A PHYSICAL ACTIVITY AND NUTRITION EDUCATION PROGRAM IN ELEMENTARY
SCHOOLS: TARGET POPULATION NEEDS, BARRIERS AND FACILITATORS TO
HEALTHY EATING AND PHYSICAL ACTIVITY
By
Simone A. Wilson

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
Human Nutrition—Master of Science
2014

ABSTRACT
A PHYSICAL ACTIVITY AND NUTRITION EDUCATION PROGRAM IN ELEMENTARY
SCHOOLS: TARGET POPULATION NEEDS, BARRIERS AND FACILITATORS TO
HEALTHY EATING AND PHYSICAL ACTIVITY
By
Simone A. Wilson
The global childhood obesity crisis, especially in the low-income (LI) minority population, has
motivated interest in interventions addressing important lifestyle behaviors such as healthy eating
(HE) and physical activity (PE). Understanding the perceived barriers (PB) and facilitators (FA)
to HE and PA experienced by children (Chld.) and parents/primary caregivers (PPC) is important
for intervention success. Based on the Social Cognitive Theory and grounded theory, a mixed
method (quantitative and qualitative) study was conducted among (n=27) 5th grade LI elementary
Chld. and 11 PPC to assess: dietary quality (DQ), PA and related behaviors, weight (wt.) and
health perceptions, food security, child and PPC wt. status, family nutrition (Nutr.) and PA, as well
as PB and FA to HE and PA. The prevalence of overweight and obesity was 59% for Chld. and
90% for PPC. Food insecurity was reported by 41% of Chld. and DQ (Healthy Eating Index-score)
for both Chld. and PPC needed improvement (64/100). For PA, 81% of Chld. were not meeting
the recommendation. For both Chld. and PPC the major FA to HE and PA were media (exergames
and televised Nutr. and PA embedded programs), the PA & HE (PE-Nut) program and community
access. The major barriers were neighborhood safety, accessibility to rec-centers, lack of
community modeling of healthy lifestyles, time and monetary constraints. Family ecology was
found to promote a positive understanding as well as enhance misconceptions of Chld. regarding
health, HE, and PA. PE-Nut and other similar programs are therefore much needed to facilitate as
well as ensure accuracy of messages/understanding in this and perhaps other target populations.

Copyright by
SIMONE A. WILSON
2014

I would like to dedicate this thesis to my late grandfather Noel Davis, my mother Claire Davis,
sister Schana Meade, nephew Camiran Meade, my beloved family both present and future and to
all those who have supported me throughout this journey. You all hold a special place within my
heart.
Love always,
Simone

iv

ACKNOWLEDGEMENTS

I would like to thank, my Major Advisor Dr. Lorraine Weatherspoon, Committee Members Dr.
Marsha Carolan, Dr. Marvin Thompson and Dr. Joseph Carlson for their guidance and continued
support during the completion of my thesis. I would also like to thank the Michigan Fitness
Foundation, Michigan Nutrition Network, and the Ypsilanti School District for making this
research project possible. I would like to especially thank all of my undergraduate research
assistants for all of their hard work and dedication, you all were amazing and I could not have
asked for a better team.

v

TABLE OF CONTENTS
LIST OF TABLES ……………………………………………………………………………..…x
LIST OF FIGURES……….……………………………………………………………………...xi
CHAPTER 1 ....................................................................................................................................1
INTRODUCTION .......................................................................................................................…1
1.1 Specific Aims…………..………………………………………...…………............................4
1.1.1 Aim 1……….…………..……….………………………………………………………. 4
1.1.2 Aim 2...………………….………………...………………………………………...……5
1.1.3 Aim 3…………..………………………………………………………………………... 5
CHAPTER 2…………………………………………………………………………………….. 6
REVIEW OF LITERATURE…………………………………………………………………… 6
2.1 The Obesity Crisis………………………………………………………………………….….6
2.1.1 National ……………………………………………………………………………….. 6
2.1.2 State of Michigan ……………………………………………………………………... 9
2.2 Factors Associated with Childhood Obesity…………………………………………………..9
2.2.1 Lifestyle Factors ……………………………………………………………………. 10
2.2.1.1 Diet ……………………………………………………………………………. 10
2.2.1.2 Physical Activity ……………………………………………………………… 13
2.2.2 The Environment………………………..…………………………………………. 16
2.2.2.1 Household …………………….……………………………………………….. 16
2.2.2.2 Location of the Residence …………………………………………………….. 18
2.2.2.3. School ………………………………………………………………………… 19
2.2.2.3.1 Parental participation in schools…………………………………………. 22
2.2.3 Socioeconomic Status ……………………………………………………………… 23
2.2.4 Beliefs and Attitudes ……………………………………………………………….. 25
2.2.5 Maternal/ Parental Influences ………….……………………………………………. 27
2.3 Implications of Childhood Obesity ........................................................................................29
2.4 School Based Interventions ....................................................................................................30
2.4.1 PE-Nut (Physical Education and Nutrition Working Together) Program ……………30
2.5 Conceptual Foundation for Research .....................................................................................33
2.5.1 Grounded Theory………………..…………………………………………………… 35
2.5.2 Social Cognitive Theory……….…………………………………………………….. 35
2.6. Gap in the Literature ..............................................................................................................37
CHAPTER 3…. ...........................................................................................................................39
METHODS ..................................................................................................................................39
3.1 Study Design ..........................................................................................................................39
3.2 Sites ........................................................................................................................................39
3.3 Study Subjects ........................................................................................................................41
3.4 Procedures ..............................................................................................................................41
3.5 Instruments .............................................................................................................................43
3.5.1 Child Assessments ………………………………………………………………….. 44
vi

3.5.1.1 Child Survey Questionnaire ……………………………………………………. 44
3.5.1.1.1 Demographic ………………………………………………………………. 44
3.5.1.1.2 Physical Activity ………………………………………………………... 44
3.5.1.1.3 Food Security ……………………………………………………………. 44
3.5.1.1.4 Dietary Assessment ..…………………………………………………........ 45
3.5.1.1.5 Anthropometric Measurements ……………………………………............ 45
3.5.1.1.6 Qualitative Interviews …………………………………………………... 45
3.5.2 Parent Assessments ……………………………………………………………….
46
3.5.2.1 Parent Survey Questionnaire ………………………………………………… 46
3.5.2.1.1 Brief Block Food Frequency Questionnaire ……………………………….. 46
3.5.2.1.2 Focus Group/ Phone interviews……………………………………………..47
3.5.3 Study participant incentives ………….……………………………………………… 47
3.6 Measurements and Variables ..................................................................................................48
3.6.1 Weight and Central Adiposity ………………………………………………………. 48
3.6.2 Dietary Intake …………………….………………………………………………….. 49
3.6.3 Physical Activity ……...……………………………………………………………….53
3.6.4 Demographic Survey ………………….……………………………………………... 54
3.6.5 Data Analysis Descriptive Statistics …….…………………………………………… 54
3.6.6 Data Analysis- Qualitative …………….…………………………………………….. 54
3.6.7 Triangulation ………………………...……………………………………………….. 55
3.7 Timeline..................................................................................................................................55
CHAPTER 4 ................................................................................................................................56
RESULTS ....................................................................................................................................56
4.1 AIM 1. Demographics, nutrition status and quality, as well as physical activity behavior and
perceptions of Sample Population ................................................................................................56
4.1.1 Child Participant Characteristics Overview………………………………………… 56
4.1.2 Parent Participant Characteristics Overview ………………………………………….57
4.1.3 Weight and Health Status……………………………………………………………...61
4.1.3.1 Children’s weight status and health perceptions ……………………………… 61
4.1.3.2 Adult Weight and Health Status ……………………………………………… 64
4.1.4 Dietary Quality ..................................................................................................................66
4.1.4.1 Dietary Quality of Children …………………………………………………….. 66
4.1.4.2 Dietary Quality of Parents……………………………………………………... 67
4.1.5 Food Insecurity ……………………………………………………………………... 69
4.1.6 Physical Activity Behaviors ..............................................................................................72
4.1.6.1 Child’s Assessment and Report ………………………………………………….72
4.1.6.2 Parent Physical Activity Perceptions …………………………………………. 78
4.1.6.2.1 Family Nutrition and Physical Activity ……………………………………. 78
4.2 AIM 2: Children’s Perceived Facilitators and Barriers to a Healthy Lifestyle ......................83
4.2.1 Personal ………………………………………………………………………………. 83
4.2.1.1 Personal Facilitators …………………………………………………………... 83
4.2.1.2 Personal Barriers ……………………………………………………………… 85
4.2.2 Home Environment ………………………………………………………………… 85
4.2.2.1 Home Environment Facilitators ………………………………………………. 85
4.2.2.2 Home Environment Barriers ……………………………………………………..87
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4.2.3 School Environment………………………………………………………………… 89
4.2.3.1 School Environment Facilitators………………………………………………. 89
4.2.3.2 School Environment Barriers……………………………………………….
91
4.2.4 Community Environment…………………………………………………………
93
4.2.4.1 Community Environment Facilitators ………………………………………
93
4.2.4.2 Community Environment Barriers…………………………………………..
93
4.3 AIM 3 Parents’ Perceived Facilitators and Barriers to family Healthy Lifestyle: .................94
4.3.1 Individual ……………...……………………………………………………………... 95
4.3.2 Home Environment ……...…………………………………………………………… 96
4.3.2.1 Home Environment Facilitators ……………………………………………… 96
4.3.2.2 Home Environment Barriers ………………………………………………….. 98
4.3.3 Child’s School Environment ………….……………………………………………….99
4.3.4 Community Environment………………………………………………………….. ..101
4.3.4.1 Community Environment Barriers ……………………………………………. 101
4.4 Grounded Theory: Systematic Processing of Healthy Lifestyle Information ......................102
4.4.1 System Messages/Sources ………………………………………………………….. 103
4.4.1.1 Family…………………………………………………………………………….106
4.4.1.1.1 Potential Positive and Negative Messages from Family Sources ……….....106
4.4.1.2 Teachers …………………….…………………………………………………. 108
4.4.1.3 Media ……………………………………………………………………….
109
4.4.1.4 Healthcare professionals ……………………….……………………………… 111
4.4.1.5 Organized Wellness, and Sports Programs …………………………………
111
4.4.1.6 Community Settings…………………………………………………………… 112
4.4.1.7 PE-Nut Program ………………………………………………………………… 113
4.4.1.8 Physical Education ……………………………………………………………… 118
4.4.1.9 Peers …………………………………………………………………………… 119
4.4.1.10 Additional Sources ……………………………………………………………. 120
4.4.2 Internal Conflicts ...............................................................................................................120
4.4.3 Fear, Anxiety, Concerns ....................................................................................................121
4.4.3.1 Body Image ………...…………………………………………………………… 121
4.4.4 Family Ecology .................................................................................................................122
4.4.4.1 Parental Positive Reinforcing Behavior .........................................................................122
4.4.4.1.1 MyPyramid/ MyPlate Recommendations …………………………………. 122
4.4.4.1.2 Obesity Concerns ………………………………………………………….. 124
4.4.4.1.3 Personal Motivation ………………………………………………………...124
4.4.4.1.4 Parent Physical Activity Messages ………………………………………… 125
4.4.4.2 Parental Behaviors that Potentially Reinforce Misconceptions ………………. 125
4.4.4.2.1 MyPyramid/MyPlate USDA Recommendations …………………………... 125
4.4.4.2.2 Convenience of Fast Food …………………………………………………. 126
4.4.4.2.3 Outlook on Food and Health …………………………………………….. 126
4.4.4.2.4 Views Regarding Childhood Obesity ……………………………………… 127
4.4.4.2.5 What Parents tell Their Children about being Physically Active ………….. 129
4.4.5 Child Understanding …………………………………………………………………..130
4.4.5.1 MyPyramid/MyPlate ………………………………………………………….. 130
4.4.5.2 Personal Eating Habits ………………………………………………………... 131
4.4.5.3 Relationship between the Foods and Weight. ………………………………… 133
viii

4.4.5.4 Physical Activity Habits. ……………………………………………………… 133
4.4.5.5 Views on School Lunch ………………………………………………………. 134
4.4.5.6 Food Environment ………………………………………………………………. 134
4.4.6 Child Misconceptions ……..…………………………………………………………. 135
4.4.6.1 Healthy Eating and Physical Activity…...………………………………………. 135
4.4.7 Data Triangulation:……………………………………………………………………136
CHAPTER 5 ................................................................................................................................139
DISCUSSION AND CONCLUSION .........................................................................................139
5.1 Discussion:……………………………………………………………………………….…139
5.2 Implications…………………………………………………………………………………153
5.3 Strengths and Limitations ………………………………………………………………….154
5.4 Summary and Conclusions…………………………………………………………………155
APPENDICES .............................................................................................................................157
Appendix A: Michigan State University IRB ............................................................................158
Appendix B: School Letters of Support .....................................................................................160
Appendix C: Recruitment Flyer .................................................................................................163
Appendix D: Consent Forms ......................................................................................................165
Appendix E: Child Survey Questionnaire ..................................................................................170
Appendix F: Parent Survey Questionnaire .................................................................................183
Appendix G: Qualitative Interview Guide for Children .............................................................190
Appendix H: Focus Group /Qualitative Interview Guide for Parents ........................................196
Appendix I: Sample Code Book of Interview Responses for Children .....................................202
Appendix J: Sample Code Book of Interview Responses for Parents .......................................205
REFERENCES ....................................................................................................................................... 209

ix

LIST OF TABLES

Table 3.1 Healthy Eating Index−2005 components and standards for scoring .......................... 53
Table 4.1 Child Demographics (Total n=27; x̅ Age= 10.5  0.64) .............................................. 58
Table 4.2 Parent Demographics (Total n =11; x̅ Age= 37  6.2)................................................. 60
Table 4.3 Child Responses to Weight Perceptions and Views on Health ................................... 62
Table 4.4 Child BMI Percentile and Adult BMI by Waist Circumference (WC) ........................65
Table 4.5 Parent’s Family Medical History ................................................................................. 65
Table 4.6 Child Self-Report of Food Insecurity by Ethnicity, Gender and Weight Status ......... 70
Table 4.7 Self-Reported Physical Activity and Sedentary Activity Behaviors Among 5th grade
students ..........................................................................................................................................73
Table 4.8 Child Perceptions of Physical Activity Barriers in the School Environment by
Ethnicity and Weight Status……………………………………………………………………..76
Table 4.9 Parent Family Nutrition and Physical Activity Responses, Parent BMI and Child BMI
Percentile…………………………………………………………………………………………81
Table 5.1 Sample Qualitative Chart of Child Themes and Sub-Themes ….………………….203
Table 5.2 Sample Qualitative Chart of Parent Themes and Sub-Themes …………………......206

x

LIST OF FIGURES

Figure 2.1 Research Components based on Social Cognitive Theory ..........................................36
Figure 4.1 Children’s Overall HEI-Scores.....................................................................................67
Figure 4.2 Parent’s Overall HEI-Scores .......................................................................................68
Figure 4.3 Model of Systematic Processing of Nutrition and Physical Activity Messages Among
5th grade Elementary Students ....................................................................................................105
Figure 5.1 Michigan State University IRB .................................................................................159
Figure 5.2a Letter of Support ......................................................................................................161
Figure 5.2b Letter of Support ......................................................................................................162
Figure 5.3 Recruitment Flyer ......................................................................................................164
Figure 5.4 Child Assent Form .....................................................................................................169
Figure 5.5 Child Survey Questionnaire .......................................................................................171

xi

CHAPTER 1
INTRODUCTION
Overweight and obesity among US children, adolescents and the population in general
were declared a “health epidemic” by the U.S. Surgeon General David Satcher in 2001. This has
unfortunately not changed. A 4.5 percent increase in obesity rates from 2005-2006 as well as
2007-2008 was reported among children 6 to 11 years (Ogden, 2010). In a 2008 report, 16.9
percent of children and adolescents ranging from ages two to nineteen years fell at or above the
95th percentile of body mass index (BMI), indicative of obesity (Ogden, 2010). Nearly one third
of all children within the United States are either overweight or obese as a direct result of poor
food options, over indulgence, economic instability, or inadequate physical activity (Bowman,
2004; Institute of Medicine, 2005; Biro, 2010). Subsequently the current surgeon general is also
focused on obesity, and has hence worked on improving communities by making it easy for
“people to eat well, exercise and make healthy choices …changing the designs of our
communities and the designs of our everyday life” (Arvantes, 2010; U.S. Department of Health
and Human Services, 2010)
Poor dietary intake has been associated with some of the most common chronic diseases
such as hypertension, type 2 diabetes, fatty liver disease, metabolic syndrome, heart disease,
multiple cancers, and low glucose tolerance (Caterson, 2004; Daniels et al. 2005; James et al.
2008). The increased prevalence of chronic disease associated with childhood obesity within this
already vulnerable population has also garnered the attention of the White House. First Lady
Michelle Obama instituted the Let’s Move campaign to increase public awareness of childhood
obesity and advocate for improved government policies that include providing healthy lunch and
physical activity regulations for children (United States White House Task Force on Childhood
1

Obesity, 2010). Health and wellness professionals have energized their efforts to combat
childhood obesity by vigorously promoting healthy food choices and physical activity.
Since children spend a significant portion of the day at school, the school environment
has long been recognized as an important venue for conducting interventions, which aim to
positively impact lifestyle choices around food consumption, health and wellness, and physical
activity. A study conducted by Briefel et al. (2009) reported that children consume about 35
percent of their daily food intake and expend 50 percent of their daily energy during school
hours. Peterson et al. (2007) reviewed several school based intervention studies conducted
within the United States and abroad that focused on both behavior change and weight reduction.
The majority of school-based interventions have focused on the curriculum, classroom, physical
education, and changing the school environment through policies related to nutrition. Studies
have also focused on reducing television viewing like the Stanford Media Awareness to Reduce
Television program (SMART) (Robinson, 1999), as well as changes in nutrient content of meals
offered to students through the National School Lunch Program and School Breakfast Program
e.g. the Child and Adolescent Trial for Cardiovascular health (CATCH) (Nader et al. 1999).
There have however, only been a few studies with sustained outcomes such as weight reduction
in adolescent youth (females in particular) as a result of an intervention (Peterson, 2007). Many
interventions now focus on the long-term benefits associated with nutrition education where the
primary focus is on initiating and maintaining behavior change, in which case, effects are
projected to transcend into long-term effects as well.
A recent federal law enacted by congress requires that local education agencies receiving
federal funding develop nutrition and other activities that fall within the nutrition guidelines for
food available on school campuses during the school day (Fox, 2009). In Michigan, the
2

Michigan Fitness Foundation (MFF) has incorporated programs such as the Physical Education
and Nutrition Education Working Together Program (PE-Nut) into schools, where 50 percent or
more of the student body are eligible to receive free or reduced priced meals, in an attempt to
address nutrition education, increase physical activity, and improve the school environment.
In addition to the school environment, the home or family environment is also important.
It is well documented that obese children are more likely to become obese adults and the risk for
childhood obesity increases when one or more of the parents are overweight (Daniels et al. 2005,
James et al. 2008). Habits learned in childhood (such as poor eating behavior and sedentary
lifestyles) typically persist into adult life and can have a deleterious influence on health outcomes
and overall weight gain (Brio, 2010; Whitaker, 1997; Sreula, 1993; Han, 2010). During early
childhood development (from birth to age 5), parents are the primary influence over their
children’s eating behaviors (Tilston, 1991; Gosling, 2008). However, as children age, parental
influences diminish; giving way to influences from the media and peer pressure (Ajzen, 1980;
Gosling, 2008).
We understand that childhood obesity is affected by several factors including but not
limited to: social influences, family resources, knowledge and attitudes about diet,
eating/snacking frequency, genetic predisposition, and emotional distress (Briefel, 2009).
Changes in lifestyle management, which incorporate the entire family, have been shown to be
successful in facilitating positive dietary changes, increasing physical activity and reducing
weight (James et al. 2008; Golan et al. 2001). Therefore, interventions targeting weight
reduction, which incorporate the entire family, are needed to increase the likelihood for
successful lifestyle changes and subsequent health status. The PE-Nut program, funded by the
USDA SNAP-Ed Program in Michigan is a great example of a school-based program, which
3

attempts to address childhood obesity, although indirectly, by integrating school activities with
the family. However, it has been difficult to document the extent to which this program is
reaching children who are not only biometrically, but who are also experiencing lifestyle
behavior challenges. This was due to funding restrictions up until the time of the study on the
types of assessments that could be conducted with SNAP-Ed dollars. This is especially true in
low-income communities, which have a large African American population with young children
at risk, such as the Ypsilanti area in Michigan, the focus of the current study. The goal of this
study was to assess nutritional status, dietary quality and physical activity behaviors of fifth
grade students from two schools located within a low -income community that is predominately
African American, and evaluate the facilitators and barriers to implementing “healthy eating and
physical activity.” In addition, the extent to which the school and home environments influence
dietary quality and physical activity behaviors in this target population with prior PE-Nut
education was of interest.

Specific Aims
In order to determine concerns related to the target population, which may be associated with
healthy lifestyles and hence obesity risk, the following specific aims were formulated for the
study.
Aim 1.
Describe the demographics, nutrition status and quality, health as well as physical activity
behavior and perceptions of a sample of predominately low income elementary students (who
participated in one full year of the (PE-Nut) program), and their primary caregivers/parents.

4

Aim 2.

Assess the perceived barriers and facilitators to healthy eating and physical activity encountered
within the school and home environment by this sample of low-income elementary school
children, who participated in PE-Nut.

Aim 3.
Determine the facilitators and barriers of parents/primary caregivers whose children participated
in the PE-Nut experience with regard to healthy dietary intake and physical activity behaviors.

5

CHAPTER 2
REVIEW OF LITERATURE
2.1 The Obesity Crisis
2.1.1 National
Childhood obesity is a serious and growing public health concern. The rates of obesity
are highest among ethnic minorities, in particular African Americans, Mexican Americans,
and Native Americans (Albright, 2008; Stevens, 2010). Ogden et al. (2010) reported that
19.6 % of children between the ages of 6-11 were above the 95th body mass index (BMI)
percentile for age, and hence obese between the years 2007-2008. More recently, twenty-five
percent Hispanic (95% CI=17.7-25.4), 24.1% Mexican Americans (95% CI=18.8-30.6),
19.4% Non-Hispanic Black (95% CI= 13.9-24.8), and 19% Non-Hispanic whites (95% CI=
14.5-23.5) fell at or above the 95th BMI percentile for age (Ogden et al. 2010). In 2009, the
national obesity rate increased by 4 percent, (from 22.9 percent in 2003 to 26.9 percent in
2009) among adults (Centers for Disease Control and Prevention, 2009). It is predicted that
one-third of the children born in 2000 or later will suffer from diabetes, heart disease, high
blood pressure, cancer, asthma and other obesity related co-morbidities as they develop into
adults.
Adult and childhood obesity rates have reached record-breaking rates in the U.S. and
globally with expensive ramifications. The U.S. spent an estimated 14.3 billion dollars on
obesity-related healthcare expenses pertaining to children and 147 billion dollars on healthcare
towards adults in the year 2008 (Hammond, 2010). A 2008 report by the Centers for Disease
Control and Prevention (CDC) predicted that our current generation of youth will have a
6

shorter life span due to poor nutritional health, physical inactivity, obesity and related comorbidities (CDC, 2008).
A report issued by the Heart and Stoke Foundation of Canada, featured a study in
which children as young as 13 years of age were diagnosed with at least one of two
cardiovascular disease (CVD) risk factors such as BMI percentile ≥ 95 , high cholesterol/lipid
profile and/or elevated blood pressure (Heart and Stroke Foundation of Canada, 2010). The
aortas of obese children examined with echocardiography showed decreased elasticity in
comparison to normal weight children (Heart and Stroke Foundation of Canada, 2010; Harris
et al. 2012). Elevated lipid and blood pressure among children with a high BMI percentile for
age and height is becoming less uncommon as researchers continue to explore obesity and
overweight associated risk factors in children (Freedman et al. 2007; Franks et al. 2010). For
example, Franks et al. (2010) found that childhood obesity was positively associated with
premature death from endogenous causes as well as hypertension. Children who remain obese
into adulthood are therefore at an increased risk for co-morbidities such as cardiovascular
disease, diabetes, cancer and other medical conditions.
Diabetes is the leading cause of kidney failure, non-traumatic lower limb amputation, and
seventh leading cause of death among adults (Ravenscroft et al. 2005; Weber, 2008; Abboud et
al. 2010; CDC Diabetes Fact Sheet, 2011). Although the prevalence of type 2 diabetes in
children is 0.4/1,000; it represents 6% of the cases of diabetes in Non-Hispanic White, 33% in
African American, 40% in Asian/Pacific Islander, and 76% among American Indian youth
(CDC, 2011), and is a serious health concern among overweight and obese children.

7

Cancers typically associated with elevated weight status, poor diet and inadequate
physical activity behaviors are endometrial, premenopausal breast, ovarian, colon and renal
cancer (Fuemmeler et al.2009). Calle et al. (2003) reported that 15-20% of deaths in the U.S. are
attributed to cancer associated with overweight or obesity. Although the mechanism behind the
development of cancer as the result of the aforementioned behaviors and weight status are
unclear, it is believed that hormonal deregulations occur in the presence of excess adipose tissue
(Fuemmeler et al. 2009).

Non-alcoholic fatty liver disease (NAFLD) has recently become an area of interest and
also recognized as a health concern among obese children. NAFLD occurs in one of ten obese
children (Schwimmer et al. 2006; Gupta, 2011). NAFLD is associated with poor quality of life
among children and is more prevalent in Hispanics than Caucasians and interestingly less
commonly seen in African Americans (Schwimmer et al 2011). Kistler et al. (2009) compared
the effects of NAFLD in obese children with normal healthy children. A Quality of Life (QOL)
survey was administered and children with NAFLD had an overall lower score (72.8 vs. 83.8, p
< 0.01) in comparison to healthy children. Thirty-nine percent of children reported an impaired
quality of life. Children with NAFLD scored relatively lower in psychosocial (70.4 vs. 81.9, p <
0.01) and physical health (77.2 vs.87.5, p < 0.01).
Asthma, sleep abnormalities, hypertension, urinary incontinence, skin infections, and
psychosocial concerns are other factors commonly seen among obese populations (Maggard et
al. 2005; Janke et al. 2007). Therefore, it is imperative to address the childhood obesity crisis in
order to prevent, ameliorate or delay the associative co-morbidities and potentially shorter
lifespan of our current and future generation.

8

2.1.2 State of Michigan
In 2007, 28.9% of Michigan youth, grades 9 through 12, were either overweight or obese
(Michigan Department of Community Health). Among this 28.9%, 18% percent of African
Americans and 11.2% of Caucasians were identified as being obese. The prevalence of obesity
was higher in males (15%) than females (9.8%) (Michigan Youth Risk Behavior Survey
(YRBS), 2007; CDC Youth Risk Behavior Surveillance System, 2007; Anderson et al, 2009).
However, the trend that we are seeing did not start in adolescents. Fourteen percent of lowincome children, ages 2 to 4 years, within the state of Michigan, between the years 2000-2006
were obese (Anderson et al, 2009). Hispanics (20.2%) and American Indians/Alaskan Natives
(16.9%) had the highest percentage of children who were obese and non-Hispanic African
Americans had the lowest (12.1%) (Anderson et al, 2009). Obesity trends nationally for children
6-11 years of age increased from 6.5% to 19.6% between the years of 1976–1980 and 2007–
2008 (CDC, 2010).

2.2 Factors Associated with Childhood Obesity
Several factors have been shown to either be directly or indirectly associated with
childhood obesity. These include lifestyle factors (diet and physical inactivity), the environment,
socio-demographic status, beliefs and attitudes, maternal and parental obesity, and cultural
factors, which are key considerations in the proposed study.

9

2.2.1 Lifestyle Factors
Lifestyle is defined as, a manner of living that reflects attitudes and values of a person or
group (American Heritage Dictionary, 2004). Lifestyle factors associated with childhood obesity
include poor dietary choices, physical inactivity, and energy imbalance.
Obesity in children is associated with endothelial arterial dysfunction, thickening of the
cardiovascular walls and early signs of atherogenesis. Woo et al. (2004) measured the effects of
diet and exercise on obesity related vascular dysfunction among 9 to 12 year old children. The
study determined that positive changes made over a six-month period to diet and physical
activity improved endothelial positive function, lowered serum cholesterol and reduced the waist
to hip ratio. These findings affirm the importance of lifestyle factors for improving overall
health.
2.2.1.1 Diet
In a 2010 White House report, it was stated that “We ( Americans) are currently eating 31
percent more calories than we were forty years ago including 56 percent more fats and oils, 14
percent more sugar and sweeteners” (United States White House Task Force on Childhood
Obesity, 2010). Briefel et al. (2009) found that sugar sweetened beverages offered in school
contributed 170 calories on average. They also found that secondary school children, who
consumed sugar sweetened beverages, on average had a higher intake of calories (by 229
calories) than children who did not. High overall energy intake and high intake of sugar
sweetened beverages are among the main dietary factors associated with the risk for developing
childhood obesity (Briefel, 2009). Fruit and vegetable intake is also a problem. Only 32 percent
of American youth are consuming adequate amounts of fruit and only 13 percent are consuming

10

the adequate amounts of vegetables (CDC, 2009). Roughly, 80 percent of Michigan adolescents
reported eating fruits and vegetables less than five times per day (CDC, 2009).
Some studies have found that children who consume school lunch have an increased likelihood
of becoming obese (Schanzenbach, 2005; Fox, 2009; Kaplan, 2011). Although, children
enrolled in the school lunch program receive more protein, vitamins and minerals within their
diet, they also consume more dietary fat and calories overall (Kaplan, 2011). Higher energy
intake coupled with inadequate physical activity leads to energy imbalance and increases the risk
for childhood obesity. The school lunch program provides meals for the general student body,
but offers free or reduced priced meals for low-income students who fall at or below the poverty
index. Some schools have a large percentage of students eligible to receive free or reduced priced
meals making this an important area for consideration. In addition meal skipping, consuming less
during breakfast, and more food during dinner is also associated with the development childhood
obesity (Lee et al. 2009; Raj et al. 2010). Lee et al. (2009) found that female children on
welfare, skipped meals more regularly in comparison to their female counterparts who had never
experienced poverty or welfare.
Bowman et al. (2004) found that once socioeconomic status (SES) in children was
controlled for, fast food consumption was independently associated with male gender, older age,
higher household income, being non-Hispanic black, and living in the south. “Children who
consumed fast food ate 187 more calories on average than those children who did not.” Overall,
children who consumed fast food, consumed more energy per gram of food, fat, carbohydrates,
added sugar, and sugar sweetened beverages and less milk, fruits and non-starchy vegetables.
They concluded that fast food consumption appeared to have an adverse effect on overall dietary
quality of children and could increase the risk for becoming overweight or obese.
11

Lack of parental supervision during meal time is also associated with childhood obesity
(Moreno et al. 2007). Typically, in cases where the parent is absent during meal time, they often
have ready to eat items accessible that require little or no preparation time. Children may also
engage in watching television during meals when parents are absent which may lead to over
eating. Videon et al. (2003) reported that having parent(s) present during meal time (evening
meal) was positively associated with adolescents consuming fruit, vegetables, and dairy.
Children who perceived their parents as actively supporting eating fruits and vegetables and
reported shopping with their parents for their favorite fruits and vegetables, tended to consume
more fruits and vegetables (Gross et al.2010).
Food preparation styles are often culturally influenced, and at times have been associated
with childhood obesity (Bramble et al. 2009; Davis et al. 2000). Portion size and types of food
consumed among adolescents are also contributing factors to childhood obesity (Jennifer, 2005).
Bramble et al. (2009) conducted a qualitative study interviewing both African American and
African Caribbean women. Among African Caribbean women, traditional foods and preparation
styles were believed to be healthier in comparison to foods available in the United States. The
women expressed that within their countries, physical activity and cooking were incorporated
into their daily lifestyle. They described traditional foods such as rice, peas, mackerel, stewed
chicken, dumplings, chick peas, curried chicken, spinach, okra, and fish from their countries as
being natural, and described American foods as being processed and “full of chemicals.” These
women found preserving their family traditions to be difficult within the US, and attributed
obesity and weight gain to acculturation to the American lifestyle.
The consensus among African American women was that cultural foods that have been
passed down within their families, although deemed important, needed to be modified in order to
12

maintain a healthy lifestyle. However, most women felt this way after experiencing diet-related
morbidities within their families. Both groups of women viewed their hectic lifestyles as barriers
to healthy eating. They associated stress with weight gain due to frequent eating, preparation
style, work schedule, and hungry children who wanted food immediately after a long day, as
reasons for resorting to fast food (Bramble, 2009).
For some individuals, access to healthy food items such as fresh fruits and vegetables is
another important factor associated with overweight and obesity. Limited or no access to fresh
produce has become a major concern among consumers living in what is now known as food
deserts (Baker et al. 2006(a); Baker et al. 2006(b)Powell et al. 2010; Rundle et al. 2009). The
term, food desert, is used to describe locations deplete (or scarce) of large chain supermarkets,
and which have a preponderance of small convenience stores selling high-energy low-nutrient
dense food. Baker et al. (2006a) found that race and income were the two determining factors
that appeared to be associated with both the location and selection of quality food outlets (food
outlets that would allow inhabitants to meet the United States Department of Agriculture
(USDA) recommendations). Baker et al. (2006a) and Ball et al. (2009) found that African
Americans living in poverty, especially in inner city areas, were less likely to have access to
grocery stores (food outlets) that would most likely enhance meeting the USDA
recommendations than their higher-income White counter-parts. Access to healthy foods of good
quality was therefore deemed much easier in higher income neighborhoods.
2.2.1.2 Physical Activity
Children who engage in physical activity are less likely to become overweight or obese.
Tremblay et al. (2003) examined the relationship among children’s physical activity, sedentary

13

behaviors, and body mass index (BMI), while controlling for gender, family structure and SES.
They determined that children who participated in both organized and unorganized sports were
less likely to be overweight or obese, compared to children who watched video games and
television excessively. The amount of time spent watching television or participating in screen
time activities is associated with weight status. Reilly et al. (2005) found that children who spent
more than eight hours per week engaging in screen time activities at age three were more likely
to be obese at age seven (Reilly, 2005). Currently children on average spend roughly 7.5 hours a
day engaging in screen time activities (White House Task Force on Childhood Obesity, 2010),
which means that adolescents are primarily involved in sedentary activities. Ruiz et al. (2011)
conducted a cross-sectional study measuring both physical and sedentary activity behaviors of
adolescents from nine European countries. Ruiz et al. (2011) found that boys (56.8%) were more
likely than girls (27.5%) to meet the recommended 60 minutes of physical activity a day. They
determined that adolescents spent 71 percent of their time (9 hours per day) engaging in
sedentary behaviors.
Troiano et al. (2008) assessed physical activity levels of children from ages 6 to 9 years,
adolescents from ages 12 to 19 years, and adults. They noticed a decline in physical activity
levels between childhood and adolescence and discovered that only 42 percent of children
between the ages of 6 and 12 years were meeting the recommendation for 60 minutes of physical
activity a day within the US. Males across all age groups were more physically active than
females. Lee et al. (2009) reported that obese females who engage in more physical activities in
adolescence were less likely to remain obese into young adulthood. In addition, they found that
adolescents whose families experienced poverty were engaged in insufficient levels of physical
activity and inadequate amounts of sleep, and were at an increased likelihood of becoming obese.

14

Physical activity during childhood improves lipid profiles, insulin sensitivity, self-esteem,
self-concept and reduces weight, (Hansen, 1991; Hagberg, 1984; Roberts, 2003; Calfas, 1994;
Rashid, 2000; LeBlanc et al. 2006). Physical activity has also been shown to have a positive
impact on academic performance and cognitive functioning (Tremblay et al. 2000; Chomitz et al.
2009; Trudeau et al. 2008,). Reed et al. (2010) provided evidence that movement can influence
intelligence and should be considered to promote cognitive development of elementary-age
children. However, schools have struggled over the years to maintain adequate physical activity
programs. Some contributing factors are unsatisfactory infrastructure, lack of equipment,
inadequate financial resources, poor attainment of the goals set, low qualification of teachers,
over-sized classes and other problems (Tremblay et al. 2000). Research has shown that
overweight and/or obese children are at a greater risk of being absent than normal weight
children (Geier et al. 2007). Trudeau et al. (2008) suggested that schools can increase physical
activity by promoting community child supervision, encouraging children to actively commute to
school, and providing exercise equipment. School programs are finding alternative ways to
engage students in physical activity on a limited budget. Nelson et al. (2011) examined the heart
rate activity of fifth grade children engaging in different methods of dance during physical
education. They found that dancing elicited moderate cardiovascular response, 124.4 beats per
minute (bpm)-143.4 bpm depending on the dance activity. Energy expenditure is vitally
important in balancing energy intake.

Screen time is defined as the amount of time one spends on a computer, watching
television, or using game consoles (Oxford Dictionary, 2011). Within the United States, children
spend on average 7.5 hours per day engaged in screen time activities. Hands et al (2011)
15

concluded that “reducing screen time, increasing physical activity participation and preventing
early adiposity before 6 years is critical in developing positive behaviors for the maintenance of
healthy weight and prevention of future obesity.” Therefore, encouraging physical activity and
reducing screen time activity is vitally important in reducing the prevalence of obesity across all
generations.

2.2.2 The Environment
2.2.2.1 Household
The environment in which a child is raised has a major impact on childhood and adolescent
weight status. The family environment is key in early childhood development. Activity
preferences, food intake patterns, and eating habits are formed during early childhood. In the
home environment, children are more likely to form good dietary eating habits and maintain
healthy weight if breakfast is eaten daily, consumption of energy dense foods is limited, eating
proper portion sizes is exercised, screen time is reduced to less than two hours per day, and
physical activity is incorporated as a part of daily activity (Niemeire et al. 2009, Toschke et al.
2011, Aggio et al. 2012, Giddings et al. 2005). Miller et al. (2011) found, that children
(kindergarteners) who ate more breakfast at home with their families, received more hours of
sleep, and in addition spent more time (minutes) in recess, had BMIs that grew more slowly over
time, than children whose mothers worked many hours outside of the home, ate both breakfast
and lunch at school, and engaged in more screen time (television viewing).
For adolescents between the ages of 8-12, “long-term family-based behavioral weight control
programs” have been successful in weight reduction for the most part (Luttikhuis, 2009; Wilfley,
2007; Young, 2007, Sato, et al. 2010). Sato et al. (2010), who based a behavioral weight control
16

program on the 1977 Social Learning Theory by Bandura, found parental weight loss to be a
better indicator of child weight loss, since adolescents successfully lost weight when their
parents also lost weight. Sato et al. (2010) found parental BMI to be the only significant
independent predictor of adolescent BMI change, suggesting the importance of parental weight
loss management in adolescent weight control. The authors concluded that parents who selfmonitored were more likely to make healthier changes at home, and as a result of “environmental
changes,” adolescent weight loss was supported. This is of relevance since Neumark-Sztainer et
al. (2003) found frequency of family meals to be positively associated with intakes of fruit,
vegetables, grains, and calcium rich foods, and negatively associated with consumption of sugar
sweetened beverages. Sato et al. (2010) also expressed that the firm and more supportive
authoritative parental style (that could potentially be associated with adolescent BMI status over
time) exhibited by parents who self-monitored their own weight status, may be in part due to
perspectives gained as a result of undergoing the challenge of having to self-monitor.
“It is also possible that parents who self-monitored may have gained a perspective
regarding the challenges of self-monitoring, which may have helped to facilitate a more
supportive yet firm parenting style (i.e., authoritative), which could play a protective role
for adolescents BMI over time (Berge et al.2010).”

The family environment, which includes the family structure, also plays a role in the rate
of obesity seen among children (Chen et al. 2010). Chen et al. (2010) found that children living
in a single maternal parent household without siblings were at a higher obesity risk than children
living within a two parent household with siblings (Chen et al. 2010). Gundersen et al. (2008)
found the risk (likelihood) for childhood overweight and obesity was also high for the majority
17

of children living in food insecure households with mothers who experienced stress within the
United States. Affordability of food items is associated with obesity. Since foods high in sugar
and fat are cheap and readily available, it has been shown that low-income families are more
likely to purchase lower cost fats and sweets as well as alcohol (Basiotis, 1998; Drewnowski,
2003; Wilde, 2000). Participants in the Food Stamp Program (FSP) reported that the price of
food was highly considered in the purchasing of food items, as well as the choice and preparation
of the food to maximize satiety (Basiotis, 1998).

2.2.2.2 Location of the Residence
The environment where one lives can have an influence on the availability and type of
foods consumed. This is also true with regard to the amount of physical activity. Glanz et al.
(2007) more specifically described the nutrition environment as the area surrounding a
designated location where a consumer purchases food, which is jointly affected by product
availability, cost, and quality of the produce. Food deserts as described in section 2.2.1.1 are
characterized by locations in which healthy food options are either not available, of poor quality
or expensive (relative to the population’s income). These areas are often times awash with liquor
and convenience stores. The convenience stores located within these areas primarily sell lownutrient energy dense foods, which are typically high in fat, sugar, calories, and sodium. These
areas could hence also be described as obesogenic environments because of the association with
poor diet quality and obesity (Turrell et al., 2002; Larson et al, 2009).
For inhabitants living in food deserts, the commute to a major chain grocery store can
take anywhere from an hour (or more) one way. Therefore, inhabitants of food deserts are
typically restricted to purchasing immediate need food items from local convenience stores.
18

Morland et al. (2002) found that fruit and vegetable intake increased by 32% among African
American women, who shopped at a supermarket and/or specialty store versus shopping at an
independent grocery (Moorland et al. 2002).

