International Journal of Obesity (2010) 34, 1134–1142
& 2010 Macmillan Publishers Limited All rights reserved 0307-0565/10
www.nature.com/ijo
PEDIATRIC HIGHLIGHT
Can Elvis Pretzley and the Fitwits improve knowledge
of obesity, nutrition, exercise, and portions in fifth
graders?
A McGaffey1, K Hughes2, SK Fidler3, FJ D’Amico4,5 and MN Stalter1
1
UPMC St Margaret Family Medicine Residency Program, University of Pittsburgh Medical Center, Pittsburgh, PA, USA;
Carnegie Mellon University School of Design, Pittsburgh, PA, USA; 3Primary Care Sports Medicine Fellowship Program,
Thomas Jefferson University Hospital, Philadelphia, PA, USA; 4Department of Mathematics and Computer Science,
Duquesne University, Pittsburgh, PA, USA and 5Department of Family Medicine, Faculty Development Fellowship Program,
University of Pittsburgh, Pittsburgh, PA, USA
2
Objective: To determine the effectiveness of an educational intervention, created with a human-centered design approach, on
children’s knowledge and beliefs related to obesity and nutrition.
Design: Pre–post intervention: we evaluated fifth graders (aged 9–12) from five urban schools using a survey instrument
at 1 week before intervention, immediately after intervention, and 1 week later after intervention.
Subjects: Of 189 fifth graders enrolled in the schools, 165 consented students (87.3%) completed baseline data. We obtained
immediate post-intervention data from 94% of them and 1-week post-intervention data from 88%.
Results: Of the 14 instrument questions that covered items under obesity, disease, nutrition, portion sizes, and exercise,
11 showed significant improvements in the percentage of correct answers. The children’s knowledge in specific areas, including
the meaning of the term ‘obesity’ and portion sizes, increased dramatically. Participatory design, child-inspired characters, handbased portions, traditional games, and attention to reception by the students resulted in an engaging presentation.
Conclusion: Simplified health vocabulary and multiple modes of presentation resulted in accessible and understandable health
education regarding obesity, nutrition, exercise, and portion size. This study yields compelling evidence that the Fitwits tools are
an effective method to promote knowledge about obesity. Future studies are needed to determine whether this knowledge can
affect health outcomes.
International Journal of Obesity (2010) 34, 1134–1142; doi:10.1038/ijo.2010.58; published online 30 March 2010
Keywords: childhood obesity; public health; human-centered design; games; health literacy
Introduction
Unhealthy lifestyles and attendant childhood obesity
are increasingly prevalent in the United States. About 16%
of US children and adolescents have a body mass index
at or above the 95th percentile.1 The youth obesity rate
has more than tripled since the 1980s, disproportionately
so for some minority groups.2–4 Accelerating health and
psychosocial problems for youth have created a sense
Correspondence: Dr A McGaffey, UPMC St Margaret Family Medicine
Residency Program, UPMC St Margaret Bloomfield Garfield Family Health
Center, University of Pittsburgh Medical Center, 5475 Penn Avenue,
Pittsburgh, PA 15206, USA.
E-mail: [email protected]
Received 4 August 2009; revised 13 February 2010; accepted 14 February
2010; published online 30 March 2010
of urgency regarding this problem.5,6 Multiple organizations
have called for effective health messages and policy
changes in schools and communities and physician
leadership.3,6–12
Nearly all children are accessible in school for health
education, making schools an ideal setting for community
interventions. Stringent academic mandates, shrinking
budgets, negative nutritional role modeling (food services,
vending machines), and reduced time for physical education, though, have thwarted efforts to provide health
education in schools.12–20 Federal legislation has recently
imposed enhanced expectations for wellness policies, but
these policies often omit easily understood nutrition education for students that is also portable to the home
environment.21,22 Schools need effective tools to educate
children and families about obesity, food choices, and
exercise.
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A McGaffey et al
1135
To curb childhood obesity, the American Heart Association
(AHA) endorses a broad, population-based educational
approach. Interventions should be relevant and motivating
to children; recognize school, family, peer, and cultural
influences; and provide a longitudinal ‘dose.’6 Our team of
designers, physicians, registered dietitians, and children
co-created a curriculum complemented by traditional games,
which conforms to these recommendations.23 Fitwits
School, the object of this study, is a 1-h classroom program
designed to inform fifth grade students about obesity and its
adverse effects and to enhance self-management skills for
students and their families. This is the first phase of three
interdependent Fitwits programs in schools, physician
offices, and with parents/caregivers.
