Top Clin Nutr Vol. 25, No. 2, pp. 151–159 Copyright c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins APPROACHES TO AND Take Off 4-Health Nutrition Education Curriculum for a Healthy Lifestyle Camp for Overweight Youth

Carolyn Dunn, PhD; Kathryn M. Kolasa, PhD, RD, LDN; Nancy Harris, MS, RD, LDN; Yancey Crawford, MPH; Sarah Henes, MA, RD, LDN; Stephanie Kinner, BA; Virginia Sutton, MPH; Sarah Colby, PhD, RD, LDN; David N. Collier, PhD, MD

Evidence exists about the effectiveness of residential summer weight-loss camps for initiating or supporting small changes in . This report describes the development and eval- uation of a nutrition-education program for overweight adolescents attending a 3-week healthy lifestyle camp. Campers were given a prescription based on MyPyramid and then self-selected their meals and snacks in a family-style service format. The curriculum included eating strategies known to contribute to healthy weights in youth. Campers demonstrated an improved ability to estimate portion sizes. Thirty-four campers completed the 3-week experience with a considered to be safe. Key words: 4 H camp, nutrition-education curriculum, overweight youth

ESIDENTIAL weight-loss and fitness healthy-food selections, nutrition education, Rcamps are popular in the United weight-loss tips, self-esteem building, and States.1,2 They typically feature , recreational activities. In the short-term, resi- dential weight-loss programs, especially those that restrict calories, appear effective across a range of health indicators.2–4 Unfortunately, Author Affiliations: Department of 4H Youth Development and Family & Consumer Sciences, NC there are no reports of long-term successes Cooperative Extension, NC State University, Raleigh in treating childhood obesity through big (Dr Dunn), Pediatric Healthy Weight Research and changes in diet and physical activity. This Treatment Center at East Carolina University (Drs Kolasa and Collier and Mss Crawford and Henes) article describes the nutrition-education and Departments of Nutrition and Dietetics (Mss Harris and Kinner and Dr Colby), Pediatrics (Ms Henes), Public Health (Ms Sutton), East Carolina University, Greenville, North Carolina. The authors thank the leadership of the TO4H advisory Conflict of Interest Disclosure: Kathryn Kolasa, PhD, team members from both North Carolina State Univer- RD, LDN has a potential conflict of interest disclosure. sity and East Carolina University, especially the teach- None of the other authors do so. ing and evaluation provided by Family and Consumer Kathy Kolasa is a member of the Nutrition Advisory Science agents Amanda McDanel and Dee Furlough, Panel for Burger King’s Positive Steps Program. Since and the assistance of the foodservice staff of the East- 2008, ten nutrition experts have served to advise Burger ern 4-H Center, especially Becky Ingalls. We appreciate King on their corporate, ongoing efforts to promote bal- the support of Kathy Cable, Health Sciences librarian at anced diets and active lifestyle choices. the Laupus Library, East Carolina University and the re- view of the manuscript by Dr Carolyn Lackey, Professor Corresponding Author: Kathryn M. Kolasa, PhD, RD, Emeritus, North Carolina State University. LDN, Pediatric Healthy Weight Research and Treatment Center at East Carolina University, 4N70 Brody Medi- Scholarships for campers were provided by the Pitt cal Sciences Bldg, 600 Moye Blvd, Greenville, NC 27834 Memorial Hospital Foundation. ([email protected]). 151 152 TOPICS IN CLINICAL NUTRITION/APRIL–JUNE 2010 curriculum designed for Take Off 4-Health Table 1. Camper demographics, N = 34 (TO4H), a healthy-lifestyle camp for over- weight youth. We have adopted the small- No. % change approach,5 immersing overweight adolescents in an environment that allows Agea,y them to learn how to make small changes in 12–15 27 79 their energy intake and increase their physical 16–18 7 21 activity. Lessons learned from implementing Race the nutrition curriculum may benefit other Black 24 70 healthcare professionals as they develop White 10 30 Gender summer camp programs. Female 26 76 Male 8 24 PROCEDURES

