PHYSICAL ACTIVITY IN YOUNG CHILDREN DURING PHYSICAL EDUCATION

CLASSES

A Capstone Seminar Paper for PTY 769: Faculty-Mentored Capstone Experience

Presented to the Faculty of the Physical Therapy Department

The Sage Colleges

School of Health Sciences

In Partial Fulfillment

of the Requirements for the Degree of

Doctorate of Physical Therapy

Andrea Nicosia

Kelly Piché

May 2013

_________________________________

Neeti Pathare, PT, PhD

Associate Professor, Research Advisor

___________________________________

Patricia Pohl, PT, PhD

Professor/Chair, DPT Program Director

PHYSICAL ACTIVITY IN YOUNG CHILDREN DURING PHYSICAL EDUCATION

CLASSES

Statement of Original Work:

I represent to The Sage Colleges that this thesis/dissertation/capstone paper and abstract (title

listed above) is the original work of the author(s) and does not infringe on the copyright or

other rights of others.

_________________________________________ ____________________

Andrea Nicosia Date of Signature

_________________________________________ ____________________

Kelly Piché Date of Signature

Permission for The Sage Colleges to release work:

I hereby give permission to The Sage Colleges to use my work (title listed above) in the

following ways:

Place in the Sage College Libraries electronic collection and make publically

available for electronic viewing by Sage-affiliated patrons as well as all general

public online viewers (i.e. “open access”).

Place in the Sage College Libraries electronic collection and share electronically for

InterLibrary Loan purposes.

Keep in the departmental program office to show to other students, faculty or outside

individuals, such as accreditors or licensing agencies, as an example of student work.

______________________________________ ____________________

Andrea Nicosia Date of Signature

______________________________________ ____________________

Kelly Piché Date of Signature

ACKNOWLEDGEMENTS

Deepest gratitude is expressed to our research advisor, Neeti Pathare, who provided

invaluable guidance and encouragement throughout the entire capstone process. It was with

her unwavering support that this research study was possible.

Sincere appreciation is also due to research collaborators. Esther Haskvitz provided

plentiful assistance with data collection and offered instrumental guidance, and Marjane

Selleck offered her esteemed expertise. Additionally, we would like to extend our thanks to

Rachel Kimball for her contributions to data collection.

We also wish to thank the elementary school, physical education teachers, and

students who were involved in this research. Without their incredible graciousness and

cooperation, this study would not have been successful.

Lastly, we express our gratitude to our families and friends for their love and support.

We thank them for guiding us in life and encouraging us to accomplish all of our goals with

hard work and dedication.

PHYSICAL ACTIVITY IN YOUNG CHILDREN DURING PHYSICAL EDUCATION

CLASSES

Andrea Nicosia & Kelly Piché

The Sage Colleges

May 2013

ABSTRACT

Physical activity (PA) is considered a key component in preventing childhood

obesity. Limited work exists on assessing PA in children ≤ 9 years during physical education

(PE) classes.

The purpose of this cross-sectional study was to evaluate PA differences during PE

classes in children classified as non-overweight (NW), overweight (OW), and obese (OB).

PA was measured using pedometers during PE classes (n = 82; age: 7.55 ± 1.22 years). Body

mass index (BMI) was calculated to classify participants into NW, OW, and OB groups. PA

levels were compared among the 3 groups and between the NW and combined OW/OB

groups for each grade. The association between PA and BMI of the entire sample was

investigated.

One-way ANOVA and post hoc analyses showed that for the entire sample,

significant differences existed in the average step counts between NW and OW groups (NW

group: 977.14 ± 146.85 steps, OW group: 857.70 ± 139.97 steps; P = .026), as well as

between NW and OB groups (OB group: 887.36 ± 113.07 steps; P = .030). Independent t-

tests revealed significant differences between NW and combined OW/OB groups for 2nd

grade (P = .044). Pearson correlation revealed a low, negative relationship (r = -.326, P =

.003) between PA and BMI for the entire sample.

Our findings suggest that differences existed in the average step counts taken during

PE classes in children classified as NW, OW, and OB. This should be considered when

establishing appropriate activities to engage students from all BMI categories during PE

classes.

Suggested Keywords: physical therapy, physical activity, childhood obesity, body mass

index, elementary school-aged children, physical education, and pedometers.

3

Introduction

The increasing concern surrounding childhood obesity has been receiving

international attention. The prevalence of obesity in the United States (U.S.) has greatly

increased in the past few decades of the 20th

century.1 From 1999-2000 to 2003-2004, the

incidence of young females, aged 2-19 years, who were overweight (OW) in the country

increased from 13.8% to 16.6%, and for young males, aged 2-19 years, from 14.0% to

18.2%.1 It appears, however, this incidence rate may be decreasing more recently

2, possibly

due to increased national awareness. Despite this change, obesity is still a serious public

health issue, especially in children. In the past 30 years, obesity in U.S. children aged 6-11

years quadrupled in prevalence, increasing from 6.5% in 1980 to 17.0% in 2006.2,3,4

An

additional 15% of youths were found to be at risk for becoming OW.5 Within the years 2009-

2010, approximately 17%, or 12.5 million, of U.S. children and adolescents were considered

obese (OB).2 According to the Center for Disease Control and Prevention (CDC) National

Center for Health Statistics, it was found that obesity was more prevalent among adolescents

than preschool-aged children in 2009-2010.2 However, in 2007-2008, 20% of children aged

2-5 years were categorized as OW or OB.6 More boys are OB than girls in both preschool

and adolescent age groups.2

It is evident that children of all socioeconomic and ethnic groups are included in the

trend of increased obesity rates, but there are certain subpopulations that are at increased risk

for obesity. Hispanic and African American children have considerably higher overall

incidence rates than Caucasian children.7 Thirty-eight percent of Mexican American children

and adolescents were OW and 20.9% were OB, while OW and obesity rates for African

Americans were 34.9% and 20.7%, respectively.7 A study from National Growth and Health

4

found that more than one-half of African American girls were at risk for becoming OW, and

over one-third were OW by the time they reached 19.5 years of age.1 Survey data

additionally supports that African American females aged 6-11 years and 12-19 years are

twice as likely to be OW than Caucasian females in the same age groups, and that the onset

rate of becoming OW is much higher than with Caucasian girls.1

In order to further understand the significance of childhood obesity, it is best to define

the term obesity. From a medical standpoint, obesity denotes excess body fat.8 Obesity in

adults is described as a body mass index (BMI) greater than or equal to 30 kg/m2, calculated

from an individual’s height and weight.2 Obesity is not as easily defined in a pediatric

population, as it is not comparable to the adult definition. One of the most common ways of

determining obesity in a child is calculating BMI through the use of the CDC growth charts.2

These charts were established in 2000, and they illustrate the percentile distributions relative

to gender and age for the pediatric population.2,8

A BMI greater than or equal to the age- and

sex- specific 95th

percentiles of these CDC growth charts signifies obesity in a child.2,8

A

BMI at or above the 85th

percentile and less than the 95th

percentile for children of the same

sex and age defines being OW.2 According to Li and Hooker (2010)

4, “BMI expresses the

weight-for-height relationship as a ratio, that is, weight (in kilograms)/ [height (in meters)].”