We decided to target this curriculum for fifth graders in
anticipation of pubertal growth changes, increasing independence in decision making, and the prevalence of energydense foods and beverages in higher grade levels.3,5,17,18,24
Our primary study objective was to collect quantitative
information regarding students’ knowledge and retention of
health-related concepts from the Fitwits School program;
secondarily, we also collected limited qualitative data
regarding children’s perceptions of this program.
Materials and methods
Setting
The program evaluation took place in fifth grade classrooms
in five urban schools in a family medicine residency school
health partnership. The fifth graders enrolled in these
schools live in low-to-mid socioeconomic urban families;
77% qualify for free lunch and 7% qualify for reduced-price
lunch. The majority of students are African American (76%).
The remaining ethnicity is white (14%) or other (10%).
Subjects
We sent Institutional Review Board-approved informed
consent forms and an explanatory cover sheet about the
Fitwits program to the parents of 189 fifth grade students. All
classroom children participated in the classroom presentation, but we administered questionnaires only to children
whose parents consented. The Carnegie Mellon University
Institutional Review Board and the Pittsburgh Public Schools
Internal Review Board approved all study procedures.
Development of the intervention
The Fitwits design team created and refined the school
program using design research methods. Design is a
discipline grounded in process that helps diverse stakeholders recognize and frame complex problems.25,26 Formative research was conducted in 2007 with a team of
designers in collaboration with members of the Children’s
Hospital of Pittsburgh Weight Management and Wellness
Center. Shadowing of participants and interviews with
parents, children, and the center’s experts helped us draw
out distinct contributors to the obesity epidemic, including
misconceptions, lack of understanding, and beliefs and
behaviors surrounding health education. From the pool of
potential problems, we determined to primarily focus on
portion control. We also felt it was important to address
another obstacle, namely, language and terms that are
unfamiliar to children and their families.23
Participatory design involves cyclical idea generation and
feedback cycles with the audience involved as co-designers.25,26 Part of this participatory design process is
exploratory research followed by the making of tools
(generative) that take into account the interests, ideas, and
cultural needs of the audienceFin this case, children living
in a low-to-mid socioeconomic urban area of Pittsburgh,
Pennsylvania. Many of our Fitwits generative tools involve
memory devices embedded in games that house key
informational facts about nutrition. During tool development with focus groups, we observed that repeated interaction with these games enabled and motivated children to
want to improve their health knowledge.23
The Fitwits School program is centered on the Fitwits and
Nitwits personas, 34 engaging food- and snack-based cartoon
characters created by health partnership children during the
design/make phase in 2007–2008 (Figure 1, top).23 The
Fitwits epitomize healthy foods and desirable lifestyle
choices, including physical activities and active hobbies;
the Nitwits typify unhealthy food choices and undesirable
lifestyle decisions. ‘Character cards’ are illustrated with a
Fitwit or Nitwit and present simple fat and sugar scales and
easily understood Fitwits ratings. Some cards include a
simple recipe that reinforces use of the hand guide to
measure portion sizes (Figure 1, bottom). Children assigned
character names, such as Elvis Pretzley, Mac and Tasha,
Queen of Wheat, Sunny Yolk, Fry Girls, Mr Leather, Biggie
Allbeef, Barfenstein, and The Belchers. Additional illustrations of the cards and game play are available at http://
www.fitwits.org.
An early childhood education expert assessed the cards and
games as appropriate for the target fifth grade audience. After 6
months of refinement, the team pilot tested the Fitwits School
curriculum in May 2008. Family medicine physicians and
designers taught the 1-h program to 99 fifth graders with
parental consent in five partnership schools. This program
began with active movement to marching music, focused on
the definition and health effects of obesity and on recommended nutrition, exercise, and portions concepts, and
included demonstrations and game play. Our survey consisted
of general questions about healthy foods, snacks, and beverage
choices and food consumption behaviors. Recorded observations by designers, physicians, and teachers commented on
the flow of the session, student and teacher engagement, and
incidents of confusion regarding content delivery.