aMean age = 14.1 y. The camp The TO4H was a 3-week residential camp olina University and Medical Center Institu- experience for overweight youth. At camp, tional Review Board. At the beginning of youth initiated weight loss, built self-esteem, camp, anthropometric data (height, weight, and learned multiple strategies for leading a and waist circumference) and assessments healthy lifestyle. The rationale and descrip- of quality of life, depression, health behav- tion of a similar, earlier effort from this group iors, and were collected from to provide this type of camp are reported the campers. Parents also completed the as- 6 elsewhere. The TO4H was a collaborative ef- sessments (results reported elsewhere).8 The fort of the Pediatric Healthy Weight Research mean baseline was 41.9. and Treatment Center at East Carolina Univer- sity’s Brody School of Medicine, the staff of Nutrition curriculum the Eastern 4-H center, a rural 4-H camp facil- Six hours were allocated by the camp’s ity, and Family & Consumer Sciences agents medical director for nutrition-education with the North Carolina Cooperative Exten- classes. An additional hour was used to sion. The camp was priced about $1000 less explain the individualized diet prescription than other weight-loss camps described and on the basis of MyPyramid.9 The objective 7 advertised on the Web. The daily schedule in- was to provide the knowledge and skills that cluded physical activities, nutrition-education campers would need to achieve a healthy classes, cognitive behavior therapy, and tra- weight when they returned home. ditional camp activities. Rather than plated, For curriculum development a literature calorie-controlled meals typically found in review was conducted, exploring relevant weight-loss camps, TO4H followed the 4-H Web sites and professional listservs for camp- camp tradition of providing family-style meals. related menus and curricula and reviewing the 4-H camp’s menu. The theory of planned Participants behavior change guided the curriculum devel- Conducted in 2008, camp participants in- opment. Nutrition-education lessons focused cluded 26 girls and 8 boys, aged 12 to 18 on food choices that participants would prac- years (Table 1). Most of the participants (70%) tice while at camp and continue upon their re- were African American and economically dis- turn home. The camp’s menus reflected foods advantaged. If Medicaid eligible, they quali- found in school meal programs and at home fied for scholarships provided by a local hos- with familiar items from the grocery store. pital’s foundation. Institutional review board The nutrition-education curriculum included approval was obtained from the East Car- a modified camp menu, “camper meal cards” Take Off 4-Health 153 with a 1-hour introduction to the use of the ular “Rethink Your Drink” graphic from the card and portion size education, six 1-hour in- ESMM-WL was changed to reflect the tim- teractive nutrition classes, counselor training, ing and beverages consumed by teenagers and a family take-home packet. (Fig 2). The interactive lessons matched the key messages and included a Power- Menu and meal camper cards Point presentation, instructor guide, handout The camp’s standard menu was modified and hands-on activities. The materials (avail- by the researchers in cooperation with the able at http://www.takeoff4health.org) were camp’s food service manager while ensuring branded as TO4H with the logos of the part- that the nutrient needs of growing adoles- nering groups. cents were met. The 2005 Dietary Guidelines One author reviewed the menus and pro- for Americans10 were followed. Meals were vided technical assistance so that the food- low in fat and sugar and whole grains and service staff could provide the appropriate- fiber were adequately supplied. Some of the sized portions of food and ensure that the changes made to the menu were adding a daily Dietary Guidelines10 were followed. Camp salad bar and fresh fruits, specifying the size of counselors and campers received training on meat portions, using skinless poultry, and low use of camper meal cards. Camp counselors fat and sugar food preparation techniques. also received a 2-hour overview on childhood Modifications were made within the camp’s obesity that included a review of evidence- budgetary constraints and no “diet” or spe- based physical activity and nutrition and be- cialty products were included. Two small daily havioral strategies for the prevention and snacks were served in addition to 3 meals. treatment of childhood obesity from a physi- Each camper received a personalized nutri- cian and a registered dietitian. A registered tion prescription, presented as a camper meal dietitian prepared the personal dietary pre- card (Fig 1) to guide food choices and portion scription and instructed the campers on its sizes at meal and snack times. To promote a use. The lessons were delivered by Family safe weight loss while at camp, the MyPyra- and Consumer Sciences agents, previously mid calorie levels9 for age and gender were trained in providing weight-management pro- chosen at the sedentary level of activity. The gramming, and a dietitian who works exclu- daily amount of food from each food group sively with overweight youth. was based on the MyPyramid food intake pat- Formative evaluation of the entire terns for each calorie level.9 A family take- nutrition-education curriculum described home packet was given to campers. Each fam- above was completed by professionals in- ily received a magnet with healthy living tips, volved in TO4H through interviews (VS), tear-off shopping lists, an Eat Smart Move written reports, and conference-call dis- More Weigh Less (ESMM-WL) magazine, an in- cussions, and at a postcamp debriefing teractive CD to aid teens making healthy food meeting. The effectiveness of the portion-size choices, a meal-planning white board, and a education was assessed through pre- and scale to monitor weight. postsurveys. Nutrition education Portion-size estimation The nutrition content (Table 2) was se- Prior to any education on the camper meal lected based on eating strategies recog- cards or portion sizes, campers completed nized as contributing to healthy weights a portion estimation assessment (PEA) sur- in youth.11 The researchers adapted com- vey. In this assessment, which has been used ponents from 2 existing programs: ESMM- in other settings with youth populations,14 WL12 and Expanded Food and Nutrition Ed- campers were shown a series of 10 NASCO ucation Curriculum’s Families Eating Smart (Fort Atkinson, Wisconsin) food models: 2 and Moving More.13 For example, the pop- starches (bread and popcorn), 2 vegetables 154 TOPICS IN CLINICAL NUTRITION/APRIL–JUNE 2010

