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Effects of theory-based nutrition intervention using learner-centered activities on bone health knowledge, intent, and influences of school-age children.
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- 1. Effects of theory-based nutrition intervention using learner- centered activities on bone health knowledge, intent, and influences of school-age children Nicole Arcilla, B.S. Julia Casey, B.S. Casey Mitchell, B.S. Lauren Simmons, B.S. Elilta Tsegai, B.S. Thesis advisor: Karen Plawecki, PhD, RD, LDN
- 2. Agenda • Background: A Review of Bone Health • Methods • Demographics • Results and Discussion • Strengths, Limitations, and Future Implications
- 3. Background: A Review of Bone Health
- 4. Calcium Overview • Key nutrient in the human body and most abundant mineral found in the human body. • 90% of total body calcium is stored in bones and teeth. • Metabolism and level is controlled by the kidneys, bones, and gastrointestinal tract. Bass, 2006; Bronner, 2003; http://courses.washington.edu
- 5. Calcium Intake • Recommended amount: – 4-8 years: 1000 mg – 9-13 years: 1300 mg • Other sources • 77% of children ages 9-19 years do not meet the recommended amount of 3 servings/day (Berner, 2013)
- 6. Vitamin D Overview • Two major forms – Vitamin D2 or ergocalciferol – Vitamin D3 or cholecalciferol • Key nutrient for bone growth and maintenance (Misra et al, 2008; Holick et al, 2004; Ross et al,
- 7. Cutaneous Vitamin D Synthesis • Affected by – Skin pigmentation • African American children have increased rates of vitamin D deficiency – Decreased time outdoors • Specifically the pediatric population – UV protection • Encourage “sensible sun exposure” – Season • Decreased sun exposure during winter months – Latitude • As latitude increases, UV radiation decreases (Bose et al, 2013; Au et al, 2014; Misra et al, 2008; Holick et al 2006, www.foodandhealth.com)
- 8. Vitamin D Intake • Breastfed infants – The American Academy of Pediatrics recommends 400 IU of vitamin D daily • Natural versus fortified food sources (Economos et al, 2014; Calvo et al, 2004; Wagner et al, 2008; Misra et al, 2008)
- 9. Bone Overview • Skeletal system role – Movement – Protection & Support – Mineral Reservoir • Development Stages – Bone growth – Bone modeling – Bone remodeling (Ralston, 2006; Little, 2011; www.harvard-wm.org 2014)
- 11. Bone Lifespan (Betts et al, 2013)
- 12. Rickets Disease • Most common form nutritional rickets affects children and adolescents • Maternal vitamin D stores influence fetal bone development • Common symptoms – Bossing of forehead – Bowed legs – Impaired growth (Namgung, 2003; Haliloglu, 2011; Mulligan, 2010; Upton, 2010)
- 13. Bone Health Disease • Adult bone disease – Osteomalacia – Osteoporosis • Currently over 200 million people diagnosed osteoporosis worldwide – 10.2 million in the United States – 43.4 million low bone mass (osteopenia) (American Academy Orthopedic Surgeons, 2009; WHO, 2007)
- 14. (The Osteoporosis Center, 2014)
- 15. Physical Activity (CDC, 2011; National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2014) • Recommendations – 60 minutes or more of age-appropriate moderate to vigorous-intensity » In 2011, only 18.5% of girls and 38.3% of boys achieved this
- 16. Types of Exercises • Aerobic Activity • Muscle Strengthening • Bone Strengthening Miketnelson.blogspot.com
- 17. Bone Strengthening Activity •Weight-bearing •Running, basketball, dancing •Resistance training •Resistance bands, free weights, weight machines (Lee, 2007; Turner, 2006; Eid, 2014; pennmedicine.org)
- 18. Related Literature •Creighton et al, 2001 •Examined BMD and markers of bone formation •41 college-aged female athletes •High impact: basketball and volleyball •Medium impact: track and soccer •Non-impact: swimming •High impact group had significantly higher total body BMD
- 20. Related Literature •Adami et al, 2008 •Examined bone formation markers •24 health sedentary women •90 minute exercise sessions 3-4x weekly •Significant increase in bone formation markers •Even minor changes in PA have positive effect on bone formation
- 21. Theories • Used to guide and build foundation of programs • Formation of decision making process • Identifying measurement indicators • Commonly used theories: – Cognitive Behavioral Therapy – Health Belief Model – Social Cognitive Theory – Theory of Planned Behavior
- 22. Theories: A Review • Cognitive Behavioral Therapy – Exploring emotions and attitudes towards a behavior – Meanings individuals may give to situations or emotions (Beck, 1976; www.hpft.nhs.uk)
- 23. Theories: A Review • Health Belief Model – Central focus: Motivation Individual’s belief on their susceptibility + Perceived benefit of change Willingness and readiness to take action (Rosenstock et al, 1988)
- 24. Theories: A Review • Social Cognitive Theory – Ongoing process between 3 main factors: • Personal, Environmental, Human behavior – All factors continuously influence each other (Bandura, 1986; mellbandura.com)
- 25. Theories: A Review • Theory of Planned Behavior – Relationship between an individual’s behavior and beliefs, attitudes, and intentions. – Most important determinant: intention (Azjen et al, 1991; sphweb.bumc.bu.edu)
- 26. Application to Batter Up for Bone Health • Behavioral theories inappropriate for intervention’s time frame • Focusing on Social Cognitive Theory – Determining participants’ motivational and influencing factors – Understanding lifestyle habits
- 27. Background Summary • Calcium and vitamin D intake • Bone biology • Physical activity • Theory focused
- 28. Methods
- 29. Study Objectives • The Batter Up for Bone Health program aimed to increase bone health knowledge and bone health behaviors in target population • Promote bone health related foods and activities in children ages 5-13 years
- 31. Survey Tools • Demographic Survey • Consent Forms • Test Surveys – Pre-test – Post-test – 21-day post-test
- 32. Test Survey Format • Pre-test – 21 questions – Food & activity knowledge – Influences • Post-test & 21-day post-test – 19 questions – Motivation & knowledge changes
- 33. Data Analysis • Descriptives – Gender – Age – Ethnicity – Camp location • Hypothesis & Inferential Testing – Wilcoxon Signed Ranks – Spearman rho Correlation – Chi-Square Goodness of Fit – Friedman – Kruskal-Wallis – Mann-Whitney U
- 35. Demographics • Demographic Survey – Age – Gender – Ethnicity – Calcium use – Supplement use Total Collected Total with consent 204 117
- 36. Camper Age and Age Group Category 5-7 Years 25% 8-13 Years 75% Age Group Category 5-7 Years 8-13 Years Age Category N* 5-7 years 19 8-13 years 58 Total 77 Average Camper Age 9.12 ± 2.01 * Reflects those who provided consent forms
- 37. Camper Gender Male 49%Female 51% Gender Male Female Gender N Female 60 Male 57 Total 117
- 38. Camp Location Elmhurst 43% West Chicago 57% Camp Location Elmhurst West Chicago Camp Location N Elmhurst 50 West Chicago 67 Total 117
- 39. Camper Ethnicity Hispani c 44%White 42% Other 14% Ethnicity Hispanic White Other Ethnicity N Hispanic 34 White 32 Other 11 Total 77
- 40. Camper Ethnicity by Location White 80% Hispanic 0% Other 20% Elmhurst White Hispanic Other White 0% Hispanic 92% Other 8% West Chicago White Hispanic Other
- 41. Camper Calcium Use 65 2 7 3 1 1 49 46 2 0 10 20 30 40 50 60 70 Frequencies Responses Frequency of Calcium Consumption Consumer N Calcium 76 Non-calcium 2
- 42. Camper Supplement Use 33 4 1 6 1 0 10 20 30 40 Frequencies Responses Frequency of Supplements User N Supplement 43 Non-supplement 35 Total 78
- 43. Results
- 44. H01: There is no significant change in knowledge and understanding of bone health practices. 49% 62% 0% 10% 20% 30% 40% 50% 60% 70% Pretest Post-test PercentCorrect Knowledge and Understanding Questions Immediate Knowledge Gained p<0.0001
- 45. H01: There is no significant change in knowledge and understanding of bone health practices. 49% 65% 61% 0 10 20 30 40 50 60 70 Pretest Post-test 21-day Post Test PercentCorrect Knowledge and Understanding Questions Average Overall Test Score of Campers For Knowledge and Understanding Based Questions p<0.0001
