Open Journal of Pediatrics, 2013, 3, 300-305 OJPed Published Online December 2013 (
Delivery and evaluation of a pilot obesity prevention
project for urban Appalachian children*
Laura Nabors1#, Michelle Burbage1, Jordan Pangallo1, Amy Bernard1, Amanda Strong1,
Sarah Gardocki1, Phyllis Shelton2, Donna Jones2
1University of Cincinnati, Cincinnati, USA
2Urban Appalachian Council, Cincinnati, USA
Received 11 September 2013; revised 8 October 2013; accepted 15 October 2013
Copyright © 2013 Laura Nabors et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Prevention of childhood obesity is a national concern
and there is a need for interventions that can be im-
plemented in community programs and are brief in
nature. This pilot project was developed to evaluate
the impact of the Children’s Healthy Eating and Ex-
ercise Program, which was adapted from the Traffic
Light Diet. Participants were urban Appalachian
children and adolescents who were enrolled in one of
two community-based summer programs. Quantita-
tive and qualitative methods were used to examine
children’s impressions of the program and to assess
what they learned during implementation of the pro-
gram. Results indicated that younger children re-
ported consuming fewer French fries or chips and
older children reported eating more vegetables at the
end of the program. Knowledge of two categories of
Traffic Light foods appeared good; however, partici-
pants showed lower knowledge about one of the food
categories. Future studies should involve parents as
well as incorporate a more rigorous evaluation design
with a comparison group to examine the impact of
this new program.
Keywords: Obesity Prevention Program for Children
With childhood obesity at epidemic proportions in our
nation, there is a growing need to find effective ways to
combat the problem and decrease children’s risk for
health hazards that result from unhealthy lifestyles [1].
Since, overweight children face significant risk of re-
maining obese and health risks in adulthood, early inter-
vention and prevention efforts are needed to address this
serious health problem [2]. Riggs et al. suggested that
prevention programs aimed at improving knowledge
about healthy eating and exercise, to encourage the de-
velopment of healthy lifestyles and prevent obesity are
needed [3]. Translating effective intervention into com-
munity-based prevention programs is an important goal
for researchers [4].
Children and adolescents are bombarded by informa-
tion about “junk food” [5]. Moreover, snack foods that
are relatively high in calories and have reduced nutri-
tional value are often more readily available than fruits
and vegetables [6]. Children in urban, low-income areas
are at risk for becoming overweight and may have poor
access to healthy food choices [7]. Goals of the current
pilot project were to describe the initial implementation
and evaluation of a healthy eating and exercise program
for children residing in low-income families in an urban
Appalachian area. There are a few studies assessing pre-
vention programming for Appalachian youth residing in
rural areas [8]. However, information is lacking about
obesity prevention programs for Appalachian youth in
urban settings. Additionally, programs typically are de-
livered in school or clinic settings, and more research is
needed on prevention programs delivered in other com-
munity settings, such as church programs or community
centers [4].
The current program was based on the Traffic or Stop
Light Diet developed by Leonard Epstein [9]. Schetzina
et al. implemented the Winning with Wellness Pilot Pro-
ject at a school in Tennessee, and the Traffic Light Diet
influenced their program as well [8]. The Winning with
Wellness Project promoted healthy eating and increased
activity at an elementary school in a rural Appalachian
area. The three categories of foods in the Winning with
Wellness Project were adapted from the Traffic Light
*Appreciation is extended to the Urban Appalachian Council for their
support of this project as well as to the Greater Cincinnati Foundation
which provided funding through a Summertime Kids grant.
#Corresponding author.
L. Nabors et al. / Open Journal of Pediatrics 3 (2013) 300-305 301
Diet. The Traffic Light Diet emphasizes “red” or whoa
foods (e.g., foods and beverages that are high in calories),
“yellow” or slow foods (e.g., pasta; foods in the mid-
range in terms of calories) and “green” or good foods
(e.g., fruits and vegetables; foods are often high in nutri-
tional value). Similarly, the Winning with Wellness Pro-
ject was developed by a registered dietician and empha-
sized “go” (fruits and vegetables), “slow” (pasta), and
“whoa” (cake) food choices. Initial findings for the Win-
ning with Wellness Project indicated positive change in
school practices and policy as well as improved nutrition
in food choices at school and increased physical activity
for children during the school day. Difficulty imple-
menting the program due to academic demands during
the school day was mentioned as a barrier to program
sustainability [8].
