Challenge l Goal l Study Design l Intervention Procedures l Outcomes l Publications l Related Studies American Indian communities suffer from obesity and diabetes at much higher rates than even the general U.S. population, which in recent years has seen an alarming increase in obesity and its adverse health effects. Given the poor long-term success rate of obesity treatment programs in the general adult population, systematically reducing obesity will require an effective primary obesity prevention program targeted towards young people.
Because of the critical need for obesity prevention in American Indian communities, researchers designed an intervention study for a primary prevention program with school-aged American Indian children. This multi-site project was completed in 1999.
To develop, implement, and evaluate a culturally appropriate, school-based intervention to promote healthful eating behaviors and increased physical activity and to prevent obesity in American Indian children.
Pathways was a two-phased, school-based, randomized trial involving six American Indian Nations collaborating with five universities: - Pima/Maricopa and Tohono O'odham with the University of Arizona
- Navajo with the University of New Mexico
- White Mountain Apache with the Johns Hopkins University
- Oglala Lakota and Sicangu Lakota with the University of Minnesota.
- The University of North Carolina is the Coordinating Center for the project.
In pursuing the Pathways study, scientists had to earn the trust and cooperation of the Indian communities by developing a genuine partnership with nonscientist American Indians who could be fully involved in the decision making process and contribute to the creation of a culturally acceptable, and scientifically rigorous, intervention. The feasibility phase was funded from September 1993 to August 1996 to plan, develop, pilot test, and assess the feasibility of conducting the full-scale study.
This phase aimed to: - determine if tribal governments, community leaders, families, school staff, and children were supportive and willing to participate in an obesity prevention program like Pathways;
- develop and pilot-test an intervention composed of food service, physical activity, and a classroom curriculum with a family component; and
- develop a field method of assessing body fat in American Indian children.
Once these were accomplished, phase two -- the full scale study -- began.
1996: The full-scale study phase was funded in September for a five-year period.
1997: Researchers began collecting baseline data at 41 elementary schools primarily serving American Indians in the Spring. Twenty-one schools were randomly selected to implement the intervention and 20 served as comparison schools. The Coordinating Center (University of North Carolina) took data on the median percent body fat at each school and ranked them into two categories. They then randomly assigned half the schools in each group to be intervention schools.
1997: Researchers began collecting baseline data at 41 elementary schools primarily serving American Indians in the Spring. Twenty-one schools were randomly selected to implement the intervention and 20 served as comparison schools. The Coordinating Center (University of North Carolina) took data on the median percent body fat at each school and ranked them into two categories. They then randomly assigned half the schools in each group to be intervention schools.
The three-year intervention, which included components related to physical activity, school food service, classroom curriculum, and family support, began with third grade children and lasted through the end of their fifth grade school year. Physical Activity: 
The physical activity portion of PATHWAYS encouraged the schools to increase high-energy activities in physical education classes and recess, with an emphasis on playing traditional Native American games.
Researchers measured physical activity by using a physical activity recall questionnaire (PAQ) and a Tritrac accelerometer. The PAQ, designed to assess activity during the preceding 24 hours, provided information about the frequency and type of physical activity children engaged in, as well as an estimate of the intensity of those activities.
The Tritrac accelerometer, a small, lightweight unit children wore for discrete periods of time, provided a more objective estimate of total activity at baseline and after the intervention. | Food Service:
PATHWAYS investigators, nutrition staff, and food service personnel at the four intervention schools collaboratively developed the food service program that provided nutritional, low-fat cafeteria meals. Through educational materials, trainings, and kitchen visits, nutrition staff helped food service personnel at each intervention school to develop and implement specific food preparation and selection guidelines. | Classroom Curriculum:
The classroom curriculum, designed for third, fourth, and fifth grade children, addressed certain high-risk behaviors identified during the formative assessment. Using social learning theory, the curriculum committee developed stories and activities based on the journey of two fictional American Indian children, Amanda and Daryl White Horse, through the six PATHWAYS nations. Drawing on the American Indian storytelling tradition, this curriculum also reinforced a rich cultural heritage of healthful eating and physical activity while highlighting local customs and practices and incorporating hands-on activities and games. PATHWAYS staff trained school teachers and provided instruction manuals and visual materials to accompany lesson plans to ensure that the curriculum was uniformly implemented between classes and schools. | Family Support: 
To address family-related high-risk behaviors, investigators developed three primary strategies to engage family support for the intervention. 1) Family fun nights: These evenings included dancing and noncompetitive physical activities. They also included taste tests so children and their parents could sample tasty low-fat foods.
