The association of physical activity knowledge, nutrition knowledge, and physical activity enjoyment in low socioeconomic elementary school children

According to the Centers for Disease Control (CDC), 17% of children and adolescents ages 2-19 are obese. The prevalence of childhood obesity is higher in minority and low sociodemographic (SES) populations. Comprehensive nutrition and physical activity interventions have resulted in reductions in childhood obesity. The purpose of this study was to explore the change in physical activity knowledge, nutrition knowledge, and physical activity enjoyment scores in low socioeconomic elementary schools during a Comprehensive Physical Activity Program (CSPAP). Secondly, associations between physical activity enjoyment scores and nutrition knowledge were analyzed. The study populations were 504 and 800 elementary school children, in grades 3-6, from five Title I schools in the Salt Lake City River District. Students completed three assessments: a physical activity knowledge assessment, a nutrition knowledge survey, and the physical activity enjoyment scale (PACES) test that were administered during the school hours. Using data from the 2015-2016 school year, the change in physical activity knowledge, nutrition knowledge, and PACES scores was assessed using three-factor 4 x 2 x 2 mixed-design ANOVA tests. The association between the nutrition knowledge and PACES scores was evaluated using Pearson's correlation coefficients. Physical activity knowledge scores increased from pretest (0.26 ± 0.11) to posttest (0.28± 0.12) significantly ( p=0.05) during the intervention. Additionally, PACES scores increased from pretest (36.84 ± 15. 14) to posttest (39.34 ± 14.79) significantly (p=0.02), during the intervention. Lastly, higher nutrition knowledge scores were significantly correlated with higher PACES scores (r=0.08; p= 0.02). These results emphasize the importance of providing physical activity and nutrition education for ethnic minority low SES elementary school children. Moreover, these findings demonstrate that improvements in physical activity enjoyment can occur during a school-based intervention. Increases in physical activity enjoyment and knowledge may translate to increases in chronic physical activity and improve children's health outcomes.

THE ASSOCIATION OF PHYSICAL ACTIVITY KNOWLEDGE, NUTRITION KNOWLEDGE, AND PHYSICAL ACTIVITY ENJOYMENT IN LOW SOCIOECONOMIC ELEMENTARY SCHOOL CHILDREN by Rose Elise Mattson A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science Department of Nutrition and Integrative Physiology The University of Utah May 2017 Copyright © Rose Elise Mattson 2017 All Rights Reserved The University of Utah Graduate School STATEMENT OF THESIS APPROVAL Rose Elise Mattson The thesis of has been approved by the following supervisory committee members: Kristine Jordan , Chair 3/8/17 Date Approved Julie Metos , Member 3/9/17 Date Approved Timothy Brusseau , Member 3/9/17 Date Approved and by the Department of Scott Summers Nutrition and Integrative Physiology and by David B. Kieda, Dean of The Graduate School. , Chair of ABSTRACT According to the Centers for Disease Control (CDC), 17% of children and adolescents ages 2-19 are obese. The prevalence of childhood obesity is higher in minority and low sociodemographic (SES) populations. Comprehensive nutrition and physical activity interventions have resulted in reductions in childhood obesity. The purpose of this study was to explore the change in physical activity knowledge, nutrition knowledge, and physical activity enjoyment scores in low socioeconomic elementary schools during a Comprehensive Physical Activity Program (CSPAP). Secondly, associations between physical activity enjoyment scores and nutrition knowledge were analyzed. The study populations were 504 and 800 elementary school children, in grades 3-6, from five Title I schools in the Salt Lake City River District. Students completed three assessments: a physical activity knowledge assessment, a nutrition knowledge survey, and the physical activity enjoyment scale (PACES) test that were administered during the school hours. Using data from the 2015-2016 school year, the change in physical activity knowledge, nutrition knowledge, and PACES scores was assessed using three-factor 4 x 2 x 2 mixed-design ANOVA tests. The association between the nutrition knowledge and PACES scores was evaluated using Pearson’s correlation coefficients. Physical activity knowledge scores increased from pretest (0.26 ± 0.11) to posttest (0.28± 0.12) significantly (p=0.05) during the intervention. Additionally, PACES scores increased from pretest (36.84 ± 15.14) to posttest (39.34 ± 14.79) significantly (p=0.02), during the intervention. Lastly, higher nutrition knowledge scores were significantly correlated with higher PACES scores (r=0.08; p=0.02). These results emphasize the importance of providing physical activity and nutrition education for ethnic minority low SES elementary school children. Moreover, these findings demonstrate that improvements in physical activity enjoyment can occur during a school-based intervention. Increases in physical activity enjoyment and knowledge may translate to increases in chronic physical activity and improve children’s health outcomes. iv TABLE OF CONTENTS ABSTRACT ....................................................................................................................... iii LIST OF TABLES ............................................................................................................. vi LIST OF FIGURES .......................................................................................................... vii ACKNOWLEDGEMENTS ............................................................................................. viii INTRODUCTION ...............................................................................................................1 Background/Literature Review .......................................................................................1 Significance of Problem ..................................................................................................5 Purpose and Hypotheses of Research .............................................................................5 METHODS ..........................................................................................................................8 Participant Selection Criteria ..........................................................................................8 Description of the CSPAP Education Intervention ........................................................8 Instruments and Data Collection .....................................................................................9 