Western Journal of Nursing
Research
http://wjn.sagepub.com
Reducing Risk Factors for Childhood Obesity: The Tommie Smith
Youth Athletic Initiative
Robert Topp, Dean E. Jacks, Rita Thomas Wedig, Jamie L. Newman, Lisa
Tobe and Angela Hollingsworth
West J Nurs Res 2009; 31; 715 originally published online May 19, 2009;
DOI: 10.1177/0193945909336356
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Reducing Risk Factors for
Childhood Obesity
Western Journal of
Nursing Research
Volume 31 Number 6
October 2009 715-730
© 2009 The Author(s)
10.1177/0193945909336356
http://wjn.sagepub.com
The Tommie Smith Youth
Athletic Initiative
Robert Topp
Dean E. Jacks
Rita Thomas Wedig
Jamie L. Newman
University of Louisville
Lisa Tobe
Angela Hollingsworth
The Louisville Metro Department of Public Health and Wellness Center
for Health Equity
This study has sought to determine if the Tommie Smith Youth Athletic
Initiative (TSYAI) intervention could decrease the risk factors for childhood obesity among children 5 to 10 years of age. The TSYAI intervention
is a 14-week after-school intervention for students in Grades K-5 that was
started during the spring of 2008. It serves 63 children in a predominantly
African American elementary school. The intervention consists of supervised
after-school sessions 3 days per week. These sessions include 2 days of physical activity (flexibility, resistance, and track-and-field training) and 1 day of 45
min of nutrition education modules based on the Transtheoretical Model of
behavior change followed by 45 min of group physical activity. Ninety-two
percent of the participants are African American and 60% are overweight or
obese (>85th percentile BMI for age and gender). The findings indicate that
the TSYAI intervention significantly improves the participant’s cardiovascular fitness, body composition, and dietary habits.
Keywords: exercise; pediatrics; diet and eating
T
he waistline of American children continues to grow, making childhood obesity a challenging public health priority. The most recent
National Health and Nutrition Examination Survey (NHANES) data indicate that 33% of children, from 6 to 11 years old, are overweight or obese
715
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716 Western Journal of Nursing Research
(Ogden, Carroll, & Flegal, 2008). Obesity in children age 5 and older is
defined by a body mass index (BMI) equal to or greater than the 95th percentile for gender and age, whereas being overweight is defined by a BMI
between the 85th and 95th percentile for gender and age (American
Academy of Pediatrics, 2007). The health problem of excessive body weight
in children is disproportionately distributed among ethnic and racial minorities. The latest NHANES data from 2003-2006 illustrates this, with the percentage of overweight or obese non-Hispanic White children at 31.6%,
non-Hispanic Black children at 36.9%, and Hispanic children at 42.8%
(Ogden et al., 2008).
Childhood Obesity
Childhood obesity is a significant risk factor for many physical and
mental health problems. In recent reviews, Mason, Crabtree, Caudill, and
Topp (2008) and the American Academy of Pediatrics (2003) reported that
the most common health problems associated with childhood obesity affect
multiple health systems, including the cardiovascular, pulmonary, endocrine, orthopedic, and psychological systems. Disorders associated with
childhood obesity include hypertension, hyperlipidemia, atherosclerosis,
asthma, sleep apnea, insulin resistance, impaired glucose tolerance, type 2
diabetes mellitus, fatty liver disease, osteoarthritis and orthopedic complications, depression, low self-esteem, eating disorders, and a decreased quality
of life (Levy & Petty, 2008; McCormick & Clarke, 2004). There is a high
likelihood that these disorders will continue into adulthood and contribute
to the development of other comorbidities, including coronary artery disease, stroke, various cancers, and more severe emotional problems. Obesity
at age 6 is associated with a 50% risk of becoming an obese adult, and 70%
to 80% of obese adolescents grow into obese adults (Guo, Wei, Chumlea,
& Roche, 2002).
To reduce childhood obesity, it is important to identify and reduce the
risk factors contributing to the problem. The primary risk factors associated
Authors’ Note: Support for this project was provided by the Louisville Metro Department of
Public Health and Wellness Center for Health Equity; Wheatley Elementary School, Robert
Wagner, Principal; University of Louisville School of Nursing, Patricia Martin, MSN, RN,
N341, Faculty Member; Horton Fruit Co., Jackson Woodard, CEO and President of Horton
Fruit; The Village of Louisville, Mozziz Dewalt, Director; and the University of Louisville
Signature Partnership, Susan Rhodes, Program Liaison. Please address correspondence to
Robert Topp at [email protected].
