CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
CONSTRUCTION AND IMPLEMENTATION OF
A WEIGHT CONTROL
PROG~~
FOR
ELEMENTARY SCHOOL CHILDREN
A Graduate Project Submitted in Partial Satisfaction
of the Requirements for the Degree of
Master of Science in
Health Science, School Health
by
Maureen O'Connell Howard
June, 1979
The Graduate Project of Maureen O'Connell Howard 1s
approved:
Helen L. Brajkovich( P.H.N. 1 M.S.
Mary C. l?ccirker 1 R.N. 1 M. S.
~
...---..
G. B. Krishnamurty, Dr.P.H.
Chairman
California State University, Northridge
ii
ACKNOWLEDGEMENTS
The author wishes to express her appreciation
to the people who contributed their time and expertise
in assisting with this project.
Acknowledgement is given
to the students in this project for their enthusiasm and
continued presence at the meetings.
A special acknowl-
edgement is made to the Committee Chairman, Dr. G. B.
Krishnamurty, for his suggestions and reassurances.
To Helen Brajkovich and Mary Parker, the
'·
~
Committee Members, my gratitude is offered for their
support.
iii
TABLE OF CONTENTS
Chapter
I.
Page
INTRODUCTION • .
1
Statement of the Problem .
3
Limitations of the Study .
3
Scope of the Study •
4
Resources Used .
4
. •
Definition of Terms
II.
5
REVIEW OF LITERATURE
6
Introduction
6
Physical and Genetic Aspects of
Obesity . • . • • • •
6
Physical Problems
7
Genetic Approach .
.
Psychological Aspects of Obesity
III.
8
9
Treatment of Obesity . •
12
Treatment of Children
13
Food Eating Practices of Young
Persons • . • • • . • •
14
Role of Physical Activity
14
PROCEDURES AND METHODS .
Introduction .
• •
16
16
Selection of Students Involved in
This Study
. • . . . . • .
16
Treatment Group
17
Control Group
17
iv
Page
Chapter
....
Parental Permission
17
School Setting
• 18
Administrative Arrangements
Resources Utilized .
• . • • 18
. . . •
Description of the Intervention
19
.
. 19
Educational Sessions .
. 19
Height and Weight
. 19
Nutrition Education
• 19
Food Diaries . • • .
. 20
On-the-Spot Checks .
20
Physical Activity
• • • • 20
Record of Activity .
.
Reinforcement of Concepts
• • 21
• 21
Test Instrument for Research Design
IV.
DISCUSSION OF THE DATA .
22
• 23
32
Nutrition Education
Mean Post Test Scores on Nutrition
Education • • . . . • • • • • • • • • 32
v.
SUMMARY, FINDINGS, CONCLUSIONS, AND
RECOMMENDATIONS . • .
• 39
Introduction .
Findings .
• 39
. .
• • 40
Major Findings of the Study
. . • . 40
• 40
Summary
Purpose of the Study •
Null Hypothesis
v
•
0
40
. 41
Chapter
Page
Approach Used to Test Null
Hyp.othesis . • . • • • • .
. • 41
Study Population
• • 41
Method • • .
. 42
Conclusions
. 42
Recommendations for Further Research .
• 43
BIBLIOGRAPHY
45
APPENDICES
• 51
vi
.LIST OF TABLES
Page
Table
I
II
III
IV
v
VI
VII.
Table of Total Group Initial Mean
Weights and t Scores . . . . • .
25
Initial and Final Excess Weight for
Treatment and Control Group
. . .
26
Initial and Final Percent Overweight
for Treatment and Control Group
. .
• .
•
28
Original and Final Excess Weights
31
Total Group Final Mean Scores on
Nutritional Knowledge . . . .
33
Responses to Post Test for Nutritional
Knowledge of the Treatment Group . .
36
Responses to Post Test for Nutritional
Knowledge of Control Group . • . . .
38
vii
ABSTRACT
CONSTRUCTION AND IMPLEMENTATION OF
A WEIGHT CONTROL PROGRAM FOR
ELEMENTARY SCHOOL CHILDREN
by
Maureen O'Connell Howard
Master of Science in Health Science
A program was constructed and implemented for the
purpose of weight control for a group of twenty-three
elementary school age children by means of educational
sessions on the Basic Food Groups, bimonthly weigh-ins·,
and review of nutritional practices.
Success in this study was defined as losing five
or more pounds or maintaining the present weight.
At the
end of the s-tudy of eighteen months, only one studen-t
neither gained nor lost five pounds.
Nutrition knowledge was significantly increased
among the treat.ment group without any observable changes
in attitudes and behavior.
viii
A conclusion derived from the study was to
concentrate further efforts on those students with relatively low excess weights since the effects were the
greatest for this group.
ix
Chapt.er I
INTRODUCTION
Obesity has been a problem for many people since
the beginning of time but society's attitudes have changed/
in the last twenty-five or thirty years.
In the 1940's,
the obese in society (those who were more than 20 percent
over the average for their body build, height, and weight)
were ignored for the most part.
During the 1950's, there
was an obsession regarding thinriess.
Thbse who did not
comply were openly ridiculed or scorned (Bray, 1976).
Until 1951, obesity was clinically thought to be a
neurosis (Collipp, 1975).
used to treat obesity.
Psychotherapy was the modality
As early as 1948, Bruch indicated
that the emotional problems had to be considered in conjunction with any diagnosed neurosis.
Americans tended to
view obesity as a "deviant form of physical disability"
{Kiell, 1973, p. 305).
Stunkard, in 1976, stated that
physicians considered the obese "frustrating, boring and
irritating."
Attitudes today have reflected the unchanging
views (held by many) that will power was all that was
needed to combat obesity.
The obese continued to think
that they were undesirable and repulsive (Collipp, 1975).
Bruch considered this continued emphasis on thinness toi
1
2
be an obsession and the "Western attit.ude towards obesity
damaging to mental health" as well as "a distortion of the
social body concept"
(1973, p. 88).
She further stated
that all classes were susceptible to this vulnerability
because of "extreme dependence on societal opinion and
judgment; this vulnerability is related to an underlying
emotional and personality problem" (Bray, 1973, p. 112).
The stigma of obesity has affected all ages but
has been especially damaging to young persons./ Bruch, in
1973, did an extensive study of obese children and determined that they:
(1}
were socially immature;
protected by their mothers;
and (4) physically inactive.
(2) over-
(3) isolated from their peers;
Other adjectives used to
describe the obese child were sad, shy, fearful, and
passive.
Previous studies in the school setting have been
conducted by Mayer (1968) and Collipp (1975).
The latter
reported a 40 percent success rate in weight reduction.
Collipp (1975) believed that the school setting
was the most logical place for weight reduction since the
children spend most of their waking hours and twelve years
of their lives as students in school.
Another researchist
concurred by stating that the children were in school for
nine months continuously and the school nurse could be
utilized for daily support of a weight control program.
3
Mayer (1968) said that utilizing the public school
systems was a practical approach to weight control:
as the largest number of needy youngsters can
be served, the service and supervision can be
continuous, it is least expensive for the individual and his family, and it places the question in the context of education where it should
be, for it is not simply a medical issue (Mayer,
1968, p. 680).
Statement of the Problem
A group of obese youngsters attending an
elementary school in Los Angeles were selected to be
part of a weight education program under the direction
of the school nurse.
The study was done to determine the
effects, if any, on:
1.
Actual weight loss of participating members.
2.
The level of knowledge about nutrition and
good dietary habits held by the participants.
3.
Health practices and attitudes as
demonstrated by the selection of foods.
Limitations of the Study
Participation in the study was limited to twentythree students identified by the school nurse as obese by
visual inspection.
Obesity was verified by Weight-Height-
Age Table form of Los Angeles Unified School District.
The program was constructed, implemented and
evaluated by the nurse only.
Other personnel within the
4
school were utilized as resource specialists on a
voluntary basis.