Figure 1. Camper meal card.

(collards and carrots), 2 fruits (apple sauce the amount of food (ounces or cups) the and fruit juice), 2 dairy products (milk and model represented. Following the PEA sur- cheese), and 2 meats (pork chop and roast vey, a 1-hour class was conducted that in- beef). Each camper held and inspected each cluded a demonstration of the use of the meal food model and then estimated in writing card to guide choices, as well as the rationale Take Off 4-Health 155 for each individual’s caloric prescription and mission is to empower youth to reach their the distribution of calories into servings from full potential, working and learning in part- food groups. Each food group was discussed nership with caring adults. While traditional including food choices, portion sizes, and camps focus on the outdoor experience, the healthier choices within each food group. 4-H pledge and its clover insignia denote 4- Campers were taught to use their hand as a H’s goal as the 4-fold development of youth: visual reference to estimate portion sizes and Head, Heart, Hands, and Health. This 4-H resi- were provided guided examples. At the con- dential camp program accommodated a multi- clusion of the class, and again at the end of component program, including nutrition edu- camp, 29 of the campers repeated the PEA. cation, to help youth achieve healthy weights. All foods listed on the PEA survey were served Positive features of the nutrition-education during the 3 weeks of camp with the excep- curriculum as well as areas for improve- tion of collards. ment were identified through the formative For each time-point (pre-, post-, and follow- evaluation. up) campers estimated portion size for each The camp provided sufficient nutrition ed- food item on the survey. Their estimates were ucation in a “real-life” environment for most subtracted from the actual portion size of the campers to lose weight at a safe rate. Six food item to determine error in estimation. hours of nutrition education were success- Differences for all items were put into abso- fully incorporated into the camp day. The nu- lute values (level of error from 100% accu- trition content for campers was appropriate racy) and summed to provide a predifference for this age group. Although we did not objec- score, postdifference score, and follow-up dif- tively evaluate the entire nutrition-education ference score. Paired t tests were used to an- curriculum, we did test the campers’ abil- alyze for statistical differences between mean ity to estimate portion sizes. Their ability scores for each time-point. to do so significantly improved from pre- to post-assessments (t [28] = 3.29, P < .05) and pre- to final assessments (t [28] = 2.86, FINDINGS AND DISCUSSION P < .05) (Fig 3). However, no significant differ- ences were found between post- and final as- All except 2 campers lost weight; which av- sessments, indicating that portion-estimation eraged 2 lb a week (an average of 6.7 lb to- training was effective and changes in ability tal weight loss over the 3 weeks or 2.5% of were retained. Although campers did improve their initial weight), with a decline of greater their ability to recognize appropriate portion than 1 body mass index unit and greater than sizes, campers might benefit from additional 2 in in reduced waist circumference.8 This 2 to 5 minute nutrition tips regarding the por- weight loss is similar to that reported by tion sizes specific to each meal or snack deliv- Gately et al2 who provided moderate calorie- ered at the time of food selection. restricted meals. About half of the campers received case management services in their Camp menus and family-style service home community and have not experienced The standard camp menus and recipes weight rebound.8 were modified to improve the nutrient value The role of a summer residential camp and energy density of the meals and did not as a strategy to initiate treatment for over- require the purchase of specialty food items. weight and obese children is of interest to The healthfulness of the camp menu could parents and professionals. In this case, the 4- be strengthened even more if the menus met H summer camp program was a good part- the criteria outlined in the Eat Smart: North ner for a not-for-profit weight-loss camp that Carolina’s Recommended Standards for All adopts the “small-change” approach. The 4-H Foods Available in School.15 156 TOPICS IN CLINICAL NUTRITION/APRIL–JUNE 2010

