Overweight children are at increased risk of becoming overweight adults, and this risk increases throughout childhood (Whitaker, Wright, Pepe, Seidel, & Dietz, 1997). The odds ratio of becoming an obese adult is 1.3 for overweight 1- to 2-year-olds, 4.1 for overweight 3- to 5-year-olds, and up to 28.3 for overweight 10- to 14-year-olds (Whitaker et al., 1997). Parental obesity is a strong predictor of adult obesity among children less than 10 years old; but among children 10 years old or greater, the child’s weight status is the stronger predictor of adult obesity (Whitaker et al., 1997). Adult obesity is associated with an increased incidence of several cancers, including colon (Murphy, Calle, Rodriguez, Khan, & Thurn, 2000), breast (Carmichael & Bates, 2004; Harvie, Hooper, & Howell, 2003), and endometrial (Kaaks, Lukanova, & Kurzer, 2002) cancers. Insulin-like growth factor 1 (IGF-1), a polypeptide thatenhances tumor development by stimulating cell proliferation and inhibiting apoptosis (Kaaks & Lukanova, 2001), is associated with increased adiposity in both children (Ong, Kratzsch, Keiss, & Dunger, 2002; Wabitsch et al., 1996), and adults (Nam et al., 1997; Voskuil et al., 2001). Elevated levels of IGF-1 have been associated with an increased risk of colon (Giovannucci, 2001), prostrate (Chan, Rimm, Colditz, Stampfer, & Willett, 1994), and breast cancer (Hankinson et al., 1997). Increased levels of certain cytokines such as adiponectin (Mantzoros et al., 2004; Miyoshi et al., 2003) and IL-6 (Fontanini et al., 1999; Onuma, Bub, Rummel, & Iwamoto, 2003; Schneider et al., 2000), and the cytokine-like protein leptin (Hardwick, Van Den Brink, Offerhaus, Van Deventer, & Pepelenbosch, 2001), are elevated with adiposity and increased cancer risk. Elevated insulin levels, as in obesity-related metabolic syndrome and type 2 diabetes, are also a risk for cancer mortality (Borugian et al., 2004). Some breast cancers likely initiated during puberty, with the rapid growth in breast tissue (Colditz & Frazier, 1995). Obese girls may be at greater risk of breast cancer, due to the earlier development (Freedman et al., 2002) and the larger accumulation of breast tissue (Freedman et al., 2003). Thus, childhood obesity increases the risk of a number of cancers.
Disparities in mortality and health outcomes have been established by socioeconomic status and ethnicity both worldwide and in the United States (Kumanyika et al., 2008). Among the many factors contributing to these health disparities in obesity and cancer risks are differences in lifestyle practices, including diet (Kranz et al., 2009) and physical activity (Kumanyika & Yancey, 2009), and the increased adiposity resulting from energy unbalance (Kumanyika et al., 2008). Fruit and vegetable (FV) intake within the context of lower caloric intake (Ledoux, Hingle, & Baranowski, 2010) and physical activity are behaviors directly related to childhood obesity prevention (Roblin, 2007). Helping children to eat more fruits and vegetables and to participate in more physical activity should have long-term health benefits (Baranowski et al., 2000).
Commonly, children consume well below the recommended minimum of five servings of fruits and vegetables per day (Baranowski, Smith, et al., 1997; Domel et al., 1993) and perform physical activity for much less than the recommended 60 minutes per day standard (Troiano et al., 2008). Of particular concern are minority populations with lower income (Taylor, Baranowski, & Young, 1998), who are more sedentary (Taylor, Beech, & Cummings, 1997) and more likely to develop chronic diseases related to sedentary lifestyles than the general population (U.S. Department of Health and Human Services, 1990). Black adolescents and females also report lower preferences for vegetables than their White counterparts (Granner et al., 2004). Since lifestyle interventions have generally not worked among ethnic-minority children (Whitt-Glover & Kumanyika, 2009), effective interventions are needed for low-income and minority populations (Taylor et al., 1998). Since dietary and physical activity habits form in early childhood and are usually maintained into adulthood (Kelder, Perry, Klepp, & Lytle, 1994; Malina, 2008), early intervention should help to reduce multiple health risks. An important related issue is whether interventions initially designed to meet the needs of one specific ethnic minority can be employed across a wider audience.