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Topp et al. / The Tommie Smith Youth Athletic Initiative 717
with childhood obesity are physical inactivity or inadequate caloric expenditure and poor dietary habits or excessive caloric intake. During the past
few decades, children have become progressively less physically active,
spending more of their leisure time in sedentary activities such as watching
television, movies, playing video games, and using the computer (Anderson,
Crespo, Bartlett, Cheskin, & Pratt, 1998; Floriani & Kennedy, 2007). This,
along with declining participation in organized sports and fewer physical
education programs in schools, contributes to the development of childhood obesity (Mason et al., 2008). The other risk factor associated with childhood obesity are poor dietary habits, including excessive intake of calories,
sugar, and sodium and insufficient intake of fruits, vegetables, and fiber
(French, Story, & Jeffery, 2001).
Most studies that attempt to reduce obesity focus on decreasing caloric
intake and/or increasing caloric expenditure. These approaches are more
challenging with children because of the child’s need for a sufficient caloric
and nutrient intake to maintain adequate growth and development. This
need to maintain caloric intake to support growth and development is in
contrast to interventions that emphasize caloric restriction (Epstein, Myers,
Raynor, & Saelens, 1998). The role of the parents and the home environment create additional challenges to addressing childhood obesity. Children
typically select their food based on the choices provided to them by their
parents, and when faced with a choice between low- and high-fat foods,
children typically choose high-fat foods, particularly if their parents are obese
(Strauss & Knight, 1999). Parents serve a significant role in providing food
choices, influencing food preferences, and increasing the risk of their child
becoming obese.
The American Academy of Family Physicians strongly recommends
parental involvement when treating obesity in children (Moran, 1999), and
the American Academy of Pediatrics (2003, 2007) advises that families be
educated and empowered on the impact they have over their children’s
physical activity and dietary habits. Multiple studies report greater success
in weight reduction in obese children when the interventions include parent
participation (Epstein, Paluch, Coleman, Vito, & Anderson, 1996; Epstein,
Valoski, Wing, & McCurley, 1990; Floriana & Kennedy, 2007; Israel,
Stolmaker, & Andrain, 1985; Mason et al., 2008). A review of 16 clinical trials
examining family involvement and weight loss in children confirmed that
parental involvement is a key component in effective interventions that
result in weight loss in children (McLean, Griffin, Toney, & Hardeman,
2006). Although efforts to target diet, physical activity, and family involvement have had some success treating childhood obesity, most of these
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718 Western Journal of Nursing Research
interventions have not had a long-term effect on reducing childhood obesity
or the risk factors associated with childhood obesity (Campbell, Waters,
O’Meara, & Summerbell, 2001).
Other investigators have reported a case management approach to be
effective in long-term management of chronic conditions in children,
including asthma (Vafiadou & Ranuro, 1999) and type 1 diabetes (Beck
et al., 2004), particularly if a parent is involved in the treatment protocol
(Schulte, Musolf, Meurer, Cohn, & Kelly, 2004). Case management is
defined as a collaborative process of an interdisciplinary team that assesses,
identifies perceptions, plans, implements, coordinates, monitors, and evaluates options and services needed to meet an individual’s health needs (Moreo
& Lamb, 2003). Case management is consistent with the Transtheoretical
Model (TM) of behavioral change. According to this model, an accurate
assessment of the individual’s perceptions related to a specific health
behavior, or stage of change, is critical when designing effective interventions that will progress them along the stage-of-change continuum and
result in desired behavioral changes (Prochaska & DiClemente, 1992). The
TM has been used to plan successful interventions to modify health behaviors, such as smoking, alcohol abuse, emotional distress, and weight loss
(Prochaska & DiClemente, 1992).
Because case management has been effective in the treatment of other
childhood chronic conditions, it seems prudent to examine the potential of
an interdisciplinary team administering an intervention mechanism framed
by the TM of behavioral change to decrease risk factors associated with
childhood obesity. The Tommie Smith Youth Athletic Initiative (TSYAI)
was composed of an interdisciplinary team of nurses, an exercise physiologist, a dietitian, health educators, members of the community, and the
child’s parent. The components of the intervention were consistent with
TM principles and attempted to progress the child and parent along the
change continuum to decrease the risk factors associated with childhood
obesity among the children in TSYAI. Thus, the purpose of this study was
to determine if the TSYAI could positively affect the risk factors for childhood obesity among children in Grades K-5 (5-10 years of age). Three
hypotheses were generated to address this purpose:
Children who participate in the (TSYAI) intervention will exhibit
Hypothesis 1: Greater cardiovascular fitness,
Hypothesis 2: Lower or normalized body composition (BMI and body composition), and
Hypothesis 3: Improved dietary habits.