Table 2. Nutrition content of Take Off 4-Health curriculum

Key messages Key skills Hands-on activity

Lesson 1: Camper Cards Explanation of personalized Illustrated portion sizes with calorie target and NASCO food models appropriate servings per food group Lesson 2: Right-Size Your Portions Demonstrations of hand to Participated in a “mindful” Portion sizes have increased over estimate portion sizes and eating exercise and activity the years strategies to right-size with stoplight foods to Large portions can lead to more portions “budget”what they eat calories than needed Used stoplight method (rarely, Portion control is key to a healthy sometimes, anytime) to weight teach variety and moderation Food selection needs to be mindful Lesson 3: Rethink Your Drink Strategies to choose Analyzed labels of common Calorie beverages can: calorie-free or lower-calorie drinks Contribute calories to overall beverages Made drinks from fruit juice diet but may not provide satiety Beverage clocks illustrated and seltzer Be replaced with calorie-free how to substitute calorie-free drinks beverages (Fig 2) Lesson 4: Enjoy More Fruits & Strategies to make fruits and Analyzed food labels with Veggies vegetables more available for “fruit”in the name and Fruit and vegetables are naturally meals/snacks asked to “find the fruit” low in calories and fat Snack clocks illustrated how to Taste tests They are KEY to weight loss/ make healthier snack choices maintenance during the day They make great snacks and meals Lesson 5: Eat Smart When You Eat Strategies to eat more meals at Used an interactive CD to Out home choose from fast-food Eating out can increase weight Strategies to choose healthier restaurants. A tote board because of serving size and options when eating out indicated nutrients for the food preparation including smaller portions foods chosen Might not be as healthy as meals at home Choose healthy options when eating out Lesson 6: Reading Food Labels Taught to use Nutrition Facts Used information on the Food labels are useful to compare panel to compare foods and package label to make the foods and identify foods lower use ingredient list to see food healthier choice when in fat and calories contents given snack and beverage They can help control portions Defined common label terms choices

Campers used, although not consistently, priate manners when passing plates of food their personalized camper meal cards. Some to others. Campers might also benefit from a youth, unfamiliar with family-style food ser- formal session on the etiquette of family-style vice, needed additional coaching about appro- meal service. Counselors appreciated their Take Off 4-Health 157

Figure 2. Rethink your drink. training but needed additional training to as- selors’, and food service staff’s ability to make sist campers in the consistent use of their and guide healthy food and beverage choices meal cards. Food service staff requested more at meal and snack times. training to better understand recipe modifica- Staff and campers recommended additional tions, portion sizes, and their role in helping interaction, such as more “real-world” oppor- campers select healthy meals and beverages. tunities, to practice newly learned skills; to It was suggested that it may be important to role play or develop skits about food; and to find a way that is easy and fun to monitor incorporate popular media such as videos and an individual’s food intake. The presence of a “You Tube” clips. The North Carolina Fam- full-time dietetic professional at camp was rec- ily and Consumer Sciences agents who par- ommended to enhance the campers’, coun- ticipated were familiar with the adult weight 158 TOPICS IN CLINICAL NUTRITION/APRIL–JUNE 2010

camper meal cards and teach campers how to use them. This curriculum could be used by others developing healthy lifestyle camps for overweight adolescents.