Knowledge Assessments ............................................................................................9 Physical Activity Knowledge Assessment............................................................9 Nutrition Knowledge Survey ................................................................................9 Physical Activity Enjoyment Scale (PACES).......................................................9 Statistical Methods ........................................................................................................10 RESULTS ..........................................................................................................................11 Changes in Physical Activity Knowledge: Grades 4-6 .................................................11 Changes in Nutrition Knowledge: Grades 3-6 ..............................................................12 Changes in PACES Score and Relationship to Nutrition Knowledge: Grades 4-6 .....12 DISCUSSION ....................................................................................................................19 CONCLUSION ..................................................................................................................23 REFERENCES ..................................................................................................................24 LISTS OF TABLES 1 Summary statistics for physical activity knowledge scores, nutrition knowledge scores, and PACES score for children grades 3rd-6th in five Title I elementary schools. ..............14 2 Summary statistics for total sample of male and female students by grade level for students who completed the physical activity knowledge survey, the nutrition knowledge survey, and PACES test.. ...................................................................................................14 3 Pre- and postintervention comparisons between physical activity knowledge scores, nutrition knowledge scores, and PACES score for students in five Title I elementary schools................................................................................................................................14 4 Comparisons of sex and grade level for the physical activity knowledge survey scores, nutrition knowledge survey scores, and PACES ...............................................................15 LIST OF FIGURES 1 Mean physical activity knowledge scores by grade level, stratified by time (baseline and follow up) in Title I elementary school children (n=504) ...........................................16 2 Nutrition knowledge survey score and grade by grade comparisons in Title I elementary school children (n=800) .....................................................................................................16 3 Mean male and female nutrition knowledge survey scores in Title I elementary school children (n=800) ................................................................................................................17 4 Mean nutrition knowledge scores from baseline to follow up for male and female students (n=800) in Title I elementary school children .....................................................17 5 Mean change in PACES score from baseline and follow up in low socioeconomic ethnic minority elementary school children (n=800) .........................................................18 6 Mean changes in physical activity enjoyment scores (PACES) for 3rd-6th grade elementary school children (n=800) ..................................................................................18 ACKNOWLEDGEMENTS I would like to thank my committee members, Dr. Kristine Jordan, Dr. Julie Metos, and Dr. Timothy Brusseau, for their support in completing this thesis project. I would also like to thank Dr. Ryan Burns for his guidance and expertise with statistics as well as Sara Goodrum and Yi Fang for their help with data collection. INTRODUCTION Background/Literature Review Childhood obesity is a significant public health issue in the United States. According to the Centers for Disease Control (CDC), 17% of children and adolescents ages 2-19 are obese (1). Obesity rates in children ages 6-11 have increased from 7% in 1980 to 18% in 2012 (1). Similarly, adolescent obesity rates for ages 12-19 have increased from 5% in 1980 to 21% in 2012 (1). In children and adolescents, obesity is associated with an increased risk of high cholesterol, high blood pressure, prediabetes, bone and joint problems, physiological and social problems, and sleep apnea (2). Obesity and overweight as a child often predicts adult obesity and associated morbidity (3). Regarding educational outcomes, Carey et al. found that obese children were significantly more likely to have school absences, school-related problems, and lower involvement in school activities, as compared to normal weight children (4). The prevalence of childhood obesity is higher in minority and low sociodemographic populations. In 2009-2010, Ogden et al. reported obesity prevalence rates in children and adolescents by ethnicity as follows: Hispanic (21.2%), non-Hispanic black (24.3%), and non-Hispanic white (14.0%) (5). Moreover, children from ethnic minority populations often have low socioeconomic status (SES) (6). Low SES minority groups often have the highest health needs (3). Between 1998-2010, obesity rates in children from low socioeconomic backgrounds significantly increased while rates 2 declined in children from higher socioeconomic backgrounds (7). Specifically, children below the poverty line have an 83% higher odds of obesity (7, 8). Additionally, Singh et al. reported that obesity prevalence is higher in children from households with lower levels of education and non-English speaking families (8-10). Enjoyment of physical activity is consistently a predictor of physical activity (11, 12). In a review of 108 studies, Sallis et al. found that enjoyment of physical activity was regularly associated with children’s physical activity (13). Further, it was observed that children (n=1,504) who reported higher levels of enjoyment from physical activity consistently predicted actual physical activity participation among both children and adolescents (14). In a comprehensive school-based intervention, enjoyment of physical activity mediated a positive effect for African American and Caucasian adolescent girls (15). Another school-based physical activity intervention showed that enjoyment of physical activity measured at baseline in children ages 8-10 (n=300) could significantly predict improvements at posttest (10 months) (16). Additionally, Labbrozzi et al. found that girls (n=134) who ranked negative perceptions of body fat, self-concept, and appearance also