- 46. H01: There is no significant change in knowledge and understanding of bone health practices Test P Value Test Value Confidence Interval/Effect Size Sample Size Overall Friedman 0.0001 Overall: 48.46 0.4841 Pretest:106 Post-test:107 21-Day Post- Test: 69 Between Gender Mann- Whitney U Pretest: 0.35 Post-test: 0.55 Pretest: 1259.00 Post-test: 1337.00 Outside Pretest: 106 Post-test: 107 Between Locations Mann- Whitney U Pretest: 0.35 Post-test: 0.54 Pretest: 1250.50 Post-test: 1318.50 Outside Pretest: 106 Post-test: 107 Between Ages Mann- Whitney U Pretest: 0.05 Post-test: 0.01 Pretest: 294.00 Post-test: 251.00 0.4164 Pretest: 73 Post-test: 74 Between Ethnicities Kruskal- Wallis Pretest: 0.07 Post-test: 0.36 Pretest: 5.29 Post-test: 2.04 Outside Pretest: 73 Post-test: 74
- 47. H02: There is no significant difference in motivation to improve bone health among campers. 0 10 20 30 40 50 60 70 80 Important Not Important Never Thought About it Frequencies Responses Question 1: It is important for kids my age to have healthy bones Pretest Post-test 21-Day Post-Test (National Osteoporosis Foundation,
- 48. H02: There is no significant difference in motivation to improve bone health among campers Test P Value Test Value Confidenc e Interval Sample Size Overall Wilcoxon Signed Ranks Pretest: 1.00 1.00 Outside Pretest: 78 Post-test: 79 21-day post-test: 60 Post-Test: 1.00 1.00 21-Day post-Test: 0.16 0.16 Between Gender Mann- Whitney U Pretest: 0.90 757.50 Outside Male: 37 Female: 41 Post-Test: 0.46 728.58 21-Day Post-Test: 0.49 424.00 Between Locations Mann- Whitney U Pretest: 0.28 662.50 Outside Elmhurst: 29 West Chicago: 49 Post-Test: 0.27 671.00 21-Day Post-Test: 0.42 393.00 Between Ages Mann- Whitney U Pretest: 0.28 166.50 Outside 5-7 years: 29 8-13 years: 40 Post-Test: 0.47 207.00 21-Day Post-Test: 0.43 126.00 Between Ethnicities Kruskal-Wallis Pretest: 0.06 5.79 Outside Hispanic: 28 White: 23 Other: 3 Post-Test: 0.12 4.20 21-Day Post-Test: 0.15 3.76
- 49. H03: There is no significant difference in influence on food choices among campers. 0 5 10 15 20 25 30 35 40 Participants Response Average Influence of Authority Pre-test 0 5 10 15 20 25 30 35 40 Participants Response Average Influence of Peers Pre-test
- 50. H03: There is no significant difference in Influence of Authority on food choices among campers. Test P Value Test Value Confidence Interval/Eff ect Size Sample Size Overall Chi-Square 0.01 Pretest 57.62 0.93 Total: 75 Between Gender Mann-Whitney U 0.40 Pretest 1104.00 Outside Male: 45 Female: 54Mean Rank-M 52.50 Mean Rank-F 47.83 Between Locations Mann-Whitney U 0.45 Pretest 1112.50 Outside Elmhurst: 45 West Chicago: 54 Mean Rank-E 52.28 Mean Rank-W 48.10 Between Ages Mann-Whitney U 0.67 Pretest 420.00 Outside 5-7 years: 18 8-13 years: 50Mean Rank-Y 32.83 Mean Rank-O 35.10 Between Ethnicities Kruskal-Wallis 0.24 Pretest 2.89 Inside Hispanic: 29 White: 29 Other: 10 Mean Rank-H 30.81 Mean Rank-W 35.40 Mean Rank-O 42.60
- 51. H03: There is no significant difference in Influence of Peers on food choices among campers. Test P Value Test Value Confidence Interval/Eff ect Size Sample Size Overall Chi-Square 0.01 Pretest 31.29 0.92 Total: 80 Between Gender Mann-Whitney U 0.99 Pretest 1146.50 Outside Male: 42 Female: 54Mean Rank-M 48.48 Mean Rank-F 48.52 Between Locations Mann-Whitney U 0.28 Pretest 994.50 Outside Elmhurst: 45 West Chicago: 54 Mean Rank-E 45.18 Mean Rank-W 51.08 Between Ages Mann-Whitney U 0.46 Pretest 368.50 Outside 5-7 years: 17 8-13 years: 49Mean Rank-Y 30.68 Mean Rank-O 34.48 Between Ethnicities Kruskal-Wallis 0.23 Pretest 2.96 Inside Hispanic: 28 White: 29 Other: 9 Mean Rank-H 37.95 Mean Rank-W 30.81 Mean Rank-O 28.33
- 52. H04: There is no significant difference in exercise enjoyment among campers. 0 20 40 60 80 100 120 Yes No I Don't Know NumberofParticipants Participant Response Pretest Question 18: Exercising is fun
- 53. H04: There is no significant difference in exercise enjoyment among campers. Test P Value Test Value Confidence Interval or Effect Size Sample Size Overall Chi-Square <0.001 150.22 .84 108 Between Genders Mann- Whitney U 1.00 1457.50 Outside Male: 53 Female: 55 Between Locations Mann- Whitney U 0.72 1408.00 Outside Elmhurst: 48 West Chicago: 60 Between Ages Mann- Whitney U 0.75 467.00 Outside 5-7 years: 18 8-13 years: 54 Between Ethnicities Mann- Whitney U 0.71 476.00 Outside Hispanic: 30 White: 32
- 54. H04: There is no significant difference in exercise enjoyment among campers 0 10 20 30 40 50 60 70 80 90 Yes No I Don't Know NumberofParticipants Participant Response Pretest Question 19: I enjoy exercise
- 55. H04: There is no significant difference in exercise enjoyment among campers. Test P Value Test Value Confidence Interval/ Effect Size Sample Size Overall Chi-Square <0.001 100.60 .81 109 Between Genders Mann- Whitney U 0.35 1288.00 Outside Male: 52 Female: 54 Between Locations Mann- Whitney U 0.28 1262.00 Outside Elmhurst: 48 West Chicago: 58 Between Ages Mann- Whitney U 0.19 402.00 Outside 5-7 years: 18 8-13 years: 52 Between Ethnicities Mann- Whitney U 0.63 420.50 Outside Hispanic: 28 White: 32
- 56. Participants’ Intent to Participate in Physical Activities 0 10 20 30 40 50 60 70 80 90 Percent Activity Post-Test 21-Day Post-Test
- 57. H05: There is no significant difference in intent to change bone health practices among participants 0 10 20 30 40 50 60 70 80 90 100 NumberofResponses Responses Question 13: I plan to eat foods that are healthy for my bones Post-test Post Post-test
- 58. H05: There is no significant difference in intent to change bone health practices among participants Test P Value Test Value Confidence Interval Sample Size Overall Wilcoxon Signed Ranks >0.05 Post-test: 0.90 21-Day post-test: 0.91 Outside Post-test: 109 21-day post-test: 68 Between Gender Mann-Whitney U >0.05 Post-test: 1410 21-Day Post-Test: 483.5 Outside Male: 84 Female: 93 Between Locations Mann-Whitney U >0.05 Post-test: 1358 21-Day Post-Test: 466.5 Inside Elmhurst: 60 West Chicago: 107 Between Ages Mann-Whitney U >0.05 Post-test: 505.5 21-Day Post-Test: 136.5 Outside 5-7 years: 27 8-13 years: 89 Between Ethnicities Kruskal-Wallis >0.05 Post-test: 4.88 21-Day Post-Test: 0.35 Outside Hispanic: 57 White: 44 Other: 14 Between Supplement Groups Mann-Whitney U Test >0.05 Post-test: 632.5 21-day Post Test: 217.5 Outside Yes: 67 No: 50 Between dairy consumers Mann-Whitney U Test >.05 Post-test: 60 21-day Post Test: 18 Outside Yes:114 No: 3
- 59. Analysis of 21-day Post-Test Questions Responses Frequency Chi- Square df P-Value More 39 23.84 2 .0001 Less 5 I don’t know 22 Total 66 0 10 20 30 40 50 More Less I don't know NumberofResponses Response Question 20: Ever since ‘Bone Health Day’ I have done bone healthy activities.
- 60. Analysis of 21-day Post-Test Questions Responses Frequency Chi- Square df P-Value More 39 23.84 2 .0001 Less 8 I don’t know 17 Total 64 0 10 20 30 40 50 More Less I don't know NumberofResponses Responses Question 21: Ever since ‘Bone Health Day’ I have eaten bone healthy foods.
- 61. Related Literature • Harmon et al’s 2014 study – Built on previous study examining influence of renovating schoolyards on physical activity (PA) – Participants: 4th and 5th graders; N = 393 – Higher ratings of social cognitive theory variables higher physical activity levels – Hispanic students had significantly higher social support scores • Social environment may determine PA levels
- 62. Findings of Circle Questions Regarding Diet Changes 0 20 40 60 80 100 120 Milk Broccoli Grilled cheese Tofu Yogurt Mac n' cheese NumberofResponses Bone Healthy Food Selections Post-Test Question 17: Circle the foods you plan to eat Yes No
- 63. Findings of Circle Questions Regarding Diet Changes 0 10 20 30 40 50 60 70 Milk Broccoli Grilled cheese Tofu Yogurt Mac n' cheese NumberofResponses Bone Healthy Food Selections 21-day Post Test Question 17: Circle the foods you plan to eat Yes No
- 64. Analysis of Open-Ended Questions 0 2 4 6 8 10 12 14 16 18 Sports Play NumberofResponses Responses 21-Day Post-Test Question 20: Give an example of what bone healthy activities you changed every since Bone Health Day
- 65. Analysis of Open-Ended Questions 0 2 4 6 8 10 12 14 NumberofResponses Responses 21-Day Post-Test Question 21: Give an example of what bone health foods you changed every since Bone Health Day.