In addition to emphasizing eating more “green” and
fewer “red” foods, the Traffic Light Diet also emphasizes
the importance of exercise to maintain a healthy weight
[9,10]. Exercise is a primary intervention to treat child-
hood obesity [11] and is also an intervention recom-
mended to prevent obesity in children [12]. Children
need to learn the importance of reducing “screen time”
(i.e., time in front of the television and computer) and
improve their involvement in activities, even those of
lower intensity levels, such as walking, yoga and slow-
paced dancing. The schools are targeted settings for im-
proving children’s activity levels; however, changing
policies to implement more activities during the school
day can be difficult due to academic demands. Thus,
community programs are another avenue for teaching
children about increasing their exercise levels and pro-
moting increased physical activity, and thus improving
The design of the Children’s Healthy Eating and Ex-
ercise Program also was influenced by key concepts
from motivational interviewing, a promising teaching
and counseling technique for providing prevention mes-
sages and information about healthy living to children
[13]. For our program, children learned about the im-
portance of setting healthy eating and exercise goals to
work in each week. They learned about “psyching up to
stay healthy!” The groups also favored participation in
projects and activities to keep the children active and
engaged. Consequently, children developed projects,
such as commercials to promote healthy eating for other
children, games, cheers to promote healthy eating, and
art activities to record what they learned. Many of the
activities capitalized on the oral tradition and story-tell-
ing orientation prevalent in the Appalachian community
[14]. The participatory approach used in developing
work products to showcase children’s learning was
beneficial and allowed children to capitalize on creative
ideas to present what they were learning. Qualitative
methods were used to evaluate information provided to
children about their creative projects and pre- and post-
intervention surveys were evaluated by using quantita-
tive methods.
2.1. Participants
Participants were 36 children in two different groups.
One group was conducted at a local church. There were
17 youth (4 boys and 13 girls; M = 8 years, SD = 4 years,
range = 4 - 16 years) in this group, entitled the “younger”
group. Seven children in the younger group were Cauca-
sian, 7 were African American, 2 were Hispanic, and 1
was biracial. There were 19 adolescents in the “older”
age group (9 males and 10 females; M = 16.21 years, SD
= 1.18 years, range = 14 - 18 years). The group for older
youth was conducted in a meeting room at the local Ur-
ban Appalachian Council (UAC) building. The adoles-
cents in this group were participating in a summer work
program sponsored by the UAC. Eight adolescents in this
group were Caucasian, 9 were African American and 2
were biracial. This study was approved by a university-
based institutional review board; parent permission and
child assent were required for participation.
Description of Activities in the Children’s Healthy
Eating and Exercise Program
Group leaders reviewed foods that could be cooked or
made for healthy meals at several sessions, focusing on
how to combine predominantly green and yellow foods,
with red foods as something a child would eat once in a
while. As a rule of thumb, children were told to try to,
“Eat four green foods for every red food”. At subsequent
sessions, students in both groups learned about packing
healthy lunches. Children in the younger group drew
pictures and discussed healthy lunches, while the chil-
dren in the older group met in small groups to talk about
eating a healthy lunch at school and packing a healthy
lunch. Ideas for healthy snacks consisting of fruit and
vegetables were reviewed in a discussion in both the
younger and older children’s groups. Children in the
younger group completed the “What’s in my Refrigerator
Exercise” where they drew the foods in their refrigerator
and then discussed what types of healthy foods were in
their refrigerators and processed ideas for eating more
healthy foods. The older youth made commercials and
songs as exercises with instructions to teach younger
children about how they could eat more red, yellow, and
green light foods.
In the small group meetings children discussed ways
to reward and motivate themselves to eat more fruits and
vegetables and exercise every day. Handouts for parents
included a review of red, yellow, and green foods and
recipes to develop healthy meals based on use of primar-
Copyright © 2013 SciRes. OPEN ACCESS
L. Nabors et al. / Open Journal of Pediatrics 3 (2013) 300-305
ily yellow and green foods. Handouts for parents with
healthy recipes were provided for participants to take
home and give to parents.