Additional findings from the same study validate age- and gender-specific BMI reference

values for the CDC growth charts after determining that a child’s age and gender have

significant effects on BMI. 4

It is regarded that BMI is the preferred measure of obesity because it is simple to

obtain, strongly associated with body fat percentage, and is accurate with identification of the

most individuals who are OW and OB.8 However, some researchers caution that BMI is

5

poorly associated with height and that it is not a complete assessment.8 Nevertheless, BMI

has been repeatedly endorsed by experts and is the preferred tool for evaluating obesity in

children from 2-19 years of age.8

Extensive research has determined that there is some predictability behind who may

become OB. Interestingly, socioeconomic status, parental education level, and type of school

that children attend all play a role in BMI status.4,9

One study specifically revealed that

among children from households with a higher socioeconomic status, who were not eligible

for the National School Lunch Program (NSLP) or School Breakfast Program (SBP), and

attended public schools had a higher average BMI (0.150) than equivalent children who

attended private schools.4

Those who were eligible for NSLP or SBP, attended public

schools, and were of a lower SES had a mean BMI 0.401 higher than those who attended

private schools. Despite socioeconomic status, those attending public schools appeared to

have higher BMI values than their counterparts in private schools. An article by Datar and

Sturm (2004)9 reported that Hispanic children whose mothers earned, at maximum, a high

school diploma, or children from low-income families were significantly more likely to be at

least OW in kindergarten and first grade.

Regardless of ethnicity, children and adolescents who are OB have an elevated risk of

numerous health conditions2,4,7

and increased mortality rates into adulthood.8 Children who

are OW and OB are increasingly diagnosed with type 2 diabetes, hypertension, and

cardiovascular disease.4-8

Children with excess weight are also at risk for being diagnosed

with psychosocial disorders, such as depressive symptoms, anxiety, low self-esteem, low

body image, and mood/conduct disorders.4-8

Nearly 58% of children diagnosed with type 2

diabetes are OB.10

Even more striking is the finding that in comparison to adults with adult-

6

diagnosed diabetes, children who are OB with a diagnosis of diabetes are at a higher risk for

comorbidities like kidney failure and death from cardiovascular events by middle-age.11

Hypertension, a cardiovascular condition, is 3 times as likely to occur in children who are

OB as opposed to children who are not OB.11

Pulmonary conditions such as asthma and sleep

apnea are also common diagnoses of children who are OW and OB.5 Apart from

cardiovascular and pulmonary complications, other systemic complications prevalent in both

OW and OB populations are advanced growth and early maturity, polycystic ovary disease7,

and non-alcoholic fatty liver disease.5,11

Non-alcoholic fatty liver disease can be described as

an irregular buildup of fat in the liver. It is correlated with obesity and insulin resistance.11

Musculoskeletal problems noted in children who are OW and OB include slipped

capital femoral epiphysis, fractures, and abnormal mechanical joint loading.11,12

In fact,

children and adolescents who are OW are more likely to have fractures than their equivalents

who are non-overweight (NW), and the change in joint loading in children who are OB is

associated with premature osteoarthritis.11,12

These musculoskeletal changes all contribute to

adaptations in gait patterns and negatively affect performance on weight bearing activities of

those who are OW and OB.12

Furthermore, these joint deformities may lead to postural

instability in children who are OW and OB13

, which in turn reduces their ability to maintain

their balance required to safely perform particular physical activities. It should be noted that

most of the above mentioned diseases and health complications associated with being OW

and OB in children can be prevented with lifestyle modifications.

Children who are OW or OB in minority populations sustain a much greater risk of

being diagnosed with any of the aforementioned conditions. Those at highest risk are African

Americans, Hispanics, and Native Americans. Compared to Caucasians, underprivileged

7

Hispanics have excessively high rates of being diagnosed with type 2 diabetes,

cardiovascular disease, and cancer.7 The risk of diagnosis is highly dependent upon gender

and age within these populations, as well.7 From 1999-2002, the incidence of diagnosed

diabetes in non-Hispanic blacks and Mexican Americans was nearly double that in non-

Hispanic whites.14

From their survey, Liao et al. (2011)15

concluded that residents in minority

communities tend to have increased barriers to health care access and greater risks of disease.

The percentages of African Americans (median 28.8% men, 37.6% women) who reported

engaging in no leisure-time physical activity (PA) were much higher than any other ethnicity.

Hispanics had the lowest percentages of persons who had their cholesterol checked and of

persons with medication-controlled high blood pressure. These certainly are contributing

factors to minorities’ increased risks of obesity-related diseases.

Not only does obesity influence physical and psychological health, but it also

negatively affects social and economic development.4 In general, economic costs associated

with obesity alone are astronomical and are anticipated to increase over time. It was

suggested that in 2003, the combination of direct and indirect costs related to obesity in the

U.S. was approximately $139 billion.4 It is estimated that by 2018, obesity will cost the U.S.

approximately $344 billion.16

Additionally, research confirms the continuation of obesity

from childhood into adulthood.8 There is a 50% chance that children who are OW at age 2

will be OW by adolescence, which is likely to continue into adulthood.11

Unsurprisingly, the

higher the BMI as a child, the greater the probability is of obesity in adulthood.5,8

In some

cases, predictability begins even earlier than childhood. Obesity later in life can be predicted

from rapid weight gain during the first week of infancy, the first 4 months, and the first year.8

Increased weight gain during the first 3 years of life was even correlated with higher BMI, fat

8

mass, and waist circumference at 17 years of age.8 All these factors underlie the importance

of targeting prevention of childhood obesity at an early age.

Prevention of obesity needs to include a number of factors, most of them starting in

the home and at school. Diet and PA are factors that are associated with obesity in children.

The combination of these factors is an essential weapon for preventing obesity in children.