2.2.2.3. School
It is well understood that a child’s eating habits are influenced by food that is available
within their immediate environment, such as the home and school (Story, 2009). The school
environment therefore, has been recognized as an important venue for conducting interventions
targeted at achieving a healthy lifestyle due to the amount to time children spend in school, its
versatility, and access to large numbers of students, including students from ethnically diverse
backgrounds. The school environment fosters learning and social development through teacher
and student modeling. Intervention strategies can be incorporated into the curriculum, providing
the opportunity to reach a large student body population repeatedly over time.
Results of the Third School Nutrition and Dietary Assessment (SNDA-III) survey
showed that daily food offerings in schools did not fully support a healthy diet for children and
adolescents. On average, diets tended to be high in low nutrient, energy dense foods (Cullen and
Thompson, 2006). Food items such as salad dressing, condiments, french fries, pizza products
and burgers were high in total and saturated fat (Crepinsek, 2009). The most notable food
groups missing for the diets of children were whole grains, fruits and vegetables, and milk
products such as non-fat or low-fat (USDHHS, 2005). SNDA-III did however, find that children
who participated in the National School Lunch Program (NSLP) consumed more nutrients at
lunch than those children who did not participate. NSLP participants consumed more protein,

19

vitamin B-12, riboflavin, calcium, phosphorus, potassium, and zinc than non-participants (Story,
2009).
Children within the majority of schools across the United States have access to a la carte
foods and vending machines that offer competitive food items such as sweetened beverages as
well as salty and sugary snacks. Schools often rely on the sale of a la carte and vending machine
items as additional revenue to support school programs. Fox et al. (2009) reported that 40
percent of school children consumed at least one or more competitive food items during the
course of the school day. Briefel et al. (2009) reported that 68 percent of school children
consumed sugar-sweetened beverages from both vending machines and choices in the cafeteria
(a la carte). Twenty-five percent of children consumed sugar sweetened beverages at school and
55 percent consumed them at home. Fox et al. (2009) concluded, that “limiting children’s access
to low-nutrient, energy dense foods at school may be a promising tactic for reducing children’s
total caloric intake.” In elementary schools, where French fries (or similar potato products) and
dessert items were offered in subsidized school meals, more than once per week, the likelihood
of a rise in obesity rates was significantly higher (Fox, 2009). Story proposed that
comprehensive strategies be put into effect to reduce low nutrient, energy-dense food and
beverages at the school for population-based obesity prevention in an attempt to reduce the total
energy intake of children. Immediate changes in the school environment unfortunately will not
occur overnight. Regulations put in place will expedite the process as research begins to
demonstrate how changes made to the school environment improve overall diet and physical
activity behaviors.
It was not too long ago in 2005, when the majority of schools across the United States
began to cut physical activity programs as well as others due to overwhelming budget cuts and
20

governmental emphases on science, math, and English (No Child Left Behind Act) ( Noffsinge,
2005). However, the rising rates of obesity within the United States could not be ignored and as a
result, the government has not made it mandatory that schools receiving federal funding from e.g
the national school lunch program provide wellness programs that include both nutrition
education and physical education. Physical activity requirements are often implemented through
recess, physical education, and intramural sports and has been reported to improve student focus,
physical activity participation, awareness of healthy habits, alertness and enjoyment (Evenson et
al. 2009). Some common challenges faced among schools regarding the implementation of
physical activity/education policies for elementary and middle school students were reports of
insufficient time through the school day (49 to 53 percent), lack of teacher participation (24 to 26
percent), and concern regarding the amount of time spent engaging in physical activity versus
academic pursuits (20-15%) (Evenson et al., 2009). However, Story et al. (2009) found that
physical activity environments and policies can be added to school curricula without causing
academic hindrance. They found support for physical activity implementation within the school
environment offered physical, emotional, and social benefits to students. However, less than half
of the states within the US, require the recommended amount of physical education/activity
(Story et al. 2009).
In 2007, only 25 states sponsored policies that supported physical activity promoting
activities (Story et al. 2009). Four percent of elementary schools and 8 percent of middle schools
were meeting the requirements for the daily recommendations for physical activity (Lee et
al.2007).Taylor et al. (2011) found that each additional 10-unit increase in playground facilities
was associated with 3.8% more activity overall (counts/minute) among children and 7.5% more
moderate vigorous physical activity (MVPA) over the course of a day. In addition a 3.2%

21

increase in overall activity (counts/minute) and 8.3% more MVPA was observed during recess
only, indicating that the number of permanent playground facilities in the school is associated
with higher physical activity. Therefore policy makers could have a vital role in enhancing
opportunities for much needed physical activity in schools and likely also in communities.
2.2.2.3.1 Parental participation in schools
Parental participation in schools has been an underlying issue among both teachers and
researchers. Due to their time constraints and demanding time schedules it has been particularly
difficult to engage parents especially of minority school-age children to participate within the
schools. Besides the regular Parent Teacher Association members, who are typically white and
middle-class (Kim, 2009), minority parental participation within schools is low. This could be
attributed to barriers such as language, difference in child rearing beliefs or practice, education
level, low socioeconomic status, low self-esteem, physically demanding jobs, lack of social
networking, and negative previous school experiences (Kim, 2009). The lack of “visible”
participation of minority and low income parents within schools cannot be assumed to be a lack
of devotion towards their children's education. Kim (2009), posed an argument that, schools play
a role in the lack of involvement by minority parents within the schools. Some of the reasons
listed were the school’s friendliness and the initiation of positive communication, the diversity of
parental involvement programs, and school policies (Kim, 2009). Other factors that should be
considered are the parents’ work hours or availability.
Parents of low SES often work long hours decreasing their access to schools during
normal business hours. Researchers should acknowledge some of the perceived barriers by both
parents and school administrators that affect minority and low income parental participation

22

within schools, and find effective ways to encourage participation of these parents and parents
overall. In terms of capacity, some schools are more equipped than others in their ability to train
employees to reach out to parents and increase engagement programs offered by school. (Kim,
2009; Moles, 1993). Efforts made by the schools to build effective communication between the
two parties (parents and schools) to reduce some of the aforementioned barriers will enhance
efficacy of school-based interventions.

2.2.3 Socioeconomic Status
Obesity is often reported as being associated with socioeconomic status. Socioeconomic
status (SES) is categorized into three groups (high, medium and low) and encompasses
educational attainment, income, occupation, and social status (American Heritage Dictionary,
2005). Educational attainment over the years has been established as a good predictor of SES
(Lareau, 2003; Strenze, 2007). Higher educational attainment is usually associated with higher
income. Likewise, the higher the education level, the lower the reports of health complications
(American Psychological Association, 2007). Hence, those individuals who have obtained
professional and doctoral degrees have lower incidences of health complications than those
individuals who obtained a high school diploma or less (American Psychological Association,
2007).
Differences typically seen in low-income families in comparison to families of high SES
are the tendency to live from day to day and focus on immediate needs versus future unforeseen
needs. Families of higher socioeconomic status tend to better meet their immediate needs, as well
as establish excess wealth and luxuries to pass on to subsequent generations (Conley, 2001).
Socio-economic status differences also tend to be evident interracially. According to Thomas

23

Shapiro, (in his book entitled Hidden cost of being African American, 2004) the differences that
we see in the SES gaps are due to savings income differences.
“African Americans are unable to participate in savings and its associated wealth because
their gross income is significantly lower than their white counterparts along with their
rate of inheritance. The amount of income one inherits can make a huge difference in
their economic placement status. Economic status also plays a role in housing, education
and employment discrimination.”
However, this might not necessarily pertain to African Americans specifically, but for low SES
populations in general. Slominski et al. (2011) conducted a longitudinal study that spanned 30
years and described adolescent mental health as a predictor of educational attainment, and
subsequently adult occupational attainment. The cycle seems continuous; families of loweconomic status are often unable to provide their children with academic support, and this is in
part due to limited financial resources and/or time. We now know that disparities seen in
education among low-socioeconomic groups transpire into occupational attainment, which later
affects health status (Slominski et al 2011).
Food insecurity is often seen among low-socioeconomic groups. In 2007, the USDA
reported that 8.3 percent of households with children were food insecure (Nord, 2009). The
USDA reports, that out of the 8.3 percent, 0.8 percent of the households with children were in
the very low food security category. This means that children were not receiving regular meals
(Nord, 2009). Widome et al. (2009) found that dietary eating patterns of food-insecure youth
differed from those who were food secure. Food insecure youth reported eating less family meals
and breakfast per week, and reported eating more fast food than food secure youth. Food
insecure youth also had higher intakes of fat than their food secure counterparts. Although they
24

reported similar benefits of healthy eating, food insecure youth reported higher aversions to
healthy food due to taste (Widome et al. 2009), possibly a function of unfamiliarity.

Children of lower SES are also more likely to have a sedentary lifestyle and a high BMI
index as are adolescents (Newacheck et al., 2003; Chen et al., 2010; Gundersen, 2008; Eagle,
2012). This could most likely be a result of insufficient neighborhood resources and healthy food
accessibility. According to Currie’s study, poor children overall had higher reports of poor health
in comparison to their non- poor counterparts (Currie, 2009). Lee et al. (2009) found that 14% of
female children who reported being in poverty or on welfare were obese adolescents compared to
9% of children who never experienced poverty or welfare. For female children, adolescent
neighborhood poverty and low parental education were both indicators of obesity in adulthood
(Lee et al. 2009).

2.2.4 Beliefs and Attitudes
In some cultures, for example Latinos and African Americans, being slightly overweight
is not only widely accepted, but often praised and encouraged. “Thick” or “healthy” are terms
used to describe the weight status of those who, according to Western perception, might
otherwise be perceived as overweight or obese (James, 2008). Redsell et al. (2010) interviewed
38 parents (12 of whom were overweight and 8 were obese). Parents within this study admitted
to feeding their children every time they fussed or cried. Food was implemented as a security
blanket, mechanism of comfort, and reward in some cases by parents from infancy because they
perceived hunger to be a major problem. This might have resulted in excess calorie intake and
overweight.

25

He (2007) conducted a study in Canada among low income elementary school students
and their parents. He found that 38% of parents incorrectly identified their children’s weight
status and, as long as their children were physically active and maintained “a good appetite” they
did not perceive the children as being overweight. Parents were more concerned about their
children being underweight; when in fact their children were normal or overweight. Booth et al.
(2009) found that Hispanic parents were concerned about school-age children being overweight,
but were reluctant to address the issue with their own children. Instead they preferred issues
regarding overweight and obesity be addressed by healthcare practitioners (not friends or other
professionals), or externally by restricting marketing to children, providing education for parents,
providing more opportunities for physical activity and access to healthy food. They thought that
the school should play a positive role in eating and physical activity, but should not have control
over what food items were brought into the home.
Parents who choose to remain unreceptive to recommendations concerning their
children’s health status are placing their children at a higher risk for developing chronic disease.
Monitoring dietary intake and physical activity are well established methods to prevent and
reduce the risk for acquiring chronic disease (UDSDA, 2010). However, if parents are not open
to developing good habits for their child during childhood, it is likely that children will continue
unhealthy dietary and physical activities into adulthood. Behavior changes initiated by the entire
family have been shown to be more successful than behavior change targeting one individual
(Sato et al. 2010). Thus, if parents do not see the need for change, then interventions focused on
children are at an even higher risk of being unsuccessful long-term.

Kelly et al. (2011) assessed the racial differences seen in body dissatisfaction and image

26

among 6-11 year old girls and found that perceptions of body dissatisfaction did not differ
between African Americans and Caucasians. Most girls in both racial groups underestimated
their actual size, and 99 percent of girls reported ideal figures smaller than their actual body
sizes. However, African American girls selected a larger body image to represent their ideal
body size. The authors concluded that obesity might mitigate cultural factors that protect
African American girls from feelings of body dissatisfaction. Van den Berg et al. (2010) found
that body dissatisfaction and self-esteem were strongly related among nearly all groups of
adolescents for both boys and girls. Obesity was viewed as a sickness among obese children, and
they were aware of the dietary and physical activity habits necessary to be healthy, but admitted
to needing external support (Serrano et al. 2010). Serrano et al. (2010) also found that obese
children were cognizant of society’s acceptance of lean and slender bodies as the standard of
beauty. They attributed their low self-esteem to body image, and reported feelings of guilt that at
times caused them to socially isolate themselves (Serrano et al. 2010).

2.2.5 Maternal/ Parental Influences
It is still uncertain to what extent parental involvement and weight loss predicts weight
loss success in children. However, previous studies have indicated that parental involvement is
associated with greater weight loss among school-aged children (Kitzmann & Beech, 2006, Sato
et al. 2010). Epstein et al. (2001) evaluated the effects of a parent focused behavioral
intervention on parent and child eating changes as well as impact on weight among families with
at least one obese parent. They found that over the course of one year, overweight parents and
children who reduced their intake of high-fat/high sugar foods and increased fruit and vegetable

27

consumption lost a considerable percentage of weight in comparison to the parent and child
pairs, who only decreased their consumption of high-fat/high sugar foods.
Obese children are more likely to become obese adults; and that risk increases for obese
adolescents (Guo, 2000; Sato et al., 2010). Maternal obesity is a highly correlated predictor of
childhood obesity, along with income, and living in a single parent home (Strauss, 1999; Hediger
et al. 2001). If a mother is overweight the likelihood of the child becoming overweight triples;
and quadruples if the mother is obese (Hediger et al. 2001). It appears as though the pattern of
maternal obesity increasing the odds of female adolescents remaining obese into adulthood is
particularly strong for females (Lee et al. 2001). Parental eating behaviors/practices are often
directly reflected in the weight status of the children.
Taveras et al. (2010) assessed early childhood risk factors for obesity. The objective was
to find associated risk factors for obesity from the prenatal period through 4 years of age. The
investigators found that children were more likely to become obese if their parents experienced
higher rates of depression during pregnancy, introduced their children to solid foods before 4
months of age, had higher rates of maternal restrictive feeding practices, had higher intakes of
sweetened beverages and fast food, and allowed children to have a television in their room by
age 2. A study conducted by Jouret et al. (2007) in France, assessing factors associated with
preschool aged childhood obesity found that “children being overweight at the age of four was
associated with gender (female), an overweight mother, and diabetic grandparent.” Interestingly
there were no significant associations with gestational age and overweight or obesity. However,
children who were overweight at 9 to 12 months, were at an increased risk for being overweight.
Nutrient intake did not have a significant impact on weight status for girls, but the study did find

28

that boys who were overweight consumed higher fat and energy foods compared to their nonoverweight counterparts.
Rosenkranz et al. (2011) evaluated the relationship between parenting behaviors and
physical activity to child weight status. The study determined that maternal encouragement for
child physical activity positively related to physical activity and child’s weight status
(Rosencrantz et al. 2011). There was a negative correlation between mother-child shared
physical activity and child’s weight status.

2.3 Implications of Childhood Obesity
“Childhood obesity increases the risk of metabolic, cardiovascular, and respiratory comorbidities as well as psychosocial outcomes which include impaired quality of life, decreased
self-confidence, and social interactions (Weiss, 2004; Zeller, 2006; Sato et al. 2010)”. Nearly
147 billion dollars per year is spent on obesity-related co-morbidities (Hammond, 2010).
Obesity contributes to 26 million deaths per year and about 22 million children under the
age of five were overweight according to the 2005 World Health Organization (WHO) Global
report (World Health Organization, 2005). Lee et al. (2009) indicated that Black and Hispanic
females are more likely to stay obese from adolescence into adulthood. This puts minorities at a
larger disadvantage since Lee et al. (2009) also found that the odds of staying obese from
adolescence into young adulthood was 70% if the adolescent lived in poverty or received welfare
during adolescence in comparison to those who had not experienced poverty or welfare (the
trend was particularly strong for females.)
First Lady Michelle Obama in February 2010, announced the initiation of Lets Move, a
national campaign set forth to target childhood obesity with the hope that our current generation
29

of youth will reach adulthood at healthier weights (United States. White House Task Force on
Childhood Obesity, 2010). Let’s Move is a comprehensive, collaborative, and communityoriented campaign that includes strategies to address both individual and environmental factors
that lead to childhood obesity. Leaders in government, medicine and science, business,
education, athletics, and community organizations have been engaged in promoting a uniform
message to increase fruit and vegetable consumption along with physical activity.
Obesity is just as much a major health concern as the fight against under-nutrition
worldwide. Interestingly enough, they are juxtaposed affecting all age groups (WHO, 2012).
Women in general are known to have higher rates of obesity, and males have higher rates of
being overweight (WHO, 2012). Overweight and obesity are equally detrimental to long term
health such as diet-related non- communicable diseases: diabetes mellitus, cardiovascular
disease, hypertension, stroke and cancer as mentioned earlier (WHO, 2012). Therefore, it was
concluded that if effective interventions are not conducted, we are at serious risk of the next
generation dying prematurely or living a life plagued by debilitating chronic conditions that
reduce the quality of life (WHO, 2012).

2.4 School Based Interventions
2.4.1 PE-Nut (Physical Education and Nutrition Working Together) Program
School based interventions are designed to bring about health awareness that will inform
students of healthy food alternatives and the importance of physical activity. By setting the stage
for promotion of healthy food and physical activity, school based interventions provide an
environment conducive for optimal student learning. In an attempt to combat the childhood
obesity epidemic within Michigan, the Physical Education and Nutrition Education Working

30

Together (PE Nut program), funded by the USDA and the Michigan Nutrition Network (MNN)
of the Michigan Fitness Foundation (MFF), was initiated. PE-Nut is administered in over 400
low-income schools, throughout the state of Michigan.
The concept of the intervention program was developed with the notion that in order to
prevent obesity, it is critical that children not only receive sound physical education (Exemplary
Physical Education Curriculum (EPEC)), but nutrition education as well. The objective of PENut is to foster a positive change in students’ food choices, physical activity, and knowledge of
nutrition. Each school is provided with an outside nutrition educator, who teaches lessons from
the Healthy Classroom, Healthy Schools curriculum (HCHS). The main focus of HCHS is to
transform the classroom (school environment) into a place where students and staff members can
learn and practice healthy eating and physical activity habits that will lead to a healthier lifestyle.
HCHS also increases opportunities for children to make healthy choices and be physically active.
Each lesson includes a nutrition activity, tasting experience, physical activity break, and family
letter. The goal is to encourage positive lifestyle behavior practices.
Classroom teachers are given resources and support from outside nutrition educators, and
regional coordinators as well as receive training on how to supplement lessons taught by the
nutrition educator; using physical activity breaks (known as Fit Bits) and reading books with
nutrition themes as a part of their language arts (Health Through Literacy). Health Through
Literacy, consists of nutrition themed books provided by PE-Nut as part of the classroom
component reinforcement tools. Each book is provided with a tip sheet that initiates discussion,
activity, and food tasting ideas to enhance the health message and make connections to math,
social studies, science, and language arts. At least one teacher from each school attends a training

31

session to learn about the goals of PE-Nut and how to complete monthly logs of activities
implemented.
The physical activity component of PE-Nut uses the Exemplary Physical Education
Curriculum (EPEC) (Michigan Fitness Foundation, 2006). EPEC is an award winning physical
education curriculum that teaches standard based physical education, which incorporates
nutrition messages. Physical educators are trained in EPEC and attend annual meetings. PE-Nut
also provides take home material to connect with parents and inform them of what their child is
learning.
The PE-Nut program is based on the Ecological Model and involves four tiers: the
individual, classroom, school environment, and community that also includes parents/guardians.
At individual level, students learn how to improve their own eating and physical activity habits
by taking part in the Healthy Classrooms, Healthy Schools curriculum and engaging in structured
physical activity lessons (Michigan Fitness Foundation, 2006). At the classroom level
interpersonal groups, are used to encourage more healthful behaviors among peers, information
sharing, and support needed to make good nutrition and physical activity choices. By guiding
students and teachers through the process of assessing their current classroom and school
environments, both students and teachers are motivated to make changes that support healthy
eating and physical activity. At community and family level, it is expected that support and
expansion of what is learned in the classroom occurs. Therefore, the intervention, which begins
within selected classrooms, serves as a model for peers, family members, school administrators,
policy makers, and community leaders.
During the 2008-2009 academic year, PE-Nut presence within the schools was shown to
have a positive effect on children’s food choices and nutrition knowledge. Approximately 21,138
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students across the state of Michigan were involved, 68% of whom were eligible for free or
reduced lunch. Eighty-two percent of 1,682 children, who completed a survey, agreed that they
were “pretty smart about healthy foods”, 82.1 percent “Liked most fruits”, 72.7 percent reported
they ate “a lot of different foods”, 81.7 percent reported trying new foods, and 87.1 percent
reported being physically active on a daily basis. In conclusion, children were willing to try new
foods introduced through PE-Nut and discuss them with their parents. While these preliminary
findings are encouraging, they are not sufficiently comprehensive to assess dietary quality, actual
PA or child risk for overweight and obesity in this vulnerable population, and hence the
additional justification of need for such a program. Therefore, the current project addressed this
important task.

2.5 Conceptual Foundation for Research
We currently understand, as aforementioned in the above literature review, that there are
multiple factors that affect obesity and health, such as socioeconomic status, food access,
personal beliefs, cultural norms, the environment, knowledge, and support. Individuals are
influenced by the environment which might subsequently impact behavior. Therefore each of
these factors are never independent of one another, but can be grouped as individual,
environmental and behavioral. How these three factors (individual, environment, and behavior)
interact among each other needs to be further understood. For example, what low income African
American children and their parents perceive as impeding and/or facilitating healthy eating and
physical activity behaviors will allow us to better target interventions specifically to their needs.
Quantitative data is more readily available and strongly suggest that there is just cause for
concern for the low income and/or overweight/obese African American community in relation to

33

health, and that there are external factors that increase health risk. Thirty-seven percent of
African American males 20 years or above and 51 percent of African American women 20 years
or above within the United States are obese (National Center for Health Statistics, 2010).
Approximately 39% of males and 44 % of African American women suffer from hypertension
within the United States (National Center for Health Statistics, 2011). Nineteen percent of the
African Americans reported not having health insurance coverage (Adams et al. 2010). This
report is of great concern especially since the leading cause of death among African Americans
is heart disease, cancer and stroke (Heron, 2010). In 2007-2008, 19.9% of children between the
ages of 6-11 were obese. Roughly 20% of boys (19.8%), and 29.2% of African American girls
were obese (Ogden, 2010). The National Center for Health Statistics Report (2011) showed that
among children 1-14 years of age, cancer was the second cause of death and heart disease was
the fifth leading cause of death in the year 2007 ( Xu, 2010). Heart disease accounts for 4% of all
deaths related to children between the ages of 1–14 years old (Xu, 2010). However, the manner
in which external factors influence the African American population and the best method to offer
support is still not clearly understood. Gaining the perspectives of African American children
and their parents will give us a better understanding of how to better provide support.
To accomplish this, the current study encompassed and attempted to explain both the
perceived barriers and facilitators to healthy eating and physical activity among 5th grade African
American children and their parents who received some nutrition and physical activity
intervention, using the grounded theory approach. The grounded theory places emphasis on the
views, values, beliefs, feelings, assumptions and ideologies of the individual (Charmaz, 2006). It
moves beyond gathering descriptive information by both generating and discovering a theory
during the process. The Social Cognitive Theory accounts for environmental influences (social

34

norms, community access, ability to change the environment), personal factors (attitude,
expectation, knowledge etc.), and behavior (skills and practice) that all play a part in the
character development of human beings (Bandura, 1989). Once we address the social aspect of
decision making and behavior change, we can then take it a step further and begin the process of
transitioning from exemplifying previous behavior or attitudes to implementing the desired
outcome or goal. This process is described by the trans-theoretical model (TTM) (Prochaska et
al.2001). We used these theories and model as the foundation framework of the research process.
2.5.1 Grounded Theory
The grounded theory is a qualitative research design in which the inquirer generates a
general explanation of a process, action, or interaction shaped by the views of a large number of
participants (Strauss et al.1999). It provides for the generation of a theory of action interactions,
or process through interrelating categories of information based on data collected from the
individuals. Constructivist grounded theory places more emphasis on the views, values, beliefs,
feelings, assumptions, and ideologies of individuals. The grounded theory methodology is often
used in cases where the voices of an individual, group, or population have not been heard, such
as in the case of the target population for this study. The grounded theory allows for the platform
of thoughts, perceptions, opinions, or accepted wisdom of people surrounding an issue or subject
that we would otherwise not hear from, or about.
2.5.2 Social Cognitive Theory
The Social Cognitive Theory (SCT) developed by Albert Bandura, is constructed around
three chief reciprocal factors individual, environmental and behavioral as depicted in the figure
1. The environment is described as external factors and can be either a social factor, which can
include family, friends and colleagues; and/or physical environments, such as a location or
35

community. It is also based on the theory that people learn vicariously through other people
(modeling of behaviors and mimicking activities) (Bandura, 1989; Bandura, 1977). At the
individual level, the theory includes self-efficacy (the belief in one’s ability to accomplish a task)
and self- regulation (development, commitment, and actual implementation of a goal and the
plans to attain the goals) as factors that influence personal motivations and actions (Bandura,
1989; Bandura, 1977). Behavioral considerations include incorporating desired behavior
outcomes into routine practice, which would be for example for the purpose of the current study
practicing healthy eating and physical activity behaviors on a daily basis (Bandura, 1989;
Bandura, 1977).

BEHAVIOR
Physical Activity
Healthy Eating

INDIVIDUAL

ENVIRONMENT

Knowledge, Personal
Preference,
Expectation, Self-efficacy,
Beliefs, Ideas, Cognitive
Reasoning

Availability, Accessibility,
Media, Peers, School, Home,
Family, Community
Demographics, Societal
Characteristics, SES

Figure 2.1 Research Components based on the Social Cognitive Theory

36

Bandura’s SCT also places a huge distinction between, being morally competent
(knowledgeable, having the capacity or ability, skills, awareness of moral rules and regulations,
and cognitive ability to construct behaviors) and morally performing (Bandura, 1989; Bandura,
1977). He describes moral competence as having the ability to perform a moral behavior, and
moral performance is the act of doing the moral behavior within a specific situation (Bandura,
1989; Bandura, 1977). Moral performance is further described as being influenced by rewards
and incentives. Bandura’s SCT also includes observation and modeling as key learning
components. Observation aids in both learning and knowledge acquisition. He believed that
modeling enables one to acquire basic rules and strategies for dealing with different situations
and can be exemplified through intrapersonal modeling through the use of media.

2.6. Gap in the Literature
In order to reduce obesity, diet-related co-morbidities, and physical inactivity among
child intervention programs need to initiate change within the family, classroom, community and
school environments collectively. There is a need, therefore, to determine effective ways to
positively influence children and their families (especially those from low SES communities),
who are at higher risk for diet and physical inactivity related co-morbidities, to not only
implement, but also sustain healthier dietary and physical activity behaviors. Among
schoolchildren, it is critical that the family, community as well as the overall school environment
be addressed.
Public health professionals need to increase the efficacy of their efforts to counteract
childhood obesity by understanding the barriers and motivators children and their parents face
and experience (Gosling, 2008). Therefore, this study will utilize data from two sample low-

37

income schools with a large proportion of African American children and 1) describe the risks
for overweight\obesity; 2) determine perceived barriers and facilitators of a healthy lifestyle
experienced in the home and school environment perceived by children; and 3) determine
perceived barriers and facilitators experienced by the parents/primary caregivers of a sample of
children from two low-income elementary schools. The information gathered from this thesis
will provide a greater understanding of the obesity risk (nutritional status, dietary quality and
physical activity) as well as the facilitators and barriers faced by children and their primary
caregivers towards healthy eating and engaging in routine physical activity. In addition, the goal
is to enhance the efficacy of future school-based interventions, such as PE-Nut.

38

CHAPTER 3
METHODS
3.1 Study Design
The grounded theory constructivist approach was employed to guide the study design. A
mixes method qualitative and quantitative design was used to assess children who completed one
year of the Physical Education and Nutrition Working Together program (PE-Nut) Healthy
Classrooms Healthy Schools curriculum and their parents/primary caregivers. Subject
recruitment and data collection was conducted over the course of five months (February-June
2012), after obtaining Michigan State University Institutional Review Approval as well as
permission from school principals and the superintendent for Ypsilanti schools, where the
research was conducted. A small pilot study was first conducted to assess the study feasibility,
test instruments and to determine the time needed for study data collection.

3.2 Sites
The study included two elementary schools located in Ypsilanti, Michigan. Ypsilanti,
Michigan is located in Washtenaw County and has a total city population of 19,435 according to
the 2010 U.S. Census data. Sixty-one percent of the population is White, 29% Black, 0.58%
Native American, 3.9% Hispanic or Latino and 3.4% of Asian race (U.S. Census Bureau, 2010).
There are a total of 8,026 households in Ypsilanti City, 29% of which have children under the
age of 18. Nine hundred seventy-five of these households are run by single female parents, 61 %
of whom have children under the age to 18 (U.S. Census Bureau, 2010). The 2007-2011
American Community Survey 5- year Estimates, reported the mean household income for
inhabitants living in the City of Ypsilanti, MI as $47,498 and the median household income for
39

residents with families was $33,699 (Census Bureau 2013). According to the 2007-2011 U.S.
Census Bureau State & County Quick Facts, 26.4% of Ypsilanti residents are living below the
poverty index, which is 10.7% higher than Michigan’s State average of 15.7% (U.S. Census
Bureau, 2013). In 2009, 33.5% of the Ypsilanti population was living below the poverty line, in
comparison to the state wide average of 16.2% (http://www.city-data.com/poverty/povertyYpsilanti-Michigan.html).
The two schools selected for the study share similar socioeconomic and demographic
characteristics within the Ypsilanti school districts of Washtenaw County. This school district
was selected due to its large population of African American low-income students.
Elementary School A of the Ypsilanti school district had a student enrollment of 414
students, in grades K-6, for the 2011-2012 academic year (Center for Educational Performance
and Information (CEPIa), 2012), of which 336 (81.2 percent) were receiving free or reduced
priced meals. Seventy-one percent of Elementary School A students were African American,
20% were Caucasian, 3.3 % were Hispanic, and 1.6% were of Asian or American Indian decent.
Elementary school B, of the Willow Run school district, had a student body enrollment of 471
students for the 2011-2012 academic year. Three hundred seventeen (67.3%), were receiving
free or reduced priced meals (CEPI, 2012b). During the 2011-2012 academic school year the
Elementary School B student population consisted of 63.2% African American, 29% Caucasian,
4.4% Hispanic, and 1.4% children/students of Asian or American Indian decent.

40

3.3 Study Subjects
Our target population was fifth grade students who previously completed one year of the
Michigan Nutrition Network’s Physical Education and Nutrition Education Working Together
(PE-Nut) program. The children were selected from participating PE-Nut classrooms. Eligible
students were confirmed by administrators and PE-Nut nutrition educators after official
permission was obtained. The primary researcher and PE-Nut educator recruited parents and
students through flyers (see Appendix C) and take home packages. Each recruitment package
contained a flyer, which provided brief information regarding the research and study eligibility
and a consent form (see Appendix D) explaining the purpose of the study and its confidentiality.
In addition, parents were recruited through school-wide events hosted by the school for parents
and children. Parents were asked to complete the consent forms and return them to their
children’s homeroom teacher.
One hundred and five students and parents were recruited to participate in the study. Of
the one hundred and five students, seven students and one parent agreed to participate from
Elementary School A and twenty children and eleven parents from Elementary School B. Data
collection continued within these two groups (parents and children) until qualitative data
saturation was reached. It was estimated that twenty-four parents and forty students would be
necessary for the completion of the study. However, data saturation was reached at twenty child
and eight parent participants.

3.4 Procedures
Prior to the initiation of the study, meetings were held with both the Michigan Fitness
Foundation/ Michigan Nutrition Network Staff and representatives of each elementary school

41

from the Ypsilanti Public School district. Letters supporting the involvement of the research
study were obtained from each of the participating elementary school principals and the
superintendent. Ethics approval was obtained from Michigan State University Institutional
Review Board (IRB) (Appendix A). Recruitment packages were then distributed to the one
hundred-five eligible participants within participating 5th grade PE-Nut classrooms. Consent
forms (Appendix D) were to be signed and returned to their homeroom teacher within one week
of its dispersal. Returned consent forms were then collected from each participating 5th grade PENut classroom located within Elementary Schools A and B prior to the start of the midwinter
break during the month of February 2012.
Parents who agreed to participate in the study were contacted by phone and through take
home letters. An appointment was scheduled by the primary researcher to participate primarily in
a focus group discussion, or when deemed more appropriate, an in-depth telephone interview.
Data collection began during the month of March 2012 with a small pilot study consisting of four
child participants. Data collection techniques for the children were subsequently adjusted to take
place over the course of two days instead of one to reduce the respondent burden and increase
involvement. On day one, the interviewer who was collecting data identified children whose
parents had signed the consent form and obtained the child’s written assent (Appendix D) by
reading the assent form to the child and then asking him/her to sign. On day one, after assent was
obtained, the interviewer collected data from the child which included 1) socio-demographic,
family history and physical activity information, 2) a 24-hr dietary recall and 3) anthropometric
assessment. On day two, children completed 1) an in-depth qualitative interview, which was
audio recorded and 2) a second 24-hour dietary recall. Children were provided with school
supplies valued at $20 as an incentive upon completion of all three parts of the data collection
42

Parents were contacted by telephone and take home letters to schedule focus group
appointments. Focus groups for parents were held at corresponding elementary schools during
the evening. Once scheduled, each parent completed a survey questionnaire, Block Brief 2000
Food Frequency Questionnaire for Adults (Block G et al. 1990, NutritionistQuest, 2013) and
engaged in the focus group. Parents who were unable to attend the focus groups due to
scheduling conflicts were asked to participate in an over the phone in-depth interview.
Over the phone interviews occurred in two steps. Parents first completed the qualitative
in-depth interviews, which were audio recorded verbatim. Parents were then asked to schedule a
date and time to complete the survey questionnaire and Block Brief 2000 Food Frequency
Questionnaire for Adults. The investigator subsequently contacted and completed both the Block
Brief 2000 Food Frequency Questionnaire for Adults and survey questionnaires with the parent
over the phone. Parents were sent $20 grocery store gift certificates as incentives via certified
mail after all the necessary data were obtained.

3.5 Instruments
Both descriptive data describing the study sample demographics and qualitative data of
5th grade students in the Ypsilanti Community School District and their parents/primary
caregivers were assessed. The qualitative interviews assessed individual knowledge influences
that the home, school and neighborhood environments as well as behavioral factors that may
have an impact on healthy eating and physical activity behaviors.

43

3.5.1 Child Assessments
3.5.1.1 Child Survey Questionnaire
The interviewer assisted survey questionnaire (Appendix E) incorporated several components,
which addressed socio-demographic information, physical and sedentary activity behaviors, food
security, dietary intake patterns and anthropometric assessment.
3.5.1.1.1 Demographic
Demographic questions obtained from children included but were not limited to age, gender,
ethnicity, family history, total number of individuals living in a household and parental marital
and employment status.

3.5.1.1.2 Physical Activity
Physical activity questions were adapted from the School Physical Activity and Nutrition Project
SPAN (Hoelscher et al. 2003). Physical activity questions were used to assess the physical
activity behaviors of the study participants. In addition, the adapted physical activity questions
from SPAN addressed sedentary behaviors as well as weight perceptions and potential barriers
such as being teased or bullied, which might cause children to be more reclusive and not actively
participate in group activities with their peers such as physical education or recess (Parrish,
2012).
3.5.1.1.3 Food Security
The USDA’s September 2006 Self-Administered Food Security Survey Module for Children
Ages 12 Years and Older was adapted and used to descriptively assess the child’s perceptions of
44

food security and gain from a child’s perspective, their impressions of the household food
security environment.
3.5.1.1.4 Dietary Assessment
Two twenty-four hour dietary recalls were collected, using the USDA standardized procedures
(Blanton, 2006; Moshfegh, 2001; Moshfegh, 2008), with the use of food models. Investigators
were also equipped with monthly school menus to verify reported items. The twenty-four hour
dietary recalls were typically collected within one week of each other capturing usual dietary
intake that reflected both weekday and weekend food intake. Information from the 24-hour
dietary recalls was collected to provide dietary quality information and used to generate a HEI
index score (Guenther et al. 2008).
3.5.1.1.5 Anthropometric Measurements
Student heights, weights and waist circumferences were measured privately by the primary
researcher and/or one of six trained associates in a private location at the schools provided by the
school administrators.
3.5.1.1.6 Qualitative Interviews
Once the descriptive demographic survey was completed (Aim 1), children were asked to
complete an interviewer assisted in-depth open ended qualitative interview to determine from
their perspective, the facilitators and barriers to healthy eating and physical activity within the
school and home environment (Aim 2). The qualitative interview guide that was developed
incorporating questions from the DEAL DiEt and Active living Study survey instruments
(Maynard et al. 2009). Each child was interviewed in a private place such as individual room or

45

private section of the library designated by the school. In-depth interviews from 17 students were
analyzed, and from those seventeen interviews, thirteen additional students were asked to
complete a second series of open-ended in-depth qualitative questions, which further expounded
on the theme concepts generated from the first series interview responses. This information was
used to construct the hypothesis and the basis of our grounded theory, regarding children’s
perceptions of perceived barriers and facilitators to healthy eating and physical activity
encountered within the school and home environment. Interviews were audio recorded and
transcribed verbatim by trained undergraduate research assistants.

3.5.2 Parent Assessments
3.5.2.1 Parent Survey Questionnaire:
The survey questionnaire included demographic information as well as the Family Nutrition &
Physical Activity questions which aimed to assess environmental and behavioral factors of the
family, which may influence weight status (Ihmels et al. 2009). Additional questions regarding
physical activity and dietary behavioral factors of both the family and child were also addressed
(Appendix F).

3.5.2.1.1 Brief Block Food Frequency Questionnaire:
Once parents completed the parent questionnaire, they were also interviewer assisted to complete
the Block Brief 2000 Food Frequency Questionnaire for Adults (Block G et al. 1990,
NutritionistQuest, 2013), which assessed the parents’ usual dietary intake over the course of one
year.

46

3.5.2.1.2 Focus Group/ Phone interviews:
Focus groups were conducted at the participating schools. The interview guide incorporated
questions from the DEAL parental qualitative interview guide (Maynard et al. 2009). In the event
that parents were unable to attend the focus groups, they were given the option of participating in
a phone interview. The interview guide asked questions concerning facilitators and barriers
experienced in regards to healthy dietary intake and physical activity behaviors for them and
their families based on the social cognitive theory. An open forum group discussion (n= 2) was
led by the primary researcher, audio recorded and transcribed verbatim to generate central
themes. From these findings and themes, new questions were generated (grounded theory) to
further determine if those themes re-occurred and to provide more in-depth information
concerning the themes. New parents were asked to engage in a focus group (n=2) or over the
phone in-depth interview (n=7) in order to complete this aspect of data collection. This data was
also audio recorded and transcribed in order to generate central themes, which were used to
support or enhance the data that was obtained from the initial focus group.
3.5.3 Study participant incentives
Incentives allotted to children for their participation in the study included school supplies
(pencils, pens, notebooks etc.) valued at $20.00. The parent incentive for participation was of
equal value, $20 dollar Meijer (local grocery store) gift card.

47

3.6 Measurements and Variables
3.6.1 Weight and Central Adiposity
Weight status was assessed from measurements of standing height, weight, and waist
circumference (to provide an indication of central adiposity). A one day training session was
held for all researchers (primary researcher and 2-3 undergraduate research assistants) to reduce
inter examiner error. The research team (trained in proper procedures to collect anthropometric
measurements) took students in groups of 5 to be measured in a facility provided by the school.
Each student removed their shoes socks and excess clothing for their standing height, weight,
and waist circumference assessments, which were measured privately. All measurements were
taken in duplicates (average of two measurements). Outliers were removed and additional
measurements were taken if necessary.
Parents’ anthropometric measurements were also done privately prior to the beginning of
the focus group. Standing height and weight measurements were taken after shoes were
removed. Parents, who conducted over the phone interviewers, were asked to self-report their
height, weight, and waist circumferences (or pants size it they were unaware).
Body weight was measured to the nearest 0.1 kg using a calibrated electronic weighing
scale (TBF-300A, Tanita, Tokyo Japan). Participants were asked to step on to the scale and wait
for 3 seconds as the scale determined the correct weight.
Height was measured using a portable stadiometer (217 Seca, Hanover MD). Participants
were asked to stand with their backs straight against the portable stadiometer, feet flat, and arms
hanging loosely by their sides. Stature was measured at the maximum distance from the floor to
the vertex of the head and recorded to the nearest millimeter. Measurements were taken in

48

duplicates of two. If the second measurement exceeded greater than 0.1 millimeters, a third
measurement was taken.
Body mass index (BMI) percentile was calculated using the BMI-percentile “Calculator
for Child and Teens English Version” found online at
http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx . Children were classified as obese (BMI- forage greater than or equal to the 95th percentile), overweight (85-95th percentile BMI-for-age),
normal weight (5th - 85th percentile BMI-for age) or underweight (below the 5th percentile BMIfor-age) as per CDC guidelines (CDC, 2011). Waist circumference was measured with a nonstretchable measuring tape. Measurements were taken once (or twice if considered inaccurate)
over light clothing at the highest point of the iliac crest. Anthropometric procedures were
obtained from the Anthropometric Standardization Reference Manual (Lohman, 1991).

