Get Fit Kids: A Feasibility Study of a Pedometer-Based Walking Program

Abstract

Introduction:

Childhood obesity has reached epidemic proportions in the United States and is a complex health problem with many biological, environmental, and psychosocial causative factors. While there are many factors that must be addressed to combat the prevalence of childhood obesity, prevention is typically viewed as the best solution for children. In an effort to address childhood obesity prevention and promote daily physical activity, a 12-week, pedometer-based walking program, Get Fit Kids, was designed and implemented with elementary school children. The primary aim of this study was to assess the feasibility and effectiveness of Get Fit Kids with an underserved population of Baltimore City public elementary-school children.

Methods:

Children in third through fifth grades participated in this quasi-experimental study during the 2008–2009 school year. The primary research aim was to evaluate the feasibility and effectiveness of the program as measured by the change in step counts from the children's pedometers, participant satisfaction, and program costs. Secondary measures were change in body mass indices (BMI) and teacher satisfaction with the program.

Results:

Using a paired samples t test, children's step counts as measured at the beginning and conclusion of the program were significantly increased (t=3.374, p=0.001).

Conclusion:

Introduction

Childhood obesity has reached epidemic proportions in the United States. The prevalence of obesity among children aged 6 to 11 years tripled from 6.5% in 1980 to 19.6% in 2008, while the prevalence of obesity among adolescents aged 12 to 19 years increased from 5.0% to 18.1% during the same period.¹ This current prevalence of obesity in America's children and adolescents exceeds the 15.7% target cited by the Healthy People 2020 goals.²

Much like many U.S. cities, Baltimore, Maryland, is challenged by childhood obesity. In a recent publication from the Robert Wood Johnson Foundation, the F as in Fat Executive Summary reports that 25–30% of Maryland children aged 10 to 17 are overweight or obese.³ In a 2007 report by the Baltimore City Health Department, 13% of children aged 2 to 5 years enrolled in a supplemental nutrition program for women, infants, and children in Baltimore City were obese, and 18.5% of Baltimore City high school students were identified as obese.⁴ In a separate study in Baltimore, Jehn et al. reported that there was a high prevalence of overweight and at-risk-for-overweight school children, citing a 33.9% prevalence in their sample.⁵ Some studies suggest that obesity may be even more prevalent in minority children and children of lower socioeconomic status.⁵ In a recent report by the Office of Minority Health, the percentage of overweight African-American girls aged 6 to 11 years was 24% compared to 14% for non-Hispanic white girls of the same age.⁶ For boys of the same age, nearly 19% of the African-American boys were overweight compared with 16% of Caucasian boys.⁶ Coupled with the known risk factors of sedentary behavior, unhealthy diets, environmental, and genetic factors, it is apparent why the prevalence of childhood obesity is increasing.

Children who are overweight or obese are more likely to be overweight or obese as adults and are prone to many significant health problems. One study found that 80% of children who were overweight at 10 to 15 years of age were obese adults at 25 years, while another study found that 25% of obese adults were overweight as children.¹ The same study also found that if a child becomes overweight before the age of 8, obesity in adulthood is likely to be more severe.¹ In addition, other researchers have recently reported that being overweight or obese between the ages of 14 and 19 years was associated with increased mortality in adulthood (after the age of 30) caused from a variety of systemic disease.⁷ Childhood obesity affects children adversely in a variety of ways with often serious consequences including, hypertension, dyslipidemia, insulin resistance, fatty liver disease, sleep disturbances, and psychosocial problems.⁷

Prevention of childhood obesity must be aimed at utilizing family-based, community-based, and primary care-based healthcare strategies. One such strategy is to promote daily physical activity in school-age children to combat their sedentary lifestyles. While there is much discussion in the literature on the appropriate level of physical daily activity, there is an agreement that Americans do not get enough daily physical activity. The U.S. Presidents' Challenge Physical Activity and Fitness Awards program in 2002 publicly promoted the 10,000 steps per day level for adults, but acknowledged that it was not enough for children.⁸ In a study by Tudor-Locke et al., BMI-referenced step counts were recommended as 12,000 steps per day for 6 to 12 year-old girls and 15,000 steps per day for boys.⁸ This same study also cited that approximately 65% of children aged 8 to 16 years watch more than 2 hours of television per day, and that only 22% of these same children participate in physical education classes in school.⁸ Clearly, there is a need to promote and engage children in increasing their daily physical activity in an effort to prevent obesity and acquire an active, healthy lifestyle.

