. Validated self-administered questionnaires assessing
dietary and physical activity (PA) behaviors were administered to students in grades 6–9 in the 72 pilot schools. Mixed-
effects logistic regression controlling for clustering of schools and demographics was used to calculate odds ratios and
confidence intervals to evaluate changes pre- and post- intervention.
Results: All 72 schools implemented FUTP60 during the 2009–2010 school year. Action strategies most frequently chosen
by the schools included increasing breakfast participation and new activities before and after school. Positive and
significant changes in students’behaviors (n= 32,482 at pretest and 29,839 at post-test) were noted for dairy, whole
grains, fruit, and vegetable consumption and PA levels pre- and post-intervention (OR 1.05 to 1.27). Students aware of the
program at post-test were significantly more likely to report healthier eating and PA behaviors than students unaware of
the program (OR 1.1 to 1.34).
Conclusions: FUTP60 pilot findings indicate that a low intensity program focused on wellness policy implementation is
associated with small positive changes in student behaviors, especially when students were aware of the program.
Although these initial results are promising, a more rigorous controlled study is warranted as a next step.
Keywords: School wellness policies, Obesity, Students, Adolescent, Dietary behaviors, Physical activity, School meals,
Health promotion
* Correspondence: Deanna.M.Hoelscher@uth.tmc.edu
1
University of Texas School of Public Health, Austin Regional Campus,
Michael & Susan Dell Center for Healthy Living, 1616 Guadalupe St., Suite
6.300, Austin, TX 78701, USA
Full list of author information is available at the end of the article
© 2016 Hoelscher et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Hoelscher et al. International Journal of Behavioral Nutrition and Physical Activity
(2016) 13:59
DOI 10.1186/s12966-016-0379-5
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Background
A recent report from the United States (U.S.) Institute of
Medicine (IOM) concluded that schools are a crucial
focal point for prevention strategies [1]. In particular,
schools provide both food and opportunities for physical
activity (PA), so the school environment can have a sig-
nificant effect on student diets and activity levels [2].
One assessment of changes made between the 2006–07
and 2009–10 school years in elementary schools’food
environments was made using a 16-item questionnaire.
The authors of this article surmised that the number of
schools that had made improvements during this time
period was low. The guidelines that were the least likely
to be implemented included changing lunch items to in-
clude more whole grains and low-fat/non-fat dairy foods
and focusing on limiting competitive food sales to fruits,
vegetables, whole grains, low-fat dairy, water and 100 %
juice [3].
The Healthy, Hunger-Free Kids Act of 2010 strength-
ened and reinforced the need for school districts’imple-
mentation of wellness policies for nutrition and physical
activity in the United States [4]. Unfortunately, a major-
ity of students do not attend schools that have fully im-
plemented wellness policies for nutrition and physical
activity [5]. Analysis of surveys from a nationally repre-
sentative sample of schools identified gaps between
schools’wellness practices and policy requirements. This
study found that the percentage of schools that required
all five areas of the wellness policy mandate decreased
between 2009–10 and 2010–11 school years, from 55 to
46 %, respectively. The authors of the study indicated
that the decrease in the number of school districts with
competitive food and beverage guidelines was the pri-
mary contributor to the overall negative trend [5].
Effective implementation of wellness policies relies on
the students’acceptance of the changes. Yet, most school
wellness efforts have overlooked the most crucial stake-
holders —the students themselves [6]. The involvement
of students has been shown to increase student
acceptance in an array of health-related areas and is there-
fore promising in the area of obesity prevention [7, 8].
Students have valuable, relevant ideas that improve the
content of programs and make buy-in from others, in-
cluding parents, much easier [9, 10]. Studies in school re-
form found that when students had meaningful
involvement in an effort there was improved school per-
formance and a personal connection was fostered between
the student, school and staff [11, 12].
The objective of this study was to evaluate implemen-
tation of the Fuel Up to Play 60 (FUTP60) program in
schools that were diverse in racial/ethnic composition,
size, regional location, and socioeconomic status. The
program aim is to help schools implement their wellness
policies by engaging students in activities to improve
access to healthful, good tasting food and drinks, and in-
crease the number and type of opportunities for students
to be physically active. The purpose of this paper is to
describe the initial implementation of the FUTP60 pro-
gram and to assess the effects of the program on student
nutrition- and physical activity-related behaviors in 72
schools during the 2009–2010 school year.
