Addressing Health Disparities in Childhood Obesity, One Summer at a Time
Phase: NA
Conditions: Obesity, Childhood
Sponsor: Northern Arizona University

COVER PAGE 
 
 
Study Title: Addressing Health Disparities in Childhood Obesity, One Summer at a Time 
Clinical Trials Registration Number: NCT03595332 
Date of document: April 15, 2018 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Study Protocol 
 
Background 
Childhood obesity is one of the most urgent health challenges of our time. Obesity rates of Native American and Hispanic children 
are far higher than national averages, placing these children at high risk for early mortality, cardiovascular and metabolic conditions 
including diabetes, depression and overall poor quality of life.1-3 By the 5th grade, approximately 50% of Hispanic and Native children 
are already overweight, and Native children have type 2 diabetes rates 9 times higher than non-Hispanic Whites.4 In our area, 
obesity rates are highly concentrated: most obese and overweight children are enrolled in 4 of the 10 elementary schools, which 
include primarily underserved Hispanic and Native American children. 
 
Recent research has further demonstrated that the ‘obesity gap’ facing minority students is largely due to summer weight gain.5-9 
Based on local data, it was confirmed that children in our school district were much more likely to worsen their weight-related health 
status during the summer than during the schoolyear. However, statewide, only 22% of children participate in summer activities, 
despite 65% of parents expressing interest.10 Finally, ages 7 to 11 have been found in national data to see a sharp increase in 
obesity rates.11 Indeed, locally in 2015, approximately 20% of 7 year-olds are overweight or obese, but 35% of 11-year olds. Thus, 
we know which populations are at highest risk, at what developmental age changes occur most rapidly (ages 7-11) and that 
interventions are most needed in the summer, but that this need is not being met.  
 
A modest amount of research has evaluated summer programming, but almost none among Native Americans/Hispanics. In the 
early 2000s, the CDC developed a ‘Summer Scorecard’ intervention,12 a partnership with local businesses to provide children with a 
‘scorecard’ of subsidized or free local activities. The VSS has not been tested among Hispanic and Native American children. 
Therefore, this study assessed the effectiveness of the VSS among children ages 5-13 in the 4 highest risk schools in the Flagstaff 
area. Outcomes included body composition (BMI) percentile score, reported physical activity and self-efficacy using survey 
instruments previously developed and tested by the CDC. 
 
VERB Summer Scorecard Program Description: In 2001, the CDC launched VERB It’s What You Do!, a 5-year year national 
social marketing campaign to increase awareness, improve attitudes, and increase physical activity among 9-13 year olds (“tweens”). 
The campaign was developed after extensive formative research, grounded in a logic model that shows a pathway to chronic disease 
reduction,45 and tested in 3 follow-ups using a nationally representative sample.13-16 The campaign was coordinated with local 
vendors who provided opportunities to be active. In 2004, the VERB Summer Scorecard (VSS) intervention was developed in 2004. 
The VSS consists of a ‘scorecard’ including 24 squares, each representing an activity of at least one hour (see Appendix A for our 
local version). In collaboration with community partners, children were provided with free or discounted opportunities for a variety of 
activities. When children attend either an activity at a participating facility or supervised activity at home for a minimum of 60 minutes, 
they received either a stamp from the community partner or a parent’s signature on one of the squares. 
 
 

Activities: 
Each participating child was provided with a scorecard including 24 activities (see Appendix A). Children received 12 free passes to 
utilize local facilities including a local aquatic center, athletic club (including gym, indoor/outdoor swimming pool, basketball and 
racquetball courts etc.), climbing gym, ice skating rink and activity center (including bouncy houses, laser tag etc.) and classes 
offered by a local health program. Other activities could be done on their own and included hiking local trials, going to parks and 
could be signed off by a parent. Children were instructed to return the card at the end of the summer and receive an incentive prize 
for returning the card. 
 
Measures: 
Demographic variables. Child’s age (in years), sex (male or female), ethnicity (American Indian/Alaskan Native, Hispanic, White, 
Black/African American, Native Hawaiian/Pacific Islander or Two or more), grade level and school membership were collected by the 
school district. Height and weight were collected at each school during the school day by a community outreach coordinator trained 
in research quality measurements, supported by the school nurse and volunteers. Children were asked to take shoes and jackets off 
and items out of their pockets. Height to the nearest quarter inch was measured twice with a Charder HM200P Portstad Portable 
Stadiometer. Weight was measured to the nearest 0.1 pounds with a Health O Meter 752KL Heavy Duty Remote Display Digital 
Scale. Children’s first weight status was considered their baseline, with ≤5th BMI percentile for their age and sex considered 
underweight, 5th to 85th percentile healthy weight, ≥85th percentile overweight and ≥95th percentile as having obesity 
 
Behavioral constructs. Health behavior constructs (13 questions) aligned with Social Cognitive Theory were assessed. Key 
constructs include self-efficacy (“I think I can be physically active even if it is hot or cold outside.”), social norms (example: “My 
friends think that doing physical activity is fun”), and access or barriers to participation in physical activity and summer programs 
(“There are lots of places near where I live where I can do physical activities”).  
 
Reported activity and sedentary behaviors. A total of 8 questions ask about participation in the VERB program, types of activity in 
the past 7 days and participation in other summer programs. The number of activities reported were counted and compared before 
and after the intervention.  
 
Recruitment: 
Children were recruited directly at each school by research staff in collaboration with school physical education or health and 
wellness instructors. Recruitment occurred by providing flyers and tables at school events and drop-off/pick up. Parents were 
provided with a consent form and children with an assent form explaining the risks and benefits. English and Spanish versions were 
available. Upon completion of both forms, participants were measured and surveyed (see measurements below).  
 
Sample Size calculations: The estimated sample size needed to have sufficient power to detect a moderate effect size (using a 
Cohen’s d of 0.3 as the reference) is 240 children, or 120 per arm. Based on our preliminary data, for each academic year, the 
average BMI change ranges from 0.35 to 0.55 units, with a standard deviation that varies across ethnic groups and years from 0.80 

to 1.00. An example of an effect between two groups or time points that would match a Cohen’s d of 0.3 would be one group in which 
the children on average increases their BMI by 0.5 units, and another group where participants increase their BMI by 0.2 units (0.3 
unit difference), with standard deviations of 1.0. These effects (BMI difference of 0.3kgm2) are just above the mean weighted effect 
size reported in the most comprehensive and recent meta-analysis on childhood obesity studies of 0.30kg/m.9,10 With a two-tailed 
test and alpha level of 0.05, a sample size of 80 children per arm (a retention rate of 67%) would result in an associated statistical 
power≥ 80% to detect intervention effects between arms from one time point to the next. With very similar parameters and sample 
sizes, prior research has indicated that based on simulation studies,17 these parameters demonstrated excellent power (≥80%) in 
detecting these size differences. 
 
Institutional Review Board: 
All protocol activities were approved by the Institutional Review Board of Northern Arizona University (protocol #1193689) and the 
Flagstaff Unified School District. Parental consent forms and children assent were attained for each participant. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Appendix A: Scorecard