- 66. Summary of Results • Knowledge Outcomes • Physical Activity • Perceived Importance • Influences – Authority & Peers • Theories
- 67. Strengths, Limitations and Future Applications
- 68. Strengths of Batter Up For Bone Health • Program is adaptable for gender, ethnicities, SES, ages, cultures, and dietary lifestyles • Targets lifestyle habits to promote bone health • Overall low-cost and attention holding for population • Program saw good retention rates • Intervention tool was age appropriate for verbiage and utilization of images, pilot test was conducted, color coded for ease of analysis after the intervention • Mimics bone health practices
- 69. Positive Outcomes of Study • Knowledge gained • Knowledge retention
- 70. Limitations of The Study • Sample size • Time frame • Lack of diversity beyond Caucasian and Hispanic • Reading level of survey too high for younger population • Tools were not fully validated prior to use • Time inconsistencies within bases
- 71. Future Applications • Implementation within schools – Physical education classes – Science classes – Health classes • Can apply to a larger group • Possible expansion into a longer program • Further tool validation
- 72. Summary The Batter Up for Bone Health program is an exemplary theory-based intervention using learner-based activities to promote the importance of bone health during optimal bone development.
- 73. Thank you! • West Chicago School District • Elmhurst Park District • Goodie bag donors • Benedictine University’s Nutrition Department • Dr. Karen Plawecki
- 74. References •http://www.healthguidepk.com/wp-content/uploads/2014/01/keep-your-bones-healthy1.jpg •Berner L, Keast D, Bailey R, Dwyer J. Fortified foods are major contributors to nutrient intakes in diets of US children and adolescents. Journal of the Academy of Nutrition and Dietetics. 2014:2212-2672. •Betts JG, DeSaix P, Johnson E, et al. Anatomy & Physiology. Houston, TX: Openstax College; 2013. •Upton D. Effects of Rickets. Debbie Upton Medical Illustrator. 2010. Accessed from: http://debbieupton.com/products-page/effects-of-rickets/ •World Health Organization. WHO Scientific group on the assessment of osteoporosis at primary health care level. World Health Organization Press. 2007. Available at http://www.who.int/chp/topics/Osteoporosis.pdf. Accessed November 11, 2014. •The Osteoporosis Center. About Osteoporosis. 2014. Available at http://www.theosteoporosiscenter.com/osteoporosis.html. Accessed November 5, 2014. •National Osteoporosis Foundation. Emotional Aspects of Osteoporosis. 2014. Accessed from: http://www.theosteoporosiscenter.com/osteoporosis.html •http://www.hpft.nhs.uk/_uploads/documents/help-for-adults/cbt2-cbt-approach.pdf •Beck, AT. Cognitive Therapy and the Emotional Disorders. New York: Penguin. 1976. •http://www.jblearning.com/samples/0763743836/chapter%204.pdf •Rosenstock IM, Stretcher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Healthy Education Quarterly. 1988; 15(2):175-183.
- 75. References•Mirsa M, Pacaud D, Petryk A, et al. Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics. 2008;122(1):398-417. •References: Holick MF 1. Sunlight and vitamin d for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease. Am J Clin Nutr 2004;80(suppl):1678S-88S. •Ross AC, Taylor CL, Yaktine AL, et al. DRI Dietary Reference Intakes Calcium Vitamin D. Washington, D.C.: National Academies Press; 2011. •Bose S, Breysse PN, McCormack MC, et al. Outdoor exposure and vitamin D levels in urban children with asthma. Nutrition Journal. 2013;12:81;1-7. •Au LE, Harris SS, Jacques PF, et al. Adherence to a vitamin D supplementation intervention in urban schoolchildren. J Acad Nutr Diet. 2014;114:86-90. •Mirsa M, Pacaud D, Petryk A, et al. Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics. 2008;122(1):398-417. •Holick MF 2, Garabedian M. Vitamin D: photobiology, metabolism, mechanism ofaction, and clinical applications. In: Favus MJ, ed. Primer on the metabolic bone diseases and disorders of mineral metabolism. 6th ed. Washington, DC: American Society for Bone and Mineral Research, 2006:129-37. •Economos CD, Moore CE, Hyatt RR, et al. Multinutrient-fortified juices improved vitamin D and vitamin E status in children: a randomized controlled trial. J Acad Nutr Diet. 2014;114(5):709-17. •Calvo MS 1, Whitting SJ, Barton CN. Vitamin D fortification in the United States and Canada: current status and data needs. Am J Clin Nutr. 2004;80(suppl):1710S-6S. •Wagner CL & Greer FR. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008;122(1):1142-1152.
- 76. References•Mirsa M, Pacaud D, Petryk A, et al. Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics. 2008;122(1):398-417. •National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. 2013. •lbertson, AM, Tobelmann, RD, Marquart L. Estimated dietary calcium intake and food sources for adolescent females: 1980-92. J Adolesc Health. 1997 Jan;20(1):20-6. •Tiedje K, Wiedland ML, Meiers SJ, et al. A focus group study of health eating, knowledge, practices, and barriers among adolescent immigrants and refugees in the United States. International Journal of Behavioral Nutrition and Physical Activity. 2014, 11:63. •Bibiloni et al. Body image and eating patterns among adolescents. BMC Public Health. 2013, 13:1104. •Clarke B. Normal bone anatomy and physiology. Clin J Am Soc Nephrol. 2008;3 Suppl 3:S131-9. •MacKelvie KJ, Khan KM, Petit MA, et al. A school-based exercise intervention elicits substantial bone health benefits: A 2-year randomized controlled trail in girls. Pediatrics 2003;112(6):447-452. •Bailey DA, McKay HA, Mirwald RL, et al. A six-year longitudinal study of the relationship of physical activity to bone mineral accrual in growing children: The University of Saskatchewan Bone Mineral Accrual Study. J Bone Miner Res 1999;14:1672-1679. •http://www.cdc.gov/physicalactivity/everyone/guidelines/children.html •National Institute of Arthritis and Musculoskeletal and Skin Diseases. Exercise for your bone health. Updated January 2012. Accessed May 2014. http://www.niams.nih.gov/health_Info/Bone/Bone_Health/Exercise/default.asp •Eid MA, Ibrahim M, Aly SM. Effect of resistance and aerobic exercises on bone mineral density, muscle
- 77. References •Turner CH. Bone Strength: Current concepts. Ann NY Acad Sci 2006;1068:429-446. •Lee M, Carroll TJ. Cross education: possible mechanisms for the contralateral effects of unilateral resistance training. Sports Med 2007;37(1):1-14. •Adami et al. Physical activity and bone turnover markers: a cross-sectional and a longitudinal study. Calcif Tissue Int 2008;83(6):388-392. •Creighton DL, Morgan AL, Boardley D, Gunnar Brolinson, P. Weight-bearing exercise and markers of bone turnover in female athletes. J Appl Physiol; 2001;90:565-570. •Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, N.J.: Prentice-Hall. 1986. •http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/SB721-Models/SB721-Models3.html •Azjen I, Driver BL. Prediction of leisure participation from behavioral, normative, and control beliefs: an application of the theory of planned behavior. Leisure Science. 1991; 13:185-204.
Notas del editor
- Bass J, Chan G. Calcium nutrition and metabolism during infancy. Nutrition. 2006; 22:1057-1066. Bronner F. Mechanisms of intestinal calcium absorption. J Cell Biochem. 2003 Feb 1;88(2):387-93. Image Source: http://courses.washington.edu/conj/bess/calcium/calcium.html Calcium is key for multiple body processes including bone growth and maintenance, cardiac function, blood clotting, blood pressure, cellular communication, brain function, signal transduction, and muscle contraction. Less than 1% of total body calcium is needed to support these critical metabolic functions stated prior. If 1% is not met through diet then the body beings redirecting calcium from the bones. As bones are developing they may not reach their potential and bone mass may be lost. Calcium metabolism and body level is controlled by the kidneys, bones, and the gastrointestinal tract and is regulated by three hormones including Parathyroid hormone (which keeps the serum calcium level from dropping too low), Calcitonin (which keeps the serum calcium level from rising too high), and 1, 25-dihydroxy vitamain D (which can help build or resorb bone depending on the needs of the body at that time).