Scope of the Study
The study was ongoing for three school semesters
from February 1977 to May 1978.
It was limited in time
due to conflicts with the basic educational plans of the
teachers.
Each child was seen for a total of 30 to 60
minutes every two weeks.
Resources Used
Personnel involved in this study included the
school physician who referred children to the program
after a physical examination.
The physician also had the
authority to refer children for remedial physical education because of obesity.
The most cited handicap for
obese youngsters was unfitness.
play and muscle reaction.
They were handicapped in
They also fatigued easily
(Anderson, 1973; Thomas, 1972).
The remedial physical
education teacher worked with each child to increase physical fitness, endurance, and body awareness.
Project
Mainstream (where children with handicaps have been integrated into the classrooms), also worked with obese children.
This project provided tutorial services, individual
.
counseling, and educational sessions on nutrition.
The
dieticians of the Los Angeles Unified School District
5
provided ample educational materials in. the form of
posters, films, and teaching suggestions.
Definition of Terms
The following terms were basic to this study:
1.
Overweight.
Individuals who weighed more than
10 percent to 20 percent above the average for their body
build, height, and weight.
2.
Obesity.
Those individuals who weighed 20
percent or more above the average for their body build,
height, and weight (according to leading nutritionists
and researchers).
3.
at a meal.
Balanced
Meal~
A serving of each food group
The four groups were listed as:
legumes, eggs, cheese, etc.;
(1) meat,
{2) fruits and vegetables;
(3) milk and dairy products; and (4) breads and cereals
or grains.
4.
Excess Weight.
The difference between ideal
weight and actual weight.
5.
Percentage Overweight.
The difference between
actual weight and the mean weight for height, age and sex.
Chapter II
REVIEW OF LI'l'ERATURE
Introduction
There was a vast amount of printed material on
the subject, of obesity.
The writer chose, as nearly as
possible, the latest views on this subject as well as the
.most practical for children in both home and school.
areas covered were as follows:
aspects of obesity;
approach;
The
(1) physical and genetic
(2) physical problems;
(3) genetic
( 4) .psychological aspects of obesity; ( 5) treat-
ment of obesity;
{6) treatment of children;
(7) food eat-
ing practices of young persons; and (8) the role of
physical
activ~ty.
Physical and Genetic Aspects
of Obesity
Obesity has
bee~
a known major health concern.
Knowles estimated there were 80,000,000 overweight Americans (Kahn, 1978).
Obesity was defined as "that physio-
logic state in which excessive fat is stored at various
sites" (Merck Manual, 1972).
as follows:
Mayer {1968) expressed it
"If you look fat you probably are fat" and
"an obese person is too fat for his or her own good."
Robinson (1973)
stated there v1ere 16 to 30 percent of
6
7
element.ary school children who were overweight and three
million of the young people between the ages of twelve
and nineteen who needed medical attention for obesity.
A study was done in 1937-39 on obese children
ages ten to thirteen.
The average age at followup was
31 years and showed that 86 percent of the boys and 80
percent of the girls
~,Jere
still ovenveight as adults (US
Dept of HEW, 1966).
Mayer (Collipp, 1975) stated that
obesity before the age of nine or after fifteen had a
poor prognosis.
Knittle, another researcher, believed a
dietary regime should be started before the age six, and,
in some cases at the age of two, if a lifelong history of
obesity was to be avoided (Winick, 1975).
Physical Problems
Obese babies and children suffer from a tendency
to have knock knees, flat feet, back trouble (as they grow
older), excessive clumsiness, e*aggerated shortness of
breath, and less exercise tolerance, more respiratory
ailments, they also become easily tired and had aches and
pains in the legs, and were susceptible to psychosomatic
illnesses such as asthma (Ellis, 1976).
Adults suffered from their share of
ailments.
phys~cal
They included diabetes, hypertension, heart
disease, back trouble, and ea1:lier deaths as compared to
their non-obese counterparts.
8
Genetic Approach
Knittle studied forty-three elementary school
obese
aryd~-fion·-obese
children.
He found that at all age
levels research showed that obese children had larger fat
cells and a greater number of cells than controls of normal weight.
By age seven all obese children had cell num-
bers equal to or greater than non-obese adults (Huenemann,
1974).
Hirsch concurred
wit~
the cell theory that adults
who were obese as adolescents had increased numbers of fat
cells as --compared with the average non-obese persons.
Eid, a British investigator, found that rapid weight gain
during the early months of life led to obesity by the age
six to eight (Huenemann, 1974).
The fat content of the
cells could be reduced but not the number of the fat
cells.
Hirsch found that most fat cells were laid down
in the last months of pregnancy and in ·the first year of
life or early adolescence.
This theciry has not as yet
been proven (Huenemann, 1974).
Nemir, a health educator,
said that obesity was most prevalent during infancy,
puberty, and adolescence.
Garn disagreed with the early induction hypothesis
that fat cells as a baby led to obesity in adults.
He
claimed that poor, fat 'l.mn:en raising lean children disproved that fat cell theory.
A study, done in New York
City, revealed that obesity was seven times more prevalent
in the lower classes than in the highest social class
9
(Collipp, 1975) •
The rn.idtmm _r,lanhattan study also showed
a direct correlation between obesity and social class,
social mobility, and generation in the United States.
Other researchers suggested that lower classes did not
regard obesity as undesirable as did those of the higher
social classes (Hafen, 1975).
Previous research indicated that if both parents
were obese, there was an 80 percent chance that the children would also be obese.
If only one parent was obese,
the rate fell to 40 percent (Collipp, 1974).
These fig-
ures supported, in part, the genetic theory of obesity.
Concomitantly, the social factors in eating had to be
considered.
Psychological Aspects of
Obesity
The most serious psychological complication of
obesity has been the disturbance of the body image.
Body
image has been defined as "the concept which each individual has of his own body as an object in space, independently and apart from all other objects" (Stunkard, 1961).
Schilder, in 1935 1 was the first to consider
body image which he defined as "the picture of one's own
body which has been formed in the mind or the way in
which the body has appeared to one's self" (Bruch, 1973,
p. 87).
Body image disturbances occurred most frequently
as a result of being obese as an adolescent.
Stunkard
10
(1967) tested twenty obese girls in grades four through
six and found disturbances did not occur before adolescence.
He was convinced that adolescence was the age par-
ticul~rly
vulnerable to peer pressure.
However this was
not the cause of the developing disturhances in the body
images connected with five 9irls out of the total study
and control group of forty girls.
Three factors have been crucial to the
development of the body image disturbance in children:
1. Age of onset of obesity.
2. · Presence of neurosis.
3. Parental evaluation of the obesity
(Stunkard 1 1961).
Disturbances in body images for Stunkard's groups
were present thirty years after weight loss with the women
still expressing undue concern ?bout their appearance.
Stunkard believed that this small group of three in the
study group and two in i:he control group had validity in
determining the onset of disturbance because of the following reasons:
1. None of the women were obese after age
nineteen yet they had disturbances.
2. The disturbances were confined to
individuals who reacted to peer or family pressun~s in attempts to reduce.
' 3. Twenty years later, the women had
emotional scars from their short experience
with obesity as an adolescent (Stunkard, 1967).
Bruch (1973) termed these the "thin fat people"
who had disturbances in body image long after successful
weight reduction.
Manella and Mayer (1963) studied obese
11
children at a camp and reported passivity which they
defined as expression of lack of self assertiveness and
initiative sim1.lar to passivity among minority groups.
Bruch suggested that obese children have been
brought up differently than normal weight children.
Obese
children have the inclination to think of themselves as
more important to the world despite the fact that they
cannot achieve what they should (Collipp, 1975).
These
children have become insecure and helpless because they
could not reach goals; frustration sets in and consequently the children overeat.
B~uch
believed that these
children had a misinterpretation of their own importance.