Methods
Study design
This study used an uncontrolled, pre-test/post-test
evaluation of a low-intensity intervention, FUTP60, with
serial cross-sectional samples. Primary outcome mea-
sures to evaluate the effect of school’s implementation of
the program included student consumption of fruits,
vegetables, whole grains, milk/low fat dairy foods, and
physical activity in and outside of school.
School recruitment
The geographic areas chosen to recruit schools were
based on Dairy Council staff availability and a U.S.
National Football League (NFL) Club location. To repre-
sent different regions of the United States, recruitment
focused on districts in the Northeast, Midwest, North-
west, and Southwest (Table 1). The goal was to recruit a
convenience sample with a wide variety of school types
and students. The school districts recruited represented
large and small enrollment, school lunch and breakfast
programs availability, a mix of student demographics
(race, ethnicity, and socio-economic status), and urban,
rural, and suburban settings. One school district in an
area without an NFL team was also recruited.
School districts and schools were compensated for
staff or other resources necessary for data collection.
Each participating school had opportunities to apply for
grants totaling up to $5000. Schools were given monet-
ary incentives to complete student surveys, among other
evaluations, within the necessary timeframe.
Consent and approval
The district administration for each school district
approved implementation of the program and the
subsequent evaluation. Parents provided consent for
student participation in all school wellness activities
using a passive or ‘opt out’consent process; student
assent was required. The Institutional Review Board
at The University of Texas Health Science Center at
Houston approved study protocols (UT Health, HSC-
SPH-15-0590).
Program description
FUTP60 is a low-intensity program without detailed cur-
ricula and instructions for delivery. The National Dairy
Council (NDC) and National Football League (NFL)
Hoelscher et al. International Journal of Behavioral Nutrition and Physical Activity (2016) 13:59 Page 2 of 9
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created FUTP60 with expert advisors, students, and
school stakeholders to include a community participa-
tory model [13, 14] that includes broad engagement by
school members, e.g., teachers, parents, school staff, stu-
dents. The program goals were to increase access and
consumption of fruits, vegetables, whole grains and low-
fat and fat-free dairy, and to increase opportunities to be
active for least 60 minutes every day. Based on school
resources, program advisors’time, and school testing,
among other factors, schools determine the intensity or
depth of the program’s implementation (Fig. 1). FUTP60
has two main program components: [1] social marketing
elements that leverage NFL role models to motivate and
engage youth, and [2] a web-based support system for
school program leaders.
A Dairy Council staff member served as the imple-
mentation study coordinator, who was responsible for
several schools in a region. The coordinator’s roles in-
cluded school district recruitment, coordination of
events with NFL teams or players, provision of on-site
Table 1 Fuel Up to Play 60 (FUTP60) school district location, number of schools & students, and school grade levels at baseline data
collection (2009)
Cities and states where school districts were located Schools (n) School grade levels
a
Total students (n)
Philadelphia, Pennsylvania 10 5th–8th 2282
Des Moines, Iowa 8 6th–8th 5234
Chicago, Illinois 4 5th–8th 2950
Minneapolis, Minnesota 3 5th–8th 1182
Newark, New Jersey 9 6th–8th 1750
Houston, Texas 12 6th–8th 9607
Bloomington, Indiana 4 5th–8th 4203
Phoenix, Arizona 7 7th–9th 7904
Meridian, Idaho 12 6th–8th 10173
a
School grade levels vary in middle school, and can range from
5th grade to 9th grade, depending on the location
Fig. 1 Diagram of Fuel Up to Play 60 Program Elements and the sequence schools followed. School adapted program elements to meet priority
needs for school wellness and students’interests. After schools implemented the program Kick-Off, other activities were done in tandem.
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training, monitoring of program progress, assistance
with data collection, and serving as a liaison with na-
tional evaluation team members.
The program advisor was the main coordinator of the
intervention at the school level, and was responsible for
communication with external partners and the imple-
mentation study coordinator. The program advisor pos-
ition was voluntary, and was staffed with teachers,
school nurses, physical education and health teachers,
and school food service professionals who had the en-
thusiasm and capacity to serve in this role. In some
schools, the principal or other school administrator
nominated or appointed the program advisor. The first task
of the advisor was to form a school team with interested
school-level stakeholders (e.g., school administrators,
teachers, school food service professionals, parents, and
community representatives) and between 10 to 20 students.