Behavioral interventions induce changes in mediating variables (i.e., factors that causally influence the behavior, such as the home environment or self-efficacy to perform behavior). Changes in the mediating variables change the behavior (Baranowski et al., 1997). Behavioral interventions need to identify and work in channels appropriate to specific kinds of children to optimize their effect on the mediating variables. Previous research has shown that a badge program could change behaviors among Girl Scouts (Cullen, Bartholomew, & Parcel, 1997). Almost 3 million boys were involved in scouting in the United States in 2008 (Boy Scouts of America, 2008). Scouts are encouraged to take responsibility for developing good health habits, a component of physical fitness (Cullen et al., 1998). "Urban Boy Scouts" provides a promising opportunity to reach inner-city ethnic-minority children (Cullen et al., 1998). Boy Scouts thus provide a promising channel to enable boys to adopt a healthier lifestyle. In light of this opportunity, we built a relationship with the Urban Boy Scout program of the Sam Houston Council in 1998, to enhance their fitness badge programs. The leaders of Urban Scouting were interested in providing meaningful experiences for their scouts, who were at high risk for obesity and consequent cancer. They participated in the program design.
GOAL AND HYPOTHESIS
The goal of this project was to enable Boy Scouts to eat five or more servings of FV and engage in 30 minutes or more of moderate to vigorous physical activity per day. The hypothesis was that a behavior-change program based on social cognitive theory principles and change procedures would help scouts make changes toward these goals.
CONCEPTUAL FOUNDATION
Behaviors are under the influence of multiple factors, making them difficult to change (Baranowski, Lin, et al., 1997). Most identified behavioral influences (candidate mediators for intervention programs) had low predictiveness (Baranowski, Cullen, & Baranowski, 1999) and only a few significantly predicted behavior (Barrios & Costell, 2004). Most childhood obesity prevention programs do not have the desired effect (Brown, Kelly, & Summerbell, 2007). Thus, a challenge is how to design and implement behavioral change procedures among targeted populations through appropriate implementation channels (Kalakanis & Moulton, 2006; O’Connor, Jago, & Baranowski, 2009).
Simply providing children with the knowledge that eating fruits and vegetables and being physically active will prevent obesity, cancer, heart disease, and diabetes does not necessarily motivate them to actively make healthier choices (Contento, 2008). Thus, providing some knowledge of what behaviors to change and how to change them may be necessary, but not sufficient, for behavior change. Health behavior interventions are most likely to be effective if guided by relevant behavioral theories (Contento, Manning, & Shannon, 1992). Using the mediating/moderating variable model as the conceptual framework, interventions need to target variables that influence the behavior (Baranowski, Lin, et al., 1997).
Bandura’s social cognitive theory (SCT) (Bandura, 1986) described a system of triadic reciprocal determinism of cognitive, environmental, and behavioral factors, that has been a commonly used theoretical foundation for behavior change programs. Observational learning, or the vicarious acquisition of knowledge and skills from watching others, is a primary source of information that promotes both cognitive and behavioral development. By observing other people’s behavior, people may acquire information about many challenges, and about the skills needed to overcome them. Self-efficacy is the belief in one’s ability to perform specific behaviors (Bandura, 1977) and mediates the application of knowledge and skills to behavior change (Maibach & Cotton, 1995). Outcome expectancy is the expectation that certain behaviors produce outcomes (Bandura, 1994). People act on their beliefs about what they are capable of doing and about the outcome of their behavior. Linking healthy behaviors to attaining something that kids want (i.e., rewards), such as achievement badges for Boy Scouts, and delivering the message in a fun, interactive way, such as logging into an interactive website to read comics and play online games, should motivate them to improve their diet and physical activity (Baranowski et al., 2002; Jago et al., 2006).
