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Service Delivery Innovation Profile

Comprehensive School-Based Program Increases Positive Health Behaviors and Reduces Risk Factors for Type 2 Diabetes Among Mexican-American and Other At-Risk Youth


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Snapshot

Summary

The Bienestar Health Program is a comprehensive and culturally competent school-based behavior modification program intended to prevent or delay the onset of type 2 diabetes among Mexican-American and other at-risk youth. The program uses multiple interventions across a variety of settings and audiences to enhance participants' self-efficacy in making healthy choices around nutrition and physical activity. The program increases positive health behaviors and reduces risk factors for type 2 diabetes among participants.

Evidence Rating (What is this?)

Strong: The evidence consists of three cluster-randomized control studies of the program, comparing fitness levels, fiber intake, blood sugar levels, body mass index, waist circumference, fasting insulin levels, and prevalence of obesity among students in intervention and control group schools.
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Developing Organizations

Social & Health Research Center; Texas State University-San Marcos - Department of Curriculum and Instruction; University of Texas at San Antonio - Department of Counseling, Educational Psychology and Adult and Higher Education; University of Texas at San Antonio - Department of Health and Kinesiology; University of Texas Health Science Center - Department of Pediatrics
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Use By Other Organizations

The Bienestar program has been approved by the Texas Education Agency and is being implemented in elementary schools across 27 Texas school districts, most of which are located in low-income neighborhoods in the cities of San Antonio and Laredo. The program is also being implemented in the Yakima Valley Independent School District in Washington State and in the Lafayette Parish Independent School District in Louisiana. In addition, the program has been implemented and is currently being evaluated in 20 Mexican elementary schools in Ciudad Victoria, Tamaulipas.

Date First Implemented

1995
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Patient Population

Age > Adolescent (13-18 years); Child (6-12 years); Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Immigrantsend pp

Problem Addressed

Diabetes is one of the most common chronic diseases affecting children in the United States. Although childhood diabetes has traditionally been type 1 (juvenile-onset) diabetes, an increasing number of U.S. children and adolescents, especially Hispanic/Latino and other minority youth, have been diagnosed with type 2 (adult-onset) diabetes over the past 20 years.1 Obesity and physical inactivity are major factors contributing to this increase.
  • High prevalence, with increases in type 2 diabetes, especially among Hispanics: More than 215,000 children and adolescents younger than 20 years have diabetes.2 Although no hard data are available, researchers estimate that type 2 diabetes accounts for between 8 and 45 percent of all new cases of childhood diabetes.1 Type 2 diabetes is more common among Hispanic children than their non-Hispanic white counterparts.1
  • Obesity and inactivity a contributing factor: Obesity and lack of physical activity have been identified as major factors contributing to the increased prevalence of type 2 diabetes among school-aged children and adolescents.1,3

What They Did

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Description of the Innovative Activity

The Bienestar Health Program is a comprehensive, bilingual, school-based behavior modification program designed to prevent or delay the onset of type 2 diabetes in Mexican-American and other at-risk youth. The program delivers three main health messages (increase dietary fiber intake, decrease saturated fat intake, increase physical activity) across multiple settings and audiences. The five key components of the program, offered in both English and Spanish, are as follows:
  • Health education: The health education component is administered in 45-minute sessions once a week over 13 weeks; sessions address nutrition, exercise, self-control, self-esteem, and diabetes.
  • Physical education: The physical education component promotes physical activity through 32 moderate to vigorous physical activities administered in 45-minute sessions four times per week.
  • Student health club: The student health club consists of a 1-hour meeting held 1 day per week after school for 26 weeks. The club is designed to reinforce classroom activities through physical activities, cooking classes, and crafts. Student participation is voluntary and parents are encouraged to attend.
  • Family education: The family education component consists of quarterly newsletters and 1-hour meetings held with parents once every 2 months. Parent meetings consist of four kinds of activities: cooking demonstrations, dancing (e.g., salsa), a nutrition game (e.g., bingo), and an exercise game (e.g., "wheel of health").
  • School cafeteria: The cafeteria component, which is designed to improve food service staff knowledge of diabetes and nutrition, includes seven lessons conducted in 30-minute increments; sessions are held once a month during break times. Topics covered include purchasing and preparing healthy food selections, improving presentation of healthy foods, and persuading students to make healthier choices (e.g., eat more fruits and vegetables and fewer fatty foods).

