Smart-Phone Obesity Prevention Trial for Adolescent Boys in Low-Income

Communities: The ATLAS RCT

Jordan J. Smith, Philip J. Morgan, Ronald C. Plotnikoff, Kerry A. Dally, Jo Salmon,
Anthony D. Okely, Tara L. Finn and David R. Lubans
Pediatrics 2014;134;e723; originally published online August 25, 2014;
DOI: 10.1542/peds.2014-1012

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/134/3/e723.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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 ARTICLE

Smart-Phone Obesity Prevention Trial for Adolescent

Boys in Low-Income Communities: The ATLAS RCT
AUTHORS: Jordan J. Smith, BEd,a Philip J. Morgan, PhD,a WHAT’S KNOWN ON THIS SUBJECT: Adolescent males from low-
Ronald C. Plotnikoff, PhD,a Kerry A. Dally, PhD,a Jo Salmon, income communities are a group at increased risk of obesity and
PhD,b Anthony D. Okely, PhD,c Tara L. Finn,a and David R. related health concerns. Obesity prevention interventions
Lubans, PhDa
targeting adolescents have so far had mixed success. Targeted
aPriority Research Centre in Physical Activity and Nutrition,
interventions, tailored for specific groups, may be more appealing
School of Education, University of Newcastle, Callaghan, New
South Wales, Australia; bCentre for Physical Activity and Nutrition
and efficacious.
Research, Deakin University, Burwood, Victoria, Australia; and
cInterdisciplinary Educational Research Institute, University of WHAT THIS STUDY ADDS: A multicomponent school-based
Wollongong, Wollongong, New South Wales, Australia intervention using smartphone technology can improve muscular
KEY WORDS fitness, movement skills, and key weight-related behaviors among
adolescent, intervention studies, obesity, physical activity, physical low-income adolescent boys.
fitness, randomized controlled trial, schools, sedentary lifestyle
ABBREVIATIONS
ATLAS—Active Teen Leaders Avoiding Screen-time
RT—resistance training
SEIFA—Socio-Economic Indexes For Areas
SSB—sugar-sweetened beverage abstract
Mr Smith was involved in the study design and acquisition, analysis, OBJECTIVE: The goal of this study was to evaluate the impact of the
and interpretation of data; he also participated in the drafting and
revision of the manuscript. Drs Morgan, Dally, Plotnikoff, Salmon,
Active Teen Leaders Avoiding Screen-time (ATLAS) intervention for ado-
and Okely obtained funding for the study and were involved in the lescent boys, an obesity prevention intervention using smartphone
study concept and design; and Ms Finn was involved in the technology.
acquisition of data. Dr Lubans obtained funding for the study; was
involved in the study concept and design; participated in the METHODS: ATLAS was a cluster randomized controlled trial conducted
analysis and interpretation of data; and was involved in the in 14 secondary schools in low-income communities in New South
drafting and revision of the manuscript. All authors revised and Wales, Australia. Participants were 361 adolescent boys (aged 12–
approved the final version of the manuscript as submitted.
14 years) considered at risk of obesity. The 20-week intervention
This trial has been registered with the Australian and New
Zealand Clinical Trials Registry (ACTRN 12612000978864;
was guided by self-determination theory and social cognitive theory
registration date was October 8, 2012 [www.anzctr.org.au]). and involved: teacher professional development, provision of fitness
www.pediatrics.org/cgi/doi/10.1542/peds.2014-1012 equipment to schools, face-to-face physical activity sessions,
doi:10.1542/peds.2014-1012 lunchtime student mentoring sessions, researcher-led seminars,
Accepted for publication Jun 20, 2014
a smartphone application and Web site, and parental strategies for
reducing screen-time. Outcome measures included BMI and waist
Address correspondence to David R. Lubans, PhD, Priority Research
Centre in Physical Activity and Nutrition, School of Education, circumference, percent body fat, physical activity (accelerometers),
Faculty of Education and Arts, University of Newcastle, Callaghan, screen-time, sugar-sweetened beverage intake, muscular fitness, and
NSW, Australia 2308. E-mail: david.lubans@newcastle.edu.au resistance training skill competency.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
RESULTS: Overall, there were no significant intervention effects for BMI,
Copyright © 2014 by the American Academy of Pediatrics
waist circumference, percent body fat, or physical activity. Significant in-
FINANCIAL DISCLOSURE: The authors have indicated they have tervention effects were found for screen-time (mean 6 SE: –30 6 10.08
no financial relationships relevant to this article to disclose.
min/d; P = .03), sugar-sweetened beverage consumption (mean: –0.6 6
FUNDING: This study was funded by an Australian Research
Council Discovery Project grant (DP120100611). The sponsor had
0.26 glass/d; P = .01), muscular fitness (mean: 0.9 6 0.49 repetition; P =
no involvement in the design or implementation of the study, in .04), and resistance training skills (mean: 5.7 6 0.67 units; P , .001).
analyses of data, or in the drafting of the manuscript.
CONCLUSIONS: This school-based intervention targeting low-income
POTENTIAL CONFLICT OF INTEREST: The authors have indicated adolescent boys did not result in significant effects on body
they have no potential conflicts of interest to disclose.
composition, perhaps due to an insufficient activity dose. However, the
COMPANION PAPER: A companion to this article can be found on
page e846, online at www.pediatrics.org/cgi/doi/10.1542/peds.
intervention was successful in improving muscular fitness, movement
2014-1940. skills, and key weight-related behaviors. Pediatrics 2014;134:e723–e731