reported low levels of physical activity enjoyment (17). Thus, interventions that target enjoyment of physical activity may also decrease rates of obesity and overweight among children (17). Schools provide a unique opportunity for obesity prevention programs due to the amount of time children spend in schools and the ability to impact a large population of children (3). First, children spend nearly 900 hours of instruction time annually in schools (18). Second, in the fall of 2016, there were approximately 50.4 million students enrolled in primary and secondary schools, with an estimated 35.4 million students in 3 prekindergarten to grade 8 (19). Furthermore, children who learn positive health behaviors at an early age may have decreased rates of obesity and overweight later in life (20). School-based physical activity education interventions have reported improvements in body mass index (BMI), aerobic fitness, and physical activity knowledge (21-23). Li et al. detailed a 12-week physical activity program with physical education (PE) motor skill development, activities for overweight/obese children, the inclusion of physical activity at home, and health education lectures (22). Results showed that children in the intervention group (n = 388) had a significant decrease in BMI, with a significant increase in moderate to vigorous physical activity (MVPA) (22). Similarly, increases in health-related fitness knowledge may translate to increased physical activity levels of high school students (23). Regarding barriers, Longmuir et al. reported that children ages 8-12 with reduced physical literacy may be less likely to participate in physical activity (24). Additionally, children from low socioeconomic families have added barriers that may prevent them from participating in physical activity (25, 26). School-based nutrition education interventions have demonstrated significant improvements in nutrition knowledge. Carraway-Stage et al. integrated science and nutrition in the 4th grade curriculum (27). Results indicated that intervention students (n = 443) displayed a significant increase in nutrition knowledge, as compared to controls (n = 319) (27). Turnin et al. utilized an interactive software program as a nutrition intervention for middle school children (n = 580). After one school year, study findings included a decline in BMI z-scores and increased consumption of fruits, vegetables, dairy, and starchy foods (28). Habib-Mourad et al. delivered classroom educational sessions for 9- 4 11 year olds (n = 387), with the focus on increasing fruit and vegetable consumption, increasing MVPA, and identifying healthy snacks and drinks. At postintervention, nutrition knowledge scores and self-efficacy scores increased significantly from baseline after 12 weeks (29). Other programs that included a nutrition education intervention demonstrated improvements in nutrition knowledge and also showed reductions in body weight (20, 30). Comprehensive nutrition and physical activity interventions have resulted in reductions in childhood obesity (21, 31, 32). Maatoug et al. provided education sessions on the importance of fruit and vegetable consumption, benefits of physical education, and how to increase physical activity into daily life in a three-year school-based intervention (33). Results indicated a decline in the percentage of obese children (7% to 6.5%) in the intervention group (n = 1,929), as compared to the increase in the percentage of obese children (4.5% to 6.9%) in controls (n = 2,074) (33). Also, children in the intervention group ate more fruits and vegetables, as compared to controls (33). Nemet et al. found that in a physical activity, nutrition education, and behavioral health intervention, obese children (n=46) had a decreased BMI, body fat percentage, and cholesterol levels after a three-month intervention, in comparison to controls (32). In a one-year follow up, intervention children continued to have significant differences in body weight, BMI, and body fat percentage in comparison to the control group (32). Another elementary school intervention utilized a Comprehensive Physical Activity Program (CSPAP), with observed improvements in the food environment, as well as educational strategies in an intervention for kindergarten through 5th grade children (n ≈ 2,400 per year) (34). Study findings showed a 15.2% decrease in childhood obesity over a six-year span (34). 5 Let’s Get Fit to Learn is a school-based nutrition and physical education program in five Title I schools in Utah. This program is based on the CSPAP approach (35). Let’s Get Fit to Learn is funded by the Carol M. White Physical Education Program (PEP), whose goal is to support and improve nutrition and physical education programs in schools to help prevent and reduce the prevalence of childhood obesity. The funding agency provides training for physical education teachers and classroom teachers and personnel, with the scope to reach 13,000 students in 22 school districts (35). The goals of Let’s Get Fit to Learn are: 1) “to improve the knowledge, skills, behavior, and attitudes of students towards physical activity and healthy eating [and] 2) to build a model for a school and Community Living Centers based wellness program that will strengthen the ability of the district to meet the state standards for Health and Physical Education” (35). Significance of Problem To our knowledge, there are limited studies in a low socioeconomic student population that document changes in physical activity knowledge, changes in nutrition knowledge, and changes in physical activity enjoyment scale (PACES) scores during a CSPAP intervention. Purpose and Hypotheses of Research The purpose of this study was to compare the associations among physical activity knowledge, nutrition knowledge, and physical activity enjoyment scores in low socioeconomic elementary schools. 6 The specific aims of this study were: 1. To analyze two physical activity knowledge test scores from students (n = 504), in grades 4-6 from five schools, to determine if there was a statistical difference between pre- and post-physical activity knowledge. 2. To compare two nutrition knowledge survey scores from students (n = 800), in grades 3-6 from four schools, to determine if there was a statistical difference between pre- and post-nutrition intervention knowledge. 