Context of the Innovation

The Bienestar program is a collaborative effort involving the Social & Health Research Center, the University of Texas at San Antonio, and Texas State University-San Marcos. The Social & Health Research Center is a nonprofit organization committed to improving the health and social well-being of at-risk populations. The University of Texas at San Antonio is the second largest component of the University of Texas system with six colleges and three campuses. Texas State University-San Marcos (formerly Southwest Texas State University) is a major university with 10 colleges and two campuses. The impetus for the Bienestar program came from Dr. Roberto Treviño, who gained significant experience in treating diabetes through his work in critical care at four San Antonio hospitals and through his medical practice, an 18-physician group that provides care in five clinics located in low-income neighborhoods. These experiences made it clear to Dr. Treviño that a new approach was needed, because the traditional medical model is not effective in reducing the incidence or complications of type 2 diabetes.

Did It Work?

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Results

The Bienestar Health Program has provided health information and services to hundreds of children in 27 school districts across Texas. Two cluster-randomized control studies have found that the program increased physical fitness and dietary fiber intake and reduced blood sugar levels, changes that should lead to reduced risk of type 2 diabetes. Information provided in October 2011 indicates that a third cluster-randomized controlled trial also found that the program reduced risk factors, including body mass index, percentage of children with waist circumference at or above the 90th percentile, fasting insulin levels, and prevalence of obesity.
  • More children served, particularly in Hispanic and low-income communities: The Bienestar program is being implemented in 397 schools (302 elementary and 95 middle) within 27 school districts across the state of Texas. The majority of these schools are located in the southwestern portion of the state and have large Hispanic and economically disadvantaged student populations. For example, Hispanics comprise between 83 and 98 percent of the total student population of 95,406 within the five San Antonio school districts currently implementing the program. In addition, 76 to 98 percent of students in these five districts are eligible for the free and reduced lunch program.
  • First study finds increased fitness and fiber intake, reduced blood sugar levels: Twenty-seven inner-city San Antonio, TX, elementary schools serving primarily Mexican-American and economically disadvantaged fourth graders were randomly assigned to either intervention (n = 13) or control (n = 14). This study yielded the following results:
    • Lower blood sugar levels: Mean fasting capillary glucose levels for students in intervention group schools decreased (87.72 to 87.53), while levels increased (89.47 to 89.99) for students in control group schools.
    • Better fitness levels: Mean fitness scores significantly increased (63.9 to 65.71) for students in intervention group schools and declined (65.93 to 65.2) for those in control group schools.
    • More fiber intake: Mean dietary fiber intake significantly increased (11.15 to 11.53) for students in intervention group schools and declined (10.79 to 10.65) for those in control group schools.
    • No impact on fat intake and body fat: There was no significant difference between intervention and control group schools regarding body fat percentage and saturated fat intake.
  • Second study shows increased fitness: Nine elementary schools serving 561 fourth-grade students from inner-city neighborhoods were randomly assigned to either intervention (n = 5) or control (n = 4). The study found a statistically significant increase (+2.9 points) in mean physical fitness scores for students in intervention group schools and a decrease (–.2 points) in mean physical fitness scores for students in control group schools.
  • Third study shows improvement in several risk factors: In a study of 42 schools and more than 4600 students, children in intervention schools had a lower risk of having type 2 diabetes risk factors—measured by body mass index, percentage of children with waist circumference at or above the 90th percentile, fasting insulin levels, and prevalence of obesity—than children in the control group. For example, children in the intervention schools had 19 percent lower odds of being obese at the end of the study than those in the control group, and intervention group participants exhibited a lower fasting insulin level than control group participants (updated October 2011).

Evidence Rating (What is this?)

Strong: The evidence consists of three cluster-randomized control studies of the program, comparing fitness levels, fiber intake, blood sugar levels, body mass index, waist circumference, fasting insulin levels, and prevalence of obesity among students in intervention and control group schools.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Theoretical grounding: A review of diabetes and obesity literature suggested that knowledge-based approaches to weight reduction and healthy lifestyle promotion were not effective in sustaining desired behavioral changes (e.g., making healthy food choices). This realization led to the adoption of a social learning model with social systems approach, which is the cornerstone of the Bienestar program.
  • Program modification based on pilot test and ongoing evaluation: Project developers piloted the Bienestar program for 2 years with fourth grade students in two parochial schools in San Antonio's poorest school district. Developers modified the program based on the findings of this study and subsequent evaluations. The program is currently being evaluated in 20 Mexican elementary schools in Ciudad Victoria, Tamaulipas.