- Berner L, Keast D, Bailey R, Dwyer J. Fortified foods are major contributors to nutrient intakes in diets of US children and adolescents. Journal of the Academy of Nutrition and Dietetics. 2014:2212-2672. Nuts: http://toprankedrecipes.com/nuts-about-nuts/ Beans: http://www.popsugar.com/fitness/Why-Beans-Good-You-26691384 OJ: http://www.consumerreports.org/cro/magazine-archive/september-2009/food/orange-juice/types/orange-juice-types.htm Greens: http://www.mealsonwheelspeople.org/our-story/newsold/nutrition-blog/how-to-include-dark-leafy-greens-in-your-diet/ Fish: http://aperfectpalate.com/how-long-to-cook-fish-rule-of-thumb/ Dairy: http://www.huffingtonpost.com/kalyn-weber/aspartame-in-milk_b_3225416.html For our intended sample the recommendations vary from 1000-1300 mg per day depending on age. This equates to children and adults consuming 3 servings of dairy or dairy alternative products daily along with dark leafy greens, nuts, fish, and beans to ensure adequate calcium intake. Fortified foods are an alternative to dairy products and whole foods such as fortified juices, cereals and grains, and margarines. *Tofu as long as made with calcium salts. A study by Berner in 2013 found that without the intake of fortified foods a large percentage of the 7250 children studied would have been inadequate with intake of numerous micronutrients including calcium. Also, 90% of teenage girls do not meet the calcium recommendations per day which occurs near after our intended samples ages. (Rafferty)
- Next we will discuss vitamin D: another key nutrient for bone health. Vitamin D is a group of fat-soluble sterols found in two major forms within the body, vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). Vitamin D2 is generally human made and added to foods and supplements while vitamin D3 is synthesized in the skin of humans and is also consumed in a diet of animal-based foods. Vitamin D3 can also be added to supplements and food. Both vitamin D2 and D3 are biologically inactive until they are converted to the active form of vitamin D in a two-step process, which occurs in the liver and the kidneys. Vitamin D is a key nutrient required for bone growth and maintenance throughout the life span. Calcium binding protein, a protein that actively aids in calcium absorption is vitamin D dependent. Therefore, without adequate vitamin D bones can become soft, thin, and brittle and possibly lead to deficiency related diseases such as rickets. In addition to building bones, vitamin D also has other key roles throughout the body including cell growth, immune function, and anti-inflammation
- When skin is exposed to UV light, 7-dehydrocholesterol, naturally occurring in the skin, is converted to previtamin D3 and then undergoes a thermally induced transformation to vitamin D3 . On the screen are some factors that affect cutaneous vitamin D synthesis. Darker skin pigmentation can limit cutaneous vitamin D synthesis due to the melanin that competes for UV radiation. Consequently, African American children tend to have higher rates of vitamin D deficiency. A study by Au et al found that Non-Hispanic blacks are more likely to not adequately meet the serum vitamin D recommendations. Decreased time outdoors has also led to limited sun exposure within the pediatric population. While sunscreen may help prevent overexposure to sunlight that causes many harmful effects on the skin, it may inhibit adequate vitamin D production. Research suggests the only guaranteed way to insure adequate cutaneous vitamin D synthesis is five to thirty minutes of sunscreen-free exposure, between 10 AM and 3 PM, at least twice a week. Which is something we stressed during the intervention when discussing “sensible sun exposure” Lastly, as latitude increases, UV radiation decreases, leading to decreased cutaneous vitamin D synthesis. A study by Au et al found that children living in the Southern regions of the United States had a higher prevalence of adequate serum vitamin D compared to children living in the Northern region. Individuals living above 40 degrees latitude (Philadelphia to Chicago to Sacramento) are unable to make adequate vitamin D during winter months due to minimal UV radiation.
- With cutaneous vitamin D synthesis from sun exposure declining in the pediatric population, children must rely more on dietary and supplement sources of vitamin D to combat vitamin D deficiency. A study of 85 breastfed infants in Iowa by Ziegler et al found that vitamin D deficiency was common in exclusively breastfed infants without vitamin D supplementation. The American Academy of Pediatrics recommends all exclusively breastfed infants be supplemented with 400 International Units or IUs of vitamin D daily within the first two months of life. Natural sources of vitamin D include oily fish, liver, organ meats, and egg yolks. However, because children do not commonly consume these foods, they must then rely on vitamin D fortified foods to avoid deficiency. Therefore vitamin D-fortified juice, along with milk and ready to eat breakfast cereal, may help to alleviate vitamin D deficiency in the pediatric population.
- Now we’ll give a brief overview of the skeletal system important functions and development. Bones provide mechanical support for joints, tendons and ligaments, protect internal vital organs, and acts as a reservoir for calcium and phosphorus in the preservation of normal mineral homeostasis. Bone is a complex and dynamic tissue that undergoes growth, renewal, and repair throughout the lifespan. Once formed, the bone grows and changes shape by modeling, a process in which either bone formation or bone resorption occurs on a given bone surface.
- Bone remodeling is a lifelong process that functions to renew the skeleton and involves sequential bone resorption and ossification at the same location. In this image you can see that osteoclasts cells are responsible for removing old bone tissue, next mature osteoblast cells deposit new bone tissue in the same area, followed by mineralization phase; a short period in which the new bone area calcifies. Bone remodeling functions to strengthen the skeletal system by process of renewing in order to maintain normal bone mass. Bone remodeling abnormalities can attribute to bone related diseases which we’ll also discuss. [RALSTON]
- This image represents the stages in which bone grows and remodels throughout the lifespan. Where significant growth is seen from birth through adolescence and bone mass peaks between 20–25 years of age and levels remain relatively static until the age of 45, thereafter bone density starts to fall for both genders [Ralston]. Although bone density falls with increasing age in both genders, there is an accelerated phase of more rapid bone loss in women over the age of 50, due to the effects of estrogen deficiency that occurs during menopause, causing an imbalance of bone resorption and bone formation [Ralston & Schrader]. Next we’ll discuss bone diseases briefly. Picture Citation: Betts JG, DeSaix P, Johnson E, et al. Anatomy & Physiology. Houston, TX: Openstax College; 2013.
- There are 3 main types of rickets disease including: nutritional, hypophosphatemic, and renal rickets. The most common form is nutritional rickets characterized by vitamin D deficiency. Skeletal development during last trimester in pregnancy is critical, as the fetus becomes exclusively dependent on maternal resources of vitamin D, calcium, phosphorus, and magnesium [Namgung]. Vitamin D plays a pivotal role in fetal skeletal mineralization and low maternal vitamin D3 stores may result in a lower transfer to the fetus, putting them at greater risk for rickets, delayed bone ossification, lower bone mineral content, and impaired overall bone growth [Hallioglu]. Vitamin D deficiency also leads to hypocalcaemia in newborns as vitamin D is responsible for calcium absorption. Clinical manifestations of rickets as you can see from the image includes bossing of the forehead in which the forehead protrudes outward, knocked knees in which knees angle inward and touch when straightened, bowed legs is where the legs curve outward at the knee, widening of wrists and ankles, pigeon chest in which breast bone pushed forward, spine and pelvic deformities which contribute to short stature. These deformities may not all be present, but deficiency causes the bones to soften and weaken and weight bearing load on bones causing abnormalities in growth. Prevalence/Incidence?? Picture Citation: Upton D. Effects of Rickets. Debbie Upton Medical Illustrator. 2010. Accessed from: http://debbieupton.com/products-page/effects-of-rickets/
- Vitamin D and calcium deficiency in early years is most commonly presented as rickets however prolonged state of deficiency can result in adult onset of rickets namely, osteomalacia [Lapillonne]. Osteomalacia is the softening of bones often results from a loss of skeletal mass caused by inadequate mineralization of the normal bone tissue after growth plates have fused. Osteoporosis was commonly defined as low one mass and deterioration of bone tissue leading to enhanced susceptibility of bone fragility and increased risk of fracture incidence. However now World Health Organization defines osteoporosis on the basis of bone mineral density measurement which allows for diagnosis and treatment prior to incident fracture. [WHO 2004] According to the World Health Organization up to 70% of women over the age of 80 have osteoporosis, with 18 million people at risk of developing the disease. [American Academy Ortho Surg]. Currently there are over 200 million people diagnosed with osteoporosis worldwide with 10.2 million being from the US. And 43.4 million affected with low bone mass. If current trends continue, based on NHANES 2005-2010 data Wright et al study projects by the year 2020 the number of adults over the age of 50 with osteoporosis or low bone mass will grow to 64.4 million in the US and by 2030 to 71.2 million.[Wright] Additional Citation World Health Organization. WHO Scientific group on the assessment of osteoporosis at primary health care level. World Health Organization Press. 2007. Available at http://www.who.int/chp/topics/Osteoporosis.pdf. Accessed November 11, 2014.