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Topp et al. / The Tommie Smith Youth Athletic Initiative 719
Method
The study involved children in Grades K-5 and their parents recruited
from a single elementary school located in a predominately African American,
inner-city neighborhood during the spring semester of the school year. Child
and parent participants were recruited in the targeted neighborhood through
various approaches, including announcements in schools, churches, and community centers and three information sessions held at the school, each on a
different day and time. The information sessions involved an explanation of
the intervention and a question-and-answer period; interested parents were
asked to schedule a time to complete baseline data collection prior to their
children’s participation in the TSYAI intervention. The parents and children
were also told they would be invited to a similar data collection appointment
following completion of the 14-week TSYAI intervention. Once scheduled
for baseline data collection, the parent provided informed consent and the
child was provided with an assent form prior to their participation. Children
were excluded from the intervention if their parent reported that the child had
a history of cardiovascular disease or any other physical condition that prohibited continuous physical activity at a moderate intensity. Because it was
considered unethical to refuse participation of participants who wished to be
involved in the TSYAI intervention, which had a high degree of benefit and
a low probability of risk, a nonintervention comparison group was not developed. Thus, the design of the study involved following a single group of
children that participated in the TSYAI intervention, with data collection
occurring prior to and following the 14-week intervention.
The recruitment procedures resulted in 63 children and their parents
assenting and consenting respectively to participate in the TSYAI. These
children and their parents completed varying amounts of the proposed data
collection procedures prior to and following the 14-week intervention.
Forty-nine subjects completed the assessments of body composition and
cardiovascular fitness at both data collection points. Because both the parent and the child needed to be present for collection of the analysis of dietary habits, only 33 records were completed at both the pre- and posttest.
Intervention Description
The TSYAI intervention consisted of three weekly 90-min after-school
sessions conducted for 14 weeks. Two of these weekly sessions involved
track-and-field activities supervised by local track coaches, research staff,
health department employees, and local high school students who were
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720 Western Journal of Nursing Research
involved in track-and-field events in their high school. The track-and-field
activities consisted of calisthenics, strength and flexibility exercises, sprinting, and distance running. During the third weekly session, the children
received a 45-min nutrition education module and engaged in a 45-min non–
track-and-field alternative physical activity (dodge ball, crabwalk soccer,
freeze tag, agility course, etc).
For the nutrition education modules, the children were divided into two
groups and provided with age-appropriate nutrition education (see Tables 1
and 2). These modules were consistent with the TM of behavior change and
supervised by program staff including nurses, nursing students, and a registered dietitian. The first six modules focused on cognitive components
involved in progressing the children from precontemplation or contemplation to preparation and action stages of TM concerning their dietary habits
(changing attitude, perceptions, beliefs, and knowledge). The remaining
nutritional modules focused on behavioral components aimed at progressing
the child toward action and maintenance stages of behavior change concerning their dietary habits (planning, setting goals, monitoring behavior, etc.).
Most of the weekly nutrition educational modules included homework for
the child and his or her parent to complete and return the following week.
Study staff provided each child a small incentive for completing the weekly
homework (water bottle, T-shirts, notepads, etc.).
For the first 2 weeks, all children participated in the same nutritional education modules that were aimed at changing their attitude, perceptions, beliefs,
and knowledge about obesity, chronic disease, and eating fast food. During the
first nutrition education module, the children developed a family tree of obesity and obesity-related diseases and confirmed the family tree with their parent. The movie Supersize Me was watched by the children in Week 2, and the
health implications of eating a diet that includes a high proportion of fast food
was discussed between the children, project staff, and parents. During Weeks 3
to 14, children in Grades K and 1 were read books by the project staff that
included nutrition information. This was followed by a nutrition education
activity and homework to be completed with their parent. Throughout Weeks 3
to 14, children in Grades 2 to 5 engaged in a variety of nutrition education
activities that included homework to be completed with their parent. During
each weekly nutrition education module, the children were provided with
healthy snacks focused on exposing them to fresh fruits, vegetables, high-fiber
breads and cereals, and appropriate portion sizes. The snacks were rotated
every 4 weeks and focused on four different content areas, including energy
and complex carbohydrates, vegetables and fruit, fiber, and calcium. Snacks
were allocated at approximately 150 calories per child and consumed under
the supervision of the study staff.
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Topp et al. / The Tommie Smith Youth Athletic Initiative 721
Table 1
Nutrition Education Modules for Children in Grades K to 1
Week
Book or Topic
Home Assignment
1 and 2 Same as Grades 2 to 5
below
3
Growing Vegetable Soup by Drawings of vegetables
L. Ehlert
4
Surprise Garden by Z. Hall Games on vegetables; list
& S. Halpern
vegetables on food
guide pyramid
5
The Gigantic Turnip by A. Turnip and recipe
Tolstoy & N. Sharkey
6
One Bean by A. Rockwell
Food guide pyramid
& M. Halsey
7
Spriggles: Health and
Identify healthy fruits and
Nutrition by J. A.
vegetables
Gottlieb & M. Gottlieb
8
D.W. the Picky Eater by M. Identify sources of calcium
Brown
9
Growing Vegetable Soup by Complete the food guide
L. Ehlert
pyramid for 2 days
10
Spriggles: Activity and
Exercise by J. A.