Several other activities, emphasizing the importance of
increasing daily activity levels, were completed weekly
in both the younger and older groups. Group leaders re-
viewed exercises one could do while sitting in a chair
(e.g., leg lifts, arm waves). Information from the “Let’s
Move” website (www.letsmov was discussed with
children in both groups. At each session the children
exercised or discussed the importance of 20 - 30 minutes
of daily exercise. Several activities were reviewed as
being important to build into a weekly exercise routine
including: dance, morning stretches and jumping jacks,
playing a favorite game outside, becoming involved in a
favorite sport, and walking after a meal and around the
neighborhood with friends. Moreover, during groups
facilitators reviewed easy exercises children could do
during television commercials (such as scissor kicks,
dancing, and jumping jacks) and ideas for reducing time
spent being sedentary or in front of a television or com-
puter screen. Children discussed healthy eating and exer-
cise goals in small groups with facilitators each meeting.
They identified goals for themselves and discussed how
they progressed each week toward their goals.
The older children participated in 5 groups, whereas
the younger children participated in 6 groups. Groups for
the adolescents or the older group lasted for about 45
mins. The groups for younger children lasted for at least
90 mins. And children had more time to exercise and eat
a healthy meal. For the younger group, dance was re-
viewed as an important exercise. Children danced to mu-
sic from DVDs playing children’s songs at most group
meetings. The younger children ate a meal at the end of
each group and the team for this project cooked healthy
meals using primarily yellow and green stoplight diet
foods, such as chicken quesadillas, pizza wheat bagels,
salads, and plenty of fruit and vegetable plates. Meals
were a chance to reinforce what foods comprised a
healthy meal and ideas from My Plate.
2.2. Procedures
Before the intervention began, in the first session, chil-
dren completed questions to examine what they ate yes-
terday. Questions addressed how many times they ate the
following: 1) chips and fries (chips were defined as po-
tato, corn, and tortilla chips, Cheetos, and other snack
chips), 2) vegetables, 3) fruits, and 4) sweet rolls,
doughnuts, cookies, brownies, pies or cake. Children
selected one of four responses including 1) never, 2) 1
time, 3) 2 times, or 4) 3 or more times. Children also an-
swered this question about exercise, “On how many days
in the past 7 days did you engage in activity that made
your heart beat fast and made you breathe hard for at
least 20 minutes?” Children were provided with pictures
of activities and they were listed (e.g., tennis, basketball,
swimming, dancing, running). Children selected an an-
swer from eight items from “0 days”, “1 day”, “2
days”, …up to “7 days”. Children participated in the
weekly groups described in the previous section of this
paper. Group leaders recorded their impressions of chil-
dren’s participation in and comments about different
group activities. At the end of the final session, children
again completed the nutrition and exercise questions and
they also completed a question where they wrote or dis-
cussed what they learned during the intervention about
healthy eating.
Five paired t-tests were performed to analyze pre-post
intervention change in consumption of French Fries and
chips (potato chips, Cheetos, or any other snack chip),
vegetables, fruits, sweet rolls, donuts, cookies, brownies,
pies, and cake, and engaging in physical activity for
children in the older and younger groups. A Bonferroni
correction was used to adjust the alpha levels for the five
Fourteen of the participants in the older group com-
pleted the pre- and post-test questionnaire. The means
and standard deviations for their answers to the five
questions are presented in Table 1.
There was a significant change in eating vegetables,
t(1, 13) = 6.431, p = 0.001. The older youth consumed
more vegetables at post-test compared to their responses
at the pretest assessment. There were no significant dif-
ferences for the other items at the two time points. Four-
teen of the children in the older group completed a ques-
tion assessing their perceptions of whether participating
in the Healthy Eating classes improved their knowledge
about healthy eating. Ninety-two percent (n = 13) re-
ported that participating in the classes improved their
knowledge. Specifically, 2 reported that their knowledge
Table 1. Results of paired t-tests for healthy eating questions
for children in the older group.
Item Pretest Post-test
French fries
and chips 0.7860.802 0.714 0.994
Vegetables* 0.5710.756 3.07 1.071
Fruits 0.92860.917 0.92860.829
Sweet rolls, donuts,
cookies 0.92801.141 0.786 1.051
Exercise 2.2862.054 2.714 2.431
Note. *Significant different between pre- and post-test means.
Copyright © 2013 SciRes. OPEN ACCESS
L. Nabors et al. / Open Journal of Pediatrics 3 (2013) 300-305 303
Table 2. Results of paired t-tests for healthy eating questions
for children in the younger group.