Other researchers support Bruch's theory of·obese
children being reared differently from others.
as follows:
Ayd stated
"the obese child is reared in a milieu in
which he becomes a focus of family conflicts, a recipient
of subtle hostility and rejection, and is treated differently than his sibling" (Lasagna, 1974, p. 39).
Children have tended to blame almost all
disappointments on their obesity.
Obese girls were only
able to list a few positive att.ributes about themselves
(Hammar, 1972).
"The major difference between obese and
non-obese groups were in negative body image and low self
esteem, depression, and lack of confidence and experience
in social interaction" (Hammar, 1972, p. 378).
•"f'
12
At a twenty year follow up of Qbese patients,
Bruch found 40 percent of these patients were significantly and emotionally maladjusted.
Treatment of Obesity
Stunkard has stated that most obese persons
WOl..lld not stay with the cou:r.·se of treatment.
He also
found that those tvhc di,d the most would not lose weight
while those who d5_d lose considerable weight would regain
it (Lasagna, 1974).
He further stated:
"Obesity is a
chronic condition, resistant to treatment, and prone to
relapse"
(Stunkard, 1976, p. 186}.
Up until 1951, obesity was considered to be a
neurosis and clinically treated by psychotherapy.
The
concept of will power was all that was needed to cure
obesity '-'las held by many doctors.
Methods used in the
1950's included diets, therapy, formula diets and drugs
(Bruch, 1973).
Hammar (1972) found no difference <,::ver a ten year
period between group therapy versus individual therapy in
a study at a obesity clinic.
However, he discovered indi-
viduals did better -vTi i:h continued support from the same
person.
Collipp (1975) supported the same idea but he
suggested that individual therapy had an advantage because
the person had an opportunity to know the child better.
13
Behavior modification appeared to have the best
success rate of any modality both in losing and maintaining weight (Jeffrey, 1974; Stunkard, McLaren-Burne, 1959).
In his review of the literature in 1959, Stunkard
studied one hundred patients in the Nutrition Clinic of
New York Hospital.
Twelve out of twenty patients lost
more than twenty pounds in two years, thirty-nine did not
return after the first visit, and twenty-eight never
returned to the referring or any other clinic in the New
York Hospital.
The outcome of his study of determining
factors in treat"nent was tha·t men wei-e more successful in
reducing than women.
Stuart (1971) affirmed that the control of stimuli
was more important than the motivation in their treatment.
Other authorities thought that motivation \vas the key factor in successful reducing (Anderson, 1972; Carmen, 1976;
Kaufman, 1975).
Hammar stated t:hat treatment for obesity was
ineffective.
Therefore, early identification and inter-
vention was necessary (Collipp, 1975).
Treatment of Children
At no. time was a low caloric diet advocated for
children.
Researchers agreed that restriction in the
diet at the pre-puberty age could "retard growth, upset
14
maturation, and result in smaller adult size" (Garn,
1976).
Mayer (1976} suggested that an active ten year
old boy needed 2400
c~lories
for normal growth while an
active ten ye::l.r old, girl required 400 more calories than
her thirty-five year old mother.
Emphasis was placed on increasing intake of fresh
fruits and vegetables and eliminating a diet high in
carbohydrates.
Food Eating Practices of
Young Persons
Moomaw (1978) found that 25 percent of ten and
eleven year olds went eighteen hours without a meal.
Breakfast was omitted and the children did not eat·from
6 p.m. the evening before until noon the following day.
Carbohydrate foods provided prompt satiety for hungry
children.
Anderson stated as follovls:
The seeds of obesity are all too often sown
in childhood by well meaning but misguided parents and other relatives, and nurtured in adolescence by incorrect and ill advised feeding
habit.s, fertilized in some cases by seductive
advertisements which sometimes make food appear
vaguely sexual (and therefore desirable) to give
or receive luxury carbohydrate foods.
The harvest of obesity is reaped in adult life in a
crop of major and minor mental and physical disabilities culminating in a shortened life span
(Lasagna, 1974, p. 39).
Role of Physical Activity
Mayer (1978) suggested nutrition education at
the pre-puberty age group along with a daily exercise
15
program.
He suggested one hour of daily physical
exercise with three hours on weekends and vacations to
aid in weight reduction (Collipp, 1975).
Studies of
obese children in sports (volleyball and swimming) show
that they spent less time in motion than children of normal weight.
Obese girls ate several hundred calories less
than the non-obese but they spent only one-third as much
time being physically active (Hayer, 1968).
Bray studied the psychological effects of
exercise on the non-obese.
It was found that:
Self satisfaction and self acceptance
increased, and there was improvement in the
perception of physical self, adequacy in social
interaction and overall level of self esteem
and self confidence (Bray, 19 7 3) • ·
Chapter III
PROCEDURES AND METHODS
Introduction
This chapter has been divided into the following
sections:
(1) the first section included the school set-
ting, administrative arrangements, and the resources
utilizedi
(2) the second section disclosed the selection
of students, the supervision treatment group, the control
group and parental permissioni and (3) the last section
covered the description of the interve.ntion, educational
sessions, height and weight, nutrition education, food
diaries, on-the-spot checking, physical activity, records
of activity, reinforcement of concepts, and test instrument for research design.
Selection of Students Involved
in -:This Study
An annual review of health cards and referrals
from individual teachers were the initial sources of the
selection of students.
The referral system expeditated
the identification of more children than the school nurse
was able to handle in the two days a week assignment at
the school.
16
17
The students were initially classified as obese
by visual inspection.
Obesity was verified by Weight-
Height-Age Table form of Los Angeles Unified School District.
Approximately 10 to 15 percent of the school
population were defined as being obese and only the most
severely obese were chosen.
Treatment Group
The treatment group originally consisted of
twenty-three students ranging in age from seven to twelve
years.
Of these, eighteen children finished the program,
while five students were eliminated due to moving from
the area.
Control Group
The control group numbered ten students with the
age also ranging from seven to eleven years.
The method
of choosing these students was to have every third referral to the nurse's health office become a member of the
control group.
Parental Permission
Letters were sent to the parents of the treatment
group requesting a conference with the school nurse.
These initial conferences were all individual so that the
parents would feel that the school nurse was interested in
each child personally.
A family history of obesity as
well as a dietary history were obtained at the initial
18
conference.
A thorough physical examination was strongly
urged for all the students before they were enrolled in
the program.
School Setting
The target population was selected from a small
elementary public school in Los Angeles Unified School
District with an enrollment of 525 students.
The ethnic
makeup of the school was 99.9 percent Black.
The commu-
nity was composed of working middle class people who had
single family dwellings in the immediate area and some
multiple dwellings on the outer perimeters.
In addition to a school nurse two days a week, the
school was assigned:
(1} a psychologist two days a week;
(2) a remedial teacher two days a week;
(3) a physical
education teacher one day a week; and (4) Hainstream
teacher one day a week.
These resource personnel were
assigned the same days as the school nurse.
Administrative Arrangements
The principal of this particular school had
expressed the desire to have the school nurse conduct an
indepth nutrition educational program because of his observations of the childrens' deplorable eating habits.
The need and the interest were there; so, with the principal's permission and encouragement, the idea of a
weight control group was initiated.·
19
Resources Utilized
The school psychologist, the remedial physical
education teacher, and the Mainstream advisor were
utilized as resource personnel.
Description of the Intervention
Educational Sessions
At the initial meeting with the students, an
overview of the bimonthly sessions was presented.
During
this time, the purpose of the program was also explained
to groups of three or four students who were chosen
according to their age and sex.
Future meetings for
small groups were planned.
Height and Weight
Each student was measured on the same scale for
height in stocking feet.
Concomitantly, all the weights
were done on a balance type scale.
The students were
asked to graph their initial height and weight on nutrition guides (see Appendix A).
Nutrition Education
Instruction in nutrition has been in the school
program from kindergarten through twelfth grade as illustrated in the instructional guide published by Los
Angeles City Schools.
Reviews of the Basic Food Groups
were done at every session by means of filmstrips,
20
nutrition quizzes, and interviews during the students'
lunch period.