Gottlieb & M. Gottlieb
Spriggles: Activity and
Exercise by J. A.
Gottlieb & M. Gottlieb
Count on Pablo by B.
Dubertis & R. McKillip
11
12
13
Count on Pablo by B.
Dubertis & R. McKillip
14
Surprise Garden by Z. Hall
& S. Halpern
Video, computer, etc.
Complete log of physical
activity
Identify sources of
calories, fat, and salt at
fast-food places
Identify sources of
calories, fat, and salt in
foods cooked at home
Dealing with situations
where unhealthy foods
could be eaten
Class Activity
Hand-washing
Show and wear 15-lb
body suit, decorate
planters
Plant garden, prepare
food
Bean drawings
Examine and taste
fruits and
vegetables
Eat baby lettuce,
colds and flu,
hand-washing
Grocery store
scavenger hunt for
vegetables
Activity based on
foods eaten
(outside)
Foods for running,
i.e., fiber foods
List favorite foods in
food guide pyramid
Identifying how much
fat and sugar in
foods
Eating your garden
Data Collection
Data were collected from the child participant and his or her parent prior
to and following participation in the 14-week intervention. This data collection occurred at the targeted elementary school during off school hours after
school or on weekends. Four categories of data were collected, including
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722 Western Journal of Nursing Research
Table 2
Nutrition Education Modules for Children in Grades 2 to 5
Week
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Content, Activity, and Homework
Complete a family tree of obesity and obesity-related diseases. Discuss
relationships between obesity and disease in your family and the pros and cons
of being overweight.
Watch Supersize Me video. Discuss the health implications of eating a diet that
includes a high proportion of fast food. Complete a log of duration of time
spent watching television, working on computer, or playing video games for 3
days.
Describe the food pyramid guide. Identify foods within the categories of the food
pyramid.
Identify fat and sources of calories of foods in a fast-food restaurant. Examine a
fast-food restaurant menu and identify high- and low-fat foods.
Identify healthy foods containing vegetables and fruits. Complete a handout
identifying vegetables and fruits you have eaten.
Identify healthy foods containing dairy and other sources of calcium. Complete a
handout identifying high- and low-fat dairy foods you have eaten.
Read food labels before eating. Complete a handout in which you practice reading
food labels and identify nutrient values of your favorite foods.
Identify ways in which fat, calories, and sodium are added to foods cooked in the
home. Develop weekly, monthly, and lifelong dietary goals and activities that
will help meet those goals. Complete the How Does Weight Gain Occur
Questionnaire.
Eating foods according to the food guide pyramid. Keep a diet recall log for 3
days writing down everything you eat according to the food guide pyramid.
Activity and calories: Eat three different specific foods (celery, apple slices, and
oatmeal cookie) and burn a similar amount of calories in physical activity as
these foods contain.
Eat and have healthy foods available in the home: Identify different healthy foods
in your home (fruits, vegetables, and dairy products)
Demonstrate exactly how much fat and sugar was consumed in your diets. Using
scoops of sugar and scoops of fat, identify how much sugar and fat you ate
yesterday.
Read labels on common foods obtained at the grocery store. Identify foods that
are sources of fiber, fat, vitamin C, and protein.
Go out to eat and consume healthy foods. Identify and eat foods lower in fat and
calories when eating at a fast-food restaurant. Keep a food record of the foods
you eat or would like to eat at a fast-food restaurant.
demographic information, cardiovascular fitness, body composition, and
dietary habits of the child.
Demographic information was collected from the parent prior to beginning the intervention only by having them complete a brief demographic
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Topp et al. / The Tommie Smith Youth Athletic Initiative 723
questionnaire inquiring about the child’s age, gender, race, and health
history. In addition, this questionnaire inquired about how many people
lived in the child’s home, the ages of these individuals, and who is the
person responsible for purchasing food and preparing meals consumed by
the child.