Healthy, nutritious meals should be provided at schools for all children.4 To accomplish this,

parents should also be aware of recommended daily values for the various food groups and

how to provide these amounts to their children.6 Getting the appropriate amount of PA is

another factor in preventing childhood obesity. According to the U.S. Department of Health

and Human Services (2008)17

, a minimum of 60 minutes of daily PA is suggested for

children and adolescents aged 6-17 years. Lack of PA or a sedentary lifestyle is a factor

correlated to possible obesity in middle school children.7 This is a phenomenon increasingly

observed in many young children. Despite the benefits of PA, a substantial number of

children are not meeting recommended guidelines for PA.17

Increased PA is inversely related

to childhood obesity. The more PA children participate in the less likely they are to become

OB.4,7,18

PA also decreases the likelihood of obtaining sedentary-related diseases such as type

2 diabetes and cardiovascular disease, increases self-esteem, and improves overall health and

wellness.19

The American Academy of Pediatrics recommends encouraging PA in all children to

help with this weight loss.20

Specifically, prevention studies have shown that incorporating a

low-fat diet and 150 minutes of exercise per week over a 3-year period helped to reduce the

risk of developing type 2 diabetes by 58% in adults with impaired glucose tolerance.21,22

One

study showed that reducing the amount of time playing video games and watching television

9

combined with reducing the amount of food eaten while watching television helped to reduce

BMI, triceps skinfold thickness, waist circumference, and waist-to-hip ratios in children.23

By promoting weight loss and prevention of weight gain, type 2 diabetes can be prevented in

children.24

As alarming as the incidence is for childhood obesity and the increased adverse health

outcomes, findings suggest that prevention of this epidemic has been hindered because

parents are unable to recognize that their children are OW or OB.6 Due to these factors,

schools have often been identified as a major setting for childhood obesity research and

education.4,25

Schools promote PA instruction in a safe environment, and educators can be

trained in healthy behavior curriculum.25

Most of the nation’s youth are exposed to these

healthy lifestyle choices just by attending school.25

These lifestyle choices, health education,

dietary habits, and PA have all been identified as modifiable variables that influence

childhood obesity.25

Moreover, physical education (PE) classes in schools may assist in the

prevention of childhood obesity.9 Children are meant to fulfill some daily requirements of PA

within PE classes, which could hopefully decrease their risk for obesity.9

PE classes in schools are meant to increase the amount of PA children receive in a

day, but current PE classes do not seem to be bridging the gap in PA for children. A report

concluded that children observed in the study did not receive the recommended amount of

PA in PE class weekly.26

Rather, they received only 25 minutes per week of moderate-to-

vigorous physical activity (MVPA) in PE class.26

Datar and Sturm (2004)9

explored the

relationship between the amount of time allotted for PE class and children’s BMI. They

found that when receiving an extra hour of PE class, elementary-aged girls who were OW or

at risk for being OW showed reductions in BMI.9 Recent data from 2011 shows that only

10

29% percent of high school students participated in at least 60 minutes of daily PA.27

The

percentage of these high school students who attended PE classes daily decreased from 42%

in 1991 to 25% in 1995 and remained stable at that level until 2011 (31%).27

These studies

support the notion that higher amounts of PA in PE class will reduce the likelihood of

childhood obesity.

There is an increased use of pedometers to encourage PA in children, as PA is

essential in the prevention of childhood obesity. Pedometers are used to count the number of

steps a user takes within an allotted time frame. This is intended to help the user measure the

amount of PA he/she is partaking in during a given day. Previous studies have shown the

accuracy and reliability of pedometers in counting the number of steps taken.28,29

The number

of steps counted by the pedometer should correlate to the distance walked by the user,

providing an estimate of PA. The current guidelines for PA recommend greater than 30

minutes of high intensity activity greater than 3 times per week, or at least 30 minutes of

moderate intensity activity daily. Many health promotion programs equate this to getting at

least 10,000 steps daily. However, more recent research has shown that 30 minutes of

moderate intensity PA translates to 3,000-4,000 steps only when paired with specific

guidelines for this number of steps. The steps must be greater than or equal to 100 steps per

minute, be accumulated in at least 10-minute bouts, and be over and above a baseline daily

step goal.30,31

For example, in a study by Welk et al. (2000)32

, a daily step count of 11,603

was recorded when vigorous activity was included in that day, and a step count of 8,265 was

recorded with only light and moderate activity. In an individual who is sedentary and OB, the

number of steps may help break the pattern of a non-active life and in turn help with a

11

weight-loss or PA goal. In an active individual, a pedometer is useful to track the number of

steps for a PA goal as long as it falls into the guidelines of activity previously mentioned.33

It has been assumed that levels of PA have an impact on being OW or OB in children,

and while most articles support this statement, others do not concur.34

Globally, some studies

do not confirm the relationship between PA and childhood obesity. Instead, these studies

found a relationship between a child’s weight and sedentary behavior.35,36

However, in a

systematic review34

, 16 of the 17 articles included in the review measured the association of

PA and childhood obesity. Five of the articles had strong negative correlations between PA

and childhood obesity.34

Previous research has investigated the possible trends in the amount of PA between

children who are OB and children who are not OB with ages ranging from 5-12 years old in

the U.S. Trost et al. (2001)37

explored this trend in sixth graders who were and were not OB

using accelerometers. They concluded that in comparison to counterparts who were not OB,

children who were OB exhibited significantly lower PA values. In a separate study, Trost et

al. (2003)38

looked at PA levels in preschool children aged 3-5 years who were OW and NW,

and it was determined that while there were no weight-related differences between girls, boys

who were OW had significantly lower PA levels than boys who were NW. Eisenmann et al.

(2007)39

looked at PA in a sample of 608 children who were OW or OB with a mean age of

9.6 years using a pedometer for a total of 7 days. Results concluded that children not meeting

the pedometer-based PA recommendations were at twice the risk of being OW or OB.

Laurson et al. (2008)40

assessed PA using pedometers and a child survey on TV, computer,

and video game use in children 7-12 years old to determine the likelihood of being OW.

12

Children not meeting the PA or screen-time recommendations were 3-4 times more likely to

be OW than those who complied with the screen-time recommendations.

PA and weight status were also assessed in different age ranges outside the U.S. PA

and physical fitness were assessed in Flemish schoolchildren aged 12-18 years who were

considered OB or not OB.41

Using the European physical fitness test battery and the Baecke

Questionnaire, it was determined that subjects who were OB had poor performances on

weight bearing tasks, but had similar levels of leisure-time PA as those who were not OB.41

A study completed in Switzerland interestingly concluded that there were no weight-related

differences in MVPA levels between 676 first and fifth graders who were at normal weight

or OW.42

Additionally, it was concluded that MVPA accelerometry levels were significantly

higher for all children on days that they had PE classes, which improved their overall PA

levels on those days.42

Despite this, the percentage of MVPA the children received on days

with and without PE was still low. The MVPA gained in PE classes significantly contributed

to the overall daily MVPA levels of children who were OW.42

After a widespread search of the literature, it was found that there were many studies

that explore PA in children, but there was a great deal of variability within these studies. PA

was measured in many ways, such as accelerometers, pedometers, parent- or self-reports,

heart rate monitoring, and direct observation.34

The number of sessions used to measure PA

levels also ranged from 3-7 days. Researchers chose variably different child populations on

whom to conduct their research. These samples ranged from high school students, some or all

middle-school students, some elementary-level students, and preschool students as young as

3 years old. The structure and type of PA differed as well. Though schools have been

identified as an important environment to promote PA and prevent childhood obesity, only

13

limited work has been conducted to compare the levels of PA during PE classes among

different BMI groups. Specifically, work by a few authors1,43,44

has been conducted in

students aged 11-16 years and offers conflicting evidence regarding this topic.

