batter up for bone health
TRANSCRIPT
Batter Up For Bone Health: Education intervention to improve bone health knowledge in school-
age children
Sarah Allaben, BSErica Auriemme, BSAlexis Blandine, BS
Kiah Ehrke, BSEllen Hashiguchi, MPHMaggie Tignanelli, BS
Thesis advisor: Karen Plawecki PhD, RD
On Deck● Background ● Methods● Demographics● Results and discussion● Strengths and limitations● Future implications for research
Batter Up for Bone HealthAn interactive, behavioral theory-based education game mimicking a game of baseball.
Objectives: 1. Improve bone health knowledge
and behaviors for 7-10 year olds. 2. Educate children on foods rich in
vitamin D and calcium. 3. Promote physical activities that
support healthy bone development.
Tested in both school and camp settings.
Bone OverviewCortical Bone and Trabecular bone1
● Crystalline hydroxyapatiteCa5(PO4)2
Osteogenesis = the formation of bones2
● Osteoblasts: bone building● Osteoclasts: bone resorption
Leading Players● Calcium & Vitamin D● Physical Activity
(Lian, 2004; Gilbert, 2000)
Mechanism of BonesOsteogenesis
● Osteoblasts + Bone Matrix play pivotal roles1
○ Basic steps:■ Synthesis of matrix■ Matrix mineralization■ Bone remodeling
Osteoblasts● Parathyroid Hormone (PTH) and Estrogen
Bone matrix ● Inorganic compounds● Organic compounds
(Kini, 2012)
Bone Remodeling
●Constantly undergoing modeling
●Osteoblasts have a dual function
●Average lifespan of each remodeled unit in humans is 2-8 months1
(Kini, 2012)
Bone Remodeling● Peak bone
height velocity slows at puberty
(Fortes, 2012)
Bone Remodeling•Highest plasma bone biomarkers in 10-12
year olds1
• Osteocalcin• Bone Alkaline Phosphatase• C-Terminal telopeptide
•Decreased with bone age + breast development1
•At puberty, girls are in Tanner Stage 4 [physical maturation]2
(Fortes, 2014; WHO, 2014)
Bone Lifespan● Trabecular bone grows faster than cortical bone● Maximize peak bone mass in adolescence ● Remodeling increases in peri- and early postmenopausal women.● 5-10% of total bone is renewed annually
Bone Health DiseasesRickets/Osteomalacia
●Softening and weakening of bone
●Osteoid accumulates in the bone tissue below the growth plate
○Bone eventually forms bowing shape1
●Not only Vitamin D deficiency
○Poor calcium and phosphorous intake2
(Nield, 2006; Thacher, 2013)
Incidence of Rickets/Osteomalacia
● Incidence has increased since 20001
○ Most incidences occur in African Americans
(Thacher, 2013)
Bone Health DiseasesOsteoporosis • Translates to porous bone • Resorption happens more quickly than
osteoid formation
• 1 in 3 women and 1 in 5 men are at risk 1
• Common fractures in hip, spine and wrist
• Why prevention is important • 10% increase in peak bone mass,
reduces risk of fracture by 50%1
(IOF, 2015)
Calcium Overview
● Positive effect on bone mass in children and adolescents 1
● Nutrient of Concern
(Webb, 2014)
Calcium Overview
● Serum calcium is kept constant at bone’s expense
● Increasing calcium consumption has greater bone benefits
(Houillier, 2006)
(WWEIA, 2014; Rehm, 2015)
Calcium
(Van Stuijvenberg, 2015)
Cross-sectional study - South Africa• 2-5 year olds• 62.6% did not consume milk
Calcium • 21% EAR
Vitamin D• 15% EAR
Results• Significant stunting
(Hever, 2015)
(Weishaar, 2013)
Distribution of serum 25-hydroxyvitamin D levels by racial/ethnic group in the US population
Vitamin DRDA - 15 μg or 600 IU/day¹
• 97.5% of children aged 1–18 years
Dietary Intake¹
• 77% of total vitamin D
• 5.8 μg/day
Serum 25-hydroxyvitamin D: >20 ng/mL²
• Children 6-11 years vs. ages 1-5 years
• Non-Hispanic black children
• Hispanic children
(Moore, 2014; Mansbach, 2009)
Vitamin D12-week randomized, double-blind, controlled study
• 6-10 year olds
• 3 Beverage Groups: Ca, CaD, CaDEA
Results
• CaD & CaDEA groups
Improved 25(OH)D status
(Economos , 2014)
Joint Force Ground Force
Types of Exercise
(Behnke, 2012)
Ground Force Research● Short-term bone biochemical response1
○ Sample: 15 male students○ Age 20-35○ Bilateral jumping
■ ranged from 520 - 2278 jumps (mean=1270)○ Venous blood sample taken pre and post exercise
■ CTx■ P1NP
● Positive % increase○ No significant correlation between number of jumps and
P1NP
(Rantalainen, 2009)
Ground Force Research
Physical Activity Trends in the Pediatric Population
• Recommended 60 minutes daily activity between ages 6 - 17
1
• Physical Education within the School through a Comprehensive School Physical Activity Program
• Physical Education Classes • Movement within the
Classroom • Recess 2
(USDHHS, 2011; CDC, 2015)
Example of Comprehensive School Physical Activity Program Design
(Orlowski, 2013)
Research Shows● A decrease in physical
education classes in high school○ 13% decrease from 1991 to
20131
● Physical education classes offered 3 days/week in elementary school2
○ Early Childhood Longitudinal Study
○ 20,000 8th grade students
○ Physical Education offered 3 days a week
(CDC, 2015; Vericker, 2014)
Triple Play!