In order to address childhood obesity in Baltimore and promote the importance of daily physical activity, the University of Maryland Medical Center, in partnership with the University of Maryland School of Medicine and Merritt Athletic Clubs, developed a 12-week pedometer-based walking program, Get Fit Kids, designed to encourage and motivate school-age children to walk 13,000 steps per day. The primary aim of this study was to assess the feasibility and effectiveness of Get Fit Kids with an underserved population of Baltimore City public elementary-school children.

Materials and Methods

Institutional Review Board approval was obtained from the University of Maryland in order to analyze and publish the program findings. Initially, 419 elementary school children, from five Baltimore City public schools, voluntarily enrolled in the Get Fit Kids program during the 2008–2009 school year. This was the second year this program was offered in Baltimore City schools through a grant from the Maryland Department of Health and Mental Hygiene (DHMH) as a feasibility study to examine broader use. A sixth school started the program but withdrew due to lack of student interest and school leadership support. Two of the original five elementary schools did not complete the pre- and post-program measurements due to low participation and attrition. Thus, three schools completed the study with children completing all or a portion of the 12-week program.

Get Fit Kids is a 12-week, pedometer-based walking program modeled after the award-winning program, Get Fit Maryland, but intended specifically for elementary school children.⁹ There were two primary goals of the program: to educate children about the daily physical activity requirement of 13,000 steps per day, and to increase the children's awareness of their physical activity based upon the logged steps on their personal pedometers. All participating children attended a kick-off assembly where they were instructed on how to wear a pedometer and record step counts correctly. Children also participated in a “virtual shopping bag” experience where they selected healthy foods for their shopping bags. This hands-on nutritional informational experience was intended to show the dual importance of healthy diets and daily physical activity as related factors to overall health. In addition, each child received written educational materials in their registration backpacks on healthy snack ideas, the Food Pyramid, pedestrian safety, and physical activity options. Teachers received suggestions about how to engage children and ways to include the step counting into their curriculum. At the conclusion of each 4-week period, children received an incentive prize for completing the 4-week cycle. Lost or broken pedometers were replaced during the entire program for all participants. In addition, the program was overseen by a board-certified family medicine physician and managed by a masters-prepared registered nurse (RN).

Using a convenience sample, a quasi-experimental design was used to compare pre- and post-test measures of step counts and body mass indices (BMIs) in participating children. Random selection and assignment did not occur, as it was the intent of this study to include all children who wanted to participate in the program and to use the natural effect of attrition to form the comparison group. The study took place in the spring of 2009 within the 2008–2009 school year.

Procedure

Information about the Get Fit Kids program and a waiver were sent home to parents requesting permission for children to participate. After receiving a signed waiver from parents or guardians, children received a backpack with a pedometer, logbook, pen, and health information at a scheduled school Get Fit Kids kick-off event and were enrolled in the program. Convenience samples of children were used for comparisons based on their completion of the 12-week program. Children who did not complete the program but were available for both the pre- and post-program height and weight assessments were included in the study in the “did not complete” category. Children who completed the program with 12 weeks of recorded daily step counts and were available for pre- and post-program height and weight assessments were included in the study in the “completed” category.

On completion of the first month, children's logbooks were collected and reviewed. Initial step counts were self-reported and collected from the children's log books on the third day of the program, which was designated as Time 1. At the program completion, the ending step counts were again collected from the students' logbooks from the third to the last day of recording, which was designated as Time 2. Step counts were reviewed and documented by the sole study registered nurse at both Time 1 and Time 2 and were collected from children's self-reported step counts using the same type of pedometer on all participants.

During the same day or same week as the program initiation, children's heights and weights were measured using school-based scales. This measurement became the pre-program BMI. On the third-from-last day of the program, children were again measured for heights and weights on the same school-based scales. This measurement became the post-program BMI. Heights and weights were assessed by the sole study RN at the beginning and completion of the program. BMIs were calculated both times using the CDC's online BMI Child and Teen Calculator and were then categorized into CDC's four weight status categories (see Table 1).¹⁰

Table 1.

Center for Disease Control's Weight Categories

Weight status category	Percentile range
Underweight	<5th percentile
Healthy weight	5th percentile to <85th percentile
Overweight	85th percentile to <95th percentile
Obese	≥95th percentile

Source: Centers for Disease Control, Retrieved July 2009¹⁰ www.cdc.gov/healthyweight/assessing/bmi/childrens_BMI.