PEDIATRICS Volume 134, Number 3, September 2014 e723

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Although the global prevalence of obesity “silver bullet” to the global obesity to assess their eligibility for inclusion.
seems to have plateaued in recent years,1 pandemic. Alternatively, they may have Students failing to meet international
the overall proportion of young people more utility as adjuncts to face-to-face physical activity or screen-time guide-
who are overweight or obese remains behavior change interventions. To the lines22 were considered eligible and
high, particularly among those of low authors’ knowledge, no previous study were invited to participate.
socioeconomic status.2 Considering the has used smartphone technology in
serious consequences of pediatric obe- a school-based obesity prevention pro- Sample Size and Randomization
sity,3 and the high likelihood of weight gram14 and few existing smartphone
Power calculations were conducted to
status tracking into adulthood,4 there is “apps” include evidence-based behavior
determine the required sample size for
a strong rationale for targeting the change techniques.19 Therefore, the
detecting changes in the primary out-
health behaviors of adolescents.5–7 primary aim of the present study was to
comes (ie, BMI, waist circumference).
It has been recommended that obesity evaluate the effects of the multicompo-
Baseline posttest correlations and SD
prevention efforts should be directed to- nent, school-based obesity prevention
estimates for BMI (r = 0.97, SD = 1.1) and
ward those most susceptible, such as intervention incorporating smartphone
waist circumference (r = 0.96, SD = 11.6)
adolescents living in low-income commu- technology, known as ATLAS (Active Teen
were taken from our pilot study, and
nities.8 Adolescent boys of low socioeco- Leaders Avoiding Screen-time). This ar-
calculations assumed a school clustering
ticle reports the 8-month (immediate
nomic status are particularly predisposed effect with an intraclass correlation of
postprogram) intervention effects.
to unhealthy weight gain, and the global 0.03.11 Based on 80% power, an a level of
prevalence of obesity is higher among 0.05, and a potential dropout rate of 20%,
male adolescents compared with fe- METHODS it was calculated that 350 participants (ie,
male adolescents.1 In addition, although Study Design and Participants 25 from each school) would be required
adolescent boys are typically more ac- to detect a between-group difference in
Ethics approval for this study was
tive than girls,9 they are more likely to BMI of 0.4 kg.m22. In addition, the pro-
obtained from the human research
engage in high levels of recreational posed sample size would be powered to
ethics committees of the University of
screen-time and consume large amounts detect a between-group difference of 1.5
Newcastle, Australia (July 3, 2012), and
of sugar-sweetened beverages (SSBs).9,10 cm in waist circumference. After baseline
the New South Wales Department of
However, apart from our pilot study,11 assessments, schools were paired on the
Education and Communities (September
no interventions have specifically tar- basis of their geographic location, size,
6, 2012). School principals, teachers,
geted adolescent boys from low-income and SEIFA value and were randomized to
parents, and study participants all
communities. either the control or intervention group.
provided informed written consent. The
The challenges of modifying the health Randomization was performed by an in-
design, conduct, and reporting of this
behaviors of adolescents and designing dependent researcher with the use of
trial adhere to the CONSORT statement.20
culturally appropriate interventions a computer-based random number–
The rationale and study protocols have
have prompted researchers to explore producing algorithm.
been reported previously. 21 Briefly,
the utility of novel behavior change ATLAS was evaluated by using a cluster
techniques. Such strategies include the randomized controlled trial conducted Intervention
use of e-health (ie, Internet-based) and in state-funded coeducational second- ATLAS was informed by the PALs (Physical
mHealth (ie, mobile phone) technologies ary schools within low-income areas of Activity Leaders) pilot study,11,23,24 and
to encourage young people to devel- New South Wales, Australia. The Socio- a detailed description of the intervention
op physical activity behavioral skills Economic Indexes For Areas (SEIFA) of is reported elsewhere.21 In summary,
(ie, self-monitoring, goal setting)12,13 and relative socioeconomic disadvantage ATLAS is a multicomponent intervention
improve lifestyle behaviors.14 Mobile (scale: 1 = lowest to 10 = highest) was designed to prevent unhealthy weight
phone (and smartphone) ownership used to identify eligible schools. Public gain by increasing physical activity, re-
among young people is accelerating at secondary schools located in the New- ducing screen-time, and lowering SSB
a rapid rate.15,16 Although evidence for castle, Hunter, and Central Coast re- consumption among adolescent boys
the efficacy of mHealth interventions to gions of New South Wales with a SEIFA attending schools in low-income areas.
improve health behaviors in young value of #5 (lowest 50%) were consid- Self-determination theory25 and social
people is starting to emerge in the ered eligible. All male students in their cognitive theory26 formed the theoretical
published literature,17,18 it is unlikely first year at the study schools com- basis of the program. Briefly, the in-
that such interventions will provide the pleted a short screening questionnaire tervention aimed to increase autonomous