Cardiovascular fitness was assessed while the child completed a 3-min
step test protocol. The step test protocol required the child to step up and
down on a 12-in. bench at a rate of 24 steps per minute for 3 min. A Polar
heart rate monitor (Polar Electro, Finland) was used to continuously monitor the heart rate of the participant during the test. Heart rate was recorded
throughout the test and immediately on cessation of the test (t0) and at 1 (t1)
and 2 (t2) min posttest. In similar studies of children, other researchers (Yin,
Hanes, et al., 2005) have used this test, which has been shown to be responsive to changes in cardiovascular fitness resulting from increases in physical activity (Yin, Moore, et al., 2005). A cardiovascular fitness (CVF) score
was calculated by taking the total exercise time in seconds (ts) multiplied
by 100 and then divided by the sum of the three heart rate values measured
postexercise; CVF = ts × 100/(t0 + t1 + t2). This CVF score has been used in
community-based interventions, with obese children demonstrating responsiveness to changes in fitness in previous studies (Trevino et al., 1999).
Body composition was assessed through various means, including height,
weight, body mass index (BMI), hip-to-waist circumference ratios, and
body composition using skin-fold calipers. Height was assessed with the
child’s shoes removed using the portable Seca 225 Height Rod stadiometer.
Weight was assessed using a portable electronic self-zeroing scale. Hip and
waist circumferences were measured from the average of three consecutive
trials using a measuring tape. Hip circumference was assessed at the level of
the greater trochanter whereas waist circumference was assessed at the
umbilicus. The Jackson­–Pollock (J-P) three-site skin-fold assessment using
skin-fold calipers was used to determine body fat percentage (BF%), fat-free
mass (FFM), and fat mass (FM; Jackson & Pollack, 1985).
Dietary habits of the child were measured by the study’s registered and
licensed dietitian conducting a food frequency interview with both the child
and his or her parent together. Data provided by the food frequency interview were classified by the dietitian into food groups according to the new
Food Guide Pyramid (United States Department of Agriculture [USDA],
2005). During this interview, the child with the help of his or her parent
indicated the number of servings of a food group consumed per day during
the past day, week, or month on the Food Pyramid (USDA, 2005). These
values were standardized to weekly intake of foods in each group.
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724 Western Journal of Nursing Research
The overall study design involved a pretest–posttest of a single group
during a 14-week duration of time. The analysis involved repeated measures
univariate analysis to determine if the participants significantly (p < .05)
decreased their risk factors for childhood obesity during the study.
Results
The participating children were 92% African American, 51% female, and
8 ± 1.82 years of age, with 60% being overweight or obese (BMI > 85%
age and gender specific). There were 37 intervention sessions offered during
14 weeks, with the children attending an average of 70% of the sessions
offered. A majority of the participants lived in households with an average
of 4.74 individuals, with 3.14 of these individuals being less than 18 years of
age. A majority of the children (61%) resided in households with a total
income of less than $30,000. The parents reported that their children engaged
in an average of 146 min (21 min per day) of exercise weekly; however,
30% of the sample reported their children received no exercise weekly and
an additional 30% did not respond to the question.
Table 3 presents the body composition and cardiovascular fitness of the
child participants at baseline and following the TSYAI intervention. The
participants who completed the two data collection points (n = 49, 78%)
significantly increased their body weight by approximately 3 lb and increased
their height by almost an inch during the duration of the study. During the
intervention, the child participant’s body mass index (BMI), BMI relative to
their age and gender (BMI percentile), and percentage body fat did not
change; their lean weight increased on average by 2.3 lb per child, with no
significant change observed in fat weight or waist-to-hip ratio. Following
the TSYAI intervention, the maximum heart rate recorded during the 3-min
step test protocol significantly decreased and the cardiovascular score
increased, both indicating the participants exhibited improved cardiovascular fitness as a result of participating in the intervention. The child participant’s heart rate measured at 1 and 2 min after stopping the stepping protocol
demonstrated a faster heart rate recovery following the TSYAI intervention,
also indicating improved cardiovascular fitness. Finally, a greater percentage of participants attempting the 3-min stepping protocol could complete
the protocol at the completion of the intervention (96%) compared with the
percentage completing the step test protocol at baseline (87%). These results
indicate that the sample improved their cardiovascular fitness and lean body
mass over the duration of the intervention.
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Topp et al. / The Tommie Smith Youth Athletic Initiative 725
Table 3
Analysis of Body Composition and Cardiovascular Fitness (n = 49)
Variable
Baseline
Retest
Change Weight (lb)
86.4 ± 39.1
90.2 ± 42.5
3.3
Height (in.)