3.6.2 Dietary Intake
Dietary intake for children was measured using the Multiple-pass 24-hour dietary recall
method (Blanton, 2006; Moshfegh, 2001; Moshfegh, 2008)). Twenty-four hour dietary recall
information was collected in five steps. Participants were asked to provide: 1) a quick list
(uninterrupted) list of food items consumed within the past 24-hours 2) interviewers probed for
foods which may have been forgotten 3) children reported the location and time of consumption
and 4) the amount/portion size of the food items consumed 5) the interviewer preformed a final
probe to ensure that no food items were missed. The dietary intake data included one week day
and weekend day. Food models were used to enhance accuracy of reported portion sizes
(questions regarding such things as portion sizes and differences between whole and 2% milk
were also addressed throughout the interviews).

49

Dietary intake information was gathered from the 24-hour dietary recalls and analyzed
using the USDA’s “What’s In the Foods You Eat Search Tool” website
(www.ars.usda.gov/Services/docs.htm?docid=17032). The “What’s in the Foods You Eat Search
Tool” provided the nutrient content of the foods and beverages reported, in addition to the
subgroups required to conduct the Healthy Eating Index (HEI) scores.
Information gathered from both the 24-hr multiple-pass dietary recall (children) and
Block Food Frequency (parents/caregivers) were used to generate HEI scores. The healthy
eating index (HEI) 2005 (Figure 3.1) is a 12-component scoring system validated by Guenther et
al. (2008). HEI consists of five food groups from the U.S. Department of Agriculture Food
Guide Pyramid, four nutrients recommended by the Dietary Guidelines for America and an
additional component assessing variety of the overall diet (Guenther et al. 2007).
For adults, the Block Brief 2000 FFQ was sent to NutritionQuest for data analysis. The
nutrient content was then analyzed, in gram amounts, based on the consumption pattern and
frequency (i.e. never, every day, once per week, few times per year) of a particular food item
reported by the respondent.
The USDA Food Codes were identified from the “What’s In the Foods You Eat Search
Tool” website (www.ars.usda.gov/Services/docs.htm?docid=17032) and coupled with the food
items reported in the Brief Food Frequency Questionnaire. Once the foods and recipes were
identified and coded, the information was merged with the MyPyramid Equivalencies Database
and used to generate a HEI score for each of the HEI components (Cook et al. 2004;
McCullough, 2000). The five food groups assessed were grain (bread, cereal, rice and pasta),
vegetables (in this case included potatoes), fruit (juice and whole fruit), milk (milk, yogurt, and

50

cheese) and meat (poultry, fish, eggs, nuts and dry beans). USDA’s recommended intakes for
girls and boys respectively for grains are 9 and 9.9 ounces, vegetables 4 and 4.5 cups, fruits 3
and 3.5 cups, milk 2 and 3 cups, meat 2.4 and 2.6 ounces. The scoring components are listed in
the HEI (Figure 3.1). In addition to the food group’s sodium, saturated fat and calories from solid
fats alcoholic beverages and added sugars (SoFAAS) were also assessed (Guenther et al. 2008)

The USDA Center for Nutrition Policy and Promotion (CNPP) developed the Health
Eating Index (HEI) to serve as a dietary quality and overall health risk indicator (Guenther et al.
2008)). Krebs-Smith et al. (2010) found that children (between the ages of 9 and 13) were not
meeting the USDA plate method recommendations (previously known as MyPyramid) for total
fruit (78.4%), vegetables (92%), milk (67%), grains (17%), whole grains (98%), and meat and
beans (52%). Ninety-seven percent of boys and girls between the ages of 9-13 yrs were
exceeding the maximum recommendations for energy and solid fats. Eighty- six percent of boys
and 92% of girls exceeded the recommended allowance for added sugars. Children and
adolescents between the ages of 2-18 years have an average total caloric intake of 2,027 per day.
Pizza, grain-based desserts, whole milk, regular cheese, sausage ( franks, bacon, and ribs),
reduced fat milk, fried white potatoes, pasta (and pasta dishes), dairy desserts, and burgers were
among the top ten items consumed among children 9-13 years old and key contributors of solid
fats (National Cancer Institute, 2010). Soda, fruit drinks, grain-based desserts, candy, ready-toeat cereals, syrups, yeast breads, whole milk, and reduced milk were among the top 10
contributors of added sugar in the diets of 9-13 year old boys and girls (NCI, 2010a).
Key nutrients of interest included fat (saturated fat), fiber, protein, calcium, folate,
potassium, the minerals iron and zinc as well as overall total energy and caloric intake. The
prevalence of hypertension is particularly high among the African American population (USDA,
51

2010). Excessive sodium has been linked to hypertension within the U.S., and potassium is
recommended by Healthy People 2010 to counteract the effects of sodium on high blood
pressure as well as reduce the risk of kidney stones, and bone loss (USDA, 2010). Potassium is
predominately found within fruits, vegetables, and milk. Dietary fiber intake among children and
adults within the U.S. is not sufficient. On average, Americans consume 15 g of dietary fiber
instead of 17-25 g per day (USDA, 2010). Dietary fiber helps reduce cardiovascular disease,
obesity, and type 2 diabetes risks and can be consumed naturally from whole grains, fruits and
vegetables. Dietary fiber should be consumed by adults and children regularly to increase
nutrient density and regulate the gastrointestinal system (USDA, 2010). Calcium intake within
the U.S. is low. Inadequate calcium intake is a concern among children (starting at 9 years old),
adolescents, and adult women. Inadequate calcium intake increases the risk for osteoporosis in
the future (USDA, 2010). Iron deficiency is often seen in women and young girls during puberty.
Sources of iron include lean meat, poultry, legumes, white beans, lentils, spinach, and iron
fortified foods (easily absorbed when coupled with foods containing vitamin C). Twenty percent
of women and adolescents within the U.S are folate deficient (USDA, 2010). Sources of folate
include beans, peas, oranges (and juice), dark green vegetables, spinach, mustard greens and
fortified products (USDA, 2010). The current dietary intake of children is not meeting the
current recommendations and as a result putting them at risk for being deficient in key nutrients
and at risk for becoming overweight and obese (Kennedy, 1995). Excessive calorie intake (in the
form of added sugars, fat, carbohydrates, and protein) coupled with inadequate physical activity
is associated with cardiovascular disease, hypertension, diabetes, overweight and obesity seen in
children and adults (Johnson et al. 2007; Krauss et al. 1996; Longo & Fontana 2010; Jebb 2004;
Wadden et al. 2011; Guenther et al. 2013; Goran & Treuth 2001).

52

Table 3.1 Healthy Eating Index−2005 components and standards for scoring1
Standard for
Maximum
Standard for
minimum score
Component
Points
Maximum Score
of zero
Total Fruit (includes 100%
juice)
5
≥0.8 cup equiv. per 1,000 kcal No Fruit
Whole Fruit (not juice)
5
≥0.4 cup equiv. per 1,000 kcal No Whole Fruit
Total Vegetables
5
≥1.1 cup equiv. per 1,000 kcal No Vegetables
Dark Green and Orange
No Dark Green or
2
Vegetables and Legumes
5
≥0.4 cup equiv. per 1,000 kcal Orange
Total Grains
5
≥3.0 oz equiv. per 1,000 kcal
No Grains
Whole Grains
5
≥1.5 oz equiv. per 1,000 kcal
No Whole Grains
3
Milk
10
≥1.3 cup equiv. per 1,000 kcal No Milk
Meat and Beans
10
≥2.5 oz equiv. per 1,000 kcal
No Meat or Beans
4
Oils
10
≥12 grams per 1,000 kcal
No Oil
Saturated Fat
10
≤7% of energy5
≥15% of energy
≥2.0 grams per
Sodium
10
≤0.7 gram per 1,000 kcal5
1,000 kcal
Calories from Solid
Fats, Alcoholic beverages,
and Added Sugars
(SoFAAS)
20
≤20% of energy
≥50% of energy
1

Intakes between the minimum and maximum levels are scored proportionately, except for
Saturated Fat and Sodium (see note 5).
2
Legumes counted as vegetables only after Meat and Beans standard is met.
3

Includes all milk products, such as fluid milk, yogurt, and cheese, and soy beverages.

4

Includes nonhydrogenated vegetable oils and oils in fish, nuts, and seeds.

5

Saturated Fat and Sodium get a score of 8 for the intake levels that reflect the 2005 Dietary
Guidelines, <10% of calories from saturated fat and 1.1 grams of sodium/1,000 kcal,
respectively.
Source: Guenther PM, Krebs-Smith SM, Reedy J, Britten P Juan, W, Lino, Carlson MA, Hiza
HA, and Basiotis PP. USDA Center for Nutrition Policy and Promotion and National Cancer
Institute.

3.6.3 Physical Activity
Physical activity questions were adapted from the School Physical Activity and Nutrition
Project SPAN (Hoelscher et al. 2003). The seventeen questions adapted from the SPAN
questionnaire assess physical activity, sedentary activity, the children’s comfort level with
53

engaging in physical activity among their peers, weight perceptions, and knowledge about health
and physical activity.

3.6.4 Demographic Survey
The demographic qualitative survey for the children and parents included sociodemographic questions that addressed age, ethnicity, parental marital status, religious affiliation,
educational level, health-related family history, parental employment status, and household
demographics. In addition parental surveys addressed annual household income.

3.6.5 Data Analysis Descriptive Statistics
Descriptive characteristics for the a) socio-demographic data, b) Dietary quality,
c) physical activity (means, standard deviations) were computed using STAT 10.0 SE 2007 for
each variable. Unbiased estimates of coefficients replaced missing or questionable data.
Unusable data was dropped from analysis this included data collected without proper consent
forms or students who provided consent but later declined participation within the study prior to
the completion of data collection.

3.6.6 Data Analysis- Qualitative
Qualitative data from audio taped interviews was transcribed verbatim and the transcripts
were checked for accuracy by listening to the audio conversations two to three times. Both the
qualitative interview transcripts and in-depth open ended questions were coded separately and
agreed upon by two researchers to ensure reliability and confirmation of any reoccurring themes.
Qualitative Data were analyzed using QRS NVivo 8 Copyright 1999-2009.

54

3.6.7 Triangulation
Triangulation is the process of ensuring quality data by validating the information
collected across multiple sources. More specifically 1) quantitative data (demographic, physical
activity, 24-hour dietary recalls data) were cross checked with qualitative data 2) parental
interviews were cross-checked against both their child’s interview and survey questionnaires, 3)
the school menus were used to validate food reports on the child’s 24hr dietary recalls

3.7 Timeline
IRB approval from Michigan State University was obtained in October, 2011.
Discussions relevant to recruitment, scheduling data collection, and data collection procedures
occurred with nutrition educators and school principals within the month of December 2011.
Staff training of personnel took place prior to data collection during late January to ensure proper
and consistent data collection procedures. Data collection occurred March 2012 through June
2012.

55

CHAPTER 4
RESULTS
4.1 AIM 1. Demographics, nutrition status and quality, as well as physical activity
behavior and perceptions of Sample Population
4.1.1 Child Participant Characteristics Overview:
Child demographic data is depicted in Table 4.1. Twenty-five middle childhood and 2 young
teens (n=27), 10 females and 17 males participated in the study. The age of child participants,
ranged from 10-12 years with a mean age of 10.5 (SD=0.64). At the time of data collection
(February-May 2012), all participants were in the 5th grade. Seven participants were from School
A where 87% of students were eligible to receive free or reduced price meals, and 20 students
were from School B where 82.7% percent of students were eligible to receive free or reduced
priced meals during the academic school year 2011-2012. The majority of participants identified
themselves as Non-Hispanic Black (n=15), followed by Multiracial (n= 9), and Non-Hispanic
White (n=3) (Table 4.1).
English was the dominant language spoken in the household reported by most participants
(n=25); one participant reported Spanish as the dominant language spoken in his household and
one child reported both English and Spanish as languages spoken in his household (English by
his mother and Spanish by his stepfather). For the majority of the participants, the mother was
reported as the primary caregiver for the child (n=14), followed by mother and father (n=6),
father (n=3), mother and grandparent (n=1), mother and stepfather (n=1), and mother, father and
nanny (n=1). The participants reported the marital status of their parents as being single (n=13),
married (n=8), separated (n=3), divorced (n=4) and widowed (n=1). Children primarily described
56

their households as consisting of 4 family members, but 8 households had 6-12 members of
which 6-9 were children. They also reported that most parents were employed full (n=9) or parttime (n=4).

4.1.2 Parent Participant Characteristics Overview:
Eleven parents participated in the study. Parent demographic data is reported in Table 4.2. The
age ranged from 28-47 years with a mean age of 37 (SD=6.3). The majority of the parents were
Non-Hispanic White (n=6), followed by Non-Hispanic Black (n=4). Five of the participants were
married, and 3 were separated. The majority of the parents had some college education (n= 5);
one parent had a graduate degree. Several were employed full time; 2 parents chose not to
disclose their occupational status. The total household annual income reported by the parents
ranged from less than or equal to $20,000 to $70,000 or above.

57

Table 4.1 Child Demographics (Total n=27; x̅ Age= 10.5  0.64)
Variable
Gender
Male
Female
BMI Percentile
5 - <85th
85th <95th
≥95th
School
School A
School B
Ethnicity
Non-Hispanic Black
Non-Hispanic White
Multiracial (Other)
Parent Marital Status
Single
Married

Separated
Dominant Language Spoken in Household
English
Spanish
Both English and Spanish

n=27

Percent

17
10

63
37

11
5
11

41
18
41

7
20

26
74

15
3
9

56
11
33

16
8
3

59
30
11

25
1
1

93
4
4

58

Table 4.1 (Cont’d)
Variable
Primary Caregiver
Mother and Father
Mother
Father
Grandparents
Mother and Grandparent
Parental Employment Status
Full time
Part Time
Unemployed
Total Number of People in
Household
≥4
5-9
≥10
Total Number of Children in the
Household
≥ 1-2
3-5
≥6

n=27

Percent

8
14
3
1
1

30
51
11
4
4

13
7
7

48
26
26

16
9
2

59
33
7

13
12
3

44
44
11

59

Table 4.2 Parent Demographics (Total n =11; x̅ Age= 37  6.2)
Variable
Gender
Male
Female
Body Mass Index (BMI)
Normal (18.5-24.9)
Overweight (25-29.9)
Obese (≥30)
School
School A
School B
Ethnicity
Non-Hispanic Black
Non-Hispanic White
Interracial (Other)
Parent Marital Status
Single
Married
Divorced/Widowed

n=11

Percent

1
10

9
91

1
1
9

9
9
82

1
10

9
91

4
6
1
4
5
2

36
55
4
36
45
18

Variable
Education
High School
Some College
Certificate
College
Graduate
Parental Employment Status
Employed Full Time
Unemployed
Total Number of People in Household
≥4
5-9
≥10
Total Number of Children in the Household
≤4
9-May
≥10
Annual Household Income
≤ $20,000
$20,00-34,999
$60,000-69,999
$70,000-above

60

n=11

Percent

2
1
1
6
1

18
9
9
55
9

8
4

73
27

6
4
1

55
36
9

9
1
1

82
9
9

4
2
3
2

36
18
27
18

4.1.3 Weight and Health Status
4.1.3.1 Children’s weight status and health perceptions
Among the child participants, 11 were of normal BMI-percentile (5- < 85th), five children were
overweight (85th- <95th), and 11 children were obese (≥95th). Table 4.3 shows that thirteen
children reported they were trying to lose weight, a majority of which were males (n=8). Of
these, three were of normal BMI percentile, two were overweight and 8 were obese. More than
half (51%) of the students felt that in comparison to students of the same height, they weighed
the right amount. Nine students believed that they weighed too much in comparison to the
students within their grade of similar height. Of the nine students, three were of normal weight
and six were obese. A majority of the students (n=14) agreed with the statement, “If I run and
play I will have fewer health problems”. Of the nine students who partly agreed with that
statement, four were of normal BMI percentile, two were overweight, and three were obese.
Among the family medical history related disease reported, several children reported having a
family history of heart disease (n= 1), hypertension (n=3), glaucoma or eye problems (n=4),
diabetes (n=3), cancer (n=1), smoking (n=15), or alcohol consumption (n=3).
Waist circumferences were measured for both children and adults (Table 4.4). Children of
normal BMI percentile (n=10) had an average waist circumference of 59.2 cm. Children who
were overweight had an average BMI percentile (n= 4) of 70.2 cm. Children who were obese had
an average waist circumference of 82.1

61

Table 4.3 Child Responses to Weight Perceptions and Views on Health

Variable
What are you trying to do about
your weight?
Lose Weight
Gain Weight
Stay the Same
Compared to other students in
your grade who are as tall as
you, do you think you weigh:
Too much
The right amount
Too little
If I run and play every day, I
will have fewer health problems.
Agree
Disagree
If I am overweight I am more
likely to have more health
problems like cancer or heart
disease.
Agree
Disagree

Total

Non-Hispanic
White (n=3)
Female
Male

Ethnicity
Non-Hispanic Black
(n=15)
Female
Male

Other
(n=9)
Female
Male

13
3
11

0
0
1

1
0
1

4
0
1

2
3
5

1
0
3

5
0
0

9
14
4

0
1
0

1
1
0

4
0
1

1
6
3

1
3
0

2
3
0

14
13

0
1

1
1

4
1

5
5

1
3

3
2

10
17

0
1

1
1

1
4

3
7

1
3

4
1

62

Table 4.3 (Cont’d)

Variable
What are you trying to do
about your weight?
Lose Weight
Gain Weight
Stay the Same
Compared to other students
in your grade who are as tall
as you, do you think you
weigh:
Too much
The right amount
Too little
If I run and play every day, I
will have fewer health
problems.
Agree
Disagree
If I am overweight I am
more likely to have more
health problems like cancer
or heart disease.
Agree
Disagree

Total

BMI Percentile
85th <95th
5-<85th (n=11)
≥95th (N=11)
(n=5)
Female Male Total Female Male Total Female Male

3
2
6

1
0
5

2
2
1

2
1
2

1
0
0

1
1
2

8
0
3

3
0
0

5
0
3

3
6
2

2
3
1

1
3
1

0
4
1

0
1
0

0
3
1

6
4
1

3
0
0

3
4
1

4
7

3
3

1
4

2
3

0
1

2
2

8
3

2
1

6
2

4
7

2
4

2
3

1
4

0
1

1
3

5
6

0
3

5
3

63

4.1.3.2 Adult Weight and Health Status
As depicted in Table 4.4, only one parent was of normal BMI (18.5-24.9); the remaining parents
were either overweight (BMI 25-29.9; n=1) or obese (BMI ≥30; n=9). Parents reported a family
medical history of cardiovascular disease (n=2), cancer (n=7), hypertension (n=14), glaucoma
(n=7), diabetes (n=13), smoking (n=7), and consumption of alcohol (n=6) (Table 4.5). Based on
waist circumference data, parents whose weight status fell into the normal BMI had a waist
circumference of 71cm. Parents who were overweight (n=1) had an average waist circumference
of 91cm. Parents who were obese had an average waist circumference of 104.2cm. According to
the CDC and the National Heart, Lung and Blood Institute classification of associated disease
risk in concordance with classifications of overweight, obesity and waist circumference, parents,
who were overweight and had a waist circumferences of 88 cm or less, were at an increased risk
for developing type 2 diabetes, hypertension and cardiovascular disease (CVD). Parents who
were obese and fell into the BMI category of 30-34.9 (n=2) and 35-39.9 (n=2) with a waist
circumference that exceeded 88 cm for women and 102 cm for men were at very high risk for
developing type 2 diabetes, hypertension and CVD. Parents whose BMI was 40 or above and
whose waist circumference was greater than 102 cm (n=1) were at extremely high risk of
developing type 2 diabetes, hypertension and CVD (n=3).

64

Table 4.4 Child BMI Percentile and Adult BMI by Waist Circumference (WC)
Variable

Waist Circumference
(cm)



Adult BMI

Child BMI Percentile
5 - <85th
(n=10)

85th <95th ≥95th
(n=4)
(n=10)

18.5-24.9
(n=1)

25.0-29.9
(n=1)

30 -35
(n=2)

≥36*
(n=3)

59.2

70.2

71

91

93

115.5

82.1

Disease risk for Type 2 Diabetes, Hypertension, and Cardiovascular Disease for Men WC ≤102 cm and
Women WC ≤88cm who are overweight BMI 25-29.9 is increased.
Disease risk for Type 2 Diabetes, Hypertension, and Cardiovascular Disease for Men WC≥102cm Women
≥88cm who are obese BMI 30-35 is very high and whose *BMI is who exceeds 40 + (n=1, Male) is extremely
high

Table 4.5 Parent's Family Medical History
Cardiovascular
Participant Disease
Cancer Hypertension
A1004
E001
E0023
E003
E004
E006
E009
E010
E014
E019
E022

2

1
2
1
1

4
2

2

1
1
1
3

Glaucoma Diabetes Smoking Alcohol
1

4
2

1

2
4
2

2
1
1
1

3

1
2
1
2

1
1

65

2

4.1.4 Dietary Quality
4.1.4.1 Dietary Quality of Children:
The overall dietary quality of the 5th grade students was assessed using the Healthy Eating Index
(HEI-score) based on 12 components as described in Table 3.1 and presented in Figure 4.1. In
the area of total grains (4.8/5), meat and beans (8.4/10), and saturated fat (8.9 /10), 5th grade
students earned scores fairly close to the recommended intakes. Students dietary quality scores
for total fruit, whole fruit, and milk scores were less than recommended at 3.3/5, 3.1/5, 6.6/10
respectively. The subcomponents scores were as follows: whole grains (1.3 /5), total vegetable
(2.6/5), dark green leafy vegetables (2.6/5), sodium (2.5/10), oils (5.5 /10), and calories from
SOFAs (15.1/ 20). The children’s intakes were hence far below the recommendations. The
overall HEI score was 64/100 indicating a moderate dietary quality with room for improvements.
The daily intakes of the following key nutrients were also calculated: dietary fiber, sodium,
potassium, calcium, iron, and folate. The mean intake compared to those recommended for
children 9-13 years by the National Academy of Sciences (NAS, 2005b) were 22g (SD=4.53) for
fiber (recommended=31g for boys and 26g for girls); 2,473.2 mg (SD=664.98) for sodium
(recommended tolerable upper intake level for sodium= 2.2g for both boys and girls); 1672.4 mg
(SD=600.98) for potassium (recommended= 4.5g (4500mg) for both boys and girls); 657.01mg
(SD=269.77) for calcium (recommended= 1,300 mg for both boys and girls); 11.61mg
(SD=3.89) for iron (recommended= 8mg for both boys and girls); and 457.94 µg (SD=149.8) for
folate (recommended= both 300 µg for boys and girls). In addition, the mean total energy intake
and protein intakes were 1398.5 and 56 grams compared to the average daily recommendations
of 2000 kcal/day and 34g of protein for both boys and girls.

66

70
65
60
55
50
45
40
35
30
25
20
15
10
5
0

Child Score

HEI Total Score

Calories from SOFAS

Saturated Fat

Sodium

Oils

Meat and Beans

Milk

Whole Fruit

Total Fruit

Dark Green Orange…

Total Vegetables

Whole Grains

Total Grains

HEI-Score

Food Groups

Figure 4.1 Children’s Overall HEI Score
4.1.4.2 Dietary Quality of Parents:

The food frequency data for parents showed parents receive an overall HEI score (Figure 4.2) of
64 out of a 100. Among the areas, which they could improve, were increasing the consumption
of whole grains (1.2/5), total and dark leafy green vegetables (3.7/5), and the consumption of
dairy (5/10).
The daily intakes of the following key nutrients were also calculated: dietary fiber, sodium,
potassium, calcium, iron, and folate. The mean intakes compared to those recommended for
adults between the age of 31-50 years by the National Academy of Sciences (2005b) were 18.2g

67

(SD=15.05) for fiber (recommended= 38g for males and 25g for females); 2277.8 mg
(SD=102.2) for sodium (recommended tolerable upper intake level for sodium= 1.5g (1500mg)
for both males and females); 2883.5 mg (SD=1764.8) for potassium (recommended =4.7g
(4700mg) for both males and females); 742.6 mg (SD=397.4) for calcium (recommended= 1000
mg for both males and females); 12.7 mg (SD=6.1) for iron (recommended= 8 mg for males and
18mg for females); 365.25 µg (SD=236.4) for folate (recommended= 400 µg for both males and
females). In addition, the mean total energy and protein intakes were 1994.9 kcal and 76 grams
respectively compared to the daily recommendations of 2000 kcal and 56g of protein for males

HEI Score

and 46g for females.
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0

Parent's HEI
HEI-Score

Food Group

Figure 4.2 Parent’s Overall HEI Score

68

4.1.5 Food Insecurity
A little more than half of the students (n=15) reported no instances of food insecurity within their
households (Table 4.6). Twelve students were worried that food within their household would
run out before their family could afford to buy more. The specific food security concerns
expressed were as follows: actually running out of food 2-6 times in the past year (n=6); inability
to eat from all of the food groups (n=7) or eating less due to financial constraints (n=9). In
addition, skipping meals for part or an entire day was reported by 3 students.

69

Table 4.6 Child Self-Report of Food Insecurity by Ethnicity, Gender and Weight Status

Variable

Total (%)

Concerns about food running out
Yes
48
No
52
Has food run out in the past?
Yes
26
No
74
Unable to eat foods from all the food groups
Yes
33
No
67
Reduced food intake due to limited money
Yes
41
No
63
Reduced size of meals due to limited money
Yes
22
No
78
Meal skipping due to limited money
Yes
4
No
96
Hunger in the past month due to insufficient food
Yes
22
No
78
Did y not eat for a whole day due to lack of food
Yes
11
No
89

Non-Hispanic
White (n=3)
Female
Male

Ethnicity
Non-Hispanic Black
(n=15)
Female
Male

Other
(n=9)
Female

Male

0
1

1
1

1
4

5
5

2
2

4
1

0
1

0
2

0
5

4
6

1
3

2
3

0
1

1
1

1
4

4
6

0
4

3
2

0
1

0
2

0
5

6
4

1
3

4
2

0
1

0
2

0
5

3
7

0
4

3
2

0
1

0
2

0
5

1
9

0
4

0
5

0
1

0
2

0
5

4
6

0
4

2
3

0
1

0
2

0
5

2
8

0
4

1
4

70

Table 4.6 (Cont’d)

Variable

BMI Percentile
5-<85th
85th <95th
≥95th
(n=11)
(n=5)
(N=11)
Total Female Male Total Female Male Total Female Male

Concerns about food running out
5
Yes
6
No
Has food run out in the past?
3
Yes
8
No
Unable to eat foods from all the food groups
3
Yes
8
No
Reduced food intake due to limited money
3
Yes
8
No
Reduced size of meals due to limited money
2
Yes
9
No
Meal skipping due to limited money
0
Yes
3
No
Hunger in the past month due to insufficient food
2
Yes
9
No
Did y not eat for a whole day due to lack of food
0
Yes
11
No

3
3

2
3

2
3

0
1

2
2

6
5

0
3

6
2

1
5

2
3

2
3

0
1

2
2

2
9

0
3

2
6

0
6

3
2

2
3

0
1

2
2

4
7

1
2

3
5

1
5

2
3

4
1

0
1

4
0

4
7

0
3

4
4

0
6

2
3

2
3

0
1

2
2

2
9

0
3

2
6

0
1

0
2

2
13

0
5

2
8

0
9

0
4

0
5

0
6

2
3

2
3

0
1

2
2

2
9

0
3

2
6

0
6

0
5

2
3

0
1

2
2

1
10

0
3

1
7

71

4.1.6 Physical Activity Behaviors
4.1.6.1 Child’s Assessment and Report
Self-reported physical activity behaviors by children are depicted in Table 4.7. The majority of
the students engaged in 30 minutes of physical activity (n=23) at least one to three times per
week; 6 reported engaging in physical activity 4-6 times per week. Within the past year many of
the students had participated in an organized sport (n=18).
Most children traveled to school by school bus (n=19); 5 of these students were overweight and 6
were obese. Seven students utilized family transport; of these 4 were obese. Only one student
reported walking to school and was identified as being obese.
Sedentary behaviors reported by children indicated that the majority of boys (n=11) and girls
(n=7) spent one hour or less watching television, using the computer, and/or playing video games
per day. Two children reported playing video games and using the computer for five hours or
more.
Child perceptions of physical activity barriers in the school environment were also assessed
(Table 4.8). Eight students reported feeling somewhat safe in the school environment (n=8).
More than half of the student population reported experiencing peer verbal bulling. With the
majority of the students reporting experiencing verbal bulling almost every day (n=10) when
asked in peer bulling.

72

Table 4.7 Self-Reported Physical Activity and Sedentary Activity Behaviors Among 5th grade students
Gender

Variable
Exercise for at least 30
minutes
≤ 3 per/wk
4-5 per/wk
≥ 6 per/wk
Play outdoors for 30 minutes
or more, not during school
hours
≤ 3 per/wk
4-5 per/wk
≥ 6 per/wk
Sports teams during the past
12 months
0 Teams
1Team
2 Team
3 or more
Currently involved in an
organized physical activities
No
Yes

Ethnicity
NonNonHispanic Hispanic
Female Male
White
Black Other
Total (n=10) (n=17)
(n=3)
(n=15)
(n=9)

BMI Percentile

5-<85th
(n=11)

85th<95th
(n=5)

≥95th
(n=11)

22
4
2

7
5
0

14
1
2

3
0
1

12
2
1

7
2
0

8
2
1

5
0
0

8
2
1

18
3
5

6
1
2

12
2
3

2
0
1

10
1
3

6
2
1

8
1
2

4
0
1

6
2
2

9
12
3
3

4
3
2
1

5
9
1
2

2
1
0
0

6
6
1
2

1
5
2
1

3
5
1
2

1
3
0
1

5
4
2
0

18
9

4
6

14
3

3
0

11
4

4
5

8
3

5
0

5
6

73

Table 4.7 (Cont’d)
Gender

Variable

Hours per day
watching TV, DVDs,
or movies away
from school
0-<1hr.
1-2hrs
3-4hrs
≥ 5hrs.
Able to Play outside
after school instead
of watching TV
Not Sure
A little Sure
Very Sure
Hours spent on
computer
0- <1hr.
1-2hrs
3-4hrs
≥ 5hrs

Ethnicity

BMI Percentile

NonNon5Hispanic Hispanic Other
85th <95th ≥95th
<85th
White
Black
(n=9)
(n=5)
(N=11)
(n=11)
(n=3)
(n=15)

Total

Female
(n=10)

Male
(n=17)

6
9
7
5

7
3
0
0

11
5
0
1

0
2
0
1

1
5
5
4

5
2
2
0

2
6
1
2

2
1
2
0

2
2
4
3

3
8
16

1
2
7

2
6
9

0
1
2

2
4
9

1
3
5

2
1
0

1
1
3

0
4
7

18
7
0
2

7
2
0
1

11
5
0
1

2
1
0
0

10
3
0
2

6
3
0
0

8
3
0
0

3
1
0
1

7
3
0
1

74

Table 4.7 (Cont’d)
Gender
Female Male
(n=10) (n=17)

Ethnicity
NonNonHispanic
Hispanic
Black
White (n=3)
(n=15)

Variable

Total

Hours spent playing
video games
0- <1hr
1-2hrs
3-4hrs
≥ 5 hrs.

15
9
0
3

8
1
0
1

7
8
0
2

1
2
0
0

2
12
11
2

1
6
3
0

1
6
8
2

0
1
2
0

BMI Percentile
Other
(n=9)

5<85th
(n=11)

85th
<95th
(n=5)

≥95th
(n=11)

9
4
0
2

5
3
0
1

6
3
0
2

3
2
0
1

6
4
0
1

2
5
7
1

0
6
2
1

1
6
4
0

1
2
1
1

0
4
6
1

Minutes of daily
physical
activity/exercise
expected
≤ 20 min
30-45 min
50-60 min
I don't know

75

Table 4.8 Child Perceptions of Physical Activity Barriers in the School Environment by Ethnicity and Weight Status
Ethnicity
Non-Hispanic
Non-Hispanic
Other
White (n=3)
Black (n=15)
(n=9)
Variable
Total
Female
Male
Female
Male
Female
Male
School Safety
Somewhat safe
Mostly safe

8
21

0
1

1
1

1
4

3
7

2
4

1
4

Peer verbal bullying
Never
1-3 times
Almost every day

9
8
10

1
0
0

1
1
0

3
1
1

2
2
6

2
2
0

0
2
3

Peer physical bullying
Never
1-3 time
Almost every day

19
4
1

1
0
0

2
0
0

3
1
1

8
2
0

4
0
0

1
4
0

18
5
4

1
0
0

1
0
1

2
2
1

8
1
1

4
0
0

2
2
1

24
3

1
0

1
1

5
0

10
0

4
0

3
2

Excluded from Participation
Never
1-3 time
Almost every day
Affect participation in group physical
activity during school
No
Yes

76

Table 4.8 (Cont’d)

Total

5-<85th (n=11)
Female Male

Total

BMI Percentile
85th <95th (n=5)
Female Male

Somewhat safe
Mostly safe

3
8

3
3

0
5

2
3

0
1

2
2

3
8

0
3

3
5

Peer verbal bullying
Never
1-3 times
Almost every day

5
3
3

3
2
1

2
1
2

1
1
3

1
0
0

0
1
3

3
4
4

2
1
0

1
3
4

Peer physical bullying
Never
1-3 time
Almost every day

9
1
1

4
1
1

5
0
0

4
1
0

1
0
0

3
1
0

6
5
0

3
0
0

3
5
0

9
1
1

4
1
1

5
0
0

3
1
1

1
0
0

2
1
1

6
3
2

2
1
0

4
2
2

11
0

6
0

5
0

5
0

1
0

4
0

8
3

3
0

5
3

Variable

Total

≥95th (N=11)
Female Male

School Safety

Excluded from Participation
Never
1-3 time
Almost every day
Affect participation in group physical activity
during school
No
Yes

77

4.1.6.2 Parent Physical Activity Perceptions
Parents were asked to report the required amount of physical activity an adult should engage in
per day. Responses ranged from 30 minutes (n=4), 40-45 minutes (n=2), 1 hr (n=3) to 3-4 hrs
(n=1). Parents were asked to report where they acquired information concerning the
recommendations for physical activity. Three parents indicated that this was common
knowledge, 3 reported that it was an educated guess, 2 parents reported television (one
mentioned specifically Saturday morning cartoons), 1 from a book, and 1 from an adult weight
loss class.
4.1.6.2.1 Family Nutrition and Physical Activity
The Family Nutrition and Physical Activity Screener was used to assess the family obesogenic
environment (data depicted in Table 4.9) (Ihmels et al. 2009).
The Family Meal Patterns: The family meal patterns component evaluated both the obesogenic
risk factor of skipping breakfast, and eating family meals. Three participants received a score of
ranging from 7-8 indicating an acceptable family meal pattern environment; 8 parents received a
score of 5-6 which is borderline at risk.
Family Eating Practices: Family eating practices addressed meals eaten away from home and
eating meals in front of the television, which are both practices that could potentially put a child
at risk for poor eating habits and/over eating. Six parents received a score between 5-6
indicating moderate risk, 5 parents received a score ranging from 7-8 indicating an acceptable
family environment.

78

The Food Choices: The food choice component addressed the consumption of packaged foods,
which contain a higher salt and fat content than fresh food items. Three parents received a score
ranging between 3-4 (at risk), 4 parents’ scores ranged from 5-6 (moderate risk), and 4 parents
received a score of 7 (acceptable).
Food Beverage Choices: The food beverage choice component addressed the intake of sugarsweetened beverages, which have been linked to excess calories, and associated with obesity and
in addition reduced consumption of dairy, putting children at risk for lower intakes of calcium.
Five parent’s received a score ranging from 3-4 (at risk), 7 parents received as score ranging
from 5-6 (moderate risk), and 2 parents received a sore of 7 (acceptable).
Restriction and Reward: The restriction and reward component evaluated parents behaviors of
restricting snack food items, which in turn may increase the desirability of the items. Firm
restriction of certain food items may impede the child’s ability to learn to regulate intake of some
desirable snacks. Parent of using food or beverage items as a reward may also send the child the
wrong signals where they may “value these food items over healthier options.” One parent
received as score of 3 (at risk), 6 parents received a score ranging between 5-6 (moderately at
risk), 4 parents received a score ranging from 7-8 (acceptable family environment).
Screen Behavior and Time Monitoring: The screen behavior and time monitoring component
addressed extreme television viewing, video game usage and unmonitored usage. Excessive
sedentary activities such as screen time activities have been shown to be associated with obesity.
It is recommended that children engage in 2 hours or less of sedentary activities. Three parents
received a score of 2 (high risk), 2 parents received a score of 4 (at risk); 3 parents received as
score ranging between 5-6 (moderate risk); 3 parents received a score of 8 (acceptable family
environment).
79

The Health Environment: The health environment component includes such practices as
providing opportunities for physical activity, and limiting television viewing. Two parents
received a score of 4 (at risk), 8 parents received as score ranging between 5-6 (moderate risk)
concerning the Health Environment component; and only 2 people received and “acceptable”.
The Family Activity Behavior: The Family Activity Behavior component addressed the family’s
involvement in physical activity with their child. Physical activity related behaviors included:
screen behavior and time monitoring, environmental support, as well as family and child activity
and sleep patterns. By modeling such behaviors, parents are helping to establish healthy views on
physical activity. Seven parents received as score of 5 (moderate risk) and only 4 parents
received a score ranging between 7-8 (acceptable family environment).
The Child Activity Involvement: The Child Activity Involvement component addressed the
child’s engagement in routine physical activity, which is associated with a reduced risk of
becoming overweight or obese. Two parents received a score ranging from 3-4 (at risk), seven
parent received a score ranging from 5-6 (moderately at risk); and 2 parents received a score
ranging from 7-8 (acceptable family environment).
The Family Routine Component: The Family Routine component addressed regularly scheduled
bedtime. Irregularly scheduled bedtimes have been shown to increase the risk for childhood
overweight. Three parents received a score ranging from 5-6 (moderate risk) and eight parents
received a score ranging from 7-8 (acceptable family environment).
Total Family Nutrition and Physical Activity Score: Overall, nine parents received a total FNPA
score ranging between 51-58 which fell into the at risk category, two parents received scores
ranging between 72-73 falling into the acceptable family environment category. (see Table 4.9)

80

Table 4.9 Parent Family Nutrition and Physical Activity Responses, Parent BMI and Child BMI Percentile
Participant Parent BMI Child BMI Family Meal
Family
Food Choice Beverage Choices Restriction/Reward
Percentile
Patterns
Eating Habits
70
A1004
40
6
6
4
5
6
E001

37.7

100

6

7

7

3

3

E003

44.4

9

5

7

6

5

7

E004

36.9

85

5

6

5

4

8

E006

31.8

92

6

7

3

4

5

E009

29.9

72

5

6

4

4

6

E010

37.6

97

7

5

7

5

6

E014

30.6

98

5

6

6

4

6

E019

22

93

7

7

7

7

8

E022

30.1

53

8

7

7

7

8

E023

31.2

70

6

6

6

6

6



Adult BMI below 18.5 Underweight, between 18.5-24.9 Normal, between 25.0-29.9 Overweight, ≥30 Obese; Child BMI
Percentile < 5th percentile underweight, 5th- <85th percentile healthy weight, 85th percentile - < 95th percentile Overweight, ≥
95th percentile Obese.



Each Component Score is based on an 8 pt scale ranging from 0-2 extreme risk, 3-4 at risk, 5-6 at moderate risk, 7-8acceptable family environment; The Total FNPA overall score ranges from 20-40 at extreme risk, 41-60 at risk, 61-70 at
moderate risk, 71-80 acceptable family environment.
81

Table 4.9 (Cont’d)
Parent
Participant BMI
A1004
40

Child BMI
Percentile
70

Family Screen time
Meal
behavior and
Patterns monitoring
6
5

Family
Healthy
Activity
Environment Involvement
5
5

Child Activity Family
Involvement
Routine
5
8

Total
FNPA
Score
55

E001

37.7

100

6

8

6

5

5

8

58

E003

44.4

9

5

2

5

8

5

8

58

E004

36.9

85

5

2

4

5

4

8

51

E006

31.8

92

6

8

6

5

6

7

57

E009

29.9

72

5

4

6

5

5

8

53

E010

37.6

97

7

2

4

7

3

5

51

E014

30.6

98

5

5

5

5

6

6

54

E019

22

93

7

8

5

8

8

8

73

E022

30.1

53

8

6

8

8

5

8

72

E023

31.2

70

6

4

5

5

7

5

56



Adult BMI below 18.5 Underweight, between 18.5-24.9 Normal, between 25.0-29.9 Overweight, ≥30 Obese; Child BMI
Percentile < 5th percentile underweight, 5th- <85th percentile healthy weight, 85th percentile - < 95th percentile Overweight, ≥
95th percentile Obese.



Each Component Score is based on an 8 pt scale ranging from 0-2 extreme risk, 3-4 at risk, 5-6 at moderate risk, 7-8acceptable family environment; The Total FNPA overall score ranges from 20-40 at extreme risk, 41-60 at risk, 61-70 at
moderate risk, 71-80 acceptable family environment.
82

4.2 AIM 2: Children’s Perceived Facilitators and Barriers to a Healthy
Lifestyle
Based on the social cognitive theory, which was the theoretical foundation of the study, the
primary themes that emerged from the study as facilitators to healthy eating and physical
activity by children were personal motivation and being in control, teacher modeling, use of
media, and neighborhood food and environment support. These will be discussed within the
context of personal, home, school, and community environments.