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 ARTICLE

motivation for physical activity through TABLE 1 Description and Dose of Intervention Components in the ATLAS Intervention
enhancing basic psychological needs Intervention Component Dose Description
satisfaction (ie, autonomy, competence, Teachers
relatedness) during scheduled school Teacher professional Two 6-h Teachers attend 2 professional development workshops
development workshops during the study period (preprogram and mid-program).
sports. In addition, the intervention fo-
The workshops provide a rationale for the program, outline
cused on improving resistance training the intervention strategies (ie, program components,
(RT) self-efficacy and also aimed to behavioral messages), and explain the theory behind the
develop self-regulatory skills (ie, self- intervention.
One fitness Each school receives 1 visit during their regularly scheduled
monitoring and goal setting) to increase instructor sport session from a practicing fitness instructor (ie, personal
incidental physical activity. Similarly, session trainer). The fitness instructor will deliver the session while the
the intervention was designed to in- teacher observes and completes the session observation
checklist.
crease participants’ autonomous motiva- Parents
tion to limit screen-time27 by providing Parent newsletters Four Parents of study participants receive 4 newsletters containing
information regarding the consequences newsletters information on the potential consequences of excessive screen
use among youth, strategies for reducing screen-based
of screen-time and strategies for self-
recreation in the family home, and tips for avoiding conflict
regulation. ATLAS was aligned with cur- when implementing rules. They are also provided with their
rent guidelines recommending that youth child’s baseline fitness test results.
regularly engage in vigorous aerobic ac- Students
Researcher-led Three 20-min Participants attend 3 interactive seminars delivered by members
tivities and physical activities to strengthen seminars seminars of the research team. Seminars provide key information
muscle and bone.22 surrounding the program’s components and behavioral
messages, including current recommendations regarding
The intervention was delivered from youth physical activity, screen-time, and resistance training,
December 2012 to June 2013 and in- and also outline the student leadership component of the
volved a number of components that are intervention.
Enhanced school Twenty 90-min Sport sessions are delivered by teachers at the study schools.
described in Table 1. The smartphone
sport sessions sessions Activities include elastic tubing resistance training, aerobic-
app was designed to supplement the and strength-based activities, fitness challenges, and modified
delivery of the enhanced school sport ball games. Behavioral messages are reinforced during the
and interactive sessions by providing cool-down period.
Lunchtime physical Six 20-min Students participate in 6 lunchtime physical activity mentoring
participants with a medium to monitor activity–mentoring sessions sessions. These self-directed sessions involve recruiting and
and track their behaviors, set goals, and sessions instructing grade 7 boys in elastic tubing resistance training.
assess their RT skill competency. In ad- Smartphone app 15 wk The smartphone app and Web site are used for physical activity
and Web site monitoring, recording of fitness challenge results, tailored
dition, the app provided tailored moti- motivational messaging, peer assessment of RT skills, and goal
vational and informational messages via setting for physical activity and screen-time.
“push prompts.” The parental news- Pedometers 17 wk Participants are provided with pedometers for self-monitoring.
Students are encouraged to set goals to increase their daily
letters were designed to engage parents
step counts and monitor their progress using the pedometer.
and encourage them to manage their Pedometer step counts can also be entered into the smartphone
children’s recreational screen-time. app for review.

