Translating evidence based violence and drug use prevention to obesity prevention: development and construction of the Pathways program

Abstract

Effective school-based obesity prevention programs are needed to prevent and reduce the growing obesity risk among youth. Utilizing the evidence-rich areas of violence and substance use prevention, translation science may provide an efficient means for developing curricula across multiple health behaviors. This paper introduces Pathways to Health, a school-based obesity prevention program that was developed by translating from evidence-based violence and drug use prevention programs, Promoting Alternative THinking Strategies and the Midwestern Prevention Project STAR (STAR). We illustrate how a hypothesized underlying behavior change mechanism in two domains of risk behavior, violence and substance use, can be applied to obesity prevention. A 4-step translational process is provided and may be relevant for use in developing other curricula to address multiple health risk behaviors. Practical application 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 prevention 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 (Pathways) study was to utilize existing evidence-based programs and translate the scientific rigor and theoretical constructs to other health behaviors in children, specifically those with application to obesity prevention. 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. Furthermore, there is a large body of implementation research to build upon within those fields to help design a maximally effective school-based program. Building upon the successes of these evidence-based programs would potentially allow for efficiency in the design of new programs targeting different health behavior outcomes.

Pathways began with a hypothesis that dysregulated behavior could be an underlying mechanism contributing to the obesity epidemic. Inhibitory control, emotional control, planning and organization and working memory are skills subsumed under the term executive cognitive function (ECF) and are necessary for regulating behaviors and decision making in order to achieve goals [9, 10]. Prior research suggests that self-regulation and decision making as it relates to food consumption and physical (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 specifically, individual ECF sub-skills may be associated 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 manage 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 consumption 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 children 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 palatability 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 sidewalks and neighborhoods). Furthermore, for some children, sedentary behaviors such as watching television 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 dysregulation 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 emotion 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 prevention. 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 underlying risk factors that arise from poor social and emotional competence. PATHS was based on the principles of emotion theory [42, 43] but more specifically the Affective–Behavioral–Cognitive–Dynamic (ABCD) model of development [4, 39]. The ABCD model places primary importance on the developmental integration of affect, behavior, cognition and emotion language.

Pathways also identified STAR, a nationally recognized 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 interactive homework activities with parents who complement in-school program skills training [46]. In addition, the STAR parent component that involved homework activities (e.g. rule-setting for health behavior, encouragement of family-based activities) and parental skills training (i.e. parent–child communication 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, situational and environmental factors interact to influence 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 designing 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 activities from information provided in the literature and takes it through formative evaluations and formal randomized controlled trials [47]. Pathways followed 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 translation model consists of (i) conceptual mapping, (ii) model building and refinement, (iii) pilot studies and (iv) efficacy study (see Fig. 1).

Fig. 1.

Translation and development process.

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 candidate programs, the third phase of conceptual mapping was to deconstruct the programs and map the theoretical concepts together to view any overlapping constructs between the two programs and search the literature for the new obesity-related target risk factors (see Table I).

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.

Understanding the underlying theoretical foundation 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 prevention curriculum was needed in order to address and test the proposed hypotheses. Thus, a literature review was done in the following areas: PATHS and STAR outcomes, mediation analyses and theories; Emotional intelligence, social and emotional competence, neurocognitive circuitry of emotional/social 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 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 interviews, focus groups and class assessments with teachers, parents and students. Results from formative evaluations conducted during this step helped to refine the activities, define target mediators more precisely and direct development of the overall curriculum. Step 2 also includes assessment of the original programs for programing logistics such as delivery structure, sequencing, age-appropriate content 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 identifying core components from the PATHS curriculum and modifying to target attitudes toward food intake and physical activity for fifth graders. Five representative lessons focusing on self-control, emotional 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 situations 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 teachers and students drove the second iteration of the activity development and a second phase and formative evaluation was completed (See Table II).

