***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Pathways , a multisite school-based study aim ed at promoting healthful eating and increasing physical activity , was a r and omized field trial including 1704 American Indian third to fifth grade students from 41 schools ( 21 intervention , 20 controls ) in seven American Indian communities . METHODS The intervention schools received four integrated components : a classroom curriculum , food service , physical activity , and family modules . The curriculum and family components were based on Social Learning Theory , American Indian concepts , and results from formative research . Process evaluation data were collected from teachers ( n=235 ) , students ( n=585 ) , and families .  Knowledge , Attitudes , and Behavior Question naire data were collected from 1150 students including both intervention and controls . RESULTS There were significant increases in knowledge and cultural identity in children in intervention compared to control schools with a significant retention of knowledge over the 3 years , based on the results of repeating the third and fourth grade test items in the fifth grade . Family members participated in Family Events and take-home activities , with fewer participating each year . CONCLUSION A culturally appropriate school intervention can promote positive changes in knowledge , cultural identity , and self-reported healthful eating and physical activity in American Indian children and environmental change in school food service BACKGROUND The purpose of this study was to examine the impact of the Pathways intervention on pychosocial variables related to physical activity and diet in American Indian children . METHODS Schools serving American Indian children were r and omized to a multicomponent intervention or control condition . At baseline ( fall of third grade ) and in the spring semester of third , fourth , and fifth grade s 755 boys and 692 girls completed a classroom-administered question naire . The question naire assessed self-efficacy , knowledge , and behavioral intentions related to diet and physical activity , as well as weight loss behaviors and body image . RESULTS Knowledge of nutrition and physical activity messages increased in both boys and girls in the intervention group compared to controls ; however , knowledge of which foods contained more fat did not increase consistently . Compared to controls , self-efficacy to be physically active increased among girls in intervention schools , but not among boys , whereas self-efficacy to make more healthy food choices did not increase more than in controls in either gender . In the intervention group , compared to controls , healthy food intentions and participation in physically active behaviors increased in both boys and girls . Perception of healthy body size and weight loss attempts did not differ in the intervention and control groups . CONCLUSION The Pathways intervention program had a positive impact on several aspects of obesity-related knowledge , attitudes , and behaviors CONTEXT Individuals with diabetes are at increased risk for cardiovascular disease ( CVD ) , but more aggressive targets for risk factor control have not been tested . OBJECTIVE To compare progression of sub clinical atherosclerosis in adults with type 2 diabetes treated to reach aggressive targets of low-density lipoprotein cholesterol ( LDL-C ) of 70 mg/dL or lower and systolic blood pressure ( SBP ) of 115 mm Hg or lower vs st and ard targets of LDL-C of 100 mg/dL or lower and SBP of 130 mm Hg or lower . DESIGN , SETTING , AND PARTICIPANTS A r and omized , open-label , blinded-to-end point , 3-year trial from April 2003-July 2007 at 4 clinical centers in Oklahoma , Arizona , and South Dakota . Participants were 499 American Indian men and women aged 40 years or older with type 2 diabetes and no prior CVD events . INTERVENTIONS Participants were r and omized to aggressive ( n=252 ) vs st and ard ( n=247 ) treatment groups with stepped treatment algorithms defined for both . MAIN OUTCOME MEASURES Primary end point was progression of atherosclerosis measured by common carotid artery intimal medial thickness ( IMT ) . Secondary end points were other carotid and cardiac ultrasonographic measures and clinical events . RESULTS Mean target LDL-C and SBP levels for both groups were reached and maintained . Mean ( 95 % confidence interval ) levels for LDL-C in the last 12 months were 72 ( 69 - 75 ) and 104 ( 101 - 106 ) mg/dL and SBP levels were 117 ( 115 - 118 ) and 129 ( 128 - 130 ) mm Hg in the aggressive vs st and ard groups , respectively . Compared with baseline , IMT regressed in the aggressive group and progressed in the st and ard group ( -0.012 mm vs 0.038 mm ; P < .001 ) ; carotid