On the basis of this feedback and the non-significant
results of the general nutrition surveys, we revised several
elements. To stir student interest at the outset, we replaced
International Journal of Obesity
Fitwits: obesity, nutrition, exercise, portions
A McGaffey et al
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Figure 1 Fitwits and Nitwits characters were created and named by children from Pittsburgh, Pennsylvania (top). Each character card features a Fitwit or Nitwit
character, a simple fat and sugar scale, and Fitwit rating, and some cards include a recipe that reinforces the hand guide to portion size (bottom).
the marching music and asked everyone to dance to
age-appropriate popular music. The dancing both reinforced
content and broke down any perceived social barriers the
fifth graders might feel toward the presenters. We simplified
the health vocabulary and added more opportunities for
visual and hands-on learning. Newly designed 1-min multimedia videos with the Fitwits and Nitwits characters highlighted concepts and allowed the presenters to transition to
other activities. We added an instructional flipbook with
explanations and information for parents. The team realigned the learning objectives and student surveys to reflect
the exact program contents.
Study design
We used a prospective study design measuring fifth graders’
knowledge 1 week before the intervention (baseline), the day
International Journal of Obesity
of the intervention (Post 1), and 1 week after intervention
(Post 2). We administered a 14-item multiple-choice test at
all three points in time. Secondarily, we collected qualitative
data, either on the day of the intervention or within 1 week,
from an open-ended letter asking students to share their
remarks about the program. As the original objective of this
component was simply to examine the children’s comments,
there was no pre-defined fixed coding scheme. Three
investigators (AM, KH, SF) independently reviewed the
remarks and grouped them into general categories.
Procedure
We distributed paper copies of 14 multiple-choice questions.
One parent visited all five schools and read aloud each
question (Table 1) and the four possible answers; each
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Table 1
Area
Frequency distribution of responses to Fitwits questions pre-intervention (the correct choice for each question is in italics)
(Question)
Response choices
Freq (%)
A healthy body weight
Too much weight for height
Growth problems that only affect adults
A weight problem that cannot be helped
27
58
16
64
(16%)
(35%)
(10%)
(39%)
Good for getting on the ice skating team
Good for looking more grown-up
A cause of health problems
Okay because it will improve as a grown-up
5
10
119
31
(3%)
(6%)
(72%)
(19%)
Dizziness
Diarrhea
Diabetes
Dry skin
20
17
118
10
(12%)
(10%)
(72%)
(6%)
Hearing loss
Heart disease
Faster healing
Head colds
8
128
10
19
(5%)
(78%)
(6%)
(12%)
Water
Juice
Soda-pop
Biggie-sized soda-pop
161
1
1
1
(98%)
(0.5%)
(0.5%)
(0.5%)
47
35
37
45
(29%)
(21%)
(23%)
(27%)
Fried
Baked
Steamed
Natural
139
15
9
2
(84%)
(9%)
(6%)
(1%)
How hungry you are
How big your hands are
How large your plate is
How much the package says is one serving
39
5
6
114
(24%)
(3%)
(4%)
(70%)
Fist
2 fingers
3 fingers
Palm
55
15
23
72
(33%)
(9%)
(14%)
(44%)
2 cupped hands
2 fingers
3 fingers
Palm
25
54
27
59
(15%)
(33%)
(16%)
(36%)
Fist
2 fingers
3 fingers
Palm
70
14
12
68
(43%)
(9%)
(7%)
(42%)
Fist
2 fingers
Palm
2 cupped hands
29
83
38
15
(18%)
(50%)
(23%)
(9%)
Obesity
What does obesity mean?
Childhood obesity isy
Disease
If you are obese it could lead to problems such asy
If you are obese it could lead to problems such asy
Nutrition
You should drink morey
How many servings of fruit are in an average fruit roll-up?
0
1
2
3 or more
Which of the following foods contain the most fat?
Portion
How much pasta is wise for you to eat depends ony
Your portion of meat should be the size of youry
Your portion of French fries should be the size of youry
Your portion of veggies should be the size of youry
Your portion of cheese should be the size of youry
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Table 1 (continued)
Area
(Question)
Response choices
Freq (%)
1 thumb-tip
2 fingers
1 thumb
Palm
22
43
78
21
(13%)
(26%)
(48%)
(13%)
20 min a day being active
60 min a day being active
15 min a day being active
30 min a day being active
18
89
15
43
(11%)
(54%)
(9%)
(26%)
Your portion of ketchup should be the size of youry
Exercise
You should spend abouty
student then selected his/her answer. To minimize potential
memory bias, the 14 questions at time Post 1 were reversed and
the order for the answers within each question was randomized. We included two questions on obesity, two on obesityassociated disease, three on nutrition, six on portion sizes, and
one question on exercise. Experienced fifth grade teachers and
an elementary school principal approved the survey content,
vocabulary, reading level, and multiple-choice format.
