FinalDraft

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THE CITADEL
Charleston, South Carolina
The Citadel Graduate College
EFFECTS OF AFTER-SCHOOL PROGRAMMING ON BODY MASS INDEX, BODY
COMPOSITION, AND ACTIVITY LEVELS IN KINDERGARTEN THROUGH FIFTH
GRADE
Leonard Scott Kirby
School of Science and Mathematics
Department of Health, Exercise, and Sport Science
May, 2012

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Leonard Scott Kirby
THESIS COMMITTEE
Thesis Chair ___________________________
Dena Garner, Ph.D.
Committee Member ___________________________
Tim Bott, Ph.D.
Committee Member ___________________________
Allison Eidson, Kaleidoscope Coordinator
Examination Date of Thesis ___________________________

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TABLE OF CONTENTS
TABLE OF CONTENTS…………………………………………………………………………………….3
LIST OF TABLES…………………....………………………………………………………………………..4
LIST OF FIGURES…………………………………………………………………………………………....5
ABSTRACT……………………………………………………………………………………………………..6
LITERATURE REVIEW……………………………………………………………………………………8
METHODS……………………………………………………………………………………………………27
Sample……………………………………………………………………………………………...28
Data Collection…………………………………………………………………………….…….29
Data Analysis…………………………………………………………………………………….30
RESULTS……………………………………………………………………………………………………...31
DISCUSSION………………………………………………………………………………………………...37
REFERENCES……………………………………………………………………………………………….44
APPENDIX A: PREVALENCE OF CHILDHOOD OBESITY IN THE US………………….50
APPENDIX B: ACTIVITIES USED IN THIS STUDY……………………………………………52
APPENDIX C: INTERNAL REVIEW BOARD DOCUMENT …………………………………59
APPENDIX D: CONSENT FORM……………………………………………………………………...65

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LIST OF TABLES
TABLE 1: Characteristics of Study Sample…………………………………………31
TABLE 2: BMI Changes From Baseline to 12 Weeks Post-Treatment…..33
TABLE 3: Changes In Steps From Baseline to 12 Weeks Post-
Treatment…………………………………………………………………………35
TABLE 4: Changes In Percent Body Fat From Baseline to 12 Weeks Post-
Treatment………………………………………………………………….……...36

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LIST OF FIGURES
FIGURE 1: Differences Among Weights………………………………………………..32
FIGURE 2: Differences Among Heights………………………………………………...32
FIGURE 3: Changes In BMI Between Baseline to 12 Weeks Post-
Treatment………….……………………………………………………………...34
FIGURE 4: Average Number of Steps From Baseline to 12 Weeks Post-
Treatment…………………………………………………………………………35
FIGURE 5: Average Percent Body Fat From Baseline to 12 Weeks Post-
Treatment…………………………………………………………………………37

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ABSTRACT
Much research has cited the importance of increasing physical activity
sessions/intensity to lower body fat percentages within the child population
(Stephens & Wentz, 1998; Carrel, Clark, Peterson, Nemeth, Sullivan, & Allen, 2005).
Charleston County School District initiated a new program called Get Out, Get Active!
within several afterschool programs, with its purpose to encourage healthy eating
habits and increase activity. While this program is admirable, its effectiveness on
childhood obesity is not well understood. Thus, the purpose of this study was to
evaluate body mass, body composition, and physical activity levels of students
enrolled in this program at one school. Students in the program (n= 73; 43 males
and 30 females) were between kindergarten and fifth grade. The guidelines of the
program, as determined by the school, was to spend 1 hour, 1 day per week playing
outdoor games for each for the following groups K-1st, 2nd and 3rd, 4th and 5th
graders for a 4 month period. Pre and post measurements were taken on the first
and last week of the study to assess changes in body mass index and body
composition, via skin fold thickness of the calf and triceps, and pedometer
differences within a subgroup of students. Means and standard deviations were
calculated using one-way ANOVA tests on Statistical Package for the Social Sciences
(SPSS) Version 10.1 for Windows. Significance was set at p<0.05. The results of the
study showed no significant improvements in body mass index; K-1st (p=0.378), 2nd-
3rd (p=0.143), 4th-5th (p=0.161) or body composition; K-1st (p=0.272), 2nd-3rd
(p=0.106), 4th-5th (p=0.456). However, there were significant improvements in
pedometer steps taken from pre to post; K-1st (p=0.00) and 4th-5th (p=0.019). This

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study shows that although activity may be provided in an afterschool setting, there
is a need for a more stringent protocol (increased intensity and sessions) to
potentially affect body mass index or body composition for this population.

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Literature Review
Obesity is defined as a medical condition in which excess body fat has
accumulated to the extent that it may have an adverse effect on health, leading to
reduced life expectancy and increased health problems. Obesity increases the
likelihood of various diseases, particularly heart disease, type 2 diabetes, breathing
difficulties during sleep, certain cancers, and osteoarthritis (Ogden, Carroll, Curtin,
Lamb & Flegal, 2010). The short- and long-term association with morbid outcomes
raises the level of importance for understanding this epidemic as a major public
health concern, not only for adults, but also more importantly for children and
adolescents (Durstine, Moore, Painter, & Roberts, 2009). Childhood obesity is
particularly troubling because the extra pounds often start children on the path to
developing the same co-morbidities as adults encounter, but at a much earlier age.
As a result, these persons’ life expectancies would dramatically decrease (Ogden et
al., 2010).
Although there are several definitions and measurements for determining if a
child is overweight or obese, almost all use some variant of Body Mass Index (BMI).
Expressed as weight in kilograms divided by height in meters squared (kg/m^2),
BMI defines people as overweight with BMI between 25 kg/m^2 and 30 kg/m^2
and obese with BMIs greater than 30 kg/m^2. In children, it varies with age, making
BMI definitions of overweight for children more complex than definitions for adults
(Ruhm, 2007). After BMI is calculated for children and teens, the BMI number is

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plotted on the Centers for Disease Control and Prevention (CDC) BMI-for-age charts
to obtain a percentile ranking (Centers for Disease Control and Prevention [CDC],
2011). Percentiles are the most commonly used indicator to assess the size and
growth patterns of individual children in the United States. The percentile indicates
the relative position of the child’s BMI number among children of the same sex and
age. The growth charts show the weight status categories (underweight, healthy
weight, overweight, and obese) used with children and teens (Centers for Disease
Control and Prevention [CDC], 2011). These charts indicate that BMI levels above
the 95th percentile for age and sex, or exceeding 30, whichever is smaller, is the
standard by which obesity is classified in children and adolescents (Levin, 2009).
Childhood obesity has been on the increase in the United States since 1976
(See Appendix A). Among preschool children aged 2-5, obesity increased from 5.0%
to 10.4% between 1976-1980 and 2007-2008 and from 6.5% to 19.6% among those
aged 6-11. For adolescents aged 12-19, obesity increased from 5.0% to 18.1%
during the same period (Ogden et al., 2010). Prevalence estimates of the number of
obese children vary depending on variations in obesity classification systems and
ethnic origins within population samples (Levin, 2009). Geographically, there is a
greater prevalence of obesity for blacks and whites in the South and Midwest than in
the West and Northeast. Hispanics in the Northeast had lower obesity prevalence
than Hispanics in the Midwest, South, or West (Centers for Disease Control and
Prevention [CDC], 2011). Specifically, in South Carolina, there was a higher
prevalence of overweight or obese blacks (39.8%) than whites (25.3%). In addition,

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gender differences including all races were relatively close (32.9% male, 30.5%
female) (South Carolina Department of Health and Environmental Control
[SCDHEC], 2011).
Various epidemiological studies have identified several critical periods in the
childhood and adolescent years where an event or occurrence can have an enduring
effect on the structure or function of organs, tissues, and body systems, leading to
chronic diseases such as obesity. Although some of these events may occur at a
particular time, they can also have the tendency to accumulate over many years. For
example, studies have demonstrated a direct positive relationship between higher
birth weight and increased BMI attained in later life (Graf, Koch, Kretschmann-
Kandel, Falkowski, Christ, & Coburger, 2004). These studies reported possible
explanations for this to be lasting changes in proportions of fat and lean body mass,
central nervous system appetite control, and pancreatic structure and function.
Other data suggests that rapid weight gain during infancy is associated with obesity
later in childhood (Daniels, Arnett, Eckel, Gidding, Hayman, Kumanyika, Robinson,
Scott, St. Jeor, & Williams, 2005). Dietz (2004) cites that early rebound of the BMI is
associated with an decreased risk of higher BMI in adulthood, with early rebound
being defined as reducing the child’s BMI levels at an early age before chronic health
problems set in (Dietz, 2004). Other data suggests that BMI at age 7 or 8 is as good a
predictor of obesity as age at BMI rebound (Perez, Munoz, Cortes, & De Pablos,
2007). If so, this could prove to be a useful tool in helping prevent obesity by
identifying children at risk before the development of the epidemic.