3. To evaluate two PACES scores from students (n = 800), in grades 3-6 from four schools, to determine if there was a statistical difference between pre- and postPACES scores and to correlate PACES scores with nutrition knowledge scores from students in grades 3-6 from four schools. For the first aim, we hypothesized that there would be a statistically significant difference between pre- and post-physical activity knowledge. The null hypothesis for this research was that there would not be a statistical difference between the two surveys. For the second aim, we hypothesized that there would be a statistical difference in nutrition knowledge survey scores from pre- and post-nutrition knowledge intervention. The null hypothesis was that there would not be a difference between nutrition knowledge survey scores from pre- and postintervention. For the third aim, we hypothesized that there would be a statistically significant difference in PACES scores between pre- and postintervention. Additionally, we hypothesized that increases in PACES score would be associated with improvements in nutrition-related knowledge. The null hypothesis for this research was that there would not be a statistical difference 7 between pre- and postintervention and that there would be no associations between PACES scores and nutrition knowledge scores. METHODS Participation Selection Criteria A convenience sample of children (n = 2,099) from five low-income elementary schools from the Mountain West Region of the U.S were recruited. Children from 1st - 6th grades were asked to participate, with total enrollment across the five schools. Using information from the school district website, around 91% of children were of an ethnic minority and 60% of children were from low-income families (36). Of the total participants, girls (n = 1,099) and boys (n = 1,000) were enrolled in 3rd (25%), 4th (47%), 5th (31%), and 6th (8%) grade. Prior to data collection, written approval was acquired from the students and assent was obtained from the parents. The University of Utah Institutional Review Board approved the protocols employed in this study and all procedures conformed to the principles embodied in the Declaration of Helsinki. Description of the CSPAP Education Intervention The physical activity and nutrition education intervention occurred during the school year of 2015-2016. Physical activity leaders (PAL) worked with classroom and PE teachers to best implement the education. Physical activity and nutrition knowledge was integrated into PE lessons and classroom activity breaks through activities and lessons. Additionally, PAL created bulletin boards, handouts, and other educational materials for the intervention. 9 Instruments and Data Collection Knowledge Assessments Physical activity knowledge assessment. The PE Metrics physical education activity test was developed by the Society of Health and Physical Educators (SHAPE) (37). This test provides assessments for the National Standards for Physical Education including the following: motor skills and movement patterns, comprehension of movement concepts and strategies, qualities of an active lifestyle, and student knowledge of appropriate behavior during physical activity (37). The PE Metrics test consists of 28 questions organized into specific performance descriptors relating to health-related fitness knowledge (38). Hodges et al. found PE Metrics to be a valid and reliable tool in evaluating health-related fitness knowledge (38). Students took the test online during school hours once in October and again in either March, April, or May. Nutrition knowledge survey. Students completed a computer-based multiple choice assessment in approximately 10 to 15 minutes. The 15-item survey focused on the following domains: types of healthful foods, food functions, and food groups. Scores were calculated by adding the total of correct answers and then dividing by 15 for percentage correct (39). PALS administered the survey during school hours once in October and again in March, April or May. Physical activity enjoyment scale. The PACES was administered as a computerbased evaluation, with both the PE Metrics test and the nutrition knowledge survey. The PACES was developed by Kendzierski and DeCarlo as a method to test enjoyment of physical activity (40). The PACES test has been shown to be a valid measure of enjoyment of physical activity in children, with prior administration in low 10 socioeconomic minority elementary school populations (40, 41). The test measures physical activity enjoyment via an 11-item survey. The survey is scored on a five-point scale ranging from 1 (strongly agree) to 5 (strongly disagree). Sample questions include “physical activity is very exciting” to “physical activity is no fun at all.” Several questions (1, 5, 6, 7, 8, 10) were reverse coded to ensure an accurate score. Total scores were summed, with a high score correlating with high physical activity enjoyment. PALS administered the surveys once in October and again in March, April, or May. Statistical Methods The data were screened for outliers using box plots. Histograms and Q-Q plots were used to test normal distribution. Descriptive statistics (mean and standard deviation) were reported for each dependent variable. To test the hypothesis that physical activity knowledge, nutrition knowledge, and PACES scores would increase during the CSPAP intervention, and to examine the modifying effects of grade level and sex, 4 x 2 x 2 mixed-design analysis of variance (ANOVA) tests were employed. For each dependent variable, statistically significant time main effects were reported as well as any statistically significant 2-way or 3-way interactions. The dependent variables were physical activity knowledge, nutrition knowledge, and PACES scores. The independent factors were grade level (3rd-6th), sex, and time. Levene’s Test was used to test the assumption of homogeneity of variance. Bonferroni post hoc tests were utilized if there were any statistically significant differences among grade levels. An a priori alpha level was set at p≤0.05 and the data were analyzed using SPSS (Version 21.0 Armonk, NY, USA). RESULTS Change in Physical Activity Knowledge: Grades 4th-6th Students (n=504) were chosen based on inclusion criteria from the five Title 1 elementary schools. Students took the physical activity knowledge survey in October 2015 and again in either March, April, or May 2016. Summary statistics are presented in Tables 1 and 2. With physical activity knowledge as the dependent variable, and sex and grade as independent variables, after the CSPAP intervention, physical activity knowledge scores increased significantly from pre- intervention to postintervention (p=0.045) (Table 3). Sex and grade level were tested as effect modifiers. Sex was significant (F (1, 492) = 4.10, p=0.04) with female students achieving higher scores than males (Table 4). Grade was also significant (F (2, 492) = 17.93, p=0.00). Statistical differences were noted between 5th and 6th graders (p=0.02) with 5th graders scoring higher (Table 4). As well, there were statistical differences between 4th and 5th graders (p=0.00) with 5th graders again scoring higher in the physical activity knowledge assessment (Table 4). A combined effect modifier of both grade and time was also significant (F (2, 492) = 3.27, p = 0.04). The average 4th grade score decreased pre- (M = 0.24) to postintervention (M = 0.24) while both 5th and 6th graders mean score increased from pre- to postintervention (0.28 to 0.32 and 0.24 to 0.28), respectively (Figure 1). 