1. Batter Up For Bone Health: Education
intervention to improve bone health
knowledge in school-age children
Sarah Allaben, BS
Erica Auriemme, BS
Alexis Blandine, BS
Kiah Ehrke, BS
Ellen Hashiguchi, MPH
Maggie Tignanelli, BS
Thesis advisor: Karen Plawecki PhD, RD

2. On Deck
● Background
● Methods
● Demographics
● Results and discussion
● Strengths and limitations
● Future implications for research

3. Batter Up for Bone Health
An 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.

4. Bone Overview
Cortical Bone and Trabecular bone1
● Crystalline hydroxyapatite
Ca5(PO4)2
Osteogenesis = the formation of bones2
● Osteoblasts: bone building
● Osteoclasts: bone resorption
Leading Players
● Calcium & Vitamin D
● Physical Activity
(Lian, 2004; Gilbert, 2000)

5. Mechanism of Bones
Osteogenesis
● 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)

6. Bone Remodeling
● Constantly undergoing modeling
● Osteoblasts have a dual function
● Average lifespan of each
remodeled unit in humans is 2-8
months1
(Kini, 2012)

7. Bone Remodeling
● Peak bone height
velocity slows at
puberty
(Fortes, 2012)

8. 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)

9. 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

10. Bone Health Diseases
Rickets/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)

12. Incidence of Rickets/Osteomalacia
● Incidence has increased since 20001
○ Most incidences occur in African
Americans
(Thacher, 2013)

13. Bone Health Diseases
Osteoporosis
• Translates to porous bone
• Resorption happens more quickly than
osteoid formation
• 1 in 3 women and 1 in 5 men are at risk1
• 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)

14. Calcium Overview
● Positive effect on bone
mass in children and
adolescents 1
● Nutrient of Concern
(Webb, 2014)

15. Calcium Overview
● Serum calcium is kept
constant at bone’s expense
● Increasing calcium
consumption has greater
bone benefits
(Houillier, 2006)

16. (WWEIA, 2014; Rehm, 2015)

17. 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

18. (Hever, 2015)

19. (Weishaar, 2013)
Distribution of serum 25-hydroxyvitamin D levels by racial/ethnic group in the US population

20. Vitamin D
RDA - 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)

21. Vitamin D
12-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)

22. Joint Force Ground Force
Types of Exercise
(Behnke, 2012)

23. 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)

24. Ground Force Research

25. Physical Activity Trends in the Pediatric Population
• Recommended 60 minutes daily
activity between ages 6 - 171
• Physical Education within the
School through a Comprehensive
School Physical Activity Program
• Physical Education Classes
• Movement within the Classroom
• Recess2
(USDHHS, 2011; CDC, 2015)

26. Example of Comprehensive School
Physical Activity Program Design
(Orlowski, 2013)

27. 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)

28. Triple Play!

29. Social Cognitive Theory
• Learning occurs
within a social
context

30. 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

31. 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)

32. Batter Up! For Bone Health
The Rules [Methods]

33. 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

34. Intervention Layout and
Base Information

35. Survey Tools
• Recruitment Flyer
• Consent to participate
• Demographics
• Three Measurable Tests

36. Survey Timeline

37. Tips For the School

38. Location
Location Participants
with
Consent
Forms
School 59% (n=99)
Camp 41% (n=69)

39. Gender

40. Ethnicity
Chart: Ethnicity of Participants
with Consent Forms
n = 165

41. Ethnicity by Location
N=67 N=98

42. Calcium Sources Consumed

43. Multivitamin Sources Reported

44. 7th Inning Stretch
(Results)

45. 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= 61
M=58
F: 0.61
M: 0.64
Females:2.02
Males: 2.46
-0.08 0.940 Inside
Between Agesc Total N=118
(7)=1
(8)=32
(9)=49
(10)=36
Total: 13.16
7yr: 13.00
8yr: 12.33
9yr: 13.25
10yr: 13.79
Total: 2.23
7yr: --
8yr: 2.89
9yr: 1.91
10yr: 1.82
F=2.43 0.069 Outside
Between
Locationsb
Total N= 129
S= 93
C= 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