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Because childhood obesity often persists into adulthood and is associated
with numerous chronic illnesses, children who are obese are often tested for
metabolic syndromes such as hypertension, diabetes, and hyperlipidemia (Lau,
Douketis, Morrison, Hramiak, Sharma, & Ur, 2007). The prevalence of the metabolic
syndrome in adolescents is 4% overall, but it is 30% to 50% in overweight children,
which is believed to be triggered by a combination of genetic factors and
environmental factors such as excess calorie intake and reduced levels of physical
activity. Studies show that the metabolic syndrome has a profound affect on CVD
risk in youth (Coates et al., 1998). Although there is limited prospective data
evaluating the long-term implications of the metabolic syndrome in youth, Dietz
(2008) suggests that obesity in youth is associated with hyperinsulinemia,
decreased insulin sensitivity, and increased total cholesterol and triglycerides.
Concerns with insulin sensitivity and hyperinsulinemia cite that these issues
are highly correlated with type 2 diabetes mellitus. This disease is yet another
metabolic condition that has been on the rise among obese adolescents. Type 2
diabetes mellitus had been primarily an adult disease; however, type 2 diabetes
mellitus now occurs in adolescents typically with a BMI >30 kg/m^2. The
prevalence of type 2 diabetes mellitus in US adolescents is 4.1 in 1000 individuals,
causing great concern with regard to risk for CVD (Daniels et al., 2005). On the other
hand, it is not known whether the level of risk for adolescents with type 2 diabetes
mellitus is equivalent to that of adults nor whether adolescents typically have a
prolonged period of asymptomatic hyperglycemia, often observed in adults

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(Mitchell, 2009).
Not only are obese children at a high risk for physical co-morbidities, but also
research has shown they are at risk for psychosocial problems. Overall, there is little
information about the relationship between psychosocial factors and obesity in
youth. Most research in the area of psychosocial issues in obese children resides
with assessing the effects of obesity on depression rates with this population. Zhao
and colleagues (2009) found that adults who had been diagnosed with clinically
defined major depression during their youth had greater BMI than adults who did
not suffer from depression during their youth (26 versus 24 kg/m^2 at 10 to 15
years of follow-up). Zhao et al (2009) also found that the development of
overweight children also may be related to other psychosocial difficulties such as
peer relationships while Strauss (2006) reported data demonstrating significant
consequences of decreasing self-esteem in overweight children with these more
isolated relationships (Zhao, Ford, Dhingra, Li, Strine, & Mokdad, 2009). Strauss’
study showed that obese children with decreasing levels of self-esteem showed
significant elevated levels of loneliness, sadness, and nervousness (Strauss, 2006).
Obese children with falling self-esteem were also more likely to engage in high risk
behaviors such as smoking and alcohol consumption, beginning with fourth to sixth
graders (Jackson, 2007). Overweight children were found to have fewer friends, and
social network mapping suggested that normal-weight children have more
relationships with a central network of children, compared to overweight children
who tend to have more isolated relationships. In addition, overweight children

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usually have to deal with being teased about weight. Teasing overweight youth has
been shown to be associated with an increase in thoughts and attempts of suicide
(Daniels et al., 2005).
Due to tremendous negative psychosocial, psychological, and physiological
implications for overweight/obese children, a large body of research has sought to
assess effective strategies in the treatment of this population. Guidelines for the
treatment of overweight/obesity in children are based on age, degree of overweight,
and presence of co-morbidities. For children with BMI >85th percentile, there are
three potential goals for weight management: (1) slowed rate of weight gain to
achieve BMI maintenance, (2) weight maintenance to improve BMI with height,
and/or (3) gradual weight loss at a rate of one to two kg/month to improve BMI
(Daniels et al., 2005). While obese children are going through treatments, it is
recommended to follow a plan that focuses on slow weight loss. However, this may
not be recommended for all children or for older adolescents who have completed
linear growth and may require more aggressive weight loss to reduce any possible
long-term risks.
In order to achieve success in weight management, there must be aggressive
familial and professional assistance. Braet and colleagues (1997) provide five
guiding principles important for the treatment of overweight in children which
include: (1) establishing individual treatment goals and approaches based on the
child’s age, degree of overweight, and presence of co-morbidities, (2) involving the

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family or major caregivers in the treatment, (3) providing assessment and
monitoring frequently, (4) consider behavioral, psychological, and social
correlations of weight gain in the treatment plan, and (5) providing
recommendations for dietary changes and increases in physical activity that can be
implemented within the family environment and that foster optimal health, growth,
and development (Braet et al., 1997). Braet and colleagues (1997) cite that if these
principles are closely followed as a child, their current and future success with
weight loss will occur. In addition to these recommendations, it is suggested that
children who are <85th percentile with no other health risk factors are screened
(weight, height, and BMI percentile calculated and plotted) every year. Identification
of risk for overweight before adolescence is encouraged so that health habits can be
improved at a stage of increased parental influence and control (Goran et al., 1999).
Strategies to achieve an optimal rate of pounds gained during these earlier
years (pre-adolescence) may help families and children acquire the critical life skills
to better balance energy intake with energy expenditure. The goal should be to work
toward establishing healthy environments within homes, while schools and the
community should work together to encourage families and children to practice and
maintain the life skills necessary to maintain a healthy weight (Carter, 2002). To aid
in the parental role regarding successful weight loss in children, various
interventions have been put into place to treat obesity complications. Obesity
prevention includes both population- and individual-orientated approaches.
Population approaches focus on environmental and policy change that have the

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lowest cost, critical for reaching the least-advantaged population segments (Braet et
al., 1997). Prevention interventions are individually oriented, usually delivered in
specialty care, primary care, and health systems. Prevention approaches are
important and appropriate for children who are already overweight. Individually
oriented prevention strategies are usually highly intensive, costly, and have low
reach in terms of the numbers that can potentially be served (Daniels et al., 2005).
Another challenge of obesity prevention includes the need to develop
strategies well matched to the social and cultural contexts of children in ethnic
minority populations with a high risk of obesity (Yancy & Kumanyika, 2007). Eating,
activity, and perceptions of weight and health are strongly influenced by cultural
norms, attitudes, and values. For example, body image development occurs in a
cultural context, and ethnic/cultural groups differ in their shared understandings as
to valued and disvalued body image (Carpio et al., 2008). For instance, the mean
BMI at which white women and girls typically express body dissatisfaction is
significantly lower than that for African American women and girls (Fitzgibbon,
Blackman, & Avellone, 2005).
In addition to population-specific, another possible approach to the
prevention of childhood obesity is that of setting-specific programs. Setting-specific
approaches target institutions providing access to groups of children, such as
schools and Head Start programs. Although one can intervene in the actual setting
itself, one big limitation of setting-specific approaches is the inability to reach a

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large portion of the population (Whitaker et al., 1997).
In understanding the success of any program targeting obese and overweight
children, research cites that the more successful treatment plans focus on two key
tenants, which includes the reduction of calories taken in and the number of calories
expended. In the fight to reduce obesity, age-specific dietary modification is the
cornerstone of obesity related treatment. The major goals in dietary management
include providing appropriate caloric intake, providing optimum nutrition for the
maintenance of health and normal growth, and to help the child develop and sustain
healthful eating habits (Daniels et al., 2005). Assessment begins with an
understanding of the child’s dietary pattern before any modifications are imposed.
Since caloric needs may vary widely, individualizing the caloric intake
recommendation and monitoring weight change are essential.
In the home setting, it is necessary that the parents and guardians play an
important role in the development of proper eating habits by children. The home
environment has the potential to affect children’s energy balance and diet
composition in numerous ways. Parents can also influence the family environment
by exposing the children to certain foods, by actively encouraging children to eat
certain foods or by allowing only certain foods in their regular diets (Golan,
Weizman, Apter, & Fainaru, 2008). The physical and emotional environments in
which eating and activity behaviors are developed are also important at-home
variables (Golan & Crow, 2004). Finally, parents can also play an important role in

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the child’s physical activity involvement. They can promote a non-sedentary lifestyle
by encouraging the children to become involved in various types of physical activity
in which they express the most interest. All of these types of interventions at home
have shown to produce positive results such as increased self-esteem as well as a
positive relationship between the parent and the child (Barlow & Dietz, 2008).
Because an important component of success in children is the incorporation
of physical activity, understanding the amount of regular physical activity is critical
for the prevention of abnormal weight gain. The current recommendation for the
amount of physical activity is 60 or more minutes of regular exercise daily (Centers
for Disease Control and Prevention [CDC], 2011). Within that time, the website
recommends the child engage in three types of physical activity: aerobic activity,
muscle strengthening, and bone strengthening. Aerobic activity can include
moderate intensity exercises such as brisk walking or vigorous intensity exercises
such as running. For muscle strengthening, activities such as gymnastics and push-
ups are highly recommended. In addition, activities such as jumping rope and
running aid in bone strengthening (Centers for Disease Control and Prevention
[CDC], 2011). Ruhm (2007) cites that recommended activities for young children
must be enjoyable and work in conjunction with the child and family’s lifestyle and
be rewarding aside from the health benefit.
In order to promote physical activity for the child, various community, home
and school based programming has been implemented. Irwin et al (2010) found
that when children were exposed to a jointed programming effort (including