The control group participated in usual

practice (ie, regularly scheduled school
ments were conducted 8 months from scale (model no. UC-321PC, A&D Com-
sports and physical education lessons)
baseline (immediate postintervention) pany Ltd, Tokyo, Japan). BMI was cal-
for the duration of the intervention but
and will be conducted again at 18 months culated by using the standard equation
will receive an equipment pack and
from baseline (long-term follow-up). As- (weight in kilograms/height in meters
a condensed version of the program
sessors were blinded to treatment allo- squared). Waist circumference was
after the 18-month assessments.
cation at baseline but not at follow-up. measured to the nearest 0.1 cm against
the skin in line with the umbilicus
Assessments and Measures Primary Outcome Measures by using a nonextendible steel tape
Trained research assistants completed Height was recorded by using a porta- (KDSF10-02, KDS Corporation, Osaka,
baseline data collection at the study ble stadiometer (model no. PE087, Japan). Weight status was established
schools during November through De- Mentone Educational Centre, Moor- from BMI z scores calculated by using
cember 2012, at the same time of day abbin, Victoria, Australia), and weight the LMS method (World Health Orga-
whenever possible. Follow-up assess- was measured with a portable digital nization growth reference centiles).28

PEDIATRICS Volume 134, Number 3, September 2014 e725

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Secondary Outcome Measures sessions conducted by teachers); (2) an overall retention rate of 81.2% from
Body fat percent was determined by school sport session fidelity determined baseline. Participants who did not
using the Imp SFB7 bioelectrical im- by using the ATLAS session observation complete follow-up assessments were
pedance analyzer (ImpediMed, Ltd., Eight checklist (ie, compliance with the pro- more active on weekdays (P = .03) and
Mile Plains, Queensland, Australia).29 posed session structure and activities, weekends (P = .01). There were no sig-
Physical activity was assessed accord- recorded by a member of the research nificant differences for body composi-
ing to standardized protocols30 using team); (3) attendance at sessions; (4) tion outcomes.
Actigraph accelerometers (model GT3X+ engagement with intervention com-
ActiGraph, LLC, Fort Walton Beach, FL). ponents (eg, smartphone app, pedo- Changes in Body Composition
Analyses for weekday physical activity meters); and (5) program satisfaction Changesforalloutcomesare reported in
were performed for participants who (ie, responses to a postprogram evalu- Table 3. No intervention effects were
wore their monitor for $600 minutes ation questionnaire). found for the primary outcomes of BMI
on at least 3 weekdays (Monday–Friday); and waist circumference or for percent
analyses for weekend physical activity Statistical Analysis body fat. Changes in BMI (mean 6 SE:
included participants who wore their All analyses were conducted in December –0.4 kg.m22 6 0.26; P = .15), waist
monitor for $600 minutes on at least 1 2013 by using SPSS for Windows version circumference (mean: –0.5 6 0.95 cm;
weekend day (Saturday–Sunday). Non– 20.0 (IBM SPSS Statistics, IBM Corpora- P = .57), and percent body fat (mean:
wear time was defined as 30 minutes of tion, Armonk, NY; 2010) with a levels set –0.9% 6 0.77%; P = .22) for those
consecutive zeroes. Mean counts per at P , .05; data were assessed for nor- classified as overweight/obese at base-
minute were calculated to provide mality. Intervention effects for the pri- line were all in favor of the intervention
a measure of overall activity, and the mary and secondary outcomes were group. However, these effects were not
cut points proposed by Evenson et al31 examined by using linear mixed models statistically significant. Of the 19 partic-
were used to categorize intensity (ie, adjusted for school clustering and par- ipants who improved their weight sta-
time spent in moderate to vigorous ticipant socioeconomic status, and all tus, 13 (68%) were in the intervention
physical activity). Hand grip dynamom- analyses followed the intention-to-treat group; of the 9 participants who re-
etry (Smedley’s dynamometer; TTM, principle.36 Prespecified subgroup anal- gressed to a more unhealthy weight
Tokyo, Japan) and the 90-degree angle yses21 for all body composition outcomes status, only 1 (11%) was in the inter-
push-up test29,32 provided a measure of were conducted for those classified as vention group. Pearson’s x 2 test indi-
upper body maximal strength and local overweight/obese (combined as a single cated a significant difference in favor of
muscular endurance, respectively. Rec- group) at baseline. In addition, the pro- intervention boys: x2 (2) = 8.08, P = .02.
reational screen-time was self-reported portional difference between treatment
by using a modified form of the Ado- groups among those improving their Changes in Behavioral Outcomes
lescent Sedentary Activity Question- weight status (ie, moving from “obese” to No significant differences were observed
naire.33 Two items were used to assess “overweight” or from “overweight” to for overall activity (mean counts per
consumption of SSBs.9 Finally, RT skill “healthy weight”) or regressing to minute) or moderate to vigorous physical
competency was assessed by using a poorer weight status (ie, moving from activity. However, intervention boys
video analysis of the Resistance Train- “healthy weight” to “overweight” or from reported less screen-time (mean: 230 6
ing Skills Battery.34,35 Participants per- “overweight” to “obese”) was explored 10.08 min/d; P = .03) and SSB consump-
formed 6 movement skills considered to by using Pearson’s x 2 test. tion (mean: 20.6 6 0.26 glass/d; P = .01)
be the foundation for more complex
than control boys at follow-up.
movements used in RT programs. RESULTS
Process Evaluation The flow of participants through the Changes in Fitness and Skill
A number of process measures were study is reported in Fig 1. Fourteen Outcomes
used to determine the reach, imple- schools were recruited, and 361 boys There was a significant intervention ef-
mentation, and participant and teacher (mean age: 12.7 6 0.5 years) were as- fect for upper body muscular endurance
satisfaction of the ATLAS intervention. sessed at baseline (Table 2). Follow-up (mean: 0.9 6 0.49 repetition; P = .04). In
The process evaluation included: (1) assessments at 8 months were com- addition, a significant between-group
intervention implementation (ie, the pleted for 154 (85.6%) control group difference was observed for RT skill
percentage of intended school sports participants and 139 (76.8%) interven- competency in favor of intervention
sessions and lunchtime mentoring tion group participants, representing boys (mean: 5.7 6 0.67 units; P , .001).