Item Pretest Post-test
French fries
and chips* 1.143 0.690 0.429 0.535
Vegetables 1.00 0.577 1.714 0.756
Fruits 0.7143 0.756 1.286 0.951
Sweet rolls,
donuts, cookies 1.857 0.900 0.8571 0.690
Exercise 3.714 2.138 3.286 3.498
Note. *Significant different between pre- and post-test means.
improved, 5 reported that their knowledge improved “a
lot”, and 6 reported “amazing improvement”. One youth
reported that participating in the healthy eating groups
did not improve knowledge.
Seven children in the younger group completed pre-
and post-test data on the questionnaire. The means and
standard deviations for each question/item are presented
in Table 2.
There was a significant change in eating French Fries
and chips, t(1, 6) = 3.873, p = 0.008. Children consumed
fewer French Fries and chips at the post-test compared to
their responses at the pretest assessment. There were no
significant differences for the other items at the two time
points; however, mean differences were in directions
indicating healthier eating at post-test. Six of the children
in the younger group completed a question assessing
their perceptions of whether participating in the Healthy
Eating classes improved their knowledge about healthy
eating. Three of the children reported that their knowl-
edge improved, 1 reported improved “a lot”, and two
endorsed “amazing improvement”.
Qualitative Analyses
Four coders met three times and reviewed younger chil-
dren’s drawings of their refrigerators and healthy lunches
as well as older children’s commercials and games as
well as any notes or observations recorded by group
leaders. Coders reviewed the information and determined
common categories in the data. The first two meetings
were used to review information and coders developed
ideas for themes or categories in the children’s products.
During the third meeting the coders reviewed the data
again and determined, via consensus, the common ideas
in the children’s work products. These ideas are de-
scribed in the following sections for the younger and
older group.
Younger Group: My Refrigerator and Healthy Lunch
Drawings. There were wide individual differences in the
amounts and types of food in each children’s refrigerator.
There typically was ranch dressing, catchup, and mustard
in each refrigerator. Fruits usually were apples and or-
anges. The most common vegetable was carrots. Meats
typically were hotdogs or bologna. Pizza and milk also
were staples in most refrigerators. The coders reviewed
children’s drawings of what they packed in their lunches.
Most drawings depicted at least 2 “junk or snack foods”
such as chips or gummy worms. Vegetables typically
were not present; some children had a fruit. Many had
leftovers, such as a meat dish. After a few groups chil-
dren were again asked to draw their ideas of a healthy
lunch. The second round of drawings was reviewed and
children added fruits and vegetables, and field notes
made by researchers indicated that the children reported
that they would pack more of these items in their lunches.
Analysis of notes from groups and notes recorded while
children were drawing indicated that children either did
not mention or did not always understand the meaning of
foods in the yellow food group. Most of their discussions
focused on red and green food categories, for which they
showed a good understanding.
Older Group: Games and Commercials. Games fo-
cused on reduction of red foods and increasing one’s
knowledge of green or healthy foods so that one could
eat more of them. Several of the games were designed as
question and answer to name healthy (green) and un-
healthy food (red). These games were similar to Jeopardy
and other quiz show games, with colorful props for chil-
dren to use. In general games stressed the importance of
increasing intake of green foods and reducing the intake
of red foods and the message that this would lead to a
“healthier” lifestyle. Yellow foods were either not men-
tioned or infrequently mentioned, without much explana-
tion demonstrating comprehension of this food category.
When developing commercials several of the adoles-
cents in the small groups developed jingles or songs,
often to rap music. Here is one jingle or song,
“I know you like soda and lots of chips, but you need
to eat something like asparagus. Eggrolls are good and
salami too, you need to eat healthy, eat some honeydew.”
Here is another jingle or song,
“Broccoli and carrots are all green food. Donuts and
muffins are not really cool. Olives, meatloaf, omelet and
nectarines are foods that are in-between. Chili and gra-
nola can raise blood pressure, chose the healthy foods
it’s the best gesture.”
In games and commercials, green foods were typically
referred to as “healthy” foods and red “foods” were re-
ferred to being unhealthy. Again, little reference was
made to “yellow foods”. Coders reported that adoles-
cents’ understanding of yellow foods lagged behind their
knowledge about and understanding of when and how
many red and green foods they should eat. The foods that
Copyright © 2013 SciRes. OPEN ACCESS
L. Nabors et al. / Open Journal of Pediatrics 3 (2013) 300-305
were most commonly mentioned were fruits, as a green
food, and red foods. Adolescents discussed how red
foods tasted good, but weren’t all that “good for you”.
The older youth loved fruits and were open to discussion
of eating more fruits. Exercise was not typically men-
tioned in the commercials and games developed by the
older youth. It was evident that references to changing
activity levels were lacking in the games or commercials
developed by the older children.