In addition to intervention duties, the program advisor at
each school completed process evaluation questionnaires
that included questions about strategies implemented, pro-
gram materials and involvement of the students.
The school team was responsible for conducting an
initial evaluation of the school wellness environment
using the FUTP60 School Wellness Investigation (SWI)
survey along with student surveys, which assessed pos-
sible changes to food, nutrition, and physical activity and
ideas about using NFL merchandise, among other items,
as rewards and prizes for students' participation. The
SWI instrument was completed by the school team, with
input from various school stakeholders (e.g., school nu-
trition professionals, PE teachers, principals, etc.). The
SWI instrument was developed by adapting questions
from: (1) the School Health Index [15], which is com-
monly used for school self-assessment of wellness pol-
icies, as well as from (2) a similar survey from the
Massachusetts Action for Healthy Kids and the John C.
Stalker Institute for Food and Nutrition at Framingham
University (“Students Taking Charge”, http://www.ac-
tionforhealthykids.org/storage/documents/Students_Ta-
king_Charge/10_minute_student_survey_PDF.pdf). Most
changes included adapting questions to ensure that mid-
dle school students could understand the content. The
instrument included questions about school wellness
practices for nutrition (n= 13 questions), physical activ-
ity (n= 10 questions) and family/community involve-
ment (n= 6 questions). Schools’responses were entered
into a database and scored based on a four-point rubric;
a higher score indicated more wellness practices, or im-
provements in wellness practices, were in place.
Using these data as an initial needs assessment,
schools developed healthy eating and physical activity
action strategies to fit their school’s schedule and culture
from a menu of resources. FUTP60 provided these re-
sources to aid in implementation in a “Playbook”of
best-practice action strategies, ‘how-to’information for
building teams and engaging key audiences, evaluation
ideas, grant applications, and videos with NFL players
explaining the program and providing inspiring mes-
sages to students. All of these were available on the
FUTP60 website as well as in hard copy form.
Figure 1 illustrates the flow of the program’s imple-
mentation. Once the team had student input and action
plans developed, a kick-off event was held for the stu-
dent body. Schools could also determine if they would
participate in the National Challenge. The Challenge re-
quired students to earn points by tracking their own ac-
tions to improve diet and physical activities during the
previous day. Schools also determined the level of pro-
motion used to encourage students to take the wellness
pledge located on the FUTP60 website. Technical assist-
ance for adult stakeholders throughout the intervention
was delivered in person and via web-based training vid-
eos, e-newsletter with tips from educators, and phone
and email “help desk.”
An array of NFL merchandise to use incentives or re-
wards was provided to each school. These items in-
cluded footballs, t-shirts and jackets, signed small
helmets, among others. Schools used grant dollars to
purchase other prizes such as mini iPods, gift cards, and
movie tickets to incentivize participation. Communica-
tion and promotional tools with healthy eating and
activity messages included banners, posters, school sign-
age, flyers, template newsletter articles and P.A. an-
nouncements within the schools; ideas for kick-off
events; NFL player visits; and local challenges and con-
tests with prize opportunities. Local and national public
relations increased overall awareness of the program and
delivered health-related messages.
Measures
Student behaviors
Students in grades 6–9 at the 72 schools completed a
questionnaire adapted from the validated, self-
administered School Physical Activity and Nutrition
(SPAN) questionnaire [16] at pre-implementation/baseline
(September-October, 2009) and post-implementation/fol-
low-up (April-May, 2010). The student self-administered
survey included questions about demographics, foods
eaten the prior day, physical activity in and outside of
school, attitudes about school wellness and FUTP60 pro-
gram, and participation/awareness of the program.
SPAN questions have been used to assess dietary in-
take and physical activity behaviors in previous studies,
and items have been evaluated in racially/ethnically di-
verse, low-income populations [17–19], and have been
found to have acceptable validity and reliability [18–19].
Dietary assessment items asked about consumption of
the food on the previous day: “Yesterday, how many
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Content courtesy of Springer Nature, terms of use apply. Rights reserved.