Presentation of the intervention
The finalized Fitwits School Program presented in October
2008 consisted of four parts: (1) the introduction began
with 2 min of vigorous dancing to popular music; (2) a
20-min didactic presentation included health topics on energy
balance, a simple definition of obesity, recognition of
unhealthy foods, physical activity recommendations, and
portion size instruction using the students’ own hands.
Children were also taught about obesity-associated diabetes,
heart disease with a dilated, fat-encased heart versus a
healthy heart image, and high blood pressure. Two instructive ‘commercial breaks,’ featuring the Fitwits and Nitwits
characters, emphasized portion size and contrasted the
impact of soda versus water; (3) a 10-min hands-on
demonstration segment included identification of fat- and
sugar-laden foods and use of hands and clay modeling to
define personal portion sizes; and (4) during the game play,
groups of students played the trivia and memory games for
about 30 min to reinforce prior messages. The hand portion
guide, in particular, was reinforced by the Fitwits didactic
presentation, a portions commercial break, hands-on activities, the memory game, and trivia cards.
At the conclusion of the program, all students received a
Fitwits package to take home to their families. This package
included the Fitwits and Nitwits character cards, the trivia
and memory games, and a brief booklet with the main
health and portion size concepts. Students were asked to
share the contents, try the recipes, and play the games
with their parents. Three investigators (AM, KH, SF)
jointly conducted these Fitwits School sessions. Together
with teachers and a school administrator, the investigators
International Journal of Obesity
observed the dance participation, the reaction to messages
found in the didactics, commercial breaks, hands-on
demonstrations and games, and the overall engagement.
Evaluation
The main outcome measure was the number (percent) of
correct responses to each question on the knowledge test. From
preliminary testing, 14 questions met the objectives of the
program. We examined each question’s responses independently; we did not intend to create a composite score by
summing any or all of the questions’ responses. For simplicity,
the questions were organized into five groupings (Table 1).
Statistical analysis
Initially, we used basic descriptive statistics (means, medians,
and frequency distributions) to describe the demographic
characteristics and the baseline data. We either used
parametric or non-parametric statistical tests to compare
the gender and age distributions between the schools. As the
results of these tests showed no significant differences
between the schools, results from all schools were combined.
Each of the 14 questions was modeled separately where each
participant had repeated measurements at three time points.
We used generalized estimating equations to make inferences about the population rates and also to estimate the
odds of a correct answer from Post 1 to baseline and also
from Post 2 to baseline. We present 95% confidence intervals
to show the precision of the odds ratios. P-values cited were
obtained from the regressions and no adjustment was made
for multiple comparisons. We performed statistical analyses
using SAS software.
Results
A large proportion (87.3%) of 189 fifth graders enrolled in
the five schools returned consents and comprise the study
group. The 165 consented students completed the baseline
survey with class sizes ranging from 29 to 44 students. We
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A McGaffey et al
1139
had high follow-up completion rates. Most of the students
were either 10 years (59%) or 11 years of age (33%), with the
remaining few being either 9 years or 12 years. Gender
distribution was fairly even, 46% female and 54% male.
There were no significant differences in the ages or gender
mix among the schools. Data from all of the schools were
combined for further analyses.
Table 1 shows the baseline results for the 14 questions
grouped by pertinent topics. Correct answers for each of
the questions are in italics. Before the intervention, most of
the students did not know how to define obesity, although
about three-quarters knew that obesity can cause health
problems, specifically diabetes and heart disease. Leading
misperceptions included obesity as a problem beyond help,
the expectation that childhood obesity would improve
with maturity, and that the average fruit roll-up contains
fruit, in accord with misleading packaging. Almost all of the
students knew that it was preferable to drink water instead
of sweetened beverages and that fried foods are high in fat.
Regarding portion sizes, there were low numbers of correct
answers for all six questions. Just over half correctly
answered concerning daily exercise recommendations.
The percentages of correct responses to each of the
questions at each time point are shown in Table 2. Of the
14 questions, 11 questions show highly significant (Po0.01)
increases in the percentage of correct responses at either one
or both follow-up time points compared with the baseline.
For the three questions that did not show a statistically
significant increase, the majority of students had already
correctly answered them pre-intervention.
