- Email: [email protected]
Park-based afterschool program to improve cardiovascular health and physical fitness in children with disabilities
ARTICLE IN PRESS
Disability and Health Journal
-
(2014)
-
www.disabilityandhealthjnl.com
Brief Report
Park-based afterschool program to improve cardiovascular health and physical fitness in children with disabilities Kanathy Haney, M.S., B.S.W.a, Sarah E. Messiah, Ph.D., M.P.H.a,b,*, Kristopher L. Arheart, Ed.D.a,b, Eric Hanson, M.P.A.c, Allison Diego, M.P.A.c, Jack Kardys, M.S.M.c, Kevin Kirwin, M.P.A.c, Renae Nottage, B.A.c, Shawn Ramirez, B.S.c, Gabriel Somarriba, D.P.T.b, and Lucy Binhack, B.A.c a
b
Department of Epidemiology and Public Health Sciences, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA Department of Pediatrics, Division of Pediatric Clinical Research, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA c Miami Dade Department of Parks, Recreation and Open Spaces, Miami, FL, USA
Abstract Background: Children with disabilities are more likely to be overweight or obese and less likely to engage in physical activities versus their peers without disabilities. Objective: The effect of a structured afterschool program housed in a large county parks system on several obesity-related health outcomes among children with disabilities was examined. Methods: Children/adolescents with a developmental and/or intellectual disability ages 6e22 (N 5 52, mean age 13.7 years) who participated in an afterschool (either 2010e2011 or 2011e2012 school year) health and wellness program called Fit-2-PlayÔ were assessed. Pre-post comparison of outcome variables (mean height, weight, waist/hip/midarm circumference, fitness tests, and a 9-item health and wellness knowledge assessment) via general linear mixed models analysis was conducted to evaluate the effectiveness of the program for normal and overweight/obese participants. Results: Normal weight participants significantly improved pre-post mean number of push-ups (9.69e14.23, p 5 0.01) and laps on the PACER test (8.54e11.38, p ! 0.01) and the overweight/obese group significantly improved the number of sit ups (7.51e9.84, p ! 0.01) and push ups (4.77e9.89, p ! 0.001). Pre-post mean health and wellness knowledge composite scores significantly improved for all participants ( p ! 0.01). Conclusions: Parks-based afterschool programs can be effective community resources for instilling physical health in both normal weight and overweight/obese children with disabilities. More studies are needed to ascertain whether community-based afterschool health and wellness programs can be implemented and sustained across this population. Ó 2014 Elsevier Inc. All rights reserved. Keywords: Disability; Children; Obesity; Prevention; Physical activity
The Centers for Disease Control and Prevention (CDC) reports that obesity is 38% higher in children with disabilities compared to their peers without disabilities.1e3 Moreover, individuals with disabilities are less likely to engage in physical activities, are exposed to more screen time, and have a worse overall health status as a result versus their peers without disabilities.4e6 As such, Healthy People
There are not conflicts of interest to report for any authors. The work presented here has not been previously published or presented. * Corresponding author. Department of Pediatrics, Division of Pediatric Clinical Research, University of Miami Leonard M. Miller School of Medicine, Batchelor Children’s Research Institute, Room 541, 1580 NW 10th Avenue, Miami, FL 33130, USA. Tel.: þ1 305 243 1943; fax: þ1 305 243 8475. E-mail address: [email protected] (S.E. Messiah). 1936-6574/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2014.02.006
20204 and the National Prevention Strategy7 among others8 recommend including individuals with disabilities in health promotion programs to decrease their overall health risks. The afterschool setting can provide an alternative setting for obesity prevention and wellness activities with potential for significant impact since 8 million children attend afterschool programs in the US.9 Historically, children with disabilities have not been fully represented in afterschool programs that specifically promote physical and mental health yet would likely benefit from such programs. Few studies in the literature specifically focus on outcomes of afterschool health and wellness programs designed for children with disabilities.10 Thus, we report here the anthropometric, physical fitness and health and wellness knowledge outcomes of an afterschool program among a diverse sample of children with disabilities.