times did you eat….”Categorical response options
ranged from none to 3 times. Questionnaire items about
breakfast and lunch habits asked if the student ate the
school breakfast or school lunch almost always/always,
sometimes, or almost never/never. Questions about
physical activity asked about on how many of the previ-
ous days (range of 0 to 7) that students had engaged in
that specific activity. Participation in sports teams at
school was assessed with an item that had response op-
tions ranging from 0 to 3 or more teams. Program
awareness was determined with a question that stated,
“Have you seen, read or heard about a program in your
school called Fuel Up to Play 60 designed to make your
school a healthier place by encouraging you to eat great-
tasting/good-for-you foods and get more physical activ-
ity?," with a yes/no answer response option.
No identifiers were used on questionnaires, and stu-
dents not in school on the day the survey was adminis-
tered were not included in data collection for that time
period. Each school’s program advisor was instructed
about and led the implementation of the student survey.
Most schools chose a portion of class time for students
to complete the questionnaire.
Process evaluation
Process evaluation measures were conducted throughout
the school year. Schools’plans and progress were
tracked and documented. Information collected included
what activities schools chose to help change nutrition
and physical activity and how schools’students were
involved as strategies were implemented. Evaluation
methods included coordinators’observations of events
and action strategies at schools; site visits by a member
of the national evaluation team, grant applications and
results reported by schools’program advisors, and quan-
titative surveys completed by school food service profes-
sionals (district and school), program advisors, and
Dairy Council coordinators.
Data analysis
Dietary and physical activity data were dichotomized
into variables that approximated U.S. Dietary Guidelines
recommendations and the Physical Activity Guidelines
for Americans, respectively. Thus, fruit consumption
was dichotomized into variables of consumption of three
or more times on the previous day versus 2 or fewer
times on the previous day. For physical activity, variables
were dichotomized into 60 minutes of physical activity
on 5–7 days of the past week or physical activity for
7 days of the past week. Breakfast and lunch consump-
tion were dichotomized into always or almost always eat
lunch/breakfast versus sometimes or never/almost never.
Mixed-effects logistic regressions, controlling for
school attended, gender, race and grade level, were used
to calculate odds ratios and confidence intervals to as-
sess changes between pre- and post-program, while ac-
counting for clustering at the school level. At follow-up,
mixed effects logistic regression models with the same
covariates were used to assess differences in nutrition
and physical activity behaviors between students who re-
ported being aware of the FUTP60 program versus those
who reported not being aware of the program. Students
were modeled as belonging to one of three ethnic
groups: Hispanic, African American, or white/other. The
other races, including Native Americans, Asians, and Pa-
cific Islanders, each represented less than 5 % of the
sample, and were combined into the white/other cat-
egory as a result. This method has been used previously
with SPAN survey analyses [20].
Results
Study sample
Seventy-two middle and K-8 schools encompassing
grades 6–9 from 11 school districts participated in the
FUTP60 implementation (Table 1). The study popula-
tion recruited represented a wide variety of schools:
small, medium and large enrollment sizes; rural, subur-
ban and urban locations; and diverse race/ethnicity and
socio-economic status. School enrollment ranged from
145 to 1,750. Most of the schools (n= 59, 82 %) were
middle schools, while 15 % (n= 11) were junior high
schools and 3 % (n= 2) were high schools.
Demographics of sample
The school populations included a significant proportion
of Hispanic/Latino and/or African-American students
(Table 2). In more than half of the schools, 60 % or more
of the students qualified for free or reduced-price school
meals (range for schools 25 to 87 %). The student popu-
lation was evenly divided between boys and girls, and
the grade distribution was fairly evenly split among
grades 6 to 9 with the least number of students coming
from the 9th grade (Table 2). There were no statistically
significant differences in the gender or racial/ethnic dis-
tributions of the students between baseline and follow-
up. As expected, the average age at post-intervention
was approximately 6 months higher than pre-
intervention.
Implementation of program components
Seventy-two schools fully implemented FUTP60 be-
tween October 2009 and the end of April 2010. The
most frequently chosen Playbook action strategies for
improving healthy eating included: increasing school
breakfast participation (36 % of schools, n= 26) and
taste-testing/selecting new foods (28 %, n= 20). To
improve physical activity, the majority of schools fo-
cused on new activities before and after school (44 %,
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n= 32) and daily walking clubs before, during, and
after school (44 %, n= 32). At pre-test, 61 % (18,823
of 30,992) of students were aware of FUTP60 pro-
gram activities, compared to 82 % (23,604 of 28,888)
at follow-up (OR = 2.745, P< 0.001). In most schools
(97%)atfollow-up,atleast50%ofstudentswere
aware of FUTP60 program activities, while in 68 % of
schools at least 80 % of students were aware of the
program.