Social Cognitive Theory
• Learning occurs within a social context
Social Cognitive Theory
Self efficacy is positively associated with healthy eating habits1
• Significant model pathway (B=+0.46) from self-efficacy to percentage energy intake, p=.001
(Lubans, 2012; Larsen, 2015)
Self efficacy predicts outcome expectations2
• Self efficacy increased .728 from pretest to posttest
• Outcome expectations increased 2.52 from pretest to posttest
Social Cognitive Theory
Children ate more F & V when exposed to peers eating F & V1
• N=749• Increased F & V
consumption post-intervention (p<.001), increased F & V consumption at home (p<.05)
(Horne, 2004)
Batter Up! For Bone Health
The Rules [Methods]
Purpose of Batter Up! for Bone Health
Improve bone health knowledge and behaviors for school children ages 7-10 years:
• Identifying bone healthy foods
• Participating in physical activities associated with bone health
Intervention Layout and Base Information
Survey Tools• Recruitment Flyer• Consent to participate• Demographics• Three Measurable Tests
Survey Timeline
Tips For the School
Location
Location Participants with
Consent Forms
School 59% (n=99)
Camp 41% (n=69)
Gender
EthnicityChart: Ethnicity of Participants
with Consent Forms
n = 165
Ethnicity by Location
N=67 N=98
Calcium Sources Consumed
Multivitamin Sources Reported
7th Inning Stretch
(Results)
H01 There is no difference in overall bone health knowledge gained.
Pre-to Post-test
Sample size Mean Difference
standard deviation
test value
p-value confidence interval/effect
size
Overalla 119 Pre-test: 12.55 Post-test: 13.17
Pre-test: 1.85 Post-test: 2.46
-3.03 0.003 0.1239
Between Gendersb
Total N= 129 F= 61M=58
F: 0.61
M: 0.64
Females:2.02Males: 2.46
-0.08 0.940 Inside
Between Agesc
Total N=118(7)=1(8)=32(9)=49(10)=36
Total: 13.167yr: 13.00 8yr: 12.339yr: 13.25 10yr: 13.79
Total: 2.237yr: --8yr: 2.899yr: 1.91 10yr: 1.82
F=2.43 0.069 Outside
Between Locationsb
Total N= 129 S= 93C= 26
S: 0.74
C: 0.19
School: 1.93
Camp: 3.11
1.11 0.27 Inside
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male, S = School, C = Camp
H02 There is no difference in overall bone health knowledge retained.
Post- to 21-day post test
Sample size Mean Standard deviation
Test value
p-value Confidence interval/effect size
Overalla 118 Post-test: 13.4121-day posttest: 13.48
Post-test: 1.9921-day posttest:2.07
-0.49 0.627 outside
Between Gendersb
Total N= 128 F= 60M= 58
F: -0.02M: 0.17
F: 1.14M: 2.13
-0.60 0.548 outside
Between Agesc
Total N= 117(8) N= 29(9) N=52(10) N=36
Total: 13.45 8yr: 13.25 9yr: 13.52 10yr: 13.54
Total: 0.098yr: 0.529yr: 0.19 10yr: -0.42
2.67 0.074 outside
Between Locationsa
Total: 128(S) N=97(C) N=21
S: 0.01 C: 0.38
S: 1.72C: 1.63
-0.91 0.306 inside
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male, S = School, C = Camp
H03 There is no difference in overall bone health knowledge gained in the schools.