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community, home and school based), this resulted in the students’ ability to gain
knowledge of the necessary health information to which they had not been exposed.
The program, known as Get Fit with the Grizzlies, used a local sport organization
and cause-related marketing to better deliver health information to school-aged
populations (Irwin, Irwin, Miller, Somes, & Richey, 2010). Specifically, this program
involved a pre/posttest protocol, where every fourth and fifth grader in the
Memphis city school system during the 2006 to 2007 school year (N=17,066) was
evaluated. This Get Fit program, principally influenced by the Social Cognitive
Theory (SCT) developed by Miller and Dollard (1941), used survey research to
measure health knowledge acquisition and health behavior change. Another study
similar to the Irwin research evaluated the effectiveness of the Mind, Exercise,
Nutrition, Do it (MEND) Program, a multi-component community-based childhood
obesity intervention (Sacher, Kolotourou, Chadwick, Cole, Lawson, Lucas, & Singhal,
2010). In particular, this study randomly assigned 116 obese children to either
intervention or a six month delayed waiting list control intervention. Children and
parents in both groups attended eighteen 2-hour educational and physical activity
sessions held twice weekly in sports centers and schools, followed by a twelve week
free family swimming pass. At baseline and six months, waist circumference, BMI
body composition, physical activity level, sedentary activities, cardiovascular fitness,
and self-esteem were all assessed, with a follow-up twelve months from baseline.
This study found that participants in the intervention group had a reduced waist
circumference (P<0.0001) and BMI (P<0.0001) at six months compared to the
controls. At twelve months, children in the intervention group had reduced their

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waist and BMI (P<0.0001). This study concluded that, with these positive results
combined with the attendance rate of 86%, families found this intensive
community-based intervention acceptable (Sacher et al., 2010).
Researcher Ruhm (2007) also adds that a beneficial way to have a successful
child’s physical activity plan would include implementing these programs in the
school setting. Schools are identified as a key setting for public health strategies to
lower or prevent the prevalence of overweight and obesity (Institute of Medicine,
2005). Children spend more time in schools than in any other environment away
from home, where they receive the most continuous and intensive contact and
influence (Frumkin, 2006). Although the school system’s primary role is to educate
students in both academic subjects and the civic values and social responsibilities
that will prepare them to reach their full potential, health and education success has
been proven to be intertwined (Frumkin, 2006). Therefore, schools have an
unparalleled opportunity to promote children’s health by creating an environment
in which children eat healthy foods, engage in regular physical activity, and learn
lifelong skills for healthy eating and active living. In particular, local school physical
activity programs, such as the one used in this study, Get Out Get Active, promote a
healthy lifestyle through recreation, nutrition, and physical activities among the
youth in the area. Charleston County Community Education’s website emphasizes
the following reasons to participate in Get Out Get Active: reduces stress, increases
the child’s confidence and fitness levels, provides opportunities to make new friends
and learn new games, while aiding to maintain a healthy weight and heart

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(Charleston County Community Education [CCCE], 2011).
To analyze the impacts of school intervention on childhood obesity, a
literature review by Shaya and colleagues (2008) found that, of the 15 studies
utilizing only physical activity programs, 13 of the studies reported positive
statistical significant results with interventions. Of the 16 studies that exclusively
utilized solely educational models and behavior modification strategies, 12 reported
positive statistically significant results. Finally, 15 of the 20 physical activity and
education combination studies reported positive results in their quantitative
measures (Shaya, Flores, Gbarayor, & Wang, 2008). For example, there were two
studies by Carrel, Clark, Peterson, Nemeth, Sullivan, & Allen (2005) and Stephens
and Wentz (1998) that demonstrated positive results in adiposity and fitness
measures such as BMIs, sit-and-reach flexibility, and aerobic capacity with children
enrolled in short-term physical activity interventions. The Carrel et al. (2005) study
used 50 overweight middle school children with BMIs above the 95th percentile and
randomized them to lifestyle-focused, fitness-oriented gym classes (treatment
group) or standard gym classes (control group) for nine months. After undergoing
evaluation of fasting insulin and glucose levels, body composition, and VO2 max
from baseline to the end of the school year, it was found that the children enrolled in
fitness-oriented gym classes showed greater loss of body fat, increase in
cardiovascular fitness, and improvement in fasting insulin levels than control
subjects (students attending standard gym classes) (Carrel et al 2005). Another
similar study reported by Stephens and Wentz (1998) used 99 students from two

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Cleveland Public Schools. One school received a 15-week intervention program that
met three times a week for physical activity sessions, while the other school served
as the control and received no supplemental activity other than a regularly
scheduled physical education class held once a week. By obtaining skin fold
thickness, heart rate response to sub maximal exercise, and sit and reach flexibility
measurements, Stephens and Wentz (1998) found that the treatment group showed
significant improvements in all three measurements, specifically that interventions
within the classroom can significantly improve levels of fitness in elementary school
children (Stephens & Wentz, 1998).
A study performed by Harrell et al. (1996) found that short-term
interventions lasting less than six months in duration cited positive statistically
significant results in reducing diastolic blood pressure, increasing physical activity
incidence, and reducing triceps’ skin folds of study participants. In particular, the
study by Harrell and colleagues tested a classroom-based intervention used in
twelve random schools across North Carolina in order to reduce cardiovascular
disease risk factors in elementary school children. Specifically, the subjects
(n=1274) who were in third and fourth grade were taught both an eight-week
exercise program and an eight-week class on nutrition and smoking. After analyzing
survey regression models at the school level and multivariate analysis of variance
and analysis of covariance models at the individual level, it was reported that the
children in the intervention group had significantly greater knowledge (7.9% more
correct) and a significant increase in self-reported physical activity than children in

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the control group. Also, the intervention group reported a reduction in total
cholesterol level (-5.27 mg/dl), an increase in aerobic power (1.76 ml/kg/min), a
reduction in body fat (-0.04 mm), and smaller rise in diastolic blood pressure (-1.32
mm Hg) than the controlled children. Harrell and researchers concluded that this
classroom-based, public health approach improved children’s cardiovascular
disease risk profiles and is vital due to this being the time when most children
develop their health habits (Harrell, McMurray, Bangdiwala, Frauman, Gansky, &
Bradley, 1996). Rodgers et al (2001) supported some of these outcomes in a similar
study and found that, by collecting outcome measures of BMI, triceps skin fold
thickness, diastolic and systolic blood pressure, resting heart rate, three minute
step-test, one minute recovery heart rate, and knowledge regarding the fat content
of foods, that the intervention group improved more than the control group on
tricep skin fold thickness (p<.03), diastolic and systolic blood pressure (p<.01 and
p<.08, respectively), and nutrition knowledge (p<.02).
Although the classroom setting can prove to be a vital environment to
promote the importance of physical activity in the school setting, research has
shown that further interventions can be put into place during recess time. Daily
recess is determined to be a necessary part of the elementary school experience that
allows children to develop physical competence, health-related fitness, personal and
social responsibility, and enjoyment of physical activity so that they are more likely
to become active for a lifetime (Stellino, Sinclair, Partridge, & King, 2009). Recess
can make a worthwhile contribution to the recommended 60 minutes of moderate

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to vigorous physical activity per day (Babkes and Sinclair, 2004). To put this into
perspective, Ridgers and Stratton (2005) determined the physical activity levels of
boys and girls during recess and analyzed their data by gender and age, while
establishing the extent to which school recess contributes to daily physical activity
accumulation. After being randomly selected from eighteen schools, 149 boys and
147 girls wore heart rate monitors to measure their response to their level of
physical activity. After the researchers determined that the boys’ physical activity
was greater than the girls’ and an even larger number of boys than girls met the
proposed marker of 40% of playtime spent in moderate to vigorous activity, Ridgers
and Stratton suggested that schools can play a significant role in increasing these
results. They recommended that educators and health promoters need to come
together to identify strategies that focus on the promotion of physical activity
through recess, so that the short-term and long-term effects on the children’s
physical activity patterns can be identified (Ridgers & Stratton, 2005).
Beighle and researchers (Beighle et al., 2006) examined children’s physical
activity during recess and outside of school by having third, fourth, and fifth grade
students (N=270; 121 boys, 150 girls) wear sealed pedometers during a fifteen
minute recess period and outside of school for four consecutive school days. Beighle
and colleagues found that males accumulated more activity time engaging in
physical activity during recess and outside of school (78% and 23%, respectively)
than girls (63% and 20%, respectively) in a third, fourth, and fifth grade population
(N=270; 121 boys, 150 girls). Beighle et al. and Ridgers et al. both suggested