12 Change in Nutrition Knowledge: Grades 3rd-6th Students (n=800) were chosen based on inclusion criteria from four Title I elementary schools. Students took the knowledge survey in October 2015 and again in March, April, or May of 2016. Summary statistics are presented in Tables 1 and 2. With nutrition knowledge as the dependent variable, and sex and grade level as independent variables, after the CSPAP intervention, nutrition knowledge scores increased (M =10.96) to (M=11.17). However, there were no significant differences found between October 2015 and May 2016 (p=0.15) (Table 3). Sex and grade level were then tested as effect modifiers. Both grade (F (3, 784) = 5.685, p=0.001) and sex (F (1, 784) = 5.331, p=0.02) proved significant with female students scoring higher than male students (Figure 2 and 3, Table 4). The 5th grade students had significantly higher scores than 3rd grade students (p=0.001) and 4th grade students (p=0.005) (Table 4, Figure 4). Changes in PACES Score and Relationship to Nutrition Knowledge: Grades 3rd-6th Students (n=800) were chosen based on inclusion criteria from four Title I elementary schools. Students took the PACES survey in October 2015 and again in either March, April, or May of 2016. Summary statistics are presented in Tables 1 and 2. With PACES score as the dependent variable, and sex and grade level as independent variables, PACES score increased significantly (p=0.02) between October 2015 and May 2016 (Table 3, Figure 5). Additionally, grade level was tested as an effect modifier. There was a significant difference between 4th and 6th grade (p=0.04) with 4th 13 graders having higher mean PACES scores (Figure 6, Table 4). Pearson’s correlation coefficients revealed a positive association between nutrition knowledge score and PACES score (r=0.08; p<0.02). There were no significant differences between time (pre- and postintervention) and sex. 14 Table 1. Summary statistics for physical activity knowledge scores, nutrition knowledge scores, and PACES score for children grades 3rd-6th in five Title I elementary schools. Variable n Mean ± SD Min. Max. 95% Confidence Interval PA Survey 504 0.26 ± 0.12 0.00 0.68 NS 800 11.00 ± 1.78 4.00 14.00 (10.90, 11.11) PACES 800 38.00 ± 14.81 1.00 55.00 (37.10, 38.90) (0.26, 0.27) PA Survey = Physical activity knowledge survey score (number reflects average percentage correct) NS = Nutrition knowledge survey score PACES = Physical Activity Enjoyment Score survey n = number of students Table 2. Summary statistics for total sample of male and female students by grade level for students who completed the physical activity knowledge survey, the nutrition knowledge survey, and PACES test. Variable Males Females Grade 3 Grade 4 Grade 5 Grade 6 PA Survey 240 264 n/a 236 218 50 NS 382 418 262 261 222 55 PACES 378 417 259 259 222 55 1,000 1,099 521 992 662 160 Total PA Survey = Physical activity knowledge survey NS = Nutrition knowledge survey PACES = Physical Activity Enjoyment Scale survey Table 3. Pre- and postintervention comparisons between physical activity knowledge scores, nutrition knowledge scores, and PACES score for students in five Title I elementary schools. Pre (mean ± SD) Post (mean ± SD) P-value PA Score 0.26 ± 0.11 0.28 ± 0.12 0.045* NS 10.89 ± 1.74 11.18 ± 1.70 0.15 PACES 36.84 ± 15.14 39.34 ± 14.79 0.017** PA Score = Physical activity knowledge survey score NS = Nutrition knowledge survey score PACES = Physical Activity Enjoyment Scale score *p<0.05 = significant difference between pre- and postintervention PA scores **p<0.05 = significant differences between pre- and postintervention PACES scores Table 4. Comparisons of sex and grade level for the physical activity knowledge survey scores, nutrition knowledge survey scores, and PACES. Male Female Grade 3 Grade 4 Grade 5 Grade 6 0.26 ± 0.12 0.27 ± 0.11* n/a 0.24 ± 0.09 0.30 ± 0.13** 0.25 ± 0.12 NS 10.95 ± 2.00 11.11 ± 0.43*** 10.83 ± 1.51 10.89 ± 1.81 11.42 ± 1.72**** 11.11 ± 2.08 PACES 37.89 ± 15.15 38.29 ± 14.90 37.99 ± 14.91 39.22 ± 14.49***** 38.14 ± 15.01 33.22 ± 17.17 PA Score PA Score = Physical activity knowledge survey score NS = Nutrition knowledge survey score PACES = Physical Activity Enjoyment Scale score * p<0.05 for significant difference between male and female PA knowledge survey scores ** p<0.05 for significant difference between 5th grade students and 4th and 6th grade students *** p<0.05 for significant difference between male and female nutrition knowledge survey scores **** p<0.05 for significant difference between 5th grade students and 3rd and 4th grade nutrition knowledge survey scores ***** p<0.05 for significant differences between 4th and 6th grade students for PACES score 15 16 Mean PA Knowledge Score = Mean physical activity knowledge score *P<0.05 for significant differences between 5 th graders and 4th and 6th graders with 5th grade students scoring higher Grade and time were significant (p=0.039); average 4th grade score decreased pre- (M = 0.244) to postintervention (M = 0.235) while both 5th and 6th graders average score increased from pre- to postintervention (0.281 to 0.321 and 0.235 to 0.280), respectively Figure 1. Mean physical activity knowledge scores by grade level, stratified by time (baseline and follow up) in Title I elementary school children (n=504). * p<0.05 for significant difference between 5th grade students and 3rd and 4th grade scores Figure 2. Nutrition knowledge survey score and grade by grade comparisons in Title I elementary school children (n=800). 17 * p<0.05 for significant difference between male and female nutrition knowledge survey scores Figure 3. Mean male and female nutrition knowledge survey scores in Title I elementary school children (n=800). *p<0.05 for significant differences between male and female average scores Figure 4. Mean nutrition knowledge scores from baseline to follow up for male and female students (n=800) in Title I elementary school children. 