In the School
Sample size Mean Standard deviation
test value
p-value Confidence interval/effect size
Overall Knowledgea
93 Pre-test: 12.80 Post-test: 13.54
Pre-test: 1.64 Post-test: 1.91
-3.71 0.0001 0.20
Knowledge Between Gendersb
Total N= 93 F= 49M= 44
F: 0.88 M: 0.59
F: 1.86M: 2.02
0.71 0.478 inside
Knowledge Between Agesc
Total N= 93(8) N= 21(9) N=39(10) N=33
0.74 1.93 0.90 0.412 outside
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male
H04 There is no difference in overall bone health knowledge retained in the schools.
In the School
Sample size Mean Standard Deviation
test value
p-value Confidence interval/effe
ct size
Overall Retentiona
97 Post-test: 13.65 21-day: 13.66
Post-test: 1.76 21-day: 1.75
-0.06 0.953 outside
Retention Between Genders b
Total N= 97 F= 50M= 47
F: -0.08M: 0.11
F: 1.01 M: 2.25
-0.52 0.604 outside
Retention between Ages c
Total N= 97(8) N= 22(9) N=42(10) N=33
0.01 1.72 2.60 0.080 outside
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male
Table: Bone health knowledge gained and retained in both locations; isolated in a school setting.Target Group
Sample Size
Mean Standard Deviation
Test value (F)
p-value Confidence interval/effect size
Overall Knowledge and Retention d
112 Pre-test: 12.53Post-test: 13.3821-day post-test: 13.52
Pre-test: 1.88 Post-test: 2.0221-day post-test: 2.05
18.94 0.0001 0.26
Overall Knowledge and Retention in Schools d
92 Pre-test: 12.80Post-test: 13.6121-day post-test: 13.65
Pre-test: 1.65Post-test:1.80 21-day post-test: 1.79
14.89 0.0001 0.25
dRepeated Measures ANOVA
Knowledge gained and knowledge retained at both locations; camp isolation.
p-value, camp <0.0001
p-value, school <0.0001
Overall scores
H05 There is no change in knowledge increase of calcium-containing foods among the participants.
Target Group
Sample Size (N)
Mean Difference
Standard Deviation
Test Value
P - Value
Confidence Interval/Effect Size
Overalla 113 Pretest: 4.73Posttest: 5.24Mean Diff: 0.51
Pretest: 0.87Posttest: 0.96
6.89 0.0001 0.28 (M)
Between Gendersb
Total N = 113 (F) N = 58(M) N = 55
F: 0.43M: 0.60
F: 0.70M: 0.87 -1.14 0.26
Outside
Between Agesc
Total N = 112(8) N = 30(9) N =46(10) N =35
Total: 0.528 yr: 0.37 9 yr: 0.5010 yr: 0.63
Total: 0.52 8 yr: 0.379 yr: 0.5010 yr: 0.63
1.04 0.38
Outside
Between Locationsb
Total N = 113 (S) N = 89(C) N = 24
S: 0.53C: 0.46
S: 0.72C: 1.02
0.31 0.76
Outside
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male, S = School, C = Camp
H06 There is no change in knowledge retention of calcium-containing foods among the participants. Target Group
Sample Size (N)
Mean Difference
Standard Deviation
Test Value
P-Value Confidence Interval/Effect Size
Overalla 115 Posttest: 5.5721DayPost: 5.21 Mean Diff: -0.36
Posttest: 0.9521DayPost: 1.01
0.79 0.43 Outside
Between Gendersb
Total N = 115(F) N = 60(M) N = 55
F: -0.08M: -0.04
F: 0.70M: 0.96
-0.30 0.76
Outside
Between Agesc
Total N = 114(8) N = 29(9) N =49(10) N =36
Total: -0.08 8 yr: 0.039 yr: -0.0610 yr: -0.19
Total: 0.81 8 yr: 0.639 yr: 0.9410 yr: 0.75
0.66 0.52 Outside
Between Locationsb
Total N = 115(S) N = 94(C) N = 21
S: -0.07C: 0.00
S: 0.82C: 0.89
-0.37 0.71 Outside
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male, S = School, C = Camp
H07 There is no change in knowledge increase of calcium-containing foods among the participants (school isolated).