The students in the treatment group were
given a suggested basic menu pattern at the initial meeting.
(See Appendix B.)
Food Diaries
Food diaries were kept by the students for one
week each semester.
The reliability of the responses was
questioned by the examiner because few "junk foods" were
listed and there had been no weight loss listed.
On-the-Spot Checks
Teachers reported the presence of "junk foods" at
recess and lunch period.
Direct observation by the exam-
iner also showed a preponderance of "junk foods" during
the lunch period.
It was found that most of the students
(obese and non-obese) left salads, fruits, and vegetables
untouched at the noon meal due to the fact that they ate
only the carbohydrate foods.
Physical Activity
Physical activity was believed to have the main
emphasis in conjunction with nutrition education.
The
remedial physical education teacher worked with each student weekly to develop muscle strength, flexibility, and
agility along with creating emphasis on body awareness.
21
Inactivity seemed to be a major problem both in
and out of school.
At school, physical education was not
a scheduled daily activity.
Teachers withheld physical
education as a means of discipline.
mandated curriculum was not legal.
This abuse of the
However it was prac-
ticed.by some teachers and overlooked by administration.
Record of Activity
Students were asked to keep a record of the
physical activities which they did for one week of each
semester.
Many of the students performed less than five
hours of exercise each week.
This was due to the fact
that most parents were both working and did not allow the
students to play unattended after school.
Almost all the
students listed watching television as the daily after
school activity.
Parents were encouraged to have their
children engage in some form of strenuous activity on
· the weekends.
Reinforcement of Concepts
The remainder of each meeting consisted of:
(1) progress report of weight gain or loss; {2) review
of dietary habits during the interim;
answer period;
(3) question and
(4) nutrition presentation; and (5)
physical activity during the interim.
22
The students graphed their
pre~ent
\veight on
their guides which the. parents were to initial.
Parents
were asked to give positive, verbal reinforcement for
their children's attempts.
The school nurse used cartoons
of happy faces for weight losses and sad faces for weight
gains.
At no time was a negative remark made to a student.
Test Instrument for
Resea:r,ch Design
The Post-test Only Control Group Design was
utilized in the project.
Campbell (1966) stated "in
educational research, particularly in the primary grades,
we must frequently experiment with methods for the initial introduction of entirely new subj-ect matter, for
which pre-tests in the ordinary sense are impossible"
(p.
25).
The test used was as follows:
R
X
R
The test was a composite of:
Dairy Council Test;
(1)
the National
(2) the standard nutrition quizzes;
and {3) the knowledge of nutrition as taught to all elementary students by the classroom teacher.
tained twenty items:
The test con-
{1) ten true or false nutrition
questions; and (2) ten "Complete A Heal" pictures.
question was worth five points.
(See Appendix C.)
Each
. Chapter IV
DISCUSSION OF THE DATA
The purpose of this study was to determine if
nutrition education had a measurable effect on the treatment group in a weight control program.
presented:
This chapter
(1) an analysis of the data; and (2) a dis-
cussion of the significant findings from the data.
The following null hypotheses
1.
~Jere
stated:
There would be no significant difference
between the treatment group and the control group regarding weigh·t.
2.
There would be no significant difference
between the treatment group and the control group in the
post test on nutrition information.
The treatment group consisted of six boys and
twelve girls ranging in age from 7.2 to 11.6 years of age
with a mean age of 9.7.
inches.
Initial heights ranged from 51-58
Initial weights were from 90 to 163 pounds.
The control qroup had four boys and six girls
between the ages of 7.9 to 11.5 with a mean age of 9.7.
The initial heights for this group ranged from 53 to 58
inches with initial weights from 92 to 142 pounds.
23
24
A "t" test was used to determine if there was a
significant statistical difference between the treatment
and the control groups for weight as shown in Table I.
'l'he null hypothesis that there was no significant
difference between the treatment group and the control
group with respect to initial weight was accepted.
Excess weight in the treatment group initially
ranged from 22 to 61 pounds; from there it went from 20
to 71 pounds at the final session.
The control group
figures were 24 to 63 pounds initially and then increased
from 37 to 61 pounds at the end.
Five students in the
treatment group had a decrease in excess weight as compared with only two students in the control group as
evidenced in Table II.
Pounds which have been lost has been the usual
measure of success in adults but for the rapidly grmv:i.ng
child it can be deceptive.
The change in percentage over-
weight was selected to assess actual change in obesity.
Percentage overweights were expressed as the differences
between actual weight and mean weight for height, age, and
sex (Los Angeles Unified School District Table).
The per-
cent ovenveight at the onset of the treatment group was
114.7 and 114.4 at the final session.
The control group
initially was 107.6 and the final session was 115.4.
Nine perso~s ou~ of 18, or 50 percent in the
treatment group showed a decrease in percent overweight.
25
Table I
Table of Total Group Initial
Mean Weights and t Scores
Group
Number
Mean
d. f.
(degree of
freedom)
Treatment
18
120
26
Control
10
114
26
t
.9049*
*
Not significant at the .05 level.
26
Table II
Initial and Final Excess Weight for Treatment
of Control Group
Pat.ient
Age
(yr)
Excess
Weight
Onset
Height
(in)
Weight
51
54
54
57
58
58
58
98
102
109
139
146
120
106
110
104
123
90
101
163
132
130
120
145
135
37
31
38
57
61
38'
38
46
40
52
22
30
55
53
55
38
56
46
41
60
41
50*
31
45
68
71
62
29*
48*
40*
53
54
58
55
53
54
53
54
56
57
92
98
126
108
99
122
106
112
142
135
24
27
41
34
31
51
38
41
63
51
37
41
52
38
37
56
47
43
61*
50*
(lb)
Final
Session
Treatment
Gro_up
s
1
2
3
4
5
s 6
8 7
s 8
8
8
8
8
s
9
810
Sll
812
813
Sl4
Sl5
816
S17
818
7.2
7.11
9.0
10.2
11.3
11.6
8.3
8.3
8.2
8.6
9.1
9.3
9.11
10.0
10.3
1L2
11D2
11.4
~
'
!::;....,
1
.J
53
52
52
54
53
54
61
56
55
57
41
41
41
58
62
29*
1:
Control
Group
8 1
8 2
s 3
s 4
s 5
8 6
s 7
s 8
8 9
SlO
7.9
9.2
10.0
10.3
8.6
9.7
9.8
10.4
11.2
11.5
* Denotes decrease in excess weight
Sl-86. ~,;ere males and S7-Sl8 females in the treatment
group
Sl-84 were males and S5-Sl0 females in the control group
\
\
' - ,/.
~
27
However, only three or 30 percent out of ten students
in the control group showed a decrease in percent overweight.
Although 50 percent showed a decrease it appeared
to be a chance occurrence, only 30 percent having shown a
decrease in the control group might be of some significance (see Table III).
The findings from Table III represented a mean
percentage drop of only 3 percent for the treatment group
with an increase of 7 percent.
Gross (1976) stated the
mean pound change was of little value in judging the
sue~
cess of the treatment since one dramatic loss or gain
would mask the other gains or losses.
Table III visual-
ized these findings.
The results shown on Table III were not entirely
discouraging, however, because the increase in height
accounted for some decrease in percent over-weight change.
While the eighteen students gained weight ranging from
three to twenty-eight pounds, nine of the treatment group
effected a decrease ranging from 4 to 19 percent.
The
control group had three students reflecting a decrease
from 4 to 15 percent.
