INTRODUCTION
Rates of overweight and obesity are alarmingly high in the United States[1] whereas physical activity and cardiorespiratory fitness levels are low, particularly among minority adolescents.[2,3] Only one quarter of youth 12-15 years meet recommended guidelines of at least 60 minutes per day of moderate- to vigorous-intensity physical activity.[4] The increase in nutritional needs of students during this period of accelerated growth should be considere with information on meeting daily energy requirements using fruits, vegetables, grains, dairy, and oils provided.[5] Unfortunately, many adolescents fail to meet daily recommendations for important nutrients.[6] Schools are equipped to address these issues, however, facing pressure to improve reading, math, and standardized testing scores, physical and health education requirements have dropped and should be improved.[7,8] In response to these cuts, many studies have started using active learning models whereby physical activities are integrated into academic lessons and may even possess an academic component to the lessons.[9-11] For example, the program Planet Health[12] targeted middle school adolescents integrating health-related units into traditional classes (e.g., language arts, math, science, and social studies), concomitant with brief, micro-sessions in physical education. Among boys and girls, it was effective for reducing sedentary behaviors and increasing curriculum-based knowledge.[13] A 3-4-month program integrating health and nutrition into an existing science curriculum and adding either aerobic exercise or standard physical education classes was also effective in reducing body fat, insulin resistance, and inflammatory markers in 8th grade adolescents.[14] However, the physical activities did not possess an academic component and were not integrated into the academic lessons. The MEND program is a comprehensive afterschool program empowering youth to reduce obesity by improving physical activity, nutrition, and self-esteem.[15] Results have shown reductions in BMI and waist circumference along with positive cardiovascular and self-esteem outcomes.[15] However, MEND requires a strong family interface and often working-class parents don’t have the time and opportunity to commit to these programs.[15]
The translational health in nutrition and kinesiology (THINK) program is a stand-alone curriculum designed to excite, motivate, and empower youth to improve their personal lifestyle behaviors. There is also emphasis on physical literacy which is the confidence, competence, and motivation to pursue an active, healthy lifestyle along with knowledge of the benefits of an active lifestyle.[16] The program differs from the traditional pedagogical approach in that it uses an active learning paradigm which engages students with the materials presented, encourages participation in class, and fosters collaborative group work.[17]
Given the need for youth to improve physical fitness levels and meet nutrient recommendations without sacrificing time spent in academics, the THINK program provides a more integrative approach to learning. There are no other nutrition and kinesiology programs using hands- on laboratory and physical activities to improve aforementioned variables. The purpose of the THINK pilot program was to improve physical fitness and physical literacy along with curricular knowledge in nutrition and exercise science in 7th grade students using an active learning model. It is hypothesized that a translational health program encompassing nutrition and kinesiology will result in improvements in: a) physical fitness and components of physical literacy and b) nutrition and exercise science knowledge.
METHODS
The principal of one middle school located within the southeastern region of the United States invited university investigators to conduct an in-school THINK curriculum and initiate a community/university partnership for 7th grade students. This was done after successful completion of earlier pilot studies.[18,19] Informational fliers were sent to parents of students in the 7th grade as well as to the parent-teachers association informing them in greater detail about the nature of the THINK curriculum. Following school approval, a total of 35 students were initially enrolled in the program. However, one student moved out of the country and another student was dismissed from school for disciplinary reasons, leaving a total of 33 students completing the program. Approval was provided by the University of Miami’s Institutional Review Board for use of Human Subjects (protocol #20170693), the Miami Dade County Public School Board (protocol #2303) and school principal.
All participants were required to complete baseline and post-testing measurements in order to be included in the data analysis. Attendance was taken daily and final grades reflected a weighted average of scores on homework assignments, school quizzes, and midterm and final examinations. A total of 33 students completed all assignments and testing for the program. The THINK program ran for five months (one semester) starting in the Fall and ending in the Spring of 2018, with scheduled classes two days per week from 1:00-3:00 PM for a total of four hours per week. Baseline and follow-up testing ran for two weeks at the beginning and end of the semester.
PROGRAM
The THINK program consisted of three components: 1) health-related themes that challenged students to think creatively to come up with their own solutions, 2) hands-on laboratory experiences built upon self- awareness and self- recognition of physical function, problem solving, and reinforcement of outcomes, and, 3) structured physical activities consisting of different sports, team relays, and innovative drills. Each theme used active learning, placing greater emphasis on the learner by empowering students to translate and better apply the information learned.