Target Group
SampleSize (N)
Mean Difference
Standard Deviation
Test Value
P-Value Confidence Interval/Effect Size
Overalla 89Pretest: 4.84Posttest: 5.37Mean Diff: 0.53
Pretest: 0.80Posttest: 0.82
-6.88 0.0001 0.31 (M)
Between Gendersb
Total N = 89(F) N = 47(M) N = 42
F: 0.53M: 0.52
F: 0.58M: 0.86
0.52 0.96 Outside
Between Agesc
Total N = 89(8) N = 21(9) N = 36(10) N = 32
Total: 0.538 yr: 0.389 yr: 0.5010 yr: 0.66
Total: 0.728 yr: 0.599 yr: 0.8810 yr: 0.60
0.96 0.39 Within
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male
H08 There is no change in knowledge retention of calcium-containing foods among the participants (school isolated).
Target Group
Sample Size (N)
Mean Difference
Standard Deviation
Test Value
P-Value Confidence Interval/ Effect Size
Overalla 94 Posttest: 5.3921DayPost: 5.31Mean Diff: -0.08
Posttest: 0.8121DayPost: 0.89
0.88 0.38 Outside
Between Gendersb
Total N = 94(F) N = 50(M) N = 44
F: -0.10M: -0.46
F: 0.58M: 1.03
-0.32 0.75 Outside
Between Agesc
Total N = 95(8) N = 22(9) N = 39(10) N = 33
Total: -0.078 yr: 0.099 yr: -0.0310 yr: -0.24
Total: 0.898 yr: 0.619 yr: 0.9610 yr: 0.75
1.22 0.30 Outside
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male,
H09 There is no difference between knowledge of Vitamin D sources among participants.
Target Group
Sample Size (N)
Mean Difference
Standard Deviation
Test Value
P Value
Confidence Interval/Effect Size
Overalla 107 Pretest: 4.20Posttest:4.59Difference: 0.39
Pretest: 0.84Posttest: 0.64
-5.61 0.0001
0.23
Between Locationb
Total N = 107(S) N = 85(C) N = 22
S: 0.39C: 0.41
S: 0.73C: 0.73
-0.12 0.905 Outside
Between Genderb
Total N =107(F) N = 57(M) N = 50
F: 0.37 M: 0.42
F: 0.72M: 0.73
-0.37 0.715 Outside
Between Agesc
Total N = 106(8) N = 28(9) N = 43(10) N = 34
Total: 0.388 yr: 0.36 9 yr: 0.3510 yr: 0.44
Total: 0.718 yr: 0.739 yr: 0.6910 yr: 0.75
0.21 0.888 Outside
Between Ethnicitiesc
Total N = 106(H) N = 18(W) N = 74
Total:0.40H: 0.39 W: 0.35
Total: 0.73H: 0.78W:0.71
0.70 0.622 Outside
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male, S = School, C = Camp, W = White, H = Hispanic
Target Group
Sample Size (N)
Mean Difference
Standard Deviation Test Value
P Value
Confidence Interval/ Effect Size
Overalla 111 Posttest: 4.6021DayPost: 4.55Difference: -0.15
Pretest: 0.65Posttest: 0.89
0.70 0.486 Outside
Between Locationb
Total N = 111(S) N = 90(C) N = 21
S: -0.02 C: -0.14
S: 0.58C: 1.01
0.53 0.604 Outside
Between Genderb
Total N = 111(F) N = 58(M) N = 53
F: -0.07M: -0.02
F: 0.67M: 0.69
-0.39 0.700 Outside
Between Agesc
Total N =110(8) N =28(9) N =47(10) N =35
Total:-0.02 8 yr: 0.25 9 yr: -0.04 10 yr: -0.20
Total: 0.62 8 yr: 0.659 yr: 0.5910 yr: 0.58
4.42 (F)
0.014 0.08
Between Ethnicitiesc
Total N = 111(H) N = 19(W) N = 77
Total: -0.05H: -0.21W: -0.01
Total: 0.68H: 1.03W: 0.62
0.77 0.573 Outside
H010 There is no significant difference between retention of Vitamin D sources among participants.
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male, S = School, C = Camp, W = White, H = Hispanic
p<0.012
*Repeated Measures ANOVA
H010a There is no significant difference between retention of Vitamin D sources between the Hispanic and White population.
H011 There is no significant difference between knowledge of Vitamin D sources among school participants.