Changes to students’eating and activity behaviors
Students’self-reported changes in eating and activity be-
haviors from baseline to follow-up are presented as odds
ratios with 95 % confidence intervals (Table 3). The
odds-ratios in Table 3 can be interpreted as the extent of
change in student behaviors post-intervention, relative
to baseline. Thus, for example, taken as a whole, stu-
dents were 1.27 times more likely to eat whole-grains 3
or more times per day, and 1.25 times more likely to
play on one or more sports team after the intervention
than before the intervention. Compared to baseline, stu-
dents were more likely to report consuming dairy, whole
grains, fruit or fruit juice and vegetables at follow-up.
More significant changes were found for boys compared
to girls, especially for milk and dairy products. The like-
lihood of dietary changes at follow-up compared to base-
line was similar among white and Hispanic/Latino
children in the schools, but African American students
showed fewer positive changes.
The likelihood of engaging in physical activity was sig-
nificantly higher among all students at follow-up relative
to baseline except among African American students,
who were no more or less likely to engage in physical ac-
tivity 60 minutes for each of the last 5 to 7 days. Girls
and white/other students were less likely to report al-
ways or almost always eating breakfast in spring com-
pared to fall; all groups were less likely to report always
or almost always eating school lunch at follow-up.
The likelihood of consuming milk, dairy foods, fruit or
fruit juices, vegetables, breakfast and school lunch was
significantly increased in students who reported being
Table 3 Dietary and physical activity behaviors in Fuel Up to Play 60 (FUTP60) schools at follow-up (spring 2010, n= 29,839) com-
pared to baseline (fall 2009, n= 32,482)
All Gender Race/Ethnicity
Male Female White/Other Hispanic/Latino African American
Milk ≥2 times/d
a
1.0
b
(.96–1.03)
c
1.05
b
(1.00–1.10)* .95
b
(.90–.99) .98
b
(.94–1.02) 1.01
b
(.95–1.07) 1.03
b
(.95–1.12)
Dairy ≥3 times/d
a
1.05 (1.02–1.09)* 1.08 (1.03–1.14)* 1.02 (0.97–1.07) 1.04 (1.00–1.09)* 1.08 (1.02–1.15)* 1.02 (0.94–1.10)
Whole Grains ≥3 times/d
a
1.27 (1.21–1.34)* 1.33 (1.25–1.43)* 1.19 (1.10–1.29)* 1.32 (1.23–1.41)* 1.20 (1.09–1.31)* 1.29 (1.15–1.45)*
Fruit or Fruit Juice ≥3 times/d
a
1.10 (1.06–1.14)* 1.10 (1.05–1.15)* 1.10 (1.05–1.15)* 1.13 (1.08–1.18)* 1.05 (0.99–1.12) 1.08 (1.00–1.17)*
Fruit ≥3 times/d
a
1.13 (1.08–1.19)* 1.10 (1.03–1.18)* 1.17 (1.09–1.25)* 1.15 (1.08–1.23)* 1.15 (1.05–1.26)* 1.05 (0.94–1.18)
Vegetables ≥2 times/d
a
1.10 (1.06–1.14)* 1.10 (1.05–1.16)* 1.09 (1.04–1.15)* 1.11(1.07–1.17)* 1.08 (1.01–1.16)* 1.06 (0.97–1.16)
Always or Almost Always Eat
Breakfast
0.96 (0.93–0.99) 1.02 (0.98–1.07) 0.90 (0.86–0.95)* 0.93 (0.89–0.97)* 1.01 (0.95–1.07) 1.01 (0.93–1.10)
Always or Almost Always Eat
School Lunch
0.85 (0.82–0.88)* 0.83 (0.79–0.87)* 0.86 (0.81–0.90)* 0.87 (0.83–0.92)* 0.78 (0.74–0.84)* 0.86 (0.79–0.94)*
PA
d
≥60 Minutes At Least 5 of 7
Last Days
1.13 (1.09–1.17)* 1.17 (1.11–1.22)* 1.09 (1.03–1.14)* 1.12 (1.07–1.17)* 1.18 (1.10–1.26)* 1.09 (1.00–1.19)
PA
d
≥60 Minutes Each of 7 Last Days 1.15 (1.10–1.20)* 1.16 (1.10–1.23)* 1.13 (1.05–1.22)* 1.17 (1.10–1.24)* 1.16 (1.06–1.28)* 1.05 (0.93–1.17)
Participated on ≥1 Sports Team
at School
1.25 (1.21–1.29)* 1.28 (1.23–1.35)* 1.21 (1.15–1.27)* 1.26 (1.20–1.32)* 1.21 (1.13–1.28)* 1.28 (1.18–1.39)*
a
Self-reported times student ate foods on previous day.