During the laboratory segment, students learned how to use pedometers, goniometers, dynamometers, calipers, tapes, and blood pressure cuffs in order to develop clinical, hands-on skills. Students also examined life size replicas of muscles and bones and used bony landmarks and palpation to measure skinfold and girth measurements. Some of the laboratories also featured a competitive element such as “Simon Says” where students had to point to the correct bone (i.e., ulna, femur, acromion process) or muscle (i.e., deltoid, gastrocnemius, and triceps) to stay in the game. During the physical activity portion, emphasis was on maximizing motor skill development, promoting creativity and self-expression, and fun while reinforcing health-related themes. For example, following the nutrition unit, students had to sprint to a bag containing groceries, pick up an item from the shopping bag, then sprint to the MyPlate poster and place the item under the correct food group. Points were awarded for the fastest team with the most accurate placement of supermarket items.
The pilot study was based upon the general conceptual model showing that positive relationships are observed between physical activity and physical fitness which, in turn, result in improvements in general health and quality of life across a variety of medical conditions and disease states.[20] The curriculum included learning experiences within the larger framework of the Social Cognitive Theory[21] to promote self-efficacy across four domains: 1) mastery experiences which refers to creating an environment where students feel they can succeed through sustained effort, 2) vicarious experiences which refers to the strengthening of one’s beliefs using different experiences provided by different models, 3) social persuasion which refers to the strength of one’s beliefs that they can succeed, and, 4) somatic and emotional change which refers to the barriers and setbacks encountered in promoting behavioral change. The THINK program prepared students for these challenges by providing a quality education that stimulated creative thinking in an upbeat environment conducive to learning.
At baseline and post-testing, all students completed the Physical Activity Enjoyment Scale.[22] Subjects provided responses to being physically active (I enjoy it…My body feels good…It gives me energy…I have fun) using a rating scale from I strongly agree to I strongly disagree. Scores on the scale have a reported internal consistency of .93 using Chronbach’s alpha and the scale is considered a valid, reliable measure of how much participants were enjoying their physical activities. Using a Likert Scale, with (1) representing poor and (5) representing excellent, participants were asked to rate how they felt they would perform in each of the physical fitness measures at baseline and post-testing.[23,24] Ratings on each physical fitness measure were evaluated accordingly and the average score using five physical fitness components, were then computed. All physical fitness tests were carefully described to students prior to allowing them to rate how they would perform. Nutrition habits were evaluated by examining dietary patterns and eating behaviors of participants before and after the program using the Adolescent Food Habits Checklist.[25] The checklist addressed areas in which adolescents are more likely to have some degree of personal control with respect to consumption of calorically dense foods, low fat alternatives, fruits and vegetables, and snacking behaviors. Scores on this scale had a Chronbach’s alpha of .81 and a reported high test-retest reliability at r = .90.
Exercise knowledge / physical literacy was evaluated using a 25-item test with multiple choice, matching, and true/false questions. The items were derived from key information taught in the classroom by the teacher and director of the THINK program and included information on on terminology, fitness concepts, and the importance of metabolic health. For example, in one question, students were asked to complete the three primary risk factors associated with coronary heart disease. Nutrition knowledge was evaluated on a separate 25- item test consisting of standard nutrition information taught in class. For example, in one question, students were asked if a serving of macaroni and cheese contains 240 calories with 12 grams of fat/serving, then what is the percentage of fat in one serving. All tests were presented as raw scores in the data analysis although both tests were curved for grading purposes.