52.7 ± 5.1
53.6 ± 5.3
0.89
BMI
21.1 ± 6.2
21.3 ± 6.8
0.20
BMI percentile
77.2 ± 25.5
77.0 ± 26.8
–0.2
% Body fat
22.3 ± 15.5
22.1 ± 16.0
–0.2
Fat weight
24.5 ± 29.0
25.9 ± 31.3
1.4
Lean weight (lb)
61.9 ± 15.6
64.2 ± 15.8
2.3
Hip-to-waist ratio
0.86 ± 0.06
0.85 ± 0.06
–0.01
Resting HR
92.7 ± 11.1
92.7 ± 12.5
0
Max HR
165.2 ± 19.1
158.9 ± 19.4
–6.3
CVF score
43.2 ± 11.6
49.8 ± 8.03
6.6
One-minute HR recovery
118.5 ± 26.6
109.7 ± 20.3
–8.7
Two-minute HR recovery
105.4 ± 17.8
100.2 ± 16.1
–5.2
Participants completing
53 complete, 46 complete, 13% vs 4% the protocol 7 incomplete, 2 incomplete, incomplete
3 no data 15 no data
p<
.00
.00
.25
.89
.77
.06
.00
.43
.98
.00
.00
.04
.05
.02
Note: BMI = body mass index; CVF = cardiovascular fitness; HR = heart rate.
Thirty-three (52%) participants completed the data collection of the
dietary habits of the child at both data collection points (see Table 4).
Analysis of the dietary habits of the child participants indicated a trend
toward improving their food choices over the duration of the intervention.
The data indicated the participants consumed significantly more green vegetables and less fruit juice at the completion of the intervention. This table
also indicates serious deviations in the children’s dietary intake from the
recommended amounts. These deviations include no high-fiber foods, low
amounts of fruits and vegetables, high-fat milk consumption, and high
intakes of added sugar and high-fat meats.
Discussion
The purpose of this study was to determine if the TSYAI could positively affect the risk factors for childhood obesity among children in Grades
K-5 (5-10 years of age). In general, the study’s hypotheses were supported.
The 14-week intervention resulted in greater cardiovascular fitness, normalized body composition, and improved dietary habits of the child participants. The findings also indicate the feasibility of the intervention, with
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726 Western Journal of Nursing Research
Table 4
Analysis of Dietary Habits (n = 33)
Variable
Baseline
Breads and grains <1 g fiber
Breads and grains 1-3 g fiber
Breads and grains >3 g fiber
Green vegetables
Yellow vegetables
High-starch vegetables
Fresh fruit
Fruit juice
Prepared fruit Sweetened beverages
Added sugar
Milk <1 g fat
Milk 1-3 g fat
Milk >3 g fat
Meat <5 g fat
Meat 5-10 g fat
Meat >10 g fat
Fat from animal source
Fat from vegetable source
6.23 ± 1.68
0.74 ± 0.64
.0
0.45 ± 0.38
0.21 ± 0.29
0.34 ± 0.27
0.86 ± 0.68
1.23 ± 1.10
0.45 ± 0.40
1.50 ± 1.25
5.33 ± 2.53
0.08 ± 0.30
1.42 ± 0.89
1.20 ± 0.78
1.00 ± 0.40
0.90 ± 0.78
2.28 ± 1.10
3.00 ± 1.24
0
Retest
Recommended
5.63 ± 1.03
1
0.93 ± 0.96
2
0
1-2a
0.66 ± 0.69
0.5-1
0.15 ± 0.18
0.5-1
0.34 ± 0.23
1-2
0.75 ± 0.86
2-3a
0.72 ± 0.26
0.49 ± 0.29
1.47 ± .94
b
4.96 ± 1.70
0.06 ± 0.20
1.63 ± 1.02
2-5b
1.13 ± 0.64
0.96 ± 0.33
1-2a
1.00 ± 0.70
2.40 ± 1.02
3.04 ± 0.99
0
p<
.06
.36
N/A
.02
.30
.98
.38
.02
.62
.89
.34
.41
.31
.64
.71
.49
.52
.80
N/A
a. Lower range represents younger children (Grades K-2) whereas upper range represents
older children. Fruit, milk, and meat servings represent all groups; however, fresh fruit, lowfat milk, and meat products are recommended.
b. Food guide pyramid recommends three servings of milk per day for all age groups more
than 9 years of age; however, the Dietary References Intake can only be achieved by four to
five servings for children more than 9 years of age.
the 63 participants initially enrolled documented attending 70% of the intervention sessions that were offered. Finally, the results indicate no negative
effects of the TSYAI on the outcome variables measured.
Although favorable, the results of this intervention indicate a number of
serious health problems among the participants, which need to be addressed.
First, more than 60% of the individuals who initially enrolled in the intervention exhibited BMI percentiles that classified them as overweight or
obese compared to the national average of 37% of preadolescents being
classified as overweight or obese. Second, although favorably affected by
the intervention, the participants exhibited cardiovascular fitness and dietary
habits that were below or outside of recommended levels following the
intervention. These findings indicate the significant problem of excessive
body weight, low levels of cardiovascular fitness, and poor dietary habits
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Topp et al. / The Tommie Smith Youth Athletic Initiative 727
among this sample of predominately African American elementary-schoolage children.