46. 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: 13.41
21-day posttest:
13.48
Post-test: 1.99
21-day
posttest:2.07
-0.49 0.627 outside
Between
Gendersb
Total N= 128
F= 60
M= 58
F: -0.02
M: 0.17
F: 1.14
M: 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: 0.09
8yr: 0.52
9yr: 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: 1.72
C: 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

47. 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= 49
M= 44
F: 0.88
M: 0.59
F: 1.86
M: 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

48. 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/effect
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= 50
M= 47
F: -0.08
M: 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

49. 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: 12.53
Post-test: 13.38
21-day post-test:
13.52
Pre-test: 1.88
Post-test: 2.02
21-day post-test:
2.05
18.94 0.0001 0.26
Overall
Knowledge
and
Retention in
Schools d
92 Pre-test: 12.80
Post-test: 13.61
21-day post-test:
13.65
Pre-test: 1.65
Post-test:1.80 21-
day post-test:
1.79
14.89 0.0001 0.25
dRepeated Measures ANOVA

50. Knowledge gained and knowledge retained at both locations; camp isolation.
p-value, camp
<0.0001
p-value, school
<0.0001
Overall
scores

51. 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: 4.73
Posttest: 5.24
Mean Diff: 0.51
Pretest: 0.87
Posttest: 0.96
6.89 0.0001
0.28 (M)
Between
Gendersb
Total N = 113
(F) N = 58
(M) N = 55
F: 0.43
M: 0.60
F: 0.70
M: 0.87
-1.14 0.26
Outside
Between
Agesc
Total N = 112
(8) N = 30
(9) N =46
(10) N =35
Total: 0.52
8 yr: 0.37
9 yr: 0.50
10 yr: 0.63
Total: 0.52
8 yr: 0.37
9 yr: 0.50
10 yr: 0.63
1.04 0.38 Outside
Between
Locationsb
Total N = 113
(S) N = 89
(C) N = 24
S: 0.53
C: 0.46
S: 0.72
C: 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

52. 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: 5.57
21DayPost: 5.21
Mean Diff: -0.36
Posttest: 0.95
21DayPost: 1.01
0.79 0.43 Outside
Between
Gendersb
Total N = 115
(F) N = 60
(M) N = 55
F: -0.08
M: -0.04
F: 0.70
M: 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: 0.03
9 yr: -0.06
10 yr: -0.19
Total: 0.81
8 yr: 0.63
9 yr: 0.94
10 yr: 0.75
0.66 0.52 Outside
Between
Locationsb
Total N = 115
(S) N = 94
(C) N = 21
S: -0.07
C: 0.00
S: 0.82
C: 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

53. H07 There is no change in knowledge increase 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 89
Pretest: 4.84
Posttest: 5.37
Mean Diff: 0.53
Pretest: 0.80
Posttest: 0.82 -6.88 0.0001
0.31 (M)
Between
Gendersb
Total N = 89
(F) N = 47
(M) N = 42
F: 0.53
M: 0.52
F: 0.58
M: 0.86
0.52 0.96
Outside
Between
Agesc
Total N = 89
(8) N = 21
(9) N = 36
(10) N = 32
Total: 0.53
8 yr: 0.38
9 yr: 0.50
10 yr: 0.66
Total: 0.72
8 yr: 0.59
9 yr: 0.88
10 yr: 0.60
0.96 0.39
Within
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male

54. 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: 5.39
21DayPost: 5.31
Mean Diff: -0.08
Posttest: 0.81
21DayPost: 0.89
0.88 0.38 Outside
Between
Gendersb
Total N = 94
(F) N = 50
(M) N = 44
F: -0.10
M: -0.46
F: 0.58
M: 1.03
-0.32 0.75 Outside
Between
Agesc
Total N = 95
(8) N = 22
(9) N = 39
(10) N = 33
Total: -0.07
8 yr: 0.09
9 yr: -0.03
10 yr: -0.24
Total: 0.89
8 yr: 0.61
9 yr: 0.96
10 yr: 0.75
1.22 0.30 Outside
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male,