CONCLUSIONS

The nutrition education curriculum, devel- Figure 3. Decreasing error in overall portion esti- oped for TO4H camp, was incorporated in mations observed at pre-, post-, and follow-up as- the camp day and had several positive as- sessments. Differences between pre- to post- and pects. The nutrition curriculum appeared to pre- to follow-up were observed (P <.05). No dif- be unique to weight-loss camps in that it pro- ferences were observed between post- and follow- vided a “real-world” and “small-change” ap- up assessments. proach to healthy eating and nutrition educa- tion. Campers not only lost weight at a safe management12 and the Expanded Food and and realistic rate, but were also able to take Nutrition Education program’s curriculum13 home and try the strategies at home after and were confident in their teaching. Their the camp experience. Areas for improvement availability in the rural area made them an were noted to make the curriculum more en- especially valuable resource. The agents be- gaging and relevant to campers and other ado- lieve a registered dietitian should prepare the lescent learners.

REFERENCES

1. Wellberry C. Weight loss camps and their effect on 2008/08/16/business/16camp.html?ex=13766256 childhood obesity. Am Fam Physician. 2006;73:139– 00&en=404c7fc6aleb0817&ei=5124&exprod= 140. permalink. Accessed August 17, 2008. 2. Gately PJ, Cooke CB, Batty JH, Bewick BM, Radley 8. Collier DN, Crawford Y. “Take Off 4-Health”Residen- D, Hill AJ. Children’s residential weight-loss programs tial Summer Camp and Follow up for High Risk can work: a prospective cohort study of short term Youth. July 1, 2009–January 30, 2009. Unpublished outcomes for overweight and obese children. Pedi- report to the Pitt Memorial Hospital Foundation from atrics. 2005;116:73–77. the ECU Pediatric Healthy Weight Research and Treat- 3. Spain VK, Bialeschki MD, Henderson KA . Kids and ment Center, Greenville, North Carolina. healthy lifestyle: how camps can help. Camping 9. US Department of Agriculture. MyPyramid tracker Mag. 2005;78(5):26–33. and planner. Food intake pattern calorie levels. 4. Cooper C, Sarvey S, Collier D, et al. For compari- http://www.mypyramid.gov/downloads/MyPyramid son: experience with a children’s obesity camp. Surg CalorieLevels.pdf. Published 2009. Accessed July 31, Obes Relat Dis. 2006;2:622–626. 2009. 5. Hill JO. Can a small-changes approach help address 10. US Department of Health and Human Services and the obesity epidemic? A report of the Joint Task Force US Department of Agriculture. Dietary Guidelines of the American Society for Nutrition, Institute of for Americans, 2005. 6th ed. Washington, DC: US Food Technologists, and International Food Informa- Government Printing Office; 2005. tion Council. Am J Clin Nutr. 2009;89:1–8. 11. Spear BA, Barlow SE, Ervin C, et al. Recommendation 6. Pratt KJ, Lamson AL, Collier DN, et al. Camp for treatment of child and adolescent overweight and golden treasures: a multidisciplinary residential sum- obesity. Pediatrics. 2007;120:S254–S288. mer camp promoting weight-loss and a healthy 12. Dunn C, Kolasa K, Vodicka S, et al. Eat smart, lifestyle for adolescent girls. Fam Syst Health. move more, weigh less: a pro- 2009;21(1):116–124. gram for adults. J Extension. 2010;48(1): Tools 7. Saul S. Priced out of . New York of the Trade/1TOT1 http://www.joe.org/joe/2010 Times. August 16, 2008. http://www.nytimes.com/ february/tt1.php. Accessed March 24, 2010. Take Off 4-Health 159

13. Dunn C, Andersen K, Thaxton S, et al. Families Eat- 15. Eat Smart, Move More North Carolina. Eat smart: ing Smart and Moving More. Raleigh, NC: NC Coop- North Carolina’s recommended standards for all erative Extension Service, NC State University ; 2005. foods available in school. http://www.eatsmart 14. Colby SE, Johnson L, Cutrell SB, Haldeman LA. Por- movemorenc.com/EatSmartSchoolStds/EatSmart tion size estimation among newly arrived Latino im- SchoolStds.html. Published 2004. Accessed October migrants. Top Clin Nutr. 2009;24(2):139–144. 5, 2008.