It is evident that the topics of PA and childhood obesity are important based on the

numerous physical and economic risks associated with this health condition. More research

needs to be conducted in a school setting such as during PE classes with a sample including

children from a wider age range that encompasses more than two elementary school grade

levels at a time, as well as an increased number of sessions to assess PA levels for improved

data analysis. Stronger data is needed to further validate the differences in PA between

children who are OW and OB. Previous studies have evaluated sample sizes including a

specific age/grade or a small range of ages or grade levels, but to our knowledge no study has

been conducted on comparing PA and BMI in children ≤ 9 years of age during PE classes.

Many of the factors that contribute to childhood obesity and the associated health

complications can be prevented and modified early on; hence it is imperative to investigate

these questions in young children (≤ 9 years of age).

The primary purpose of this study was to determine the differences in the levels of

PA as assessed by the average number of steps using pedometers between BMI categories

(NW, OW, and OB) in young children during their PE classes. This was evaluated in the

entire sample as well as at each grade level. It was hypothesized that children who are OW or

OB would have a lower step count during PE classes when compared to their peers who are

NW for the entire sample and at each grade level. Secondarily, the relationship between BMI

and PA during PE classes was investigated using pedometers in the entire sample of young

14

children. It was hypothesized that a strong, inverse correlation between BMI and PA would

exist.

Methods

Design and Sampling

The cross-sectional study was conducted through the Department of Physical Therapy

at Sage Graduate School in Troy, New York. IRB approval was obtained to perform the

study at an elementary school in Upstate New York. The elementary school and PE instructor

were contacted throughout the IRB approval process and consented to participate in the

study. Consent forms, a description of the study’s purpose, and all study procedures were

sent to the parents of all children from kindergarten through third grade (see Appendix A).

Eighty-five children, aged 5-9 years consented to the study. One participant utilized a

wheelchair for mobility and data could not be obtained for this participant, as the child did

not participate in PE. Also, pedometers are not validated for individuals utilizing

wheelchairs. Two additional participants were excluded from the study due to insufficient

data, leaving a final sample size of 82 participants. Data were collected in the spring and fall

of 2012 and analyzed in fall 2012.

Procedure

Researchers participating in data collection included 2 certified physical therapists,

who were also professors at The Sage Colleges, and 3 physical therapist students. All

procedures conducted during data collection were standardized and completed based on a

protocol.

15

All PE classes were conducted by a NYS certified PE instructor. During the first PE

class, the PE instructor introduced the study to the consented participants. Assent was

obtained from each consented participant before placing the pedometer at every PE session.

Each participant was provided with a Yamax Digiwalker SW-701 pedometer during their

allotted PE class tagged with a number from 1 to 16. The participants received the same

numbered pedometer at each PE class thereafter. The pedometers were placed on each

participant’s waistband unless clothing restricted this placement, in which case the

pedometers were then placed on the participant’s pants pocket. All instances in which the

pedometer was not placed on the waistband, or if a different pedometer number had to be

used for any reason, it was documented on the particular participant’s data collection sheet

for that day. Once placed on the waistband each pedometer was reset to zero, and the cover

was closed over the screen by the researchers. This prevented the participant from reading

the step count before the end of the session. The participants were instructed not to touch or

shake the pedometers and to allow the researcher remove it for them at the end of class.

During the PE sessions, researchers observed the activities. The PE classes typically

were 30 minutes in duration with 5-10 minutes being instructional, which left approximately

15-20 minutes for activity. In the event that the pedometer fell off the participant during the

class, the pedometer was replaced and the time the pedometer fell off was recorded. At the

end of the PE sessions, participants lined up to get the pedometers removed by the

researchers. Pedometers were then carefully opened for data to be recorded on individual

student tracking sheets. The time the pedometers were placed on the students and the time

they were removed were recorded.

16

The students participated in a number of activities throughout the study. The PE

instructor conducted classes containing general aerobic conditioning with activities such as

skipping, jogging, jump-rope, and galloping. She also instructed the participants in various

stretches and abdominal breathing exercises. The participants learned games that provided

upper extremity exercise and general strengthening, and a few classes also contained dance

portions for increased body awareness and movement.

Additionally, height and weight (Health o meter Professional Dial Scale, Sunbeam

Products, Inc.) were measured without shoes to calculate the BMI for each participant. The

BMI was used to determine whether each participant fell into a NW, OW, or OB category

based on CDC categories.45

If the participant was removed from the PE class to take his/her

height and weight, the time he/she re-entered class was recorded for pedometer accuracy.

Outcome Measure

The primary outcome measure utilized in this study was PA as measured by number

of steps taken using a Yamax Digiwalker SW-701 pedometer. Pedometers are used to

measure PA by counting the number of steps a user takes within an allotted time frame.

Previous studies have shown the accuracy and reliability of pedometers in counting the

number of steps taken.28,29

Specifically, a systematic review by Bjornson (2005)46

states that

Yamax Digiwalker pedometers are “reliable and valid [when] compared with 5 other

pedometers”. In a study by Schneider et al. (2003)28

that compares various brands of

pedometers, the Yamax SW-701 pedometer is reported to have one of the highest reliability

> 0.99. It was also very accurate in counting the number of steps. The pedometer showed

results within ± 16.9 of the actual number of steps taken (P < 0.050).28

These results were

17

taken after a 400-meter track walk at a self-selected speed.28

Another study by Welk et al.

(2000)32

looked at the reliability of the Yamax Digiwalker under walking and jogging

conditions on a standardized track. They found that the intra-class coefficient under the

walking condition was moderate at r = 0.56, which meant that the Yamax recorded within

10% of the observed step count in 26 of 31 trials. Under the jog conditions the intra-class

coefficient was high at r = 0.89, which meant that the Yamax recorded within 10% in 28 out

of 31 trials.32

In another study, the intra-class correlation coefficient between average

pedometer steps and actual steps recorded during treadmill walking was found to range from

0.541 at 40 minutes on the treadmill and 0.997 at 94 minutes on the treadmill. Here, four

pedometers were assessed: the Digiwalker SW-200, Walk4Life 2505, Digiwalker SW-701,

and Sun TrekLINQ. Intra-class correlation coefficient values increased as time on the

treadmill increased.29

Data Analysis

Data for all participants were compiled in an Excel spreadsheet. Data from two

participants were not included due to lack of insufficient sessions. After calculating the

descriptive statistics, outliers were identified as participants who had step counts 2 standard

deviations above or below the mean. These outliers were eliminated from the data, and the

averages were recalculated. One participant was considered an outlier, leaving 82

participants included in data analysis. A one-way ANOVA with a Bonferroni’s post hoc

analysis was used to assess the average number of steps between the NW, OW, and OB

groups. In addition, data were analyzed for each grade level, combining the OW and OB

groups to ensure adequate sample size for comparisons. Independent t-tests determined the

18

differences for each separate grade for NW and OW/OB groups. Additionally, Pearson’s

correlation coefficient was calculated to study the relationship between BMI and the average

number of steps for the entire sample. SPSS 20.0 was used to perform data analysis. Results

were considered significant at an alpha level of 0.05.