18 PACES score = Physical Activity Enjoyment Scale score *p<0.05 = significant difference between pre- and postintervention physical activity enjoyment scale (PACES) scores Figure 5. Mean change in PACES score from baseline and follow up in low socioeconomic ethnic minority elementary school children (n=800). PACES score = Physical Activity Enjoyment Scale score * p<0.05 = significant differences between 4th and 6th grade student PACES scores Figure 6. Mean changes in physical activity enjoyment scores (PACES) for 3rd - 6th grade elementary school children (n=800) DISCUSSION Physical activity knowledge scores significantly increased from pre- to postintervention. The current study results support previous findings of improvements in physical activity knowledge during school-based programs (32, 42, 43). Moreover, our results are comparable to Tsia et al., as that study reported increases in physical activity knowledge among ethnic minority low SES children (n=840) in a school-based intervention (44). Additionally, studies indicate that increases in physical activity knowledge are associated with reductions in BMI and improvements in aerobic fitness (21-23, 32). Overall, the literature supports the importance of incorporating physical activity education in a comprehensive school-based intervention. The physical activity knowledge results also yielded significant differences between the 5th and 6th grades, as well as between the 4th and 5th grades. Students in the 5th grade scored higher than both 4th and 6th grade students. These results could be explained by Hodges et al. who found the PE Metrics test to be a valid tool for 5th grade students, with consideration that the tool may not be applicable to all age groups (38). Additionally, 4th grade scores decreased from pre- to postintervention, while both 5th and 6th grade scores increased from pre- to postintervention. In a review, Budd and Volpe reported that children of older age often respond better to interventions, as compared to younger children (45). Lastly, there was a difference in knowledge scores by 20 sex, with females scoring higher than males. This finding may be explained by a review of school-based obesity prevention programs (46). This review found that gender may be a factor in intervention effectiveness, with social and behavioral interventions more effective in females and structural interventions more beneficial in males (46). Thus, study outcomes based on sex may be accounted for by the type of physical activity knowledge intervention. The CSPAP intervention demonstrated increases in nutrition knowledge scores; however, contrary to our hypothesis, this increase was not statistically significant. Current research demonstrates that nutrition education interventions result in improvements in knowledge, thus, our results are inconsistent with previous research (20, 27-30). Similarly, Gower et al. reported that 1st-4th grade students (n=74) significantly improved nutrition knowledge scores (12.2 ± 1.9 to 13.5 ± 1.6 ; p<0.001) upon completion of a four-week intervention, as compared to controls (39). While the computerized testing method was similar to the current study, Gower et al. implemented detailed lesson plans, with four weekly nutrition education classes (39). Another nutrition intervention for low SES minority children showed significant improvements in nutrition knowledge after a substantial intervention focused on classroom lesson plans, posters, food pictures, student workbooks, and parental homework (47). A further intervention utilized a game-based educational intervention to yield significant increases in nutrition knowledge (48). Therefore, the current results could be explained by the limited nutrition education implemented. Additionally, there were significant differences in nutrition knowledge scores between sexes, with females scoring higher than males. These results are in contrast to 21 previous findings in the literature. Warren et al. found no differences between the sexes in a 14-month school-based nutrition education intervention for children ages 5-7 (n=213), with overall nutrition knowledge improvements of 15% (49). Finally, the current study results showed that 5th grade students had significantly higher scores than both 3rd and 4th grade students. In summary, older children may benefit more from interventions, with sex differences due in part to learning differences between males and females (46). Physical activity enjoyment scale scores significantly increased following the CSPAP intervention. Furthermore, there was a statistical difference between 4th and 6th grade students, with 4th graders reporting a higher enjoyment of physical activity. Our results corroborate previous findings that physical activity enjoyment scores increase during school-based interventions (15, 16). Additionally, the current study demonstrated increased physical activity enjoyment in both boys and girls following the intervention. This result is in contrast to earlier studies that reported greater declines in physical activity levels for girls, as compared to boys, during childhood (50, 51). Regarding outcomes, research indicates that enjoyment of physical activity is associated with active behavior, with potential subsequent reductions in BMI (13, 14, 17, 52). Additionally, for the current study, the physical activity enjoyment scale showed a positive correlation with nutrition knowledge. Thus, as average nutrition knowledge increased, the PACES score increased. The strengths of this study include the large sample size, the specific health parameters chosen, and the ethnic minority and low SES population. The large sample size allows for closer representation of the actual population, limiting outliers within the 22 data. Additionally, ethnic minority and low SES children have a higher prevalence of childhood obesity; therefore, studies that are focused on this group specifically may help prevent increases in childhood obesity rates. Finally, the health parameters selected are valid assessments. There are several limitations to this study, including the following: the use of a convenience sample, the physical activity and nutrition intervention, the knowledge assessments, and the potential confounding variables. First, this study utilized a convenience sample, which may be prone to bias and under- or over-representation of groups within the sample. Second, the physical activity and nutrition knowledge intervention was minimal, consisting of education implemented into PE lessons, classroom activity breaks, and informative bulletin boards. Third, culturally appropriate foods were not used in the nutrition knowledge survey, which may have led to confusion among study participants. Additionally, the knowledge assessments were the same for all grade levels and for non-English speakers, which may have contributed to skewed results. Finally, potential confounding variables, such as previous physical activity level, history of disease, and dietary habits, were not included in the data analysis. There is limited research in a low