The average increase in height during the study
was one and a half inches due to the fact that the students had not reached their growth "spurt.". The remaining nine students in the treatment group showed an
increase of 2 percent and 18 percent for a total decrease
Table III
Initial and Final Percent Overv:eight for
Treatment and Control Group
Patient
Number
Age
(yr)
Height
(in)
Weight
(lb)
7.2
7.11
9.0
10.2
11.3
11.6
8.3
8.3
8.2
8.6
51
54
54
57
58
57
53
52
52
54
53
54
61
56
55
57
98
102
109
139
146
120
106
110
104
123
90
101
163
132
130
120
Percent
Overweight
Weight
Change
Final
Session
(lb)
Percent
Overweight
Final
Session
Percent
Overweight
Change
Treat.ment
Group
s
s
s
s
1
2
3
4
8 5
s 6
s 7
s 8
s 9
(m)
(m)
811
812
813
S14
815
816
(f)
(f)
(m)
(m)
(m)
(m)
(f)
(f)
(f)
SlO (f)
(f)
(f)
(f)
(f)
9.1
9.3
9.11
10.0
10.3
11.2
61%
43%
54%
70%
7')Q
c. • . ..
46%
56%
72%
63%
7 39.;
~0
32%
4 2 ?,s
50%
.
6 '7 9-,,
73%
43%
+ 7
+21
+ 3%
64%
+ 7%
50%
+14
50%
- 4%
+ 8
65%
- 5'?1
+:!_0
66%
- 6%
-1- 3 - ... . ..... ---31 {; ......-----·--- ... . . ·-15%
+ ?!1-c,
+ 6
58%
+16%
+18
88%
+ 5
60%
- 3%
63%
-10%
+ 6
+ 9%
+16
41%
+18%
+19
60%
5 fi ,~
+ 6%
+23
+28
no%
+13%
.;- 5%
+11
78%
""· 7%
3G%
+ 9
~
IV
0')
Table III (Continued)
~'leight
Patient
Number
Sl7 (f)
Sl8 (f)
Age
(yr)
Percent
Overweight
Change
Final
Session
(1b)
Percent
Overweight
Final
Session
Percent
Overweight
Change
Height
(in)
Weight
(lb)
11.2
11.4
58
58
145
135
63%
52%
+11
+ 6
44%
40%
-19%
7.9
9.2
10.0
10.3
8.6
9.7
9.8
10.4
11.2
11.5
53
54
58
55
53
54
53
54
56
57
92
98
126
108
99
122
106
112
142
135
35%
38%
42%
44%
46%
72%
56%
58%
82%
65%
+16
+17
+15
+12
+ 9
+ 9
+16
+10
+ 8
+16
52%
55%
58%
46%
52%
75%
66%
54%
69%
50%
+17%
+17%
+16%
+ 2%
+ 6%
+ 3%'
+10%
- 4%
-13%
-15%
--12%
Control
Group
s
s
1
2
S 3
s 4
s 5
s 6
s 7
s 8
s 9
S10
(m)
(m)
(m)
(m)
(f)
(f)
(f)
(f)
(f)
(f)
IV
t.P
30
of only 1.22 percent.
The remaining seven students in
the control group had increases in percent overweight
ranging from two to seventeen pounds.
As was anticipated, each student gained most of
his or her weight during summer vacation.
Only two stu-
dents in the treatment group managed to lose poundage
during Christmas vacation; they had a loss of two pounds
each.
Success in this study was defined as losing five
or more pounds or maintaining the present weight.
During
the study, failure was defined as a weight gain of five
or more pounds.
Seventeen students fell into the failure
group with only one boy neither gaining nor losing·five
pounds.
A "t" test was done to determine if the observed
correlations were significantly different from zero
between original and final excess weight on both treatment and control group.
The results showed a significant
correlation as shown in Table IV.
The "t" test was done
for each of the correlations.
The 61.23 percent of variation in final excess
weight was statistically related to variations in original excess weight of the treatment group and 83.47 percent of the control group.
31
Table IV
Original and Final Excess Weights
Number
Correlation
Coefficient
d.f.
(degree of
freedom)
Treatment
18
.78249
16
Control
10
.91361
8
Group
*
Significant at the .05 level.
t
5.02668*
6.3554*
32
The heavier the student was at-the onset the
more likely he would be less successful in reducing the
excess weight.
Nutrition Education
The value of nutrition education has been
questioned in the past by Baker (1972) when knowledge
was significantly increased by a group of fourth and
fifth.graders without any behavioral change$ that were
observable.
One of the findings of this study demon-
strated that although nutrition knowledge increased among
the treatment group, attitudes and behavior were not
altered as judged by on the spot checks and conferences
with students and-parents.
Mean Post Test Scores on
Nutrition Education
Other studies (Kaufman, 1975; Dwyer, et al., 1967)
showed that obese students had a better understanding of
calories and nutrition than normal weight students.
Knowledge alone has not been found to change behavior.
For behavior.to be changed, motivation has been needed
along with the belief that health would be altered for
the better.
One researcher (Osman, 1972) felt that:
through meaningful involvement;
(1)
(2) eliminating nutri-
tional misconceptions; and (3) increasing the value of
33
Table V
Total Group Final Mean Scores
on Nutritional Knowledge
Treatment
Group
Number
Mean
Test
Score
18
83.33
d. f.
(degrees of
freedom)
t
26
2.025*
Control
Group
*
10
78.50
Significant at .05 level.
26
34
information taught the students would affect positive
behavioral changes.
S.tudents between the ages of eight
and t\vel ve have been given some choice as to the foods
consumed outside the home.
However, the main source of
nutrition remains in the home.
Parents answered truthfully when questioned about
home meals.
Most of them were feeding large families and
resorted to high carbohydrate meals because of inflation
and the high cost of food.
School lunches tended to rein-
force this eating pattern by having two or three high
carbohydrate foods at one lunch (spaghetti, garlic bread
and frosted cake for dessert).
A change in nutritional
behavior was difficult to effect due t'o economics, · cultural patterns of eating, and the students' lack of interest in the long term effects of good nutrition.
An interesting study by Marston (1975) on the
behavioral
eatin~~attern
of children showed that they
followed the same pattern as adults.
The author dis-
closed the following:
Fatter children ate faster (more bites per
unit of time, fewer chews per bite) but, eating
more; they spent about the same total amount of
time eating. They also hesitated less between
bites, toyed·less with their food, and drank
more while chewing (p. 223).
The post test nutrition results supported Baker's
(1972) findings that knowledge was increased without any
observable behavioral changes.
35
The treatment group did well on the questions
which tested knowledge.
However, they did not do well
on the questions which tested attitudes.
were shown on Table VI.
These findings
Question five was a good example
because it revealed the group memorizing the Four Basic
Groups but not being able to determine correct amounts
for a daily diet.
Attitudes and behavior were included
because the students:
(1} may still feel the need to
have more than the recommended amount; or (2) might be
unaware of just how little was needed to fulfill the
requirements.
The control group experienced the same results
basically.
They answered inadequately on the knowledge
questions as evidenced on Table VII.
Neither the treatment nor the control group
experienced difficulty completing the picture portion
of the test.
Table VI
Responses to Post Test for Nutritional Knowledge
of the Treatment Group
R e s p o n s e s
Treatment Group
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
1
+
+
+
-
-
+
+
-
+
+
+
+
+
+
+
2
+
+
+
-
+
+
+
- -
+
+
-
+
+
+
3
+
+
+
-
+ +
-
+
+
-
+
-
+
+
+
4
+
+
+
-
+
+
+
-
+
+
+
+
+
+
+
5
+
+
+
-
+
+
+
-
+
+
-
-
+
+
6
+
+
+
+
+
+
+
+
-
+
+
+
-
7
+
+
+
+
-
+
-
+
+
-
+
+
+
+
8
+
+
+
+
+
-
+
+
+
+
+
+
+
9
+
+
+
+
+
+
+
+
+
+
+
+
+
10
+
+
+
- + - -
+
+
-
+
+
-
+
+
-
+
11
+
+
+
+
-
+
-
-
+
+
+
+
+
-
+
12
+
+
+
- -
+
+
-
+
+
+
+
+
+
+
Ul
+'
s::
Q)
"d
::I
+'
tr.l
.
Questions and Pictures
+
w
0'\
Table. VI (Continued)
Treatment Group
Ul
1
2
3
4
5
6
7
8
9
10
11
12
13
14.