4.2.1 Personal:
4.2.1.1 Personal Facilitators:
Children were primarily motivated to eat healthy and be physically active because of personal
aspirations of becoming a professional athlete, a personal desire not to be viewed as lazy, or
belief in the health benefits. These were depicted in the following interesting quotes:

“I think when I eat at home sometimes I think I’m gonna, be a I wanna be a baseball
player, I wanna be a football player and a basketball player and a baseball player and I
wanna be a really good athlete[A002].”
“Well usually I feel that if I don’t get out too much, that I might not live longer--a longer
life and that I won’t be able to lose some weight. So I run outside and start
playing[E1010].”

One individual displayed his personal motivation, by sharing his story of attempting to sell candy
bars in his community so that he could have enough money to purchase fruits and vegetables for
himself, and his family.
83

“Well, I.. I said this earlier like way back [umhmm] I said, I said I wanted to save money
[umhmm] I only go outside for an hour and nobody wants to buy no chocolate, but I just
try my best .. I can buy healthy foods for me, myself, me, myself and my family [A004].”

Sibling rivalry was also mentioned as a motivating factor for one student, who identified himself
as being overweight and was motivated as result of being teased by his sibling,

“Sometimes, because like um my brother um because I um had gained a lot of weight and
the doctor said I mean (something) 100 and I was like (inaudible) cause my brother was
teasing me about it and so I said I’ll show you what fat is and I lost some weight and he
was like oh you’re not fat no more [E1013].”

Concerns with body image (n=10) and health (n= 16), also served a facilitator to positive health
concepts regarding energy balance, such as were seen with the participants. Due to his interest in
maintaining an “ideal” body weight, the first quote shows how he avoided gaining weight by
making sure he went outside and exercised after a meal.
“Because like sometimes people eat that and then they be like … oh I feel so sick,
because they [their]like in love with it [the food]and like and then they like go to sleep.
And like when you first eat something and then you lay down you can gain, that weight
can stay in your body. But when I eat a lot of fat foods, I II don’t want to be just sitting
down and watching TV or go to sleep, I I like be up and go outside and do everything I
can to get all of that weight and make sure I’m like like um supposed to be the way it is
[E1013].”
“That you should be healthy that you shouldn’t get really big cause the bigger you get the
more health problems you get and you could die. From how big you are. Cause it’s very
easy to get a heart attack when you’re big. Like a 5 year old on the news, he had a heart
attack because of how big he was [E002]”
“Because it has like….uhm sometimes…like sometimes people put like salt on it and it
can cause on it and they said it can cause cancer and stuff like that. And uhm like it has
sugar in it, and sugar is pretty much seen as unhealthy E1010.”

84

4.2.1.2 Personal Barriers:
Personal barriers reported by the children included a lack of motivation or tiredness in some
cases (n= 7).
“I don’t live in Ypsi so like. It usually does it . Well when I get home late. That doesn’t
make me want to play late, but sometimes I play at night if my sisters friend is over. Or
just my sister[E1014].”

Enjoyment of junk food taste and hunger (n=2) were also perceived as barriers to healthy food
choices.
“oh pretty much nothing because I really don’t really listen when it comes to junk food if
I like it… when I’m seriously hungry and I see junk food I, I look for the best thing to eat
[E1007].”

“The taste, and um, I don’t like yea I don’t like the taste, so usually I just don’t get it
[A001]” and “It’s easy to eat healthy, it just depends if you want to or not [E008].”

Personal health or health concerns were expressed as challenges such as having asthma or
instances when they felt sick (n= 2) as evidence by:
“Sometimes like sometimes (clears throat) I hate running cuz I have asthma [E1005].”

4.2.2 Home Environment
4.2.2.1 Home Environment Facilitators:
Family was referenced by 22 children as a source of information about health, healthy eating and
physical activity.
“…My mom, my dad, my grandma, my aunt, my uncles and everybody in the family
[E1002].”
85

Parents were especially viewed as valid sources of information by the children,
“Probably not my parents, cause my parents taught me nothing wrong [E1002]”.
It became evident that there were distinctions made in the messages from family sources reported
by children. These messages were further categorized into potentially positive and potentially
negative messages.
Potentially positive messages from family sources were messages that were unbiased and did not
pose a negative threat to the child’s wellbeing. Examples of a positive message expressed by
children were as follows,
“well every time I wanna go to the store and she says you know if you eat well you can be
very strong and grow up and my grandma told me if I can get in sports so I can be a
better athlete [A002].”
The parent/primary guardian was perceived as facilitating good dietary practices or engagement
in physical activity towards achieving a future goal set by the child.
“Like my dad tells me what’s healthy for me to eat and what’s not. Like and he tells me to
go outside certain times so I can be active and play [E1005].”
“like my mom teach[es] me what not to eat and what to eat and how .. How you should
exercise so your body will have energy ….. My grandma always tell[s] me there, like she
thinks jogging is good, walking…we do fast walking E1016.”

Family pets were also mentioned as facilitators to physical activity by two participants. One
participant mentioned that she liked doing physical activity with her dog, because “he listens to
me”. Interestingly, the use of media, within the home was viewed as a facilitator for both healthy
eating and physical activity by children as portrayed in both the following two quotes
respectively (n=4).

86

“well based on what I see on TV is people always eating healthy. And on this one
channel, on cartoon-network, this one dog says to his owner “Johnny, eat the carrot”
and find out that his eye vision gets really stronger …and then it lets me know that
carrots actually help me see in the dark. Milk actually helps you get stronger bones,
meats actually helps you- you know- get your body working. Fruits helps your heart. And
vegetables help you um, think [E1010].”
“No he, well, I know T.V. I watch it and it helps me. It helps me, like when ‘Dancing with
the Stars’, it helps me workout, stretch my arms [A004].”
Some children within the study made a clear distinction between regular video games, and those
(such as the Xbox connect and Nintendo Wii) that actually require movement. They specifically
mentioned interactive video games such as “Just Dance” and the “Wii Fit” as facilitating
engagement in physical activity (n=2).

“The Wii Fit is like exercise, so it got exercise and there, there’s this right thing that
shaped like a square but it’s bigger and we turn on the Wii and then you jog and play you
get a jump and then there’s a connect [A007]”

4.2.2.2 Home Environment Barriers:
Potentially negative messages from family sources were deemed as those that could evoke fear
or feed into insecurities about body image. These messages were expressed by several children
(n= 9). For example, some family members provided information, which was not entirely factual,
and potentially disturbing/misleading.
“When..when my grandma be saying about oo I heard this [inaudible] was on the TV and
they was eating too much junk food and then they almost exploded[ E101]”
“She, she get[s] me very paranoid… She, she like, I don’t want to say threaten me… I
guess that’s the word I can say, she says if you keep eating sugar, you’re going to get
diabetes. So I don’t, but that[s] mostly my sister [E1014].”

87

Children also reported messages from family members that fed into insecurities regarding body
image as depicted by with participants A004 and E1015 respectively:
“That’s, because it made me fat, and my mom, and I had to go to the gym with my dad to
help me workout and be skinny again.”
“yeah because as I am eating, I’m getting bigger, because my mom is saying my face
[is] getting fat, like that [demonstrates].”

Family barriers reported by children included, parents using food as a rewards and extended
family members such as uncles and aunts bringing fast food when they visited (n= 2).
“ummm when my dad wants to take me out to eat and stuff at McDonalds sometimes and
with special occasions and stuff like when I win a game, that’s all.. when most of the
time, sometimes my uncle comes over at our house and brings like a lot of junk food and
stuff like McDonalds and he brings chips and he brings pizza and Taco Bell [A002].”

Children also mentioned money as a barrier to buying healthy food and parents being too tired,
not interested or busy to take them someplace where thy could engage in physical activity.
“sometimes my parents don’t have enough money to buy it [E1017.]”

“Well, I..I tried asking my mom, “Can we go to the park” and we only go there, like, once
a month. I said “Can we go to the park?” “Not today,” she says all the time. I just sit in
my room doing nothing. I really should be going outside but my time extends like one
hour. My mom says that, I just have to sit there doing nothing I can’t do no fun things in
the house. My mom says I might break something. Uh I might break something and do
something that might hurt someone [umm].”
“Nothing, all my parents do is watch TV [E1017].”

Screen time (television and computer) was viewed as a major barrier to physical activity (n=11).
One student specifically described his computer as a distraction to physical activity, and another

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mentioned that his aunt had introduced him to a particular television series, which they watched
together.

“Well, usually when the TV’s on, I usually end up stopping for a minute and watching it,
and I usually end up watching it the whole entire day. And usually I get on [my]
computer and look up how to play this one song on the piano. And I go to my piano in my
room and try to start playing the song. And then getting up and running to the computer,
piano computer, piano- like that, trying to figure out the song [E1010].”
“It’s like there’s a movie called The Lying Game…. And I like I’m just trying to find out
who took the twin sister..Cause my Auntie got me into watching that movie and she
natural uh natural um I forgot what the movie’s called…Natural Survivors I think…. It’s
two um and (inaudible) and The Ghost Whisperer, my auntie, she gets me to watch the
movies with her and I start to like them.”

4.2.3 School Environment
4.2.3.1 School Environment Facilitators:
Teachers were identified as a source of information regarding healthy eating, and physical
activity (n=5). For example, in the school environment a teacher modeling healthy eating was
found to be a positive influence by one student.

“Well, it’s healthy because, she like, she never come out like with junk food or cookies
like we do for snacks, and even for snacks she gets something healthy. Unlike her, WE
come out with a bag of chips or something to snack, she come out with some healthy stuff,
ummm, for snack today I don’t know what she had, it was something green, so I didn’t
even bother to ask. And I think, I think that she’s good, she’s kind of nice because, that,
she’s not eating junk food like us, she be trying to get us not to eat the junk food, but we
don’t go that way. For snack we always have junk food [E006].”

In School A, the salad bar also was considered a facilitator to healthy eating, because they were
able to connect the choices with some of the knowledge they had gained.

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“well, I think the salad bar,… that may good. I know--…. Mmhmm. And it be having a
lot of fruits and vegetables and then.. I kind of like that kind of stuff [A001]” and “The
things that make it easier for me to eat healthy is fruits and the low fat milk, and the
salads, ‘cause they’re from the food groups that help you stay strong and fit. And the low
fat milk gets your bones bigger [E1010].”

The children also found the offering of fruits during snack time as a positive influence in
conjunction with the salad offerings at lunch.

“It’s easy, it’s very easy because they give you healthy snacks and you get to choose if
you want um salads or whatever they have at the salad bar [A003].”

What children from both schools wanted to see offered more were fruits and vegetables,
preferring the fruits over the vegetables because of the sweet taste.

“because fruits, fruits is good for you, vegetables are good to you too but I think like
vegetables are better for you because they don’t have like a sweet taste like not really at
all. Fruits have like a sweet taste too but it’s still good for you like pineapples [E1019].”

The PE-Nut program was also specifically mentioned as a facilitator to healthy eating and
physical activity among children. One student, in response to the question about how information
from PE-Nut had helped the family, described how the PE-Nut program changed the family
environment,

“Like cause me and my sister we didn’t really like eat any vegetables or anything like
that, all we would do is eat like junk food and stay in the house all day and just watch TV
and play the Wii and stuff. And now like we started playing, we’ll go outside and play
and like get active and stuff with our family [E1005].”

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What is particularly unique is that the schools involved in the program have engaged in a schoolwide approach of promoting health and physical activity. This was clearly evident in the fact that
one student reported her librarian as instrumental in providing advice about healthy eating and
physical activity;

“…uh our library teacher, teaches this program, and teaches us if you eat healthy foods
and non-healthy foods like this, and just sit and change the channel and sit and be lazy
you can be fat. But if you, if you stay healthy and active and play some games and stuff
you won’t be fat [E1018].”

When we asked how weight is related to the foods we eat, one child responded they were
informed by their teacher that food was related to the physical appearance and functioning.

“what you eat, is what you are made out of or something, just like our teacher told me
[E1003].”
The implication of that statement, as follows, definitely indicated there was a connection to
health,
“That like if you eat cake or something then you’re gonna get fat or something. Like,
you’re not gonna[get] fat if you eat, like, one piece. You’re not gonna get like really fat,
you’re just gonna get a little bit fat and then if you eat, like, healthy stuff you’ll get
stronger bones and you might be, you might be more active. You might feel more active,
like to move around. But… okay [E1003].”

4.2.3.2 School Environment Barriers:
Classroom barriers (n=9) included social events (classroom parties, classroom snacks, and Friday
“Go-Getters” described as weekly prizes presented to students) as well as school meal food
preparation. During these social events, children described “junk foods” as key featured items.
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A majority of the students reported meat, which was perceived as being uncooked, as a barrier
to healthy eating (n=9), as well as fat and grease content of the meals. The following quotes
provide evidence of these three findings.
“..for break time, today like Friday, we do go-getters and we uh we get like to choose
a prize so I like choose candy and uh, I like I- I take that home, or I just eat [it] on the
bus [E1007].”
“like if its, um because sometimes um I see pink in the meat sometimes so that’s why I
think it’s not healthy because it’s not all the way cooked… cause my mom said don’t
eat it if you see pink meat cause you’ll get sick and I don’t wanna get sick. [A003].”
“Because they, they [school meals] um they sometimes all they be having is just they
be having a whole bunch of like fat on the foods [A001]”. “Umm sometimes I eat
school lunch sometimes I bring my own lunch because the school lunch is greasy and
my mom don’t want me to get like don’t eat greasy.... because they’re …they’re
greasy food. They have a lot of grease on it and if you eat a lot of grease …if you eat
a lot of grease it won’t be good for your body [E1016, Female]”

Among the physical activity barriers mentioned by children in the study, was replacement of
physical education and recess with Art and Media classes (n= 2); being criticized by others, and
the competitive nature of the activities (n= 8).
“Music might stop me we don’t do like, like we don’t do a lot of running in there. We
just... we just like sit down sometimes watch movies and TV like singing and we just sit
down and watch TV [E1016].” “Art. Um, art, media even though media does help you, I
don’t know how art helps you [E1002].”
“People making fun of you and sometimes when they think you are doing it wrong, they
try and correct you, when you are doing the best you can [E010, Male]”.

One child specifically reported a dislike for physical education because she received a grade of a
C+ that removed her from the honor roll (in which she had been a part of for several years).
“Umm… I don’t really like P.E. , but since it is healthier, I guess I can give it a chance.
But I still don’t like it….I kind of got a bad grade, I got a C+ and it got me off the Honor
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Role. That’s why I hate it. And I have been on honor roll all times… So, now I’m not… If
it’s not about Honor Role and stuff, I like it. It’s fine [E1014].”

4.2.4 Community Environment:
4.2.4.1 Community Environment Facilitators:
Children considered neighborhoods that had a major chain grocery store in close proximity as a
facilitator to healthy eating in their environment (n=4).

“Easy cause we live right by a grocery store [A003].”

More importantly, children positively viewed neighborhoods where their community members
practiced physical activity and were seen eating healthy foods, as well as safe neighborhood
environments with park facilities as beneficial.
“it’s pretty easy because the people who live next to us have 3 kids and they’re [Names
children] and they like to eat healthy too like us and our families get together and play
and we went to school together and that’s where[who] I played my 6th tournament with
[A002].”
“Canton Park it’s near and it’s really big and it’s really safe. There’s another one next
to it and it’s very, it’s like almost the same size but little bit smaller…and I see people
help out with the community...[A007].”

4.2.4.2 Community Environment Barriers:

Neighborhood barriers mentioned included neighborhood safety, the food environment and
accessibility to recreation centers such as parks (n=24). Among the top noted neighborhood
barriers was the lack of community modeling of healthy eating and physical activity. Children
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reported that not seeing it, made it difficult to engage in such behaviors themselves. The lack of
grocery stores and the presence of gas stations and liquor stores, were also specifically touted as
negative influences. In addition to the neighborhood food environment, children also expressed
neighborhood safety as both a concern and barrier to engaging in physical activity. The inability
to go the park unsupervised, lack of facilities in close proximity, and lack of community sharing
were common threads in the participant responses.

“there is not, there is not a lot of grocery stores and places to get food in my
neighborhood …because a lot of people in my neighborhood don’t eat healthy like, my
family [A001].”
“because gas station sell those chips, pop, and candy[A005]”and “There’s a lot of liquor
stores down there[ E1002].”

“I can’t go alone, and I have to go with an adult. Someone.. I can’t go by myself ‘cause I
can get snatched up. And killed or something, so I at least gotta I have to go with
somebody who’s old enough. And who’s responsible [E1007, Male]”
“Well, people in West Willow ..they don’t give a lot of foods to people. They, they keep
them for themselves. They get, they take the food for themselves and I hardly get nothing.
I say, sometimes I go to peoples door and say, um can I borrow somethin, somethin and
then, sorry we’re almost out [oh]. They have to save it for themselves and tell lies, and
that’s why I never wanted to live in that neighborhood [A004].”

4.3 AIM 3 Parents’ Perceived Facilitators and Barriers to family Healthy
Lifestyle:
The key themes which emerged relative to parental facilitators and barriers to healthy lifestyle
were lack of self-motivation (n= 7), income status (n=8) and time (n= 10), and environmental
constraints (n=5). These will be discussed within the individual, home, child’s school and
community contexts.
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4.3.1 Individual
Among the parents, the individual facilitators for healthy eating and physical activity were
providing a healthy environment for their children and self-motivation to lose weight. Parents
suggested that having classes where they could learn about healthy food, as well as how to
achieve and maintain a healthy weight would serve as a facilitators if available. It appears that
for parents, changes in dietary and physical activity habits would be more effective in a
supportive group setting. Personal barriers reported by parents, were time (n=10) and lack of
motivation (n= 7), as well as cost and budgetary constraints (n= 8).

“Um, probably like a class or something, I think like a healthy uh uh class where you can
eat healthy foods and talk about different ways to stay in shape um I think that would be
better because like if they give you fliers and things I get a lot of fliers and stuff, and
some of them I read most of them I don’t you know only if my kids point them out and say
hey read this then I read it. But if I was taking a class I would probably take more in and
benefit from it because I’m there. Yea [E003-E012]”

“like uh my eating habit is more of a grab and go type of thing. Cause I’m always at
work. So the stuff that’s around me is the stuff I grab [E001]” and “I don’t, there’s
nothing holding me back other than lack of motivation [E004].”

“Sometimes cost. And being busy. Usually I’m on the go. If you don’t prepare or grab a
healthy snack, then you’re just grabbing something cause you’re starving. Um and cost is
a big one. For me, from week to week I call it- “G.G”- gas and groceries. (others
laughing) It’s very hard to try to have—to buy organic for one, I haven’t even tried even
buying organic, ‘cause it’s just not in the budget. Just to buy a good variety of fruits and
vegetables and feed 6 people, and um to have enough to make it from week to week is
very hard [ E009].”

“I’m very open to it. Like I said, I already do it. But I think a lot of it is having more
resources to spend more and doing organics and things like that- budget. Like
transitioning into it; I’ll say I’m already in it but I wanna do more [E1019].”

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Fear of dying or developing dietary related co-morbidities, served as strong motivation for some
(n= 6)
“Life. Like what she said I don’t want to die at the age of 40…. I want to live to be long
and I don’t want to have diabetes high blood pressure any of them things that be killing
people these days to be one of the reasons why because I wanted to be a gluttony
[E006].”

4.3.2 Home Environment
4.3.2.1 Home Environment Facilitators:
Parents found that limiting the amount of “junk food” and increasing the availability of fruits and
vegetables in the household were important facilitators. In addition they reported that
information from PE-Nut that they received through their children helped them to make healthy
food choices in their home environment.
“Um yes. Yes because like I think the main issue would be for my kids, when they’re
really hungry and let’s say we run out of vegetables or something like that, because I
usually have a lot of vegetables and um fruits cause its quick and then, they eat it before
dinner. But if I run out and there’s donuts and stuff they’re grabbing donuts and
whatever. So like for me I just, when I realized it I just stop buying so much because that
way they only have the choice of whatever’s in there and if they have to wait for me to
cook then they just have to wait [E1003-E012].

“Um they help me cook, um they tell me about programs in school like the PE-Nut
program ... Yea, they’re like I wanna make this! (laughs) or the PE-Nut program told us
to play more and do this.Yea they come home and tell me everything they learned, so that
that’s helps out a lot [E003-E012].”

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From a physical activity perspective, parent engagement in family activity was perceived as a
positive. Family activities reported by parents and their children reported included walks in the
park, bicycle riding and swimming. Some families participated in regular physical activity.
“we bike ride, uh go to the park, we take long walks with the dogs [E009].
“Go swimming. That’s about it I can’t think of anything else. Go to the park [E006]”
“uhm, what do we do exactly to be physically active? um I said it already, we work out
together we run together and we- that’s about it [E019].”
Since the change in technology, family activities have also changed to include interactive video
games (exergames), which are not typically considered as engagement in family physical
activity. Time spent playing exergames were viewed as a great opportunity for family physical
activity among parents,

“Go to the park play dodgeball on the Xbox…“Dude you’re jumping all over that living
room we’re hands and trying to kick your feet keep these balls from flying [E010]”

Regardless of the type of physical activities parents engaged in with their children, there was a
sense of satisfaction and accomplishment.

“[how do you feel,] good…‘cuz you know you’re not only doing something good for
yourself but you’re also doing it for your children [E009]. Yea, exactly [E1019].”

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4.3.2.2 Home Environment Barriers:
In the home environment, time was seen as a barrier to engaging in physical activity. One mother
described her struggle with time, as being monopolized with housework and running errands for
the household.

“yea, it’s like basically I do house work. A lot, until as much as I can stand, and then um,
running errands, mostly a big portion of my day is running a lot of errands cause I have
(inaudible) and then you go out and you forget, sometimes. I forget to eat, literally, and
then when I do eat I want to eat a whole [lot] because I haven’t eaten and then after
awhile[E003-E012].”

Lack of interest (n=2) and money (n=2) to engage in physical activity was also reported as a
barrier to parents. Parents expressed the desire to have their children engage in organized sport
activities, but found money to be a limitation.
“lack of interest … umm sometimes the price of things [E004].”

“Um, more opportunities in the community. A lot of the recreational things that the kids
want to do like getting involved with baseball teams and soccer teams and dance classes
or stuff like that it costs a lot of money. Um, I’m a single parent. It’s harder for me to
provide those things for my children. Um, I have to maintain the bills and make sure
there’s food in the house, and those aren’t always what I can afford to do for the girls.
Like the program here that they have at the school called “Girls on the Run,” my
daughters in, both of the girls, um my the younger one her best friend that stays with us
too, she’s in the program too [E009].”

With regard to healthy eating, lack of family interest (n=1), money, (n=8), and time constraints
were key contributors, expressed by parents.

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“well I love vegetables but my family does not umm and I’m not one just like umm and I
wish I like chicken but I don’t.. It’s a lack of interest from the family really [E004].”

“either you’re out of time or you’re out of money or you’re out of time and money.” “Um
not having a lot of time sometimes money, like the vegetables are expensive, so money…
Money mostly because if I had if I had more money to purchase like vegetables that we
don’t normally eat, they’re more expensive, you know like green beans and carrots and
stuff like that [E003-E012].”

“Sometimes, not always, I eat meals with the family Thursday, Friday, Saturday and
Sunday and Monday Tuesday Wednesday I’m on breakfast schedule.”

Parents described meal times with their families as family communication time, especially for
the children to talk. They viewed this as an opportunity for them to become informed on their
children’s everyday interactions with peers, and other daily activities.
“No the kids talk more than I do. We, me and my boyfriend don’t talk, it be (inaudible)
they talk. And [child’s Name]talks too. Yea he answers whenever his sisters talk. The kids
talk, we just listen. I use that as a time to eavesdrop on what they’re talking about, I let
them go and I just come in every now and then like “really?” “No way! What else
happened?” You know, yea that’s about it. [E006].”

4.3.3 Child’s School Environment
Parents felt as though the school meals could use improvement (n=8). One parents specifically
mentioned that there should be a balance between perceived food children’s preference and
dietary quality. However, changes in the school menu offerings such as whole-wheat products
and school breakfast were also viewed as positive. In addition, there was an appreciation for the
important role school meals played in the lives of children whose families did not have the
resources.

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“Well um I think it needs to be a mix between being something the kids really like and
something that’s healthy. Um my daughters always complaining about the milk tasting
funny [[E003-E012].”

“I do see the school here though has integrated a lot of wheat product, whole grain
bread and whole grain muffins and stuff like that. Where um the other schools my
children have been in I have not seen that, [E009]”
“I appreciate the fact that like the schools now a days um like my kids I could drop them
off um 15 minutes early for school every day if I didn’t have the means and they could at
least get breakfast. Now granted breakfast is like a pop tart sometimes and like a thing of
milk. But for some kids they don’t have anything, so like I appreciate that…. [E022]”

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4.3.4 Community Environment:
4.3.4.1 Community Environment Barriers:
The neighborhood environment was reported as being of concern in that it did not support
healthy eating and physical activity behaviors. Parents (n=3) reported that grocery stores were
not in close proximity to where they lived.
“Ummm healthy food choices in my neighborhood (laughs) nothing? (laughs) I don’t
know they don’t really promote like healthy food. We don’t have like a good market that’s
like really close by unfortunately um the grocery store is close enough but even there they
don’t necessarily promote like healthy eating. So I would say nothing (laughs) [E019].”

“There aren’t any in my neighborhood. I know for me, if I forget an ingredient or if I
want fresh fruits and vegetables and don’t have them right , at that minute, and I don’t
want to go all the way to Kroger’s or Meijer’s which is far. There’s like a Dollar General
right by where I live, but they don’t have the fresh fruits and vegetables…oh yea. So even
if it’s something on the shelf, it’s helpful. Like Kmart, they have certain things there too
but if they had a fresh fruits and vegetable area that would be pretty cool [E009].”

Lack of neighborhood facilities and a safe environment were primary barriers encountered by
parents towards engaging in physical activity (n=5). Parents also reported that a major barrier
with regard to lifestyle behaviors that their children experienced within the neighborhood
teasing,

“well there’s no gym, you know you have to go. I have an office and community centerit’s not a community center. I don’t want to go to the park, drive far away[A1004]”and
“A: yes um around here we live on kind of a busy street and its not like the grandest
neighborhood like so I don’t let my son ride his bike down our street so that’s kind of a
challenge and like when I get up and go jogging in the morning I don’t just like go out my
door and go jogging I get in my car and drive to a park that’s like a mile down the road
and then go jogging there because I don’t feel safe [E022]”

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“Cause we don’t know our neighborhood [E006] and “Cause we live in the projects and
its just a bad place [E010].”
There’s a park directly behind our thing, but you can’t send your kids to the park there’s
all kinds of rats there. I’m gonna stop saying rats, that’s the only thing, rats are ghetto
people for people who don’t know (laughs.) [E006]”.
“ a nicer, group of kids, I don’t know….umm I mean [Child’s Name] is smaller than a lot
children and tender hearted, So [Child’s Name] can be the kid to pick on. I think once
they’ve seen him cry [other children] and everyone knows they can make him cry . He’s
getting on pretty well about it, this year happens to be a particularly good year for him,
Um I mean, he gets picked on, on the bus, he gets picked on in school, he gets picked on
at lunch, he gets picked on at recess, he gets picked on outside at my house. I mean, I
don’t know, he’s not a bad kid he’s a big hearted kid, so he, I know he doesn’t take no for
an answer. If the kid doesn’t like him he thinks that he needs to try just that much harder
to make that person be his friend [E004].”

When asked if the parents felt safe sending their children to the neighborhood park the parents
were especially concerned as follows:

“No, guns go off daily [E010],” “Oh, hell no![E006].”
“Stray bullet hit one of the kids, my kids don’t go there [E010]” and “If I can’t look out
the window and see you, you can’t go outside. I don’t care if you is 11 or 12 it’s not the
right neighborhood, or it’s not the right area, maybe if we were in Ann Arbor but,
Ypsilanti, No [E006].”

4.4 Grounded Theory: Systematic Processing of Healthy Lifestyle Information

Based on the grounded theory methodology approach, our initial findings sought to explore the
perceived barriers and facilitators to healthy eating and physical activity experienced by children
and their parents/primary caregivers. In-depth interviews and focus groups captured the voices of
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predominately low-income 5th grade students and their parents/caregivers. After seventeen
interviews were completed with children, we learned that children were concerned and had
misconceptions regarding topics surrounding weight, overall health, healthy eating and physical
activity. Questions were thus further developed to explore these concerns and misconceptions
which surfaced during our interviews (Glaser et al. 1967). We were able to identify that children
were receiving information about health, healthy eating and physical activity from numerous
sources that resulted in fear, anxiety and concern. These messages were either reduced or
elevated depending on the family ecology. The family ecology, as depicted in the model which
evolved (Figure 4.3), determined whether or not the child maintained a balanced understanding
of health, healthy eating, and physical activity or an unbalanced view in which misconceptions
obtained and processed from various sources were reinforced or dispelled. Figure 4.3 shows how
children who participated in our study, process and internalize messages regarding health,
healthy eating and physical activity. More specifically evidence is provided on how messages
regarding health, healthy eating, and physical activity if not nurtured within a supportive family
environment have the potential to elicit fear, anxiety and misconceptions concerning regarding
health, healthy eating and physical activity. This could lead to issues in the future relative to
lifestyle behaviors and weight. These messages as portrayed in Figure 4.3 will be discussed
under the subheadings 4.4.1 System Messages/ Sources, 4.4.1.2 Internal Conflicts, 4.4.1.3 Fear
and Anxiety, 4.4.1.4 Family Ecology, 4.4.1.5 Child Understanding, and 4.4.1.6 Child
Misconceptions

4.4.1 System Messages/Sources
A dominant emerging theme, grounded within the data, was that of system messages. We noticed
that much of the information regarding health, healthy eating, and physical activity was drawn
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from various sources of information. The information regarding health, healthy eating and
physical activity appeared to be processed heuristically by children. Heuristic processing is
defined as a limited mode of information, which calls for less cognitive efforts and fewer
cognitive resources (Eagly et al.,1993). Eagly et al. (2003) provides a more definitive example of
this, “When individuals are processing heuristically they are viewed as focusing on the subset of
available information that enables them to use simple rules or cognitive heuristic information to
formulate their judgments and decisions”. Messages received from the various sources, served as
the children’s solid foundation of knowledge regarding nutrition and health; which ultimately
became evident as factors that shaped their behavior. These sources include the family, teacher,
media, healthcare professionals, and organized wellness and sports programs.

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System Messages
Family, PE-Nut, PE,
Media, HCP, Teachers,
Peers, OS, Community,
School Employees

Child

Fear, Anxiety, Concern
Heart Disease, Diabetes,
Blood Pressure,
Overweight, Obese, Death

Internal Conflicts

Fruit & Veg, Healthy
vs. Unhealthy Eating

Negative
Family Ecology

Positive
Family Ecology
(n=13)

Implications
for Disordered
Eating (n=5)
Balanced
Understanding
Reinforced

(

Child
Misconceptions
Reinforced

Figure 4.3 Systematic Processing of Nutrition and Physical Activity Messages Among
5th grade Elementary Students

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4.4.1.1 Family:
Among the 27 participants, 22 referenced a family member as a source of information regarding
health, healthy eating and physical activity. Children reported receiving messages from their
entire family. Information included the certain ingredients in some foods, which they perceived
made them, unhealthy. They also described being encouraged by parents who explained why
certain foods were not healthy, as well as the importance of moderation. Overall, messages from
family sources were deemed valid by several or most participants (n=22).
“My mom, my dad, my grandma, my aunt, my uncles and everybody in the family [E1002,
Male].”
“…my mom tells me a lot of stories what’s healthy for me and so, that’s most of the stuff
she says. But the reason I didn’t say white bread, cause she said they have a lot of
preservatives in them so, she said wheat is more healthier [E1014, female].”
“From my mom and my dad….. They teach [taught] me about how carrots are healthy
for you and uhh junk food is not healthy [A007, Male].”
“My parents, like they tell us what to eat and like if it’s not healthy we can only have like
half of it and save the rest for another..[E1005, Female].”
“Probably not my parents, cause my parents taught me nothing wrong [E1002, Male].”

4.1.1.1 Potential Positive and Negative Messages from Family Sources:
It became evident that there were distinctions between the messages reported by children from
their family sources. These messages were further categorized into potentially positive and
potentially negative messages. Potentially positive messages from family sources were messages

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that were unbiased and did not pose a potential negative threat to the child’s well being, but an
unbiased balanced view about health, healthy eating and/or physical activity. As described in
section 4.2.3 under family facilitators, many messages perceived and reported by children were
both encouraging and positive. Children described parents as not only encouraging engagement
in physical activity, but also engaging in the activities themselves.

“Um, my mom’s always encouraging us to get up and go outside, and most of the time
she’s out there with us doing stuff and being active [E1009, Male].”

Children also expressed that making healthy food choices outside of the home was easy because
their parents had taught them.

“it’s easy because I’ll always eat healthy food in the house and umm my mom taught me
to eat healthy food when you’re out [E1016, Female].”

A distinguishing factor was that parents related healthy eating in a positive manner to their
children, and were supportive or encouraging.
“well every time I wanna go to the store and she says you know if you eat well you can be
very strong and grow up and my grandma told me if I can get in sports so I can be a
better athlete [A002],”
“yeah they tell me to eat healthy everyday [E1018, Female].”

Potentially negative messages from family sources were messages that could bring about fear or
feed into insecurities about body image. These messages generally focused around weight, or
included adverse consequences for not eating healthy. As described in section, 4.2.3, comments
such as the following could result in long-term negative outcomes. Of particular concern was

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messages that appeared to induce anxiety about current health status, or were perceived as being
threatening.

“My mom says she is going to put me on a diet. So, I still have weight and I weigh up to
80 pounds [umhum], plus the kilometers and my mom said I want to be below 60 [hum].
So that’s why she is putting me on a diet [A004, Male]”
“She, she get me very paranoid…… She, she like, I don’t want to say threaten me… I
guess that’s the word I can say, she says if you keep eating sugar, you’re going to get
diabetes. So I don’t, but that[s] mostly my sister [E1014].”

4.4.1.2 Teachers
Teachers were also identified as a source of information regarding health, healthy eating and
physical activity by students (n=5). Even the librarian as seen in 4.2.4.provided advice about
healthy eating and physical activity. Children reported that teachers provided information about
health, through the PE-Nut program’s “Fit bit tips”, as well as based on their own outlook on
health.

“Well, well we got this teacher named [Teacher’s Name] every morning she gives us a
healthy PE-Nut tip [E1006, Female].”
“Umm, what you eat is what you are made of or something, just like our teacher told
me…[E1003, Male].

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4.4.1.3 Media
Media sources (n=13) included television (food network programs, movies, commercials)
internet, and video games. The majority of the comments concerning media as a source of
information pertained to the home environment. However one child described watching a
documentary in gym class on the topic of health. The child’s description of the movie, although
not confirmed, appeared to be from the documentary “Super Size Me”.

“Oh when I was in gym, I was watching this movie and it was about how this guy, he was
eating lots of hamburgers and he got fat so he had to go to the uh [the], doctors
[E1007].”

Television served as a source of information about which foods were considered healthy.

“Yea, they said like eat cereal, low fat stuff and then chocolate milk and stuff. ……Like to
eat healthy and like eat stuff that’s healthy and like you can eat a little bit of fat but not a
lot …“yes, like my family and uh the TV and stuff [E1008, Male].”
[E1008, Male].
One child’s justification for oranges being healthy was because she saw them being advertised
on a Michigan commercial:

“Oranges [as a healthy food]… I just think they healthy cause they always put em on like
Michigan good stuff on commercials, so I’m just guessing that’s healthy [E1006].”

One child mentioned using the internet as a means of looking up information about food, in
addition to watching the cooking network.

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“On the internet [source of information about food], Yea like I be watching the cooking
show and my grandma tell[s] me what’s healthy for me [E1013].”

The media was also a generator of fear and anxiety relative to the development of chronic
disease. Participant E1002, fearfully described an event in which a 5 year old passed away of a
heart attack due to weight,

“That you should be healthy that you shouldn’t get really big cause the bigger you get the
more health problems you get and you could die. From how big you are. Cause it’s very
easy to get a heart attack when you’re big. Like a 5 year old on the news, he had a heart
attack because of how big he was.

Participant E1014 (female), described feeling fearful about developing diabetes and high blood
pressure. Although the mechanism regarding how she would develop diabetes from having high
blood pressure was unclear, it was apparent that she was concerned about developing either
because she understood that people had died from these diseases after viewing the information
from the television.

“Umm.. I heard a lot of people dying about it [Diabetes]. Cause like something sugar is
a thing that I can’t live without, and if my blood pressure goes up that’s bad. That’s
why….. Umm just scared about my blood pressure going up…. If it goes overboard you,
you can get very sick or die….
When asked where she got the information from, she replied: “umm T.V.[source of
information]”

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4.4.1.4 Healthcare professionals
Healthcare professionals such as physicians were considered a credible source of information
about health, healthy eating and physical activity among some children (n=4). For example, one
child believed that zucchini and carrots where healthy because it was mentioned by her doctor,

“the doctor said that’s healthy. I forgot what else I named… carrots. They’re healthy,
because they got vita….mmmins in it [E1006]”

4.4.1.5 Organized Wellness, and Sports Programs
Among the 5th grade girls (n=4) attending School B, a majority of the information gathered
regarding health, healthy eating and physical activity was perceived as coming from an
afterschool twice a week program called Girls on the Run. Girls on the Run was mentioned as
providing a supportive and encouraging environment where children learned about health, and
engaged in physical activity. Girls on the Run was also mentioned as the source of information
about self-esteem and healthy eating,

“well last year I did girls on the run and we talked about health and a lot of stuff
[E1012]”
“Yeah. When I get home, on Mondays and Tuesdays we have Girls on the Run and we
have to walk around the school. And so far I’ve been walking two to three miles every
day and then I usually skate, because I like skating. Or I go outside and throw footballs
around [E1009].”
“They talk about your health, they talk about how to be healthier and the reason I
learned like, like they teach us a lot of things about health and also negativity and that’s
not really what’s it about. But its much, much more about health. .....But girls on the run
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still helps me, it says don’t eat that much fattening, and it also helps me with the exercise
[E1014].”

Organized sports (n=3), served as sources of information about physical activity. Messages
concerning health and physical activity were inferred through the child’s engagement. Participant
A002 viewed organized sports as avenues to enhance physical skills such as running endurance
and motor skills.

“umm my football team, my basketball team and my baseball team….. well my football
team helps me so I can run better and my basket ball team so I can uhh shoot better and
my baseball team helps me so I can swing better and can catch better [A002, Male].”
Participant E1019, reported his team as a source of lifestyle information: “oh yeah umm my team
and I play all day, always,[and they] always say like don’t eat so you can play,.. so you can be
active and stuff [E1019, Male].”

Although his interpretation of the information was not factual, the message of not eating right
before engaging in vigorous activity was garnered either through coaches or his team peers.
Participant E020 participated in ballet and received information about the importance of building
muscle, for enhancing her performance as a dancer.

“umm well I go to I don’t really know any places but I go to ballet and they, they help me
shape my muscles and like be a better dancer…[E1020]”

4.4.1.6 Community Settings

The church was interestingly also listed as a source of information about food and health.

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“oh I guess I do that church thing we do in summer and we talk about food and there’s
like healthy food and stuff like that ….[E1015].”

Participant E1006, acknowledged the Detroit Eastern Market as a place where she learned about
food and health. She described her experience at the Eastern Market as an opportunity to taste,
try unfamiliar foods, and not be afraid. She also described the Eastern Market as an environment
where “junk food’ is limited or not available. The Eastern Market is a place that she and her
family have attended for several years.

“ Oh, that’s easy. In Detroit, at this downtown place, I don’t know what it’s called- East
Market, yeah East Market, and it’s real nice too, ‘cause it’s like they got, they don’t sell
no junk food or nothing, besides these honey sticks, but they’re not junk to be honest, and
it’s like they got, they got a lot of fruit, vegetables, and that, and they give you samples,
and it’s like when I first went there, for my first time we tried, I was like three years old,
and we still go, but my mom bribes me to eat this, um, I eat it with salad, but the way they
put it, they have a lot of pepper and all that on it, but they said it was still healthy, and
she begged me to eat but I say I didn’t cause they cooked it, then I ran, but she had to
catch me. And then I got it, I tried and it was very good, and we just always go there and
they always have samples and stuff. Like, it was good. It was a pineapple, and I don’t
know, it was a different color inside, which I thought would be very disgusting, but it was
good…… And I can try different foods without being scared [E006]….”
4.4.1.7 PE-Nut Program
Messages from PE-Nut centered primarily on healthy eating and physical activity. This was
directly evident in the response from almost all (n=26) of the children.

“Mmm, a lot of, healthy foods on[and], how to live- how to live healthy [A001, Male].”

Participant responded,
“uhhh I learned how to be more healthy, and how to eat better…[A002]”

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“..to be healthy and exercise.[E1004]”
“because they encourage you to eat healthy and not eat unhealthy, so basically, eat
healthy more than you do unhealthy and work out and stay fit [E1019,Male]”

It is also important to note, that the children perceived the messages obtained from PE-Nut as
valid information. For example when one participant was asked why she thought some of the
food items she recalled were healthy, she explained that it was because the PE-Nut Educator told
her;

“ Apples, Oranges, milk, whole grain bread, whole grain rice… Because, because… (shy
and trails off)….. (Quietly) Because Ms. [PE-Nut Educator] told us that they make our
bodies stronger [E005, Female].”
Among the concepts learned, were the importance of “coloring your plate.” having a variety of
foods from all food groups, consuming discretionary calories in moderation and the importance
of whole grains as expressed by participant A004 as concepts learned through the PE-Nut
educator. They also expressed an interest in continuity of the PE-Nut education, evident in the
following quote.