socioeconomic student population that documents changes in physical activity knowledge, nutrition knowledge, and physical activity enjoyment during a CSPAP intervention. Further, there is a lack of research that compares the associations between the physical activity enjoyment scale and nutrition knowledge. Due to the high prevalence of childhood obesity, the current study may help to guide the development of comprehensive school-based interventions in low socioeconomic and ethnic minority groups. CONCLUSION Physical activity knowledge and physical activity enjoyment scores increased significantly during a CSPAP intervention in children in grades 4th-6th in five Title I elementary schools. Additionally, nutrition knowledge scores increased, although not significantly, in children in grades 3rd-6th. The study results demonstrate that physical activity and nutrition education are essential components in a comprehensive schoolbased intervention in an ethnic minority low socioeconomic population. Furthermore, these findings indicate that improvements in physical activity enjoyment can occur during a school-based intervention. Increases in physical activity enjoyment and knowledge may translate to increases in chronic physical activity and improve children’s health outcomes. A multicomponent school-based intervention may be able to decrease rates of childhood obesity and provide a framework for future interventions. REFERENCES 1. Ogden CL, C. C, Fryar M, Flegal C. Prevalence of obesity among adults and youth: United States, 2011-2014. National Center for Health Statistics 2015;219:1-8. 2. Centers for Disease Control. Childhood Obesity Facts [Internet]. [cited 2016 15 Oct]. Available from: https://www.cdc.gov/healthyschools/obesity/facts.htm. 3. Patton GC, Sawyer SM, Santelli JS, Ross DA, Afifi R, Allen NB, Arora M, Azzopardi P, Baldwin W, Bonell C, et al. Our future: a Lancet commission on adolescent health and wellbeing. The Lancet 2016;387(10036):2423-78. doi: 10.1016/S0140-6736(16)00579-1. 4. Carey FR, Singh GK, Brown Iii HS, Wilkinson AV. Educational outcomes associated with childhood obesity in the United States: cross-sectional results from the 2011–2012 National Survey of Children’s Health. The International Journal of Behavioral Nutrition and Physical Activity 2015;12(Suppl 1):S3-S. doi: 10.1186/1479-5868-12-S1-S3. 5. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States 2011-2012 Journal of the American Medical Association 2014;311(8):806-14. 6. Jin Y, Jones-Smith JC. Associations between family income and children's physical fitness and obesity in California 2010-2012. Preventing Chronic Disease 2015;12(17). 7. Datar A, Chung PJ. Changes in socioeconomic, racial/ethnic, and sex disparities in childhood obesity at school entry in the united states. JAMA Pediatrics 2015;169(7):696-7. doi: 10.1001/jamapediatrics.2015.0172. 8. Singh GK, Kogan MD, Van Dyck PC, Siahpush M. Racial/ethnic, socioeconomic, and behavioral determinants of childhood and adolescent obesity in the United States: analyzing independent and joint associations. Annals of Epidemiology 2008;18(9):682-95. doi: 10.1016/j.annepidem.2008.05.001. 25 9. Ogden CL, Lamb MM, Carroll MD, Flegal KM. Obesity and socioeconomic status in children: United States 1988-1994 and 2005-2008. NCHS data brief no 51. Hyattsville, MD: National Center for Health Statistics, 2010. 10. Ogden CL, Carroll MD, Curtin L, Lamb MM, Flegal KM. Prevalence of high body mass index in US children and adolescents, 2007-2008. Journal of the American Medical Association 2010 303(3):242-9. 11. DiLorenzo TM, Stucky-Ropp RC, Vander Wal JS, Gotham HJ. Determinants of exercise among children. II. A longitudinal analysis. Preventive Medicine 1998;27(3):470-7. doi: http://dx.doi.org/10.1006/pmed.1998.0307. 12. Mullen SP, Olson EA, Phillips SM, Szabo AN, Wójcicki TR, Mailey EL, Gothe NP, Fanning JT, Kramer AF, McAuley E. Measuring enjoyment of physical activity in older adults: invariance of the physical activity enjoyment scale (paces) across groups and time. The International Journal of Behavioral Nutrition and Physical Activity 2011;8:103-. doi: 10.1186/1479-5868-8-103. 13. Sallis JF, Prochaska JJ, Taylor WC. A review of correlates of physical activity of children and adolescents. Medicine and Science in Sports and Exercise 2000;32(5):963-75. 14. Sallis JF, Prochaska JJ, Taylor WC, Hill JO, Geraci JC. Correlates of physical activity in a national sample of girls and boys in Grades 4 through 12. Health Psychology 1999;18(4):410-5. doi: 10.1037/0278-6133.18.4.410. 15. Dishman RK, Motl RW, Saunders R, Felton G, Ward DS, Dowda M, Pate RR. Enjoyment mediates effects of a school-based physical-activity intervention. Medicine and Science in Sports and Exercise 2005;37(3):478-87. 16. Elbe A-M, Wikman JM, Zheng M, Larsen MN, Nielsen G, Krustrup P. The importance of cohesion and enjoyment for the fitness improvement of 8–10-yearold children participating in a team and individual sport school-based physical activity intervention. European Journal of Sport Science 2017;17(3):343-50. doi: 10.1080/17461391.2016.1260641. 17. Labbrozzi D, Robazza C, Bertollo M, Bucci I, Bortoli L. Pubertal development, physical self-perception, and motivation toward physical activity in girls. Journal of Adolescence 2013;36(4):759-65. doi: http://dx.doi.org/10.1016/j.adolescence.2013.06.002. 18. Center for Public Education. Hours of Instruction by State [Internet]. [cited 2016 7 Oct]. Available from: http://www.centerforpubliceducation.org/MainMenu/Organizing-a-school/Time-in-school-How-does-the-US-compare. 26 19. National Center for Educational Statistics. Back to School Statistics [Internet]. [cited 2016 16 Nov]. Available from: http://nces.ed.gov/fastfacts/display.asp?id=372. 20. Rosario R, Oliveira B, Araujo A. The impact of an intervention taught by trained teachers on childhood overweight. International Journal of Environmental Research and Public Health 2012;9(4):1355-67. 21. Puder JJ, Marques-Vidal P, Schindler C, Zahner L, Niederer I, Bürgi F, Ebenegger V, Nydegger A, Kriemler S. Effect of multidimensional lifestyle intervention on fitness and adiposity in predominantly migrant preschool children (Ballabeina): cluster randomised controlled trial. The BMJ 2011;343:d6195. doi: 10.1136/bmj.d6195. 22. Li X-H, Lin S, Guo H, Huang Y, Wu L, Zhang Z, Ma J, Wang H-J. Effectiveness of a school-based physical activity intervention on obesity in school children: a nonrandomized controlled trial. BMC Public Health 2014;14:1282. doi: 10.1186/1471-2458-14-1282. 23. Thompson A, Hannon JC. Health-related fitness knowledge and physical activity of high school students. Physical Education 2012;69:71-88. 