Sample

From the initial population of 419 enrollees from the three participating schools, 56 (24%) children successfully completed the 12-week program, submitting complete step count and body mass index (BMI) information. The 175 children who did not complete the full 12-week program were used as a comparison group. Of the remaining 188 children not included in this study, 21 participants were excluded from the analysis because their BMI data could not be calculated using the online CDC Child/Teen calculator, since they were categorized as morbidly obese, or their step counts were illegible or inaccurate. The remaining 167 children did not have daily step counts logged or were absent or unavailable during the height and weight assessments pre- and post-program. While racial status and socioeconomic data were not collected directly from participants, it is relevant to note that 99.3% of the children in the sample's three schools were African-American, and 80% of the children received free or reduced price meals, according to the schools' official profiles.¹¹

Data analysis

Two basic measures were used in this study with the participants pre- and post-program: step counts and BMIs. Differences in BMIs were measured for children who completed the program and children who did not complete the program, and step counts were measured only in the children who completed the program at Time 1 and Time 2. Statistical analyses included descriptive statistics using a chi-square test for independence and a t-test to compare differences among the characteristics of the two groups of children, “complete” and “did not complete.” A paired-sample t-test was performed to determine if there was a difference in the mean step count of the children who completed the program at Time 1 and Time 2. T-tests for independent means were also completed to compare BMIs between the groups. Additional data were collected on participants' satisfaction with the program and self-reported behavior change at the conclusion of the program. Children and their teachers completed separate, but similar surveys. All analyses were conducted using SPSS software (v18).

Results

The sample of children included in this analysis consisted of 231 children, approximately 8 to 10 years of age (56 “complete” group; 175 “did not complete” group) attending the three participating Baltimore City public schools (see Table 2). Forty-two percent of the total study participants were male, and 58% were female. By grade, 29% were third graders, 35% fourth graders, and 37% fifth graders. For this entire population, 60% of the children were categorized as a “healthy weight,” 17% were “overweight,” and 23% were “obese.” Therefore, 40% of the children were either overweight or obese. In the entire population, only one child was “underweight” (CDC, Child and Teen Weight Status Categories, 2009).⁹

Table 2.

Demographic Characteristics of Students (N=231)

Characteristic	“Completed” GFK program n=56 n (%)	“Did not complete” GFK program n=175 n (%)	p value¹
Grade level			p=0.000
Third grade	12 (21)	55 (31)
Fourth grade	33 (59)	47 (27)
Fifth grade	11 (20)	74 (42)
Sex			p=0.036
Male	16 (29)	81 (46)
Female	39 (71)	94 (54)
BMI category (pre)			p=0.138
Underweight	1 (2)
Healthy weight	31 (55)	105 (60)
Overweight/obese	24 (43)	70 (40)
BMI percentile (mean)
Pre	74.17	69.76	p=0.286
Post	71.60	70.83	p=0.859
BMI (mean)
Pre	19.82	20.39	p=0.196
Post	19.764	20.377	p=0.435
Step count (mean)			p=0.001
Time 1	6,567
Time 2	10,804

Note: ¹Chi-square used for categorical variables; t-test used for continuous variables.

GFK, Get Fit Kids; BMI, body mass index.

Completion of program

Data analysis was completed on the percentages of completions of students by grade, gender, and BMI status. Using a chi-square test for independence, there was a statistically significant difference between grade level and completion group, χ² (n=232)=20.031, p=0.000, φ=0.294. Fourth graders were most likely to complete the 12-week program, accounting for 59% of the “completed” group, even though fourth-grade children were fairly evenly dispersed within the total population. A chi-square test for independence (with Yates Continuity Correction) also revealed that there was a statistically significant difference between gender and completion group, χ² (n=230)=4.393, p=0.036, φ=0.149. Of the children who completed the program, 71% were girls and 29% were boys, even though the original gender distribution in the entire sample was fairly equally, with 57% girls and 42% boys.

Feasibility

Step count analysis

There was a statistically significant difference in the step counts from Time 1 (M=6,567.73, SD=5,189.51) to Time 2 (M=10,804.60, SD=11,664.81), t=3.374, p=0.001 (two-tailed). The mean difference in the step counts was 4,236.87, with confidence levels ranging between 1,715.633 and 6,758.098.

Participant satisfaction

Satisfaction with the program was measured among the children and teachers as part of the overall program evaluation. The survey instrument was designed solely for program evaluation with the Get Fit Kids program, and therefore did not have established reliability or validity. Survey participation was voluntary and anonymous. Both surveys included 10 items, and the children's survey was delivered in a child-friendly format with an appropriate reading level. Thirty-two students (62% of children who completed the program) completed the survey (see Table 3). Eighty-one percent of the children surveyed reported that the Get Fit Kids program helped them increase their daily physical activity, and 100% of the students reported that their pedometers were easy to use. In addition, 88% of the children surveyed responded that they would continue daily physical activity after the program was over.

Table 3.