55. 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: 4.20
Posttest:4.59
Difference: 0.39
Pretest: 0.84
Posttest: 0.64
-5.61 0.0001 0.23
Between
Locationb
Total N = 107
(S) N = 85
(C) N = 22
S: 0.39
C: 0.41
S: 0.73
C: 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: 0.72
M: 0.73
-0.37 0.715 Outside
Between
Agesc
Total N = 106
(8) N = 28
(9) N = 43
(10) N = 34
Total: 0.38
8 yr: 0.36
9 yr: 0.35
10 yr: 0.44
Total: 0.71
8 yr: 0.73
9 yr: 0.69
10 yr: 0.75
0.21 0.888 Outside
Between
Ethnicitiesc
Total N = 106
(H) N = 18
(W) N = 74
Total:0.40
H: 0.39
W: 0.35
Total: 0.73
H: 0.78
W: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

56. Target
Group
Sample Size
(N)
Mean Difference Standard Deviation Test
Value
P
Value
Confidence Interval/
Effect Size
Overalla 111 Posttest: 4.60
21DayPost: 4.55
Difference: -0.15
Pretest: 0.65
Posttest: 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: 0.58
C: 1.01
0.53 0.604 Outside
Between
Genderb
Total N = 111
(F) N = 58
(M) N = 53
F: -0.07
M: -0.02
F: 0.67
M: 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: 0.65
9 yr: 0.59
10 yr: 0.58
4.42
(F)
0.014 0.08
Between
Ethnicitiesc
Total N = 111
(H) N = 19
(W) N = 77
Total: -0.05
H: -0.21
W: -0.01
Total: 0.68
H: 1.03
W: 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

57. p<0.012
*Repeated Measures ANOVA
H010a There is no significant difference between retention of Vitamin D sources between the
Hispanic and White population.

58. H011 There is no significant difference between knowledge 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 85 Pretest:4.26
Posttest:4.65
Difference:0.39
Pretest: 0.79
Posttest: 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: 0.72
M: 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: 0.73
8 yr: 0.75
9 yr: 0.68
10 yr: 0.77
0.25 0.778 Outside
Between
Ethnicitiesc
Total N = 85
(H) = 2
(W) = 71
Total: 0.39
H: 0.00
W: 0.34
Total:0.73
H: 0.00
W: 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

59. 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: 4.68
Posttest:4.66
Total Mean Diff: - 0.02
Pretest: 0.54
Posttest: 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: 0.41
M: 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: 0.58
8 yr: 0.57
9 yr: 0.52
10 yr: 0.61
3.15
(F)
0.048 0.07
Between
Ethnicitiesc
Total N = 90
(H) N = 2
(W) N = 75
Total: -0.02
H: 0.00
W: -0.01
Total: 0.58
H: 0.00
W: 0.63
0.12
(F)
0.975 Outside
apaired t-test; bindependent samples t-test; c One-way ANOVA; F = Female, M = Male, W = White, H = Hispanic

60. Pre to Posttest Sample Size Mean Standard
deviation
Test Value P-value Confidence
interval
Overalla 113 Pretest: 4.00
Posttest: 3.88
0.85 1.53 0.127 Inside
Between Gendersb Total N= 113
(F) N = 57
(M) N = 56
F: -0.05
M: -0.19
F: 0.91
M: 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: -0.14
7 yr: ---
8 yr: -0.22
9 yr: -0.02
10 yr: -0.22
Total: 0.83
7 yr: 0.99
8 yr: 0.83
9 yr: 0.68
10 yr: 0.82
0.53 0.657 Outside
Between Locationsb Total N = 113
(S) N =89
(C) N =24
S: -0.08
C: -0.25
School: 0.79
Camp: 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