Results of this study indicated that knowledge about the
Traffic Light Diet improved and children were satisfied
with the program [9]. These findings were consistent
with other programs showing success in adapting the
Traffic Light Diet for schools, such as the Winning with
Wellness Program [8]. Children also reported change in
eating behaviors, indicating that they had absorbed in-
formation about this program in a relatively small num-
ber of group meetings. Findings from quantitative analy-
ses showed that adolescents in the older group reported
consuming more vegetables at the end of their classes.
Children in the younger group stated that they were con-
suming fewer French fries and chips at the end of their
groups. Inspection of the means for the healthy eating
questions did indicate change in the direction of “health-
ier” eating, but results were not statistically significant
for the majority of questions, which could have occurred
because the sample size for this study was small.
Analysis of younger children’s drawings and com-
ments they provided about their artwork and analysis of
games and commercials developed by older children
indicated that they had successfully learned information
about the Traffic Light Diet [9] as a result of their par-
ticipation in the Children’s Healthy Eating and Exercise
Program. Results also indicated that children tended to
focus on the green and red food categories, displaying
less knowledge about the yellow food category. Coders
believed that the yellow foods were more difficult to
categorize and understand as foods to “watch” in terms
of being careful not to consume too much of them. It
may be that with more sessions, and greater explanation,
children and adolescents could have demonstrated a bet-
ter understanding of yellow foods.
A significant proportion of the children did not com-
plete the post-intervention questionnaire. This occurred
because they missed the final group or did not provide
assent to complete the questionnaire. All of the children
participated in art and other creative activities, such as
developing commercials and games. Activities capitaliz-
ing on creativity and oral report of learning were favored.
Capitalizing on the strong oral tradition in the Appala-
chian culture may be a preferred method for gathering
evaluative data when implementing prevention programs
[14]. Additionally, exercise change was rarely mentioned
in interviews or discussion groups by children. Learning
about ways to help children learn the importance of ex-
ercise and increasing daily activity levels is a goal for
future prevention programming. Furthermore, finding
methods to assess whether children’s knowledge was
relayed to parents and resulted in actual change in their
lives needs to be assessed in future studies. There are
several other factors that may have limited the gener-
alizability of study findings, including the small sample
size utilized for this pilot project, using only child report
to assess outcomes, and the differences in sessions be-
tween the older and younger children’s groups. However,
the project was successfully delivered in an urban area
with very low-income families and successful results,
especially when utilizing qualitative methods to gather
data, were recorded.
When delivering this program several lessons were
learned and these may be of benefit to others developing
prevention programs for youth in urban settings. First,
children gravitated toward creative activities, interviews
and discussions. Also, there were wide individual differ-
ences in the amounts of exercise each child engaged in. It
may be that rather than discussing activity levels in
groups, one-on-one time with a group leader would have
motivated the children to engage in more activities. Daily
activity is a cornerstone of maintaining a healthy weight
and lifestyle [2,11,12], and finding ways to incorporate
this message into future prevention programming is im-
portant. Anecdotal data revealed that children in the
younger group really enjoyed discussing the red and
green foods they ate in meals provided at the end of the
group. Incorporating eating and discussion of the Traffic
Light Diet into prevention programming may be an op-
timal teaching tool in prevention groups.
Our results add information about what components of
information and prevention techniques work when
teaching children about the Traffic Light Diet in a rela-
tively small number of meetings in community programs.
Specifically, when there are relatively few sessions to
train children, it may be important to focus on discussing
eating fewer red and a greater number of green foods.
Another idea is to reinforce the “yellow” food category
each session, in order to determine if this helps children
or adolescents retain this information. Parents’ involve-
ment was not a cornerstone of this pilot program. In-
volving parents and other family members in the pro-
gram may be a key to impact all realms of a child’s eat-
ing and exercise habits. Further information on individ-
ual impact of the Children’s Healthy Eating and Exercise
Program could be obtained by using a case study design,
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L. Nabors et al. / Open Journal of Pediatrics 3 (2013) 300-305
Copyright © 2013 SciRes.
where detailed information is gathered on child progress
and change in activity level and weight also could be
measured. In future studies, more rigorous examination
of the effectiveness of dissemination studies assessing
the impact of the Traffic Light Diet in urban settings will
provide further information on the community impact of
this program for instruction related to obesity prevention
in children.
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