arterial cross-sectional area also regressed ( -0.02 mm(2 ) vs 1.05 mm(2 ) ; P < .001 ) ; and there was greater decrease in left ventricular mass index ( -2.4 g/m(2.7 ) vs -1.2 g/m(2.7 ) ; P = .03 ) in the aggressive group . Rates of adverse events ( 38.5 % and 26.7 % ; P = .005 ) and serious adverse events ( n = 4 vs 1 ; P = .18 ) related to blood pressure medications were higher in the aggressive group . Clinical CVD events ( 1.6/100 and 1.5/100 person-years ; P = .87 ) did not differ significantly between groups . CONCLUSIONS Reducing LDL-C and SBP to lower targets result ed in regression of carotid IMT and greater decrease in left ventricular mass in individuals with type 2 diabetes . Clinical events were lower than expected and did not differ significantly between groups . Further follow-up is needed to determine whether these improvements will result in lower long-term CVD event rates and costs and favorable risk-benefit outcomes . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00047424 Background Culturally adapted interventions are needed to reduce diabetes-related morbidity and mortality among Native Hawaiian and Pacific People . Purpose The purpose of this study is to pilot test the effectiveness of a culturally adapted diabetes self-management intervention . Methods Participants were r and omly assigned in an unbalanced design to the Partners in Care intervention ( n = 48 ) or wait list control group ( n = 34 ) . Assessment s of hemoglobin A1c , underst and ing of diabetes self-management , performance of self-care activities , and diabetes-related distress were measured at baseline and 3 months ( post intervention ) . Analysis of covariance was used to test between-group differences . The community steering committee and focus group data informed the cultural adaptation of the intervention . Results There were significant baseline adjusted differences at 3 months between the Partners in Care and wait list control group in intent-to-treat ( p < 0.001 ) and complete case analyses ( p < 0.0001 ) for A1c , underst and ing ( p < 0.0001 ) , and performing diabetes self-management ( p < 0.0001 ) . Conclusions A culturally adapted diabetes self-management intervention of short duration was an effective approach to improving glycemic control among Native Hawaiian and Pacific Isl and ers BACKGROUND Childhood obesity is a major public health problem in the United States , particularly among American Indian communities . OBJECTIVE The objective was to evaluate the effectiveness of a school-based , multicomponent intervention for reducing percentage body fat in American Indian schoolchildren . DESIGN This study was a r and omized , controlled , school-based trial involving 1704 children in 41 schools and was conducted over 3 consecutive years , from 3rd to 5th grade s , in schools serving American Indian communities in Arizona , New Mexico , and South Dakota . The intervention had 4 components : 1 ) change in dietary intake , 2 ) increase in physical activity , 3 ) a classroom curriculum focused on healthy eating and lifestyle , and 4 ) a family-involvement program . The main outcome was percentage body fat ; other outcomes included dietary intake , physical activity , and knowledge , attitudes , and behaviors . RESULTS The intervention result ed in no significant reduction in percentage body fat . However , a significant reduction in the percentage of energy from fat was observed in the intervention schools . Total energy intake ( by 24-h dietary recall ) was significantly reduced in the intervention schools but energy intake ( by direct observation ) was not . Motion sensor data showed similar activity levels in both the intervention and control schools . Several components of knowledge , attitudes , and behaviors were also positively and significantly changed by the intervention . CONCLUSIONS These results document the feasibility of implementing a multicomponent program for obesity prevention in elementary schools serving American Indian communities . The program produced significant positive changes in fat intake and in food- and health-related knowledge and behaviors . More intense or longer interventions may be needed to significantly reduce adiposity in this population BACKGROUND Type 2 diabetes mellitus is a growing concern worldwide , particularly in Indigenous communities , which have undergone a marked nutrition transition characterized by reduced intakes of traditional foods and increased intakes of market foods . Few studies have assessed the relationships between differing dietary patterns and risk for type 2 diabetes  in Indigenous communities in Canada . The objective of the study was to characterize dietary patterns using factor analysis ( FA ) and to relate these patterns to the