THE INITIAL PROGRAM
The 5-a-Day achievement badge for Urban Boy Scouts was a preliminary intervention designed to help African American Boy Scouts to increase their fruit and vegetable consumption. To ensure that the intervention materials were culturally sensitive (Resnicow, Baranowski, Ahluwalia, & Braithwaite, 1999), focus group discussions were conducted (Cullen et al., 1998). The focus groups (Cullen et al., 1998) found that the urban Boy Scouts’ preference for vegetables was low; their FV-preparation skills were limited; and they did not purchase FV for snacks. Although FV were available at home, they were not in easily accessible forms, and the boys reported low participation in food preparation. They reported setting only global goals (e.g., general aims such as getting good grades or being popular at school) and did not understand self-monitoring their progress toward achieving their goals. Although African American (AA) boys were likely to consume FV as often as corresponding European American boys, there were ethnic differences regarding the type of FV consumption. For example, African American boys were more likely to have eaten potato salad, whereas European American boys were more likely to have consumed bananas, strawberries, watermelon, other white potatoes, corn, salsa, and vegetable soups.
A pilot test (Baranowski et al., 2002) was conducted with Boy Scouts and their families to assure clarity of message, relevance, and acceptance by the target group. Although the pilot test resulted in a 0.8 FV serving increase (Baranowski et al., 2002) among African American Boy Scout troops in Houston, Texas, the research team learned that the 1-hour educational session during every week’s troop meeting conflicted excessively with other troop responsibilities. As a result, many of the in-troop behavioral components were transferred online, so as to minimize troop time.
Two innovative Boy Scout badge programs were developed, each with 9-session in-troop activities, plus corresponding weekly Internet activities. Troop leaders led the weekly in-troop sessions, which focused on fun (as an outcome expectation) and interactive skill-building activities that taught the scouts related functional knowledge and skills to enhance the scouts’ self-efficacy, and allowed them to achieve their behavior change goals. The online components incorporated fun and interactive role modeling, goalsetting, goal review, and problem-solving elements that allowed the scouts to set and review their behavioral change goals, and solve potential problems throughout that process. Each week, the in-troop interactive activities took about 20-30 minutes, and the online program activities took about 10-20 minutes to complete, giving a total of about 30-50 minutes of program activities. The completion of goals took additional time at home during the week, depending on the goals that the scouts set, for which the scouts received goal points toward earning their respective badges (5-a-Day or Fit-for-Life).
THE 5-A-DAY BADGE PROGRAM
The goal of the 5-a-Day badge program was to help scouts learn to eat at least five servings of FV a day, by setting weekly goals to eat FV at a specific meal or snack, and establishing skills and an environment supportive of that. Each week during the troop meeting, the scouts participated in the 5-a-Day badge skill-building activities, which were focused on learning FV preparation skills (by preparing meal-specific, quick, and easy FV recipes that had been taste tested with boys prior to the program). Such in-troop preparation of simple recipes taught scouts recipe preparation skills, and the tasting should have enhanced their preference for FV (Birch, McPhee, Shoba, Pirok, & Steinberg, 1987). The scouts received a 5-a-Day recipe topic with all the troop recipes, and additional ones to prepare later at home.
Week 1 in-troop activities: At the initial troop meeting, troop leaders announced the new 5-a-Day achievement badge and explained the requirements for earning the badge, including attending meetings, preparing FV recipes, logging onto the badge website, and completing goal-setting and monitoring tasks. The scouts were given rules and safety tips to follow during recipe preparation, including always to wash their hands before handling or eating food, the fundamentals of collecting ingredients, and cooking utensils, knife, and other kitchen equipment safety information; they were instructed to always have an adult present to supervise them, since most boys around 10-14 years old do not have enough experience to prepare recipes by themselves. The weekly recipe preparation assignment chart and the rotation of duties were explained and the scouts were given their first recipe to prepare for tasting. The food preparation process was completed solely by the scouts, but was closely supervised by the troop leader. The scouts were given a "My Way to 5-a-Day" motto, to help them remember how to find and prepare FV they liked to eat. At the end of each session, the troop leader reminded the scouts to go to the badge website that evening or the next day, to set their badge goal to eat FV for an after-school snack.
Week 2 in-troop activities: At the beginning of each subsequent week, the troop leader met with each scout, prior to the formal troop meeting, to review his web log-in and goal achievement. This week, the scouts played a "SOLVE IT" game (based on the TV game show Family Feud) to problem-solve ways to overcome barriers to meeting their badge goal. The game scenarios included common problems that scouts have in meeting their goal to eat FV for a meal or snack. Then the scouts discussed the next week’s goal, to eat a fruit or drink a 100% fruit juice for breakfast, and prepared two breakfast fruit smoothie recipes to taste.