Results

Descriptive characteristics of the participants are presented in Table 1. Following data

analysis, the sample consisted of 82 participants (7.55 ± 1.22 years): NW group- n = 45; OW

group- n = 12; OB group- n = 25. Results of the one-way ANOVA are presented in Table 2.

Analyses comparing the average number of steps between all children in the NW, OW, and

OB groups using the one-way ANOVA showed that for the entire sample, there were

significant differences in the average step counts taken between the 3 groups. Bonferroni’s

post hoc analysis revealed significant differences between the NW group and OW group (P =

.026), in addition to between the NW group and OB group (P = .030) (Table 3). There were

no significant differences in the average number of steps between the OW and OB groups (P

= 1.000).

Analyses were conducted for each grade level, and NW and OW/OB groups in

second grade showed significant differences in average number of steps (P = .044). No

significant differences were noted between the two groups for kindergarten, first grade, or

third grade (P = .061, .453, and .092, respectively) (Table 4).

Pearson correlation analysis showed a low, negative correlation between BMI and

average number of steps of the entire sample (r = -.326, P = .003).

19

Discussion

The main findings from the present study suggest that young children who are NW

take a significantly greater number of steps than the children who are classified as both OW

and OB during PE classes. Also, the OW and OB groups were not significantly different in

their number of steps.

With a growing concern about childhood obesity, schools are regarded as an

important environment to promote healthy exercise behaviors in children.47

PE classes are

currently mandated in schools, but only the amount of time spent in PE is regulated rather

than the amount of PA in which students actually partake.47

PE classes are meant to provide

children with a regulated amount of PA during school hours, but if some children are not

participating as actively, they may not be reaping the benefits of PE class. The findings of the

present study offer an important insight into this topic.

Our findings correspond with the work conducted by Fairclough (2003)43

on the

measurement of levels of PA of 20 high school girls during their PE classes. Unlike the

current study, PA was measured by heart rate telemetry and accelerometry. It was determined

that the 20 girls participated in MVPA for nearly 39% of class time, which is below the 50%

class time criterion proposed by Healthy People 2010.43

Likewise, it was suggested by the

significant moderate inverse relationship between body fat and accelerometer counts that the

girls with increased body fat were less active than the girls with less body fat in the PE

classes. Another study by Fairclough and Stratton (2006)44

concurs with the findings in the

present study. In a sample of 68 children (48 normal weight, 15 OW, 5 OB, aged 11-14

years) it was determined that the children who were classified as normal weight reported they

enjoyed PE more (P = 0.008) and were more competent (P = 0.005) than their peers who

20

were OW. Cardiorespiratory fitness, as measured by a graded treadmill test was significantly

greater in the children with normal weight (P < 0.0001). Conversely, no differences in the

time spent in MVPA and vigorous PA were observed between the two groups.44

Although the above evidence supports the current findings, there are existing studies

that have conflicting results. A study examining the PA of 198 high school students during

PE classes concluded no significant differences in the number of steps taken between those

who were OW and those who were NW. 1

Instead, it was determined that males and

Caucasians were more active than females and African Americans. The opposing outcomes

between this study and the current study can be explained by the differences in activities in

which the participants engaged. Hannon (2008)1 used a large sample of high school students

who played organized, 2-team activities such flag football, ultimate Frisbee, and soccer. The

present study monitored and recorded the number of steps taken by younger children during

their participation in a variety of activities, including dancing, aerobic conditioning,

flexibility and strengthening exercises, and abdominal breathing exercises. These activities

were not as structured as the team sports and were slightly modified between each grade

level. The activities in the present study also focused more on running and jump-roping,

which engages children in more cardiovascular-type exercise.

Our findings that children who are OW/OB are less active compared to their peers are

in line with previous studies conducted on PA outside of the PE classes. Specifically, it is

reported that school-aged children who are OW or OB tend to spend more time in sedentary

activities during school and at home.4,7,18

A literature review by Li and Hooker (2010)4

reported that increased time spent watching television on a school day was positively

correlated with BMI in children. They also found that when participating in sports activities

21

outside of school, PE class had a negative correlation with BMI. Children who have parents

that regularly exercise or play sports also tend to be more active and have lower BMI.

Another study by Chung et al. (2012)48

obtained significant results when researchers explored

the trends in PA by age level, gender, and BMI in 1560 U.S. girls and 1587 U.S. boys.

Instead of dividing the sample into grade levels, small ranges of age groups were separated.

PA was measured by accelerometers for an average total of 7 days. Chung et al. (2012)48

exposed statistically significant results that girls aged 6-8 years who were OW, OB, or very

OB had less moderate and vigorous PA than girls who were NW or underweight. This trend

was the same for boys aged 6-8 years, except the results were not statistically significant for

the moderate levels of PA. Overall, girls and boys of all age groups who were underweight

and NW spent more time in moderate and in vigorous PA than OW, OB, or very OB

children. In the current study, the children in the OB group had slightly higher numbers of

steps than children in OW group. This could be explained by the differences in sample sizes

and gender distribution within these groups (the OB group had more boys compared to girls).

The current study is the first study evaluating the effect of BMI on step counts

specifically taken during PE classes in young children (≤ 9 years) from kindergarten through

third grade. Other studies have also used pedometers to examine the effect of PE on the

amount of PA children receive, but without comparing BMI categories. A study by

Dauenhauer and Keating (2011)49

used Omron HJ-112 pedometers to measure total steps of

8-11 year-old children during PE class. In this population more than half of the students fell

greater than or equal to 85th

percentile for BMI-for-age. Children attended 2 PE classes per

week, one for 30 minutes and another for 60 minutes. The children continued to wear the

pedometers throughout the rest of the week and weekend, as well. The results showed that

22

children were taking significantly less steps on weekend days than weekdays (P < .050), as

well as taking significantly less steps during the 30-minute PE classes compared to the 60-

minute PE classes (P < .010). Children also took significantly less steps on days with no PE

compared to 30- and 60-minute days (P < .001). However, there were no significant

differences on 0- and 30-minute days. Interestingly, children took significantly more steps on

60-minute PE days, excluding steps taken during PE class. This suggests that they engaged in

more PA even outside of PE on 60-minute PE days. Here, PE classes not only allow children

to gain PA during class, but it indirectly encourages PA outside of class, as well.49

Another study evaluated PA in 279 middle school children in the Rocky Mountain

region of the U.S.50

The study participants wore Walk4Life pedometers for 5 school days

with at least 2 of the days including 35-minute PE classes. Participants wore the pedometers

until bedtime, at which time they recorded their steps and received parent confirmation by

signature. The study found that on days including PE, students accumulated significantly

more steps than on days that did not include PE. The participants were also separated by

activity level based on their step counts per day. They were divided into least active,

moderately active, and highly active categories. On PE days, the least active group recorded

significantly less steps than the moderate or high activity groups. The moderate and high

activity groups did not have significant differences.50

This suggests that children who are

least active on a regular basis are also consistently less active during PE.