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additional strategies in an effort to further increase participation in recess physical
activity, which included: increasing the availability of equipment, having supervising
teachers encourage unstructured games that maximize activity time, and having the
physical education teacher teach games that can be played at recess focusing on
inclusion, low organization, and maximize activity (Beighle, Morgan, LeMasurier, &
Pangrazi, 2006; Ridgers & Stratton, 2005).
Although recess is very important in aiding in childhood obesity prevention,
after-school physical activity programs seem to be an alternative option to increase
activity in school-aged children. These programs have progressively become more
popular. For example, there were thirty-four Kaleidoscope after-school programs in
Charleston County School District in the 2010-2011 school year (Charleston County
Community Education [CCCE], 2011). Although these programs are often very
simple in nature, they are effective in that they are typically non-competitive in
nature, thus being able to target and include the children who were already at
overweight and obese levels. Also, these programs are inexpensive and can be held
on the school grounds. In addition, most programs include games that make
learning about nutrition more interesting and fun for the children (Trost,
Rosenkranz, & Dzewaltowski, 2008).
When assessing the intensity of exercise alone, after-school programs
research cites differences between light, moderate, and vigorous activity and their
effects on a child’s percent body fat. For example, The Centers for Disease Control

25
and Prevention website identifies two ways to distinguish moderate- and vigorous-
intensity: (1) consider a scale of zero to ten (sitting a zero, moderate-intensity a five
or a six, vigorous-intensity a seven or eight, and a ten the highest level of activity).
For example, when a child does moderate-intensity activity, the child’s heart will
beat faster than normal, thus breathing harder than normal. When a child does
vigorous-intensity activity, the child’s heart will beat much faster than normal,
making the child breathe much harder than normal and (2) consider the activity the
child is doing and compare it to the average child. For example, when a child walks
to school with friends, the child is probably doing moderate-intensity aerobic
activity, but when the child gets to school and runs during recess, the child is
typically doing vigorous-physical activity (Centers for Disease Control and
Prevention [CDC], 2011).
To show that an after-school program focusing on moderate to vigorous
physical activity has a beneficial effect on fitness and body composition, Gutin et al.
(2008) and Vizcaino et al. (2008) assessed fitness and body composition levels in
elementary school aged children. Gutin et al. (2008) used the Medical College of
Georgia Fitkid Project (40 minutes of academic enrichment activities and 80
minutes of moderate-to-vigorous physical activity) to evaluate the effect of a three-
year after-school physical activity intervention on aerobic fitness and percent body
fat, while Vizcaino et al. (2008) created their own program consisting of 90 minutes
per week for a total of 24 weeks (cluster-randomized trial, composed of ten
intervention and ten control schools, using a total of 1044 children [mean age=9.4

26
years] in a recreational, non-competitive physical activity program conducted
during after school hours on school premises). Gutin et al. (2008) randomized
eighteen schools into intervention or control arms, where a total of 617 students
(mean age= 8.5 years) participated, approximately half at each arm. During the
beginning and end of the third, fourth, and fifth grade year, fitness levels were
measured with heart rate response to a bench-stepping task, while percent body fat
and bone density were measured with dual-energy x-ray absorptiometry. Gutin and
researchers (2008) found that the children in the intervention schools improved in
fitness and percent body fat during the school years and returned to levels similar to
those in the control group during the summers. This is similar to outcomes cited by
Vizcaino and colleagues (2008) in which they showed a decrease in tricep skin-fold
thickness in both boys (-1.14 mm; p<0.001) and girls (-1.55 mm; p<0.001), as well
as a reduction in the percentage of body fat in girls (-0.58%; P=0.02). Vizcaino and
researchers also concluded that their study coincides with previous studies that
after-school programs increased physical activity in schoolchildren (Dwyer, Coonan,
Leitch, Hetzel, & Baghurst, 1983), which also led to a reduction in skin-folds, but not
BMI. In both studies, although researchers assessing changes in BMI found no
significant differences between BMI in pre and post in both the controlled nor the
intervention groups, there were significant improvements in skinfold thickness and
percentage body fat (Gutin, Yin, Johnson, & Barbeau, 2008; Vizcaino, Aguilar,
Gutierrez, Martinez, Lopez, Martinez, Garcia, & Artalejo, 2008). In addition, although
these programs proved to be successful during the school year, the researchers did
stress that positive effect of the previous year’s participation on fitness and percent

27
body fat was lost, highlighting the importance of year-round programs to promote
healthy growth in youths.
Trost and colleagues (2008) took previous after-school physical activity
programs a step farther by describing the physical activity levels of groups defined
by sex and weight status in split-up after-school sessions. For data collection, the
researchers recruited seven after-school programs of forty-seven students in grades
3-6, where they were asked to wear accelerometers for the duration of their
attendance to the program. The researchers assessed physical activity on six
occasions during an academic year (three fall and three spring), where activity
counts would then be uploaded to a customized data-reduction program. By
determining the minutes of sedentary, light, moderate, vigorous, and moderate-to-
vigorous physical activity, Trost et al. (2008) found that boys exhibited higher levels
of moderate, vigorous, and moderate-to-vigorous, and lower levels of sedentary and
low physical activity, than girls. In addition, only the gender differences for low,
vigorous, and moderate-to-vigorous physical activity were significant (p<0.05).
After considering separate after-school settings in various environments (free play
indoors, organized physical activity indoors, free play outdoors, organized physical
activity outdoors, snack time, and academic time), data collected showed that the
organized, outdoor physical activity to be the only after-school session where there
showed a significant difference (p<0.05) between non-overweight and overweight
children. Trost et al. (2008) concluded that, although after-school programs seem to
be an important contributor to the physical activity of attending children, there is

28
ample room for improvement by making better use of existing time devoted to
physical activity (Trost, Rosenkranz, & Dzewaltowski, 2008).
Based on the research of obesity and children, increased physical activity in
this population leads to lower obesity rates. Therefore, the purpose of this study is
to target children in an after-school based setting where they will have the
opportunity to receive physical activity one day a week for a period of three months.
The hypothesis is that such an intervention may promote a healthy lifestyle as
indicated by positive changes in body composition.
METHODS
This research study focused on assessing the effects of an activity based
program within the Kaleidoscope program offered through the afterschool
programming in the Charleston, S.C. area. According to the Charleston County
Community Education (CCCE) website, there were thirty-four Kaleidoscope after-
school programs for elementary children in Charleston County School District
during the 2010-2011 school year (Charleston County Community Education
[CCCE], 2011). For the majority of Kaleidoscope afterschool programs, students
work on homework with supervision and play on the playground. In addition, many
Kaleidoscope programs offer adjunct programs such as karate, Spanish, and musical
instruction with fees attached. Due to the increased need to improve physical
activity with all children, the Kaleidoscope program now offers a free program for

29
children called the Get Out Get Active program. Get Out Get Active is a fitness
challenge program designed to promote healthy lifestyle among elementary/middle
school age students while combating the youth obesity epidemic.
Get Out Get Active is very simple in nature and can be effective by targeting
the children who were already at overweight and obese levels. During this study,
games and activities were held on the playgrounds and consisted of a combination
of elimination and non-elimination games. Examples of non-elimination games
include: Red Rover, Snake, and Electricity. Examples of elimination games include:
Capture The Flag, Not In My Backyard, and Steal The Bacon. Appendix B provides
further explanations of methods and procedures of these games, along with a listing
of additional games used. Mixing the two types of activities was administered to
ensure the closest amount of participation from both average weight and
overweight children. Jennie Moore Elementary’s Kaleidoscope program sets aside a
one-hour period per week to achieve Get Out Get Active’s main objective, which is to
achieve a maximal amount of physical activity each week.
Sample
To be eligible for the study, subjects needed to be regular attendees of the Get
Out Get Active program at Jennie Moore Elementary. Students in the program (n=
73; 43 males and 30 females) were in kindergarten to fifth grades, with an age range
of five to eleven. Out of the 73 total participants in the study, approximately 50 were
Caucasian, 18 were African-American, and 5 were Asian or Hispanic. Prior to the
beginning of the study, approval was obtained by the Institutional Review Board at

30
The Citadel, ensuring the research subjects involving human subjects follow federal
regulation (See Appendix C for copy of consent form and IRB). In addition, the legal
guardian of each participant signed a consent form asking for permission to be
granted for children to participate in the study. The consent form explained certain
criteria including: description and explanation of procedures, risks and discomforts,
potential benefits, compensation and treatment for injury, and consent.
For this program, each student participated in one day of physical activity;
kindergarten and first grade on Mondays, second and third grades on Wednesdays,
and fourth and fifth grades on Fridays. For the data collection, student data was
collected on the day they were assigned to participate in the program; kindergarten
and first grade on Mondays, second and third grades on Wednesdays, and fourth
and fifth grades on Fridays. Although the average number of subjects participating
on a given day was 25 on Mondays, 18 on Wednesdays, and 15 on Fridays,
pedometer data for steps taken could only be collected from 12 of the total
participants on a given day due to a restricted amount of pedometers available for
use.
Data Collection
This study was completed over a period of four months, from September-
December 2010. Pre and post measurements were taken on the first and last week
of the study to be able to assess changes in BMI, as determined by the student’s
height, weight, and skin fold thickness. Using a Dectecto® weighing scale, height and
weight measurements were taken in the nurse’s office at Jennie Moore Elementary.