ARTICLE IN PRESS 2
K. Haney et al. / Disability and Health Journal
Methods Design A pilot, single arm, pre-post 10 month (length of one school year) study was conducted. Fit-2-PlayÔ is managed by the Miami-Dade County Department of Parks, Recreation and Open Spaces (MDCPROS) and takes place every afternoon from 2 pm to 6 pm. Sample All students had to provide their individual education plans (IEPs) to document they were currently receiving special services for their disability in school and therefore qualified for the same program in the afterschool setting. The children included in this analysis had a range of known disabilities including attention deficit hyperactivity disorder (n 5 8), autism (n 5 19), cerebral palsy (n 5 1), Down syndrome (n 5 3), physical (n 5 1), learning (n 5 1), intellectual (n 5 7), cognitive (n 5 6), lead poisoning at birth (n 5 1), PVR natal stoke (n 5 1), speech issues (n 5 3), and severe asthma (n 5 1).
-
(2014)
-
sessions are conducted weekly (and biweekly some weeks) on Fridays in the place of homework hour. Children are typically grouped by age for all activities. Outcome measures University of Miami faculty and staff members trained all parks field staff (coaches with physical education backgrounds) on appropriate anthropometric, blood pressure and physical fitness data collection methods and techniques. In turn, parks staff conducted all pre-and post data collection on-site and data were uploaded to a shared database. Additionally, MDCPROS bachelor and master’s level recreation directors with education backgrounds in health and wellness and exercise physiology oversaw on-site measurement procedures and collection of all pre-and post data to ensure measurement fidelity.
Description of program
Anthropometric measures Weight was collected on calibrated scales (Seca Model 869, Seca North America East Medical Scales & Measuring Devices, Hanover, MD). Children did not wear their shoes, were asked to empty their pockets, and only wore light clothing (e.g. shorts, t-shirt). Height was measured using a stadiometer (Seca 217 Mechanical Telescopic, Seca North America East Medical Scales & Measuring Devices, Hanover, MD). Body mass index (BMI) was calculated as weight (kilograms) divided by height (meters)2 and was then converted to an age-and sex-adjusted percentile and z score.14 BMI has been shown to be a reliable and valid measure of both total body fat and percent of body weight as fat among children in previous studies.15e17 Waist circumference18 and its relationship to both height19 and hip circumference19 are simple, yet valid surrogate measures of cardiometabolic disease risk (e.g. cardiovascular disease and/or type 3 diabetes).20,21 Waist, hip and midarm circumferences were measured with a tape measure (Gulick model 1098990, Mabis, Jesup, GA). Waist circumference was measured in the horizontal plane at a point marked just above the right ileum on the midaxillary line at minimal respiration.22
The Fit-2-PlayÔ curriculum is comprised of (1) Sports, Play and Active Recreation for Kids (SPARK)11 an evidenced-based12 outcome oriented structured active recreation for children with a focus on developing and improving motor skills, movement knowledge, social and personal skills and (2) EmpowerMe4Life, a health and wellness education curriculum grounded in the American Heart Association’s scientific recommendations in promoting heart-healthy lifestyles.13 Children are exposed to the Fit-2-PlayÔ program and curriculum on a daily basis after homework is completed. Park ‘‘coaches’’ introduce different physical activities for at least 1 h each afternoon. Health and wellness education
Physical fitness Physical fitness refers to those components of fitness that have a relationship with health such as (1) cardiorespiratory fitness, (2) musculoskeletal fitness, and (3) motor fitness.23 The following components of the validated President’s Council on Exercise’s standardized testing protocol were used to test physical fitness.24,25 Flexibility was assessed with the modified sit and reach test (Novel Products Flex Tester sit-and-reach box model 00004, Rockton, IL) that has recently been validated for hamstring and low back flexibility in both children and adolescents.26
Participants Mean age of the entire sample was 13.7 years old (64.7 years), 75% of the sample were boys and the majority selfidentified as Hispanic (65%), followed by non-Hispanic Black/African American (23%), and non-Hispanic White (12%). At baseline/pre-test, 48% of the sample was normal weight, 13% were overweight, and 38% were obese (Table 1). Procedures Parents of children ages 5e24 who participated were asked to sign a consent form for their child to participate in the pre-post test measurements to evaluate the Fit-2-PlayÔ program (N 5 52; out of a total of 172 total participants with disabilities). The study was approved by the University of Miami Institutional Review Board.