The main clinical implication from the present study is that children who are OW or

OB take fewer steps during structured PE classes than their peers. The physical activities

typically performed during PE classes involved games that included running to various

“exercise” stations and jump-rope. Children in all grades participated in a national jump-

23

roping program that required jump-roping at the start of each PE class. The difference in step

counts may be attributed to several factors, including musculoskeletal differences reported

between children in different BMI categories.1,12,13

These differences may affect performance

of PE activities like running and jump-rope. A literature review by Chan and Chen (2009)12

discussed the effect of obesity on the musculoskeletal system in children and adolescents.

Musculoskeletal conditions such as slipped capital femoral epiphysis and Blount’s disease

are associated with increased BMI and excess body fat in adolescents. Blount’s disease stems

from abnormal tibial growth, causing tibial genu-varum and tibial torsion. Genu-valgum has

also been correlated with childhood obesity. Musculoskeletal effects such as genu-varum and

genu-valgum cause abnormal weight bearing on the lower extremities and increased forces

on the knee joints. Children who are OW or OB and develop these conditions may take fewer

steps because their joints are withstanding increased forces or their joints are not aligned

properly. Chan and Chen (2009)12

also reported that children who are OW or OB must carry

excess weight in their daily activities; thus, they seem to be lacking in weight bearing and

endurance activities. Children who are OW or OB must compensate for this excess weight by

adapting their gait patterns. They spend less time in single-leg stance and more time in dual

stance, as well as dynamic stance-limb knee varus, increased stance-limb knee rotation, and

swing-limb circumduction. All of these factors during gait could affect the number of steps

children who are OW or OB take during PE class. Another aspect to consider is

musculoskeletal pain with weight bearing activities.12

Children who are OB tend to have

increased musculoskeletal pain than children who are NW. Low back, knee, and foot pain are

common complaints in this population. Pain in the lower extremity joints could have altered

the step counts for children who are OW or OB. Hannon (2008)1 also identifies the effect of

24

excess body fat and weight bearing activities. Children or adolescents who are OW or OB

have excess body fat throughout the body, which adds to the weight carried on muscles and

bones. Therefore, the body experiences increased energy demands resulting in increased

heart rate and increased physiological loads that could possibly compromise their

performance.

Postural balance is also affected by being OW in children.13

According to D’Hondt et

al. (2008)13

, children who are OW or OB have more difficulty performing fine motor skills

when postural constraints are applied compared to children who are NW. Here, a sample of

250 children aged 5-12.8 years from Belgium performed a peg-placing activity under two

postural conditions. They completed the activity in both sitting and standing in tandem stance

on a balance beam. Children who were OW or OB had significantly less peg-placing scores

when standing tandem on the balance beam. The increased postural demand of this activity

seemed to affect their fine motor performance significantly when compared to children who

were NW. Furthermore, this study showed that as BMI status increased performance

decreased, so children who were OB had significantly less scores than even the children who

were OW.

McGraw et al. (2000)51

examined gait and postural stability in boys aged 8-10 years,

comparing 10 boys who were not OB, between the 15th

and 90th

percentile, and 10 boys who

were OB, above the 95th

percentile. To assess gait, boys were required to walk 30 meters at

normal, slow, and fast cadences. The postural stability portion consisted of standing in

“normal” stance and tandem stance under “full vision”, “dark”, and “visual conflict”

conditions. The visual conflict condition used a domed headpiece encircling the head. A

PEAK Motus Video Analysis System was used to analyze gait and a Kistler measurement

25

platform was used to analyze postural stability. Results showed that boys who were OB spent

significantly more time in dual stance during gait. They also showed significantly greater

sway, energy, and variability in postural stability when compared to boys who were not OB.

These findings suggest that boys who are OB have more difficulty with postural stability, or

balance. This relates to the current study in that the activities performed during PE class may

have called for increased gait or balance demands on the children, which could have affected

their step counts. If children who are OW or OB have more difficulty in these areas, they will

present with less step counts and less participation in PE.

In addition, the cardiovascular issues that are associated with childhood obesity could

explain the differences in the number of steps taken between NW and OW/OB groups. A

study by Drinkard et al. (2001)52

determined there is a strong correlation between BMI and

distance completed on the 12-minute walk/run test (a cardiorespiratory fitness test) in a group

of 18 female adolescents who are OB (r = 0.82). Evidence also supports the fact that

functional and cardiovascular fitness declines due to the excess body fat the individual has to

transport.53,54

From a physiological standpoint, young children who are OB or at risk of

becoming OB commonly present with larger, thicker hearts.54

The increased heart mass,

particularly of the left ventricle, adversely affects the heart’s efficiency to pump blood

throughout the body, causing the myocardium to fatigue more quickly in an individual who is

OB.54

There is a decrease in systolic and diastolic function, which may be related to both

severity and duration of excess adipose tissue.54

The additional body fat and the negative

physiological changes of the heart could have undesirably altered the ability for the children

who are OW and OB to tolerate some of the PE activities, especially those that tested

cardiovascular fitness like running and jump-rope.

26

In the present study, when separating the sample by grade level, results were only

significant for second graders when comparing the number of steps taken between the NW

group and a combined group of OW and OB categories. To clarify, within each grade level

the average numbers of steps were compared between the group of children who were NW

and the group of children who were OW or OB. This result could be explained by the

number of children in the second grade class being one of the highest number compared to

other grade levels (n = 22). The kindergarten, first, and third grades only had 22, 18, and 20

students, respectively. The second grade had 14 children who were NW and 8 who were OW

or OB. The lack of statistical significance for the other grades could be explained by the

small sizes. Although these results were statistically insignificant, this data does hold some

clinical relevance. In each grade, we observed a trend that suggested that children who were

NW still had higher numbers of steps than their counterparts who were OW or OB.

The present study noted that the correlation between the average number of steps and

BMI within the entire sample was -0.326. These findings are consistent with previous

studies. Other cross-sectional studies have determined that the correlation coefficients

between PA and measures of obesity are less than 0.30.55,56

A study by Eisenmann et al.

(2007)37

revealed that when correlating BMI and pedometer values of 608 U.S. boys and

girls with a mean age of 9.6 years (25-30% of them were OW or OB), the partial correlation

was 0.22 in boys and 0.25 in girls. Despite the low correlation, the researchers analyzed the

boy and girl samples together and determined that the children who were not meeting the

daily pedometer guidelines were twice as likely to be classified as OW or OB compared to

those meeting the recommendations for PA. Another study57

looked at the relationship

between BMI and activity level of 126 kindergarteners and third graders in Hawaiian

27

schools. In this study, PA was measured by the score produced from the Physical Activity

Questionnaire for Children (PAQ-C). PAQ-C is a self-administered seven-day recall measure

that assesses general PA levels during the school year for children. It was determined that

there was an exceptionally low correlation of 0.008 between PA and BMI. Other correlations

were analyzed only to show that regardless of grade level or gender, there was no

relationship between level of PA and BMI.

Conversely, results from other studies show stronger correlations. The systematic

review issued by Prentice-Dunn and Prentice-Dunn (2011)34

found five strong negative

correlations between overall PA and childhood obesity. This same article also did state that

the results they found in their literature review concerning this correlation were mixed.