31
Skin fold thickness were assessed on the subject’s middle left triceps and left middle
inner calf using the SlimGuide® Creative Health Products skin fold calipers.
Measurements from the calipers were taken in order of calf to triceps and were
repeated three times to obtain a median value.
To get the most accurate measurement of the subjects’ physical activity
during each weekly session, Walk4Life® W4L™ PRO Model 3 Function Digital
Pedometers were used. The subjects were given the pedometers immediately before
the physical activity session and were constantly encouraged to not tamper with the
devices during the course of the physical activities. The subjects wore the
pedometers on their right hip to ensure consistency. To ensure the maximal interest
and participation from the participants, a variety of activities were included. Some
of these activities included organized sports games (kickball and soccer), non-
elimination games (indoor obstacle courses and relay games, i.e. Red Rover), and
elimination games (wheelbarrow race and musical chairs). Appendix B describes a
complete explanation of games. Upon the completion of the session’s activities, the
pedometers were taken and measurements were recorded.
Data Analysis
The subjects’ observed average physical activity (pedometer readings) was
compared pre and post, along with measured pre and post BMI measurements
(height, weight, skin fold thickness) to determine positive or negative differences
between measures.
Means and standard deviations were calculated, and differences in means

32
were compared using One-way ANOVA tests on Statistical Package for the Social
Sciences (SPSS) Version 10.1 for Windows. Significance was set at p<0.05 for all
statistical tests.
RESULTS
This study examines various measurements collected during a three-month
after school physical activity program to determine if an increase in physical activity
could facilitate an improved BMI over a period of time. Height and weight were
taken before and after the three-month program to establish the increasing or
decreasing changes in BMI. Calf and triceps skin fold thickness measurements were
also taken at these times to make similar comparisons. By using a pedometer, the
participants’ amount of activity was measured throughout the three-month period
by determining their average number of steps taken.
A total of 73 students participated in the study by completing the three-
month after-school physical activity intervention. Descriptive characteristics of the
participants are summarized in Table 1 and Figure 1.
Table 1: Characteristics of Study Sample
Group Number Age
(Standard
Deviation)
Average
Weight
(lb)(SD)
Average
Height (in)
(SD)
Kindergarten 16 5.1 (0.219) 50.12 (7.213) 45.67 (1.979)
First 16 6.3 (0.440) 51.07 (4.996) 47.03 (2.528)
Second 8 7.0 (0) 67.83 (23.507) 50.68 (2.559)
Third 13 8.1 (0.143) 77.52 (26.399) 52.43 (2.682)
Fourth 14 9.4 (0.548) 80.84 (17.061) 54.18 (1.835)
Fifth 6 10.2 (0.408) 92.75 (20.165) 57.3 (1.311)

33
Age, Weight, and Height Data is presented as mean values followed by standard
deviations in parentheses.
Figure1: Differences Among Weights (average inpounds)
Figure2: Differences Among Heights (average ininches)
BMI Differences
Results obtained from changes in Body Mass Index (BMI) during the three-
month period were split into three groups based on which grades participated
together (kindergarten and first, second and third, and fourth and fifth). These
results can be seen in Table 2 and Figure 3. There was no significant difference
between pre-treatment and post-treatment changes in BMI among all three groups;
kindergarten and first (p=0.378), second and third (p=0.143), and fourth and fifth
(p=0.161).
Table 2. BMI Changes From Baseline to 12 Weeks Post-Treatment
Group N Pre-
Treatment
(SD)
Post-
Treatment
(SD)
Percent
Change
Kindergarten -
First
14 16.30 (1.419) 16.63 (1.929) 1.98%
Second – Third 9 18.90 (5.758) 19.40 (5.381) 2.58%
Fourth - Fifth 10 18.88 (3.138) 18.58 (3.143) -1.61%

34
BMI data is presented as mean values followed by standard deviations in
parentheses.
Figure3. Changes In BMI Between Baseline to 12 Weeks Post-Treatment
Average Number of Steps
Results obtained from changes in number of steps during the three-month
period were split into three groups based on which grades participated together
(kindergarten and first, second and third, and fourth and fifth). These results can be
seen in Table 3 and Figure 4. Although there was a significant difference between
pre-treatment and post-treatment with the kindergarten-first grade group (p=0.00)
and fourth-fifth grade group (p=0.019), there was no significant difference between
pre-treatment and post-treatment changes in pedometer readings amongst the
second-third grade group (p=0.80).
Table 3. Changes In Steps From Baseline to 12 Weeks Post-Treatment
Group N Pre-
Treatment
(SD)
Post-
Treatment
(SD)
Percent
Change
Kindergarten -
First
11 901 (483.819) 1807.5
(703.301)
50.15%
Second – Third 6 1335.6
(883.685)
2618.3
(1814.391)
48.99%

35
Fourth - Fifth 4 1219.3
(463.434)
2683.3
(1090.395)
54.56%
***Pedometer data is presented as mean values followed by standard deviations in
parentheses.
Figure4. Average Number of Steps From Baselineto 12 Weeks Post-Treatment
* represents significant differences (p<0.05)
Percent Body Fat
Results obtained from changes in percent body fat during the three-month
period were split into three groups based on which grades participated together
(kindergarten and first, second and third, and fourth and fifth). These results can be
seen in Table 4 and Figure 5. There was no significant difference between pre-
treatment and post-treatment changes in percent body far among all three groups;
kindergarten and first (p=0.272), second and third (p=0.106), and fourth and fifth
(p=0.456).
Table 4. Changes In Percent Body Fat From Baseline to 12 Weeks Post-Treatment
Grade N Pre-
Treatment
(SD)
Post-
Treatment
(SD)
Percent
Change
Kindergarten - 11 18.66 (3.259) 17.86 (3.329) -4.48%

36
First
Second - Third 8 20.71 (9.615) 23.80 (8.11) 12.98%
Fourth - Fifth 9 22.33 (3.353) 22.82 (4.291) 2.15%
Percent Body Fat data is presented as mean values followed by standard deviations
in parentheses.
Figure5. Average Percent Body Fat From Baselineto 12 Weeks Post-Treatment
DISCUSSION
Prior research has shown that after-school physical activity programs can be
effective in reducing the BMI levels of its participants on the elementary school
level, thereby being an operative tool to affect the prevalence of childhood obesity in
elementary schools (Coleman, Tiller, Sanchez, Heath, Sy, & Milliken, 2005; Carrel,
Clark, Peterson, Nemeth, Sullivan, & Allen, 2005; Stephens & Wentz, 1998). Two
studies by Lionis et al. (1991) and Manios et al. (1999) reported significant positive
effects of after-school programs on BMI on a mixed sample of male and female
elementary children. Specifically they found that in addition to the established after-
school based physical activity program, interventions such as changes to school
curricula, printed educational materials, community-based programs, and
counseling sessions were utilized. Both studies demonstrated a smaller increase in
BMI from baseline to follow-up for those in the intervention group compared to the
control group. With the intervention group experiencing an increase of one or less

37
in their BMI ratings, versus an increase of almost two for those in the control group.
Other after-school programs have examined effectiveness of programs by
breaking down the levels of physical activity and the average amount of time the
children spend in each level. One study by Trost and colleagues (2008) assessed
seven after school programs (grades 3-6) in the Midwestern United States, with
measurements on six different occasions throughout the academic year. They found
that students on average exhibited 42.6 minutes of sedentary physical activity, 40.8
minutes of light physical activity, 13.4 minutes of moderate physical activity, and 6.9
minutes of vigorous physical activity. Here, the average accumulation of moderate to
vigorous physical activity was 20.3 minutes (Trost, Rosenkranz, & Dzewaltowski,
2008). Researchers found that, although sedentary and light physical activity levels
were significantly higher than moderate to vigorous levels of physical activity, there
was significant positive change in BMI (p=0.619).
However, other studies have found non-significant differences with BMI with
school based activity intervention. A meta-analysis conducted by Harris and
colleagues (2009) researched several electronic databases with objective data on
changes in BMI in school-based physical activity interventions. Within the eighteen
total studies analyzed in this meta-analysis, researchers found that in fifteen studies
for there to be no significant difference between children who received a school-
based physical activity intervention and those in the control group (weighted mean
difference -0.05kg/m^2), indicating that body composition did not improve with