Week 3 in-troop activities: The scouts talked about what they usually ate for an after-school snack and how they could incorporate FV snacks into their usual routine. They discussed the next week’s goal, to eat FV for an after-school snack, and prepared two fruit snack recipes to taste.
Week 4 in-troop activities: The scouts talked about what they usually ate for school lunch and how they could incorporate a vegetable snack into their usual lunch. They discussed the next week’s goal—to eat a vegetable at school lunch—and prepared two vegetable lunch recipes to taste.
Week 5 in-troop activities: The scouts talked about what vegetable they usually ate for dinner. Since increased availability and accessibility of FV at home has been correlated with intake (Jago, Baranowski, Baranowski, Cullen, & Thompson, 2007), scouts used role-playing activities to learn asking and negotiating skills so that they could ask for FV at home. This prepared them for setting their next week’s goal, to eat a vegetable at dinner. The scouts then prepared two vegetable dinner recipes to taste.
Week 6 in-troop activities: The scouts talked about what they usually ate at their favorite fast-food restaurant and how they could incorporate FV into their selections, using real fast-food restaurant menus to find appropriate choices. They also discussed the next week’s goal, to eat FV at a fast-food restaurant. Next the scouts prepared two 100% fruit juice drink recipes to taste.
Week 7 in-troop activities: The scouts reviewed what they learned about eating FV for meals and snacks, and completed a worksheet to create their own "My Way to 5-a-Day" plan for their goal to eat five servings of FV on Saturday and Sunday during the upcoming weekend. Next, the scouts prepared two vegetable snack recipes to taste.
Week 8 in-troop activities: The scouts reviewed what they had learned about eating FV for meals and snacks while working on the 5-a-Day badge. They played a "Top 10" game to help them create their own "My Way to 5-a-Day" plan to meet next week’s goal, to eat five servings of FV every day after they received their 5-a-Day badge. Next, the scouts prepared their own combination of vegetables in a "That’s a Wrap" sandwich recipe to eat.
Week 9 in-troop activities: The 5-a-Day achievement badge award ceremony was held. Troop leaders repeated the purpose of the badge program, then congratulated and recognized all scouts who had successfully completed the 5-a-Day achievement badge requirements and earned their badge. Each scout’s name was called as he was presented with the 5-a-Day achievement badge, given a handshake, and told that he should wear it with pride, knowing that he had achieved the goal of learning how to eat five servings of FV a day, every day. The troop leader ended the ceremony by reminding the scouts to continue to eat five servings of FV every day.
In addition to the weekly troop meeting activities, scouts logged onto the badge website each week, where they set their badge requirement goals to eat FV and make FV recipes at home. To ensure that the badge goals only included FV, scouts played video games on the website to learn what foods counted as FV, and what food items—such as juice drinks, Kool-aid, apple pie, French fries, and so on—were excluded, either because they did not have enough FV or because they were too high in fat and sugar. To be counted, a FV goal must include at least a full serving of FV and must be cooked without fat. The goals on the badge website had the scouts clearly state what behavior they would do, as well as when and how they would do it (i.e., action implementation intentions). Scouts had one week in which to complete each badge requirement goal. The troop leader monitored the scouts’ weekly log-ons and accumulated points.
The welcome page featured four cartoon images of the "Troop 5 Alive" scouts of different racial and ethnic groups, with a black background color. Each participating scout had his own username and password to log into the website, and was encouraged to log in at least twice a week. The initial login was to set their goal, and the second was to record achievement of their goal before the next week’s troop meeting. Once logged in, the badge website page contained three sections. At the top was a "5-a-Day" bar, showing the scout’s progression across the week’s goals. On the left navigation panel there were different tabs, containing the various games and goal sections for the 5-a-Day badge.