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 ARTICLE

4.4 6 0.5), and they reported enjoying

both the preprogram (mean: 5.0 6 0.0)
and mid-program (mean: 4.9 6 0.4)
professional development workshops.

DISCUSSION
The goal of the present study was to
determinetheeffectivenessoftheschool-
based ATLAS intervention for adolescent
boys. No significant intervention effects
were observed overall for body compo-
sition. However, for those who were
overweight/obese at baseline, there was
a trend in favor of intervention partic-
ipants for all body composition out-
comes. Significant intervention effects
were found for secondary outcomes,
including upper body muscular endur-
ance, RT skill competency, self-reported
screen-time, and SSB consumption.
The intervention effects for body com-
FIGURE 1 position outcomeswere negligible, which
Flow of participants through the study process. is similar to the findings of a trial in-
volving Dutch teenagers.38 Our inclusion
criteria aimed to identify boys at in-
Process Evaluation with the lunchtime sessions was some- creased risk of obesity based on their
No adverse events or injuries were what lower (mean: 3.7 6 1.0). physical activity and screen behaviors.
reported during the school sports ses- A detailed evaluation of the smartphone This approach was selected to reduce
sions, lunchtime leadership sessions, or app can be found elsewhere.37 Briefly, the potential for weight stigmatization,
assessments. On average, schools con- smartphone (or similar device) owner- which may occur if inclusion is contin-
ducted 79% 6 15% of intended school ship was reported by 70% of boys, and gent on participants’ BMI. However, it is
sports sessions and 64% 6 40% of 63% reported using either the iPhone or possible that by using these broad in-
intended lunchtime sessions. Four sport Android version of the ATLAS app. Those clusion criteria, our ability to see signif-
session observations (2 per school students who did not have access to icant improvements in anthropomorphic
term) were conducted at each school. a smartphone could access the same measures was minimized, as a number
Adherence to the proposed session features via the ATLAS Web site. Almost of “healthy weight” boys with little scope
structure at observations 1, 2, 3, and 4 one-half of the group agreed or strongly for change were included in the study.
was 61%, 58%, 90%, and 96%, re- agreed that the “push prompt” mes- Indeed, the majority of recruited boys
spectively. Students were expected to sages reminded them to be more ac- were classified as having a healthy
attend at least 70% of sport sessions and tive, reduce their screen-time, and weight at baseline and remained so for
at least two-thirds of lunchtime sessions. drink fewer sugary drinks, and 44% of the duration of the intervention. In-
Sixty-five percent of boys attended participants agreed or strongly agreed terestingly, it has been suggested that
$70% of the sport sessions but only that the ATLAS app was enjoyable to while school-based interventions should
44% of boys attended at least two-thirds use. Self-reported pedometer use was continue to target all students, analysis
of lunchtime sessions. Participant sat- moderate, with 44% of boys wearing of the primary outcome(s) should per-
isfaction with the ATLAS intervention was their pedometer sometimes and 30% haps focus on overweight/obese youth.39
high (mean: 4.5 6 0.7 [scale of 1 = wearing their pedometer often. In ad- The findings of the present study were in
strongly disagree to 5 = strongly agree]). dition, all 4 newsletters were sent to contrast to those of our pilot study in
Students enjoyed the sports sessions 86% of parents. Teacher satisfaction which significant intervention effects for
(mean: 4.5 6 0.7); however, satisfaction with the intervention was high (mean: multiple measures of body composition