38
physical activity (Harris, Kuramoto, Schulzer, & Retallack, 2009). In addition, the
change in BMI for those who received various physical activity programs within
their intervention was not significantly different than that of control children
(weighted mean difference -0.08 kg/m^2, 95% Confidence Interval -0.22 to 0.07).
Researchers also found in this meta-analysis that duration of each study did not
affect the results significantly. For studies that lasted up to a year, the weighted
mean difference was -0.09 kg/m^2 (95% CI -0.29 to 0.12). For studies lasting longer
than a year, the weight mean difference was not significantly different (0.00
kg/m^2, 95% CI -0.21 to to 0.21).
Thus as cited, the research is controversial regarding the effectiveness of
afterschool programs and effect on BMI. Therefore, the purpose of this study was to
differentiate the effect of a newly developed Charleston County School District after
school program on BMI levels on the children who participate. The goal was to
determine if this program would be meaningful for students, and if so, to continue
the program. If not, the outcomes would be assessed for changes to programming.
This study indicated that, based on the original design of the Get Out Get
Active program, school-based physical activity interventions did not improve BMI.
Therefore, such present interventions (i.e. one day per week with low to moderate
intensity exercise) are unlikely to have a significant effect on the increasing
prevalence of childhood obesity. In an effort to improve the effectiveness of the
current structure of Get Out Get Active, several factors need to be taken into account

39
to accomplish the program’s goal: frequency, duration, intensity of activities (light,
moderate, and vigorous activity), overall structure, proper parental and teacher
influence, and various other demographical and socioeconomic factors. These are all
important for policy-makers who continue to promote school-based physical
activity as a central component of the strategy to reduce childhood obesity (National
Conference of State Legislatures [NCSL], 2007).
Based on observations made during data collection, there are several
possible explanations for why there was an unexpected rise in BMI levels over the
three-month period. In the school setting, more time during each session could be
dedicated to incorporate a mixture of light, moderate, and vigorous level physical
activity instead of one level of physical activity per session. Also, there should be
more than one day a week in which each participant should be involved with Get Out
Get Active (recommendation would be at least two to three days per week). Also, the
instructor needs to ensure that activities are as individualized as possible in order
to satisfy the students’ needs. As a result, this will help ensure maximum interest
from students. During school hours, initiatives need to be put into place so that the
proper amount of physical activity is received from all grade levels. Results from
this study showed that there was a rise in overall BMI levels between first and
second grade subjects. Based on the information provided from the physical
education teacher at Jennie Moore Elementary and the coordinator for the
Kaleidoscope program at Jennie Moore Elementary, although all grades go to
physical education class for 45 minutes once a week, there is a low amount of that

40
time dedicated to learning fundamental skills. In addition, upon consideration that
grades 1-5 get an additional 45 minutes for half of the school year, it is also worth
noting that, starting in second grade, students spend more time at their desks in
school and have more homework, increasing their sedentary time. During
kindergarten and first grade, they are constantly in motion and have more time to
move around in the classroom and recess.
Although this study produced unexpected results favoring increased BMI
levels, there were positive trends regarding activity levels. Pedometer results over
the first two weeks of data collection as compared to the last two weeks of data
collection showed a significant improvement. Pedometer pre values were analyzed
over the first two weeks of data collection and pedometer post values were analyzed
over the last two weeks of data collection, with averages taken after each two-week
period. This was performed to detect changes in amount of physical activity from
beginning to end of the program. It was observed that, over the last two weeks of
the three-month study, pedometer readings improved significantly compared to the
pedometer readings of the first two weeks of the study (901 steps vs. 1807.5 steps
for kindergarten-first, 1335.6 steps vs. 2618.3 steps for second-third, and 1219.3
steps vs. 2683.3 steps for fourth-fifth). It should be noted that a balance of light,
moderate, and vigorous physical activity was incorporated during both time
periods. All levels of activity were used to encourage subjects of all ranges of
physical ability to participate. Possible explanations of the increased pedometer
readings would include the familiarity with the instructor of Get Out Get Active to the

41
subjects and which activities the subjects preferred to participate in, thereby
improving the effectiveness of the program.
This study had several limitations. The children in the study were only
exposed to the Get Out Get Active program for a total of one day per week for only
one hour per session. Also, it could be argued that the program could be more
successful if there were more time to assess changes in the subject’s BMI levels. For
example, the study could be designed to last for a school year’s time (from August to
May). There was no control on physical activity and dietary behaviors during the
summer months leading up to the study. Another limitation of this study would
include a lack of comparison of a control versus an experimental group. As a result,
there was no way to consolidate one single variable to see if one was a significant
factor in the rise in BMI levels versus another possible variable.
Although we were unable to account for time outside of school, based on the
results of the study, we suggest that parents and/or guardians should take more
initiative and increase involvement over the control of their children’s food intake
behavior and amount of physical activity (Golan & Crow, 2003). In an attempt to
prevent overweight and/or negative health consequences with their children, it is
suggested that parents adopt various methods and programs that have shown prior
success (Birch & Davison, 2001). Such methods as suggested by Birch and Davison
(2001) include the need for parents to provide an environment where there is
consistency in children’s food intake patterns, eating styles, and the development of

42
activity preferences and patterns. As a result, these patterns shape children’s
developing weight status. In addition, Birch & Fisher (1998) showed that parental
influences increased children’s preference for restricted foods as well as their intake
of such foods while diminishing self-control in eating.
Research consistently shows that the majority of American children do not
consume diets that meet the Dietary Guidelines for Americans, nor do they achieve
the recommended levels of daily physical activity. As a result, more children in the
United States are overweight today than at any time in its history. Obesity
prevention efforts need to begin early, focusing on children and families and the
environments in which they live, such as schools, home, and communities. Schools
can help in the fight against obesity by creating environments conducive to healthful
eating and physical activity (Story, Kaphingst, & French, 2006). For instance,
programs like Get Out Get Active have proven to be an example of one of these
efforts. In conclusion, schools must work together with parents and the community
to create an environment where children eat healthfully, become physically fit, and
develop lifelong habits that contribute to wellness, the nation could be well on its
way to preventing obesity (Story, Kaphingst, and French, 2006).

43
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The Medical College of Georgia Fitkid Project. International Journal of
Pediatric Obesity, 3(s1), 3-9.
Harrell, J.S., McMurray, R.G., Bangdiwala, S.I., Frauman, A.C., Gansky, S.A., & Bradley,
C.B. (1996). Effects of a school-based intervention to reduce cardiovascular
disease risk factors in elementary-school children: The Cardiovascular Health
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Harris, K., Kuramoto, L., Schulzer, M., & Retallack, J. (2009). Effect of school-based
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Irwin, C.C., Irwin, R.L., Miller, M.E., Somes, G.W., & Richey, P.A. (2010). Get fit with
the Grizzlies: A community-school-home initiative to fight childhood obesity.
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Institute of Medicine (IOM). (2005). Preventing Childhood Obesity: Health in the
Balance. Washington DC: National Academic Press.

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Jackson, C. (2007). Initial and experimental stages of tobacco and alcohol use during
late childhood: Relation to peer, parent, and personal risk factors. Journal of
Addiction Behavior, 22, 685-698.
Lau, D.C., Douketis, J.D., Morrison, K.M., Hramiak, I.M., Sharma, A.M., & Ur, E. (2007).
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Levin, B. (2009). Synergy of nature and nurture in the development of childhood
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48
grade students. Available at: http://www.just-for-kids.org/links.htm.
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49
Medicine, 33, S172-S174.
Zhao, G., Ford, E.S., Dhingra, S., Li, C., Strine, T.W., & Mokdad, A.H. (2009). Depression
and anxiety among US adults: associations with body mass index.
International Journal of Obesity, 33, 257-266.
Appendices
Appendix A: Prevalence of Childhood Obesity In The United States

52
Appendix B: Activities Used In This Study
Not In My Backyard
Foam rubber items (balls, frisbees, etc) were placed on a line in the center of
the designated area. The group was divided into two groups and were instructed to
stand at opposite lines at the ends of the designated area. For instance, see the
below diagram (O’s being one team and X’s the other):
O O O O O O O O O O O O O O
________balls________
X X X X X X X X X X X X X X X
At my signal, both teams ran to the center and began throwing the items to the other
“yard”. Upon my signal, everyone was to freeze, and wait until I counted each side’s
items. The side with the most “garbage” in their yard, lost.
Source:
http://eduref.org/Virtual/Lessons/Physical_Education/Motor_Skills/MMS0001.ht
ml
Monsters, Inc.
After explaining to the children that, for this activity, they will be “monsters”
hiding in “closets”, the hula hoops were scattered about on the ground, leaving
enough space between the hoops for the children to move freely. They were to begin
outside of a hoop. Upon my signal, the children were to be “monsters” wandering
about looking for a closet to jump into. In doing so, the children could perform any

53
locomotive skill during the activity (hopping, skipping, jumping, etc). After I signaled
to stop, the children were to jump into a “closet” (hula hoop) and give their best
monster growl. The process would be repeated, with one or two hoops taken away
at a time, until only two hoops remained.
Source: http://www.pecentral.com/lessonideas/PrintLesson.asp?ID=3893
Hungry Crabs
Prior to the activity, a large area was set up with boundaries marked by
cones. Bean bags were scattered throughout the designated area. Also, one hula
hoop was placed on the outside of each edge of the boundaries. The students were
divided into four groups and each group was placed at one of the four hula hoops. I
explained to the students that the area inside the cones is the “ocean” and the bean
bags are “crab food”. Also, I explained to them that their team hula hoop is where
they were to place the bean bags they collect.
Source: http://www.pecentral.com/lessonideas/PrintLesson.asp?ID=7000
Snake
All children formed a line. The first child in the line was given a beanbag,
placed on their head. All the children held on to each other’s waist and moved
forward like a snake. If the head of the snake were to drop the beanbag, the child at
the end of the line had to wait until they passed the beanbag. This child picked the
beanbag up and ran to the front of the line. This child became the head with the
beanbag on their head. The game was continued until everyone got to be the head.