Table 2
Area
Students were more aware of the sugar content of products
after the demonstrations, including knowing that 13
teaspoons of sugar are in a 12 oz can of regular soda pop.
The students tripled the correct answer to the question about
the amount of fruit in a fruit roll-up in the Post 1 (88%) and
Post 2 (87%) surveys.
For the 11 questions that showed significant improvements in the follow-up time points, all of the changes are
large enough to be considered clinically relevant (Table 2).
For example, at baseline, 35% knew that obesity was ‘too
much weight for height’ and after the intervention, students
were 5.2 times and 6.0 times more likely to get that question
correct (as illustrated from the odds ratios comparing Post 1
and Post 2 to Pre, respectively). Measures of knowledge on
nearly all survey questions increased by a statistically
significant margin. Whether large or small, the odds ratios
further illustrate the magnitude of the effect the Fitwits
program had in improving knowledge in certain areas.
Of the 165 children in the study, 107 (65%) returned a
thank you note with individual remarks. In these notes, the
children mentioned many specific elements of the program.
The fifth graders were appreciative of the focus on knowing
what and how much to eat and the derivative health
benefits. The overall fun experienced by the students was
evident. Many children also expressed a desire for the Fitwits
team to return to their school (Table 3).
Teachers, a school administrator, and the investigators
(AM, KH, SF) observed reactions to elements in the
presentation and the general flow. Students and school
personnel exhibited interest and acceptance during
Percentage of students correctly answering the Fitwits School survey questions by time
Pre
(n ¼ 165)
Post 1
(n ¼ 155)
Post 2
(n ¼ 145)
ORa (95% CI)
(Post 1 to Pre)
ORb (95% CI)
(Post 2 to Pre)
What does obesity mean?
Childhood obesity isy
35%
72%
74%*
78%
77%**
86%**
5.2 (3.2, 8.5)
1.4 (0.8, 2.3)
6.0 (3.6, 9.9)
2.3 (1.3, 4.1)
If you are obese, it could lead toy
If you are obese, it could lead toy
72%
78%
82%
94%*
80%
92%**
1.8 (1.0, 2.9)
4.2 (2.0, 8.7)
1.6 (0.9, 2.7)
3.2 (1.6, 6.4)
You should drink morey
How many servings of fruit are iny
Which of the following foods containy
98%
29%
84%
97%
88%*
88%
98%
87%**
83%
0.7 (0.2, 3.2)
17.7 (9.8, 31.8)
1.4 (0.7, 2.7)
0.9 (0.2, 4.4)
16.5 (9.2, 29.7)
0.9 (0.5, 1.6)
How
Your
Your
Your
Your
Your
3%
44%
16%
43%
50%
13%
74%*
79%*
80%*
73%*
86%*
81%*
68%**
75%**
72%**
56%**
75%**
83%**
90.6
4.9
21.0
3.6
5.9
26.6
66.3
3.8
13.2
1.7
3.0
32.5
75%*
79%**
(Question)
Obesity
Disease
Nutrition
Portion
much pasta is wise for you to eat?
portion of meat should bey
portion of French fries should bey
portion of veggies should bey
portion of cheese should bey
portion of ketchup should bey
(34.7, 200)
(3.0, 8.1)
(11.8, 37.2)
(2.3, 5.8)
(3.4, 10.2)
(14.6, 48.6)
(25.4, 172)
(2.3, 6.2)
(7.6, 22.8)
(1.1, 2.7)
(1.8, 4.8)
(17.4, 60)
Exercise
You should spend abouty
a
54%
2.5 (1.6, 4.1)
3.1 (1.9, 5.2)
b
OR, odds ratio, comparing the odds of correct answers from Post 1 to Pre. OR, odds ratio, comparing the odds of correct answers from Post 2 to Pre. *Indicates
Po0.01 comparing Post 1 to Pre, **indicates Po0.01 comparing Post 2 to Pre.
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Table 3
Letter instructions and Fitwits letter themes
Fitwits thank you letter format
Dear fifth grader,
What did you like about the Fitwits program? Take a minute to write
about it. (The videos, the Fitwits and Nitwits characters, the presentation,
the hands-on demonstrations, the games.)
When you are done please give the letter to your teacher. Thank you!