Target Group
Sample Size (N)
Mean Difference
Standard Deviation
TestValue
P Value
Confidence Interval/ Effect
Size
Overalla 85 Pretest:4.26Posttest:4.65Difference:0.39
Pretest: 0.79Posttest: 0.55
-4.94 0.0001
0.22
Between Gendersb
Total N = 85(F) N = 46(M) N = 39
F: 0.41 M: 0.36
F: 0.72M: 0.74
0.34 0.734 Outside
Between Agesc
Total N = 85(8) N = 20(9) N = 34(10) N = 31
Total: 0.39 8 yr: 0.40 9 yr: 0.32 10 yr: 0.45
Total: 0.738 yr: 0.759 yr: 0.6810 yr: 0.77
0.25 0.778 Outside
Between Ethnicitiesc
Total N = 85(H) = 2(W) = 71
Total: 0.39H: 0.00 W: 0.34
Total:0.73H: 0.00W: 0.72
1.08 0.371 Inside
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male, W = White, H = Hispanic
H012 There is no significant difference between retention of Vitamin D sources among school participants.
Target Group
Sample Size (N)
Mean Difference Standard Deviation
Test Value
P Value
Confidence Interval/ Effect
Size
Overalla 90 Pretest: 4.68Posttest:4.66Total Mean Diff: - 0.02
Pretest: 0.54Posttest: 0.74
0.36 0.717 Outside
Between Genderb
Total N = 90(F) N = 48(M) N = 42
F: 0.00 M: -0.05
F: 0.41M: 0.73
0.37 0.710 Outside
Between Agesc
T0tal N = 90(8) N = 21(9) N = 37(10) N = 32
Total: -0.02 8 yr: 0.14 9 yr: 0.54 10 yr: -0.22
Total: 0.588 yr: 0.579 yr: 0.5210 yr: 0.61
3.15 (F)
0.048 0.07
Between Ethnicitiesc
Total N = 90(H) N = 2(W) N = 75
Total: -0.02H: 0.00 W: -0.01
Total: 0.58H: 0.00W: 0.63
0.12 (F)
0.975 Outsideapaired t-test; bindependent samples t-test; c One-way ANOVA; F = Female, M = Male, W = White, H = Hispanic
Pre to Posttest Sample Size
Mean Standard deviation
Test Value P-value Confidence interval
Overalla 113 Pretest: 4.00Posttest: 3.88
0.85 1.53 0.127 Inside
Between Gendersb Total N= 113(F) N = 57(M) N = 56
F: -0.05M: -0.19
F: 0.91M: 0.79
0.89 0.375 Inside
Between Agesc Total N = 112(7) N =1(8) N =31(9) N =45(10) N =35
Total: -0.147 yr: ---8 yr: -0.229 yr: -0.0210 yr: -0.22
Total: 0.837 yr: 0.998 yr: 0.839 yr: 0.6810 yr: 0.82
0.53 0.657 Outside
Between Locationsb Total N = 113(S) N =89(C) N =24
S: -0.08C: -0.25
School: 0.79Camp: 1.07
0.81 0.09 Inside
H013 There is no difference in overall physical activity knowledge gained.
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male, S = School, C = Camp
Post to 21-Day Post
Sample size
Mean Standard deviation
Test Value
P-value Confidence interval/effect size
Overalla 114 Posttest: 3.8521-day Posttest: 3.90
Post-test: 0.7521-day Posttest: 0.83
-0.61 0.537 Outside
Between Gendersb
Total N= 114(F) N = 59(M) N = 55
F: 0.01M: 0.07
F: 0.68M: 0.83
-0.39 0.69 Outside
Between Agesc Total N = 113(8) N = 28(9) N = 50(10) N = 35
Total: 0.058 yr: -0.039 yr: 0.1610 yr: -0.02
Total: 0.758 yr: 0.699 yr: 0.8410 yr: 0.66
0.90 0.409 Outside
Between Locationsb
N=114(S)=93(C)= 21
School: -0.01Camp: 0.28
School : 0.69Camp: 0.95
-1.34 0.192 Outside
H014 There is no difference in physical activity knowledge retained.