54
Source: http://www.canteach.ca/elementary/gamesteams4.html
Steal The Bacon
The group of children was divided into two equal teams, forming two parallel
lines about 20 feet from each other, facing each other. An object was placed in the
middle, between the two teams. I went down each line and assigned each person a
number. I began the game by calling a random number. The object was for the two
children with that number, one from each team, to be the first to grab the “bacon” in
the middle of the two lines and return to their line untagged by the other child. If
they returned untagged, they received one point. If they were tagged, no points were
awarded. Some variations used were calling out even numbers, odd numbers, and
multiples of numbers, such as 2 or 3.
Source: http://www.greatgroupgames.com/steal-the-bacon
Human Chain
Two children started the game by holding hands and chasing the other
children. The children they caught joined the chain by linking hands. When another
child is caught, I told them they could have stayed together or split in even numbers
and linked together at will. The game was played until all children were caught.

55
Red Rover
At first, two teams were chosen of equal size, and formed two lines, facing
each other and holding hands. One side started by picking a person on the opposing
team and saying “Red Rover Red Rover, send “child’s name” right over”. The child
called upon then let go of their teammates and ran as hard as they could to try and
break through the line. If the child broke through, they got to choose one person
from the opposing team to go back and join their line. If the child failed to break
through, they became part of the other team. The team that ended up with all
children was the winners.
Capture The Flag
There were two teams split up into equal numbers. A field was split up
evenly between teams by placing cones in a middle line. The teams were given a
time period of five minutes to hide their flag in their part of the field. After being
notified from each team they were ready, I signaled the game to begin. Each team
took off into their opposing team’s half of the field to try and capture the flag. If a
child got caught and tagged by a member of the opposing team, they had to go to jail
and could only be freed by a teammate who grabs the member in jail when the
opponent is not looking. The first team to capture the flag wins.

56
Dizzy Basketball
Players were divided into two groups. Each team was given a basketball and
one baseball bat. One player at a time went to their baseball bat, bent over, and put
their head on the end bat and circled five times while at that position. After that,
they picked up their basketball, dribbled down the court to the hoop, and shot their
basketball until they made it in. After making it, they dribbled back down the court
to their team. Once that child made it back, the next in line repeated the same. The
first team to finished won.
Source: http://eduref.org/Virtual/Lessons/Physical_Education.html
Bean Bag Shuffle
Students started with a beanbag in their hand (four different colors [blue,
green, red, and yellow]). After handing out the bags, I instructed that each bag
represented a loco motor skill and the student would have to perform that motion
until I said to stop without dropping their bag (blue bags=skip, green bags=gallop,
red bags=hop, and yellow bags=slide). Once I said stop, the students dropped their
bag, found a bag of another color, and, on my cue, performed that skill until they
performed all loco motor skills.
Source: http://pecentral.org/lessonideas/ViewLesson.asp?ID=6795
Team Shuffle
All players were divided into four equal teams. Each team lined up in the four
different corners of the field, behind one another. The object of the game was for

57
each team to get all of their members to their opposite corner. Several variations of
loco motor skills were used in this exercise (hopping, skipping, jumping, etc.). This
was done while all the other teams did the same skill, resulting in them all meeting
in the middle. They were to do this with both hands out to be used as bumpers for
protection, with each player following one behind another. Once each member got
through the middle and reached the other side, they were to sit down in a line up
position. The first team with all members sitting was declared the winner.
Source: http://www.funattic.com
Blind ,One-Legged, “Odd” Arm Kickball
In this variation of kickball, the kickers were blindfolded and I instructed the
children as to when to listen for either my signal or for the sound of the ball rolling
across the grass. When the kicker made contact with the ball, there was another
person who coached them as to where to run towards first base, and so on. For the
infielders and outfielders, they used some variations: either playing with one leg or
throwing with their non-dominant arm.
Hot Potato
This game used a slight variation to this game’s normal rules: using the
children’s feet instead of their hands. A medium sized ball along with a child chosen
to be “it” was placed in the center of a circle. The rest of the children formed the
circle. The child who is “it” pushes the ball with his or her feet, trying to get it out of

58
the circle. The other children try to stop the ball with their feet. Once the ball got out
of the circle, another leader was chosen. The ball was called the “hot potato” in this
activity.
Simon Says
One child was chosen to be “Simon” as the other children stood in a straight
line. “Simon” then calls out an action for the children to follow. I stressed that it be
something more physical. Examples were: jumping in place, squatting, and running
in place. If “Simon” said “Simon says” (action), the other children were to perform
that action. If “Simon” only said that action, those that still did the action were out
and had to sit out the rest of the time. The last child standing was declared the
winner.

59
Appendix C: Internal Review Board Document
Proposal for Research Involving Human Subjects
Name: Dena Garner
Department: Health, Exercise, and Sport Science
Status (student,faculty, etc.): Faculty
If student,faculty advisor/sponsor:
I. In a 2 to 3 page summary, provide a general description of the research project making sure that
this description covers the following areas:
A. The research question(s) (Page 2)
B. A clear statement of research methodology, including the number of subjects to be used
and the statistical analysis(ses) planned. (Page 2)
C. The scientific or educational benefits of the research. (Page 1-2)
D. The potential risk to subjects, IF ANY. Describe fully. (Page 2)
E. Describe intended participants, procedures that will be used to recruit those
participants, any payments or compensations planned, whether results will be made
available to participants and how. (Page 2 & 8)
F. Description of any deception, necessity of the deception, and plans for debriefing
subjects at the conclusion of participation. (Page 2)
G. Estimates of the following:
1-average amount of time required for participation (indicate hours,minutes) (Page 7 &
13)
2-total number of items on questionnaires or tests (Page 11 &12)
Childhood obesity is associated with a number of problems such as Type II
diabetes, altered glucose metabolism, sleep apnea, hypertension, and
cardiovascular disease. Obese children are at risk for these secondary
diseases both in childhood and through adulthood. The cost of treating
health issues associated with obesity in adulthood is estimated to be between
98 to129 billion dollars. In addition, two of the determinants of obesity
(reduced physical activity and poor nutritional habits) results in 300,000
deaths per year. Thus, to protect children from such devastating health
implications, there must be focus on educating and promoting healthy
lifestyles at a young age. However, due to the stressed lifestyles that most
families lead these days, physical activity and healthy eating habits are
neglected. In addition, physical education in schools is often limited to 1 day
per week with no nutritional recommendations. Thus, the purpose of this
study is to target children in a setting where they will have an opportunity to
receive physical activity and nutritional counseling 2 days a week for fall
term 2008. The hypothesis is that such an intervention will promote a
healthy lifestyle as indicated by positive changes in body composition and
nutritional surveys.