“Well, I learned about the grains and not eating the unhealthy foods. And that uh and
that you can eat unhealthy foods but it’s like eat it once a day. .. Well she [PE-Nut
Educator] taught us about the pyramid, but I haven’t seen her, ah, in a while so I’m
forgetting about the pyramid…. She taught me, to color your plate I do that a lot.

Other students took away from PE-Nut that you should eat healthy as well as exercise.
Participant A003 also introduced the concept of reading ingredient labels and discerning the
contents of the food to determine whether they are healthy.

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“Um that you should eat healthy, and move around a lot, and you should choose like the
right things to eat and you should always look on the pack of ingredients and see if it’s
healthy [A003, Male].”

For some students, the message processed from PE-Nut was to restrict certain foods and
consume others in moderation. For example, participant A006, perceived ham as a food item he
should not consume and that oil should be consumed in moderation,

“…and she tells you[that you] can’t eat too much meat, like umm, she tells us you can’t,
you can’t have ham, like eat the ham, [you can have]some oil but not too much oil in
your food.”

It also appeared as though the perceived reason why children believed that certain foods and
macronutrients should be consumed in moderation was for the purpose of reducing weight gain;
and that weight status was equivalent to good or ideal health. In this respect, food items
characterized as greasy were perceived as needing to be consumed in moderation.

“I learned that you shouldn’t eat greasy food all the time. We should eat good food for
you or like we would gain fat [E1016, Female].”
“That you’re supposed to eat healthy and not junk food all day...Like you can eat it once
in a while but not a lot [E1008].”
“Um, that you should make healthy food choices all the time and it’s okay to only
sometimes eat unhealthy things, but you should stick to eating healthy [E1009, Female].”

A reoccurring health concern among children, was developing diabetes, which is particularly
high among minority groups,

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“Um, that you should eat healthy and not eat fattening food, cause you can get like,
diabetes from eating fattening food, and, that’s pretty much it [E1003, Male].”
“Oh, from the PE-Nut lady? Oh I learned a lot. I learned lots of things from 1st grade all
the way to 5th. So, one I learned that uh, that everything that has a lot of grease gets you
fat and unhealthy. And if you eat a lot of butter, it actually uh it actually messes up your
heart. And if you have too much salt, it goes as well [E1007, Male].”
“Umm I learned that we can, like every time we eat, we can, we can have little sweets
now and then. But not as much umm; or we could gain weight if we have a lot of sugar or
a lot of unhealthy things. And umm, umm you can always try new like; I never tried
guacamole before but I tried it with PE-Nut, and it was actually good. So you can try new
things and see if you like them [E1020, Male].”
Some children used the expression “good food” and “bad food” while explaining what they
learned from PE-Nut. This was a concern because characterization of foods in such a manner is
discouraged because it may promote food aversions and depending on food availability.

“I learned that don’t eat bad foods, that uhh eat healthy food because it’ll give you more
strengths, and allow you growing up, you can get taller [A007,Male].”

Children also perceived that certain foods give your certain attributes and provide health
benefits, in their interpretation of messages from PE-Nut.

“Like, um what foods are good for you and what foods are not. And everything.…. Tells
us like if you drink milk or something it will make your bones stronger and everything
…… she tells us what foods will do, will help your body and stuff and everything
[E1003]”
“that if you eat healthier you’ll get stronger, and if you eat healthier you be healthier
[E1017, Male].

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Despite the fact that the children associated certain chronic diseases with poor diet quality, it was
clear that there was some misunderstanding of how such foods contributed to diet-related comorbidities such as cancer and heart disease (see E1010 response below). However, it appeared
overall that children learned, that if you eat healthy and exercise, you will have fewer health
problems,

“that the more healthy choices you make, the more you can get active, get out and play
and the more you can get your body fit. And your heart- your blood can go through/flow
smoothly and you won’t have heart problems like cancer, and you could um…they help
you enough to live longer [E1010, Male].”
“ ….she tells like [you] what you should eat that’s healthy, and what you need, that’s one
thing… how you can eat and make, make your heart better [E1013, Male]”

The concept that healthy foods can be eaten in excess, and you can still remain in shape was a
concept one student seemed to enjoy and take away from PE-Nut.

“ I learned that you can eat all kind of foods any kind of food everything like healthy a
whole bunch of healthy food but you can still be fit [E1013].”
The use of “Fit Bits” short nutrition messages provided by the PE-Nut program was specifically
identified, as a source of information delivered by school faculty and staff,

“Mrs. [Name], the lady something like the PE-Nut lady she gives us PE-Nut bits every
day. But in the beginning we never listened to them but when the PE-Nut lady started
coming, we always listen to them now [E1006].”

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4.4.1.8 Physical Education
Physical educators were also deemed as sources of information providing guidance and advice
about healthy eating and physical activity. Children were asked about the most important lesson
learned in physical education. Their responses ranged from describing certain foods which
should be avoided, to concepts regarding teamwork. Among the food items that were specifically
mentioned were candy or “junk food”, as well as physical activity;

“oh! Not to eat, not to eat that much junky, junk food and don’t just sit there while some,
other people [are] exercising. They’ll just stand there and watch everybody; ‘cuz you
really aren’t getting stronger or you’re not getting enough energy [E017].”

The majority of the (n=15) children indicated that physical education classes promoted physical
activity. In addition, they received advice regarding how many hours should be spent engaging in
screen time activities.

“Um, gym teacher tells me that he wants us to run around a lot and be active, not sit on
the couch and watch TV or play games and stuff. And, she says that, that what you eat is
what you made out of [E1003].”
“it tell me like eat right and you get in the food groups like the pyramid and thing and
like you should like watch TV for only like an hour or like the computer for hour a day
you should always get active [E1019].”
“Um, PE, gym. He talks a lot about food and we run around a lot and he tells us not to
give up because if you do you’re not gonna grow anymore like you’re not gonna be better
at it, get better at it [A003]”

Participant E1019 reported that the most important lesson he learned in physical education was
to stay fit and exercise and not to become overweight or obese,

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“stay fit, and don’t, don’t grow up and be a big person [E1019].”

Some messages delivered to children did employ scare tactics, which seemed to generate a
shock factor;

“Oh when I was in gym, I was watching this movie and it was about how this guy, he was
eating lots of hamburgers and he got fat so he had to go to the uh, doctors. Then I uh uh,
I uh our gym teacher told us [to] run 10 laps and we usually play lots of games in gym
[E1007]…”
4.4.1.9 Peers
Peers are important sources of information including topics on health and food. Despite the fact
that the messages were inaccurate, and potentially had a negative connotation, children still
appeared to place some value on the messages from friends

“Sometimes, I don’t bring anything [break for snack at school]. But if it is to bring
something, Hot Fries and I learned from my friend. I don’t know but I got paranoid
again. She said if you eat hot fries every day you will burn holes in your stomach to make
it more fattening [E1014].”
“They teach me not to eat fast food and to always eat good food or you like you will start
to get fatter and fatter and won’t be able to get friends [E1016].”
Children also provided strong opinions about what made their peers “healthy” versus
“unhealthy” based on the items chosen during lunch and snack time

“Not to eat candy, because not all the time because it’s bad for you. And still talking
about people, people that’s not healthy the ah chips, sodas, doesn’t bring healthy lunch.
And lunchables, one person in my class brings lunchables to school [umhum] and he
always giving it away so he could get healthy foods at lunch [A004].”

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4.4.1.10 Additional Sources
Additional sources mentioned where information was gathered about health, healthy eating and
physical activity were Social Workers, Guidance Counselors and Fitness Centers (Gym).

“Yes there was Miss [School Counselor], this is where we watch things about bullying
and stuff and how healthy and being healthy is important [E1018].”

4.4.2 Internal Conflicts
The theme of internal conflicts emerged, when it became evident that certain children were
struggling with their desire to eat healthy and lead a healthy lifestyle as well as resist the desires
to consume foods that they identified as unhealthy.

“I think its [eat healthy] easy but hard cause like some days I like to eat healthy food all
the time, some days I don’t really like to eat healthy [E1005, Female].”
“Yeah it’s real bad because yeah I think it’s unhealthy because when it comes to junk
food, I just love eating so I just get a lot of it…..well I don’t want to make changes but I
have to, ‘cause I’m not trying to be big when I get older [E1007,Male].”
“And it’s kinda hard to choose between foods that might have healthy stuff in it and that
might not [E1010, Male].”
“ [pause] hmmm… I don’t know. Kind of in the middle….Cause, I feel like, eating, like,
cookies and all but my momma only says you can eat that at least once a day….. Cause I
still beg for junk food, but she [Mother] end up saying no, then I just get a apple or
something and go upstairs. Cause I kind of still l like junk food, but it’s 50-50. I still like
vegetables and all, but I still like junk food [E1006, Female].”

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4.4.3 Fear, Anxiety, Concerns
The theme of Fear, Anxiety, and Concern was exhibited around messages about health and
consequences. The key manifestation seemed to be body image and weight fixation for some.
4.4.3.1 Body Image
It was apparent there was a fixation on weight among the children who participated in the study.
Some students reported restricting food intake in order to maintain their weight. They were also
motivated to engage in physical activity to control weight.

“ Well one thing as long as I eat like very little, very little food I can at least like play
outside and when I play outside I at least try to lose all bad and all and then pretty much,
I’m pretty much fine really!... ummm well that for me, I don’t know, just tired![E1022,
Male].”
“ummm so I don’t get chubby [E1018, Female],”
“I play outside, I ride my bike, I walk my dog, play at the park. Mostly outside since I
wanna lose weight… It seems like people can do more things if you’re not carrying a lot
of weight on you [E1014, Female].”

All the children were ultimately concerned about being overweight, and recognized that food
played an important role. Most were motivated to eat healthy and be physically active (or eat less
n=1) for fear of becoming overweight or obese.

“Well, their good [school meals]. That’s why I, they helped me loose weight and I go
home I weigh 80 something ah I just don’t want to be like that, so that’s why I’m trying to
get rid of it. My fat that I already have and replace it with healthy, well replace it. And I
don’t want to be fat no more [A004, Male].”
“Mmm, I’ll say um, uh, well I think like I love corn and I like I love a lot of um vegetables
and um the things that’s like well I love to eat fish because they say fish is like healthy for
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you…And if you’re on a diet, yea so I will I will love like to eat fish a lot. And … I think
they are healthy because like um like they have like they have a lot of calories in it…Well
not a lot of calories, because it has less calories [E1013, Male].”
“I don’t know, well I don’t want to be big and stuff [Motivation to exercise] [A003,
Male].”
“Well, I don’t want to eat too much fruits because I’ll get ,get fat again I, I like the, I
just, like it the way they give me it, because its helping me, it really helps a lot…. Fruit
Fruits, vegetables!, yeah vegetables! help me..[A004, Male].”

Children however, also viewed excess weight as a barrier to being physical active. There was
also a heightened concern about the health consequences of overweight and a poor diet.

“Um it’s good to eat healthy because like you could actually run around and be an
athlete or something cause if you’re fat you couldn’t really do nuthin. But you could get
off the weight by eating and running [E1008, Male].”
“Um I think that I’ll probably do the same thing because I don’t wanna be big and fat
and I don’t wanna be obese and I don’t wanna have heart, diabetes and stuff like that and
heart disease. So that’s why…. That’s why that I’ll eat the same way that I’m eating now
[A003, Male].”
“Well usually I feel that if I don’t get out too much, that I might not live longer--a longer
life and that I won’t be able to lose some weight. So I run outside and start playing
[E1010, Male].”

4.4.4 Family Ecology
4.4.4.1 Parental Positive Reinforcing Behaviors
4.4.4.1.1 MyPyramid/ MyPlate Recommendations
We asked parents to share information regarding MyPyramid/MyPlate USDA recommendations.
Most parents were unaware of the MyPyramid recommendations but several (n=9) had an idea of

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the food groups and concept of MyPlate. However, we did notice a difference between parents
who had an overall balanced understanding of the USDA Recommendation and those who did
not. Parents, who had a more balanced understanding, displayed more confidence as evident in
the following responses by E019.

“ I do. I don’t know much, or exactly what it is. But your plate should be mostly fruits
and vegetables, and a sufficient amount of protein, and then um, small portion of carbs
and should be no sweets, but low amount of sweets. And for a dinner plate should not
have fruits but that whole pyramid thing… Hm, I actually think it’s pretty easy but I do
think you have to do research as far as like, you’re asking serving sizes and I don’t know.
And I consider myself pretty healthy; I try to make sure we get a well balanced diet and
you know do exercise and stuff. But I do stuff that I have to spend time on and make it a
lifestyle- better lifestyle. And even without knowing the serving sizes, I can still
incorporate them in my diet; and I’m sure- I’m more than, 100% sure- that we get
enough and on daily basis. So I do think it’s easy to do, I just think I should probably
research what the actual serving suggestions are [ E1019, Female].”

Parents were partly able to describe the serving sizes, but it was clear that this was an area in
which further clarification and nutrition education was needed.
“Dairy, fruits & vegetables. And I don’t know exactly they should eat according to each
category every day [E009].”

“I don’t know exactly. But she said dairy, fruits, vegetables, and protein, the carbs, and
of course the fats. I want to say for protein, 5-6 servings a day..? and then the fruits and
vegetables: 2 to 3, and I’m not sure about the carbs and all that other stuff [E019].”

Parents also expressed that they believed that they had control concerning their child’s dietary
intake. This is a positive position to hold concerning the home food environment. By taking
control, parents likely assume responsibility for the foods they bring into the home, as well as for
their children’s intake.
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“I think parents have more control than we realize, because we’re the ones that bring the food
into the home. The children don’t work, they don’t get the groceries [E009].”

4.4.4.1.2 Obesity Concerns
Participant E019 also believed that the trends that we see in childhood obesity, did have a lot to
do with parenting. However, her approach, was slightly different. She actively engaged in
physical activity, with her family, and self-reflected on her dietary habits to see if there were
areas in which she could improve. She incorporated a menu, which would allow her to plan out
meals in advance, to cut, cost and reduce the amount of convenience food shopping on days
when there was a high volume of activities.
“I think it comes from home, is what I think. I think it’s a lot of lack of um, lack of
knowledge. Parents don’t know and so therefore their kids don’t know, and before you
know it you’re looking at an obese kid. ….Yea and just um as I’ve gotten older I’ve
noticed that you know my taste has changed and I too am on that bandwagon of wanting
to you know be healthier. And just looking at my own diet and you know just seeing
where I can make changes. I think I’ve been a I grew up with a good base for being pretty
healthy, but I still you know had changes that I needed to make too so it just kinda made
me look at my own eating habits and just to see what I can do better. And actually, since
the beginning of the year, I started doing a menu for at home. And I have it up on a
board, one of the dry erase boards. And so I do a weekly menu so I can kind of think out
you know what- what’s gonna be a healthy meal, for Monday, for Tuesday you know for
the whole week, and then that helps me grocery shop. And then the kids know what to you
know what to do. And sometimes when I make small tweaks to the menu then they’re like
“well what happened to that?” “That was supposed to be for today.” But sometimes I
have to make a change because of whatever reason but um but yea, yea “E019.”

4.4.4.1.3 Personal Motivation
Parents who tended to reinforce positive balanced understanding were self-motivated to lose
weight and follow a healthy lifestyle at home.

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“What’s something that helps you- helps me? My own self, I guess [E019], “my
children….they keep me busy[ E009].”

4.4.4.1.4 Parent Physical Activity Messages
Parents who actively engaged in routine physical activity, were motivated by their personal goals
to encourage the family to follow their example.
“uh that it’s good for you. You start with what you can do, your personal goal, and you
work at it. It’s hard but it wouldn’t be worth it if it were easy [E019].”

4.4.4.2 Parental Behaviors that Potentially Reinforce Misconceptions
4.4.4.2.1 MyPyramid/MyPlate USDA Recommendations
We asked parents to share information regarding the MyPyramid recommendations. As noted
earlier all parents struggled to recall the recommendations and serving sizes for their children
according to the USDA MyPyramid/MyPlate. We did notice a difference between parents who
had a basic understanding of the USDA recommendations and those who did not. It was also
apparent that fundamentally parents, who did not display a balanced understanding were wary
(or afraid) of certain foods, because they linked these foods to certain health complications.
“Um I know I’ve seen it. (Child’s name) brought some information home from school,
and we looked through it. It says you’re supposed to have more fruits & vegetables on the
plate, versus less proteins. Carbohydrates definitely aren’t good [E009].”

When asked why she felt this way she responded that,
“you need them but they do, they can..too many carbohydrates can cause you to have
problems with your health. Along with diabetes, and things like that [E009].”

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4.4.4.2.2 Convenience of Fast Food
For the majority of the parents, meals (especially fast foods) were eaten away from home to
accommodate busy work and child activity schedules, for convenience, or as a part of family
rituals, such as family night. When asked why foods were eaten away from home, participant
E010 mentioned convenience,
“Convenience. I’m not gonna lie- [E1010].”
Family socializing was also a reason for eating convenience foods,
“Sometimes family night. I do Pizza Hut family night once a week. And like she said
convenience. McDonalds is closer why not [E006]?”

4.4.4.2.3 Outlook on Food and Health
Parent’s outlook on life determined likelihood of engaging in healthy behaviors. The media had
interesting mixed influences on parents. It was sometimes not clear if sufficient information was
given or if the sources was misinterpreted. Some specific sources of information in this respect
were books and day time television shows, such as Dr. Oz and the Doctors.
“I heard suff on TV like Delilah, you know Delilah there on channel 2, about eating
healthy but I’ve never you know actually looked into it. I’m not a real big health fanatic. I
kind of live day to day and I figure that what happens happens. I don’t think about what I
eat, I’m not gonna lie. Cause you only got one life to live, as long as I’m not (indulgent?)
and being greedy I live, I eat. Same with my kids, I don’t restrict them [E010].”

“No”. “I read in a book that we shouldn’t eat a lot of red meat due to issues related to
digestion, and that’s a big part of fatty intake. We should have a lot more dark green
vegetables, dark green and orange vegetables and fruits to balance out a healthy
lifestyle….. [E010].”

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4.4.4.2.4 Views Regarding Childhood Obesity
Parents were asked to share their views on the issues surrounding the childhood obesity crisis.
During the focus group, two parents discussed how they addressed weight issues with their
children within their own households. Parent E006, addressed the issue by changing the
household environment, but also discussed her concern with her child in a more direct manner,
not taking into account personal feelings of the child. Participant E010, took a more indirect
approach with her child, in an attempt to avoid adverse feelings, which she believed could arise
if not handled sensitively. Their fundamental belief was that way too many children were “fat”,
and lack of supervision or negligence on the parent’s part was a key factor to childhood obesity.
“Parents [are] not paying attention to what they kids eat. I don’t think there’s any excuse
for any child to be overweight because I feel like parents should just supervise what their
kids eat. Cause like with [Daughters Name] when I realized my baby was wearing a 5-6
Juniors- not 16’s no more, I immediately changed everything in the household, … as far
as eating and I talked to [Daughters Name] and I was like look, you don’t want to be 12
years old looking like Precious. …I’m for real though you gotta talk to your kid. Parents
these days they don’t. I feel like if you’re not paying attention to your child and you know
what another thing is too? If the parent don’t care about their weight, some parents
might not care cause I got a god sister and a god mother and the mama is super super fat
and [it’s] ridiculous and so is the daughter and I don’t think she care cause they go and
just eat goodies together. … I said with my daughter, I sat down and I talked to her I
explained to her, some of the stuff might of hurt. Cause I know it did hurt her when I told
her do you want to go to prom and look like Precious? …. But I don’t care. Cause I
rather break her down on the inside and make her drop her weight now and think about
what she eat[s] at an early age instead of just and be 12 years old and it be harder for
her to lose it. … [E006].”

The direct approach, was viewed as a little harsh for the other parent, who responded
“You don’t want to sit there and get your kids so upset that they feel like they’re being
cut down though, you know what I’m saying?.... Like cause I do say stuff to [Son’s Name]
like dude you need to slow down cause you’re getting fat. And then I look at it and I’m
like ok you know I’m not trying to make you go throw up or be bulimic anemic but you
need to really slow down. And I do the same thing with [Child’s Name] and [Child’s
Name]do you really need seconds? I mean look were trying to eat healthy here do you
really need seconds? You can have some jello before bed or something. [E1010]”

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“You don’t want to be too mean though [E010, Female]”

“Yea but I feel like with today’s society and with today’s kids it works better that way.
Because I’d rather herself [be] conscience think about what I said 3 days later whether it
was mean or not instead of do it. I don’t care if I did say you was gonna look like
Precious. Every time you sit in front of that plate you’re goona think ‘damn. I might get
fat like Precious.’ Oh well I bet you gonna push the plate away [E006, Female].”
“Or you’re gonna eat it and you just won’t care [E010, Female].”
“Yea and that’s when you get to the point where you know your child needs help and that
means nothing you’re doing is working [E006, Female].”

“Cause I always tell my daughter do you want to get big like me and not be able to lose it
[E010, Female]?”

Participant E006, believed that her daughter, was able to handle such criticism as opposed to
other children who may need a more sensitive approach; that it depends on the child and the
family.
“You know some people- some kids like, like I said, I guess this will fall back to what I
said before, like I do say rude stuff to my daughter to make her think about it later but not
all kids can take that some. Kids their parents might say that to them and they might want
to go kill theyself or something so to each his own and it all depends on the kid and the
family [E006]”

Another distinction between the two family ecologies (families that reinforce positive
understanding and families that potentially elicit negative behaviors in children) was the source
of motivation. Parents were motivated to make healthy food choices in their home environments
because of their children’s weight status (overweight) or because they themselves were

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overweight or obese. This is likely why they had such strong emotions towards the children’s
weight status.

“My kids already being overweight. Me being overweight, and I’m trying to lose weight
and I want my kids to lose weight [E010].”

“Same thing me being overweight and just wanting to cook healthy and wanting to be
healthy so yea that’s it [E006].”

4.4.4.2.5 What Parents tell Their Children about being Physically Active
Parents’ response to talking to their children about physical activity was also interesting; one
parent took a more direct approach, telling her child that they should engage in physical activity
so that she could lose weight. Although similar views were held by parents behind motivating
their child to exercise, the parent’s did not reach a consensus on the approach. Messages
portrayed to their children included:
“Need to lose weight, work out [E010]”
“Yea. You need to lose weight work out and in order to lose weight you got to exerciseand eat healthy [E006].”
Parent E006, also mentioned that her messages regarding the need to engage in physical activity
differed between her two children in the same household, based on child’s weight status.
“I don’t say it to my skinny one I just say it to my medium built one because I want her to
lose weight. Yea the skinny one I don’t bother, matter of fact she needs to eat more cause
she’s bony [E006].”

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Parents who were exhibiting parental behaviors that might negatively reinforce child behaviors
tended to be motivated to engage in physical activity for fear of dying. Despite this being a
motivation to work out, E006 viewed family activity as a time for family fun, and did not view it
as exercise.

“Life. Like what she said I don’t want to die at the age of 40…. I want to live to be long
and I don’t want to have diabetes high blood pressure any of them things that be killing
people … Family time. It’s things that I don’t even consider it to be exercise we just get
up and do stuff. Yea, I don’t base stuff on exercising” [E006].”

4.4.5 Child Understanding
Child understanding of food and nutrition emerged as a grounded theory theme as we evaluated
the children’s views on their food environments, personal eating habits, the potential to change
their eating habits, level of understanding regarding healthy eating and physical activity, personal
views on school meals and snacks, understanding of weight, and the relationship between weight
and foods. We found that children responded in a manner that exhibited personal reflection and
reasoning.
4.4.5.1 MyPyramid/MyPlate
In the assessment of knowledge concerning MyPyramid/MyPlate, most children a demonstrated
basic understanding of MyPyramid or MyPlate recommendations. This was evident in the
following quote,
“Um, I know you should have vegetables, dairy, um, protein, and um, [pause] I forgot the
other one but you should have it on your plate every time you eat something. …. Um, I
think half the plate of fruits and vegetables, a cup of dairy, and then oh um, ¼ of protein
[E1009, Female].”

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The children who demonstrated a sound understanding of MyPyramid/MyPlate
recommendations provided either an overall objective of the recommendations or a description
of the food groups,

“yes, the MyPlate pyramid. I mean the MyPyramid- is like a pyramid that tells all about
healthy food choices. And I’ll give you some examples. Like the fruits, vegetables, grains,
meats, and dairy. And they have specific stuff that go in each category. And there’s the
sometimes category at the bottom, that let’s you know sometimes you can have it,
sometimes you can’t. And depending on the category, you should have at least 1 thing
from each category [E1010, Male].”
“Um I think that’s what you should do because um they give you ideas how you can be
more healthier and that you should exercise more like they have it on the pyramid. They
have a lot of comments they say that you should exercise more [A003, Male].”

A notable concept, aside from mentioning the food groups, was coloring your plate.
“ (quickly) eat the right foods….Color your plate…. Eating colorful things, like
vegetables [A005, Female].

4.4.5.2 Personal Eating Habits
Personal eating habits were assessed to acquire, information concerning how the individual felt
about personal eating habits. A majority of the students (n=15) felt that their eating habits were
acceptable, while others understood that improvements could be made but were content without
making changes.

“…I eat a lot of fruits and vegetables and I always have every food from the food groups
[A003, Male],”
“yeah yeah most, most of the time [eating habits healthy]….. hmph fruits, vegetables,
pasta, spaghetti, umm and some other stuff I don’t really know what to call them my mom
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cooks some stuff I don’t really know but it’s good [provided examples]….. I always eat
healthy [E1019, Male]”

When probed on how to maintain a healthy diet participant A002 responded as follows,

“Just pay attention….don’t uhh don’t get the greasy stuff you don’t want to get to your
plate just get fruits and some stuff you want. …. [pauses] I really don’t know, ummm try
not to, uh don’t pay attention to the other stuff just eat what you have [A002, Male].”

The remaining students (n=7) were well aware of the changes that could be made to improve
their personal eating habits, but were content with not making change.
“ I eat a lot of junk food mostly.. and then like if I, well, at home I usually eat a lot of
apples and celery is really all I eat for fruits and vegetables and the rest I just eat junk
food … my junk food is unhealthy… [Views on overall diet] mostly unhealthy.”
“hmm hmph.. I don’t like it… no…: yeah [I would be able to make changes] but I
don’t… I can but I don’t want to because I don’t want to[E017, Male]”

The children were asked to explain if they felt there was any relationship to their current diet
and what will happen as they age. Responses were mixed, but essentially suggested that future
circumstances may change, and some did not see a relationship between current eating behaviors
and health.

“Well, when I eat now it’s good, when I get older. I don’t know if I’m going to eat the
same things [A004, Male],”
“umm no because I could’ve change my eating habits when I’m older than when I’m
younger [E1020, Female].”

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“no….because like you could, you could change while you, like say you were eating fast
food and umm like you stopped eating fast food and start eating healthy and then you’ll
lose weight and stuff like that [E006, Female].

4.4.5.3 Relationship between the Foods and Weight.
The children were asked if they believed there was a relationship between the foods consumed
and weight. The majority of the students (n=17) agreed. They were then asked to explain why
they thought there was a relationship between the foods consumed and weight. Some students
expressed a more balanced understanding that certain foods if eaten in excess could result in
weight gain (n=10). Sample responses were;
“That um, it, if you eat healthier foods it can help maintain your weight and the more
greasy foods you eat, it makes you overweight and helps you gain weight [E1009,
Female]”
“Like, if you don’t eat healthy and you just eat non-healthy foods and don’t exercise
you’ll get fat. But if you exercise and eat pears and apples and snack and stuff and have
like a small piece of chicken and get active you can get healthy [E1018, Female].”
4.4.5.4 Physical Activity Habits.
The participants were also asked to discuss their current physical activity habits. Some students
(n=11) expressed that they were confident with the amount of physical activity they engaged in,
on a regular basis. Others indicated that this was something they needed to improve.
“I need to get out more, outside more… Cause um I spend a lot of time in front of the
TV.”
For some students (n=5), the amount of physical activity they should engage in daily was
unclear.

“well one, at least an hour I guess[be physically active] [E1019, Male]”
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4.4.5.5 Views on School Lunch
Children were asked to explain their views on school lunch, and whether or not they believed it
was healthier to bring lunch from home or eat the lunch provided by the school. The responses
varied,
“I think its’ healthier to eat lunch at school ‘cuz mostly everything on the food menu is
whole grain … and whole grain and healthy for you [A001, Male].”
Participant E018, relied on school meals due to financial constraints at home, but was of the
opinion that schools should offer both healthy and “non-healthy snacks.”

“I think there should be more healthier snack choices at school but I also like to eat chips
once in a while you know. I think they should have healthy and non-healthy snacks at the
snack cart so they have two always you can have a healthy snack and non healthy
snack….. umm lunch provided by the school. They can’t do stuff at my house because uhh
we’re running short on money [E1018, Female].”

4.4.5.6 Food Environment
Children who lived in environments that had limited access to grocery stores or parks were
cognitively aware of certain changes, which could be made to the environment to promote
healthy eating and physical activity. Participant E1002, for example shared his views on what
environment changes he would make.
“I would make it- I’d make sure that it’s easy to get them… Um healthy foods…. I’d go to
the grocery store. …. Ok, if I was the mayor I would put a grocery store where um
eagle’s market liquor store is [E1002, Male].”

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4.4.6 Child Misconceptions
Misconceptions emerged as a theme, because it became evident that some children were
combining error with truth. Their understanding of food (n=9), healthy eating (n=20), health
(n=11) and physical activity (n=17) was slightly skewed. Some interesting examples follow,
which included the notion that certain fruits were unhealthy and would cause weight gain.
“ Um, all the vegetables, fruits,[umhum], but not fattening fruits[umhum], and healthy
drinks [umhum], like milk and dairy products, like yogurt and..and yogurt and ..
something and oils that doesn’t including fattening and grains……I think grapes
[umhum], oranges, mango are fattening fruits, not the apple…..That’s, that’s because it
made me fat, and my mom, and I had to go to the gym with my dad to help me workout
and be skinny again [A004, Male].”

“Cause of the calories…. It has salt and stuff and olive oils and stuff and it um builds up
in molecules I think and they come together and make fat…. It makes you bigger [E1002,
Male].”
4.4.6.1 Healthy Eating and Physical Activity
Most children viewed (n= 26) eating healthy as being associated with being smart, tall, and fast,
“Hm, they are- they are strong, mmm…. smart and….They don’t get sick a lot. They
don’t get colds and stuff like that. They viewed children who were unhealthy as slow,
weak, sickly, and not as intelligent “Um, not that strong and…they get- they get sick a
lot…. and they ..well, they are lazy in class [A001, Male].”

Misconceptions were identified concerning the amount of time and types of physical activity
children should engage in (n=15).

“Hm, well, I don’t think hiking or um, walking or is good exercise ‘cuz you’re not doing
nothing much…. at least half an hour..like, 4 times[a week] [A001, Male].”

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4.4.7 Data Triangulation:
Data triangulation occurred in several ways: objective vs. qualitative, parent vs. child, child vs.
school menu. The FNPA tool, used to identify obesogenic environments, was triangulated
against the parents’ report of their home environments and the child’s current BMI percentile for
age status. Parents whose overall FNPA score fell into the at risk category tended to have
children who were overweight, and whose family ecology appeared to support a more
unbalanced view concerning health, healthy eating and physical activity reported among
children. Parents whose FNPA score fell into the acceptable category, tended to have a family
ecologies that appeared to support a more balanced view on health, healthy eating and physical
activity. The children’s account of the dietary intake was crossed checked against the items
available on the school menus. The use of this method assisted in both verifying and validating
the child’s ability to accurately recall items eaten within a 24 hour time period. Child and parent
qualitative interviews were crossed checked against one another for accounts of similar events
for example, children and parents account of family activities,
“We play on the trampoline, sometimes we play little big game of baseball [Child].”
“Like if they’re having fun they don’t even like realize that they’re getting exercise so
right now I’ve got the pool going in the back yard so they’re swimming like all day every
day and we’ve got the trampoline in the backyard so they’re either on the trampoline or
in the pool or going back and forth [Parent].”

“oh and bikes, bikes, bike sometimes… oh boy umm I tried and it was not a good sight.
So that’s something that I’ll set a goal for over the summer but I got on the bike and umm
I was clearly winded, and my legs hurt really really bad after, after going around the
block maybe like one time. That that one time [laughs] so that’s my goal ……actually get
on a bike umm but I thought since I’ve been doing elliptical thing that would be a breeze
but I guess maybe it’s a different form of yeah so… [Pause] that’s my plan to buy a bike
and still have to do that this summer [Parent].
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“When my mom was not old. Not saying she’s old she turning forty though. Umm wait
she already forty because her birthday is today. So I guess, umm when, when she was like
37 or 38 we used to ride bikes together. I think the only reason why we can’t do that any
more is because she maybe doesn’t feel like it [Child].

Similar perceptions and concerns regarding their weight.

“great I mean … mommy daughter time ...because we need to lose weight so it’s so much
better working on it together, make the effort together …….[Parent].”
“I play outside, I ride my bike, I walk my dog, play at the park. Mostly outside since I
wanna lose weight [Child].”

“My parents always said how my sister was so skinny and I was the “chunky” one; and
how she was the pretty one and I wasn’t. It started from there [Parent]”
“That’s, that’s because it made me fat, and my mom, and I had to go to the gym with my
dad to help me workout and be skinny again [ChildA004]”

Perceptions concerning healthy foods,

“I make myself drink the juice. I am not a vegetable eater because I have six children and I
don’t have time to watch what I eat. I’m always on the go so I go to the grocery store and
get the fresh juices [Parent].”
“Well, some foods make you skinny. Like protein drinks, and healthy drinks like apple
juice… [Child].”

Barriers to physical activity due to concerns regarding neighborhood safety,
“Nothing… Cause we live in the projects and it’s just a bad place [Parent].”
“Sometimes the place isn’t safe. Most of the time and there is enough area to play
[Child].”

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Triangulation of the child’s survey questionnaire across the parent’s qualitative interviews also
occurred. For example a child reported being bullied in the survey questionnaire and the parent
also discussed this event in the qualitative interview,
“[Child’s Name] is smaller than a lot children and tender hearted, So [Child’s Name] can be the
kid pick on. I think once they’ve seen him cry [other children] and everyone knows they can make
him cry . ….. I mean, he gets picked on, on the bus, he gets picked on in school, he gets picked on
a lunch, he gets picked on at recess, he gets picked on outside at my house… [Parent].”

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CHAPTER 5
DISCUSSION AND CONCLUSION
5.1 Discussion:
Diet and physical activity play a key role in weight status and overall health. In order to describe
the demographics of the 5th grade students and their primary caregivers, we evaluated their
weight status, dietary intake via the Healthy Eating Index (Weinstein, 2004), food security, and
physical activity behaviors. Childhood overweight and obesity were found to be a major health
concern among the children within this study. Fifty-nine percent of the children were identified
as either overweight or obese. Recent data for the state of Michigan, showed that 15% of youth
were overweight and 12.1% obese (YRBSS, 2011). The proportion of children who were obese
among our population was therefore higher than both the national prevalence of 18% and state
for children between the ages of 6-11 yrs. Although a small sample due to the qualitative nature
of the study and limited parent response, overweight and obesity was staggering for the adults.
Ninety percent of the adults who participated in the study were either overweight or obese, some
of which exceeded a BMI greater than 36 (BMI ranged from 22-44). Research has shown that
children who are obese in childhood and adolescence are more likely to become overweight or
obese adults (Brio, 2010; Whitaker, 1997; Sreula, 1993; Han, 2010).
We were able to identify parents (and potentially children) who are at risk for chronic diseases
such as Type 2 diabetes, cardiovascular disease and hypertension based on family history, waist
circumference and weight status. Although waist circumferences cut off points have not been
established for children, it may be plausible to assume that based on family history, dietary
intake and BMI percentile for age that these children may also be at increased risk for developing
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a chronic related disease. Therefore, our data showed that both children and adults were at risk
for developing chronic diet-related diseases (especially Type 2 Diabetes) based on their current
weight status and family history related disease.
When dietary quality was assessed, children who were obese had an average HEI score of
61.4/100, which falls into the “need to improve category” (Kennedy et al. 1995). Regardless of
weight status, children showed the need for improvement in the areas of consuming whole grains
(1.3/5), total vegetables (2.6/5), dark leafy greens (2.6/5), total fruit (3.3/5), and whole fruit
(3.1/5). The sodium intake was also relatively high (2.6/5) supporting the greater intake of “fast”
and processed foods reported within the children’s diet. This data supports findings from the
YRBSS 2011. Among adolescent youth in the state of Michigan, 36% reported eating vegetables
and 38% reported eating fruit, less than once per day (CDC, 2011); indicating that the low
consumption of fruits and vegetables among the middle to young adolescent population needs to
be addressed. This was also true for the subset of parents who showed very few inconsistencies
between their dietary quality and that of their children. Encouragement of diets high in fiber and
promotion of fresh fruits and vegetables through nutrition education is vital to ensure adequate
diet quality and reduce the risk for development of diet-related diseases. Diets high in fiber and
adequate in fruits and vegetables are key to reducing cholesterol levels, controlling blood sugar
levels and to maintaining a healthy weight (USDA, 2010).
The Family Nutrition and Physical Activity (FNPA) screener, served as an important instrument
for capturing parental practices in the home environment. Among the parents, 81% were at risk
for creating and obesogenic household environments for their children. Among the family
behaviors assessed were physical and sedentary activities such as screen time and television
monitoring, environmental support, and engagement in family activities. Seventy percent of the
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children whose parents FNPA score indicated a household environment that was at risk of being
obesogenic, had children who were identified as being overweight or obese. Therefore, as shown
in numerous studies the family home environment is an important consideration when assessing
lifestyle factors and health (Strauss & Knight 1999; Campbell et al. 2006; Campbell et al. 2007;
Larson et al. 2013; Boles et al. 2013).

Food insecurity was also an issue among children and their families. Forty-one percent of
children mentioned experiencing some degree of food insecurity and 48% of children reported
being concerned that food would run out within their households before they would be able to
purchase more. In the United States, 14% of households reported being food insecure for some
period of time over the course of the year in 2009 (Nord M, 2009). Specifically in Michigan,
21.4 % of children were living in households which reported being food insecure (Virginia
Common Wealth University Center on Human Needs, 2011). Among the avenues in which
parents and children reported dealing with issues of food security in the households were going
to relatives and receiving food and the use of food banks. In light of the current economic
situation and newly implemented government policies concerning food assistance programs such
as new policy requirements for the Supplemental Nutrition Assistance Program and a decrease in
the dollar amount of benefits received November 1, 2013 due to the end of extra benefits offered
through the stimulus package provided to participants , food insecurity could potentially be a
concern for ensuring adequate dietary quality(Nord 2013; Smith 2013; Michigan Department of
Heuman Services n.d.). It was interesting that among the 27 students who participated in the
study 25 reported eating school meals every day, (only 3 of whom were not eligible for free or
reduced price meals.) Among the eligible participants one student reported never eating school

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meals and 3 students reported eating school meals only a few times per week (once to three times
per week). Therefore, in this group of evidently food insecure students, school meals were an
important source of daily food and nutrition.
Eight percent of children were not meeting the recommendation of 60 minutes of daily physical
activity. Eight-one percent of children engaged in physical activity less than or equal to 3 times
per week for 30 minutes compared to the recommended 60 minutes of physical activity daily
(USDHHS, 2008). Within the state of Michigan, physical activity was also a concern for
children. Overall, in 2009, only 47% of youth reported engaging in physical activity for 60
minutes five or more days per week (Boinapally, 2011). Physical activity within the state of
Michigan has since increased in 2011 to 49% of youth reporting engaging in physical activity for
60 minutes five or more days per week (YRBS, 2012). Contrary to Parrish et al. (2011), peer
bullying among our subset appeared to have a minimal effect on willingness to engage in
physical activity. Only 11% of children within our study reported not wanting to engage in
physical activity because of peer bullying. However, teasing was mentioned by both the children
and parents as a barrier to engaging in physical activity. In addition, parents were unaware of the
recommended amount physical activity required for adults; their response ranged from 3-4 hours
of physical activity to 40 minutes. Only three parents were able to identify the correct amount of
daily physical activity required, two of which determined this information from reading literature
and the other through a weight management class.
While the majority of the students reported watching television for 2 hours or less (55%), 44% of
children reported engaging in 3 hours or more to television viewing. This was higher in
comparison to the 30% of Michigan youth who spent 3 or more hours watching television in the
year 2009 (Boinapally, 2011). Eleven percent of children within our study spent greater than

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5hrs playing video games in comparison to the 23% of Michigan youth who spent 3 or more
hours either on the computer or playing video games (Boinapally, 2011). Therefore screen time,
which is perceived to be a major concern by many (Wagner et al, 2012; Rey-Lopez et al.2008;),
is also notable in this vulnerable group.