Dear Fitwits Team,
Most common themes from a total of 107 lettersa
Unprompted
The word ‘fun’ was mentioned 27 times
The word ‘health’ or ‘healthy’ was mentioned 21 times
A request to return for another session occurred 15 times
A reference to knowledge was made 30 times
Prompted
The games were mentioned 48 times
The videos/commercials were mentioned 27 times
The characters were referenced 23 times
The hands-on demonstrations were mentioned 18 times
a
More than one theme present in some letters.
discussion of energy balance, as the word ‘obesity’ was
defined, and during discussion of obesity-associated health
risks within the didactic segment. Students referenced their
own hands during the demonstrations and while playing the
memory game. The commercials (cartoon videos) particularly reinforced content and kept the fifth graders engaged in
the learning space.
Discussion
Knowledge-based curricula for obesity prevention in schools
have traditionally had disappointing results. Little change
has occurred in child nutritional habits despite increased
knowledge and awareness from curricula.27 Curricula with
added nutrition and physical activity features have shown
mixed results in the form of modest and transient changes in
excess weight or other outcomes; these are difficult to ascribe
to the intervention.27,28 Critiques of school programs note
many problem areas, but typically eschew abandonment of
the school avenue to help reverse childhood obesity.27–29
Programs with combinations of education, policy change,
improved dietary quality, and physical activity, and one
study with peer-led health promoters in elementary schools,
do show progress in achieving limited weight loss or
preventing the development of excess weight among
children.29–32
Some experts have suggested strategies to improve school
programs, including innovative thinking, enhanced research
funding, and a consensus on the most relevant weightrelated outcomes. More rigorous study designs that isolate
the effective aspects of multi-component interventions are
also needed, as are policy and environmental changes.27–29
Lytle encourages examination of ‘the ingredients’ role in
delivering change’ and the reception by students.28 Katz
International Journal of Obesity
suggests a large array and combination of strategies in
schools.29 Fitwits embodies many of these strategiesFan
innovative curriculum, instruction on improving dietary
intake and increased physical activity, hands-on skill building, print materials, tailoring for cultural relevance, focused
attention on the perceptions of the audience, and involvement of parents27–29Fand it successfully implemented these
strategies because of its participatory design approach.
Limiting intake of energy-dense foods and portion size are
two targeted behaviors with consistent evidence for prevention of childhood obesity.3,5,17,33 Clinicians have struggled
to make these recommendations understood by the lay
public.5 Uniform nutrition labels were introduced in the
United States in 1994, but their interpretation is not
intuitive for fat and sugar content nor how much to
eat.3,34,35 A food product’s serving size does not necessarily
correlate with USDA recommended portion sizes.3 Conventional portion size assessment tools for children include food
photographs (USDA MyPyramid Plan), food models, and
interactive computer-based systems with images of food.36,37
With these methods, however, estimations of portion sizes
by children and adults vary enormously.38 The design team
worked with fifth graders, registered dietitians, and physicians to address these problems. We printed simple fat and
sugar scales on the Fitwits and Nitwits cards, providing a
quick overview to limit energy-dense foods. We developed a
hand-based portion guide, a more successful method to
select correct portion sizes.39
We emphasized portion size throughout the design phase,
during the program, and within the survey. At baseline, our
students did relatively well posting correct responses for a
palm-size piece of meat and a fistful of vegetables, which are
familiar hand comparisons.36 After multiple program cues
and reinforcement of the hand guide throughout all aspects
of the program, our students showed marked improvements
in scores concerning the novel parts of the hand-based
portion guide. The Fitwits hand portion guide is pragmatic
and uses the familiar, accessible, and proportionate hands of
an individual to judge portion size at each meal. The homebound package gives families parallel information on the
hand portion guide, the Fitwits and Nitwits fat and sugar
scales, and recipes, which use hand portions.
Fitwits highlights the benefits of participatory design
methods to foster learning. The appeal of the Fitwits School
program reflects child-inspired characters and personas,
simplified health vocabulary and language, traditional
games, greatly varied learning modes and media, and a
hand-based portion guide for use in any setting. Sending
informative cards and games home is the longitudinal ‘dose’
element of Fitwits School concepts. Parents, family, and
friends have the opportunity to acquire a comparable
knowledge base that could contribute to sustained healthy
behaviors. This program responds to the AHA’s call for a
broad, population-based educational approach to childhood
obesity and meets a school and a physician need for a timeefficient, engaging presentation.5–7,9,11,13
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The students who attended the Fitwits School program
also enjoyed their experience (Table 3). The responses to the
letter introduction convey an abiding sense of fun, awakening interest in healthy behaviors, and an engagement with
the Fitwits and Nitwits personas. They appreciated the multimodal, hands-on learning structure of the class and the
hand-based portion guide. Their comments are likely a direct
result of co-creation with our learners, attention to visual
literacy, and careful crafting of ‘the ingredients’ in the
design-led interdisciplinary coalition.