24. Longmuir PE, Boyer C, Lloyd M, Yang Y, Boiarskaia E, Zhu W, Tremblay MS. The Canadian assessment of physical literacy: methods for children in grades 4 to 6 (8 to 12 years). BMC Public Health 2015;15:767. doi: 10.1186/s12889-0152106-6. 25. Gordon-Larsen P, Nelson MC, Page P, Popkin BM. Inequality in the built environment underlies key health disparities in physical activity and obesity. Pediatrics 2006;117(2):417-24. doi: 10.1542/peds.2005-0058. 26. Messiah SE, Arheart KL, Lopez-Mitnik G, Lipshultz SE, Miller TL. Ethnic group differences in cardiometabolic disease risk factors independent of body mass index among american youth. Obesity 2013;21(3):424-8. doi: 10.1002/oby.20343. 27. Carraway-Stage V, Hovland J, Showers C, Díaz S, Duffrin MW. Food-based science curriculum yields gains in nutrition knowledge. Journal of School Health 2015;85(4):231-40. doi: 10.1111/josh.12243. 28. Turnin M-C, Buisson J-C, Ahluwalia N, Cazals L, Bolzonella-Pene C, FouquetMartineau C, Martini P, Tauber M, Hanaire H. Effect of nutritional intervention on food choices of french students in middle school cafeterias, using an interactive educational software program (Nutri-Advice). Journal of Nutrition Education and Behavior 2016;48(2):131-7.e1. doi: http://dx.doi.org/10.1016/j.jneb.2015.09.011. 27 29. Habib-Mourad C, Ghandour LA, Moore HJ, Nabhani-Zeidan M, Adetayo K, Hwalla N, Summerbell C. Promoting healthy eating and physical activity among school children: findings from Health-E-PALS, the first pilot intervention from Lebanon. BMC Public Health 2014;14:940. doi: 10.1186/1471-2458-14-940. 30. Clarke KK, Freeland-Graves J, Klohe-Lehman DM, Bohman TM. Predictors of weight loss in low-income mothers of young children Journal of the Academy of Nutrition and Dietitics 2007;107(7):1146-54. 31. Sobol-Goldberg S, Rabinowitz J, Gross R. School-based obesity prevention programs: a meta-analysis of randomized controlled trials. Obesity 2013;21(12):2422-8. doi: 10.1002/oby.20515. 32. Nemet D, Barkan S, Epstein Y, Friedland O, Kowen G, Eliakim A. Short- and long-term beneficial effects of a combined dietary–behavioral–physical activity intervention for the treatment of childhood obesity. Pediatrics 2005;115(4):e443. 33. Maatoug J, Msakni Z, Zammit N, Bhiri S, Harrabi I, Boughammoura L, Slama S, Larbi C, Ghannem H. School-based intervention as a component of a comprehensive community program for overweight and obesity prevention, Sousse, Tunisia, 2009–2014. Preventing Chronic Disease 2015;12:E160. doi: 10.5888/pcd12.140518. 34. Heelan KA, Bartee RT, Nihiser A, Sherry B. Healthier school environment leads to decreases in childhood obesity – The Kearney Nebraska story. Childhood Obesity 2015;11(5):600-7. doi: 10.1089/chi.2015.0005. 35. TA. B, JC. H. Grant proposal to the United States Department of Education: The Carol M. White Physical Education Program. Let’s Get Fit-to-Learn: a comprehensive approach to nutrition and physical activity. 2013 1-23. 36. Salt Lake City School District. District Demographics [Internet]. [cited 2016 8 Nov]. Available from: http://www.slcschools.org/schools/DistrictDemographics.php#.WCT-FfkrLIX. 37. Society of Health and Physical Educators (SHAPE) [Internet]. [cited 2016 15 Oct]. Available from: http://www.shapeamerica.org/publications/products/pemetrics.cfm. 38. Hodges M, Lee C, Lorenz KA, Cipriani D. Review of the PE Metrics cognitive assessment tool for fifth grade students. Biomedical Human Kinetics 2015;7:10915. 28 39. Gower JR, Moyer-Mileur LJ, Wilkinson RD, Slater H, Jordan KC. Validity and reliability of a nutrition knowledge survey for assessment in elementary school children. Journal of the Academy of Nutrition and Dietetics 2010;110(3):452-6. doi: 10.1016/j.jada.2009.11.017. 40. D. K, K. D. Physical Activity Enjoyment Scale: two validation studies. Journal of Sport and Exercise Psychology 1991;13(1):50-64. doi: http://dx.doi.org/10.1123/jsep.13.1.50. 41. Measuring enjoyment of physical activity in children: validation of the Physical Activity Enjoyment Scale. Journal of Applied Sport Psychology 2009;21(S1):S116-S29. doi: 10.1080/10413200802593612. 42. Saksvig BI, Gittelsohn J, Harris SB, Hanley AJG, Valente TW, Zinman B. A pilot school-based healthy eating and physical activity intervention improves diet, food knowledge, and self-efficacy for native Canadian children. The Journal of Nutrition 2005;135(10):2392-8. 43. Mihrshahi S, Vaughan L, Fa’avale N, De Silva Weliange S, Manu-Sione I, Schubert L. Evaluation of the Good Start Program: a healthy eating and physical activity intervention for Maori and Pacific Islander children living in Queensland, Australia. BMC Public Health 2017;17(1):77. doi: 10.1186/s12889-016-3977-x. 44. Tsai P-Y, Boonpleng W, McElmurry BJ, Park CG, McCreary L. Lessons learned in using TAKE 10! with Hispanic children. The Journal of School Nursing 2009;25(2):163-72. doi: 10.1177/1059840509331437. 45. Budd GM, Volpe SL. School-based obesity prevention: research, challenges, and recommendations. Journal of School Health 2006;76(10):485-95. doi: 10.1111/j.1746-1561.2006.00149.x. 46. Kropski JA, Keckley PH, Jensen GL. School-based obesity prevention programs: an evidence-based review. Obesity 2008;16(5):1009-18. doi: 10.1038/oby.2008.29. 47. Larsen AL, Liao Y, Alberts J, Huh J, Robertson T, Dunton GF. RE-AIM analysis of a school-based nutrition education intervention in kindergarteners. Journal of School Health 2017;87(1):36-46. doi: 10.1111/josh.12466. 48. Rosi A, Dall’Asta M, Brighenti F, Del Rio D, Volta E, Baroni I, Nalin M, Coti Zelati M, Sanna A, Scazzina F. The use of new technologies for nutritional education in primary schools: a pilot study. Public Health 2016;140:50-5. doi: 10.1016/j.puhe.2016.08.021. 29 49. Warren JM, Henry CJK, Lightowler HJ, Bradshaw SM, Perwaiz S. Evaluation of a pilot school programme aimed at the prevention of obesity in children. Health Promotion International 2003;18(4):287-96. doi: 10.1093/heapro/dag402. 50. Craggs C, Corder K, van Sluijs EMF, Griffin SJ. Determinants of change in physical activity in children and adolescents: a systematic review. American Journal of Preventive Medicine 2011;40(6):645-58. doi: http://dx.doi.org/10.1016/j.amepre.2011.02.025. 51. Lubans DR, Morgan PJ, Dewar D, Collins CE, Plotnikoff RC, Okely AD, Batterham MJ, Finn T, Callister R. The nutrition and enjoyable activity for teen girls (NEAT girls) randomized controlled trial for adolescent girls from disadvantaged secondary schools: rationale, study protocol, and baseline results. BMC Public Health 2010;10(1):652. doi: 10.1186/1471-2458-10-652. 52. Remmers T, Sleddens EFC, Kremers SPJ, Thijs C. Moderators of the relationship between physical activity enjoyment and physical activity in children. Journal of Physical Activity and Health 2015;12(8):1066-73. doi: 10.1123/jpah.2014-0011.