Resources Used and Skills Needed

  • Staffing: The Bienestar program requires staff time comparable to other Texas Education Agency–approved school health programs and generally does not require the hiring of additional staff. Existing physical education teachers implement the health and physical education components, food service staff implement the cafeteria component, parent liaisons (usually school-level administrative staff) mail out the Parent Newsletter, and after-school caretakers implement the student health club component. Once adopted by a school, the program is institutionalized and sustained by existing school staff.
  • Training: Half-day training is available for school administrators and school personnel (e.g., physical education teachers, cafeteria managers) involved in implementation of any component of the program.
  • Costs: Costs are minimal, consisting primarily of program materials, the cost of which depend on the format desired (e.g., consumable versus nonconsumable workbooks) and the number of students targeted. For example, the cost is $12 per student to purchase the health education, physical education, and food service component workbooks and family education newsletter.
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Funding Sources

National Institute of Diabetes and Digestive and Kidney Diseases (U.S.); University Health System - Bexar County, TX; San Antonio Metropolitan Health District
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Tools and Other Resources

Printed and electronic program materials, including teacher manuals and student workbooks for grades K through 8, are available through the Social & Health Research Center. See http://www.sahrc.org for more information.

Adoption Considerations

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Getting Started with This Innovation

  • Secure buy-in from school and district leaders: Because student achievement in key academic areas takes precedence in most schools, it is essential to convince school and district leaders of the importance of targeted, structured health education and of the benefits of improving overall health as a complement to academic achievement.
  • Use available program materials: Although potential adopters may elect to develop their own materials and training approaches based on publicly available information, Bienestar program curricula and program-related materials are available through the Social & Health Research Center.
  • Arrange training for school personnel: Although not required, it is highly recommended that school personnel involved in the implementation of any component of the Bienestar program attend a half-day training session, which is available through the Social & Health Research Center.

Sustaining This Innovation

  • Train new staff: New school personnel need to be trained before they can take over the program responsibilities of departing staff members.
  • Provide adequate preparation time: It is important to provide program personnel with adequate time to prepare for activities and distribute educational materials (e.g., newsletters).

Use By Other Organizations

The Bienestar program has been approved by the Texas Education Agency and is being implemented in elementary schools across 27 Texas school districts, most of which are located in low-income neighborhoods in the cities of San Antonio and Laredo. The program is also being implemented in the Yakima Valley Independent School District in Washington State and in the Lafayette Parish Independent School District in Louisiana. In addition, the program has been implemented and is currently being evaluated in 20 Mexican elementary schools in Ciudad Victoria, Tamaulipas.

More Information

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Contact the Innovator

Roberto P. Treviño, MD
Executive Director
Social and Health Research Center
1302 S. St. Mary's
San Antonio, TX 78210
Phone: (210) 533-8886; (866) 676-7472
Fax: (210) 533-4107
E-mail: rptrevino07@msn.com

Innovator Disclosures

Dr. Treviño reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

References/Related Articles

The HEALTHY Study Group, Foster GD, Linder B, et al. A school-based intervention for diabetes risk reduction. N Eng J Med. 2010 Jul 29:363(5):443-53. [PubMed]

Treviño RP, Yin Z, Hernandez A, et al. Impact of the Bienestar school-based diabetes mellitus prevention program on fasting capillary glucose levels: a randomized controlled trial. Arch Pediatr Adolesc Med. 2004 Sep;158(9):911-7. [PubMed]

Treviño RP, Pugh JA, Hernandez AE, et al. Bienestar: a diabetes risk-factor prevention program. J Sch Health. 1998 Feb;68(2):62-7. [PubMed]

Treviño RP, Hernandez AE, Yin Z, et al. Effect of the Bienestar health program on physical fitness in low-income Mexican American children. Hisp J Behav Sci. 2005 Feb;27(1):120-32.

The Bienestar school-based program for preventing diabetes in schoolchildren: an interview with Roberto P. Treviño, MD. Therapeutic Strategies in the Intervention of Coronary Events. 2005 Dec;10-13.

Footnotes

1 Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2006. Atlanta, GA: U.S. Department of Health and Health Services, Centers for Disease Control and Prevention; 2007.
2 American Diabetes Association. Diabetes statistics [Web site]. Available at: http://www.diabetes.org/diabetes-basics/statistics/.
3 National Center for Health Statistics. Health, United States, 2008: With Chartbook. Hyattsville, MD: 2009. Available at: http://www.cdc.gov/nchs/data/hus/hus08.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.).
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Original publication: November 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: September 25, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.