ARTICLE IN PRESS K. Haney et al. / Disability and Health Journal
-
(2014)
-
3
Table 1 Baseline characteristics of 52 participants with developmental disabilities, 2010e2011 or 2011e2012 school year Entire sample (N 5 52) Normal weighta (N 5 25)
Gender Boys Girls Ethnicity Hispanic Non-Hispanic Black or African American Non-Hispanic White Age, yr Weight, kg Weight, percentile Weight, z score Height, cm Height, percentile Height, z score BMId, kg/m2 BMId percentile BMId z score Waist circumference, cm Hip circumference, cm Waist-to-hip ratio, % Waist-to-height ratio, % Midarm circumference, cm Biceps skinfold (mm) Triceps skinfold (mm) Subscapular skinfold (mm) Suprailiac skinfold (mm) Sum of thicknesses of four skinfolds (mm)
Overweight/obeseb (N 5 27)
n (%)
n (%)
n (%)
39 (75) 13 (25)
21 (84) 4 (16)
18 (67) 9 (33)
34 (65) 12 (23) 6 (12) Mean (SD) 13.7 55.9 69.2 0.5 151.7 49.8 0.2 23.5 70.5 0.8 77.7 89.3 87.1 51.3 24.4 13.0 19.4 13.8 14.9 54.7
(4.7) (24.0) (32.9) (2.2) (17.8) (35.9) (1.8) (6.9) (33.2) (1.7) (18.3) (17.1) (10.5) (10.7) (6.7) (7.5) (10.1) (7.8) (9.6) (29.8)
16 (28) 7 (64) 2 (8) Range (minemax)
18 (67) 5 (19) 4 (14) Mean (SD)c
Mean (SD)c
(6.5e22.4) (21.5e130.2) (0.0e100.0) (9.5 to 3.4) (106.1e184.7) (0.0e100.0) (4.7 to 5.2) (14.8e42) (0.0e99.9) (4.1 to 2.9) (53.1e121.4) (55.5e129.3) (65.3e130.3) (34.0e73.3) (13.6e45.0) (3.0e35.0) (6.0e48.7) (4.0e34.7) (5.0e36.7) (20.3e123.5)
13.6 42.5 44.8 0.8 152.0 50.5 0.3 17.9 42.5 0.6 64.9 80.2 81.1 42.8 20.6 8.8 13.8 11.1 9.6 42.4
13.8 68.3 91.8 1.8 151.5 49.2 0.0 28.7 96.5 2.0 89.4 97.4 92.5 59.1 28.0 17.5 25.4 18.4 22.2 75.2
e e
e e
(4.3) (13.7) (30.8) (2.3) (18.8) (32.9) (1.7) (2.5) (27.5) (1.5) (11.0) (11.9) (5.5) (5.1) (4.0) (5.8) (7.1) (6.7) (6.5) (24.2)
(5.1) (25.0) (11.9) (0.8) (17.1) (39.0) (1.9) (5.5) (3.4) (0.5) (15.6) (17.1) (11.0) (8.2) (6.7) (6.6) (9.4) (7.6) (8.3) (27.5)
n (%) Obese (>95th BMId percentile) Overweight (85th < BMId percentile ! 95th) a b c d
20 (38.46) 7 (13.46)
e e
Body mass index (BMI) ! 85th percentile for age and sex. Body mass index (BMI) > 85th percentile for age and sex. Adjusted for age and sex. Body mass index.
Muscular endurance was evaluated by the sit-up test. Subjects performed as many complete sit-ups as they could during a 60 s timed period. Muscular strength was assessed by maximal right angle push-up. When instructed, each subject performed as many complete pushups until volitional exhaustion. Absolute values were recorded.27 Aerobic fitness was assessed with a timed 400 m run and the PACER test. The PACER (Progressive Aerobic Cardiovascular Endurance Run) is a valid, multistage fitness test adapted from the 20-m shuttle run test.28 The test is progressive in intensity with the objective to run as many laps as possible. In the 400 m run, children were instructed to run a lap as fast as possible and their time was recorded.27 Push-ups, sit ups, and the PACER test practice typically occurs once every month during the school year in addition to the daily SPARK activities. Quarter mile run practice occurs approximately twice a month.