15
13
+
+
+
-
+
+
+
- -
+
+
+
+
-
+
14
+
+
+
-
-
+
+
-
+
+
+
+
+
+
+
15
+
+
+
+
-
+
+
-
-
+
+
+
+
+
+
16
+
+
+
+
+
+
+
+
+
+
+
+
17
+
+
+
+
+
-
+
+
+
+
+
+
18
+
+
+ + - - -
+
+
-
+
+
-
+
+
-
+
.jJ
c.
(!)
'"d
:::!
.jJ
(/)
R e s p o n s e s
+
+
Questions and Pictures
-
*
Correct
- Incorrect
w
~
Table VII
Responses to Post Test for Nutritional Knowledge
of the Control Group
Control Group
(I)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
1
-
+
+
-
-
+
+
-
+
+
+
-
+
+
+
2
+
+
+
+
+
- - -
+
+
+
-
+
3
+
+
+
-
+
+
+
-
+
+
-
+
+
+
+
4
+
+
+
+
-
+
+
-
-
+
+
-
+
+
+
5
+
+
+
+
+
+
-
+
+
+
+
+
+
+
+
+
+
-
+
+
7
+
+
+
+
+
+
+
+
+
+
-
+
8
+
+
+
-
-
- + -
+
6
- + -
+
+
-
+
+
+
-
+
+
+
9
+
+
- -
+
+
+
-
+
+
+
-
+
+
10
+
+
+
-
+
+
+
-
+
-
-
+
+
+
-1-l
s::(!)
'tJ
~
.j..)
R e s p o n s e s
(f.l
+
+
Questions and Pictures
+ Correct
- Incorrect
w
00
Chapter
v
SUMMARY, FINDINGS, CONCLUSIONS,
AND RECOMMENDATIONS
Introduction
Obesity has been a serious public health problem
involving all ages and strata of society.
The physical
and psychological effects it has on the individual have
been long term.
Early identification, intervention, and
treatment have been urged by physicians and nutritionists.
Review of treatment of obesity from 1928-1958
shows relative ineffectiveness of most v1eight reduction
programs.
A later review in 1966 supported earlier find-
ings that there had been no successful program to date
(1979).
The latest review in 1978 showed some short term
results when dietary counseling, behavior therapy, exercise, and control of the environment were utilized
(Coates, 1978).
The results of this study follow the same patterns
d~scribed
by Stunkard who was convinced as follows:
Most obese persons will not stay in
treatment for obesity. Of those who stay
in treatment, most will not lose weight, and
those who do lose weight most will regain it
(Lasagna, 1974).
39
40
Findings
Major Findings of
the Study
1.
There was no significant difference between
the treatment group and the control group regarding initial weight.
2.
There was significant difference between the
treatment group and the control group regarding nutrition
information in the post test nutrition test.
3.
Observation at the end of the study indicated
little or no difference in food selections by the treatment group.
4.
There was a direct correlation between
original and final excess weight.
The heavier the student
was at the onset the more likely he would be less success-·
ful in reducing the excess weight.
This was true for
both the control and the treatment group.
This chapter presented:
project;
(1) a summary of the
(2) the findings, derived from the pertinent
information of the summary;
(3) the conclusion; and
(4) recommendations for further research.
Summary
Purpose of the Study
The purpose of the study was to determine if
nutrition education had any effect on:
41
1.
Actual weight loss of
2.
The level
~f
part~cipating
members.
nutrition knowledge and good
dietary habits used by the participants.
3.
Health practices and attitudes of the students
as demonstrated by the selection of foods at home, recess,
and lunch periods.
Null Hypothesis
The following null hypothesis was stated and
outlined in Chapter I and the Appendices as well as in
the tables used throughout this study.
1.
There would be no significant difference
between t.he treatment group and the control group regarding initial weight.
2.
There would be no significant difference
between the treatment group and the control group in the
post test on nutrition information.
Approach Used to Test
Null Hypothesis
The "t" test was utilized to determine the
differences, if any, in the means of weights and nutrition test scores.
Study Population
The study population were students attending a
small elementary school in the Unified School District.
The students were judged obese by visual inspection only.
42
The treatment group were enrolled in the nutrition
education program and considered obese according to the
standard height and weight chart.
socio~economic
No variables, such as
level, parental influences, or other
demographic data, were considered.
Method
A composite test of.the National Dairy Council
and nutrition questions from the California State Series
Health Book were utilized as the test instrument for the
post test nutrition information.
All weights of both the
treatment and control groups were done on a balance scale.
Direct observation of the students at recess and lunch was
the basis for helping to determine behavioral changes and
attitudes.
Conclusions
The conclusions presented in this section of the
study were derived from data obtained from a specific
study group.
The findings, therefore, have been limited
to this group of elementary school students.
1.
The first null hypothesis was accepted since
there was no significant difference between the treatment
group and the control group in initial weight.
2.
The second null hypothesis was not accepted
since there was appreciable gain in nutrition knowledge
43
as determined by the test scores on the. post test.
Exposure to additional.nutrition information did not
effect weight reduction in the study group.
Recommendations for Further Research
Based on the findings and conclusions of this
study,
recorr~endation
for further research were as
follows:
1.
Development of a program which included
nutrition education and physical exercise for elementary
students (or earlier if feasible).
The program could be
initiated by the school nurse or other interested school
health personnel.
2.
Involvement of parents in workshops where
behavior modification methods of weight control would be
demonstrated and reinforced in the home setting.
3.
Reinforcement of an inexpensive nature to
motivate the students to continue weight loss over an
extended period of time.
4.
Additional time for personnel in the school
so the students helped would be on an individual basis
rather than in small groups.
5.
School districts taking a leadership role in
such programs by taking a closer look at school lunch
program.
44
6.
Parent education classes in nutrition with
emphasis on inexpensive, healthy ways to feed families.
BIBLIOGRAPHY
Anderson, C. L.
St. Louis:
School Health Practice.
Mosby, 1972.
c. v.
5th Edition,
Aragona, J. et al., "Treating Overweight Children
Through Parental Training and Contingency Contracting," Journal of Applied Behavior Analysi~, 8:269-278,
Fall, 1975.
Baker, M. J.
"Influence of Nutrition Education on 4th
and 5th Graders," Journal of Nutrition Education,
4(55):19-26, Jan-Mar 1972.
Bray, George A., M.D. The Obese Patient, Vol. IX,
Philadelphia: W. B. Saunders Co., 1976.
Obesity in Perspective. Fogarty
International Center Series on Preventive Medicine,
NIH, Vol. I and II, Oct. 1973.
Bruch, H.
Eating Disorders in Adolescents-the
Psychopathology of Adolescents. Edited by Zubin,
et al., The Proceedings of the Fifty Ninth Annual
Meeting of the American Psychopathological Association, NYC, 186-196, Feb. 1969.
Eating Disorders.
New York:
Basic Books,
1973.
Cain, A.
Young People and Health.
John Day Co., 1973.
New York:
The
Carmen, D. D.
"Infant and Childhood Obesity," Pediatric
Nursing, 2(6) :33-38, Nov.-Dec. 1976.
Coates, T. J. and C. E. Thoresen.
"Treating Obesity in
Children and Adolescents: A Review," American
Journal of Public Health, 68(2) :143-151, Feb. 1978.
Collipp, Platon, M.D., ed. Childhood Obesity, Acton,
Mass.: Public Science Group Inc., 1975.
Craddock, D.
Obesity and It's tJ[anagement.
E and S Livingston LTD., 1969.
45
London:
46
Dwyer, J. T., J. J. Feldman and J. Mayer.
"Adolescent
Dieters: Who Are They: Physical Characteristics,
Attitude and Dieting Practices of Adolescent Girls,"
American Journal of Clinical Nutrition, 20:1045-1056,
Oct. 1967.
Eisenhauer, J. C., and P. E. Bell.