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male, S = School, C = Camp
In the School
Sample Size Mean Standard Deviation
Test Value P-Value Confidence Interval/ Effect Size
Overalla 89 Pretest: 3.98Posttest: 3.89
Pretest: 0.71Posttest: 0.70
1.07 0.288 Outside
Between Gendersb
Total N = 89(F) N = 42(M) N = 47
F: -0.04M: -0.14
F: 0.88M: 0.68
0.59 0.554 Outside
Between Agesc
Total N = 89(8) N = 20(9) N = 37(10) N = 32
Total: -0.088 yr: -0.059 yr: 0.0010 yr: -0.21
Total: 0.798 yr: 0.829 yr: 0.8410 yr: 0.70
0.68 0.509 Outside
H015 There is no difference in overall physical activity knowledge within the school.
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male
H016 There is no difference in overall physical activity knowledge retained within the school.
In the School
Sample Size
Mean Standard Deviation
Test value
P-value Confidence Interval/
Effect Size
Overalla 93 Posttest: 3.9021DayPost: 3.89
Posttest: 0.7021DayPost: 0.81
1.48 0.882 Outside
Between Gendersb
Total N = 93(F) = 44(M) = 49
F: -0.04M: 0.02
F: 0.57M: 0.82
-0.42 0.67 Inside
Between Agesc
Total N = 93(8) N = 21(9) N = 40(10) N = 32
Total: -0.018 yr: -0.149 yr: 0.1010 yr: -0.06
Total: 0.698 yr: 0.659 yr: 0.7410 yr: 0.66
F=0.96 0.386 Outside
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male
21-Day Posttest
Sample Size
Mean Standard Deviation
Frequencies Correct
Frequencies Incorrect
Chi-Square P-Value
Video vs. Vacuum
128 1.0234 .1518 125 3 1116.281 .000
Basketball vs. Swimming
127 1.5276 .5012 60 67 .386 .535
Computer vs. Playing outside
128 1.0078 .0883 127 1 124.031 .000
Listening to music vs. dancing
128 1.1328 .3407 111 17 69.031 .000
Be active for at least ___ minutes/day
126 1.3968 .4911 76 50 5.365 .021
H017 There is no difference in physical activity knowledge retained.
*Chi square test
Principal Components
Analysis (PCA)
Pre-Test
Question New variable
Cronbach Alpha
When I see my (friends, adults at home, brothers, sisters, teachers) drinking milk, I’m more likely to drink milk
Drinking milk
.863
Like to eat what my teachers eat or when I see my teacher eat something, I like to eat that food tooMy friends and I eat the same foods
School environme
nt
.666
*Principal Components Analysis, Cronbach alpha
Principal Components
Analysis (PCA)
21-day Post Test
Question New variable Cronbach alpha
When I see my (friends, adults at home, brothers, sisters, teachers) drinking milk, I’m more likely to drink milk
Drinking milk
.885
Like to eat what my friends/teachers eatWhen I see my friends/teachers eat something, I like to eat that food too
School environment
.295
*Principal Components Analysis, Cronbach alpha
Pre-Test (n=119) 21-Day Post-Test (n=120)Response
valueYes Chi-
Square Statistic
P-Value Effect Size
Yes Chi-square Statistic
P-value Effect size
8 19
128.44
< .0001
.952 (L)
22
49.92 <.0001 .946 (L)
10 10 14
12 15 11
14 18 19
16 57 54
H018 School-age children are not influenced by others drinking milk.
*Chi square test
p<.0001
Pre-Test (n=121)
Response value
Yes Chi-Square Statistic
P-Value Effect Size
6 79
119.23
< .0001
.956 (L)
8 31
10 7
12 4
H019 The school environment does not have an effect on participants’ bone healthy nutrition behaviors.
*Chi square test
p<.0001
Pre-Test (n=123) 21-Day Post-Test (n=122)Response value
Yes Chi-Square Statistic
P-Value Effect Size Yes Chi-square Statistic
P-value Effect size
6 39
13.55
.004
.956 (L)
13
17.74 <.0001 .956 (L)
8 39 40
10 31 27
12 14 42
H020 The home environment does not have an effect on participants’ bone healthy nutrition behaviors.
*Chi square test
p=.004, <.0001
H021 There is no difference between genders with regards to influences in participants’ bone healthy nutrition behaviors.
Pre-Test 21-Day Post TestInfluences Girls Boys P-
ValueConfidence Interval
Girls Boys P-Value Confidence Interval
Drinking milk influences
61 58 .333 Inside 61 59 .136 Inside
Mean 13.15 13.69 13.57 12.71
School environment 61 60 .762 OutsideN/A
Mean 6.98 6.90
Home environment 62 61 .465 Outside 60 62 .402 Inside
Mean 8.19 8.46 9.77 9.45
*Independent t-test
Table: “It is Important for Kids my Age to Have Healthy Bones”: Pre-test*
*Chi-Square
H022 School-age children do not believe bone health is important.