Health and wellness knowledge Health and wellness knowledge was assessed using the EmpowerMe4Life13 9-item scale. Specifically, participants were asked 7 true/false and 2 multiple choice questions at both pre-and post-test about nutrition and physical activity choices. Individual and total of all 9 items (composite score) were analyzed as outcomes measures. No psychometric property data are available at this time for this pre-post assessment tool. Statistical analyses Means and standard deviations were generated for all continuous data (age, anthropometric measures) and categorical data (gender, ethnicity) are reported as frequencies and percentages. All outcome measures were dichotomized by weight status: normal weight (BMI ! 85th percentile for age and sex) and overweight/obese participants (BMI > 85th percentile for age and sex).14 For those
ARTICLE IN PRESS 4
K. Haney et al. / Disability and Health Journal
participants who were older than age 20, the 20 year old age-and sex-adjusted percentiles were applied. Normally distributed outcome variables including BMI z score, hip circumference, waist circumference, midarm circumference, waist-hip ratio, sit and reach test, 400 m run, and the health and wellness composite scores were analyzed with a general linear mixed model to generate means and standard errors. Outcomes with a binary distribution which are the correct responses for the health and wellness knowledge items are presented as percent and standard error. Data with a Poisson distribution including sit-ups, push-ups and the pacer test are presented as means and standard errors. Both types of data are analyzed with a generalized linear mixed model. All models included fixed effects for BMI group, time, and the interaction of group and time. When appropriate, covariates for age, sex, and ethnicity were included to control for their possibly confounding effects. For example, all physical fitness variables were adjusted for age and sex. A random intercept was included with parks as a subject to account for between park variation, and another random effect is included for the repeated measure time with participants nested within parks to account for the nesting of participants within parks. Contrasts were used to determine the significance of the change over time in each group and the significance of the difference between groups in the changes. The link function for binary data was the logit, and for Poisson data was the natural logarithm. The 0.05 significance level determined statistical significance. SAS 9.3 (SAS Institute, Inc., Cary, NC) was used for all analyses. Results Anthropometrics BMI z score did not significantly change for the normal weight (0.63 to 0.39) or overweight/obese group (1.99e1.81) over the study period. Similarly, there were no significant changes in other anthropometric measures for both groups from pre- to post-test (Table 2). Physical fitness Both groups improved in all physical fitness tests. Specifically, among the overweight/obese group the mean number of sit ups significantly improved from 7.5 at baseline to 9.8 repetitions at follow up ( p ! 0.01, effect size [ES] 5 0.21), mean number of push-ups significantly improved from 4.8 to 9.9 repetitions at follow up ( p ! 0.001, ES 5 0.46). The normal weight group significantly improved their mean number of push-ups from 9.7 at baseline to 14.2 at follow up ( p 5 0.01, ES 5 0.37) as well as the mean number of laps on the pacer test (8.54e11.38, p ! 0.01, ES 5 0.26) (Table 2). Health and wellness knowledge Both weight groups significantly improved their health and wellness knowledge from baseline to post-test
-
(2014)
-
assessment (mean overall composite change 6.55e7.84 questions correct in the normal weight group ( p ! 0.01, ES 5 1.01) and 6.88e8.27 questions correct in the overweight/obese group ( p ! 0.01, ES 5 1.10)). Several individual items saw similar statistical improvement (Table 3). Discussion We report here multiple key findings that have direct implications for the current childhood obesity epidemic and it’s health related consequences that both disproportionately affect children and adolescents with disabilities. Results show that both normal weight and overweight/ obese children with disabilities who participated in the Fit-2-PlayÔ afterschool program significantly improved fitness levels and nutrition knowledge over the school year. The afterschool setting has remained relatively understudied as an alternative to school-based intervention efforts and among pediatric populations with disabilities in particular.29 Those studies that have occurred in