"Nutrition Education
in the Elementary School," Today's Education, 5:38-40,
Dec. 1976.
Ellis, Audry. The Kid-Slimming Book.
Regency Co., 1976.
Chicago:
Henry
Garn, s.
"Marginal Comments--The Origins of Obesity,"
American Journal of Diseases of Children, 130:465467, May 1976.
Gilbert, s. Fat-Free, Common Sense for Young Weight
Worriers. New York: MacMillan Pub. Co., 1975.
Goldbloom, R. B.
"Obesity in Childhood," California
Medical Association Journal, 113:139, July 1975.
Gross, I., et al.
"The Treatment of Obesity in
· Adolescents Using Behavioral Self· Control," Clinical
Pediatrics, 15(10) :920-924, Oct. 1976.
Hafen, Brent Q. Overweight and Obesity: Causes,
Fallacies, Treatment. Edited by Provo, Utah, BYU
Press, 1975.
Hammar, s. L., et al.
"Treating Adolescent Obesity,"
Clinical Pediatrics, 10:46-52, Jan. 1971 •
. et al.
"An Interdisciplinary Study of
---=--=--=-Adolescent Obesity," Journal of Pediatrics, 80(3):
373-83, March 1972.
Hatfield, A., and P. Stanton. Help: My Child Won't Eat
Righ~.
Washinton, D.C.: Acropolis Books Ltd., 1973.
Huenemann, R. L.
"Environmental Factors Associated with
Preschool Obesity," Journal American Dietitic
Association, 64:480-497, May 1974.
Jeffrey, D. B.
"A Comparison of the Effects of External
Control and Self Control on the Modification and
Maintenance of Weight," Journal Abnormal Psychology,
83(4) :404-410, Aug. 1974.
47
et al.
"Behavior Therapy.versus Will Power
in the Management of Obesity," Journal of Psychology,
90:303-311, July 1.975.
Kahn, C.
"If I Die Tomorrow, It Ain't Going to be My
Fault," Family Health, Interview with John Knowles,
43-45, Feb. 1978.
Kalucy, R. S., et al.
"Some Psychological and Social
Implications of r1assive Obesity," Journal of
Psychosomatic Research, 18:465-475, Dec. 1974.
Kaufman, N. A., et al.
"Eating Habits and Opinions of
Teenagers on Nutrition and Obesity," Journal American
Dietitic Association, 66:264-268, Mar. 1975.
Kiell, Norman.
The Psychology of Obesity: Dynamics and
Springfield, Ill.: Chas. Thomas
Publishing, 1973.
Treat~ent.
Knowles, J. Views of Medical Education and Medical Care.
Harvard University Press, 1968.
Kogan, B. Health:
Man in a Changing Environment.
New York: Harcourt Brace and World, 1970.
Obesity: Causes, Consequences and
Lasagna, Louis.
Treatment. Med. Com. Press, 1974.
LeFrancois, G.
Of Children: An Introduction to Child
Development.
California: Wadsworth Publishing Co.,
1973.
~~~~--~----~-=----~~~~~-~~--~~
Leon, G. R.
"Personality, Body Image, and Eating Pattern
Changes in Overweight Persons After Weight Loss,"
Journal of Clinical Psychology, 31(4) :618-623,
Oct. 1975.
"Obesity-Psychological Causes, Correlation
and Speculations," Psychological Bulletin, 84(1):
117-39, Jan. 1977.
Levitz, L. S.
"Behavior Therapy in Treating Obesity,"
Journal of American Dietitic Association, 62:22-24,
Jan. 1973.
"A Therapeutic Coalition for Obesity:
Behavior Modification and Patient Self Help,"
American Journal of Psychiatry, 4:423-427, April
1974.
48
Manno, B., A. Marston.
"Weight Reduction as a Function
of Negative Covert Reinforcement (Sensitization)
versus Positive Covert Reinforcement," Behavior
Research and Therapy, 10(3) :201-207, Aug. 1972.
Marston, A. R., et al.
"A Note on the Eating Behavior of
Children Varying in Weight," Journal Child Psychology
and Psychiatry, 17:221-224, July 1976.
Mathes, E. lv., and A. Kahn.
"Physical Attractiveness,
Happiness, Neuroticism and Self Esteem," Journal of
Psychology, 90:27-30, May 1975.
Matsuno, A. S.
"Four Factors Affecting Weight Control
for Obese Children," Journal of Nutrition Education,
3 (1) :104-106, Sept. 1974.
Mayer, J. Overweiqht--Causes, Costs and Control.
Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1968.
"Charting a Course to Good Nutrition with
Your Children," Family Health, 30-32, August 1976.
Merck, Manual, Twelfth Edition, N.J.:
Dohme Research Lab., 1972.
Merck Sharp and
Monello, L. F., and J. Mayer.
"Obese Adolescent Girls,
An Unrecognized 'Minority' Group"? American Journal
Clinical Nutrition, 13:35-39, July 1963.
Moomaw, M. S.
"Involving Students in Nutrit.ion Education,"
Journal of School Health, 72:121-123, Feb. 1978.
Nemir, A.
The School Health Program.
Third Edition, 1970.
W. B. Saunders Co.,
Obesity and Health, u.s. Department of Health, Education
and Welfare, Washington, D. c., 1966.
Orbach, J., et al.
"Psychophysical Studies of Body
Image," Archives General Psychiatry, 12(1) :41-47,
Jan. 1966.
Osman, J. D.
"Nutrition Educational: Too Much, Too
Little or Too Bad?" Journal of School Health,
17(10) :592-596, Dec. 1972.
Pliner, P., et al.
"Responsiveness to Affective Stimuli
by Obese and Normal Individuals," Journal of Abnormal
Psychology, 83(1) :74-80, Aug. 1974.
49
"Research Councils Committee on School Health Research,"
Journal of School Health, 44:119-121, March 1974.
Rice, F. P. The Adolescent Development, Relationships
and Culture. Boston: Allyn and Bacon, Inc., 1975.
Rirnrn, I. J., and A. A. Rirnrn.
"Association Between
Juvenile Onset Obesity and Severe Adult Obesity in
73, 532 Women," American Journal of Public Health,
66(5) :479-481, May 1976.
Robinson, C. H. Fundamentals of Normal Nutrition.
Second Edition, MacMillan, 1973.
Sallade, J.
"A Comparison of the Psychological
Adjustment of Obese vs Non-Obese Children," Journal
of Psychosomatic Research, 17:89-97, March 1973.
Seltzer, C. C., and J. Mayer.
"An Effective Weight
Control Program in a Public School System," American
Journal Public Health, 60(4) :679-689, April 1976.
Stanley, E. J., et al.
"Overcoming Obesity in
Adolescents," Clinical Pediatrics, 9(1) :29-36,
Jan. 1970.
Stone, L., and J. Church. Childhood and Adolescence, A
Psychology of the Growing Persons. New York: Random
House, Third Edition, 1973.
·Stuart, R. B.
"A Three-Dimensional Program for Treatment
of Obesity," Behavior Research and Therapy, 9:177-86,
1971.
Stunkard, A., and McLaren-Burne, M.
"The Results of
Treatment for Obesity," A.M.A. Archives of Internal
Medicine, 103:78-85, Jan. 1959.
The Pain of Obesity.
Bull Publishing Co., 1976.
Palo Alto, Calif.:
and M. Mendelson.
"Disturbance in Body
Image of Some Obese Persons," Journal American
Dietitic Association, 38:328-331, April 1961.
"Obesity and Body Image I, Characteristics
of Disturbance in the Body Image of Some Obese
Persons," American Journal Psychiatrv, 123(10):
1296-1300, April 1967(a).
50
"Obesity and Body Image, II, Age at Onset
of Disturbances in the Body Image," American Journal
Psychiatry, 123(11) :1443-1447, May 1967(b) .
•,
-----.,-Archives
et al.
"'l'he Management of Obesity,"
Internal Medicine, 125:1067-1072,
June 1970.