Response (n=119)
Yes Chi-Square Statistic
198.17
P-Value
.0001
Effect Size
0.94 Very Important 112
Kind of Important
6
Somewhat Important
1
Table: “It is Important for Kids my Age to Have Healthy Bones”: Girls vs Boys (Pre-test)*
*Independent T-Test
H022a There is no difference in belief over bone health importance between genders.
Response Girls(n= 63)
Boys (n=56)
P-Value
0.62
Confidence Interval
Outside
Very Important
59 53
Kind of Important
3 3
Somewhat Important
1 0
H023 There is no difference between posttest and 21-day post-test and participant’s plan to eat foods that are healthy for their bones.
Category Sample Size
Post-Test
Mean
21-Post Test
Mean
t-value p-value Confidence Interval
Overall 79 1.29 + 0.56
1.44 + 0.61
-1.84 0.07 Inside
Female 44 1.20 + 0.55
1.36 + 0.57
-1.42 0.16 Outside
Male 35 1.40 + 0.55
1.54 + 0.66
-1.15 0.23 Outside
Table: “I plan to eat foods that are healthy for my bones*”
*Paired T-Test
H024There is no difference between post-test and 21-day post-test in ease to incorporate foods that are healthy for their bones.
*Paired T-Test
Category Sample Size
Post-Test
Mean
21-Post Test
Mean
t-value p-value Effect size/Confidence Interval
Overall 80 1.76 + 0.88
1.96 + 0.85
-2.43 0.01 0.13
Female 45 1.82 + 0.91
1.96 + 0.85
-1.43 0.16 Outside
Male 35 1.69 + 0.83
1.97 + 0.86
-1.97 0.06 Inside
Table: “It is easy to choose a snack that is good for your bones*”
*Paired T-Test
H025 There is no difference between post-test to 21-day post-test for ease to choose activities that are good for their bones.
Category Sample Size
Post-Test
Mean
21-Post Test
Mean
t-value p-value Effect size/Confidence
Interval
Overall 60 1.63 + 0.76
1.77 + 0.83
-1.16 0.25 Outside
Female 38 1.55 + 0.76
1.79 + 0.87
-1.71 0.09 Outside
Male 22 1.77 + 0.75
1.72 + 0.77
0.22 0.83 Outside
Table: “It is easy to choose an activity that is good for your bones*”
*Paired T-Test
Category Sample Size
Post-Test Mean
21-Post Test
Mean
t-value p-value Effect size/Confiden
ce Interval
Overall 113 1.77 + 0.87
1.65 + 0.75
1.53 0.13 Inside
Female 56 1.75 + 0.86
1.69 + 0.78
0.44 0.66 Outside
Male 57 1.79 + 0.88
1.59 + 0.73
1.80 0.08 Inside
H026 There was no change between post-test and 21-day post-test among school aged children’s belief that exercise is fun.
Table: “I enjoy exercise”
*Paired T-Test
H027 School-age children do not plan to engage in specific activities that are beneficial to their bones.
Activity Sample Size Yes Chi-Square Statistic
P-Value Effect Size/Confidence
Interval
Chores 92 62 11.13 .001 0.89 (L)
Stairs 91 60 9.24 .002 0.89 (L)
Dancing 91 73 33.24 .0001 0.90 (L)
Tag 91 74 35.70 .0001 0.90 (L)
Karate 91 52 1.86 0.17 Outside
Tennis 91 66 18.47 .0001 0.89 (L)
Table: Plan to Engage in Physical Activities for Bone Health: Post-Test*
*Chi-Square
Bottom of the Ninth
● Constraints for time allotted to run the game
● Language barriers during the camp session
● Decrease in sample size due to consent forms
● Further validate test
Limitations
Strengths● Appropriate for a wide range of ages
● Assessment tool incorporated social cognitive theory
● Covers wide variety of material
● Incorporated into PE classes
● Intervention can take place inside or outside
● Participants enjoyed the interactive and educational game
Implications for our study
• Causes changes in bone health knowledge and retention • Applicable in both settings
• Positive bone health behaviors will be modeled
• Influencers and understanding bone health importance can motivate
• Self-efficacy plays a role in behavior changes and motivation
Future Research● Implementing the program in
schools with different demographics
● Application of influences and modeling in children
● Female’s dietary behaviors during pubescence
Special Thanks!• Thesis Advisor Dr. Karen Plawecki• Students and faculty at St. Walter’s School• Campers and staff at West Chicago Summer Camp• Stan’s Donuts in the city
Post-Game Press Conference
References- Au L, Rogers G, Harris S, Dwyer J, Jacques P, Sacheck J. Associations of vitamin D intake with 25-
hydroxyvitamin D in overweight and racially/ethnically diverse US children November 2013 Springer, 2012.- Bailey R, Dodd K, Picciano M, et al. Estimation of total usual calcium and vitamin D intakes in the united
states. J Nutr. April 2010;140(4):817-822. - Behnke R. Kinetic Anatomy Third Edition. 2012. Available from:
http://www.humankinetics.com/excerpts/excerpts/levers-work-to-create-movement-in-the-human-body- Bone structure and function: Bone architecture. ASBMR Bone Curriculum Web site.