- This image portrays the difference of bone matrix in normal and osteoporotic hip bone. As you can see the cells are larger with thin walls in the osteoporotic bone making it more fragile and greater risk for fracture. Prolonged low levels of vitamin D status are associated with increased risk of falls and fractures in the hip, forearm and vertebrae [Peel]. The consequences of this condition is multifaceted. People diagnosed with osteoporosis, especially who have experienced a fall/fracture due to normal daily activity become increasingly reluctant to continue to participate in routine activities( like picking up the newspaper or taking the stairs). This then creates a cycle in which lack of mobility becomes normal, stemmed from fear of falling. In addition, emotional and mental impacts such as low-self-esteem and depression are common in subjects with osteoporosis. Physical changes that accompany this disease like stooping posture can lead to functional decline and contribute to low-self esteem [NOF 2014]. Picture Citation Website source: The Osteoporosis Center. About Osteoporosis. 2014. Available at http://www.theosteoporosiscenter.com/osteoporosis.html. Accessed November 5, 2014. National Osteoporosis Foundation. Emotional Aspects of Osteoporosis. 2014. Accessed from: http://www.theosteoporosiscenter.com/osteoporosis.html
- MacKelvie KJ, Khan KM, Petit MA, et al. A school-based exercise intervention elicits substantial bone health benefits: A 2-year randomized controlled trail in girls. Pediatrics 2003;112(6):447-452. Bailey DA, McKay HA, Mirwald RL, et al. A six-year longitudinal study of the relationship of physical activity to bone mineral accrual in growing children: The University of Saskatchewan Bone Mineral Accrual Study. J Bone Miner Res 1999;14:1672-1679. http://www.cdc.gov/physicalactivity/everyone/guidelines/children.html National Institute of Arthritis and Musculoskeletal and Skin Diseases. Exercise for your bone health. Updated January 2012. Accessed May 2014. http://www.niams.nih.gov/health_Info/Bone/Bone_Health/Exercise/default.asp Physical activity (PA) is essential at every age for healthy bones and is important for treating and preventing bone related diseases such as Rickets and osteoporosis. Not only does exercise enhance bone health and reduce falls, it also increases balance, coordination, and muscle strength, leading to better overall health. Physical activity increases health-related fitness levels and decreases the risk for chronic and disabling diseases (US Dept HHS). Along with decreased bone strength, physical inactivity is a major risk factor for developing coronary artery disease and it increases the risk of stroke, high blood pressure, diabetes, hyperlipidemia, and obesity (AHA, 2014). A decrease in PA may lead to the loss of BMC and an increase in the incidence of osteoporotic fractures later in life (AHA, 2014). The CDC, AHA, and Surgeon General recommend that children age 2 or older should participate in at least 60 minutes of enjoyable, moderate-intensity physical activities every day that are developmentally appropriate and varied. In 2011, only 18.5% of girls and 38.3% of boys aged 6-17 achieved this recommendation. The time of transition from childhood to adolescence is critical to bone mineral accrual, and disruptions in the normal pattern of bone growth caused by hormonal changes of puberty during this time may result in low bone mass during adulthood. In a six-year study bone mineral accrual study by Bailey et al, 53 active girls and 60 active boys accrued 10-40% more bone (depending on skeletal region) during the two years surrounding peak bone velocity than inactive children. (Bailey 1999). Aerobic activity: This type of activity moves the large muscles, such as arms and legs, and makes the heart beat faster than usual. Aerobic activity should make up most of the child’s 60 or more minutes of PA per day and can include moderate-intensity activity, such as brisk walking, or vigorous-intensity activity, such as running (CDC). Overtime, regular aerobic activity increases the strength of the heart and lungs, causing them to work more efficiently. Muscle strengthening: Muscle-strengthening activities improve strength, power, and endurance of the muscles (NHLBI). Muscle-strengthening exercises should be incorporated at least three days per week in the form of activities like gymnastics or push-ups (CDC). Bone strengthening: With bone-strengthening activities, the feet, legs, or arms support the body’s weight, causing the muscles to push against the bone. This helps increase the strength of the bone. Bone-strengthening exercises, such as jumping rope or running, should be practiced at least three days per week (CDC).
- Bone strengthening exercises are the most important when it comes to building the strongest bones, particularly weight-bearing exercises. It has been suggested that the type of PA necessary to build and maintain bone density must be the weight-bearing kind because it forces an individual to work against gravity (Arth and Musc). Weight-training, dancing, tennis, hiking, and climbing stairs are all types of PA that force an individual’s bones to work against gravity, thus strengthening the bones (Arth). Resistance training, a type of weight-bearing exercise, appears to have the greatest effects on BMD (Andreoli). Resistance training can be defined as the act of repeated voluntary muscle contractions against a resistance greater than those encountered in ordinary activities of daily living. This type of training works to increase muscle strength and endurance through repetitive exercise with resistance bands, weights, or weight machines (Lee, 2007). A study by Creighton et al looked at BMD and markers of bone turnover in 41 college aged female athletes. The researchers compared three impact groups: high impact (basketball and volleyball), medium impact (track and soccer), and non-impact (swimming) with age-matched controls. BMD was assessed using DXA and the results showed total body BMD was significantly higher in the non impact group than all other groups. In addition, it was found that athletes who train primarily in non-impact sports, such as swimming, for extended periods of time may suffer negative effects in terms of bone mineral density. Researchers suggest that these results support the theory that high weight-bearing strain rates are more effective at inducing new bone formation and enhancing BMD at weight-bearing sites than non-weight-bearing activities (Creighton, 2001). A study by Woo et al examined BMD of 180 elderly women who participated in resistance training and tai chi activities 3 times per week for 12 months. Results showed those individuals participating in in tai chi or resistance training had significantly less BMD loss at the hip compared with controls (p<0.01). These types of exercise are critical to ensure proper bone mass formation during childhood and can improve bone muscle strength and bone mass. ). The mechanism by which weight bearing exercises increase bone mass is related to dynamic strains in bone tissue regulating bone formation and reabsorption (Eid). High strains and high strain rate have osteogenic, or bone generating, effects (Eid). Bone cells act in a number of pathways as mechanotransducers that detect high stresses and signal locally for an anabolic response that result in these osteogenic effects (Turner, 2006). The most effective way to strengthen bone is by adding new bone tissue where bone stresses the greatest. This occurs when the bone adapts to mechanical loading (Turner, 2006). Mechanical forces that act on bone are generated from impact with ground, aka weight bearing exercise, and from skeletal muscle contraction, aka resistance training. In a cross-sectional and longitudinal study by Adami et al of 24 healthy sedentary women, bone formation markers, osteocalcin, and N-terminal propeptide of type 1 procollagen (P1NP), rose significantly following a one month exercise program that included 90 minute exercise sessions 3-4 times weekly. It incorporated exercising like running, walking on a treadmill, step-ups, and stair climbing, with intensity of the exercises increasing over the duration of the program. The results demonstrate that the bone formation markers are extremely sensitive, and even minor changes in PA are associated with a clear effect on bone formation. Weight bearing PA in children of the prepubertal and early pubertal stages is recognized as an important determinant of peak bone mass, and a PA intervention may represent a reasonable strategy for building strong bones and preventing bone health diseases.
- In reviewing the current literature we also came upon several different theories that had been applied to the interventions used in studies. By using theories, researchers acquire a guide and foundation for building their intervention programs. Additionally, a decision making process may be established, and measurement indicators to analyze outcomes are determined. The most common theories used in the current literature include…
- To review, cognitive behavioral therapy explores emotions and attitudes towards a behavior. It also allows exploration of how individuals provide meaning to a situation or emotions http://www.hpft.nhs.uk/_uploads/documents/help-for-adults/cbt2-cbt-approach.pdf Beck, AT. Cognitive Therapy and the Emotional Disorders. New York: Penguin. 1976.
- In the health belief model, the central focus is a individual’s motivation The theory states that an individuals belief on whether or not they are susceptible to a disease as well as their perceived benefits from making a change will affect their willingness and readiness to take action. A few limitations should be noted in this model. For one, the HBM is typically geared towards adults since it aims to improve self-care and self-management – these are not concepts appropriate for school-aged children. At a young age, children do begin to develop more independence, but they still rely heavily on adults – mainly parents and teachers. http://www.jblearning.com/samples/0763743836/chapter%204.pdf Rosenstock IM, Stretcher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Healthy Education Quarterly. 1988; 15(2):175-183.
- The social cognitive theory describes an ongoing process between 3 main factors: personal, environmental, and human behavior http://mellbandura.wikispaces.com/Social+Cognitive+Theory Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, N.J.: Prentice-Hall. 1986.
- http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/SB721-Models/SB721-Models3.html Azjen I, Driver BL. Prediction of leisure participation from behavioral, normative, and control beliefs: an application of the theory of planned behavior. Leisure Science. 1991; 13:185-204.
- In relation to our intervention program, Batter Up for Bone Health, we found that behavioral-based theories were not the most appropriate theories to apply. This was mainly due to our short intervention, making it difficult to capture and identify any real behavior change. Although elements of these theories may be found, we decided it would be best to create a program within a social cognitive theory framework. Doing so allowed us to determine the participants’ main motivational and influential factors, as well as provide us with a better understanding of lifestyle habits.
- Ca and vit D intake are both below recommended daily needs even with fortified foods. These two nutrients are essential for proper bone development. Bone development requires proper nutrient intake which is imperative for optimal bone health. In addition to proper nutrient intake, regular physical activity is also needed to build and maintain optimal bone mass. And again, the most appropriate theory to apply for our intervention is the social cognitive theory
- The National Osteoporosis Foundation (NOF) has found that a research area that needs to be asked is “How can children, adolescents and young adults maximize peak bone mass?.”(National Osteoporosis Foundation- Clinician’s Guide) Since childhood is a key time for bone formation, it is important for an education program such as Batter Up for Bone Health to discuss the importance of bone health prior to the adolescent years where body image may have a great influence on bone health practices (Clark 2008). Also, once a female begins menstruation, bone growth slows. Therefore it is critical to educate preadolescent females on the importance of positive bone health practices during the rapid bone growth period and prior to slowed bone growth related to puberty (Ross AC). Explain the picture in relation to BUBH Here you can see participants using resistance bands which provide resistance activity for both partners. Resistance force being put on the hips as she tries to run and resistance force being put on the wrists as she pulls.