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TABLE 2 Baseline Characteristics of Study Sample provides additional support for the ef-
Characteristics Control (n = 180) Intervention (n = 181) Total (N = 361) ficacy of the intervention for overweight/
Age, y 12.7 6 0.5 12.7 6 0.5 12.7 6 0.5 obese participants.
Born in Australia 168 (93.3) 174 (96.1) 341 (94.7)
English language spoken at homea 169 (94.4) 175 (96.7) 344 (95.6)
Recent literature has identified muscular
Cultural backgroundb fitness as an important indicator of
Australian 132 (73.7) 145 (80.6) 277 (77.2) health status for young people.42,43 No-
European 31 (17.3) 22 (12.2) 53 (14.8)
tably, we found significant intervention
African 6 (3.4) 1 (0.6) 7 (1.9)
Asian 3 (1.7) 4 (2.2) 7 (1.9) effects for upper body muscular endur-
Middle Eastern 2 (1.1) 0 2 (0.6) ance and RT skill competency. The in-
Other 5 (2.8) 8 (4.4) 13 (3.6) tervention activities were predominantly
Socioeconomic positionc
1–2 55 (30.9) 49 (27.1) 104 (29.0) resistance-based and as such focused
3–4 81 (45.5) 120 (66.3) 201 (56.0) on developing muscular fitness. Fur-
5–6 27 (15.2) 4 (2.2) 31 (8.6) thermore, the workouts and fitness
7–8 8 (4.5) 8 (4.4) 16 (4.5)
9–10 7 (3.9) 0 7 (1.9) challenges performed throughout the
Weight, kg 53.1 6 13.4 54.0 6 15.0 53.5 6 14.2 intervention were designed to be high
Height, cm 160.2 6 8.4 160.9 6 9.0 160.5 6 8.7 repetition, targeting local muscular en-
BMI 20.5 6 4.1 20.5 6 4.1 20.5 6 4.1
Weight status
durance rather than maximal strength
Underweight 5 (2.8) 2 (1.1) 7 (1.9) specifically. Therefore, the significant
Healthy weight 115 (63.9) 110 (60.8) 225 (62.3) improvement in muscular endurance
Overweight 38 (21.1) 39 (21.5) 77 (21.3)
Obese 22 (12.2) 30 (16.6) 52 (14.4)
and nonsignificant findings for mus-
Waist circumference, cm 76.5 6 12.3 76.2 6 12.2 76.3 6 12.2 cular strength are not surprising. In
Data are presented as mean 6 SD or n (%). addition, the improvement in skill com-
a One participant did not report language spoken at home.
b Two participants did not report cultural background.
petency was expected because a core
c Socioeconomic position determined according to population decile by using SEIFA of relative socioeconomic disadvantage component of the sport sessions was
based on residential postal code (1 = lowest, 10 = highest). Two participants did not report residential postal code. time dedicated to RT skill development
during which teachers modeled correct
were observed.11 This inconsistency body composition outcomes favored in- exercise technique and provided cor-
could be due to differences in the tervention boys who were overweight or rective feedback on boys’ movement
quantity and intensity of physical activ- obese at baseline. The magnitude of skill performance. Furthermore, ap-
ity during the enhanced school sport these changes, although not statistically proximately two-thirds of boys reported
sessions. Process data indicated that significant, may nonetheless be clini- using the app to assess and monitor
toward the end of the program, boys in cally meaningful. For example, the ad- their RT technique.
the PALs study became disengaged due justed mean difference in body fat for Intervention boys in our study reported
to the lack of variety in activities. To overweight/obese participants in the spending30minuteslessperdayengaged
maintain engagement, the ATLAS sport ATLAS intervention was 0.9%. According in screen-based recreation at follow-up
sessions provided a greater variety of to Dai et al,40 an increase of 1% body fat compared with control subjects. Similar
activities and also incorporated a is significantly associated with unfavor- findings were described in the Planet
stronger focus on movement skill de- able changes in total, high-density lipo- Health intervention,44 with the authors
velopment. Although program satisfac- protein, and low-density lipoprotein reporting an adjusted difference of 24
tion was higher in ATLAS compared with cholesterol, as well as triglycerides. minutes in favor of intervention boys.
PALs, these modifications may have Furthermore, in a study of children and The reduction in screen-time observed in
resulted in lower overall activity and/or adolescents, Weiss et al41 reported that ATLAS is likely to be conservative com-
lower activity intensity during the ses- each 0.5-unit increase in BMI was asso- pared with other studies, as our measure
sions, and hence smaller effects on ciated with significantly increased risk of screen-time was modified to account
body composition. Alternatively, be- of the metabolic syndrome. The adjusted for screen multitasking. Reducing screen-
cause PALs participants had a higher mean difference in BMI for overweight/ time was an explicit intervention target,
baseline BMI, they may have had obese subjects in our study was –0.4 and ATLAS used a number of strategies
a greater propensity for change. units, which may have clinical signifi- to encourage boys to reduce their
Although our study was not powered to cance. Finally, the proportional shift in screen-time. The relative contribution
detect subgroup differences, changes in weight status between study groups of the individual intervention components