b
Referents (1.0) are data from baseline (fall 2009).
c
CI, confidence intervals. Confidence intervals that do
not overlap with 1.0 are statistically significant. Asterisks (*) indicate statistically significant likelihoods.
d
PA, physical activity
Table 2 Description of Fuel Up To Play 60 (FUTP60) student
population in fall 2009 and spring 2010 (n= 72 schools)
Student demographics Fall 2009
(n= 32,482)
Spring 2010
(n= 29,839)
Race and Ethnicity (%)
African-American 16.8 17.2
Hispanic 28.6 28.1
White / Other 54.7 54.7
Gender (%)
Female 50.4 50.0
Male 49.6 50.0
School Grade/Age
Mean age 12.33 (SD = 1.05) 12.90 (SD = 1.14)*
Grade Distribution (%)
Grade 6 29.5 31.4
Grade 7 34.1 34.6
Grade 8 31.5 30.4
Grade 9 5.0 3.7
*p< 0.05
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aware of FUTP60, compared to those who were not
aware of the program post implementation. Also,
students who were aware of the program were signifi-
cantly more likely to report engaging in physical activity
(Table 4).
Discussion
The FUTP60 study demonstrated that a low-intensity,
flexible approach to environmental changes in schools
can lead to small behavioral changes when the student
body is aware and engaged in program implementation.
Students reported positive changes for several food and
physical activity behaviors post-intervention compared
to pre-intervention, although the magnitude of the
changes was greater in students who reported familiarity
with FUTP60. Although the FUTP60 student-adult team
was essential to program implementation, the engage-
ment of the majority of students in the majority of
schools could be considered a key factor in eliciting be-
havior changes over a brief time period.
The social marketing elements highlighting the NFL
motivated girls’and boys’participation. All communica-
tions, messages, banners, and public relations highlighted
the NFL and tied in with NFL Play 60 advertising during
the American football season. Many of the schools had
players from the local NFL Club at a school event. Players
visits to school included pep rallies, celebrations at the
end of the program, and as a reward for meeting a school
goal. Players and students often engaged in physical activ-
ity during the event.
There is an excitement generated from professional
sports that can be influential in promoting health behaviors.
Studies have shown that professional sports players have in-
fluenced youth with regard to product choices and other
buying behaviors [21]. Fuel Up to Play 60 leveraged NFL
marketing and communications at a national level to com-
plement school-level communication to motivate students’
involvement and eating and activity behaviors at school. As
others have shown, professional sports players are powerful
messengers and, partnered with public health, can motivate
youth to make healthful choices [22].
When examined by racial/ethnic group, dietary intake
and physical activity changes were less likely to reach
significance in African American students. Some of the
foods that did not show significant changes from pre-
test to post-test included milk and dairy products, which
might be as a result of perceived lactose intolerance [23].
In terms of physical activity, our data show that African
American middle school students were at lower levels of
physical activity at baseline, so improvement might be
more difficult, especially with a less intensive interven-
tion. These levels of physical activity are in contrast to
our other work in Texas, which shows African American
middle school students with higher levels of physical ac-
tivity [24]. Further development work with FUTP60
should focus on addressing barriers to dietary intake or
physical activity, either perceived or through additional
changes in the school environment, especially focused
on strategies that are most effective in African American
children.