- The intervention was intended to increase knowledge in the target population and motivate participants to practice fun interactive bone health behaviors. Prior to starting the program participants completed the pretest in the designated dugouts where our research team circulated to answer any of their questions. A total of 5 stages were included; each base, pitchers mound and homeplate were set up to represent an essential component in maintaining optimal bone health. 1st base learners were taught about both exogenous and endogenous vitamin D sources, describe the importance of wearing sunscreen and sensible sun exposure, identify sources of vitamin D, identify the location of vitamin D on a nutrition facts label, and reviewed recommended dairy servings. The learners were then split into two teams. Three plastic cups were placed on each side of a table and a bucket filled with milky colored water placed few feet away. The teams used sponges to soak the milky colored water and fill each of the 3 cups to represent the three servings of dairy. 2nd base learners were taught about weight-bearing exercises to strengthen bones. After recommendations and importance of weight-bearing activity were discussed each participant paired up and series of weight-bearing activities were played like wheel barrel race in which one partner held the legs of the other while the second partner walked on their hands to move forward. Participants also engaged in three-legged balloon race where an air filled balloon was supported between partners adjacent legs, and lastly a game of leap frog. 3rd base learners were taught about resistance physical activity. Following the verbal lesson on recommendations and types of resistance activities participants completed bicep curls, push-ups, sit-ups and burpees which involve combination of squat, push-up and vertical jump. Participants also paired up and raced using resistance bands around their waist while partners pulled. This allowed for the runner to put resistance on their hips and the puller to illicit resistance on their wrist. Upon completion the objectives of this lesson was restated and discussed briefly. Pitchers mound learners were taught about the importance of calcium and good dietary sources to include in the diet. After discussing the role of calcium in bones, participants were split up into 2 groups where each group was designated 2 baskets labeled ‘Calcium’ and ‘No Calcium’. They were asked to race each other in tossing bean bag labeled foods with and without calcium in the right baskets. After completion, each baskets were checked and discussed the right and wrong placements of bean bags. Home Plate learners were taught about building healthy plates of foods for meals. After brief introduction participants were split into 2 teams. Each team was given a bucket of food pictures and asked to place each food in the correct food category on the Myplate poster. Participants were then asked to name the group that contained the most calcium and vitamin D and discussed bone healthy beverages as well.
- The parents of participants were asked to complete demographics survey, and both parent and child required study consent forms in order to participate in BUBH intervention. The demographic survey asked gender, age, ethnicity, supplement usage, dairy product intake and food allergy questions. The consent forms were asked of participants so that statistical data could be used for study analysis. Those who did not turn in a consent form were still able to participate in the intervention but not included in statistical analysis. Explain the picture
- Prior to intervention dates, we tested the surveys with a group of children in West Chicago after school program during the school year. Content and face validity was evaluated by an age appropriate (8-9 YO) group that also included both genders. This subset was not a apart of the current study population. The tools were modified thereafter to better fit the intended audience. All three tests were in multiple choice format with short answer questions asked in the post and 21-day post test. The use of images helped participants decipher activities and foods being asked about. Explain Picture
- The independent variables gender, age, ethnicity and camp locations were tested and analyzed using the following inferential tests statistics. Explain the picture: Here we can see Lauren, engaging with participants in resistance exercise @ 3rd base
- Next we will discuss population characteristics and frequencies. On the screen are the West Chicago children running the bases as a warm up for our program.
- The Demographic Survey was developed based on examples viewed during research. It was used to gather information on the participant’s age, gender, ethnicity, calcium use and supplement use. A total of 204 children participated in Batter Up for Bone Health. However, 117 children provided consent and demographic forms. On the screen is an example of our demographic form.
- The average age of the campers was approximately 9 years. Age categories were created to allow us to compare younger and older ages. We chose these two age groups based on reading level. From now on data will reflect those who provided consent.
- There was almost an even distribution within gender. However there were slightly more female than male participants.
- We completed the Batter Up for Bone Health intervention at two locations. Courts Plus Summer Camp in Elmhurst, IL and West Chicago Summer Camp in West Chicago, IL. West Chicago had a larger population of children.
- Ethnicity information was gathered from the demographic forms. Ethnicity groups were created based on which ethnicity frequencies were the highest. Ethnicities that fell in the other category included Black, Middle Easter, and Multiracial.
- It is also important to note that West Chicago was majority Hispanic and Elmhurst was majority White.
- Through the calcium information gathered from the demographic form, we were able create two variables: calcium consumers and non-calcium consumers. The majority of our participants consumed some form of calcium containing food with dairy milk being the highest frequency. Yogurt and cheese were also popular among out study population.
- Through the supplement information gathered from the demographic form, we were able create two variables: supplement consumers and non-supplement consumers. The most popular supplement among our participants was a multivitamin. Now we will discuss the results of our study.
- The first hypothesis: There is no significant change in knowledge and understanding of bone health practices. Looking at this graph you can see that there was knowledge gained after the intervention. The immediate knowledge gained was significant with a p value <0.0001. A Wilcoxon signed-rank test showed that a one day intervention did elicit a statistically significant change in knowledge gained (Z = -7.039, p = 0.0001). From the pretest to the post-test there was a 13% increase in correct knowledge based questions. Pretest n = 106 Post-test n = 107
- The first hypothesis: There is no significant change in knowledge and understanding of bone health practices. This graph shows the overall test scores of the campers during the pretest, post-test, and the 21 day post-test. Multiple knowledge and understanding questions were asked in the format of choosing which food or activity was bone healthy. The total correct score were then compared between the pretest, post-test, and the 21-day post test to show overall knowledge gained in the form of percentages. *Individual question analysis is possible but an overall test showed greater power. *The knowledge and understanding based questions included 1-5, 8-9, 12-13, 17, and 20-21 in the pretest and 1-12 in the post-test and 21 day post-test. Looking at this graph you can see that there was knowledge gained after the intervention and overall throughout the testing period. The immediate knowledge gained was significant with a p value of … Following a Friedman test comparing overall Add pre to post p value knowledge immediately from pre to post A Friedman test was run to compare average overall scores of campers between the pretest, post-test, and 21-day post-test. For the whole, there was a statistically significant increase in knowledge from pretest, to post-test, to 21 day post-test , χ2(2) = 48.46, p<0.0001.
- A Friedman test was run on all the knowledge and understanding questions and it was found that there was an overall retention and gain of knowledge even after 21 days even though the sample size decreased. Therefore, there was knowledge retention but not sample retention. Between the pretest and post-test a statistically significant increase I knowledge was found along with an statistically significant increase from the post-test to the 21-day post-test. With a p<0.0001. Using a Mann Whitney U test it was found that there was no significant difference in knowledge retention between genders, physical locations, or age groups for the intervention and follow up. A Kruskal-Wallis test also found no significant difference in understanding between various ethnicities analyzed. Looking at gender a p value of 0.35 in the pretest and a p value of 0.55 in the post test was found meaning no significant difference occurred and the confidence interval indicated that the small sample size may have influenced the non-significance of the results. Looking at the physical locations a p value of 0.35 in the pretest and a p value of 0.54 in the post-test was found, the confidence interval for both was found to be outside the cI, this indicated that the small sample size may have influenced the non-significance of the results. Looking at the various age groups a p value of 0.05 for pretest and a p value of 0.01 for the post-test was found showing significant differences in knowledge and the p value was inside the confidence interval. Finally, a p value of 0.07 for pretest and a p value of 0.36 both lied outisde the confidence interval and may be due to the small sample size.
- The 2nd hypothesis tested was: There is no significant difference in motivation to improve bone health among campers. Hypothesis 2 is based on question 1: it is important for kids my age to have healthy bones. This graph represents children who stated having healthy bones was important. The light blue bar represents the pretest, the dark blue bar represents the post test and the white bar represents the 21 day post-test A Wilcoxon Signed Ranks test was conducted to examine the results of pretest, post-test and 21-day post-test responses to question 1 of all campers. No significant difference was found between the three tests. These results show that children already valued the importance of bone health prior to completing the intervention. Starting out with a high level of participants who value bone health is important for a bone health education program.. Statistical analysis found that bone health importance did not vary between different age groups, genders, and ethnicities. Having similar bone health values across many different genders, ages, and ethnicities illustrates that the Batter Up for Bone Health program provides a neutral topic that reaches a diverse population.
- A Mann-Whitney U tests was conducted to determine if there was a significant difference regarding importance of bone health between genders. Statistical analysis found that bone health importance did not vary between genders meaning all participants valued bone health equally. Since childhood is a key time for bone formation, it is important for an education program such as Batter Up for Bone Health to discuss the importance of bone health prior to the adolescent ears where body image may have a great influence over bone health practices. A Kruskal-Wallis test was conducted comparing the outcome of the pretest, post-test, and 21-day post-test results for participants of varying ethnicity groups. No significant difference was found between ethnicities. However, the p-value between the pretest and post-test was leaning towards significant, at p=0.06, suggesting bone health importance may vary between ethnicities. However, Batter Up for Bone Health is an ethnically neutral program that will help continue the current trend towards valued health among the ethnically diverse population. All p-values were outside of the confidence interval. This means the insignificance of the data may be related to the small sample size. Mann-Whitney U tests were also run on location, age group, calcium and supplement users with insignificant results. Overall the null hypothesis is accepted.