"New Therapies for the Eating Disorders,"
Archives General Psychiatry, 26:391-398, May 1972.
Thomas, Jane E.
"Adolescence and Weight Control," Health
Educational Journal, 36(1) :19-26, Jan. 1977.
Traub, A. C., and J. Orbach.
"Psychophysical Studies of
Body Image," Archives General Psychiatry, 11(1) :53-66,
1964.
Wheeler, M. E., and K. W. Hess.
"Treatment of Juvenile
Obesity by Successive Approximation Control of
Eating," Journal Behavior Therapy and Experimental
Psychiatry, 7(3) :235~241, Sept. 1976.
Wilner, D., et al. An Introduction to Public Health,
MacMillan Publishing Co., 1973.
Winick, M. Childhood Obesity.
and Son, 1975.
New York:
Wyden, P. The Overweight Society.
McLeod, Ltd., 1965.
John Wiley
Toronto:
George J.
APPENDIX A
51
\
"·
Name
School
.
CHART YOUR PROGRESS
Iw~.
2
Wks.
3
Wks .•
I
4
Wks.
I Wks.
5
6
Wks.
7
Wks.
8
Wks.
9
Wks.
10
Wks.
+J
..cb'l ·r-1~
+4
·r-1 1\'J
(!) ~
!$:
+2
+J
Lbs.
~+J
(!)..C:
Ul b'l
(!)·r-1
H
(!)
-2
P-l:S:
-4
-6
-8
--
-10
-12
+J
-14
·r-i 0
-16
..cb'lUlUl
(!)H
~
-18
-20
V1
N
CHART YOUR PROGRESS (Continued)
On this DATE
I started my reducing diet.
On this DATE
I should reach my IDEAL WEIGHT
For an accurate record, weigh
the same weight of clothing.
lbs.
yourself at the same hour each week with approximately
Remember that weight loss is more lasting if it is steady, not based on a "crash diet"
and should not exceed an average of two pounds per week.
ln
w
APPENDIX B
54
55
APPENDIX B
LOS ANGELES UNIFIED SCHOOL DISTRICT
Educational Support Services Division Health Resource Unit
REDUCING DIET
BASIC MENU PATTERN
(With choice of foods allowed)
BREAKFAST
LUNCH
Whole orange of
1/2 grapefruit
One egg - not fried
Butter or margarine
1 tsp
Non-fat milk, 1 glass
1/2 cup cottage cheese or
serving of lean meat
Vegetable
Butter or margarine - 1 tsp.
Fruit
Non-fat milk, 1 glass
DINNER
Serving of lean meat
Green or yellow vegetable
Butter or margarine - 1 tsp.
Salad
Fruit
Non-fat milk, 1 glass
Add ONLY ONE of the following per day to the above menu,
as it suits your pleasure:
1.
2 slices whole grain bread or toast
2. Moderate serving of cooked whole grain cereal,
non-fat milk
3. Moderate serving of potato or brown rice
Due to the restriction of certain foods, it is necessary
to add Vitamin B Complex in amounts suggested by your
physician.
HELPS FOR MEAL PLANNING
For variety of foods you may eat, see Page 2.
foods according to the Basic Menu Pattern.
Choose
56
Appendix B (Continued)
FOODS YOU SHOULD AVOID
Dairy Products
Cheese (limited,
see menu)
Condensed Milk
Whole Milk
Cream
Meats and Fish
Half and Half
Ice Cream
Malted Milk
Salad Dressings
Sour Cream
Duck
Goose
Ham
Lunch Meats
Pork
Fruits
Starches
Baked Beans
Biscuits
Bread (limited
see menu)
Corn
Crackers
Lima Beans
Macaroni
Muffins
Noodles
Parsnips
Salmon
Sardines
Sausage
Tuna
Potatoes
(limited
see menu)
Rice (limited
see menu
Rolls
Spaghetti
Sweet Potatoes
Vermicelli
Yams
Avocados
Bananas
Canned
fruits
Dates
Dried
fruits
Figs
Grapes
Nuts
Olives,
Ripe
and
green
Pomegranates
Prunes
Miscellaneous
Cakes
Candy
Chocolate
Cocoa
Cookies
Corn Chips
Doughnuts
Honey
Jams, Jellies
Nuts
DO NOT EAT:
Oil
Olives
Pickles
Pies and
other
pastries
Popcorn
Potato
Chips
Puddings
Soft
Drinks
Extra
Sugar
Syrups
Fried Foods
Gravy
Cream Soups
Oil Salad Dressings
Salty foods or add extra salt
to foods at the table
57
Appendix B (Continued)
FOODS YOU MAY EAT
Lean Meats, Fish, Poultry, and Dairy Products will help
to resist infections increase muscle tone
Beef
Veal
Lamb
Mutton
Liver
Kidneys
Heart
Tongue
Brains
Sweetbreads
Tripe
Barracuda
Carp
Crab
Filet of Sole
Haddock
Halibut
.Oysters
Shrimp
Chicken
Turkey
Non-fat Milk
fresh or
powdered
Buttermilk
Cottage Cheese
Non-fat Cheese
1 tablespoon
butter or
Margarine
Eggs
Vegetables and Fruits will help you have smooth skin that
does not bruise easily, greater resistance to infection,
healthy gums, improved elimination.
Artichokes
Asparagus
Bean Sprouts
Beets
Brussels
Sprouts
Broccoli
Cabbage
Carrots
Cauliflower
Celery
Chili Peppers
Collards
Cucumbers
Egg Plant
Endive
Green Peppers
Greens, beet
mustard,
turnip
Kale
Lettuce
Mushrooms
Okra
Onions
Peas, green
Pumpkin
Radishes
Sauerkraut
Squash, summer
SpinachString Beans
Swiss Chard
Tomatoes
Turnips
Water Cress
Zucchini
Apples
Apricots
All Berries
All Melons
Grapefruit
Lemons
Nectarines
Oranges
Peaches
Pears
Pineapple
Plums
YOU MAY HAVE:
Moderate servings of the above foods
Vinegar or lemon juice on salads
Whole fruit, not just the juice
Fruit as above, without sugar and cream
Between meal snacks of tomatoes, cucumbers,
celery, radishes, cabbage, or a cup of
plain hot tea or bouillon.
APPENDIX C
58
59
APPENDIX C
NUTRITION TEST
Part I:
Health Ideas
Mark a T for each sentence that is correct and a
F for the sentences that are incorrect.
1.
A nourishing breakfast should supply a fourth oz of a
person's daily protein and calorie requirements.
2.
Fruits and vegetables are good for you because they
contain vitamins and minerals.
3.
The kind of breakfast you eat affects the way you
think and work and how you feel, particularly during
the morning.
4.
You enjoy your food more when you eat quickly.
5.
The suggested servings in the Daily Food Guide
represent maximum amounts.
6.
A soft drink makes an excellent after-school snack.
7.
Your body needs protein in order to build new cells.
8.
The way to make sure that you get the right foods is
to eat as much as you can.
9.
Selecting foods for snacks is just as important as
selecting foods for meals.
10.
The eating habits you develop now will have a great
effect on your health in the years to come.
Part II:
Complete A Meal
Complete pictures one through five on the following
page:
In each row the meal in the yellow box is not balanced.
L.ook at the
beside each meal and mark the
makes the meal balanced.
1
Ice Cream
Ground Beef
Macaroni
Muffin
Tomato
Baked Beans
Cheese
Oatmeal
Cocoa
Peanut Butter
Fruit Salad
Soda Crackers
In each row the meal in the yellow box is not balanced.
Look at the pictures beside each meal and mark the
makes the meal balanced.
Yogurt
Banana
Nuts
In each row the meal in the yellow box is not balanced. Something
is missing. Look at the pictures beside each meal and mark the
food that makes the meal balanced.
Milkshake
Roast Beef
Biscuit
0
Baked Potato
0
Doughnut
[J
Egg