2) Family take-home “action packs” and “snack packs”: The action packs included written suggestions for meals and physical activities to involve the whole family. The snack packs provided locally available, low-fat, low-sugar foods for the child to share with the whole family.
3) School-based family advisory councils: PATHWAYS staff described the objectives and components of the intervention at an initial meeting with parents, at which time they were invited to attend future meetings. Each successive meeting provided a forum for family and community members to ask questions, and offer support for or objections to proposed intervention strategies as those evolved. |
The primary measure of intervention effectiveness was the mean difference between intervention and control schools in percent body fat (adjusted for baseline percent body fat) at the end of the fifth grade. Percent body fat (PBF) was estimated using an equation developed during the feasibility phase using measurements of height, weight, skinfold thickness, and bioelectrical impedance.
Secondary outcomes included improved changes in terms of physical activity, dietary intake, knowledge, attitudes, and behavior.
While the program had significant effects on several components of knowledge, attitudes, and behavior, it did not reduce the students' percent body fat. Key findings: - A significant reduction in percent of calories from fat did not result in a reduction in dietary energy intake (lunch).
- A combination of global and targeted interventions may be needed.
- School-based interventions need to be complemented by community and household programs.
Press release about publication of final resultsCaballero et al Final results from the Pathways obesity prevention randomized trial. Am J Clin Nutr 2003;78:1030-8.
Caballero B, Himes JH, Lohman T, Davis SM, Stevens J, Evans M, Going S, Pablo J; Pathways Study Research Group. Body composition and overweight prevalence in 1704 schoolchildren from 7 American Indian communities. Am J Clin Nutr. 2003 Aug;78(2):199-200. Caballero B, Davis CE, Evans MD, Davis SM, Story M, Stephenson L, White JA, Ethelbah B, and Lohman TG. Pathways: A School-Based Program for the Primary Prevention of Obesity in American Indian Children. J Nutr Biochem 1998; 9:535–543 Caballero B. Introduction to the Pathways Supplement. Am J Clin Nutr. 1999; 69:745S-746S Davis CE, Hunsberger S, Murray DM, Fabsitz RR, Himes JH, Stephenson LK, Caballero B, and Skipper B. Design and statistical analysis for the Pathways study.
Am J Clin Nutr 1999 69: 760S-763S Davis SM, Going SB, Helitzer DL, Teufel NI, Snyder P, Gittelsohn J, Metcalfe L, Arviso V, Evans M, Smyth M, Brice R, Altaha J. Pathways: a culturally appropriate obesity-prevention program for American Indian schoolchildren. Am J Clin Nutr 1999 Apr; 69(4 Suppl): 796S-802S Caballero B, Himes J, Lohman TG, Davis S, Stevens J, Evans M, Going S, and Pablo J. Body composition and obesity prevalence in American Indian schoolchildren enrolled in the Pathways study. Obesity Res 1999;7:22S Gittelsohn J, Evans M, Story M, Davis SM, Metcalfe L, Helitzer DL, and Clay TE. Multisite formative assessment for the Pathways study to prevent obesity in American Indian schoolchildren. Am J Clin Nutr 1999; 69:767S-772S Gittelsohn J, Toporoff EG, Evans M, Anliker J, Davis S, Sharma A, and White J. Food perceptions and dietary behavior of American Indian children, their caregivers and educators: formative assessment findings from Pathways. J Nutr Ed 2000; 32:2–13 Lohman TG, Caballero B, Himes JH, Hunsberger S, Houtkooper L, Going SB, Weber J, Reid R, Davis CE, Stewart D, and Stephenson L. Estimation of body fat from anthropometry and bioelectrical impedance in Native American children Int JObes 2000; 24:1–7 Story M, Evans M, Fabsitz R, Clay T, Holy Rock B, and Broussard BA. The epidemic of obesity in American Indian communities and the need for childhood obesity-prevention programs. Am J Clin Nutr 1999; 69:747-754
- Apache Healthy Stores: Store-based intervention to reduce obesity and chronic disease in the White Mountain and San Carlos Apache Tribes
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