https://depts.washington.edu/bonebio/ASBMRed/structure.html Updated January 16, 2004. Accessed November 15, 2015.
- Bone. http://www.c14dating.com/bone.html Accessed November 15, 2015. - Fortes CM, Goldberg TB, Kurokawa CS, et al. Relationship between chronological and bone ages and pubertal
stage of breasts with bone biomarkers and bone mineral density in adolescents. J Pediatr (Rio J). 2014;90(6):624-31.
- Hever J. 5 Ways to Optimize Bone Health. 2015. Available from: http://plantbaseddietitian.com/5-ways-to-optimize-bone-health/
- Horne, PJ, Tapper, K, Lowe CF, Hardman CA, Jackson MC, Woolner J. Increasing children's fruit and vegetable consumption: a peer modeling and rewards based intervention. European Journal of Clinical Nutrition (2004),58: 1649-1660.
- Gilbert SF. Osteogenesis: The Development of Bones. In Developmental Biology 6th edition. Sunderland (MA): Sinauer Associates; 2000. Available from: http://www.ncbi.nlm.nih.gov/books/NBK10056/.
- Houillier- International Osteoporosis Foundation (IOF). Preventing Osteoporosis. 2015. Available from:
http://www.iofbonehealth.org/preventing-osteoporosis- Kini U, Nandeesh BN. Physiology of Bone Formation, Remodeling and Metabolism.
References• Larsen, Andrew, McArdle, John, Robertson, Trina and Dunton, Genevieve. Nutrition self-efficacy is
unidirectionally related to outcome expectations in children 2015. • Lubans, David, Plotnikoff, Ronald, Morgan, Philip, Dewar, Deborah, Costigan, Sarah and Collins, Clare.
Explaining dietary intake in adolescent girls from disadvantaged secondary schools. A test of Social Cognitive Theory 2012.
• Mansbach J, Ginde A, Camargo Jr. C. Serum 25-Hydroxyvitamin D Levels Among US Children Aged 1 to 11 Years: Do Children Need More Vitamin D? Pediatrics [serial online]. November 2009;124(5):1404-1410.
• Murphy M, Douglass J, Johnson R, Spence L. Drinking flavored or plain milk is positively associated with nutrient intake and is not associated with adverse effects on weight status in US children and adolescents. April 2008.
• Moore C, Radcliffe J, Liu Y. Vitamin D intakes of children differ by race/ethnicity, sex, age, and income in the United States, 2007 to 2010 June 2014.
• Nield L. et al. Rickets: Not a Disease of the Past. American Family Physician. August 2006.• Orlowski M, Lorson K, Lyon A, Minoughan S. My classroom physical activity pyramid: A tool for integrating
movement into the classroom. . JOPERD. 2013;84(9):47-48-51. • Rantalainen T, Heinonen A, Linnamo V, Komi PV, Takala TE, Kainulainen H. Short term bone biochemical
response to a single bout of high impact exercise. Journal of Sports Science and Medicine 2009; 8: 553-559. • Rehm C, Drewnowski A, Monsivais P. Potential population-level nutritional impact of replacing whole and
reduced-fat milk with low-fat and skim milk among US children aged 2-19 years. January 2015. • Thacher T, et al. Increasing Incidence of Nutritional Rickets: A population-based study in Olmsted County,
Minnesota. Mayo Clinic Proc. Feb 2013. 88 (2):176-183.• Webb D, Donovan S, Meydani S. The role of yogurt in improving the quality of the american diet and meeting
dietary guidelines. Nutr Rev. March 2014; 72(3): 180-189.