The findings did not indicate consistent benefits of the intervention in all
of the outcomes assessed. A number of factors may have contributed to
these findings and possibly biased the results. First, a number of the participants did not complete all of the data collection protocols, which may
have resulted in a self-selection bias, affecting the results. This inconsistency in completing the data collection may have also diluted the power of
the statistical analysis to detect differences in the outcome variables as a
result of the intervention. Second, the participants had a low completion
and/or return rate for the nutrition homework (mean = 4.6 of 13 possible).
This low adherence with this component of the intervention may mean that
parents were not as involved with the intervention as the team would have
liked; therefore, this intervention may not have affected the parent’s cognitive perceptions or behaviors related to his or her child’s physical activity
or dietary habits. Several of the children had either limited parent contact,
were in custodial care with other family members or guardians, or had
parents with limited reading ability or education. Thus, on several occasions the research staff completed homework with the child without the
parent’s input or knowledge. Second, the nutritional intake was obtained
through self-report by parent and child while reviewing school breakfast
and lunch menus. Almost all children consumed breakfast and lunch during
a week day at the school. Direct observation of nutritional intake was not
possible; therefore, obtaining nutritional intake using this methodology
may be susceptible to response set or social desirability bias. The research
team, however, did observe the intake of the food snacks provided during
the nutrition education modules. All high-carbohydrate foods, crackers,
cookies, and fresh fruit were consistently consumed by all participants and
seconds requested repeatedly. Snacks in the form of vegetables and low-fat
foods were consumed less often and in lower volumes, with seconds rarely
requested. This observation validated the findings of dietary habits determined using the food frequency questionnaire. Third, the research staff
administering the intervention had limited experience at the beginning of
the intervention in conducting physical activity interventions with children,
particularly in underserved areas. This learning curve achieved by the staff
by the end of the intervention may have resulted in less than optimal intervention implementation during the initial sessions of the intervention.
Although the results of the intervention indicate the feasibility and success of the intervention, a number of limitations in the design are evident
and may further threaten the validity of the findings. First, because no
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728 Western Journal of Nursing Research
control condition was included in the methodology, there is no way to
determine if the significant improvements in cardiovascular fitness, body
composition, or dietary habits realized during the duration of the project
could also be attributable to some other confounding factor. A second
potential confounding factor may be the increased emphasis on childhood
obesity, nutrition, and physical activity in the media, popular press, and the
school’s curriculum during the TSYAI. Other potential confounding factors
that may positively affect the outcomes may have included maturation of
the sample, or seasonal effects of the children becoming more active in the
mid- and late spring. A second limitation was that the future of the intervention following the 14-week intervention was not clear to the children or
their parents. A large majority of the children and their parents wanted the
intervention to continue and may have tempered their obligation to participating without a clear commitment for continuing the project beyond the
initial 14 weeks.
Future studies in this area may wish to address a number of limitations
encountered during the completion of the TSYAI. Including a no-intervention
control group would strengthen the internal validity of the findings. Future
studies should include both nutrition and physical activity components of the
intervention but attempt to quantify the sample’s exposure to these intervention components. Third, attempts should be made to make components of the
TSYAI more culturally sensitive to the groups being recruited, including
African American and/or Hispanic cultures. Finally, future studies may wish
to examine the long-term impact of introducing an intervention that incorporates TM principles progressing the child and parent along the change continuum to decrease the risk factors associated with childhood obesity.
References
American Academy of Pediatrics. (2003). Policy statement on prevention of pediatric overweight and obesity. Pediatrics, 112(2), 424-430.
American Academy of Pediatrics. (2007). Expert committee recommendations regarding the
prevention, assessment and treatment of child and adolescent overweight and obesity:
Summary report. Pediatrics, 120, S164-S192.
Anderson, R. E., Crespo, C. J., Bartlett, S. J., Cheskin, L. J., & Pratt, M. (1998). Relationship
of physical activity and television watching with body weight and level of fatness among
children. Journal of the American Medical Association, 279, 938-942.
Beck, J. K., Logan, K. J., Hamm, R. M., Sproat, S. M., Musser, K. M., Everhart, P. D., et al.
(2004). Reimbursement for pediatric diabetes intensive case management: A model for
chronic diseases? Pediatrics, 113(1, Part 1), e47-e50.
Campbell, K., Waters, E., O’Meara, S., & Summerbell, C. (2001). Interventions for preventing
obesity in children. Cochrane Database of Systematic Reviews, 1, CD001871.
Downloaded from http://wjn.sagepub.com at UNIV OF LOUISVILLE on October 6, 2009
Topp et al. / The Tommie Smith Youth Athletic Initiative 729
Epstein, L. H., Myers, M. D., Raynor, H. A., & Saelens, B. E. (1998). Treatment of pediatric
obesity. Pediatrics, 101(3), 554-570.