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TABLE 3 Changes in Primary and Secondary Outcomes

Outcomea Baseline 8 Months Change P Value Adjusted Difference P Value
in Change
BMI
Intervention 20.7 6 0.64 21.3 6 0.64 0.60 6 0.09 ,.001 0.0 6 0.12b .84
Control 20.6 6 0.57 21.2 6 0.57 0.61 6 0.08 ,.001
Waist circumference, cm
Intervention 77.1 6 1.89 77.1 6 1.89 0.0 6 0.33 .98 0.5 6 0.45b .16
Control 77.0 6 1.69 76.5 6 1.69 20.5 6 0.31 .10
Body fat, %
Intervention 20.3 6 1.27 21.6 6 1.28 1.3 6 0.35 ,.001 0.0 6 0.48 .99
Control 22.5 6 1.14 23.8 6 1.14 1.3 6 0.33 ,.001
Grip strength, kg
Intervention 22.5 6 0.97 28.5 6 0.98 6.0 6 0.32 ,.001 0.5 6 0.45 .30
Control 20.4 6 0.87 25.9 6 0.88 5.5 6 0.31 ,.001
Push-ups (repetitions)
Intervention 9.1 6 0.99 9.8 6 1.0 0.7 6 0.35 .04 0.9 6 0.49b .04
Control 6.6 6 0.89 6.5 6 0.89 20.1 6 0.34 .73
Weekday PA, counts/minc
Intervention 538 6 30.81 515 6 33.51 223 6 18.08 .21 219 6 23.30 .41
Control 477 6 27.18 473 6 28.58 23 6 14.69 .81
Weekend PA, counts/mind
Intervention 435 6 47.19 410 6 54.85 225 6 40.25 .53 28 6 53.94b .57
Control 404 6 42.42 387 6 47.13 217 6 35.97 .64
Weekday MVPA, %c
Intervention 8.6 6 0.58 8.3 6 0.63 20.4 6 0.34 .28 20.7 6 0.44 .14
Control 7.5 6 0.51 7.8 6 0.54 0.3 6 0.28 .30
Weekend MVPA, %d
Intervention 6.2 6 0.78 6.0 6 0.90 20.2 6 0.67 .73 20.16 0.90b .80
Control 5.8 6 0.70 5.7 6 0.78 20.1 6 0.60 .82
Screen-time, min/d
Intervention 109 6 14.18 112 6 14.52 3 6 7.25 .67 230 6 10.08b .03
Control 132 6 12.78 165 6 12.94 33 6 7.0 ,.001
SSB intake, glasses/d
Intervention 3.9 6 0.40 3.1 6 0.41 20.8 6 0.19 ,.001 20.6 6 0.26b .01
Control 3.9 6 0.36 3.7 6 0.36 20.1 6 0.18 .44
RT skill competencye
Intervention 31.7 6 0.56 40.1 6 0.60 8.4 6 0.48 ,.001 5.7 6 0.67 ,.001
Control 30.7 6 0.53 33.4 6 0.55 2.7 6 0.46 ,.001
Means 6 standard errors are reported for all outcomes. MVPA, moderate to vigorous physical activity; PA, physical activity.
a All models were adjusted for school clustering and participant socioeconomic status.
b Variable transformed for analysis.
c A total of 240 and 120 participants wore accelerometers on weekdays at baseline and posttest, respectively.
d A total of 120 and 83 participants wore accelerometers on weekend days at baseline and posttest, respectively.
e Possible values range from 0 to 56.