Breakfast participation was a focal point for improv-
ing nutrition practices at 36 % of pilot schools, al-
though increased school breakfast consumption was
not one of the stated behavioral goals of the FUTP60
intervention. Students who were aware of FUTP60
were more likely to report always or almost always
consuming breakfast post-implementation compared
to students who were not aware of the program. This
finding is in contrast to the overall post-intervention
finding that girls were less likely to always or almost
always eat breakfast. In general, data from U.S. school
breakfast programs show consumption of school
breakfast decreases throughout the school year [25],
so it may be that the increased messaging from
FUTP60 might need further testing among middle
school girls, or that the intervention was not robust
enough to overcome the decreases in school meal
consumption that are documented from the beginning
to the end of the school year in both school breakfast
and school lunch [25, 26]. Greater involvement of the
students in school food service activities and partner-
ship of students with cafeteria staff can potentially
lead to greater participation in both breakfast and
lunch consumption over time. In addition, incorporat-
ing more activities involving cafeteria staff in the
FUTP60 Playbook may be merited.
Table 4 Dietary and physical activity behaviors for students
“aware”of Fuel Up to Play 60 (FUTP60) compared to students
“not aware”at follow-up (2010)
a
Dietary and Activity behaviors Odds ratios (CI)
b
Milk ≥2 times/d
c
1.23 (1.18–1.28)*
d
Dairy ≥3 times/d
c
1.18 (1.14–1.23)*
Whole Grains ≥3 times/d
c
1.00 (.95–1.07)
Fruit or Fruit Juice ≥3 times/d
c
1.14 (1.09–1.18)*
Fruit ≥3 times/d
c
1.15 (1.09–1.22)*
Vegetables ≥2 times/d
c
1.23 (1.18–1.28)*
Always or Almost Always Eat Breakfast 1.34 (1.29–1.39)*
Always or Almost Always Eat School Lunch 1.10 (1.05–1.14)*
PA
e
≥60 Minutes At Least 5 of 7 Last Days 1.33 (1.28–1.39)*
PA
e
≥60 Minutes Each of 7 Last Days 1.21 (1.15–1.28)*
Participated on ≥1 Sports Team at School 1.14 (1.10–1.19)*
a
Self-reported times student ate fo ods on previous day.
b
CI, confidence intervals.
Confidence intervals that do not overlap with 1.0 are statistically significant.
Asterisks (*) indicate statistically significant likelihoods.
c
Self-reported times student
ate foods on previous day.
d
Referents (1.0) are students who repo rted not being
aware of Fuel Up to Play 60 in spring 2010.
e
PA, physical activity
Hoelscher et al. International Journal of Behavioral Nutrition and Physical Activity (2016) 13:59 Page 7 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

There are only a few published studies on student
participation as a strategy to improve the school
wellness environment. Those reviewed in comparison
with FUTP60 have differences in program attributes,
study design, measurement instruments and outcomes
[6, 7, 27]. School-based interventions conducted prior
to 2006 were mostly randomized controlled trials im-
plemented over several school years [28–30]. Out-
comes of these studies included changes in body fat,
weight and/or waist circumference, or school environ-
ment changes such as lower fat and sodium content
of school meals and optimized physical education
classes that lead to an increase in time that students
are vigorously active. The majority of these highly
controlled interventions had modest changes in out-
comes [28–30].AprogramlikeFUTP60maybea
good adjunct to these more intensive programs, re-
inforcing key messages through the school environ-
ment, and having students participate in school
changes.
Schools implemented FUTP60 to various degrees
contingent on contextual factors such as a district
administration commitment, time given to program
advisors, budget, and other priorities such as testing.
Therefore, FUTP60 was built to accommodate various
levels of intensity in its implementation. FUTP60 is a
lower intensity program than others that reported
similar results. For example, a small study using a
youth development approach to improve the school
nutrition environment and students’diet was con-
ducted in five schools over two school years [7]. The
study had two intervention and three control schools
with students in grades 4–6(n= 360). The interven-
tion included 12 nutrition education classes that in-
cluded a youth leadership component with 9 students
receiving additional leadership training and details on
making changes to the nutrition environment. Out-
comes included an increase of ½ serving of fruit in
intervention students compared to those in control
schools [7].
Another study used a community-participatory ap-
proach, along with student leadership, as a method
for changing students’behaviors relative to healthy
food consumption and amount and effort of physical
activity. The study was summarized as being
generalizable and easy to disseminate because of the
less rigorous approach and focus on capacity building
andtraining[27].Thestudyfoundsignificantchanges
in physical activity measures, yet no change took
place in fruit and vegetable consumption. The con-
cept of low-intensity programs being a better fit for
more schools is a priority result based on the study
authors’account [27], which is the fundamental idea
behind the approach used by FUTP60.