- The 3rd hypothesis: There is no significant difference in influence on food choices among campers. Hypothesis #3 is based on pretest questions that correlated with participants environmental influences. Pre-test questions regarding influence of eating habits were combined using a form of factor analysis. Based on similar underlying constructs of these questions 2 categories were formed: Influence of Authority and Influence of Peers. The values on the y-axis represent an average of combined pre-test question responses that fall under the two formed categories. Here you can see the response average for both categories show majority of participants responding ‘yes’ to pre-test questions regarding authority and peers; and both generally have similar distribution.
- Mann-Whitney U tests were run to determine if there were significant differences in the participant’s influence of Authority between genders, camp location and age groups. There was no significant difference found between genders, camp locations or ages. The p-value’s were all outside the confidence interval indicating the small sample size may have affected the non-significant results. A Kruskal-Wallis test was conducted comparing the Influence of Authority pre-test question responses for participants of varying ethnicity groups. No significant difference was found between ethnicities. However, the p-value again lies within 95% confidence interval indicating that the sample size did not affect the non-significant results. A Chi-Square test was conducted to determine if there was a significant difference in Influence of Authority over the entire study population. A significant difference was found, with a p-value <0.01. The effect size being 0.99, which is classified as a large effect. An overall significant difference in Influence of Authority suggests that persons of authority like parents and teachers impact the food choices of participants. This finding agrees with existing research. A study examining children’s food choices showed that parents have a strong influence on their food selection, mostly seen in reducing food choices with low nutritional value (KLESGES). Although this particular study focused on food selection influence and its relation to childhood obesity and poor food choices, it provides sound evidence that supports our findings. The Social Cognitive Theory (SCT) just as Nicole mentioned proposes the complex interaction between behavior, person factors and environmental factors will elicit change behavior that can produce changes in others [REYNOLDS]. This theory involves a focus on families as an important element of social and physical environment that may influence dietary behaviors of children [REYNOLDS, BROWN]. This evidence is essential when refining the constructs of Batter Up for Bone Health as it provides further insight on the participant’s environmental influences to making bone healthy food choices.
- Mann-Whitney U tests were run to determine if there were significant differences in the participant’s influence of peers between genders, camp location and age groups. There was no significant difference found between genders, camp locations or ages. The p-value’s were all outside the confidence interval indicating the small sample size may have affected the non-significant results. A Kruskal-Wallis test was conducted comparing the Influence of Peers pre-test question responses for participants of varying ethnicity groups. No significant difference was found between ethnicities. However, the p-value lies within 95% confidence interval indicating that the sample size did not affect the non-significant results. A Chi-Square test was conducted to determine if there was a significant difference in Influence of Peers over the entire study population. A significant difference was found, with a p-value <0.01. The effect size being 0.99, which is classified as a large effect. An overall significant difference in Influence of Peers suggests that peers like friends and siblings have an impact on food choices made by participants. This coincides with Salvy and colleagues study on influence of peers and friends on children’s and adolescents eating behaviors. Peers of subjects heavily influence the amount and selection of food as peer approval becomes increasingly important during the pre-adolescent years and thereafter [SALVY]. Adolescents express that ‘healthy eating’ often conflicts with the desired image to be portrayed by peers [STEAD]. Although adolescents were not the subject studied, this ideology suggest that impressions of peers can begin as early as pre-adolescence and play a pivotal role in bone healthy food choices. As Julia mentioned the age of our study population is a critical period in which good bone health practices should be implemented to instill positive eating behaviors while their bones are still undergoing development.
- Pretest question 18: Exercising is fun. After calculating the frequency of the 108 campers, 96 answered yes,4 answered no, and 8 answered I don’t know as to whether they thought exercising is fun. A Chi-Square test was conducted to determine if there was a significant difference in the question “exercising is fun” over the entire population. A significant difference was found in the result, with a pvalue <0.0001. The effect size is .84, which is classified as a large effect size. This means a large number of participants already believed exercising was enjoyable before the intervention. 4 Mann-Whitney U tests were conducted between genders, locations, ages, and ethnicities to determine if there were significant differences in the participant’s enjoyment of exercise. All four tests showed there was no significant difference in exercise enjoyment between genders, between locations, between ages, and between ethnicities. The p-value for between genders, locations, ages, and ethnicities were all outside the confidence interval. This means that the insignificance of the data may be related to the small sample size.
- The fourth hypothesis: There is no sig dif in exercise enjoyment among campers. Pretest question 19: I enjoy exercise. After calculating the frequency of the 106 campers, 84 answered yes, 10 answered no, and 12 answered I don’t know as to whether they thought exercising is fun. A Chi-Square test was conducted to determine if there was a significant difference in the question “I enjoy exercise” over the entire population. A significant difference was found in the result, with a pvalue <0.0001. The effect size is .81, which is classified as a large effect, indicating that the campers enjoyed exercise prior to the intervention. 4 Mann-Whitney U tests were conducted between genders, locations, ages, and ethnicities to determine if there were significant differences in the participant’s enjoyment of exercise. All four tests showed there was no significant difference in exercise enjoyment between genders, between locations, between ages, and between ethnicities. The p-value for between genders, locations, ages, and ethnicities were all outside the confidence interval. This means that the insignificance of the data may be related to the small sample size. The similar statistical results from the related questions “Exercising is fun” and “I enjoy exercise” provides validity for the pretest.
- A total of 109 participants completed the post-test, while 69 participants completed the 21-day post-test. Between the administration of the post-test and the 21-day post-test, campers indicated they intended to participate in less chores (which can be generalized to being active throughout the day), taking the stairs (activities of daily living), dancing (intentionally moving), karate (balance activities), and tennis (playing a team sport). Participants intended to increase time spent participating in playing tag (generalized to playing with friends). The reduction in intent to participate in these physical activities may be due to lack of knowledge retained or from lack of motivation following the Batter Up for Bone Health intervention. Family involvement influences the activity levels of children. Gortmaker et al indicates an intervention that promotes physical activity and nutrition through educational activities and parent involvement is effective in increasing daily physical activity among children (Gortmaker 2012). These results are in agreement with Trost et al’s study that states interventions to promote exercise in children involve parental modeling of physical activities (Trost 2001). Including parents in Batter Up for Bone Health could improve overall knowledge retention and participation in bone healthy activities. To further increase participant enjoyment and involvement in exercise, studies show school-based physical activity interventions are effective. Meyer et al’s study of prepubertal and pubertal children demonstrated a multi-component physical activity intervention could increase bone health in both genders. MacKelvie et al also found that implementing high-impact exercise within the elementary school curriculum elicited substantial bone mineral accrual in pubertal girls. Implementing Batter Up for Bone Health into the school curriculum will result in higher participation rates and could allow for reinforcement from teachers on a regular basis. Trost SG, Kerr LM, Ward DS, Pate RR. Physical activity and determinants of physical activity and obese and non-obese children. International Journal of Obesity 2001;25:822-829. Gortmaker 2012 Meyer 2011 MacKelvie 2003
- In our final hypothesis, we predicted that there would be no significant difference in intent to change bone health practices among participants. To determine this, we analyzed responses for Question 13: I Plan to eat foods that are healthy for my bones. A total of 109 responses were collected for Question 13. Of these responses, 79.8% (n=87) participants responded “yes”, 1.8% (n=2) responded “no” and 18.3% (n=20) responded “maybe/unsure.” A total of 68 responses were collected for 21-day post-test Question 13. Of these responses, 77.9% (n=53) responded “yes”, 8.8% (n=6) responded “no”, and 13.2% (n=9) responded “maybe/unsure.”
- In analyzing the overall results of question 13 in both the post and 21-day post test, a Wilcoxon Signed Ranks Test was performed. No significant difference was found between the post-test and the 21-day post-test (p >0.05). A confidence interval was conducted to determine whether or not sample size had an effect on these results. Looking between the post and 21-day post-test, the p-value of 0.82 is outside a 95% confidence interval. This indicates that the sample size may have affected the non-significant finding. The null hypothesis is accepted as intent to change bone health practices between post-test and 21-day post-test were not significantly different. A Mann-Whitney U test was conducted for each analysis between genders, school locations, age groups, supplement users, and dairy consumers. In comparing differences between ethnicities, a Kruskal-Wallis Test was conducted instead. Overall, each null hypothesis was accepted due to non-significant findings and no notable trends. Reviewing the confidence interval calculations also reveal that sample size likely affected these results. However, there was an exception when analyzing between group locations where the p-value did fall between the CI therefore the small sample size did not affect the results Therefore, we will accept the overall null hypothesis that there is no difference in intent to change bone health practices among participants. However, further analysis of additional questions from the 21-day post test reveal other results.
- A Chi-Square Test was performed in order to compare the frequency of occurrence for each response to 21-day post-test Question 20 “Ever since ‘Bone Health Day’ I have done bone healthy activities”. A significant deviation was found with a p-value of .0001. This indicates that a significant amount of the campers had participated in more bone healthy activities.