Three other interesting findings of the Fitwits School
program deserve discussion. First, many of the children’s
incorrect answers reflect commonly held adult health beliefs
(Table 1). Pre-intervention, 39% thought the word ‘obesity’
indicated ‘a weight problem that cannot be helped’ and 19%
felt that obesity is ‘okay because it will improve as a grownup.’ The former suggests perception of obesity as an inherent
and insoluble problem. The view that children will outgrow
their ‘chubbiness’ is widely held, but established obesity
usually persists into adulthood.5,17 Two program aims are
to teach a definition of ‘obesity’ and to inform fifth graders
that obesity can be improved or prevented through food
selection, portion guidance, and physical activity. After
the program, students showed an improved understanding
of obesity.
Second, the Fitwits School program refuted commonly
held beliefs that children and families find the term ‘obese’
to be unnecessarily pejorative when applied to children.3,8
Health care providers often avoid use of the word ‘obese’ for
children, and organizations such as the Centers for Disease
Control and Prevention use the term ‘overweight’ instead.
Other organizations, though, including the Institute of
Medicine (2005) and an American Medical Association
Expert Panel (2007), strongly recommend the use of the
word ‘obesity’ to convey the serious health risks associated
with a body mass index at or above the 95th percentile.3,5,8
In our program, the word ‘obesity’ was projected in its health
context and was accepted by students and school personnel,
which bodes well for the nomenclatural change to ‘obese’ for
pediatric patients.
Third, the didactic portrayal of obesity-associated problems had an impact, particularly the comparison of healthy
and unhealthy hearts. In the post-test results, almost all
students recognized that obesity could lead to heart disease.
This is an important realization for the children, who may
not get this message at home. Many parents of this
generation do not recognize obesity in their children,
perceive the health risks, or express concern.40,41 The AHA
advises that increased obesity may reverse reductions in
cardiovascular disease risks made over the last half-century.6,7 Similarly, a high public perception of trends in
childhood obesity and type 2 diabetes is a necessary precondition for improvement in both conditions.3,5,8
Our study does have some important limitations. Fitwits
School took place with urban fifth graders in Pittsburgh,
Pennsylvania. The character cards reflect the ideas of urban
children and may not generalize to other populations. This
study expressly measures change in knowledge of specific
information in the program and neither predicts nor
measures behavior change. In this first step, we focused on
knowledge acquisition and retention and student engagement. We did not contrast Fitwits with usual nutrition
education, randomize schools, nor collect longitudinal body
mass index data for the learners. In our collection of student
remarks, it would have been wise to use the neutral prompt,
‘Tell us what you thought about the Fitwits program’ instead
of the potentially leading ‘What did you like about the
Fitwits program?’
Accessible and effective health education is a necessary
first step toward changing health behaviors. The Fitwits
School program provides a framework for understandable
and engaging health education for a spectrum of learners in
the fifth grade. Future expansions of Fitwits research include
assessment of knowledge retention at a longer interval,
program validation in other settings, and use of Fitwits in
combination with school policy, nutrition, and physical
activity interventions with measured health outcomes.
Teacher-led Fitwits classes are contemplated. Fitwits research
for physician offices and parent education are underway and,
when fully realized, will provide synergy to this health
conversation.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
This study is financially supported by The Heinz Endowments. On behalf of the Fitwits School Program, we gratefully acknowledge the contributions of Carnegie Mellon
University School of Design faculty and students; Goutham
Rao, MD, Megan McQuaide Montag RD, Lindsey Detwiler
RD, Joan Procopio RD LDN, Darija Neureuter Wiswell RD,
Emily Welsh MSW, Janet Yuhasz MEd, Amy Haugh MLS,
Paula Preisach, Margaret Gibson MD, Brenda Manning PhD,
Jennifer Middleton, MD MPH, Joel Merenstein, MD and the
Pittsburgh Public Schools Fort Pitt ALA, Woolslair, Pittsburgh
Montessori, and Arsenal Elementary and Urban League of
Greater Pittsburgh Charter School fifth graders, parents,
teachers, and principals.
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