60
This study will recruit volunteers from the K-grade 5 after school program at
Sullivan’s Island Elementary School on Sullivan’s Island. This program is
facilitated by Wando Community Education and consent has been obtained
from Wando Community Education and Sullivan’s Island Elementary.
Consent will also be obtained from parents and children involved in the
program, and an IRB approval will be obtained from The Citadel, prior to the
start of the study. All participation will be voluntary and a full description of
the program has been accepted and promoted by the Sullivan’s Island
Afterschool Coordinator, Jackie Meade.
Students will be provided with 30 minutes of physical activity for 2 days a
week. Exercise will include such things as running games, bicycle days,
basketball games, and walking expeditions. Physical activity will be followed
by 30 minutes of nutritional education such as the importance of 5 fruits and
vegetables, fiber intake, and decreased sugar and fat consumption in the
form of fast foods. A graduate student or I will lead the exercise and
nutritional portion of the program. In addition to the exercise and
nutritional interventions received during the program, students will be asked
to wear a pedometer and chart their progress weekly through an online
program offered by Walk4Life.com. Students will be encouraged to increase
activity with incentives (such as being chosen as leaders, stickers, and small
tokens from a treasure box of goodies) given to those who complete the most
steps each week during the program.
Prior to and after the study, body composition will be determined via the
bioelectrical impedance and the Lange skinfold calipers. Fitness level will be
determined using the Pacer Fitness Test as described by Fitnessgram. This
test asks students to run as long as possible back and forth in a 20 meter
space. In addition to the physiological measures, I will assess nutritional
content of diets with a survey that will be given at the beginning and the end
of the program. A pre/post test measure of the results will be analyzed using
SPSS statistical software. Assessments will be made on the number of steps
taken, the body fat percentage changes, if any, and nutritional changes during
the course of the study.
Sharma, M. (2006). School-based interventions for childhood and
adolescent obesity. Obesity Reviews, 7, 261-269.
II. Provide copies of the following:
A. All standardized test protocols and any questionnaires to be used. (See attached)
B. Description of any self-developed measures; any existing data on such measures. (None)
C. Any interview questions to be asked. (If the interview will be unstructured,then indicate the
general topics to be covered.) (See attached)
D. The form to be used to obtain informed consent. If written consent will not be
obtained, attach a statement of how consent will be obtained or an explanation

61
of how subjects will be debriefed and protected. (See attached).
III. Will the participants be (check one):
a. fully informed partially informed deceived
b. told that they may terminate participation at any time?...............................
x yes no
c. informed that,without penalty, they may refuse to respond to
particular questions?............................................................................
x yes no
d. informed that,without penalty, they may stop participation at any time… x yes
no
e. given a copy of the consent document to read............................................
x yes no
IV. Will the research involve:
a. physical stress or tissue damage?.................................................................
x yes no
b. the likelihood of psychological stress?........................................................
yes x no
c. deception about purposes or research (but not about risks involved)?........
yes x no
d. invasion of privacy from potentially sensitive or personal questions?........
yes x no
e. biomedical procedures?................................................................................
yes x no
f. procedures designed to modify the knowledge, thinking, attitudes,
feelings, or other aspects of the behavior of subjects?.........................
yes x no
g. the giving of false or misleading information to subjects?.......................... yes
x no
h. the withholding of information such that “informed consent”
is in question?.......................................................................................
yes x no
i. procedures will cause any degree of discomfort, harassment,invasion
of privacy, or threat to the dignity of subjects?.....................................
yes x no
If you responded “yes” to a through I under Section IV above, be sure you have fully
addressed issues of risk/deception under Section I, D or F, in the summary. If you are a
student, be sure to explain in Section I, D or F, how your faculty advisor/sponsor will
supervise the project.
V. Is this project specifically designed to involve subjects who:
a. are minors (less than 18 years of age)?.........................................................
x yes no
If yes, will consent of parents/guardian be obtained?...........................
x yes no

62
b. are prisoners?................................................................................................
yes x no
c. are institutionalized?..................................................................................... yes
x no
d. are college students?..................................................................................... yes x no
e. are K-12 students?.........................................................................................
x yes no
If yes, has permission of the schoolbeen obtained?.............................
x yes no
If yes, will consent ofparent/guardian be obtained?............................
x yes no
f. have disabilities?............................................................................................
yes x no
VI. Which of the following best describes your research project (mark all that apply)?
historical descriptive
causal-inferential archival
correlational x experimental
VII. Which of the following best describes your data collection method?
observation interview
survey educational tests
psychological tests x physiological markers
DRB/IRB Action
(Attach to Research Proposal)
The research proposal met the requirements for exempt research as follows
(assure that proper procedures for confidentiality and informed consent are
evident: check all that apply):
___/ research involving normal educational practices, in established or commonly accepted
educational settings,such as research on or comparisons among instructional strategies,curricula,
or classroom management methods [45 CFR 46 101 (b)(1)]
___/ research involving the use of educational tests (cognitive, diagnostic, aptitude,
achievement), survey procedures,interview procedures, or observation of public behavior if the data are
recorded so that subjects cannot be identified either by names or special code identifiers and where
disclosure of information will not place subjects in criminal or civil liability or be damaging to the
subjects financial standing,employability, or reputation [45 CFR 46 101 (b)(2)(I)]
___/ research involving the collection or study of existing data,documents, records,
pathological specimens, or diagnostic specimens if these sources are publicly available or if the
information is recorded by the investigatorin such a manner that subjects cannot be identified directly or
through identifiers linked to subjects [45 CFR 46 101 (4)]
___/ research involving surveys or interviews of respondents who are elected or
appointed public officials or candidates for office [45 CFR 46 101 (3) (I)]
___/ research or demonstration projects designed to study, evaluate, or
otherwise examine public benefit or service programs [45 CFR 46 101 (5)(I)]
___/ consumer acceptance studies [45 CFR 46 (6)]
Review Completed (date) ___/___/___
DRB Signatures ______________________
______________________

63
The research contained minimal risk and meet the requirements for expedited review .
DRB Signature _______________________
_______________________
IRB Chair Signature_______________________
The research contained greater than minimal risk potential and received full committee review.
IRB Chair Signature_______________________
Review Recommendations:
Accept the proposal without revision.
Send the proposal back for the needed revisions; let Chair determine
adequacy of revisions.
Send the proposalback for the needed revisions; let Committee review revisions.
Have a meeting of either the DRB or IRB, as indicated, to discuss the proposal.
Reject the proposal.
Basis of Rejection
Signature of DRB or IRB Chair, as required _________________________________
Date ___/___/___
CONSENT FORMS
General Guidelines:
Regular Form: The regular form should be used for complicated studies or studies
where the researcher may have no direct contact with subjects. The form should
address all 8 aspects of conformed consent as detailed on page 2, 1-10.
Short Form/Oral Presentation: The short form or oral presentations are appropriate when
procedures are rather simple or when the researcher will have direct contact with subjects.Both
forms of consent should still address all aspects of conformed consent.A signature is not required
for oral presentations but must include the date that it was read to each subject. Survey research
via mail does not require return of an informed consent form since return of the survey is implied
consent.

64
Appendix D: Consent Form
Consent Form to Act as a Human Subject
THE CITADEL
Subject’s name: __________________________________
Date of Consent: ____/____/_____
Project Title: Effects of an after school exercise program for K-5th graders
Description and Explanation of Procedures:
The body mass index and percent body fat of each participant will be analyzed via the skin fold
calipers and bioelectrical impedance at the beginning, middle, and end of the program. In
addition, we are interested in the effect of physical activity on motor skills. Therefore we are
assessing motor skills by an observational rubric during the program. Such skills we will
observe include running, hopping, stationary dribble, catching, over arm throw, and kicking.
The program will last the duration of the fall term (September to December). Each session will
meet for 1 hour from 3:30 to 4:30 pm. Kindergarten and 1st grade will meet on Monday, 2nd
grade and 3rd grade on Wednesday and 4th and 5th grade will meet on Friday. During each
program session students will participate in 15 minutes of fun educational sessions on the
importance of activity followed by 45 minutes of fun physical activity aimed at promoting

65
lifetime fitness.
Risks and Discomforts:
Physical exertion will be necessary to perform the bout of exercise. As with all exercises, there
is some risk of injury. Precautions will be made to ensure that proper form is utilized while
performing the exercises.
Potential Benefits:
Scientists continually seek to ways to increase physical activity in children and understand
how this affects motor skills. This study seeks to instill lifetime fitness in school aged children.
The hope is that this will translate into lifetime habits that may reduce the risk of obesity in
adulthood.
Compensation and Treatment for Injury:
This exercise is not expected to cause any discomfort beyond minor physical exertion;
however, if an injury occurs you can be referred to the sports medicine facility at The Citadel
for assessment and treatment.
Consent:
I have been satisfactorily informed about the procedures described above and the possible risk
and benefits of the project, and I agree to allow my child to participate in this project. Any
questions that I have about the procedures have been answered. I understand that this project
and this consent form have been approved by the Departmental Review Board or Institutional
Review Board at The Citadel, as appropriate, which ensures that research projects involving
human subjects follow federal regulation. If I have any further questions about this project I
will call Dr. Dena Garner, Department of Health, Exercise, and Sport Science, (843) 953-7960.
I understand that I am free to withdraw my child from participation in the project at any time
without penalty or prejudice. In addition, my child will not be identified by name as a
participant in this project. Any new information that might develop during the project will be
provided to me if that information may affect my willingness for my child to participate in this
project.
ADDENDUM: Pedometers will be incorporated and worn by the children to assess their
amount of physical activity on the days the researcher is conducting the activity as described
above. Following the activity, the children will be assessed with a 5 question questionnaire to
determine how they feel about their participation in group games.
_____________________________________ _____________________________________
Subject’s Signature Date Researcher’s Signature Date

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