- Similarly, A Chi-Square Test was performed again to analyze results from 21-day post-test Question 21 “Ever since ‘Bone Health Day’ I have eaten bone healthy foods”. A significant deviation was found again with a p-value of .0001 – also indicating that a significant amount of participants consumed more bone healthy foods. Notable differences were also found between some of the groups. Participants in the older age group had higher responses to consuming bone healthy foods and participating in bone healthy activities. This finding confirms the lesson plan’s effectiveness with our target age group of 8 to 11 years old. Similar results were also found between schools. West Chicago had a significantly higher response for consuming bone healthy foods after the program, but not physical activities. In comparing ethnic groups no significant differences were found. Interestingly enough, West Chicago’s campers were also predominantly Hispanic. Such trending results are consistent with findings from Harmon et al’s 2014 study where the researchers sought to identify factors that affect their participant’s physical activity habits. Overall, the researchers found a meaningful trend – higher ratings of SCT variables, such as social support, correlated with positive perceptions of school environment, and thus higher physical activity levels. In comparison to non-Hispanic participants, however, Hispanic students had significantly higher social support scores as well as higher physical activity scores – an indicator that social environment is a major determining factor in PA participation for Hispanic adolescents.
- Such trending results are consistent with findings from Harmon et al’s 2014 study where the researchers sought to identify factors that affect their participant’s physical activity habits. Overall, the researchers found a meaningful trend among their participants – higher ratings of social support and other social cognitive theory variables, correlated with positive perceptions of school environment, and thus higher physical activity levels. In comparison to non-Hispanic participants, however, Hispanic students had significantly higher social support scores as well as higher physical activity scores – an indicator that social environment is a major determining factor in PA participation for Hispanic adolescents.
- It was found that participants had intention to consume more than one bone healthy food according to post-test and 21-day post-test Question 17 “Circle the foods you plan to eat.” In the post-test it was found that drinking milk had the highest frequency - 88% (n=103) of participants had plan on drinking milk. Eating tofu had the lowest frequency with only 52.1% (n=61) participants selecting this option (Figure ___).
- In the 21-day post-test, the results were similar. Milk still had the highest frequency along with yogurt – both with 51.3% (n=60) of participants selecting these foods. The food with the lowest frequency was mac n’ cheese with only 27.4% (n = 32) of participants selecting this option. More than half of the participants recorded milk as their intended drink in the 21 day post-test (51.3%), revealing that the results were retained from the post-test. This may indicate that knowledge was maintained or reinforced prior learning since most participants had already been drinking milk.
- One of the final questions of the 21-day post-test required the students to fill in the blank based on what bone healthy activities they have increased since the intervention. A total of 31 children responded to this question with various bone healthy activities such as run, jump, play tennis, and play soccer. The responses were grouped into two overarching themes: sports and play. 16 children stated they have increased the amount of sports, such as soccer and basketball, they participated in since Bone Health Day and 15 children stated they have increased the amount they play, such as running/jumping/and playing tag, since Bone Health Day.
- The other fill in the blank 21-day post-test question required the students discuss what bone healthy foods they have increased since the intervention. A total of 31 children responded to this question with various bone healthy foods. The most common food increased since the intervention was milk.
- Perceived Importance of Bone Health Overall, no statistical significance was found regarding importance of bone health between gender, ages and ethnicities. However, research has found that nutrient intake varies between genders. Albertson et al found that milk and milk products were the best food sources of calcium and contributed to over half the calcium in the female’s diet. Utilizing NHANES data from females age 11-18 the researchers found that 90% of subjects consumed <100% of the RDA for calcium during the data collection period. Within the adolescent population, body image is a large determinant of nutrient consumption. A study of 12-17 year old males and females by Bibiloni et al found that female adolescents were more likely to avoid dairy products such as milk, yogurt, and cheese than their male cohorts. The study also found that females who were dissatisfied with their current weight status were the group most likely to avoid dairy products. It is important to note that these dairy products generally contain calcium and vitamin D, key nutrients for bone health. The research shows that there is a need for a program such as Batter Up for Bone Health that will combat these nutrient intake variants among genders. Influence of Authority An overall significant difference in Influence of Authority suggests that persons of authority like parents and teachers impact the food choices of participants. This finding agrees with existing research. A study examining children’s food choices showed that parents have a strong influence on their food selection, mostly seen in reducing food choices with low nutritional value (KLESGES). The Social Cognitive Theory (SCT) just as Nicole mentioned focus on families as an important element of social and physical environment that may influence dietary behaviors of children [REYNOLDS, BROWN]. This evidence is benedicial when refining the constructs of Batter Up for Bone Health as it provides further insight on the participant’s environmental influences to making bone healthy food choices. Influence of Peers An overall significant difference in Influence of Peers suggests that peers like friends and siblings have an impact on food choices made by participants. This coincides with Salvy and colleagues study on influence of peers and friends on children’s and adolescents eating behaviors. Peers of subjects heavily influence the amount and selection of food as peer approval becomes increasingly important during the pre-adolescent years and thereafter [SALVY]. Adolescents express that ‘healthy eating’ often conflicts with the desired image to be portrayed by peers [STEAD]. Although adolescents were not the subject studied, this ideology suggest that impressions of peers can begin as early as pre-adolescence and play a pivotal role in bone healthy food choices. As Julia mentioned the age of our study population is a critical period in which good bone health practices should be implemented to instill positive eating behaviors while their bones are still undergoing development.
- Overall this program can be used within various demographics, including males and females, all ethnicities as we included food and lifestyle choices beyond the traditional American diet and lifestyle, various socio-economic statuses, ages to a certain point as there is a reading and writing aspect that need to be understood, cultures, diets such as vegan and vegetarian, and can be used both indoors and outdoors along with being mobile. Targets lifestyle habits to promote bone health including bone healthy dietary choices, bone strengthening activities, and bone health nutrition education. It also reaches children at peak bone age, due to the adaptability of the program it can be implemented and was in our study at circumpubital phase in the children’s lifecycle. We used a very limited amount of funds, most of which were used for printing as all items needed for the program are common household and school items. Program was overall age appropriate for intended audience: from the intervention tool to the topics discussed to the activities applied. The program covers weight-bearing and resistance activities, sunlight exposure, dietary choices and bone health benefits of these choices.
- The study found that knowledge was gained from the pretest to the post-test and was retained up until the 21-day post-test. Here is the West Chicago campers taking the pretest survey to determine base knowledge of bone health.
- Limited by signed consent forms, unable to use all data collected. One day study limited the impact we could have with the intervention, therefore we compensated via 21-day post-test. Also, to fit in all the aspects of the intervention time was a constraint as pre and post-test had to be distributed and taken and all five bases needed to be completed all within about an hour. Within the West Chicago site we primarily worked with Hispanic populations and at the Elmhurst site we mostly worked with White populations which limited diversity at each site and in the overall study beyond Hispanic and Caucasian. During the testing lower grade levels such as the 5-7 year olds struggled with reading the test questions and answering the open ended questions in the post-tests. Also, English may not have been their first language leading to a lack of understanding or full understanding or interpretation of results. Even though the reading level of the survey’s may have been too high for the younger population this was not the studies intended population. Within the younger populations, there was potential that facilitators and peers had an impact on how they understood or answered the survey for open ended questions. We did a limited amount of validation with our tool, content and face validation done, relatively short survey we tested it purely on a small group of children from the West Chicago school district and altered the tool based on their responses and understanding but we were unfortunately unable to complete any further validation of the tool. Time limitation to collect data and run intervention meant that we did not retain all the data collected due to lack of consent received. Within the bases some finished earlier than others, this meant some bases were able to review or run through the activity multiple times while others were still in the process of finishing their base. However, this could be easily adjusted to time each base equally[HOWEVER, THIS COULD EASILY BE ADJUSTED…]
- The main future application for this program is to implement it within school, it could be placed in the curriculum of many classes or disciplines depending on what the specific school offers. It would be intended for children ages 8 to 10 years and could possibly span multiple grades and possible follow the children through multiple grade levels. Through slight program manipulation the program could be easily expanded to be adaptable for larger groups. It could also be expanded into a longer term program for example going from the current 1 day intervention which showed retention of knowledge already into a once monthly program which could discuss each “base” over each month possibly creating long term retention results. With advancement of this program further tool validation would be necessary, this would allow for increased understanding, readability, and application for the intervention.
- Bones are constantly being built, torn down, and rebuilt. During growing years, especially up to and through puberty, is the time when rapid bone is being built. With the adolescent phase being a critical time for bone growth, educators must spend ample time teaching learners about bone health action steps. Batter Up for Bone Health answers the NOF’s question “How can children, adolescents and young adults maximize peak bone mass?” with its’ lesson plans focused on maximizing bone health during the preadolescent years. Based on the participant’s high level of bone importance, the education session can quickly move through the importance of bone health in order to allot more time towards educating learners on bone health action steps Calcium, vitamin D, and physical activity play key roles in overall bone health. The years surrounding puberty represents a time when bone accrual and formation is crucial for bone health and disease prevention.