Additionally, VanZant and Toney (2012)58

looked to determine the association of these

variables in 267 sixth-grade children aged ≥ 11 years. Using a Spearman rank-order

correlation, they identified a significant strong negative correlation between BMI and PA

perceptions for all children, putting children with increased BMI at risk for sedentary

behavior.

Several factors could have potentially influenced our results. One factor may be the

differences in the children’s psychological and behavioral variables.18,59,60

Some students

naturally exhibited more active behaviors while others appeared to have sedentary habits and

had decreased participation in PE class activities. An article by Fakhouri et al. (2010)61

explored the trends of PA and of the sedentary behavior of screen-time viewing in

elementary school-aged children. This study found that less than 4 in 10 children met both

PA and screen-time recommendations synchronously. Sedentary behavior was found to be

higher in older children ages 9-11 years compared to those aged 6-8 years, however. A

28

systematic review59

looked at several correlates of PA in children aged 4-12 years and

revealed that most studies looking at children with an intention to be physically active and

those who preferred PA had a positive association with PA. In other words, these children

were more physically active than those who had no intention to be active. Most other

psychological, behavioral, social, and environmental variables assessed in the systematic

review had unclear relations. Children who are NW may already have a positive association

with PA, so they participate more actively. If children who are OW or OB attribute PA to

feelings of inadequacy, negative self-efficacy, or even pain, this may account for decreased

step counts.

Another factor to consider is the children’s interest in PE class and the activities that

they performed in PE. There were a variety of activities completed in PE during the time of

data collection which may or may not have interested the students involved in the study.

Analyses in an article by Zhang (2009)62

signified that self-determined motivation to

participate in activity was positively associated with middle school-aged students’

enjoyment, perceived effort, and level of PA. Lack of motivation had a negative effect on all

of the variables.

The third factor to consider is the variability in the amount of PA during each PE

class time. In order to minimize the variability in the amount of time the children spent

listening to directions versus active play, the results were reviewed within each grade.

Unexpectedly, each grade tended to participate in similar PE activities. Therefore, the

instruction time and active play periods were consistently similar within the grade levels.

Limitations

29

The steps tracked during the PE class reflect the activity the children performed on

that day. If all grades performed the same activity on the same day then the step number

could be attributed to the child’s performance for that activity. However, some grades

performed different activities on the same day, so this must be considered when analyzing

the results from the entire sample. This was controlled for by using data for at least 10

sessions and also analyzing step counts within each grade to try and verify that those children

performed the same activities on those days.

Additionally, the number of children in each BMI category was not equally

distributed within the grade levels. The variability adds more inconsistency to the study. Not

only was the BMI distribution imbalanced, but the overall sample size was too small to

analyze trends between PA and BMI within each grade level. This may be the reason behind

the insignificant results for kindergarten, first grade, and third grade classes.

To improve the study’s consistency, the pedometers were placed on the waistband of

the child’s pants. However, over time it was realized that some children wore clothing that

prevented proper placement or allowed the pedometer to fall off. Some children also felt the

pedometer was uncomfortable in this location. In these instances, the pedometers were placed

on the pants pockets. This may have swayed the actual step count, as well. Another variable

taken into account was when a pedometer fell off. Depending on the activity and placement

of the pedometer, some pedometers would fall off the children’s waists. The times the

pedometers fell off were recorded. All of these variables were attempted to be controlled for

by removing outliers within the step counts.

Although the number of steps recorded was used to determine the amount of PA, it

cannot measure quality of PA. The activities performed in PE varied considerably, and the

30

pedometers measure the number of steps taken, not core exercises or upper extremity

strengthening. However, core and upper extremity exercises may be useful in increasing

heart rate for weight loss.63

Using the body’s own weight will also help build strength and

endurance. The PE instructor often trained the children in activities like push-ups, arm

circles, and other upper extremity work. These exercises are important aspects of the PE class

that the pedometers cannot detect.

Clinical Relevance

Targeting the childhood obesity epidemic is an important health priority. Initiatives

related to health-and-wellness-promotion interventions to reduce the risk of obesity for all

children fall within the scope of practice for physical therapists. The school setting is the

most logical site for primary prevention interventions because of the considerable amount of

time spent by children and the access to resources. Much research has focused on school-

based health promotion programs for promoting PA, but few have targeted obesity

prevention. This provides an important area for physical therapists to be involved. The results

of this study point to the need for educators and health professionals to design innovative and

appropriate physical activities that can engage children in all BMI categories to the same

extent. As the data suggest that young children who are OW or OB have decreased steps

compared to their peers in structured PE classes, physical therapists could be involved in

maximizing PA levels for these groups during structured activities. PE classes offer an

important advantage in that all children spend equal time doing PA. How this time is used

effectively to engage all children equally remains a challenge as well as an important

opportunity for health professionals. Apart from school-based programs, physical therapists

31

could provide support at the family and community level through activities that involve after-

school programs or weekend programs. Developing activities to be performed outside of

school, such as at home, and finding ways to increase PA during the normal daily routine at

school may be other avenues that need to be explored. Also, health screenings and

presentations related to physical fitness at school events such as parent teacher meetings

could be conducted. With most children not meeting the recommendations for PA, working

synergistically with schools, parents, community organizations, and public health officials on

various initiatives, physical therapists can be instrumental in influencing the young children’s

physical fitness.

Future research

Currently, there are no guidelines for the use of pedometers in PE classes, but if step

counts can quantify the amount of activity children are actually getting in class it may help

assist meeting the PA recommended guidelines. Parents, caregivers, and educators can

monitor children’s activities and adjust activities accordingly. Future research should also

focus on identifying the barriers for participation in PE by children in the OW and OB

categories. Also, studies with longitudinal designs can provide concrete data regarding the

level of PA in young children.

Conclusion

The results of this study suggest that there may be differences in the amount of PA

during PE classes in different BMI categories in young children (≤ 9 years). There is a weak

correlation between children’s average number of steps taken in PE classes and their BMIs.

32

However, these results should be considered in order to establish appropriate activities for

children from all BMI categories to promote improved health and wellness in an effort to

prevent childhood obesity.

33

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40

TABLES

Table 1: Participant demographics.