The qualitative findings provided a more in-depth insight in to what children, and their primary
caregivers perceived as barriers and facilitators to healthy eating and physical activity within the
home, school and neighborhood environments. The major contributors to healthy eating and
physical activity within the home were positive family support and interestingly use of media.
Family encouragement and involvement in healthy eating and physical activity behaviors was
deemed especially important. Similar findings were evident in a study by O’dea (2003), where
children also acknowledged family support and engagement in physical activity as a contributor
to healthy lifestyle behavior. Family involvement, engagement and support is key to both a
positive outlook on healthy eating and physical activity, as well as to ensure adequate food intake
among adolescents. Fisher et al. (2002) found parents fruit and vegetable intake to be a predictor
of children’s dietary intake. This implied that parents who eat the recommended amounts of
fruits and vegetables will also have children who will meet the requirements.
It was interesting to note that while we typically view television as a potentially negative
influence (Marshall ,2004; Eisenmann , 2002), our findings showed that children reported the
television and interactive video games (exergames) as facilitators to healthy eating and physical
activity. Recently, more child friendly networks have begun to embed nutrition and physical
activity messages into commercials and programming. Linebarger et al. 2008 displayed
embedded nutrition messages within televised public service announcements and found that
children were able to apply the nutrition concepts within a natural setting. The use of video
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games, more specifically those which promote physical activity, as a facilitator is a fairly new
concept emerging over the past several years. Exergames have been linked to improvements in
self-confidence and esteem, by reducing social anxiety that may arise from engaging in physical
activity with large groups of people (Song, 2011). We found that some students enjoyed certain
activities such as dance, however, avoided doing so in the presence of peers; but reported
spending at least an hour playing the exergame “Just Dance”. The use of exergames to increase
self-confidence in engaging in physical activity is therefore a novel idea worth exploring where
warranted. Among the participants in this study, some reported peer bullying and exclusion from
group physical activities. In addition, several students reported purposefully not bringing proper
gym attire, and sitting out during physical activity. If children could improve their selfconfidence and motor skill development through exergames within a safe environment at home,
they may also be able to translate this new self-confidence into a larger social setting among their
peers. Exergames are assumed to increase skill and physical fitness overtime (Warburton, 2007).
The child’s sense of achievement may serve as motivation and encouragement to continue.
Sixteen of the children who reported playing video games (not necessarily exergames) were
either overweight or obese. Therefore, exergames could be a “healthier” alternative to more
sedentary screen activities. Parents also viewed family time spent playing exergames as
facilitators to physical activity. Parents reported that by allowing children to engage in physical
activity through the use of exergames, the safety of their children within their neighborhood
environment was not compromised. This is especially important to mention given the reports by
both children and parents that physical activity was a problem because of unsafe neighborhood
environments.

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A key facilitator in the home environment, to healthy eating mentioned by parents, was limiting
the amount of “junk food” in the home. Numerous studies have indicated that improving the
home environment will promote healthy eating (Anderson SE et al. 2010; Hanson NI et al. 2004;
Haire-Joshu et al. 2008). Messages from PE-Nut also contributed as facilitators within the home
environment as specifically mentioned by both children and parents.
Physical activity barriers identified within the home environment by parents were time, lack of
interest in physical activity, and cost associated with paying for gym memberships and physical
activity programs for their children. Similar reporting’s of barriers to physical activity were
expressed by children such as parents being tired and their parents going to work. Media, in
form of television, was also viewed as a barrier to physical activity among children.
The barriers found in the home environment included established family practices, which
sometimes included the use of a non-factual information as scare tactic to increase intake of
fruits and vegetables, negative comments regarding weight status and body image, use of food as
a reward, family gatherings, and insufficient monetary resources to purchase fruits and
vegetables. These are all serious considerations for intervention in this or similar communities.
Participant E006 for example possessed an authoritarian parenting style who was very proactive
in changing the home environment. However, the authoritarian parenting style has shown some
adverse effects especially in relation to healthy eating, physical activity and the need to control
weight status (Enten et al. 2009; Darling et al. 1999; Golan et al. 2004). Children who have had
authoritarian parents have been shown to develop disordered eating behaviors (Kluck,
2008;Golan et al. 2004). The barriers to healthy eating expressed among parents were family
members disinterest in healthy eating, finances and the cost of fruits and vegetables, as well as
conflicts with family meals due to work related commitments. In terms of weight, most children
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felt that they were of normal weight status. It is evident through, children were struggling with
their weight perceptions. Thirteen children felt that they needed to lose weight; of which 3 were
of normal BMI percentile. They indicated that they felt that their weight was too high in
comparison to their peers. In terms of perception by weight status, 37% of the children identified
as overweight or obese partly agreed with the statement exercising and playing can reduce future
health problem. Sixty-two percent partly believed that being overweight put them at risk for
health problems like cancer. Children who were overweight or obese tended therefore to exhibit
self-denial, regarding how their current weight could impact their own health, despite verbally
expressing how poor dietary habits and inadequate physical activity related to health. These
finding are not unusual, especially since the literature supports a parental lack of sensitivity to
accurately perceiving children’s weight status (overweight or obese) and their associated health
risk complications. A study conducted by Hyman et al. 2000, among African American and their
child weight perceptions showed that among the identified 57% obese and 12% super-obese
children identified only 44% of the care givers perceived their children’s weight to be a potential
health problem. Hyman et al 200 associated the minimization of child health risk to cultural
differences, knowledge deficient concern the future health implications of childhood obesity, and
optimism bias regarding personal health risk perceptions (Young-Hyman et al. 2000). Etelson et
al. 2003 found similar finding among the parents of obese children. According to Etelson et al.
2003 study, only 10.5% of parents of obese children (2/19) perceived their child’s weight
accurately compared to the 59.4% of other parents (38/64; p _ 0.001) (Etelson et al. 2003).
Among the school facilitators children found the PE-Nut program as a valid source of
information concerning healthy eating and physical activity. The PE-Nut program was
instrumental in children trying new foods, learning both MyPyramid and MyPlate

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recommendations and sharing this information with family, which was mentioned as also
encouraging healthful eating in certain households. Teacher modeling was also found as
contributor to healthful eating. One participant specifically mentioned that by seeing a particular
teacher practice healthy eating, it made her feel as though eating healthy everyday could be easy.
Subliminal messages, as also shown by Nairn & Fine (2008), Townsend et al. (2011) and
Crawford et al. (2010), within the environment (having those around you eat healthy) promoting
healthy eating and physical activity were positive influences and served as personal motivators.
In the schools, where the salad bar was available, children found that to be a facilitator to healthy
eating. Children enjoyed having the option to choose fruits and vegetables during lunch.
Availability of fresh fruits and vegetables was a contributor in both schools. However, children
and parents both wanted to see meals prepared onsite and have more fruits and vegetables
offered during school meals. School meals were prepared at the local high school and transported
to the elementary school for dispersal during lunch. Parents found the school offering of whole
wheat products and school breakfast as facilitators to healthy eating for their children. Children
expressed events such as classroom socials as barriers to healthy eating. School meal preparation
was reported as a barrier by children. Children expressed the certain items prepared for school
lunch appeared to contain a high amount of fat and meat items not thoroughly cooked as a barrier
to eating school meals. The replacement/the alternating of physical education with art and media
classes was also mentioned as a barriers to physical activity among children in the school.
Girls on the Run, an afterschool program designed specifically for girls, which is voluntarily
supervised and run by teachers. Students engaged in physical activity twice a week in
preparation for a 5K run upon the completion of the program at the end of the year. Parents
found this program to be a facilitator to physical activity, especially since the program did not

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cost them anything. Due to budgetary constraints, parents desired to see more such free
afterschool programs. This program was also viewed positivity by children and appeared to be an
influential source of learning about a healthy lifestyle. Mckenzie et al. (2004) study found an
increase in the engagement of moderate to vigorous physical activity among middle school
within their physical education program over the course of two years. Aguilar et al. (2010) found
similar results in their two year study. Aguilar et al. (2010) found a reduction in the frequency of
overweight among girl, lower levels of total cholesterol and apolipoprotein B in both boy and
girl within the invention group in comparison to the control group. Prosper et al. (2009)
discovered a significant decrease in the BMI of students at or above the 85th percentile as well as
significant improvements in self-esteem and lifestyle behaviors among student who participated
in the SPARK program. Stating that they believed their program has the potential to improve the
health of underprivileged youth who resided in neighborhoods that are unsafe and lack facilities
for exercise.

Among the lifestyle-related school barriers identified by children were social events such as
parties, school meal preparation (meat perceived as being uncooked and greasy items offered),
and replacement of Physical Education with an Art and Media class. There has been a growing
expression of concern about recess and physical activity time allowance in schools (The
Michigan Department of Education, 2001; Institute of Medicine, 2013). Our data confirm this
concern not only from a health care perspective as stated in the literature (Zametkin et al., 2004,
Daniels et al. 2005; Dietz 2004; CDC, 2002; Institute of Medicine, 2004, USDHHS, 2008), but
also from perceptions of both the children and parents. Therefore, changing school policy to be

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inclusive of not only physical education but allotting adequate time for physical activity
specifically should not be a key issue for those who are involved in school policy determination.
Certain students also reported being criticized by peers during physical activity and the
competitive nature of physical education among their peers as barriers to physical activity. One
student reported receiving poor grades during Physical Education as barrier to her wanting to
participate. This was an interesting point. Should physical activity be a contributing factor to
ones’ grade point average?
Within the community environment children mentioned having access to major chain grocery
stores as a facilitator to healthy eating and physical activity. They also found that communities
that actively engage in physical activity and healthy eating to be a facilitator. This highlights the
importance of not only changing the school and family environments, but community
environments as well. Promotion of healthy eating and physical activity at all levels of the
ecological systems is beneficial to promoting and sustain change at it appears. Development into
community infrastructure and increasing neighborhood safety is a start to changing the
community environments ((Design Council, 2001). This is evident in the children’s reporting of
both the lack of community modeling, neighborhood safety and modeling of healthy lifestyle
within their neighborhood environments as barriers, as well as lack of community sharing.
Research findings from Molnar et al. (2004), Bennett et al. (2007), Larson et al. (2013) and the
1999 MMWR. Morbidity and mortality weekly report on effects of perceptions of neighborhood
safety and physical activity (CDC, 1999) also support this.
Parents also did not find their community environment as facilitators to healthy eating and
physical activity. Parents discussed concerns regarding child-peer relationships in regards to
socializing, lack of promotion of healthy eating and physical activity within the communities and
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the lack of quality supermarkets in close proximity. This “food desert” phenomenon has been
especially of concern in low income population (Smith & Morton, 2009; Weatherspoon et al.
2012). In terms of facilities, parents found the lack of gyms and safe recreational centers
(including parks) as barriers within their neighborhoods. The issues regarding neighborhood
safety was a major concern among parents and has definitely been mentioned as a similar
concern by other researchers (Bennett et al. 2007; CDC, 1999; Molnar et al. 2004).
Parents expressed that providing a healthy environment for their children, the desire to lose
weight, and the fear of dying as personal motivators for healthy eating and engaging in physical
activity. However, time and lack of motivation were their key barriers to engaging in routine
physical activity and healthy eating. This is likely due to overwhelming work schedules and
other pressing priorities.
The grounded theory allowed us to explore beyond what has been previously been published in
numerous intervention programs. By employing the grounded theory methodology, we were able
to determine that despite calculated efforts to design age appropriate distinctively tailored
messages for children, aimed at addressing the concepts of healthy eating and physical activity
through helpful programs like the PE-Nut, some children were having difficulty processing the
associated benefits of healthy eating and physical activity positively due to their perceptions of
their own weight status. How children are processing and internalizing lifestyle behavior
messages from valid sources such as PE-Nut program in conjunction with messages from
surrounding sources (i.e. family, social environment, television, peers, adults) which may not be
accurate (or realistic in terms of body image/weight status), is not fully understood and still
needs to be further explored. The data from this study raised some interesting questions about the
program and how other sources of information may impact the child’s perception of weight, diet
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and health. The children within the middle childhood (n=25) and young teen (n=2), stage of
development are more conscious of their body image, which could lead to issues of disordered
eating problems (CDC, 2012; Sweeney & Zionts, 1989; Lopez et al. 2013; Neumark-Sztainer et
al. 2010). Currently there is a plethora of messages from various sources either directly or
indirectly addressing the issue of overweight or obesity. With the fight against childhood obesity
in America gaining much needed attention, it is almost improbable to believe that children are
not processing some of these messages. This was clearly evident from the data.
Our qualitative findings found there were distinct differences in the way children interpreted
messages concerning healthy eating and physical activity. Children who characterized a positive
family environment (such as eating family meal together, engaging in outdoor physical activities
on a regularly basis ether individually and with family, or reported a healthy food environment),
and who translated messages from family members positively were more likely to have a
positive balanced understanding of health and healthy eating. Children who reported potentially
negative messages from family sources and who expressed characteristics that described a
negative family environment, were more likely to have an unbalanced view of healthy eating and
physical activity; either reporting a distorted view of body image or concepts related to weight.
As seen in figure 3, children received messages from various sources (T.V., internet, doctors,
educators, peers, and family). These messages appeared generally to be delivered in a manner in
which the children are able to process the information heuristically. These messages as
interpreted by the child, in many cases resulted in feelings of fear, anxiety, and concern. These
feelings of concern manifested from messages, relating poor diet quality and inadequate physical
activity to adverse diet-related health effects, were further reinforced either positively or
negatively by influences generated from within the home environment. Children who reported
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having adequate resources at their disposal, such as a safe environment to play, grocery stores in
close proximity, and an active or strong community environment tended to have balanced views
relating to health, healthy eating and physical activity.
Parents of children who fell into a negative family ecology, tended to have children who
struggled with body image and skewed or unstable views concerning weight. Families
characterized in the negative ecology group, tended to have a parent who struggled with weight
and were not confident with their current weight status. It can be inferred from the literature that
parents who have had negative experiences with weight, impose these insecurities on their
children, thereby heightening their children’s sensitivity to messages concerning weight status
(Coulthard et al 2003; Agras et al 1999; Russel et al 1998).
The PE-Nut goal is to “present 1) simple 2) consistent 3) and ubiquitous nutrition and physical
activity messages by 1) increased participation in a physically active lifestyle, 2) increased
consumption of fruits and vegetables, whole grains, and non-fat or low fat milk or dairy products
3) balanced caloric intake from food and beverages with calories expended, 4) trying new foods,
5) choosing healthy snacks, and 6) washing hands before eating.”
It is evident that these messages were well received by children. However, some interpretations
needed further explanation. For example, findings from this study suggest that some children
may have misconceptions of how weight relates to the foods we eat, and need further explanation
of how foods are balanced calorically from a nutrient and caloric perspective. It was evident that
children within this age group are concerned/fearful of gaining weight for various reasons
(health, body image, maintaining of peer relationships, parental approval). Some students
expressed, not consuming or eating less as a way in which they maintained health. It is not
recommended that growing children restrict intake of food as a way to maintain weight (Dunger
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et al. 2006). It is natural for children within this age group to experience weight gain followed by
a growth spurt. The fact that the majority of the students were overweight or obese, does not
warrant the restriction of foods. Rather, engagement in more physical activities and incorporating
a variety of foods in their diet that are high in fiber and nutrient dense is preferably
recommended. However, some children expressed financial constraints within their households
as a reason for not consuming fruits and vegetables. Eating less or having food aversions may be
a concern for children who live in food insecure households and categorize foods as being either
“healthy” vs. “unhealthy” when financial constraints limit the availability of “healthy” foods
within their households. Research shows that foods consumed in households that are on a
restricted income tend to be high in starch, fat, and oils (Drewnowski, 2009;Stang & Story, 2008;
Croll, 2005). This is evident in the food mentioned by children such as some form of sandwich,
spaghetti, or ramen noodles.
The findings of this study were important in that they provided important biometric, family
environment, detailed dietary and physical activity information for the SNAP-ED founded
program because funding restrictively predicted such assessments in the past. It is clearly evident
that while childhood obesity is a serious concern barriers and facilitators to healthy lifestyle
behaviors are important to consider.

5.2 Implications
Our study found that children who reported potentially negative messages from parents with
regard to healthy eating and physical activity were more likely to exhibit fears and concern
regarding their weight and body perceptions as well as experience internal conflicts and
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expressed feelings of guilt regarding food (enjoyment of foods that they deemed “unhealthy”).
Similar findings of guilt associated with eating of junk food was found by O’dea, (2003).
Although, such scare tactics are also sometimes used for adults (Spahn et al. 2010; Witte 1992),
it is apparent that children and parents may be receiving information about health and healthy
eating that only requires heuristic processing. Receiving messages in this manner sometimes
result in misinterpretation of information concerning health, and as a result may lead to the
avoidance of certain foods, highlighted as a contributor to certain chronic diseases.
Given that the potential for disordered eating is elevated during early adolescents and young
adulthood (CDC, 2012; Sweeney & Zionts, 1989; Lopez et al. 2013; Neumark-Sztainer et al.
2010), nutrition information provided to children should be sound and address issues
surrounding healthful eating not weight. There is an intense focus on childhood obesity;
therefore, we should be aware of and draw a distinction between a healthy diet and lifestyle
versus purely focusing on “good” vs. “bad” foods, and weight gain as the outcome.

5.3 Strengths and Limitations
The study provided in-depth information in conjunction with facilitators and barriers to healthy
eating and physical activity among 5th grade students and their parents who participated in an
ongoing nutrition education program. Anthropometric data for both children and parents
included heights, weights and waist circumference. We were able to triangulate, child data with
parent data for a subset of the sample population.
A limitation to the study was our inability to successfully recruit an equal number of parents and
children within the study to capture the full family environment of all 27 child participants. We
were also unable to obtain one week day and one weekend day 24-hour dietary recall for one

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child participant. Children had difficulty recalling the brand names of items during the 24-hour
dietary recall. However, students often checked the labels at home and reported the brand names
during their second visit. Another limitation to the study were the multiple qualitative
interviewers using the grounder theory method. Opportunities were missed to expound about
interesting point of view mentioned by participants.

5.4 Summary and Conclusions
Childhood overweight and obesity was a major health concern among the children within this
study. Through the use of the grounded theory we found that there were distinct differences in
the manner in which children processed information about health, healthy eating and physical
activity from various external sources. It was evident within the data that children had concerns
about health problems associated with an overweight or obese weight status, which may have
been amplified through televised programs and various other sources of information. We were
able to distinguish how different children were able to handle and process this information based
on the stability and supportiveness of the home environment. Key differences were seen in
family ecologies, which promoted a positive balanced understanding of a nutrition and physical
activity and those which potentially elicited potentially unbalanced views of nutrition and
physical activity.
Key implications of our study were that there is a continued need for nutrition education and
physical education programs that promote healthy lifestyle through increasing consumption of
fruits and vegetables and engaging in regular physical activity. Parents are important for fully
understanding the entire perspective of the family environment and should be included in such
interventions. More importantly, it was evident that there is also a need for parental nutrition and
physical activity education. It is apparent that children need sufficient nutrition education to
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combat external messages about nutrition and health which may be invalid, especially as they
transition into adolescence, but the family and community environments in addition to the school
are also who strongly influential. Children whose family environment did not fully support
balanced views on health and physical activity, were more self-conscious and concerned about
weight and health related issues and tended to have families that struggled with weight related
issues as well. It was also apparent that some students from this family environment were at risk
for disordered eating, another serious concern. Therefore it is imperative that federally funded
nutrition programs, such as PE-Nut remain a key source to providing sound nutrition education
for children and develop more interactive ways in to reach families and communities.

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APPENDICES

157

Appendix A: Michigan State University IRB

158

Figure 5.1 Michigan State University IRB
159

Appendix B: School Letters of Support

160

Figure 5.2a Letter of Support

161

Figure 5.2b. Letter of Support

162

Appendix C: Recruitment Flyer

163

Figure 5.3 Recruitment Flyer
164

Appendix D: Consent Forms

165

A Physical Activity and Nutrition Education Program in Schools: Target Population Barriers and
Facilitators to Healthy Eating and Physical Activity.

Parent/Primary Caregiver Consent Form
Dr. Lorraine Weatherspoon, Associate Professor
Department for Food Science and Human Nutrition
Michigan State University
332 G.M. Trout Food Science Bldg.
Email: weathe43@msu.edu
Phone: (517) 355-8474 ex 136
Dear Parent/Caregiver,
You and your child are being asked to participate in a research project: “A Physical Activity and Nutrition
Education Program in Schools: Barriers and Facilitators to Healthy Eating and Physical Activity” that is
being conducted by Michigan State University and Physical Education and Nutrition Program Working
Together (PE-Nut) program. Anticipated participation time for parents/primary caregiver is an estimated
1hr and children an estimated 45 minutes.
Purpose of the Research:
 You are being asked to participate in a research study aimed at identifying facilitators and barriers
in regards to healthy eating and physical activity behaviors experienced by children and their
families.
 You have been selected as a possible participant in this study due to your child’s enrollment in
Ypsilanti’s School District, which is participating in an ongoing Physical Education and Nutrition
program. Up to 40 schoolchildren and their parents are being asked to participate in the study.
What you are being asked to do:
Parents:
 Parents/primary caregivers will be asked to be a part of 1 of 2 group discussions, where you will
be asked to complete a brief survey, provide information on foods that you eat and self-report
height, weight, and waist circumference. These discussions/focus groups will be held at your
child’s school or in the community, whichever is most convenient for the group. If you are not
aware of your current height, weight and waist circumference instruments will be available for
you to weigh and measure yourself if you so desire. Dietary intake information for
parents/primary caregivers will be collected in person or over the phone. In the event that you are
unable to make the group discussions, we may be able to accommodate you via a telephone
interview, only with your permission.
 Provide signed consent for yourself and for your child to participate in the study.
 Grant permission to contact you, to schedule the group discussion (focus group)
 Send signed consent form back to your child’s classroom teacher.
What your child is being asked to do at school:
 Your child will be asked to complete an interviewer-assisted survey (demographic, physical
activity, food security, dietary intake) as well as be measured for height, weight, and waist
circumference to see how well they are growing.
You Should Know:
 We hope that this study will improve how school-based interventions are done in the future as
well as provide information about why they are important to do.
 Although you may not directly benefit from your participation in this study; your responses will
help us better understand things that help or prevent you and others in your community from
following recommended physical activity behaviors and healthy eating.

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 A $20.00 gift card to Meijer will be given to you after you complete both the survey and focus
group and your child will receive school supplies valued at about $20 (eg. textbooks, school
supplies) upon completion of the study as a thank you for being a part of the study. This should
not be considered as a benefit for participation.
 There are no physical risks to you or your child. You might feel uncomfortable answering some
questions. In addition, you may not feel comfortable telling us about your weight or your waist
circumference. If you are uncomfortable answering any questions or providing a self-report of
measurements, you can say no at any time.
 To make sure we are correctly recording your views, in addition to pencil and paper
documentation, the interviews and group discussion will be audio recorded.
 The data (which includes audio recordings) for this project will be kept confidential. Names will
be replaced with a participant ID number. Information obtained from the study will be kept
confidential to the maximum extent allowable by law.
 Data will be stored and protected in a locked storage cabinet on Michigan State University’s
campus.
 Only Simone Wilson (researcher), Dr. Weatherspoon (PI) and 2-3 undergraduate student research
staff will have access to the data.
 Instructors/teachers of Ypsilanti School District will not have access to any data with names.
They will be provided with a summary of what we find.
 The results of this study may be published or presented at professional meetings, but the identities
of all research participants will remain anonymous/ confidential.
 Participation in this research project is completely voluntary. You have the right to say no and
may change your mind at any time and withdraw. You may choose not to answer specific
questions or to stop participating at any time. You will receive a $20 Meijer gift certificate card as
a thank you, for the completion of the group discussion (focus groups) and survey.
 Choosing not to participate or withdrawing from this study will not make any difference in the
quality of any services you or your child may receive and benefits to which you or your child are
otherwise entitled.
 You will be told of any significant findings that develop during the course of the study that may
influence your willingness to continue to participate in the research.
If you have concerns or questions about this study, such as scientific issues, how to do any part of it, or to
report an injury, please contact the researcher.

Dr. Lorraine Weatherspoon, Associate Professor
Department for Food Science and Human Nutrition
Michigan State University
332 G.M. Trout Food Science Bldg.
Email: weathe43@msu.edu
Phone: (517) 355-8474 ex 136
If you have questions or concerns about your role and rights as a research participant, would like to obtain
information or offer input, or would like to register a complaint about this study, you may contact,
anonymously if you wish, the Michigan State University’s Human Research Protection Program at 517355-2180, Fax 517-432-4503, or e-mail irb@msu.edu or regular mail at 207 Olds Hall, MSU, East
Lansing, MI 48824.
Your signature below means that you voluntarily agree and grant permission for your child to participate
in this research study, which includes participating in an assisted survey and interview, providing
information about food intake and having his/her measurements taken (height, weight, and waist
circumference).

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_____________________________ ________________________________________
Signature
Date
Your signature below means that you voluntarily agree to participate in this research study which includes
filling out a survey , participating in a focus group (group discussion), providing information about your
food intake, and self-reporting height, weight, and waist circumference.
_____________________________ ________________________________________
Signature
Date
You have permission to contact me at the following number to schedule the focus group (group
discussion), collect dietary assessment information, and if any additional information is needed.
_____________________

Contact Number

168

Figure 5.4 Child Assent Form

169

Appendix E: Child Survey Questionnaire

170

Participant ID ______________
Age _______

Date ____________

Gender _______

1. Ethnicity

5. Religious Affiliation

Non-Hispanic White

Episcopalian

Non-Hispanic Black

Baptist

Hispanic

Catholic

Asian

Presbyterian

Indian (Native American)

Jew

Other _____________

Seventh Day Adventist
Hindu
Muslim

2. Dominant Language Spoken in your
household?

Non-denominational

English

Other specify, ___________

Spanish
Other ________

6. Total number of people in your
household
1

3. Who takes care of you most of the
time?

2

Mother and Father

3

Mother

4

Father

Other __________

Grandparent(s)
Other ____________

7. Number of Children in household
including yourself

4. Are your Parents
Single

1

Married

2

Separated

3

Divorced

4

Widowed

Other ___________

Other__________

Figure 5.5 Child Survey Questionnaire
171

Figure 5.5 (Cont’d)
8. Does your parent or the person that

10. Do you know of anyone in your

takes care of you most of the time

family who..

Work Full time

Smokes

Work Part time

Who?__________

Work seasonally

Drinks Alcohol

Unemployed

Who?___________

Full-time student
Sick or disabled

9. Do you know of anyone in your
family who has ….
Heart Disease
Who?__________
Cancer
What type? _______
Who?__________
High Blood Pressure
Who?__________
Glaucoma/eye problems
Who?__________
Diabetes
Who?__________

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Figure 5.5 (Cont’d)
11. Last week, on which days did you exercise or take part in physical activity that made
your heart beat fast and made you breathe hard for at least 30 minutes? (For
example: basketball, soccer, running or jogging, fast dancing, swimming laps, tennis,
fast bicycling, or similar aerobic activities)

Figure 5.5 Child Survey Questionnaire (Cont’d)

12. Last week, on which days did you play outdoors for 30 minutes or more? Do not
count outdoor play during school hours.

13. During the past 12 months, on how many sports teams did you play? Sports teams
include soccer, basketball, baseball, softball, swimming, gymnastics, cheerleading,
wrestling, track, football, dance, tennis, and volleyball teams. Do not include PE
classes.

173

Figure 5.5 (Cont’d)
14. Do you currently take part in any other organized physical activities or take lessons,
such as martial arts, dance, gymnastics, or tennis?
Yes

No

15. On most days, how do you arrive at school?

16. On most school days, how many hours per day do you watch TV, DVDs, or movies
away from school?

17. How sure are you that you can play outside after school instead of watching TV?

18. On most school days, how many hours per day do you spend on a computer away
from school? (Time on the computer includes time spent surfing the Internet, instant
messaging, and playing online video or computer games.)

19. On most school days, how many hours per day do you usually spend playing video
games like Nintendo® Wii or DS, Sega®, PlayStation®, Xbox®, GameBoy®, or arcade
games away from school?

174

Figure 5.5 (Cont’d)
20. What are you trying to do about your weight?

21. Compared to other students in your grade who are as tall as you, do you think you
weigh:

22. How many minutes of physical activity/exercise should you have on all or most days
of the week?

23. If I run and play every day, I will have fewer health problems.

24. If I am overweight I am more likely to have more health problems like cancer or heart
disease.

25. How safe do you feel at school?

26. How often during the last week, at school have others...

175

Figure 5.5 (Cont’d)

27. Over the last 6 months, how often have you been bullied at school? (A student is
being bullied when another student, or a group of students, say or do nasty and
unpleasant things to him or her. It is also bullying when a student is teased repeatedly
in a way he or she doesn't like. But it is NOT BULLYING when two students of
about the same strength quarrel or fight.)

28. Does this make you not want to participate in group physical activity during school?
Yes

No

29. Are your parents physically active?
Yes

No

30. Do your parents tell you about why you should or should not be physically active?
Yes

No

31. How often do you eat school meals?
1 time/week
5 times/week

2 times/week

3 times/week

4 times/week

Never
32. Do you bring lunch from home?
Yes

No

33. Do you eat anything before or after school?
Yes

No

34. Snacks eaten during break are ….
Brought from home
Purchased at school
Don’t eat snacks during school
176

Both

Figure 5.5 (Cont’d)
35. Do your parents know what you are eating at school?
Yes

No

36. Do you tell your parents what you eat during school?
Yes

No

37. Who is in charge of what you eat at home?
Mom
Dad
Other____________

Grandparents

Older sibling

You

38. Which meals are most frequently eaten away from home?
Breakfast

Lunch

Dinner

39. How often do you eat meals away from home?
1 time/week
5 times/week

2 times/week

3 times/week

4 times/week

Never
40. How often do you eat meals with your entire family?
1 time/week
5 times/week

2 times/week

3 times/week

4 times/week

Never
41. If not often, who in particular is missing from your family meals?
Mom

Dad

Sibling

You

Other________

42. Are you worried that food at home will run out before your family can buy more?
_____ A LOT (Almost all the time)
_____ SOMETIMES (2-6 times)
_____ NEVER
_____ OTHER

177

Figure 5.5 (Cont’d)
43. In the past, has the food that your family bought run out, and your family did not
have enough money to get more?
_____ A LOT (Almost all the time)
_____ SOMETIMES (2-6 times)
_____ NEVER
_____ OTHER
44. In cases where your family was running out of money, what type of meals did you
and our family eat?
1.__________________________________________________________
2.__________________________________________________________
3.__________________________________________________________

45. How often were you not able to eat foods from all of the food groups because your
family did not have enough money?
_____ A LOT (Almost all the time)
_____ SOMETIMES (2-6 times)
_____ NEVER
_____ OTHER
46. Did you have to eat less because your family did not have enough money to buy
food?
_____ A LOT (Almost all the time)
_____ SOMETIMES (2-6 times)
_____ NEVER
_____ OTHER
47. Has the size of your meals been smaller because your family did not have enough
money for food?
_____ A LOT (Almost all the time)
_____ SOMETIMES (2-6 times)
_____ NEVER
_____ OTHER
48. Did you have to skip a meal because your family did not have enough money for
food?
_____ A LOT (Almost all the time)
_____ SOMETIMES (2-6 times)
_____ NEVER
_____ OTHER
49. How often have you been hungry, in the past month, and did not eat because your
family did not have enough food?
_____ A LOT (Almost all the time)
_____ SOMETIMES (2-6 times)
_____ NEVER
_____ OTHER
178

Figure 5.5 (Cont’d)
50. Did you not eat for a whole day, in the past month, because your family didn’t have
enough money for food?
_____ A LOT (Almost all the time)
_____ SOMETIMES (2-6 times)
_____ NEVER
_____ OTHER

Anthropometrics (Official Use Only)
Height (cm)

_______________

Weight (Kg)

________________

BMI_________________

Waist Circumference (cm) ________________

179

Figure 5.5 (Cont’d)
Multiple Pass 24-Hour Dietary Recall Process
 Explain why the assessment is being done
 Reassure the subjects it will be kept confidential
 Begin Recall
1. Quick List- Collect a list of foods and beverages consumed the previous day
a. What was the first thing you ate after you go up yesterday?
i. Avoid terms like breakfast, lunch, or dinner
b. Record only food at this time; do not worry about portion sizes until later
c. Allow extra space for adding things later
d. Do Not interrupt
2. Forgotten Foods-Probe for foods forgotten during the Quick List
a. Your turn to talk
b. Probe with open ended questions (how, what, describe)
c. Do not forget
i. Condiments
ii. Beverages
iii. Alcohol
iv. “Little bites” of food
d. Frequently missed foods
3. Time and Occasion- Collect time and eating occasion for each food
a. Review the day to them
b. Ask the subject to tell you the time of day each food was eaten
c. Ask if there are additions or corrections
4. Detail Cycle- For each food collect detailed description, amount, and additions. Review the
24-hour day
a. Obtain four kinds of information about each food/beverage
b. Kind of food/beverage
i. Fresh, frozen, canned
ii. Skim, 2%, whole milk

180

Figure 5.5 (Cont’d)
c. Preparation of food
i. Fried or baked
ii. Ingredients added
d. Portion size of food
i. Participant may underestimate so use models or examples
ii. Make sure EVERY item has some measuring unit
e. How served
i. Butter, gravy, or cream added?
f.

If you are not sure about a food, ask the participant to describe it to you
i. Is it a drink? Energy bar?

g. Get the details (color, ingredients, etc)
i. Same food, different ingredients
h. Record dietary supplements or vitamins/minerals
i.

Record any herbal supplements or home remedies

5. Final Probe- Final probe for anything else consumed
a. Remember….
i. Double-check the name on each dietary assessment form
ii. Check for completeness

181

Figure 5.5 (Cont’d)

24-HOUR DIETARY RECALL
FOOD LIST

TIME

DESCRIPTION OF
FOOD OR BEVERAGE

182

COOKING
METHOD

BRAND

AMOUNT/
PORTION

Appendix F: Parent Survey Questionnaire

183

Date ____________
Participant ID ______________
Age _______ Gender _______ Dominant Language spoken _____________
Childs Age_______ Gender____________
For questions 1-20, Please select the answers that best represents your Child/ Family.

Almost
Never

My child eats breakfast….
Our family eats meals together…..
Our family eats while watching TV …
Our family eats fast food….
Our family uses microwave or ready to eat foods …
My child eats fruits and vegetables at meals or snacks…
My child drinks soda pop or sugar drinks…
My child drinks low fat milk at meals or snacks…
Our family monitors eating of chips, cookies, and
candy…
Our family uses candy as a reward for good behavior…
My child spends less than 2 hours on
TV/games/computer per day
Our family limits the amount of TV our child watches…
Our family allows our child to watch TV in their
bedroom…
Our family provides opportunities for physical activity
Our family encourages our child to be active every day
Our family finds ways to be physically active togethe
My child does physical activity during his/her free
time…
My child is enrolled in sports or activities with a coach
or leader…
Our family has a daily routine for our child’s bedtime…
My child gets 9 hours of sleep a night …

184

Sometimes

Usually

Almost
Always

What are the mypyramid or plate method recommendations for children?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
________________________________________________

1. Have you ever been to the school to look at the menu?
_______________________________

2. How many minutes of physical activity are children supposed engage in per day?________
_________________________________________________________________________
b) How do you know this? __________________________________________________
3. How much physical activity should you engage in per day? _________________________
b) How do you know this?
______________________________________________________________
4. Which meals do you eat away from home?_______________________________________
5. Where do you and your family eat meals during the week? __________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
6. Where do you and your family eat meals on the weekend?__________________________
________________________________________________________________________________
________________________________________________________________________________

7. Are the children allowed to go and get their own snacks?
_________________________________________________________________________
_________________________________________________________________________
8. Are fruit and vegetables available, ready and cut up at home?
_________________________________________________________________________
_________________________________________________________________________
9. Do you like that girls and boys have P.E. together? Why or why not?
_________________________________________________________________________

185

10. Does your child enjoy P.E. lessons?
_________________________________________________________________________
_________________________________________________________________________
11. Do they tell you what they have been doing during P.E. or do you have to ask?
___________________________________________________________________________
_______________________________________________________________________

12. Do you feel that you encourage them to do exercise or are they motivated enough to go and
do it themselves?
_________________________________________________________________________
__________________________________________________________________________
13. Do you ask your children about what they eat at school? Why or why not?
_________________________________________________________________________
_________________________________________________________________________
14. Do you give your child extra snacks to take to school?____________________________________
Why?___________________________________________________________________________
________________________________________________________________________________
15. What snacks to you provide your child to take to school?__________________________________
________________________________________________________________________________
________________________________________________________________________________
16. Do you give your child extra money to purchase snacks at school? Why or why not?
________________________________________________________________________________
________________________________________________________________________________
17. Do you enjoy exercising? ___________________________________________________________
18. Do you enjoy exercising as a family?
__________________________________________________

___________________________________________________________________________

186

19. Ethnicity

22. Schooling Level

Non-Hispanic White

< Middle School

Non-Hispanic Black

≤ High School

Hispanic

College

Asian

Certificate

Indian

Diploma

Other _____________

Graduate

20. Marital Status (Please Indicate)

Post graduate

Single

23. Total number of people in your
household

Married
Separated

1

Divorced

2

Widowed

3

Other__________

4

21. Religious Affiliation

Other ___________

Anglican

24. Number of Children in household

Baptist

1

Catholic

2

Hindu

3

Judaism

4

Muslim

Other ___________

Non-denominational
Presbyterian

25. Occupation
_______________________

Seventh Day Adventist
Other ___________

26. Employment Status
Employed Full time
Employed Part time
Seasonally Employed
Unemployed

187

Annual Income
< $20,000
$20,000- 34,999
$35,000- $44,999
$45,000-$54,999
$55, 00 -$59,999
$60,000- $69,999
$70,000 – above

Check the following boxes below if you have a family history of any of the following
conditions, and then specify all who you know of in the immediate family.
Cardiovascular Disease
Who?_________________________________________________
Cancer, specify type _____________________________
Who?________________________________________________________________
Hypertension/High Blood Pressure
Who?________________________________________________________________
Glaucoma/eye problems
Who?________________________________________________________________
Diabetes
Who?________________________________________________________________
Smoking
Who?________________________________________________________________
Drinking Alcohol
Who?________________________________________________________________

188

Self-reported height, weight, and waist circumference. Please let us know if you need assistance.

Participant ID

Height

Weight

____________

___________

Waist Circumference

BMI

___________

___________

189

Appendix G: Qualitative Interview Guide for Children

190

Children’s In-depth Qualitative Interview
*Adapted from the Deal Children’s School Study
Qualitative Schedule: Children’s interview in school
Introducing the In-depth Qualitative Interview
Welcome them to the study and thank him/her for taking part
Tell him/her your name
Check to make sure the child has signed assent and parental consent forms which are
necessary in order to participate. Explain that everything he/she says will be confidential/
kept a secret so no one else will be able to tell who said what. Explain that the conversation
will be recorded, but that no one else other than the primary researcher and their
interviewers on the project will be able to hear it.
Explain that the topics for discussion include
o Food and eating
o Physical activity participation
o Health in general
o Providing advice about things that we think will be helpful for school children and
their health
“The aim of this interview is to understand what you think about the topics I have just
mentioned. We are really interested in finding out your opinions about what helps you and
your family and what stops you from being healthy.”
Explain that you just ask the questions and follow up certain points. What they say is up to
them but remind him/her verbally that confidentiality will be maintained, everyone will be
given a random number and no names, or the name of any places that are mentioned will
be used.
Encourage them to share their views.
Explain that the interview will last no longer than about 45 minutes to an hour unless they
have lots to say!
Thank him/her again for taking part; remind him/her that his/her help is greatly appreciated.

Aim 2. What are the children’s perceived barriers and facilitators to living a healthy lifestyle
(dietary intake and physical activity) within the school and home environment?
Individual

191

1. What in your opinion are healthy food choices? Why?
2. What are unhealthy food choices? Why?
3. What activities do you consider to be physical activity/exercise? Why?(probe to give
examples: walking, running, dancing, playing basketball, soccer, baseball, softball,
swimming, Nintendo Wii)
4. Can you tell me what activities you would not consider to be physical activity?
Why? (Probe to give examples: playing video games, watching television, using the
computer)
5. What do you know about how weight is related to foods we eat?
6. What programs or classes at school have helped you better understand
a. Health
b.

Healthy eating

c.

Physical activity

7. Besides school, where else to you gather information about food and health? (Probe:
It could be from siblings, parents, TV commercial etc.)
8. Do you think what you eat now is related to what will happen when you are older?
9. In your opinion how would you describe children at your school who are healthy?
Name at least 3 things
10. In your opinion how would you describe children at your school who are unhealthy?
Name at least 3 things
11. Can you tell me about the Mypyramid (or plate method) and its recommendations?
12. What have you learned from PENut?
Environment
SCHOOL
Healthy food Choices
13. What are things that help you make healthy food choices at school? ProbeParents, family friends, community, food access/availability, cost, personal taste,
likes/dislikes, routine/habit,.
14. What do you think about school meals?
15. What do you think about the food and/or snack choices available at school?
16. Do you think it is healthier to bring lunch from home or eat lunch provided by the
school? Why?
17. What do you eat during break time?
192

a. Do you bring anything from home?
18. What foods do you enjoy eating at school?
19. What foods do you not enjoy eating a school?
20. If you were in charge, what would you like to see offered in school meals?
21. What are things that prevent you from making healthy food choices at school?
Probe- Parents, family friends, community, food access/availability, cost, personal
taste, likes/dislikes, routine/habit, physical activity.
22. Think about the things you do at school.
a. How easy is it to eat healthy?
b. What stops you? What would make things easier?