Resting heart rates, blood pressure, and body composition were evaluated on the same day. Resting heart rate and blood pressure were taken in a seated position with a minimum 5-minute rest period using standard procedures.[26] Mean arterial pressure was measured by dividing the systolic and diastolic pressure difference by three and adding the quotient to diastolic blood pressure. Height and weight were measured using a wall mounted stadiometer and digital scale (Conair Corporation, Stamford CT, USA). Body mass index (BMI) was computed using weight (kg) divided by height (m)2. Percentiles for BMI for age and gender were calculated delineating overweight/ obese (≥85%) and obese only (>95%) for all participants using Center for Disease Control guidelines. Body fat was measured using multi- frequency segmental bioelectrical impedance analysis using the InBody 570 machine (Seoul, South Korea) which has been shown to correlate with the DEXA machine to compute body composition in adolescents.[27]
Upper body strength was measured by having subjects squeeze a Jamar hydraulic hand held dynamometer as hard as possible using the dominant hand (JA Preston Corporation, Clifton, NJ, USA) according to procedures set forth by the American Society of Hand Therapists.[28] Aerobic fitness was measured using a National Institutes of Health two- minute walk test in which participants walked a 30.5-meter course as quickly as possible in either direction (15.24 meters) with 1800 turns at each end. Scores on this test have been validated against the 6-min walk test and have been shown to be a valid and reliable estimate of aerobic fitness in children aged 6 to 12.[29,30] Abdominal muscular endurance was measured by asking participants to perform as many sit-ups as possible in one minute while resting briefly as needed to complete the test using the protocol developed by the President’s Council on Physical Fitness and Sports.[31] Lower body power was measured via the VertecTM Jump Training System (Sports Imports, Hilliard OH, USA) using a static start jump in which the adolescent’s standing height with the arm stretched overhead was subtracted from their maximum standing jump height after performing a squat countermovement to a self-selected depth.[32] Flexibility of the lower back and hamstrings was measured using a Sit- and-Reach Box (Acuflex I, Novel Products Inc, Rocktown, IL, USA). Subjects were instructed to sit on the floor with their outstretched legs abutting the Sit-and-Reach Box and move a lever as far forward as possible without bending their knees.[33]
All data were analyzed using an SPSS statistical package (version 24, IBM SPSS Inc, USA). Means and standard errors of the mean (SEM) were calculated for physical characteristics, physical fitness, physical literacy, and nutrition variables. Data was initially screened for normality by calculating skewness and kurtosis, with values ± 2.00 deemed normal. No outliers were identified. A paired samples t-test was performed to determine significant differences between baseline and post-testing in aforementioned variables at completion of the program.
RESULTS
Table 1 shows subject characteristics at baseline. Latino adolescents comprised the highest proportion of students at 54.6%, followed by White, non- Hispanic adolescents at 30.3%, and finally, Black adolescents comprising 12.1% of participants. Male students at 66.6% doubled that of female students at 33.3% of participants.
Table 1
Subject Characteristics at Baseline (n=33).
| Characteristics | Values |
|---|---|
| Age (yrs) | 12 |
| Height (in) | 60.44±0.60 |
| Weight (lbs) | 108.48±4.93 |
| Race/Ethnicity | |
| Latino (%) | 54.5 |
| White (%) | 30.35 |
| Black (%) | 15.15 |
| Gender | |
| Male (%) | 66.66% |
| Female (%) | 33.33% |
Physical characteristics are presented in Table 2. Neither BMI nor percent BMI changed as a result of the program. Mean arterial pressure significantly decreased by 5.88 mmHg or 7.27% (p = .05) after the completion of the THINK program.
Table 2
Changes in Physical Characteristics following the THINK Pilot Program.
Shown in Table 3 are the physical fitness, exercise knowledge/physical literacy, and nutrition scores and habits of participants. Muscular strength using a grip dynamometer increased 4.55 lbs. (p = .003), whereas students covered 72.19 more feet during their NIH 2-min walk test at post-testing (p ≤ .001). Lower body power on the VertecTM Jump Training System was 2.34 inches greater than at baseline (p ≤ .001) whereas students performed just under four more curl-ups in one minute at post-testing (p = .014). Exercise knowledge/physical literacy scores improved 29.67% at post-testing (p < .001) whereas nutrition science scores improved 12.67% (p ≤ 0.001). There were no significant changes in any other variables as a result of the program.
Table 3
Changes in Physical Fitness, Physical Literacy, and Nutrition Status following the THINK Pilot Program.
[i] Note: Data are presented as means ± standard error of the mean. Strength reported using grip dynamometry. Aerobic fitness is the maximum distance walked in two minutes. Power reported as maximum jump height. Flexibility recorded using a sit and reach test. Curl-ups number performed in one minute (raw score). Exercise/fitness Knowledge and Exercise Enjoyment scored on a 0-100% basis. Fitness ability perception was the average score of how well participants felt they would perform on each fitness measure using a 1-5 Likert rating scale with 1 being the lowest and 5 being the highest. Nutrition habits and Nutrition Knowledge scored on a 0-100% basis.