Mean (SD)

n = number of participants

F = female

M = male

BMI = body mass index

Non-Overweight

(NW)

< 85th

percentile

Overweight

(OW)

≥ 85th

percentile

< 95th

percentile

Obese

(OB)

≥ 95th

percentile

Age (years)

Total: 7.55 (1.22), n = 82 7.60 (1.23); n = 45 7.53 (1.06); n = 12 7.46 (1.27); n = 25

Kindergarten, n = 22 6.03 (0.32); n = 11 6.26 (0.21); n = 3 6.04 (0.30); n = 8

1st Grade, n = 18 7.04 (0.35); n = 10 6.91 (0.31); n = 3 6.88 (0.36); n = 5

2nd

Grade, n = 22 8.17 (0.49); n = 14 8.15 (0.20); n = 4 8.12 (0.55); n = 4

3rd

Grade, n = 20 9.09 (0.76); n = 10 9.15 (0.24); n = 2 8.91 (0.39); n = 8

Gender F(M)

Total: 37(45) 20(25) 6(6) 11(14)

Kindergarten 5(6) 1(2) 3(5)

1st Grade 4(6) 2(1) 3(2)

2nd

Grade 7(7) 2(2) 2(2)

3rd

Grade 4(6) 1(1) 3(5)

BMI (kg/m²)

Total: 18.69 (3.81), n = 82 15.93 (1.39) 19.18 (0.88) 22.79 (3.50)

Kindergarten 15.55 (0.97) 19.4 (1.13) 19.71 (0.86)

1st Grade 15.02 (1.44) 18.33 (0.09) 21.82 (2.34)

2nd

Grade 16.41 (1.40) 19.25 (0.64) 21.5 (0.93)

3rd

Grade 16.57 (1.36) 20.00 (0.20) 25.84 (3.67)

41

Table 2: Average step counts among groups within entire sample.

NW = non-overweight

OW = overweight

OB = obese

*Significant differences at P < 0.05

NW Group

(n = 45)

OW Group

(n = 12)

OB Group

(n = 25)

F-Value P-Value

(Alpha level = .05)

Mean (SD) Mean (SD) Mean (SD)

977.14 (146.85) 857.70 (139.97) 887.36 (113.07) 5.58 .005*

42

Table 3: Results of Bonferroni’s post hoc test (comparisons among groups for average

step counts)

NW = non-overweight

OW = overweight

OB = obese

*Significant differences at P < 0.05

Variables Mean

Difference

Std.

Error

Sig. 95% Confidence

Interval

Lower Upper

NW vs. OW 119.44064 44.33623 .026* 10.9931 227.8882

NW vs. OB 89.77393 34.04011 .030* 6.5110 173.0369

OW vs. OB -29.66671 47.92460 1.000 -146.8915 87.5581

43

Table 4: Average step counts among groups within each grade level

Mean (SD)

NW = non-overweight

OW = overweight

OB = obese

*Significant differences at P < 0.05

Grade Level NW Group

OW/OB Group

P-Value

(Alpha level = .05)

Kindergarten 1019.10 (192.26) 878.13 (135.47) .061

1st Grade 982.49 (101.64) 937.19 (148.37) .453

2nd

Grade 943.14 (125.29) 836.81 (81.09) .044*

3rd

Grade 973.22 (165.39) 862.50 (106.35) .092

44

APPENDIX

Appendix A: Informed consent form.

INFORMED CONSENT FORM

To: __________________________________________________________

You are being asked to permit______________________ to participate in a research project

entitled: Level of physical activity during physical education classes in young children

This research is being conducted by:

Neeti Pathare (Advisor, Primary Investigator)

Assistant Professor, Physical Therapy

518-244-3127

pathan@sage.edu

Marjane Selleck (Primary Investigator)

sellem@sage.edu

Esther Haskvitz (Primary Investigator)

haskve@sage.edu

Andrea Nicosia (Student Investigator)

nicosa@sage.edu

Kelly Piché (Student Investigator)

pichek@sage.edu

Regular physical activity is considered to be important for child development and health. We

are conducting a study which includes all children in kindergarten to 3rd

grade in your child’s

school. This study will look at physical activity during physical education classes in young

children. Additionally, we shall look at the link between body mass index and physical

activity during physical education classes. Body mass index is calculated from the child’s

weight and height.

Your child will participate in their typical physical education classes conducted by their

physical education instructor. All children regardless of the participation in the study will

wear a pedometer during the physical education class. A pedometer is a small machine which

calculates the number of steps taken and allows to measure physical activity. If your child

participates in the study, at the end of the physical education class the number of steps on the

pedometer will be noted. Additionally, in a separate session we shall measure your child’s

45

height and weight. This session will be about 10 minutes long and will take place during the

school day or after school at your child’s school.

Every effort will be made by the researcher to protect your child’s confidentiality. Your child

will be assigned a code name or number that will be used on all researcher notes and

documents. Notes, data records and any other identifying participant information will be kept

in a locked file cabinet. When no longer necessary for research, all materials will be

destroyed. Information from this research will be used solely for educational and scientific

purposes. In any scientific work data will be reported in aggregate. No information that

would allow the subjects to be identified will be used in the dissemination of this project.

This will include any personally identifiable information and the name or location school.

There will be no direct benefit to your child for participating in this study. However,

information obtained from the pedometers may indicate the activity level of your child in a

typical physical education class. We hope that the information obtained from this study may

lead to future use of the pedometer as a reliable and valid tool in assessing the physical

activity in overweight and non-overweight children.

The risks of this study are minimal. There are no additional safety risks beyond the risks that

occur in a regular physical education class. Apart from the physical risks, we realize that

measurement of weight is a sensitive issue. This will be minimized by using utmost care to

use appropriate language while collecting data by student physical therapists and researchers.

Digital photographs and recordings will be taken during the testing session and will be used

by the researchers for data analysis and for educational use by the Sage Graduate School

Physical Therapy Department in classroom instruction and professional presentations.

During any educational or professional presentation the subject’s identity, including facial

recognition will not be revealed without consent. All videotapes will be securely stored in a

locked cabinet and will be appropriately destroyed at the end of the study unless permission

has been granted for use in the classroom and/or professional presentations.

I give permission to the researcher to play the audio or videotape of ______________ in the

places described above. Put your initials here to indicate your permission. ________

In the event that the person for whom I am consenting is harmed by participation in this

study, I understand that compensation and/or medical treatment is not available from The

Sage Colleges. However, compensation and/or medical costs might be recovered by legal

action.

Participation is voluntary, I understand that I may at any time during the course of this study

revoke my consent and withdraw _________________ from the study without any penalty.

I have been given an opportunity to read and keep a copy of this Agreement and to ask

questions concerning the study. Any such questions have been answered to my full and

complete satisfaction.

46

I, _________________________________________, having full capacity to consent, do

hereby give permission for __________________________________to participate in this

research study.

Signed: ____________________________________________ Date: _______________

Parent or Legal Guardian

If you consent to participate in this study with your child we will ask your child if he/she is

willing to participate. The following statement will be read to your child: “Today we are

going to check your height and weight, and/or today we are going to place these pedometers

on you during your gym class. Are you willing to do these activities with us today? Please

answer ‘YES’ or ‘NO’. We may also want to take pictures/videos while you do these

activities. Will this be okay with you today? Please answer ‘YES’ or ‘NO’.”

This research has received the approval of The Sage Colleges Institutional Review Board,

which functions to insure the protection of the rights of human participants. If you, as a

participant, have any complaints about this study, please contact:

Dr. Esther Haskvitz, Dean

Sage Graduate Schools

School of Health Sciences

65 First Street

Troy, New York 12180

518-244-2264

haskve@sage.edu

47

IRB APPROVAL LETTER