Physical Activity
23. What are things that help you practice healthy physical activity behaviors at
school? Probe to get an understanding of access to sports/activities in the area,
whether some activities are better than others, who with, gender and ethnic
differences as well as other potential facilitators to exercise
24. Can you tell me about the activities that you do in P.E. (EPEC)?
a. Do you like having girls and boys do P.E. together?
b. What are the most important lessons you learned in P.E. (Nutrition, Health,
Teamwork, or Sportsmanship)?
25. If you could do anything you wanted in P.E., what would you choose to do?
26. What do you do during break times or before/after school?
27. What are things that prevent you from practicing healthy physical activity
behaviors at school?

Home

28. What are things that help you make healthy food choices at home? ProbeParents, family friends, community, food access/availability, cost, personal taste
likes/dislikes, routine/habit, physical activity?
29. Where do you eat meals at home?
30. Where do your family members eat meals most of the time?
31. Are there any rules about what you can/cannot eat at home?

193

32. Tell me about if you try to get around these rules.
33. How is meal time with your family (quiet, loud, enjoyable etc)?
34. How has information from PENut, helped you and your family at home?
35. What are some additional, ways PENut can help you and your family at home?
36. What are things that prevent you from making healthy food choices at home?
37. Think about the things you do at home.
a. How easy is it to eat healthy?
b. What stops you?
38. What are things that help you practice healthy physical activity behaviors at
home?
39. What kind of activities do you do with your family?
40. Who decides what to do?
41. What types of things do you and your sibling do to get some exercise?
42. Who would you really like to do physical activity with?
43. How much physical activity are you supposed to do?
a. In a day/week?
44. What are the different types of physical activities?
a. intensity/duration
45. What are things that prevent you from practicing healthy physical activity
behaviors at home?
Neighborhood
46. What are things that help you make healthy food choices in your neighborhood?
Probe-community, food access/availability, cost.
47. What are things that prevent you from making healthy food choices in your
neighborhood?
48. Think about the things you do in your community.
a. How easy is it to eat healthy or find healthy foods?
b. What stops you? What things would you change?
49. What are things that help you practice healthy physical activity behaviors in
your neighborhood?
194

50. Where can you go to take part in physical activities in the local area?
51. What do you think about the local area in general (enough area/facilities to play safe,
etc)?
52. What makes you decide to exercise?
a. Do you enjoy exercising by yourself, with family, with friends?
53. What are things that prevent you from practicing healthy physical activity
behaviors in your neighborhood?
54. Can you go to the parks/playground?
a. Tell me about it
55. Are you allowed to go without adult supervision?
a. Where can you go?
56. Which physical activities do you dislike?
Behavior
57. What would you say about your eating habits/what you eat (are they
healthy/unhealthy) and why?
58. If unhealthy,
a. How do you feel about making changes to what you eat?
59. What can you tell me about your current physical activity habits?
a. If you are not as physically active as you wish,
b. How willing are you to improve your physical activity habits?
60. Imagine that you had a friend who wanted to be more active but they did not know
how to. What could you say/do to help them?
61. Finally, if you were in charge, what 3 things would you do to encourage people to be
healthy?

195

Appendix H: Focus Group /Qualitative Interview Guide for Parents

196

Parental Qualitative Focus Group Questions

*Adapted from the Deal Children School Study
Qualitative Schedule: Parent/primary caregiver’s focus group interview guide
Introducing the In-depth Qualitative Interview

Welcome them to the study and thank them for taking part
Tell them your name
Check that they have all signed consent forms in order to participate and explain that
everything they say will be confidential/ kept a secret so no one else will be able to tell
who said what. Explain that the conversation will be recorded, but that no one else other
than the primary researcher and their interviewers on the project will be able to hear it.
Explain that the topics for discussion include
o Food and eating
o Physical activity participation
o Health in general
o Providing advice about things that we think will be helpful for school children and
their health
“The aim of this interview is to understand what you think about the topics I have just
mentioned. We are really interested in finding out your opinions about what helps you and
your family and what stops you from being healthy.
Explain that you just ask the questions and follow up certain points. What they say is up to
them but remind them of the ground rules
Assure them verbally that that confidentiality will be maintained, everyone will be given a
random number and no names, or the name of any places that are mentioned will be used.
Encourage them to share their views, even if their views are different from other.
Ask them to remember to respect other people’s point of view by allowing others to speak.
Explain that the interview will last no longer than about 45 minutes unless they have lots
to say!
Thank them again for taking part; remind them that their help is greatly appreciated.

197

Aim 3. What are the underlying perceptions (facilitators and barriers), parents encounter with regard
to healthy food intake and physical activity behaviors for their children?

Individual
1. What makes a healthy diet?
2. Can you think about how your diet is related to health later in life?
3. What have you read or heard about weight, healthy eating, and the importance of physical
activity?
4. Can you tell me about the MyPyramid (or plate method) and its recommendations?
5. Do you know about how many portions of fruit and vegetables you/your children should
eat in a day?
6. What about different food groups- what are they and how much should you eat from each
group?
a. How easy is it to meet healthy eating recommendations?
b. What are some things that prevent you from following the recommendations?
Why?
c. What are things that are easy to follow in the recommendations? Why?
7. How much control do you believe you have concerning what your children eat?
a. How does this make you feel?
8. How do you feel about making healthy changes in the way you and your family eat?
9. What do you think about the meals that your child eats at school?
10. Are you aware of any changes in the school meals that have taken place recently?
a. Can you tell me what they were
11. If you were to eat healthier, what are some of the changes (results) you would expect to
see?
12. What assistance would you need, if any, to improve eating habits
a. For you?
b. For your child/ren?
13. What assistance would you need, if any, to improve physical activity habits?
a.

For you?

b. For your child/ren?

198

Environment
14. Where do you get most of your information about food and physical activity?
15. What are some of the concerns you have with the increasing rates of overweight?
a. What about the weight problems in children?
16. How have programs such as “Let’s Move” spear headed by Michelle Obama influenced
the way you feel?
Home

1. What helps you to make healthy food choices at home?
2. Why are meals eaten away from home?
3. How often, do you eat meals with your entire family?
a. Which meals?
4. If, not often who in particular is missing from your meal gathering?
5. If you do eat together, do you talk around the table?
6. Are there any rules about what, where and when your child/ren can/cannot eat at home?
a. Tell me about how they might get around these
7. Tell me about cooking at home, who is in charge?

8. Are you/have you been showing your child/ren how to cook?
a. What can they do?
b. Do they offer to help you to cook or do you ask them for help?

9. How often do you cook meals ‘from scratch’?
a. Why some and not others?
10. What types of food do you cook?
a. Mainly from your own/other cultures?

11. What are things that prevent you from making healthy food choices at home?
12. Think about the things you and your child/ren eat at home. How easy is it to make
healthy food choices?
13. What are things that help you practice healthy physical activity behaviors at home?
199

14. What are things that prevent you from practicing healthy physical activity behaviors at
home?
Neighborhood

1. What are things in your neighborhood that help you make healthy food choices?
2. Think about the differences between what you do in your community and at home.
a. How easy is it to make healthy food choices in the neighborhood?
3. What are things that prevent you from making healthy food choices in your
neighborhood?
4. Think about the differences between what you do for exercise/physical activity in your
community and at home.
a. What stops you? What would you change?
5. What are things that help you practice healthy physical activity behaviors in your
neighborhood?
6. What are things that prevent you from practicing healthy physical activity behaviors in
your neighborhood?

School

1. If you were in charge, what are some of the meal items you would like to see offered in
school?
2. Who has the responsibility for ensuring a healthy diet for children?
3. How much of that responsibility should be issued to the school?
4. Think about the things your child/ren eat at school. How easy is it for them to make
healthy food choices?
5. Does your child have school meals or packed lunches?
a. Why?
6. What types of things would you like your children to eat at school?
a. Why?
7. What do you know about Physical Education at your child/ren’s school(s)?
8. Is your child a member of a school or local exercise or physical activity or sports
community team? Which ones?
9. If your child came to you and wanted to do more exercise/sporting activities, what could
you say/do to help them?
200

Behavioral

1. How do you feel about making changes to your diet?
2. What would prevent you from changing how you eat if you wanted to?
3. How willing are you to improve how you eat?
4. How willing are you to improve how physical active you are?
5. Are you open to tasting new foods?
6.
7.
8.
9.

Is your child open to tasting new foods?
Is your family open to tasting new foods?
Who does the food shopping?
What things don’t you eat?
a. Why?
b. Would you offer those things to your children?

10. What are some things you tell your child about being physically active?
11. What are some of the activities that you do with your child to be physically active?
a. How does it make you feel?
12. What are some of the activities your child does on their own? With others? And where?
13. What makes you decide to do some exercise?
14. Which activities do you dis/like?
a. How do you think this affects your child’s outlook on that activity?
15. If you could do any activity what would it be?
16. If you were in charge, what 3 things would you do to encourage people to be healthy?
a. What would you say to parents?
b. What would you say to children?
c. What would you say to school administrators?
d. What would you say to the government?

201

Appendix I: Sample Code Book of Interview Responses for Children

202

Table 5.1 Sample Qualitative Chart of Child Themes and Sub-Themes
Main Theme
Personal
Facilitator

Personal Barrier

Health Condition
Barrier
Community
Facilitator

Sub-Theme

N

Motivation
15
Lack of
Motivation
Tired
Personal taste
preference

"The taste, and um, I don’t like yea I don’t
like the taste, so usually I just don’t get it or I
don’t eat it."
8

Sick

"I hate running cuz I have asthma"
4

Neighborhood
Environment

4

Community
Support
5
Family Facilitator

Support
16

Media Facilitator

Community
Barrier
Neighborhood
safety Barrier

Quote
"because I really want to be a football and
basketball player so I like to … I try my best
and I like to run and stuff."

Nutrition and PA
embedded
programming/
exergames
Lack of
Neighborhood
Food Access

5

14

Unsafe
environment
9

203

"…It's easy to eat healthy because it's
(neighborhood) surrounded by healthy"
We have this car it like a healthy car and it
comes in our neighborhood and I don't
understand…it kinda, it gives us.., it gives
you a book of healthy tips. And it gives you
something you can try that's healthy."
"my mom always makes sure that I eat food
from each food group and sometimes we'll eat
a piece of cake but not every day, or we'll
have a cookie but not every day."
"well based on what I see on TV is people
always eating healthy"
"we play Mario Karts or Wii sports"
"There is not, there is not a lot of grocery
stores and places to get food in my
neighborhood."
"Well there is a lot of like bad people there…
I don't really play with my friends. I just stay
inside because I am afraid that people I don't
know might attack me or something."

Table 5.1 (Cont’d)
Lack of
Community
Support

Weather Barrier

Lack of
Community
Remodeling
Winter Weather
Summer Heat
Busy
Use of foods as
rewards/purchasi
ng unhealthy
foods

Family Barriers

School Food
Preparation

Peer Dynamics

8

Money (purchase
food)
Television,
Computer, Video
games
Uncooked meat
Vegetable
Preparation
School
meals/greasy
Teasing
Modeling
(bringing
unhealthy
snacks)
Corrected by
Peers

6
4

5

3

"because they're not walking and that makes
me not want to walk"
"Cus the days when its when it was
really,…like it was no snow and it was cold,
and I couldn't ride my bike and I was really
really angry. I was angry at the weather that
time."
"nothing, all my parents do is watch TV"
"well I can't because my mom, plus she, she
buys healthy drinks but not healthy, not all the
time healthy foods."
"Sometimes my parents don’t have enough
money to buy it… uhm, I would change not,
my parents not having that much money."
"When like a TV show or a move comes on"

13
7
3
13

9

204

"because like if its, because sometimes I see
pink in the meat sometimes so that’s why I
think it not healthy, because it not all the way
cooked."

"calling me fat and then you get stressed out
and eat more"

Appendix J: Sample Code Book of Interview Responses for Parents

205

Table 5.2 Sample Qualitative Chart of Parent Themes and Sub-Themes
Main Theme

Sub-Theme

N

Quote

5

E0014: okay I’m trying to do better because
we are all overweight in my house so I try to
do better. I mean we pretty much just eat like
chicken. You know that’s the biggest of the
meats we eat but I’m trying not to do as much
frying as I use too, you know I try to do a lot
of baking now or have the George Forman’s
out

5

E0014: that help me make choices at home?
Umm I’ll have to say my children and I want
them to be healthy and happy and you know I
stopped smoking I smoked for many years and
they weren’t happy and they didn’t want their
mom to die I didn’t want them to get them
infections and to stay like that they motivate
me to want to make healthier choices at home

6

E003_E012: Um I feel good about it because I
know in the long run it’s gonna help you
family, yea.

Lack of SelfMotivation

7

E001: seems like lots of work. it’s pretty much
[an] opportunity-type thing. If I have the
chance to eat...if I don’t, I don’t.

Time

10

E0014: tired.. ,out of shape, time

8

E003_E012: Um not having a lot of time
sometimes money, like the vegetables are
expensive so money.

Monitor Foods
Within the Home
Environment
(Healthy Eating)

6

003_E012: I have all the control. Yea because
I’m buying all the food…..Uh pretty good
because they’re eating right so you know I'm
not worried about it.

PE-Nut Program
(Healthy Eating)

3

E003_E012: Um they help me cook, um they
tell me about programs in school like the PENut program

Children
(Facilitator)

3

Self-Motivation

Personal
Facilitator
Providing
Healthy
Environment For
Children

Health Concern/
Benefits

Personal Barrier

Cost/Budgetary
Constraints

Home
Environment
Facilitator

E003_E012: Mostly my kids

206

Table 5.2 (Cont’d)

Parent Modeling
(Healthy Eating)

Family
Participation in
Physical
Activity
Home
Environment
Barriers

2

7

E003_E012: Um, well my kids would
probably benefit from it also because they
would learn that this is the correct way to eat,
and then you know if they see me do it then
they’ll want to eat healthier also and if they
see me eat healthy and lose weight and later
on in life they were overweight then they
probably would do what I did
E001: Ok, I can think of- my daughter
just got a bike and I ride my bike while I’m
with her.
Time, lack of products and I’m just having
more processed type much quicker and easier

Time (Physical
Activity)

Expected
Improvement in
School meals

5

8

I think they could be better (laughs); E0014: I
have heard they consider ketchup a vegetable
and someone said that someone said and
consider ketchup a vegetable and the lunch
can use that as a vegetable ..

5

Uh yea my daughter was saying something
about them eating a lot more vegetables and
having fresh fruit. Um but usually they’ll get
that at home like they’ll eat fruits and stuff
from my house so I’m not really worried
about them getting enough-

Child's School
Environment
Appreciative of
Health
improvements in
School Meals

207

Table 5.2 (Cont’d)

Community
Barriers

Neighborhood
Environment/
safety (Physical
Activity)

5

Access to
grocery store

3

Lack of facilities

5

Recreational
Facilities

1

Access to
grocery store

Nothing, nothing but fast food for miles.
I don’t know anything, there’s no community
center over here so it’s an hour to the next
across.
Recreation centers ….. if I get time to go.

4

I think that I’m close to places to purchase
healthy food and the neighborhood also has
fast food places too and makes me stop from
home and a minute from work

3

but if you maybe if you take a little class or
something and then you’re doing it by your
memory and not just by having to look on a
chart or something like that. That’s much
better because when you’re cooking you’re
adding everything in it that you really need
that’s healthy so it’s not something that you
have to keep checking on you know because
you don’t have a lot of time to do everything
(laughs)

Community
Facilitator

If they had a
class

yeah I mean like my oldest, my oldest used to
get on his bike and ride around the
neighborhood and then go on to the next
neighborhood but I can’t let him do that
anymore he has to stay in this side of the
neighborhood because like of the trouble that’s
going on in that side of neighborhood I don’t
want him on this street because it’s a bad street

208

REFERENCES

209

REFERENCES

1. Abboud H, Henrich WL, Md. Stage IV Chronic Kidney Disease. New England Journal of
Medicine. 2010;362(1):5665.http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/223907605?acc
ountid=12598. 10.1056/NEJMcp0906797.
2. Adams PF, Martinez ME, Vickerie JL. Summary health statistics for the U.S. population:
National Health Interview Survey, 2009. National Center for Health Statistics. Vital
Health Stat.2010; 10(248).
3. Aggio D, Ogunleye a a, Voss C, Sandercock GRH. Temporal relationships between
screen-time and physical activity with cardiorespiratory fitness in English schoolchildren:
a 2-year longitudinal study. Prev. Med. (Baltim). 2012;55(1):37–9. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/22561029. Accessed December 1, 2013.
4. Agras S, Hammer L, McNicholas F. (1999). A prospective study of the impudence of
eating disordered mothers on their children. International Journal of Eating
Disorders.1999;25: 253−262.
5. Aguilar FS, Martinez-Vizcaino V, Lopez M, Martinez M, Gutlerrez R, Martinez SS,
Lopez-Garcia E, Rodriguez-Artalejo. Impact of an After-School Physical Activity
Program on Obesity in Children. The Journal of Pediatrics.2010; 157(1): 36-42.
6. Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior,
Englewood. 1980.
7. Albright CL, Steffen AD, Wilkens LR, Henderson BE, Kolonel LN. The Prevalence of
Obesity in Ethnic Admixture Adult. Obesity.2008; 16: 1138–1143.
8. American Diabetes Association. Type 2 diabetes in children and adolescents. Journal of
American Academy of Pediatrics. 2000;105:671–680.
9. American Psychological Association, Task Force on Socioeconomic Status. Report of the
APA Task Force on Socioeconomic Status. Washington, DC: American Psychological
Association. Status. Washington, DC: 2007.
10. Anderson BE, Lyon-Callo SK, Monje SE, Boivin MD, Imes G. Overweight and Obesity
in Michigan: Surveillance Report Series 2009. Lansing, MI: Michigan Department of
Community Health, Bureau of Epidemiology, Chronic Disease Epidemiology
Section.http://www.michigan.gov/documents/mdch/Obesity_chapter_283600_7.pdf.

210

11. Arvantes J. U.S. Surgeon General Lays Out Goals, Priorities of Anti-Obesity Campaign
Nation's 'First Doctor' Outlines Role for Family Physicians in Obesity Fight.
2010. Available at: http://www.aafp.org/online/en/home/publications/news/newsnow/obesity/20100517benjaminaudio.html. Accessed Feb 2011.
12. Assis MA, Kupek E, Guimaraes D, Calvo MC, Andrade DF, Bellisle F. Test-retest
reliability and external validity of the previous day food questionnaire for 7-10-year-old
school children. Appetite.2008;51: 187-193.
13. Baker EA, Kelly C, Barnidge E, Strayhorn J, al e. The Garden of Eden: Acknowledging
the Impact of Race and Class in Efforts to Decrease Obesity Rates. American Journal of
Public Health. 2006;96(7):1170-11704.http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/215083508?acco
untid=12598.
14. Baker EA, Schootman M, Barnidge E, Kelly C. The role of race and poverty in access to
foods that enable individuals to adhere to dietary guidelines. Preventing Chronic Disease
Public Health Research Practice and Policy.2006; 3: 1–11.
15. Ball K, Timperio A, Crawford D. Neighborhood socioeconomic inequalities in food
access and affordability. Health & Place. 2009; 15: 578–585.
16. Bandura, A. Social cognitive theory. In R. Vasta (Ed.), Annals of child development. Six
theories of child development Greenwich, CT: JAI Press. 1989; 6:1-60.
17. Bandura, A. Social learning theory. New York: General Learning Press.1977.
18. Basiotis PP, Kramer-LeBlanc C S, Kennedy ET. Maintaining Nutrition Security and Diet
Quality: The Role of the Food Stamp Program and WIC.Journal of Family Economics
and Nutrition Review.1998; 11: 4–16.
19. Baxter SD, Hardin JW, Royer JA, Smith AF, Guinn CH. "Sources of Intrusions in
Children's Dietary Recalls from a Validation Study of Order Prompts." Journal of Health
Psychology 2008;1157-1162.
20. Baxter, SD, HardinJW, Guinn CH, Royer JA, Mackelprang AJ. Smith SF. Fourth-Grade
Children's Dietary Recall Accuracy Is influenced by Retention Interval (Target Period
and Interview Time). Journal of the American Dietetic Association.2009;109:846-856.
21. Bennett GG, McNeill LH, Wolin KY, Duncan DT, Puleo E, Emmons KM. Safe to walk?
Neighborhood safety and physical activity among public housing residents. PLoS Med.
2007;4(10):1599–606; discussion 1607. Available at:

211

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2039759&tool=pmcentrez&r
endertype=abstract. Accessed December 19, 2013.
22. Berge JM, Wall M, Loth, K, and Neumark-Sztainer D. Parenting style as a predictor of
adolescent Weight and Weight-Related Behaviors. Journal of Adolescent Health.2010;
46(4):331-338.
23. Biro FM, Wien M. Childhood obesity and adult morbidities. American Journal of
Clinical Nutrition. May 2010;91(5):1499S-1505S.
24. Blanton CA, Moshfegh AJ, Baer DJ, Kretsch MJ. The USDA automated multiple-pass
method accurately estimates group total energy and nutrient intake. Journal of Nutrition.
2006. 10:2594-2599.
25. Block G, Hartman AM, Naughton D. A reduced dietary questionnaire: development and
validation. Epidemiol 1990; 1:58-64
26. Bloomgarden ZT. Diabetes and nutrition. Diabetes Care. 2002;25(10):1869-186975.http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/223066375?acc
ountid=12598.
27. Blum JW, Jacobsen DJ, Donnelly JE. Beverage Consumption Patterns in Elementary
School Aged Children across a Two-Year Period. Journal American College of
Nutrition.2005;24(2):93-98.
28. Body mass index during childhood, adolescence, and young adulthood in relation to adult
overweight and adiposity: The Fels longitudinal study. International Journal
of Obesity.2000; 24, 1628–1635.
29. Boinapally P, Fussman C, Imes G. Overweight and Obesity Facts in Michigan Adults.
Michigan’s Nutrition, Physical Activity and Obesity Program Surveillance Brief.
Michigan Department of Community Health, Division of Genomics, Perinatal Health and
Chronic Disease Epidemiology. February 2011.
30. Boles RE, Scharf C, Filigno SS, Saelens BE, Stark LJ. Differences in home food and
activity environments between obese and healthy weight families of preschool children.
J. Nutr. Educ. Behav. 2013;45(3):222–31. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/23380192. Accessed December 11, 2013.
31. Booth ML, King LA, Pagnini DL, Wilkenfeld RL, Booth SL. Parents of school students
on childhood overweight: The Weight of Opinion Study. Journal of Pediatrics and Child
Health. 2009:45(4);194 Academic OneFile. Web. 7 Aug. 2011.

212

32. Bowman SA, Gortmaker SL, Ebbeling CB, Pereira MA, Ludwig DS. Effects of FastFood Consumption on Energy Intake and Diet Quality Among Children in a National
Household Survey. Journal of the American Academy of Pediatrics.2004;113(1):112118.
33. Bramble J, Cornelius LJ, PhD. Simpson G. Eating as a Cultural Expression of Caring
among Afro-Caribbean and African American Women: Understanding the Cultural
Dimensions of Obesity. Journal Health Care Poor Underserved. 2009;20(2):5368. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/220587234?acc
ountid=12598.
34. Briefel RR, Crepinsek MK Cabili C, Wilson A, Gleason PM. School Food Environments
and Practices Affect Dietary Behaviors of US Public School Children. Journal of the
American Dietetic Association. 2009; 109 (2): S91-S107.
35. Bureau USC. American FactFinder - Results. Available at:
http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk.
Accessed December 1, 2013.
36. Caan BJ, Slattey ML, Potter J, Quessenbury CP, Coates AO, Schaffer DM. Comparison
of the Block and the Willett Self-administered Semiquantitative Food Frequency
Questionnaires with an Interviewer-administered Dietary History. American Journal of
Epidemiology.1998:1137-1147.
37. Calfas KJ, Taylor WC. Effects of physical activity on psychological variables in
adolescents. Pediatric Exercise Science. 1994;6: 406–423.
38. Calle EE, Rodrigues C, Walker-Thurmond K, Thun MJ. Overweight, obesity and
mortality from cancer in a prospectively studied cohort of U.S. adults. New England
Journal of Medicine. 2003; 648(17):1625-1638.
39. Campbell KJ, Crawford D a, Ball K. Family food environment and dietary behaviors
likely to promote fatness in 5-6 year-old children. Int. J. Obes. (Lond). 2006;30(8):1272–
80. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16491108. Accessed January 2,
2014.
40. Campbell KJ, Crawford DA, Salmon J, Carver A, Garnett SP, Baur LA. Associations
between the home food environment and obesity-promoting eating behaviors in
adolescence. Obesity (Silver Spring). 2007;15(3):719–30. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/17372323. Accessed January 5, 2014.
41. Carlson JJ , Eisenmann JC, Pfeiffer KA, Jager KB, Sehnert ST, Yee KE, Klavinski
RA, Feltz DL. (S)Partners for Heart Health: a school-based program for enhancing

213

physical activity and nutrition to promote cardiovascular health in 5th grade
students.BioMed Central Public Health.2008;8:420-32.
42. Caterson ID, Hubbard V, Bray G, Grunstein R, Hansen B, Hong Y, Labarthe D, Seidell J,
Smith S. Prevention Conference VII Obesity, a Worldwide Epidemic Related to Heart
Disease and Stroke Group III: Worldwide Comorbidities of Obesity. Journal of the
American Heart Association. 2004;110;e476-e483.
43. CDC. Center for Disease Control and Prevention. BMI Percentile Calculator for Child
and Teen English Version. Available
athttp://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx. Accessed March 2012
44. CDC. Centers for Disease Control and Prevention . About BMI for Children and Teens.
Available
at:http://www.cdc.gov/healthyweight/assessing/bmi/childrens_BMI/about_childrens_BM
I.html#What is BMI percentile . Accessed September 2011.
45. CDC. Centers for Disease Control and Prevention . BRFSS Prevalence and Trends Data.
2003. Available at:
http://apps.nccd.cdc.gov/BRFSS/display.asp?cat=OB&yr=2003&qkey=4409&state=US
Accessed September 2011.
46. CDC. Centers for Disease Control and Prevention. Child Development. Middle
Childhood (9-11 years of age).
http://www.cdc.gov/ncbddd/childdevelopment/positiveparenting/middle2.html 2012.
Accessed July, 2012.
47. CDC. Centers for Disease Control and Prevention. (CCDC). Overweight and Obesity.
Available at: http://www.cdc.gov/obesity/data/trends.html. Update April, 27, 2012.
Accessed July, 2011.
48. CDC. Centers for Disease Control and Prevention. Child Development Middle Childhood
(9-11yrs). Centers for Disease Control and Prevention National Center for Health
Statistics website. Available
http://www.cdc.gov/ncbddd/childdevelopment/positiveparenting/middle2.html. Updated
Mach 16, 2012
49. CDC. Centers for Disease Control and Prevention. Comparison Between Detroit Students
and U.S. Students 2007 YRBS Available
at: http://www.cdc.gov/HealthyYouth/yrbs/pdf/states/yrbs07_detroit_us_comparison.pdf
Accessed May 30, 2008.
50. CDC. Centers for Disease Control and Prevention. Health E-Stat Prevalence of Obesity
Among Children and Adolescents: United States, Trends 1963-1965 Through 2007-2008.
214

Centers for Disease Control and Prevention National Center for Health Statistics website.
Available
at:http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.htm.
Updated June 4, 2010. Accessed June 23, 2011.
51. CDC. Centers for Disease Control and Prevention. Healthy Weight: Assessing Your
Weight: BMI: Child and Teen Calculator | DNPAO | CDC. Accessed May 2012.
Available at: http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx
52. CDC. Centers for Disease Control and Prevention. Majority of Americans not Meeting
Recommendations for Fruit and Vegetable Consumption.
http://www.cdc.gov/media/pressrel/2009/r090929.htm. Published September 29, 2009.
Accessed July 12, 2011.
53. CDC. Centers for Disease Control and Prevention. National diabetes fact sheet: national
estimates and general information on diabetes and prediabetes in the United States, 2011.
Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, 2011.
54. CDC. Centers for Disease Control and Prevention. National diabetes fact sheet: national
estimates and general information on diabetes and prediabetes in the United States, 2011.
Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, 2011.
55. CDC. Centers for Disease Control and Prevention. Neighborhood safety and the
prevalence of physical inactivity--selected states, 1996. MMWR. Morb. Mortal. Wkly.
Rep. 1999;48(7):143–6. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10077460.
Accessed January 7, 2014.
56. CDC. Physical activity levels among children aged 9–13 years—United States,
2002. MMWR2003; 52 (SS-33):785–788.
57. CDC. Centers for Disease Control and Prevention. Children and Diabetes (CCDC)
SEARCH for Diabetes in Youth. May 2011 Available
at:http://www.cdc.gov/diabetes/projects/diab_children.htm. Accessed June 16,2011.
58. Center for Educational Performance and Information (CEPI) (b). Free and Reduced Price
Lunch Count. Fall 2011 Building Level Data: K-12.DataAvailable at:
http://www.michigan.gov/cepi/0,4546,7-113-21423_30451_36965---,00.html .Accessed
Dec 3, 2012
59. Center for Educational Performance and Information (CEPI). 2011-2012 Pupil Public
Headcount Data Michigan Student Data System (MSDS). Building Data. Available at:

215

http://www.michigan.gov/cepi/0,4546,7-113-21423_30451---,00.html .Accessed.
December 3, 2012
60. Charmaz, K. Constructing Grounded Theory: A Practical Guide Through Qualitative
Analysis. Thousand Oaks, CA: SAGE;2006.
61. Chen A, Escarce J. Family structure and childhood obesity, Early Childhood
Longitudinal Study - Kindergarten Cohort. Preventing Chronic Disease. May
2010;7(3):A50.
62. Childhood obesity: affecting choices. The Lancet. 2010;375(9715):611611. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/199059776?a
ccountid=12598.
63. Children Youth and Family & Socioeconomic Status. Available at:
http://www.apa.org/pi/ses/resources/publications/factsheet-cyf.pdf . Accessed May, 2011.
64. Chinnock A. Validation of an estimated food record. Public Health Nutrition.2004;
9(7):934-941.
65. Chomitz VR, Slining MM, McGowan RJ, Mitchell SE, Dawson GF, Hacker KA. Is
There a Relationship Between Physical Fitness and Academic Achievement? Positive
Results From Public School Children in the Northeastern United States. Journal of
School Health. 2009; 79(1):30-37.
66. City-Data.com. City-Data. Ypsilanti, Michigan (MI) Poverty Rate Data - Information
about poor and low income residents. Available athttp://www.citydata.com/poverty/poverty-Ypsilanti-Michigan.html. Accessed December 2009
67. Conley D. Decomposing the Black-White Wealth Gap: The Role of Parental Resources,
Inheritance, and Investment Dynamics. Sociological Inquiry.2001, 71: 39–66.
doi: 10.1111/j.1475-682X.2001.tb00927.x
68. Cook AJ, Friday JE. Pyramid Servings database for USDA Survey Codes Version 2.0.
2004. Available at: http://www.ars.usda.gov/Services/docs.htm?docid=8634. Accessed
September, 2011.
69. Craig MR, Kristal AR, Cheney CL, Shattuck AL.The prevalence and impact of 'atypical'
days in 4-day food records. Journal American Dietetic Association.2000;100:421-427.
70. Crawford D, Cleland V, Timperio a, et al. The longitudinal influence of home and
neighbourhood environments on children’s body mass index and physical activity over 5

216

years: the CLAN study. Int. J. Obes. (Lond). 2010;34(7):1177–87. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/20351728. Accessed December 19, 2013.
71. Crepinsek MK, Gordon AR, McKinney PM, Condon EM, Wilson A. Meals offered and
served in US public schools: Do they meet nutrient standards. Journal of the American
Dietetic Association. 2009;109(suppl): S31-S43.
72. Croll J, Neumark-Sztainer D, Story M. Healthy Eating: What Does it Mean to
Adolescents. Journal of Neural Engenering.2001; 33:193-198.
73. Croll J. Chapter 13 Body Image and Adolescents. Minneapolis; 2005. Available at:
http://www.epi.umn.edu/let/pubs/img/adol_ch13.pdf.
74. Cullen KW, Thompson DI. Texas School Food Policy Changes Related to Middle School
à la Carte/ Snack Bar Foods: Potential Savings in Kilocalories. Journal of the American
Dietetic Association. 2005;105(12):1952–54.
75. Cullen KW, Watson K, Zakeri I. Relative reliability and validity of the Block kids
questionnaire among youth aged 10 to 17 years. Journal of American Dietetic
Association. 2008;108:862-866.
76. Currie J. Healthy, wealthy, and wise: Socioeconomic status, poor health in childhood,
and human capital development. Journal of Economic Literature. 2009;47(1): 87-122.
77. Daniels S, Arnett D, Eckel R, et al. Overweight in children and adolescents:
pathophysiology, consequences, prevention, and treatment. Circulation 2005; 111:1999
–2012.
78. Daniels SR, Arnett DK, Eckel RH, Gidding SS, Hayman LL, Kumanyika S, Robinson
TN, Scott BJ, Jeor SS, Williams CL. Overweight in Children and Adolescents:
Pathophysiology, Consequences, Prevention, and Treatment. Journal of the American
Heart Association.2005; 111: 1999-2012.
79. Darling, N. Parenting Style and Its Correlates. ERIC Digest. Clearing House on
Elementary and Early Childhood Education.1999.
http://ceep.crc.uiuc.edu/eecearchive/digests/1999/darlin99.html .Accessed August 19,
2012.
80. Davis SP, Northington L, Kolar K. Cultural considerations for treatment of childhood
obesity. Journal of Cultural Diversity. 2000;7(4):128-12832. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/219342221?acc
ountid=12598.

217

81. Dawyer J, Cosentino C, Dongln LI, Feldman H, Garceau A, Stevens M, Perry C,
Holescher D, Webber LS, Zive M. Evaluating school-based interventions using the
Healthy Eating Index. Journal of the American Dietetic Association. 2002; 102: 257-259.
82. Deja HendricksonChery SE. Fruit and vegetable access in four low-income food deserts
communities in Minnesota. Agriculture and Human Values. 2006;23(3):371-371383. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/214182654?a
ccountid=12598. 10.1007/s10460-006-9002-8.
83. Design Council. Cracking crime through design. London; 2001:1–56.
84. Dietz W. Health consequences of obesity in youth: Childhood predictors of adult disease.
Pediatrics 1998;101:518-525.
85. Dietz WH. Overweight in childhood and adolescence. New England Journal of
Medicine2004; 350:855–857.
86. Drewnowski A. Fat and Sugar: An Economic Analysis. The Journal of Nutrition.2003:
133:838S-840S.
87. Drewnowski A. Obesity and the food environment: dietary energy density and diet costs.
American Journal of Preventive Medicine. 2004;27(3S): 154-162.
88. Drewnowski A. Obesity, diets, and social inequalities. Nutrition
Reviews.2009;67(Supplement 1):S36-S39.
89. Eagle TF, Sheetz A, Gurm R, Woodward AC, Kline-Rogers E, Leibowitz R, DurusselWeston J, Palma-Davis L, Aaronson S, Fitzgerald CM, Mitchell LR, Rogers B, Bruenger
P, Skala KA, Goldberg C, Jackson EA, Erickson SR, Eagle KA. Understanding
childhood obesity in America: Linkages between household income, community
resources, and children’s behaviors. American Heart Journal. 2012;163(5): 836-43.
90. Eagly AH, Chaiken S. Process theories of attitude formation and change: The
elaboration likelihood and heuristic-systematic models, the psychology of attitudes.
Orlando, Harcourt Brace; 1993. pp.305-346.
91. Eisenmann JC, Bartee RD, and Wang MQ. Physical Activity, TV Viewing, and Weight
in U.S. Youth: 1999. Youth Risk Behavior Survey Obesity Research.2002(10):379–385.
doi: 10.1038/oby.2002.52.
92. EPEC. Exemplary Physical Education Curriculum. Available at:
http://www.epec4kids.com/. Accessed September 2009

218

93. Epstein LH, Gordy CC, Raynor HA, Beddome M, Kilanowski CK, Paluch R. Increasing
fruit and vegetable intake and decreasing fat and sugar intake in families at risk for
childhood obesity. Obesity Research. 2001;9:171–178.
94. Etelson D, Brand D a, Patrick P a, Shirali A. Childhood obesity: do parents recognize this
health risk? Obes. Res. 2003;11(11):1362–8. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/14627757.
95. Evenson KR, Ballard K, Lee G, Ammerman A. Implementation of a school-based state
policy to increase physical activity. Journal of School Health. 2009;79:231-238.
96. Falciglia GA, Horner SL, Liang J, Couch S, Levin LS. Assessing Dietary Variety in
Children: Development and Validation of a Predictive Equation. Journal of the American
Dietetic Assoication.2009;109:641-647.
97. Feskanich D, Rockett HRH, Coldits A .Modifying the Healthy Eating to Assess Diet
Quality in Children and Adolescents. Journal of American Dietetic
Association.2004;104:1375-1383.
98. Field AE, Peterson, KE , Gortmaker SL, Cheung L, Rockett H, Fox MK, Coditz GA.
Reproducibility and Validity of a food frequency questionnaire among fourth to seventh
grade inner-city school children: implications of age and day-to-day variation in dietary
intake. Journal of Public Health and Nutrition.1999;2(3):293-300.
99. Finkelstein EA, Trogdon JG. Public Health Interventions for Addressing Childhood
Overweight: Analysis of the Business Case. American Journal of Public Health.
2008;98(3)4115 http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/215091316?acco
untid=12598.
100. Fisher JO, Mitchell DC, Smiciklas-Wright H. Parental influence on young girl’s fruit
and vegetable, micronutrient, and fat intakes. Journal of the American Dietetic
Assocication.2002;102(1): 58-64.
101. Florence MD, Asbridge M, Veugelers PJ. Diet Quality and Academic
Performance. Journal of School Health.2008;78(4)209-215.
102. Fox MK, Dodd AH, Wilson A, Gleason PM. Association between School Food
Environment and Practices and Body Mass Index of US Public School Children. Journal
of the American Dietetic Association. 2009;109(2):S108-S117.
103. Franks PW, Phd, Hanson, Robert L,MD, MPH, Knowler, William C,MD, DrPH,
Sievers ML, MD, Bennett, Peter H,MB, FRCP, Looker, Helen C,MB, BS. Childhood
219

Obesity, Other Cardiovascular Risk Factors, and Premature Death. New England Journal
of Medicine. 2010;362(6):485-48593. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/223927003?acc
ountid=12598. 10.1056/NEJMoa0904130.
104. Freedman DS, Mel Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk
factors and excess adiposity among overweight children and adolescents: the Bogalusa
Heart Study. Journal of Pediatrics. 2007:150(1):12-17.
105. Fuemmeler BF, Pendzich MK, Tercyak KP. Weight, Dietary Behavior, and Physical
Activity in Childhood and Adolescence: Implications for Adult Cancer Risk. The
European Journal of Obesity. 2009; 3:179–186.
106. Gaines A, Turner LW. Improving Fruit and Vegetable Intake Among Children: A
Review of Interventions Utilizing the Social Cognitive Theory. Californian Journal of
Health Promotion. 2009; 7(1): 52-66.
107. Geier AB, Foster GW, Leslie G, McLaughlin JB, Kelly E, Nachmani J, Sherman S,
Kumanyika S, and Shults J. The Relationship Between Relative Weight and School
Attendance Among Elementary Schoolchildren. Obesity. 2007;15: 2157-2161.
108. Gentile DA, Welk G, Eisenmann JC, Reimer RA, Walsh DA, Russell DW, Callahan R,
Walsh M, Strickland S, and Fritz K. Evaluation of a multiple ecological level child
obesity prevention program: Switch what you Do, View, and Chew. BioMed Central
Medicine.2009;7:49-51.
109. Gidding SS, Dennison BA, Birch LL, Daniels SR, Gilman MW, Lichtenstein AH,
Rattay KT, Steinberger J, Stettler N, Van Horn L. Dietary recommendations for children
and adolescents. A guide for practitioners. Consensus statement from the American
Heart Association. Circulation. 2005;112: 2061-2075.
110. Glanz K, Sallis J, Saelens B, Frank L. Nutrition Environment Measures Survey in stores
(NEMSS):development and evaluation. American Journal of Preventative Medicine. Apr
2007;32(4):282-289.
111. Golan M, Crow S. Parents are key players in the prevention and treatment of weightrelated problems. Nutrition Reviews.2004; 62: 39–50.
112. Golan M, Weizman A. Familial Approach To The Treatment Of Childhood Obesity:
Conceptual Model. Journal of Nutrition Education. 2001; 33(2):102-107.
113. Goran MI, Treuth Ms. Energy Expenditure, Physical Activity, and Obesity In Children.
Pediatr. Clin. North Am. 2001;48(4):931–953. Available at:
220

http://www.sciencedirect.com/science/article/pii/S0031395505703497. Accessed
December 2, 2013.
114. Gorely T, Nevill ME, Morris JG, Stensel DJ, and Nevill A. Effect of a school-based
intervention to promote healthy lifestyles in 7–11 year old children. International Journal
of Behavioral Nutrition and Physical Activity. 2009; 6:5 doi:10.1186/1479-5868-6-5.
115. Gosling R, Stanistreet D, Swami V. 'If Michael Owen Drinks it, Why can't I?' − 9 and
10 Year Olds' Perceptions of Physical Activity and Healthy Eating. Health Education
Journal. 2008; 67(3): 167-181.
116. Gross SM, Bronner Y, Welch C, Dewebby-Moore N, Paige DM. "Breakfast and Lunch
Meal Skipping Patterns amoung Fouth-Grade Children from Selected Public Schools in
Urban, Suburban, and Rural Maryland. Journal of the American Dietetic Association.
2004;104(3):420-423.
117. Gross SM, Pollock ED, Braun B. Family Influence: Key to Fruit and Vegetable
Consumption among Fourth- and Fifth-grade Students. Journal of Nutrition Education
and Behavior. 2010;42(4):235-241.
118. Guenther PM, Casavale KO, Reedy J, et al. Update of the Healthy Eating Index: HEI2010. J. Acad. Nutr. Diet. 2013;113(4):569–80. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/23415502. Accessed November 11, 2013.
119. Guenther PM, Reedy J, Krebs-Smith SM, Reeve BB, Basiotis PP. Development and
Evaluation of the Healthy Eating Index-2005: Technical Report. Center for Nutrition
Policy and Promotion, U.S. Department of Agriculture. Available at
http://www.cnpp.usda.gov/HealthyEatingIndex.htm.
120. Guenther PM, Reedy J, Krebs-Smith SM, Reeve BB. Evaluation of the Healthy Eating
Index-2005. Journal of the American Dietetic Association.2008; 108(11):1854-1864.
121. Guenther PM, Reedy J, Krebs-Smith SM. Development of the Healthy Eating Index2005. J. Am. Diet. Assoc. 2008;108(11):1896–901. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/18954580. Accessed December 2, 2013.
122. Gundersen C, Lohman BJ, Garasky S, Stewart S, Eisenmann J. Food Security, Maternal
Stressors, and Overweight Among Low-Income US Children: Results From the National
Health and Nutrition Examination Survey (1999–2002). Journal of the American
Academy Pediatrics 2008;122:e529–e540.
123. Guo SS, Huang C, Maynard LM, Demerath E, Towne B, Chumlea WC, Siervogel RM.
Body mass index during childhood, adolescence and young adulthood in relation to adult