DISCUSSION
The THINK program was an innovative pilot program designed to integrate hands-on laboratory skills and physical activities into academic lessons to improve physical fitness/physical literacy consistent with improving knowledge of nutrition and exercise science. A general conceptual model[20] incorporating constructs from Social Cognitive Theory[21] was used to elicit positive health behavioral changes whereas an active learning paradigm incorporating laboratory experiences and physical activities was used to motivate and excite students about how their bodies respond to exercise.
According to the Task Force on Community and Preventive Services, gains in physical fitness result in improvements in general health and medical conditions such as ischemic heart disease, hypertension, cancer, and quality of life.[20] Gains in cardiorespiratory fitness are associated with improvements in serum lipids/lipoproteins, fasting glucose, and insulin levels in youth.[34] In our study, reductions in mean arterial pressure along with a trend toward lower systolic and diastolic blood pressure lend further support to incorporating a culture of health and fitness into the classroom. Among urban minority youth in general, physical activity levels are lower.[35] A total of 66.7% of students in the THINK program were Latino and African American making improvements observed in physical fitness levels even more compelling. Given accelerated reductions in physical activity levels from elementary to middle school,[36,37] improvements in physical fitness reflect the importance of integrating “theory” with “practice”.
Although physical fitness is key to improving health outcomes, physical literacy is key to addressing determinants of a physically active lifestyle. Students in the THINK program almost doubled their knowledge of exercise and physical fitness as a result of the program. Improvements in scores indicate that students were able to demonstrate knowledge of exercise science and understand the fundamental value of physical activity for health promotion and disease prevention. Since physical activity enjoyment and physical fitness perception failed to change, knowledge improved independently of physical activity enjoyment and/or perception of skills. Given the different constructs in physical literacy and the diverse methodologies used to measure physical literacy, it is not surprising that different domains (affective, cognitive, and physical), are temporally different from one another.[38] It should be noted that some researchers favor separate evaluations for each component whereas other researchers prefer a more holistic approach to the evaluation of physical literacy as a singular entity.[39]
Nutrition education is equally important as adolescents begin to make their own decisions regarding food intake. Students demonstrated a 12.67% increase in their nutrition knowledge. Unfortunately, nutrition habits did not significantly change as a result of the program. Given the different stages of readiness for change, family influences, the environment, and repeatability of positive behaviors, it has been reported to take anywhere from 66 days to 24 months to make positive changes in habits.[40,41] It is hoped that over time, participants would begin to make more informed decisions about their nutrient intake.
It is important to note that there are limitations to this pilot study. This was a small sample size and not a randomized control trial. There was no power analysis completed since all students enrolled in the 7th grade class were required to take the THINK course. In order to address the small sample size, it would be important to extend this partnership to several middle schools using randomization procedures that included a control group. Second, physical activity and other clinical outcome measures were not evaluated. It would be beneficial to include accelerometers to evaluate physical activity levels and markers of metabolic health such as insulin and glucose. Furthermore, parents who are reported to have a significant impact on their child’s behaviors at this age, were not strongly integrated into the program. Although parents were included in many of the homework assignments, final projects, and food presentations, most parents worked full time and were unable to attend final projects and student presentations during class.
CONCLUSION
As children transition from elementary to middle school, there is a large drop in their physical activity levels evidenced by the low rates of middle school youth meeting national physical activity guidelines.[36,37] This is particularly evident in minority youth, who show lower physical activity and cardiorespiratory fitness levels.[32] Interventions aimed at reducing this downward trend are critical to reducing health disparities. Although several studies have shown that integrating active programs into other academic or physical education disciplines can improve health and fitness levels,[12-14] the THINK program is the first stand- alone curriculum integrating laboratory and physical activities with nutrition and movement science education. Given positive results, it is hoped that more schools will consider implementation of the THINK program when seeking innovative programs designed to have a long- term impact on the health and well-being of our nation’s youth.
AUTHORS’ CONTRIBUTIONS
ACP conceived and designed the research, created the program and its content, drafted the manuscript, and served as the guarantor of the program; NC and GZ performed data collection and executed the program; EWF created program content, performed data collection, executed the program, performed statistical analyses, prepared figures, and edited and revised manuscript; CV performed data collection and edited and revised manuscript. All authors contributed to the development and writing of the manuscript. All authors have read and approved the final version of the manuscript, and agree with the order of presentation of the authors.