incidence of type 2 diabetes after 10 years of follow up in a First Nations community in Ontario , Canada . METHODS We conducted a prospect i ve analysis of 492 participants in the SLHDP who did not have diabetes at baseline ( 1993 to 1995 ) and were followed for 10 years . A food-frequency question naire was administered , and FA was used to identify patterns of food consumption . Multivariate logistic regression analyses determined associations of food patterns with incident type 2 diabetes , adjusting for sociodemographic and lifestyle confounders . RESULTS At follow up , 86 participants had developed incident type 2 diabetes . FA revealed 3 prominent dietary patterns : Balanced Market Foods , Beef and Processed Foods and Traditional Foods . After adjustment for age , sex , waist circumference , interleukin-6 and adiponectin , the Beef and Processed Foods pattern was associated with increased risk for incident type 2 diabetes ( OR=1.38 ; 95 % CI 1.02 , 1.86 ) . In contrast , the Balanced Market Foods and Traditional Foods Patterns were not significantly associated with type 2 diabetes . CONCLUSIONS Dietary interventions should encourage reduced consumption of unhealthful market foods , in combination with improvements in local food environments so as to increase access to healthful foods and reduce food insecurity in Indigenous communities The aim of the Bright Start study was to develop and test the effectiveness of a school environment intervention , supplemented with family involvement , to reduce excessive weight gain by increasing physical activity and healthy eating practice s among kindergarten and first grade American Indian children . Bright Start was a group-r and omized , school-based trial involving 454 children attending 14 schools on the Pine Ridge Reservation in South Dakota . Children were followed from the beginning of their kindergarten year through the end of first grade . Main outcome variables were mean BMI , mean percent body fat , and prevalence of overweight/obese children . The goals of the intervention were to : increase physical activity at school to at least 60 min/day ; modify school meals and snacks ; and involve families in making behavioral and environmental changes at home . At baseline , 32 % of boys and 25 % of girls were overweight/obese . While the intervention was not associated with statistically significant change in mean levels of BMI , BMI -Z , skinfolds or percentage body fat , the intervention was associated with a statistically significant net decrease of 10 % in the prevalence of overweight . Intervention children experienced a 13.4 % incidence of overweight , while the control children experienced a corresponding incidence of 24.8 % ; a difference of −11.4 % ( p=0.033 ) . The intervention significantly reduced parent reported mean child intakes of sugar-sweetened beverages , whole milk and chocolate milk . Changes in duration of school physical activity were not significant . Because obesity is the most daunting health challenge facing American Indian children today , more intervention research is needed to identify effective approaches OBJECTIVE The Diabetes Prevention Program ( DPP ) showed that intensive lifestyle intervention reduced the risk of diabetes by 58 % . This paper examines demographic , psychosocial , and behavioral factors related to achieving weight loss and physical activity goals in the DPP lifestyle participants . RESEARCH METHODS AND PROCEDURES Lifestyle participants ( n = 1079 ; mean age = 50.6 , BMI = 33.9 , 68 % female , and 46 % from minority groups ) had goals of 7 % weight loss and 150 min/wk of physical activity . Goal achievement was assessed at the end of the 16-session core curriculum ( approximately week 24 ) and the final intervention visit ( mean = 3.2 years ) as a function of demographic , psychosocial , and behavioral variables . RESULTS Forty-nine percent met the weight loss goal and 74 % met the activity goal initially , while 37 % and 67 % , respectively , met these goals long-term . Men and those with lower initial BMI were more likely to meet activity but not weight loss goals .  Hispanic , Asian , and Native Americans were more likely to meet the long-term activity goals , and whites were more likely to meet the initial weight loss goal . In multivariate analyses , meeting the long-term weight loss goal and both activity goals increased with age , while psychosocial and depression measures were unrelated to goal achievement .  Dietary self-monitoring  was positively related to meeting both weight loss and activity goals , and meeting the activity goal was posit 
    Output:
    
Conclusions The extent of use of strategies to promote community engagement in programs reporting significant outcomes is notable .