Student Program Evaluation Results (N=32)

Student Survey Question Items	Yes	No
Where the pedometers (step counters) easy to use?	32	0
Were the log books helpful to record your steps?	25	7
Did you track your steps in the log book each day?	20	11
Were parents, teachers, or nurses able to help you if you had any questions?	28	4
Did the Get Fit Kids program help you make healthy food choices?	27	5
Did the Get Fit Kids program help you increase your physical activity every day?	26	5
Will you continue to eat healthy and exercise 1 hour every day now that this program is over?	28	3

Note: 1 missing response item 4, 1 missing response item 6.

Costs

Expenses for this program were calculated as part of standard program evaluation. Because this program is part of the University of Maryland Medical Center's community benefit, there were no costs for participating schools or students. Costs per student were calculated as $16 per student for the 12-week program and covered the registration backpack, pedometers, written materials, certificates, and incentives. Staff time, salaries, indirect costs, and development expenses were not part of this cost calculation and were provided in kind.

Secondary measures

Body mass index analysis

There was no statistically significant difference in the pre-BMI percentile means between the “completed” group (M=74.17, SD=24.211) and the “did not complete” group (M=69.76, SD=25.598), t=2.071, p=0.286 (two-tailed). There was also no statistically significant difference in the post-BMI percentile means between the “completed” group (M=71.60, SD=25.334) and the “did not complete” group (M=70.83, SD=25.897), t=−0.178, p=0.859 (two-tailed).

Teacher satisfaction

Twelve teachers completed their survey, which represented 100% of the teachers involved in the program (Table 4). The teachers' surveys confirmed many of the students' findings. All of the teachers reported that the pedometers were easy to use for their students, and 83% of the teachers cited that the program helped their students increase their physical activity. In addition, 100% of the teachers reported that the program helped them increase their own daily physical activity as well.

Table 4.

Teacher Program Evaluation Results (N=12)

Teacher Survey Question Items	Yes	No
Where the pedometers (step counters) easy to use for your students?	12	0
Were the log books helpful to record their steps?	11	1
Was the program easy to follow for your students?	12	0
Did you have enough information to help them if they had any questions?	12	0
Do you think the Get Fit Kids program helped your students learn about the importance of daily physical activity?	10	2
Did the Get Fit Kids program help you increase your physical activity every day?	12	0

Discussion

Study results indicate that by the time of program completion, daily step counts for school-aged children who successfully completed Get Fit Kids significantly increased. The data also suggest that fourth graders and females were most likely to complete the program. It is also relevant to note that the prevalence of overweight and obesity found in this urban, underserved population of school children was assessed at 40%, which is a higher prevalence compared with the 33.9% reported in a similar population of Baltimore school children by Jehn in 2006.⁶ Additionally, 100% of the children surveyed responded that the pedometers were easy to use, and 81% responded that Get Fit Kids helped them increase their daily physical activity. Eighty-three percent of the teachers surveyed corroborated this for their students as well.

While the comparative data on pre- and post-program BMI mean percentiles between children who completed or did not complete the program showed some positive shift, the results were not statistically significant. However, 12 weeks may not be long enough to measure significant changes in BMI in children. If this study had continued or another similar study was undertaken, the authors would recommend a longer intervention time to study the effects on BMI.

Threats to the internal validity of this study include the use of convenience sampling for the initial sample selection, which could lead to a biased sample. However, for the purpose of this study, the authors wanted to allow as many children who were interested to join this program. In addition, children in the “completed” and “did not complete” comparison groups were not randomly assigned to these groups. There was also no established reliability or validity for the participant satisfaction tools because these surveys were created for the Get Fit Kids program and used solely for this purpose. Additional threats include the use of self-reported step counts. Although all the children used the same type of pedometer and were instructed to wear it in the same manner, there may have been individual differences in how the children recorded the steps into their logbooks. To help control for this variation, step counts could be averaged over several days during the beginning and concluding weeks of the program. The participant attrition rate was higher than expected and was a result of many factors, including program length, school leadership, gender, student age, and the presence of a teacher “champion” to encourage daily physical activity. It is also impossible to take into consideration the other numerous environmental or psychosocial factors that may have influenced the children's level of participation.

Conclusion

While this study shows early potential benefits for a pedometer-based walking program for elementary-aged children, further research is needed to determine if this program is of benefit and can be replicated in other populations of children and adults. Daily physical activity is an important factor in maintaining a healthy weight in children. By increasing children's awareness of their own physical activity using a pedometer, children can learn to adjust their daily physical activity to meet their daily requirements of 13,000 steps per day. Get Fit Kids is an evidence-based program that showed a statistically significant improvement in daily step counts and participant satisfaction in an urban, school-age population.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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