Epstein, L. H., Paluch, R. A., Coleman, K. J., Vito, D., & Anderson, K. (1996). Determinants
of physical activity in obese children assessed by accelerometer and self-report. Medicine
& Science in Sports & Exercise, 28(9), 1157-1164.
Epstein, L. H., Valoski, A. M., Wing, R. R., & McCurley, J. (1990). Ten-year follow-up of
behavioral, family-based treatment for obese children. Journal of the American Medical
Association, 264(19), 2519-2523.
Floriana, V., & Kennedy, C. (2007). Promotion of physical activity in primary care for obesity
treatment/prevention in children. Current Opinion in Pediatrics, 19, 99-103.
French, S. A., Story, M., & Jeffery, R. W. (2001). Environmental influences on eating and
physical activity. Annual Review of Public Health, 22, 309-335.
Guo, S. S., Wei, W., Chumlea, W. C., & Roche, A. F. (2002). Predicting overweight and obesity in adulthood from body mass index values in childhood and adolescence. American
Journal of Clinical Nutrition, 76(3), 653-658.
Israel, A. C., Stolmaker, L., & Andrain, C. A. (1985). The effects of training parents in general
child management skills on a behavioral weight loss program for children. Behavior
Therapy, 16, 169-180.
Jackson, A. S., & Pollack, M. L. (1985). Practical assessment of body composition. The Physician
and Sports Medicine, 13(5), 76-90.
Levy, L. Z., & Petty, K., (2008). Childhood obesity prevention: Compelling challenge of the
twenty-first century. Early Child Development & Care, 178(6), 609-615.
Mason, H. N., Crabtree, V., Caudill, P., & Topp, R. (2008). Childhood obesity: A transtheoretical case management approach. Journal of Pediatric Nursing, 23(4), 337-344.
McCormick, S. E., & Clarke, C. I. (2004). Prevention and management of overweight/obesity
in the community. Nutrition Bulletin, 29(3), 274-279.
McLean, N., Griffin, S., Toney, K., & Hardeman, W. (2006). Family involvement in weight
control, weight maintenance and weight-loss interventions: A systematic review of randomized trials. International Journal of Obesity & Related Metabolic Disorders: Journal of
the International Association for the Study of Obesity, 27(9), 987-1005.
Moran, R. (1999). Evaluation and treatment of childhood obesity. American Family Physician,
59(4), 861-873.
Moreo, K., & Lamb, G. (2003). Providing relevant guidelines for case management practice:
Revised CMSA standards of practice for case management. Lippincott’s Case Management,
8(3), 122-124.
Ogden, C. L., Carroll, M. D., & Flegal, K. M. (2008). High body mass index for age among
US children and adolescents, 2003-2006. Journal of the American Medical Association,
2995(20), 2401-2405.
Prochaska, J., & DiClemente, C. (1992). Stages of change in the modification of problem
behaviors. Progress in Behavior Modification, 28, 183-218.
Schulte, A., Musolf, J., Meurer, J. R., Cohn, J. H., & Kelly, K. J. (2004). Pediatric asthma case
management: A review of evidence and an experimental study design. Journal of Pediatric
Nursing, 19(4), 304-310.
Strauss, R. S., & Knight, J. (1999). Influence of the home environment on the development of
obesity in children. Pediatrics, 103, e85.
Trevino, R. P., Marshall, R. M., Hale, R. M., Rodriguez, R., Baker, G., & Gomez, J. (1999). Diabetes
risk factors in low-income Mexican-American children. Diabetes Care, 22, 202-207.
United States Department of Agriculture. (2005). Steps to a healthier you: The new food guide
pyramid. Retrieved December 3, 2005, from http://www.mypyramid.gov/
Downloaded from http://wjn.sagepub.com at UNIV OF LOUISVILLE on October 6, 2009
730 Western Journal of Nursing Research
Vafiadou, M., & Ranuro, R. (1999). Managing asthma: A pediatric program that works.
Caring, 18(11), 16-21.
Yin, Z., Hanes, J., Jr., Moore, J. B., Humbles, P., Barbeau, P., & Gutin, B. (2005). An afterschool physical activity program for obesity prevention in children: The Medical College
of Georgia FitKid Project. Evaluation & The Health Professions, 28, 67-89.
Yin, Z., Moore, J. B., Johnson, M. H., Barbeau, P., Cavnar, M., Thornburg, J., et al. (2005). The
Medical College of Georgia FitKid Project: The relations between program attendance and
changes in outcomes in year one. International Journal of Obesity, 29, S40-S45.
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