The scouts set their 5-a-Day badge goal by clicking on "Go for the Goal" button on the left. That week’s goal (e.g., after-school veggie snack for 3 days plus prepare 5-a-Day badge recipe at home) and goal statement (e.g., this week, your goal is to eat one more serving of veggies than you usually eat for an after-school snack on three different days) would appear in the middle of the screen. By clicking on the "start" button, the scouts were directed to "Go for the Goal," where they selected the dates and the targeted FV for each week’s goals. At the end, the scouts would see a summary page with the days and FV that they had chosen to meet those goals. Next, they set the Snack Down Recipe Goal by clicking on the recipe that they wanted to prepare at home for their family for the goal. They could also view recipes before making the selection. After selecting the day on which they wanted to make the recipe, they could print their detailed goal to post on the refrigerator, as a reminder of what they needed to do for the week.
When the scouts had completed their goals, before they came back to the troop meetings next week, they logged onto the website to review their goals, and to indicate the completion of the goals by checking the boxes under each goal. Those who did not meet their weekly goals participated in online and in-person problem-solving (i.e., coping implementation intentions). The in-person problem-solving session would be conducted by the troop leader just prior to the weekly meetings.
In addition to the goal-setting component, the badge website contained a number of activities (Real Times 5, Make Your Mark, Add ‘Em Up, Snack Down Recipe, Are You Game? and SOLVE IT) with which the scouts could interact during the week.
Real Times 5 was a weekly comic strip about how the "Troop 5 Alive" scouts, Jason, Jamal, Carlos, and David, met their weekly goals to earn their 5-a-Day badge. Each weekly comic described how these scouts achieved goals similar to those of the real scouts, as well as overcoming problems through self-regulatory and asking skills. Self-monitoring and problemsolving elements were included for the real scouts, to enhance their self-regulatory skills. Each episode ended with a cliff-hanger, or an unresolved problem likely to keep one of the scouts from achieving his dietary goal (e.g., a scout told his friends that he wanted to drop out of the program because his mother did not keep fruits and vegetables at home). As in a soap opera, this was intended to attract the real scout to return to the website, to find out what happened next.
Make Your Mark was a weekly problem-solving poll that asked scouts how they would solve the cliff-hanger to the problem that "Troop 5 Alive" encountered in meeting their badge requirements. The scouts read the problem and chose what they thought was the best solution for the comic character to meet the 5-a-Day badge goal. The poll provided various solutions, including both good and bad ones. After selecting a solution, a scout was given feedback on whether or not the selected solution would likely work, and why.
In the Add ‘Em Up section, a scoreboard displayed each scout’s current total of 5-a-Day badge points toward receiving their badge.
Snack Down Recipes was the online archive that stored the weekly troop and web recipes as part of the 5-a-Day badge.
In the Are You Game? section, scouts used the FV skills and knowledge learned during troop meetings to play games for additional knowledge points toward their badge. The scouts competed against other scouts in their troop in this section, and could earn "Elite 5" status if they obtained one of the top five scores on a particular game. Due to the competition factor, this was one of most visited sections of the badge website.
SOLVE IT helped a scout who experienced problems meeting his goals to find a workable solution to meet his next goal. A tailored step-by-step plan to identify the barriers and ways to overcome the barriers was created. The scout was able to print the solutions to help meet his goals. Scouts received points for completing the SOLVE IT activity. To make the process easy to remember and interesting, a SOLVE IT Rap was included:
"S" Solvin’ problems / won’t take long
"O" Once I know / what went wrong
"L" Look at ways / write them down
"V" Vote for one / works all round
"E" Eager to try / my new plan
In the event that the troop members needed to contact the troop leader or had some problems with the website, they could click the "Contact Us" button and type in the message through an online form. The intervention staff answered questions within 24 hours.
Each week, the scouts earned points toward the 5-a-Day badge for participating in the in-troop activities, logging onto the badge website, setting their behavioral goals, and completing their weekly goals. Scouts had to earn at least 10,200 of the total 17,600 possible points, to earn the 5-a-Day achievement badge. Scouts earned 100 points per week by attending weekly troop meetings, and participating in the badge activities during the troop meetings; 100 points per week by logging onto the website to set the weekly goals; 100 points per week by viewing the online comics; 100 points per week by participating in problem-solving polls; 100 points per week by recording how they did on their goals at the end of the week; 1,000 points per week by achieving the 5-a-Day goal; and 500 points per week by preparing a 5-a-Day web recipe for their families. The participants could also earn an extra 100 points by returning completed problem solutions to help meet their 5-a-Day goals, and an additional 100 points by cleaning up after the troop meetings each week.