Limitations and strengths
Since this study assessed implementation of a community-
based program, the design limited the ability to in-
clude control schools or to randomize participation in
the program; however, stratifying data based on the
student self-awareness of FUTP60 provides initial data
on nutrition and physical activity behaviors among
students who were aware of, or at least minimally ex-
posed to, the intervention strategies and implementa-
tion. As with any cross sectional data, these findings
do not imply causality, and it could be that students
who are more interested in or already engaging in
more healthful behaviors are more likely to be aware
of a new health-related program.
In terms of program implementation, schools dif-
fered in context in many ways, such as administration
buy-in, type of school food service, space limitations,
time available from the adult program leaders and
additional resources added by the school to imple-
ment the program (staff, budget, district food and nu-
trition services) that were not measured. Replication
of this study with a more rigorous study design, such
as a cluster-controlled trial with schools randomized
to either intervention or comparison condition, is
warranted as a next step.
The diversity and number of schools added strength
to the findings and potential for generalizability. Lo-
cations of the schools included suburbs and large
urban cities with significant percentage of minority
students, different types of school food service opera-
tions and differences in administrative support. In
addition, student survey measures have been previ-
ously used and have demonstrated adequate validity
and reliability in diverse student populations.
Conclusions
Results from the FUTP60 intervention suggest that a
low-intensity program that engages students in the
implementation of wellness practices can be effective
in achieving modest behavior change in various
school settings with diverse student populations
(grades 6–9). FUTP60 might have a greater impact on
student behavior if implemented as an adjunct to, and
simultaneous with, more intensive nutrition and phys-
ical education programs. Alternately, a program such
as FUTP60 might be a good first step for schools or
school districts that seek to improve child health, but
are faced with multiple barriers that interfere with
more intensive programmatic efforts. Further research
is needed to understand, with a level of certainty, the
degree of effort needed by a school to achieve mean-
ingful changes in the environment and students’well-
ness practices.
Hoelscher et al. International Journal of Behavioral Nutrition and Physical Activity (2016) 13:59 Page 8 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Abbreviation
FUTP 60: fuel up to play 60.
Competing interests
Deanna M. Hoelscher, Raja Malkani and Elizabeth A. Vandewater disclosures:
funding by MMS Education. Alicia Moag-Stahlberg disclosures: Fuel Up to
Play 60 implementation and data evaluation conducted as a paid consultant
by National Dairy Council and/or MMS Education. Karen Ellis disclosures:
Principal of MMS Education in which National Dairy Council is a client. The
authors declare that they have no competing interests.
Authors’contributions
The authors listed have been involved with implementation, data collection,
data analysis and interpretation. DMH drafted and edited the manuscript
and provided guidance for the data analysis; EAV and RM were involved
with the data analysis, statistical interpretation of results, and editing the
manuscript. AMS & KE directed program implementation and evaluation, and
drafting of the manuscript. All authors read and approved the final
manuscript.
Acknowledgments
The National Dairy Council (NDC) and Fuel Up to Play 60 supported the
preparation of this article. Implementation of the intervention was funded by
the National Dairy Council and Fuel Up to Play 60, with the help of regional
dairy councils’school wellness experts and local NFL teams, as well as the
school, students and additional community partners. The NDC did not have a
role in data analysis, manuscript preparation or in the decision to submit the
manuscript for publication. The authors would like to thank the wonderful
students, administrators, teachers, school food service, physical education
teachers, school nurses, and parents from the 72 schools that participated in
the FUTP60 implementation and evaluation. The authors would also like to
thank Melissa Campos-Hernandez for editing and formatting of the manuscript.
Author details
1
University of Texas School of Public Health, Austin Regional Campus,
Michael & Susan Dell Center for Healthy Living, 1616 Guadalupe St., Suite
6.300, Austin, TX 78701, USA.
2
Ceres Connections, Ltd., 3818 Louise St.,
Skokie, IL 60076, USA.
3
MMS Education, 105 Terry Drive, Suite 105, Newtown,
PA 18940, USA.
Received: 1 August 2015 Accepted: 28 April 2016
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