to change in screen-time is difficult to In addition to these effects on screen- this outcome. If the reduction in SSB
ascertain. However, the consequences time, intervention boys also reported consumption observed in our study is
of excessive screen-time and current significantly reducing their consump- sustained, the corresponding decrease
screen-time guidelines were made ex- tion of SSBs. The adjusted mean dif- in daily energy intake may have a con-
plicit to boys during the researcher-led ference was 0.6 glass per day (∼150 siderable impact on body composition
seminars and were reinforced by mL). A reduction in the consumption of over the longer term.
teachers during the face-to-face sport SSBs has been recommended to pre- Although it is difficult to determine the
sessions. In addition, the majority of vent unhealthy weight gain and the relative contribution of individual compo-
parents received and read the screen- onset of metabolic disorders.48 Al- nents in multicomponent interventions,
time newsletters, as reported by the though improvements in body composi- by conducting a comprehensive pro-
boys. Finally, 70% of boys reported us- tion have accompanied reductions in cess evaluation we were able to gather
ing the goal-setting function of the app, SSB consumption in previous studies,45,46 important information on the efficacy of
which allowed users to set goals for these studies were of longer duration individual strategies. Attendance at the
reducing screen-time. than ATLAS and also focused solely on sport sessions was reasonable, with

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approximately two-thirds of boys at- radiograph absorptiometry provide a vorable outcomes for behaviors known
tending a satisfactory number of ses- more accurate assessment of body to be associated with adiposity and
sions, whereas attendance at the fat. Second, we cannot rule out social cardiometabolic disorders. This study
lunchtime sessions was poor. Boys desirability bias in our assessment of demonstrates that a school-based in-
reported lower satisfaction with the screen-time and SSB consumption. tervention targeting economically dis-
lunchtime sessions, which may be due Third, we were unable to collect ATLAS advantaged adolescent boys can have
to a preference to use this period for app usage data, which prevented a a favorable impact on muscular fitness,
socializing. Compliance with the in- more thorough examination of the ef- movement skills, and key weight-related
tended session structure was moderate ficacy of this novel component. Fourth, behaviors. We encourage practitioners
at the first observation but improved similar to previous studies with ado- and policy makers to advocate for tar-
substantially over the course of the lescents,12 poor compliance to accelero- geted programs in schools for young
intervention. Usage of the ATLAS app for meter protocols reduced the available people who are disengaged in current
self-monitoring and goal setting was sample size, preventing more compre- physical education programs. Future
moderate. Therefore, additional strate- hensive assessment of change in physi- interventions using smartphone tech-
gies and features may be needed to en- cal activity. Finally, due to the targeted nology should capture objective data on
hance engagement in adolescent boys. It nature of the intervention, the results app/Web site usage throughout the in-
is important to note that the proportion of may not be generalizable to other groups tervention period, and analyses should
dropouts who were overweight/obese (eg, female subjects, those from other be conducted examining its associa-
was lower than it was for completers, socioeconomic strata). tion with changes in intervention out-
indicating that ATLAS was successful in comes. Furthermore, futuresmartphone
retaining overweight/obese boys. Finally, apps should integrate stimulating
all teachers agreed or strongly agreed CONCLUSIONS features such as social media linkage
that their students benefited from in- There is a clear need for innovative and “gamification” to support ongo-
volvement in ATLAS, thus providing obesity prevention programs that tar- ing engagement with this intervention
a strong endorsement for the program. get adolescents at risk of obesity. component.
Strengths of the present study include School-based interventions that use
the randomized controlled design, the smartphone technology have the po- ACKNOWLEDGMENTS
identification and targeting of ado- tential for health behavior change, but We thank Sarah Kennedy, Emma Pollock,
lescents at risk of obesity, objective strategies for identifying and recruiting and Mark Babic for their assistance
assessment of physical activity, the participants and increasing the in- with data collection. In addition, we
extensive process evaluation, and the tervention dose are needed. Although thank Geoff Skinner and Andrew
high retention at follow-up. However, the ATLAS program failed to achieve Harvey for their assistance with the
there were also some limitations. Al- short-term changes in body composi- ATLAS smartphone application. Finally,
though BMI is considered a suitable and tion in the overall study sample, there we thank the schools, teachers, pa-
stable measure of change in adiposity,47 was a trend in favor of overweight/ rents, and study participants for their
direct measures such as dual-energy obese boys. In addition, there were fa- involvement.

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 Smart-Phone Obesity Prevention Trial for Adolescent Boys in Low-Income
Communities: The ATLAS RCT
Jordan J. Smith, Philip J. Morgan, Ronald C. Plotnikoff, Kerry A. Dally, Jo Salmon,
Anthony D. Okely, Tara L. Finn and David R. Lubans
Pediatrics 2014;134;e723; originally published online August 25, 2014;
DOI: 10.1542/peds.2014-1012
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