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

The Pathways study needed a structured curriculum 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 specialists 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 provided to teachers on delivering the content. Most conveyed the need for the lessons to be set as a module 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 minimum of 20–30 min per day for a total of 131 lessons. Grade-specific lessons were also developed for Grades 3–5 that focused on developmentally appropriate interpersonal cognitive problem-solving skills. The Grade 3 curriculum was chosen to be the foundation for the Pathways program in order to capitalize 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). Lessons 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 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 programing (see Fig. 2). Additional ideas and optional activities 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 structured so students had clear expectations of learning objectives and included a standard order from introduction, through several activities/discussions, and a closing to provide consistency for ease of learning by students and delivery by teachers.

Fig. 2.

Structure of Pathways curriculum. Note: This figure is just an example and does not map the full curriculum. Sessions are 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 specific construct or learning objective.

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 consultation from the PATHS developer, increased classroom activity level and included more dynamic and visual teaching modalities. For example, in PATHS, students are asked ‘why is it important to pay attention?’ 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 dedicated 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 dysregulated eating behaviors (e.g. angry, bored, guilty, happy, humiliated, rejected, satisfied, tired, uncomfortable, 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 subset 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 unintended consequences occurred that would negatively 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 focused 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 conducted with teachers, parents and students at the conclusion of the pilot study. Observers in the classroom 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 sequences 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 introducing 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 emotional 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 consequences of their actions. A specific example from Pathways asks students how they feel and the problems they may face in a vignette describing a thanksgiving 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. Another 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 children 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, including higher order or complex emotions such as jealousy, 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 speculate 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 environment 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 activity. However, developmentally, students in the Pathways 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 understand 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 inclusive; 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 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 intervene 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 regarding their food choices.

The sugar camp focuses on the unhealthy consumption 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 eating 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 campaign by the Centers for Disease Control and Prevention. 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 consumption of low-nutrient foods. An extension of this philosophy is to have students seek foods that contain 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 activity) were salient enough for students to recall them and change their behaviors. Variation 2 emphasized the sugar camp philosophy while Variation 3 emphasized 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 activities 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 variant 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 ingredient 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 understand 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/decreasing 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.

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
	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; OPT ACT, Optional Activity.

Step 4: efficacy study

The goal of the development work done here to translate evidence-based violence and drug use prevention programs for application to obesity prevention was to prepare a curriculum for a school-based 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 result in the ultimate outcome of differences in overweight 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 sessions 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 challenges. 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. Pathways also had to face two-school closings due to the budget shortfall and again recruitment for new partners had to occur. We were able to face these challenges with the help of a high-level champion. In most cases, we had buy-in from a supporting school superintendant. Meetings with school principals and teachers 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 research study was that Pathways was based on established 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 implemented 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 environmental 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 environments. 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 targeting just one level [55–57]. The Pathways project aimed to strengthen the individual level by intervening with children and developing their ECF and improving their healthy decision making within contexts that are challenging (e.g. a home with limited fresh fruit and vegetables to snack on after school, neighborhoods that are dense with high fast food establishments). 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 developments of school-based obesity prevention programing 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 or political environment within the school district, may show short-term successes in behavioral outcomes 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 development process. These contributors were valuable in allowing the program to mitigate and address potential barriers. The design of the Pathways program also utilized teachers as the implementers of the program, 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 components, 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 concentrate. 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 administrators 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 researchers and curriculum developers are encouraged to design 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. Translation 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 organize the translational process and described some of the practical applications, challenges and decisions we have faced in developing Pathways. These steps are intended to guide other researchers who may choose an interdisciplinary route in developing their school-based curriculum and take advantage of fieldwork in other areas. The Pathways prevention trial is underway and future analyses will be able to shed light on the applicability of translation to a new health outcome but also on multiple outcomes. The current Pathways program, 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 translation between these health behaviors was appropriate. Future directions should include whether a true universal program that targets multiple behaviors (e.g. violence, drug use and obesity prevention) 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, voluntary 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, universal health promotion program targeting multiple health outcomes may be necessary for school-based programs in our future.

Funding

National Institute of Child Health and Human Development; National Institute of Drug Abuse at the National Institutes of Health (grant number R01-HD052107).

Conflict of interest statement

None declared.