61. Post to 21-Day Post Sample
size
Mean Standard
deviation
Test
Value
P-value Confidence
interval/
effect size
Overalla 114 Posttest: 3.85
21-day Posttest: 3.90
Post-test: 0.75
21-day Posttest: 0.83
-0.61 0.537 Outside
Between Gendersb Total N= 114
(F) N = 59
(M) N = 55
F: 0.01
M: 0.07
F: 0.68
M: 0.83
-0.39 0.69 Outside
Between Agesc Total N = 113
(8) N = 28
(9) N = 50
(10) N = 35
Total: 0.05
8 yr: -0.03
9 yr: 0.16
10 yr: -0.02
Total: 0.75
8 yr: 0.69
9 yr: 0.84
10 yr: 0.66
0.90 0.409 Outside
Between Locationsb N=114
(S)=93
(C)= 21
School: -0.01
Camp: 0.28
School : 0.69
Camp: 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

62. In the
School
Sample Size Mean Standard
Deviation
Test Value P-Value Confidence
Interval/
Effect Size
Overalla 89 Pretest: 3.98
Posttest: 3.89
Pretest: 0.71
Posttest: 0.70
1.07 0.288 Outside
Between
Gendersb
Total N = 89
(F) N = 42
(M) N = 47
F: -0.04
M: -0.14
F: 0.88
M: 0.68
0.59 0.554 Outside
Between
Agesc
Total N = 89
(8) N = 20
(9) N = 37
(10) N = 32
Total: -0.08
8 yr: -0.05
9 yr: 0.00
10 yr: -0.21
Total: 0.79
8 yr: 0.82
9 yr: 0.84
10 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

63. 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: 3.90
21DayPost: 3.89
Posttest: 0.70
21DayPost: 0.81
1.48 0.882 Outside
Between
Gendersb
Total N = 93
(F) = 44
(M) = 49
F: -0.04
M: 0.02
F: 0.57
M: 0.82
-0.42 0.67 Inside
Between
Agesc
Total N = 93
(8) N = 21
(9) N = 40
(10) N = 32
Total: -0.01
8 yr: -0.14
9 yr: 0.10
10 yr: -0.06
Total: 0.69
8 yr: 0.65
9 yr: 0.74
10 yr: 0.66
F=0.96 0.386 Outside
aPaired T-Test; bIndependent Samples T-Test; c One-Way ANOVA; F = Female, M = Male

64. 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

65. 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 too
My friends and I eat the same foods
School
environment
.666
Like the same foods my parents like or like to eat
what my parents eat
Like to eat what my friends eat
Home
environment
.58
*Principal Components Analysis, Cronbach alpha

66. 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 eat
When I see my friends/teachers eat something, I
like to eat that food too
School
environment
.295
Like to eat what my parents/friends eat
My family eats the same foods at mealtime
Home
environment
.604
*Principal Components Analysis, Cronbach alpha

67. Pre-Test (n=119) 21-Day Post-Test (n=120)
Response
value
Yes 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

68. p<.0001

69. 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

70. p<.0001

71. 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

72. p=.004,
<.0001

73. H021 There is no difference between genders with regards to influences in participants’ bone healthy
nutrition behaviors.
Pre-Test 21-Day Post Test
Influences Girls Boys P-
Value
Confidence
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 Outside
N/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

74. 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

75. 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

76. 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

77. 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/Confiden
ce 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

78. 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

79. Category Sample
Size
Post-Test
Mean
21-Post
Test
Mean
t-value p-value Effect
size/Confidenc
e 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

80. 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

81. Bottom
of the Ninth

82. ● 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

83. 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

84. 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

85. Future Research
● Implementing the program in
schools with different demographics
● Application of influences and
modeling in children
● Female’s dietary behaviors during
pubescence

86. 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

87. Post-Game Press
Conference

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