221

overweight and adiposity: the Fels Longitudinal Study. International Journal of Obesity
Related Metabolic Disorder. 2000;24(12)1628-35.
124. Gupta R, Bhangoo A, Matthews NA, Anhalt H, Matta Y, Lamichhane B, Malik S,
Narwal S, Wetzler G, Ten S. The prevalence of non-alcoholic fatty liver disease and
metabolic syndrome in obese children. Journal of Pediatric Endocrinology and
Metabolism. 2011;24(11-12): 907-11.
125. Hagberg JM, Ehsani AA, Goldring D, Hernandez A, Sinacore DR, Holloszy JO. Effect
of weight training on blood pressure and hemodynamics in hypertensive
adolescents. Journal Pediatrics. 1984;104:147-151.
126. Hammond R, Levine R. The economic impact of obesity in the United States .Diabetes,
Metabolic Syndrome, and Obesity: Targets and Therapy. 2010; 3 285–
295http://www.brookings.edu/~/media/research/files/articles/2010/9/14%20obesity%20c
ost%20hammond%20levine/0914_obesity_cost_hammond_levine.pdf.
127. Han JC, Lawlor DA, Kimm SY. Childhood obesity. Lancet. May 15
2010;375(9727):1737-1748.
128. Hands BP, Chivers PT, Hands BP, Kendall G, Larkin D, Parker HE. The associations
between physical activity, screen time and weight from 6 to 14 yrs: The Raine
Study. Journal of Science and Medicine in Sport.2011;14(5):397-403. Academic OneFile.
Web. 22 Aug. 2011.
129. Hansen HS, Froberg K, Hyldebrandt N, Nielsen JR. A controlled study of eight months
of physical training and reduction of blood pressure in children: the Odense schoolchild
study. British Medical Journal.1991;303:682–685.
130. Harris KC, Saloos HA, De Souza AM, Sanatani S, Hinchliffe M, Potts JE, Sandor GS.
Biophysical Properties of the Aorta and Left Ventricle and Exercise Capacity in Obese
Children. American Journal of Cardiology. 2012;110:897-901
131. He M. Are parents aware that their children are overweight or obese? Do they
care? Canadian Family Physician. 2007; 53(9):1493-1499.
132. Heart and Stroke Foundation of Canada (2010, October 25). Obese children show signs
of heart disease typically seen in middle-aged adults, researcher says. ScienceDaily.
Retrieved January 09, 2011.
133. Hediger ML, Overpeck MD, Kuczmarski RJ, Ruan WJ: Association between infant
breastfeeding and overweight in young children. Journal of the American Medical
Association. 2001;285:2453-2460.
222

134. Heron M. Deaths: Leading Causes for 2006. National Vital Statistics Reports.
Hyattsville, MD: National Center for HealthStatistics. 2010;58(14):1-100.
135. Hoelscher DM, Day RS, Kelder SH, Ward JL. Reproducibility and validity of the
secondary level School-Based Nutrition Monitoring student questionnaire. Journal of the
American Dietetic Association. 2003;103:186-194.
136. Hoelscher DM, Evans A, Parcel GS, Kelder SH. Designing effective nutrition
interventions for adolescents. Journal of the American Dietetic Association.
2002(00028223):S52-S52
63.http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/218462259?acc
ountid=12598.
137. Hu F. Obesity Epidemiology. New York: Oxford University Press, Inc.; 2008.
138. Hurley KM, Oberlander SE, Merry BC, Wrobleski MM, Klassen AC, and Black MM.
The Healthy Eating Index and Youth Healthy Eating Index Are Unique, Nonredundant
Measures of Diet Quality among Low-Income,African American Adolescents. Journal of
Nutrition.2009;139: 359–364.
139. Ihmels MA, Welk GJ, Eisenmann JC, Nusser SM. Development and preliminary
validation of a Family Nutrition and Physical Activity (FNPA) screening
tool. International Journal of Behavioral Nutrition and Physical Activity. 2009; 6:14.
140. Institute of Medicine of the National Academies. Childhood Obesity in the United
States: Facts and Figures. Available at:
http://www.activelivingresources.org/assets/Childhood_obesity_fact_sheet.pdf.Obesity:
Health in the Balance, 2005 page 2
141. Institute of Medicine. Educating the Student Body: Taking Physical Activity and
Physical Education to School. Washington, DC: The National Academies Press, 2013.
142. Institute of Medicine. Preventing Childhood Obesity: Health in the Balance.
Washington, DC: The National Academies Press; 2004.
143. James KS, Connelly CD, Rutkowski E, McPherson D, Gracia L, Mareno N, Zirkle D.
Family-Based Weight Management With Latino Mothers and Children. Journal for
Specialists in Pediatric Nursing. 2008; 13(4): 249-262.
144. Janke EA, Collins A, Kozak AT. Overview of the relationship between pain and obesity:
What do we know? Where do we go next? Journal of Rehabilitation Research and
Development. 2007;44(2):245- 62.

223

http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/215284954?accoun
tid=12598.
145. Jebb S. Obesity: causes and consequences. Women’s Heal. Med. 2004;1(1):38–41.
Available at: http://linkinghub.elsevier.com/retrieve/pii/S1744187006000102.
146. Johnson RJ, Segal MS, Sautin Y, et al. Potential role of sugar (fructose) in the epidemic
of hypertension, obesity and the metabolic syndrome, diabetes, kidney disease, and
cardiovascular disease. Am. J. Clin. Nutr. 2007;86(4):899–906. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/17921363.
147. Johnson RK, Frary C, Wang MQ. The nutritional consequences of flavored-milk
consumption by school-aged children and adolescents in the United States. Journal of the
American Dietetic Association. 2002;102(6):853-855.
148. Jouret B, Ahluwalia N, Cristini C, Dupuy M, Negre-Pages L, Grandjean H, Tauber M.
Factors associated with overweight in preschool-age children in southwestern France.
American Journal of Clinical Nutrition. 2007;85(6): 1643-9.
149. Kant AP. Indexes of Overall Diet Quality: A Review. Journal of The American Dietetic
Association. 1996; 96(8):785-791.
150. Kaplan K. Is the National School Lunch Program to blame (in part) for the rise of
childhood obesity? Los Angeles Times. 2011Acessed: August 7,
2011. http://articles.latimes.com/2011/apr/06/news/la-heb-school-lunch-program-obesity20110406.
151. Kelly NR, Bulik CM, Mazzeo SE. An exploration of body dissatisfaction
and perceptions of Black and White girls enrolled in an intervention
for overweight children. Body Image. 2011: 379–384.
152. Kenndy E, Hirschman J, Andrews M, Carlson S, Cristofal S, McKinney P, and Lawler
M. The Healthy Eating Index. Center for Nutrition Policy and Promotion, U.S.
Department of Agriculture. Available at
http://www.cnpp.usda.gov/publications/hei/HEI89-90report.pdf .Accessed December 3,
2012
153. Kennedy ED, Goldberg J. What Are American Children Eating? Implications for Public
Policy. Nutrition Reviews. 1995; 53(5):111-126.
154. Kennedy ET, Ohls J, Carolson S, Fleming K. The Healthy Eating Index: Design and
application. Journal of the American Dietetic Association.1995;95:1103-1108.

224

155. Kim Y. Minority parental involvement and school barriers: Moving the focus away from
deficiencies of parents. Journal of Elsevier Educational Research Review.2009;(4):80–
102.
156. Kistler KD, Molleston J, Unalps A, Abramas SH, Behling C, Schwimmer JB. Symptoms
and quality of life in obese children and adolescentswith non-alcoholic fatty liver
disease. Alimentary Pharmacology & Therapeutics. 2009; 31(3):396–406.
157. Kitzmann KM, Beech BM. Family-based interventions for pediatric obesity:
Methodological and conceptual challenges from family psychology. Journal of Family
Psychology. 2006;20(2): 175-189.
158. Kluck S. Family Factors in the development of disordered eating: Integrating dynamic
behavioral explanations. Eating Behavior. 2008; 9:471-483
159. Koletzko B.Basic concepts in nutrition: Nutritional needs of children and
adolescents. European Journal of Clinical Nutrition. 2008;3:179-187.
160. Kraus MW, Keltner D. Signs of Socioeconomic Status: A Thin-Slicing
Approach. Psychological Science. 2009 20:99106http://pss.sagepub.com/content/20/1/99.full.pdf+html.
161. Krauss RM, Deckelbaum RJ, Ernst N, et al. Dietary Guidelines for Healthy American
Adults: A Statement for Health Professionals From the Nutrition Committee, American
Heart Association. Circulation. 1996;94(7):1795–1800. Available at:
http://circ.ahajournals.org/content/94/7/1795.full. Accessed December 2, 2013.
162. Krebs-Smith SM, Guenther PM, Subar AF, Kirkpatrick SI, Dodd KW. Americans do
not meet federal dietary recommendations. Journal of Nutrition. 2010;140(10): 1832-8.
163. Lake A, Townshend T. Obesogenic environments: exploring the built and food
environments. Perspectives in Public Health. 2006;126(6):262-262267. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/231117205?a
ccountid=12598.
164. Lareau, Annette. Unequal Childhoods: Race, Class, and Family Life. University of
California Press.2003.
165. Larson NI, Story MT, Nelson MC. Neighborhood Environments: Disparities in Access
to Healthy Foods in the US. American Journal of Preventative Medicine. 2009;36 (1):7481

225

166. Larson NI, Wall MM, Story MT, Neumark-Sztainer DR. Home/family, peer, school, and
neighborhood correlates of obesity in adolescents. Obesity (Silver Spring).
2013;21(9):1858–69. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23512596.
Accessed December 21, 2013.
167. Learn the Facts. Let’s Move America’s Move to Raise a Healthier Generation of
Kids. http://www.letsmove.gov/about. Updated Accessed December, 2010.
168. LeBlanc CMA, Gomez J. Active healthy living: Prevention of childhood obesity through
increased physical activity. Council on Sports Medicine and Fitness; Council on School
Health. Journal of the American Academy of Pediatrics 2006;117(5):1834-42.
169. Lee H, Harris KM, Gordon-Larsen. Life Course Perspectives on the Links Between
Poverty and Obesity During the Transition to Young Adulthood.Population Research
and Policy Review.2008;505-532.
170. Lee HS, Lee KE, Shanklin CW. Elementary students' food consumption at lunch does
not meet the recommended dietary allowance for energy, iron, and vitamin A. Journal of
the American Dietetic Association. 2001;101(9):1060-163.
171. Lee SM, Burgeson CR, Fulton JE, Spain CG. Physical education and physical activity:
Results from the school health policies and programs study 2006. Journal of School
Health. 2007;77(8): 435-63.
172. Liberman DA, Chamberlin B, Medina, Franklin BA, McHugh B, Vafiadis SD.
Proceedings report from the American Heart Associations. The power of Play:
Innovations in getting active summit 2011: A science panel. American Heart
Association.2011;123:2507-2516.
173. Linebarger DL, Piotrowski JT. Evaluating the educational potential of health PSAs with
preschoolers. Health Communication. 2008;23(6): 516-525.
174. Longo VD, Fontana L. Calorie restriction and cancer prevention: metabolic and
molecular mechanisms. Trends Pharmacol. Sci. 2010;31(2):89–98. Available at:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2829867&tool=pmcentrez&r
endertype=abstract. Accessed November 9, 2013.
175. Lopez V, Corona R, Halfond R. Effects of gender, media influences, and traditional
gender role orientation on disordered eating and appearance concerns among Latino
adolescents. J. Adolesc. 2013;36(4):727–36. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/23849667. Accessed January 7, 2014.

226

176. Luttikhuis O, Baur L, Jansen H, Shrewsbury VA, O’Malley C, Stolk RP, Summerbell
CD. Interventions for treating obesity in children. Cochrane Database of Systematic
Reviews;2009;1-166. DOI: 10.1002/14651858.CD001872.pub2.
177. Maggard MA, Shugarman LR, Suttorp M, Maglione M, al e. Meta-Analysis: Surgical
Treatment of Obesity. Annals of Internal Medicine. 2005;142(7):54759. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/222196742?acc
ountid=12598.
178. Marshall S J , Biddle SJH , Gorely T, Cameron N, Murdey I.Relationships between
media use, body fatness and physical activity in children and youth: a metaanalysis. International Journal of Obesity.2004; 28: 1238–1246.
179. Maynard MJ, Baker G, Rawlins E, Anderson A, Harding S. Developing obesity
prevention interventions among minority ethnic children in schools and places of
worship: The DEAL (DiEt and Active Living) study. BioMed Central Public
Health. 2009;9:480.
180. McCullough ML, Feskanich D, Rimm EB, Giovannucci EL, Ascherio A, Variyam JN,
Spiegelman D, Stampfer MJ, and Willett WC. Adherence to the Dietary Guidelines for
Americans and risk of major chronic disease in men1–5. The American Journal of
Clinical Nutrition.2000;72:1223–31.
181. Mckenzie TL, Sallis JF, Prochaska JJ, Conway TL, Marshall SJ, Rosengard P.
Evaluation of a Two-Year Middle-School Physical Education Intervention: M-SPAN.
Med. Sci. Sport. Exerc. 2004;36(8):1382–1388. Available at:
http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00005768
-200408000-00017. Accessed December 17, 2013.
182. Michigan Department of Human Services. DHS - Food Assistance. Available at:
https://www.michigan.gov/dhs/0,4562,7-124-5453_5527---,00.html.
183. Miller DP. Associations between the Home and School Environments and Child Body
Mass Index. Social Science & Medicine. 2010; 72(5):677-684.
184. MMWR. Morbidity and Mortality Weekly Report. CDC. Differences in Prevalence of
Obesity Among Black, White, and Hispanic Adults --- United States, 2006—2008. 2009.
58(27);740-744. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5827a2.htm.
185. Moeller SM, Taylor A, Tucker KL, McCullough ML, Chylack LT, Hankinson SE,.
Willett WC, and Jacques PF. Overall Adherence to the Dietary Guidelines for
Americans Is Associated with Reduced Prevalence of Early Age-Related Nuclear Lens
Opacitiesin Women. Journal of Nutrition.2004; 134: 1812–1819, 2004.
227

186. Moles, O. C. Collaboration between school and disadvantaged parents: Obstacles and
openings. In N. K. Chavkin (Ed.), Families and schools in a Pluralistic society. Albany,
NY: Sate University of New York Press;1993: 21–49.
187. Molnar BE, Gortmaker SL, Bull FC, Buka SL. Unsafe to Play ? Neighborhood Disorder
and Lack Among Urban Children and Adolescents. 2004:378–387.
188. Moreno LA, Gerardo R. Dietary Risk Factors for Development of Childhood
Obesity. Current Opinion in Clinical Nutrition & Metabolic Care. 2007; 10(3): 336-341.
189. Morland K, Wing S, Diez Roux A, Poole C. Neighborhood characteristics associated
with the location of food stores and food service places. American Journal of
Preventative Medicine. Jan 2002;22(1):23-29.
190. Moshfegh AJ, Goldman J, Lacomb R, Perloff B, Cleveland L. Research results using the
new USDA Automated Multiple-Pass Method. Journal of the Federation of American
Societies for Experimental Biology. 2001;15(4):A278(abstr)
191. Moshfegh AJ, Rhodes DG, Baer DJ, Murayi T, Clemens JC, Rumpler WV, Paul DR,
Sebastian RS, Kuczynski KJ, Ingwersen LA, Staples RC, Cleveland LE. The US
Department of Agriculture Automated Multiple-Pass Method reduces bias in the
collection of energy intakes. American Journal of Clinical Nutrition. 2008;88(2): 324-32.
192. Nader PR, Stone EJ, and Lytle LA.Three-Year Maintenance of Improved Diet and
Physical Activity: The CATCH Cohort. Child and Adolescent Trial for Cardiovascular
Health. Archives of Pediatric and Adolescent Medicine.1999;153:695-704.
193. Nairn A, Fine C. Who’s messing with my mind? The implications of dual-process
models for the ethics of advertising to children. 2008. Available at:
http://www.researchonline.mq.edu.au/vital/access/manager/Repository/mq:12452.
Accessed January 6, 2014.
194. National Center for Chronic Disease Prevention and Health Promotion, Division of
Adolescent and School Health. Page last updated: June 16, 2011. Available
at http://www.cdc.gov/healthyyouth/.
195. National Center for Health Statistics (US). Health, United States, 2010: With Special
Feature on Death and Dying. Hyattsville (MD): National Center for Health Statistics
(US); 2011 Feb. Special Feature on Death and Dying. Available from:
http://www.ncbi.nlm.nih.gov/books/NBK54374/

228

196. Nelson L, Evans, M, Guess W, Morris M, Olson T, Buckwalter J. Heart Rates of
Elementary Physical Education Students During the Dancing Classrooms
Program. Research Quarterly for Exercise and Sport. 2011; 82 (2):256-263.
197. Neumark-Sztainer D, Bauer KW, Friend S, Hannan PJ, Story M, Berge JM. Family
weight talk and dieting: how much do they matter for body dissatisfaction and disordered
eating behaviors in adolescent girls? J. Adolesc. Health. 2010;47(3):270–6. Available at:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2921129&tool=pmcentrez&r
endertype=abstract. Accessed January 7, 2014.
198. Neumark-Sztainer D, Hannan PJ, Story M, Croll J, Perry C. Family meal patterns:
associations with sociodemographic characteristics and improved dietary intake among
adolescents. Journal of the American Dietetic Association. 2003;103(3):317–22.
199. Neumark-Sztainer D, Story M, Perry C, Casey MA. Factors influencing food choices of
adolescents: Findings from focus-group discussions with adolescents. Journal of the
American Dietetic Association. 1999;99(8):929-92937. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/218396159?acc
ountid=12598.
200. Newacheck PW, Hung YY, Park MJ, Brindis CD, Irwin CE. Disparities in adolescent
health and health care: Does socioeconomic status matter? Health. Services Research.
2003;38: 1235-1252.
201. Noffsinge J. Phys Ed Cuts May Leave Children's Health Behind. 2005. Accessed
August, 2011 http://www.foxnews.com/story/0,2933,176168,00.html#ixzz1UNpV7Irx.
202. Nord M. Effects of the Decline in the Real Value of SNAP Benefits From 2009 to 2011.
2013;(151). Available at: www.ers.usda.
203. Nord M. Food Insecure Household with children Prevalence, Severity, and Household
Characteristics. DC: US Department of Agriculture, Economic Research Service;
2009. http://www.ers.usda.gov/Publications/EIB56/EIB56_ReportSummary.pdf.
204. O’Dea, J. Why do kids eat healthful food? Perceived benefits of and barriers to healthful
eating and physical activity among children and adolescents Journal of the American
Dietetic Association.2003;103:497-501.
205. Obesity and the metabolic syndrome in children and adolescents. New England Journal
of Medicine, 350, 2362–2374.

229

206. Ogden C, Carroll M. Prevalence of Obesity Among Children and Adolescents: United
States, Trends 1963–1965 Through 2007–2008. National Center for Health Statistics.
2010;1-5.
207. Ogden C, Carroll M. Prevalence of Obesity Among Children and Adolescents: United
States, Trends 1963–1965 Through 2007–2008.Division of Health and Nutrition
Examination Surveys. 2010:1-5.
208. Ogden CL, Carroll MD, Curtin LR, Lamb MN, Flegal KM. Prevalence of high body
mass index in US children and adolescents, 2007-2008. Journal of the American Medical
Association. 2010;303:242-249.
209. Ogden CL, Carroll MD, Flegal KM. High Body Mass Index for Age Among US
Children and Adolescents, 2003-2006. Journal of the American Medical
Assoication. 2008;299(20):2401-2405.
210. Oxford Dictionaries. Screen Time. Oxford Dictionaries. April 2010. Oxford University
Press. 05 August 2012 <http://oxforddictionaries.com/definition/english/screen time>.
211. Parrish AN, Yeatman H, Iverson D, Russell K. Using interviews and peer pairs to better
understand how school environments affect young children’s playground physical
activity levels: a qualitative study. Health Education Research. 2012; 27(2):269-280.
212. Peterson KE, Fox MK. Addressing the epidemic of childhood obesity through schoolbased interventions: What has been done and where do we go from here? The Journal of
Law, Medicine & Ethics. 2007;(1):113-30. ProQuest Research Library. Web. 14 July
2011.
213. Powell LM, Han E, Chaloupka FJ. Economic Contextual Factors, Food Consumption,
and Obesity among U.S. Adolescents1-3. Journal of Nutrition. 2010;140(6):1175-117580. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/366007193?acc
ountid=12598.
214. Prochaska JO, Norcross JC. Stages of Change. Physcotherapy.2001; 38(4):443-448.
215. Prosper MH, Moczulski VL, Qureshi A, Weiss M, and Bryars T. Healthy for
Life/PE4ME: Assessing an Intervention Targeting Childhood Obesity. Californian
Journal of Health Promotion. 2009: 7; 1-10
216. Pühse U, Gerber M (Eds.). International Comparison of Physical Education – Concepts,
Problems, Prospects. Oxford: Meyer & Meyer Sport Ltd., 2005.

230

217. Raj M, Kumar RK.Obesity in children & adolescents. Indian Journal of Medical
Research. 2010;132 (5): 598–
607.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3028965/.
218. Rashid M, Roberts EA. Nonalcoholic steatohepatitis in children. J Pediatr Gastroenterol
Nutr. 2000;30:48–53.
219. Ravenscroft EF. Diabetes and Kidney Failure: How Individuals with Diabetes
Experience Kidney Failure. Nephrology Nursing Journal. 2005;32(5):502-502509. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/216543442?a
ccountid=12598.
220. Redsell SA, Atkinson P, Nathan D, Siriwardena AN, Swift JA, Glazebrook C. Parents’
beliefs about appropriate infant size, growth and feeding behaviour: implications for the
prevention of childhood obesity. BioMed Central Public Health.2010; 10:711.
221. Reed JA, Einstein G, Hahn E, Hooker SP, Gross VP, Kravitz, J. Examining the impact
of integrating physical activity on fluid intelligence and academic performance in an
elementary school setting: a preliminary investigation. Journal of Physical Activity &
Health. 2010;7(3): 343-51.
222. Reedy J, Krebs-Smith SM. Dietary sources of energy, solid fats, and added sugars
among children and adolescents in the United States. Journal of the American Dietetic
Association. 2010;10: 1477-1484.
223. Rees A, Thomas N, Brophy S, Knox G, and Williams R. Cross sectional study of
childhood obesity and prevalence of risk factors for cardiovascular disease and diabetes
in children aged 11–13.BMC Public Health 2009, 9:86-92.
224. Reilly J, Armstrong J, Dorosty AR, Emmett PM, Ness A, Rogers I, Steer C, Sherriff A.
Early Life Risk Factors for Obesity in Childhood: Cohort Study.BMJ. 2005;330:1357.
225. Resnicow K, Odom E, Wang T, Dudley WN, Mitchell D, Vaughan R, Jackson A,
Baranowski T. Validation of Three Food Frequency Questionnaires and 24-Hour Recalls
with Serum Carotenoid Levels in a Sample of African-American Adults. American
Journal of Epidemiology. 2000;152(11):1072-1080.
226. Roberts EA. Nonalcoholic steatohepatitis in children. Current Gastroenterol
Report. 2003;5:253–259.
227. Robinson TN. Reducing Children’s Television Viewing to Prevent Obesity: A
Randomized Controlled Trial. Journal of the American Medical
Association.1999:282(16): 1561-1567.
231

228. Rosenkranz RR, Dzewaltowski DA. Maternal Physical-Activity-Related Parenting
Behaviors May Influence Children's Physical Activity Levels and Relative
Weight. Women in Sport & Physical Activity Journal. 2011;20(1):312. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/863853804?acc
ountid=12598.
229. Rosner B, Prineas R,Loggie J, Daniels SR. Percentiles for body mass index in U.S.
children 5 to 17 years of age. Journal of Pediatrics. 1998;132(2):211-22.
230. Ruiz JR, Ortega FB, Martínez-Gómez D, Labayen I, Moreno LA, De Bourdeaudhuij I,
Manios Y, Gonzalez-Gross M, Mauro B, Molnar Ds, Widhalm K, Marcos A, Beghin L,
Castillo M J, Sjöström M. Objectively Measured Physical Activity and Sedentary Time in
European Adolescents: The HELENA Study. American Journal of Epidemiology. 2011:
kwr068v1-kwr068.
231. Rundle A, Neckerman KM, Freeman L, et al. Neighborhood Food Environment and
Walkability Predict Obesity in New York City. Environmental Health Perspective.
2009;117(3):442-4427. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/222656643?acco
untid=12598.
232. Russell, G. F, Treasure J, Eisler, I.Mothers with anorexia who underfeed their children:
Their recognition and management. Psychological Medicine. 1998; 28 (1):93-108.
233. Sato A, Jelalina E, Hart CN, Loyd-Richardson EE, Mehlenbeck RS, Neil M, Wing RR.
Associations between Parent Behavior and Adolescent Weight Control. Journal of
Pediatric Psychology. 2010; 1-10 doi:10.1093/jpepsy/jsq105. Downloaded from
jpepsy.oxfordjournals.org at Michigan State University on December 16, 2010.
234. Sato AF, Jelalian E, Hart CN, Lloyd-Richardson EE, Mehlenbeck RS, Neill M and Wing
RR. Associations between Parent Behavior and Adolescent Weight Control. Journal of
the American Pediatric Physiology. 2010;1-10.
235. Schanzenbach DW. Do School Lunches Contribute to Childhood Obesity? Journal of
Human Resources.2009;44(3):684-709.
236. Schwimmer JB, Deutsch R, Kahen T, Lavine JE,Stanley C, Behling C. Prevalence of
fatty liver in children and adolescents. Pediatrics. 2006;118(4):1388-1393.
237. Seca. Seca 217 Medical Scale and Measuring System. Hammer, Hamburg.

232

238. Serdula MK, Ivery D, Coates RJ, Freedman DS. Williamson DF. Byers T. Do obese
children become obese adults? A review of the literature. Preventative
Medicine. 1993;22:167-177.
239. Serrano SQ, Lucena de Vasconcelos MG, Pontes da Silva GA, Osório de Cerqueira
MM, Pontes CM. Obese adolescents' perceptions about the repercussions of obesity on
their health. Revista da Escola de Enfermagem da USP.2010; 44(1):25-31.
240. Shapiro T. The Hidden Cost of Being African American: How Wealth Perpetuates
Inequality. New York: Oxford University Press, 2004.
241. Slominski L, Sameroff A, Rosenblum K, Kasser T. Longitudinal predictors of adult
socioeconomic attainment: The roles of socioeconomic status, academic competence, and
mental health. Development and Psychology. 2011; 23:315-324.
242. Smith AB. Validation-study conclusion from dietary reports by fourth grade children
observed eating school meals are generalisable to dietary reports by comparable children
not observed. Journal of Public Health Nutrition. 2007;10(10): 1057-1066.
243. Smith C, Butterfass J, Richards R. Environment influences food access and resulting
shopping and dietary behaviors among homeless Minnesotans living in food
deserts. Agriculture and Human Values. 2010;27(2):141-141161. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/214177227?a
ccountid=12598. 10.1007/s10460-009-9191-z.
244. Smith C, Morton LW. Rural food deserts: low-income perspectives on food access in
Minnesota and Iowa. J. Nutr. Educ. Behav. 2009;41(3):176–87. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/19411051. Accessed January 7, 2014.
245. Smith MK. As economy improves, food assistance goes down | Michigan League for
Public Policy. 2013. Available at: http://www.mlpp.org/as-economy-improves-foodassistance-goes-down#more-19104.
246. Song H, Peng W, Lee KM. Promoting exercise self-efficacy with an exergame. Journal
of Health Communication. 2011 Feb;16(2):148-62.
247. Spahn JM, Reeves RS, Keim KS, et al. State of the evidence regarding behavior change
theories and strategies in nutrition counseling to facilitate health and food behavior
change. J. Am. Diet. Assoc. 2010;110(6):879–91. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/20497777. Accessed December 23, 2013.

233

248. Stang J, Story M. Adolecent Growth and Development. In: Guidelines for Adolescent
Nutrition Services. Minneapolis; 2008:1–8. Available at:
http://www.epi.umn.edu/let/pubs/img/adol_ch1.pdf. Accessed January 7, 2014.
249. Stevens CJ. Obesity Prevention Interventions for Middle School-Age Children of Ethnic
Minority: A Review of the Literature. Journal for Specialist in Pediatric Nursing. 2010;
15(3):233-243.
250. Story M, Nanney MS, Schwartz MB. Schools and Obesity Prevention: Creating School
Environments and Policies to Promote Healthy Eating and Physical Activity. The
Milbank Quarterly. 2009;87(1); 71-100 Academic OneFile. Web. 7 Aug. 2011.
251. Strauss RS. Knight J. Influence of the Home Environment on the Development of
Obesity in Children. Official Journal of The American Academy of Pediatrics. 1999; 103;
e85.
252. Strenze T. Intelligence and socioeconomic success: A meta-analytic review of
longitudinal research. Intelligence. 2007; 35: 401-426.
253. Stroup DF, Johnson VR, Proctor DC, Hahn RA. "Reversing the Trend of Childhood
Obesity." Prevention Chronic Disease.2009; 1-5.
254. Sweeney MM, Zionts P. The “second skin”: perceptions of disturbed and nondisturbed
early adolescents on clothing, self-concept, and body image. Adolescence.
1989;24(94):411–20. Available at: http://www.ncbi.nlm.nih.gov/pubmed/2763907.
Accessed January 7, 2014.
255. Tanita. Body Composition Analyzer Goal Setter TBF-300A. Tokyo, Japan
256. Taveras EM, Gillman MW, Kleinman K, Rich-Edwards JW, Rifas-Shiman SL.
Racial/Ethnic Differences in Early-Life Risk Factors for Childhood Obesity. Official
Journal of The American Academy of Pediatrics. 2010;125(4): 686-695.
257. Taylor RW, Farmer VL, Cameron SL, JonesKM, Williams SM, Mann JI. School
playgrounds and physical activity policies as predictors of school and home time
activity. International Journal of Behavioral Nutrition and Physical Activity. 2011; 8:38.
258. The American Heritage® New Dictionary of Cultural Literacy, Third Edition. Houghton
Mifflin Company. Socioeconomic status. Dictionary.com.
http://dictionary.reference.com/browse/socioeconomic status . Published 2005. Accessed:
August 04, 2012.

234

259. The American Heritage® Stedman's Medical Dictionary. Lifestyle. Dictionary.com.
http://dictionary.reference.com/browse/lifestyle. Published 2004. Accessed July 16,
2012.
260. The Michigan Department of Education, The Michigan Department of Community
Health, The Governor’s Council on Physical Fitness, Health and Sports and The
Michigan Fitness Foundation. The Roles of Michigan School in Promoting Health
Weight. 2001. A Consensus Paper. Available at
http://www.michigan.gov/documents/healthyweight_13649_7.pdf. Accessed April 2014.
261. Thompson FE, Subar AF, Brown CC, Smith AF, Sharbaugh CO, Jobe JB, Mittl B,
Gibson JT, Ziegler RG. Cognitive research enhances accuracy of food frequency
questionnaire reports: results of an experimental validation study. Journal of American
Dietetics Association.2001;102:1089-1099.
262. Tilston CH, Gregson K, Neale RJ, Douglas CJ. Dietary awareness of primary school
children. British Food Journal. 1991;93: 25-9.
263. Torheim LE, Ouattara F, Diarra MM, Thiam FD, Barikmo I , Hatly A and Oshaug A.
Nutrient adequacy and dietary diversity in rural Mali: association and determinants.
European Journal of Clinical Nutrition 2004; 58: 594–604.
264. Townsend N, Murphy S, Moore L. The more schools do to promote healthy eating, the
healthier the dietary choices by students. J. Epidemiol. Community Health.
2011;65(10):889–95. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21118953.
Accessed January 6, 2014.
265. Tremblay MS, Inman JW, Willms JD. The relationship between physical activity, selfesteem, and academic achievement in 12-year-old children. Pediatric Exercise
Science. 2000;12:312-24.
266. Troiano RP, Berrigan D, Dodd KW, Masse LC, Tilert T, and McDowell M. Physical
Activity in the United States Measured by Accelerometer. Medicine & Science in Sports
& Exercise.2008;40( 1):181-188.
267. Trudeau F, Shephard R J. Physical Education, School Physical Activity, School Sports,
and Academic Performance. International Journal of Behavioral Nutrition and Physical
Activity.2007; 5:10.
268. Turrell G. Hewitt B, Patterson C, Oldenburg B and Gould T. Socioeconomic differences
in food purchasing behavior and suggested implications for diet related health promotion.
Journal of Human Nutrition and Diet. 2002;15:355-64

235

269. U.S. Census Bureau: State and County QuickFacts. Data derived from Population
Estimates, American Community Survey, Census of Population and Housing, County
Business Patterns, Economic Census, Survey of Business Owners, Building Permits,
Consolidated Federal Funds Report, Census of Governments, 2010
http://quickfacts.census.gov/qfd/states/26/2689140.html.
270. U.S. Department of Agriculture and U.S. Department of Health and Human Services.
Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government
Printing Office, December
2010.http://health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf
271. U.S. Department of Education. National Center for Education Statistics. Common Core
of Data. Public School Data 2010-2011. Accessed at:
http://nces.ed.gov/ccd/schoolsearch/index.asp . Accessed December 3, 2012
272. U.S. Department of Health and Human Services and U.S. Department of Agriculture.
Dietary Guidelines for Americans, 2005. 6th Edition, Washington, DC: U.S. Government
Printing Office, January 2005.
273. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for
Americans. 2008. Available at: http://www.health.gov/PAGuidelines. Accessed October
2,2011
274. U.S. Department of Health and Human Services. Classification of Overweight and
Obesity by BMI, Waist Circumference, and Associated Disease Risk .National Heart
Lung and Blood Institute People Science Health website.
http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/bmi_dis.htm Accessed July
30, 2012
275. U.S. Department of Health and Human Services. The Surgeon General’s Vision for a
Healthy and Fit Nation. Rockville, MD: U.S. Department of Health and Human Services,
Office of the Surgeon General, January 2010.
276. U.S. Department of Health and Human Services. Physical Activity Guidelines
Advisory Committee report. Washington, DC: U.S. Department of Health and Human
Services, 2008.
277. United States. White House Task Force on Childhood Obesity: United States. Executive
Office of the President. Solving the Problem of Childhood Obesity within a generation:
White House Task Force on Childhood Obesity Report to the President. Washington,
D.C.: Executive Office of the President of the United States; 2010.
278. Van den Berg PA, Mond J, Eisenberg M, Ackard D, and Neumark-Sztainer D. The Link
Between Body Dissatisfaction and Self-Esteem in Adolescents: Similarities Across
236

gender, Age, Weight Status, Race/Ethnicity, and Socioeconomic Status. Journal of
Adolescent Health. 2010;47: 290–296.
279. Videon TM, Manning CK. Influences on Adolescent Eating Patterns: The Importance
of Family Meals. Journal of Adolescent Health. 2003; 32(5): 365-373.
280. Virginia Commonwealth University (VCU) Center on Human Needs. Food Security –
Michigan. http://humanneeds.vcu.edu/Page.aspx?nav=1&scope=22. Published 2009.
Updated 11/1/2011. Accessed July, 2012.
281. Wadden TA, Wilson GT, Stunkard AJ, Berkowitz RI, Jakicic JM, Davis KK. Obesity
and Physical Activity. Psychiatr. Clin. North Am. 2011;34(4):829–840. Available at:
http://www.sciencedirect.com/science/article/pii/S0193953X11000864. Accessed
December 2, 2013.
282. Warburton DE, Bredin SS, Horita LT, Zbogar D, Scott JM, Esch BT, Rhodes RE. The
health benefits of interactive video game exercise. Applied Physiology Nutrition and
Metabolism. 2007;32(4):655-63.
283. Weatherspoon D, Oehmke J, Dembele a., Coleman M, Satimanon T, Weatherspoon L.
Price and Expenditure Elasticities for Fresh Fruits in an Urban Food Desert. Urban Stud.
2012;50(1):88–106. Available at:
http://usj.sagepub.com/cgi/doi/10.1177/0042098012448555. Accessed December 11,
2013.
284. Weber P. Nutritional Challenges of a Dual Diagnosis: Chronic Kidney Disease and
Diabetes. Diabetes Spectrum. 2008;21(1):26-2629. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/228730564?acc
ountid=12598.
285. Weiss R, Dziura J, Burgert TS, Tabmorlane WV, Taksali SE, Yeckel CW, Savoye
M, Morrison J. Sherwin RS, Caprio, S. Obesity and the metabolic syndrome in children
and adolescents. New England Journal of Medicine.2004;350(23): 2362-74.
286. Wharton CM, Long M, Schwartz MB. Changing Nutrition Standards in Schools: The
Emerging Impact on School Revenue. Journal of School Health. 2008;78(5):245-24551. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/215669858?acc
ountid=12598.
287. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young
adulthood from childhood and parental obesity. New England Journal
Medicine 1997;37(13):869-873.

237

288. Widome R, Neumark-Sztainer D, Hannan PJ, Haines J, Story M. Eating when there is
not enough to eat: Eating behaviors and perceptions of food among food-insecure youths.
American Journal of Public Health. 2009;99(5): 822-828.
289. Wilde PE, McNamara PE, Ranney CK. The effect on dietary quality of participation in
the food stamp and WIC programs. USDA/ERS FANR Report.2000; No. 9.
290. Wilfley DE, Tibbs TL, Van Buren DJ, Reach KP, Walker MS, and Epstein LH. Lifestyle
interventions in the treatment of childhood overweight: A meta-analytic review of
randomized controlled trials. Health Psychology.2007;26: 521–532.
291. Witte K. Putting the fear back into fear appeals: The extended parallel process model.
Commun. Monogr. 1992;59(4):329–349. Available at:
http://dx.doi.org/10.1080/03637759209376276. Accessed January 8, 2014.
292. Woo KS, Chook P, Yu CW, Sung RYT, Quao M, Leung SF, Lam CWK, Metreweli C,
Celermajer DS. Effects of Diet and Exercise on Obesity-Related Vascular Dysfunction
in Children. American Heart Association. 2004; 109: 1981-1986.
293. World Health Organization. Obesity and Overweight. Media Center. Fact Sheet.
2012.http://www.who.int/mediacentre/factsheets/fs311/en/index.html
294. World Health Organization. Preventing Chronic Diseases: A vital investment. World
Global Report. Geneva: World Health Organization; 2005. World Health Organization.
295. World Health Organization. Preventing chronic diseases: A vital investment. World
Global Report. Geneva: World Health Organization; 2005.
296. Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. Deaths: Final data for 2007.
National vital statistics reports; vol 58 no 19. Hyattsville, MD: NCHS; 2010. Available
from: http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf.
297. Yawn B, Zyzanski SJ, Goodwin MA, Gotler RS, Stange KC. Is diabetes treated as an
acute or chronic illness in community family practice? Diabetes Care. 2001;24(8):13901396. http://ezproxy.msu.edu/login?url=http://search.proquest.com/docview/223059442?
accountid=12598.
298. Young-Hyman D, Herman LJ, Scott DL, Schlundt DG. Care giver perception of
children’s obesity-related health risk: a study of African American families. Obes. Res.
2000;8(3):241–8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10832767.

238

299. Zametkin, AJ, Zoon CK, Klein HW, and Munson S. Psychiatric Aspects of Child and
Adolescent Obesity: A Review of the Past 10 Years. 2004. J. Am. Acad. Child
Adolescent Psychiatry. (43)(2) 134-147.
300. Zeller MH, Roehrig HR, Modi AC, Daniels SR, and Inge TH. Health-related quality of
life and depressive symptoms in adolescents with extreme obesity presenting for bariatric
surgery. Journal of the American Academy of Pediatrics. 2006;117: 1155–1161.

239