schoolbased and YMCA afterschool settings among children who do not have disabilities show that this time of day can successfully promote health and wellness30e34 and even treat obesity successfully.35,36 The Fit-2-PlayÔ afterschool program described here includes parks that offer both exclusive and immersion programs for children with disabilities so all participants can benefit from the opportunity to develop not only better physical health but social relationships with their peers. Although there was a decrease in BMI z score in the overweight/obese group over the school year, it did not reach statistical significance. Nevertheless, this finding is encouraging because if normal childhood growth trajectories can be maintained (e.g. not gaining abnormal weight) among children with disabilities who historically struggle more with their weight versus their peers without disabilities, the risk of later onset overweight and obesity decreases.37e41 Our next key findings showed that both weight groups significantly improved in several physical fitness tests. Some have suggested that being physically fit can eliminate the health risks of being overweight, especially in terms of heart health. In adults, how fitness and fatness uniquely contribute to overall health is controversial,42 and few studies are available on the associations of changes in fitness and fatness with the development of cardiometabolic disease risk factors, with even fewer studies available in pediatric populations and very few in children with disabilities. Healthy aging adults with developmental disabilities have been shown to gain fitness benefit from interventions focusing on physical activity and healthy behaviors but more long term studies are needed to determine their effects on cardiovascular disease risk.43 In a recent review article of 34 physical fitness studies among children with mixed disabilities, it was found that 18 programs improved
Table 2 Change in anthropometric and physical fitness measurements over the 2011e2011 or 2011e2012 school year Normal weightb (N 5 25) p
Effect size
Primary end point BMI z score 0.63 Secondary end pointsd Hip circumference, cm 80.44 Waist circumference, cm 64.48 Mid-arm circumference, cm 20.19 Waist-to-hip ratio 80.30 Waist-to-height ratio 42.89 Baseline
(0.22)
0.39 (0.23)
0.24 (0.59 to 0.10)
0.16
0.40
(2.44) (2.55) (1.17) (1.73) (1.56)
79.51 (2.46) 65.60 (2.57) 20.42 (1.18) 82.65 (1.74) 43.58 (1.57) 10-month
0.93 (1.67 1.11 (3.36 0.23 (1.59 2.35 (5.95 0.69 (2.19 Change
0.47 0.05 0.32 0.53 0.74 0.22 0.19 0.37 0.36 0.32 Effect size
c d
80.40 14.64 14.23 11.38 18.90 226.19
(3.07) (2.22) (2.85) (1.87) (1.50) (34.09)
3.07 2.32 4.54 2.84 0.34 25.87
0.31 0.07 0.01 !0.01 0.73 0.29
0.41 0.29 0.37 0.26 0.10 0.36
83.96 7.51 4.77 4.76 21.06 230.36
(2.11) (2.21) (1.02) (1.52) (1.35)
(2.85) (1.06) (0.95) (0.75) (1.28) (27.40)
96.81 (2.12) 88.98 (2.22) 27.47 (1.02) 91.57 (1.53) 58.39 (1.36) 10-month 80.94 9.84 9.89 5.97 21.37 218.89
(2.93) (1.35) (1.79) (0.91) (1.28) (27.46)
p
Effect size
0.18 (0.14 to 0.51)
0.27
0.30
0.55 0.21 0.37 0.53 0.71
0.65 0.85 0.56 0.75 0.32
0.11 0.18 0.04 0.09 0.22 Effect size
(1.86 to (1.93 to (0.91 to (2.83 to (0.72 to Change 3.01 2.33 5.12 1.22 0.32 11.47
2.96) 2.34) 1.67) 3.89) 2.15) p
0.29 !0.01 !0.001 0.07 0.73 0.29
0.29 0.21 0.46 0.16 0.10 0.19
-
b
(3.00) (1.86) (1.96) (1.41) (1.47) (34.39)
97.37 89.19 27.84 92.11 59.11 Baseline
1.81 (0.22)
Change (95% CI)
(2014)
a
83.45 12.32 9.69 8.54 19.24 200.32
3.53) 1.13) 1.13) 1.24) 0.82) p
1.99 (0.22)
10-month Mean (SE)
-
Fitness test, meana (SD)d Pulse Sit ups (number) Push ups (number) Pacer test (laps) Sit-and-reach (cm) 400 m run (seconds)
to to to to to
Baseline Mean (SE)
Change represents difference between baseline and 10-month mean percent. Body mass index ! 85th percentile for age and sex. Body mass index > 85th percentile for age and sex. Adjusted for age and sex.
ARTICLE IN PRESS
Changea (95% CI)
K. Haney et al. / Disability and Health Journal
10-month Mean (SE)
Baseline Mean (SE)
Overweight and obesec (N 5 27)
5
ARTICLE IN PRESS 6
K. Haney et al. / Disability and Health Journal
-
Table 3 Change in nutrition knowledge over the 10-month school year Normal weightb
Test items/variablesa Being physically active is only for athletes It is healthy to eat fruits and vegetables at every meal Fruits and vegetables are full of nutrients and vitamins It is good to exercise an hour a day Watch TV instead of exercise I should limit the amount of TV How does being physically active help your body Identify the activity that is most physically active Identify the bad drink Overall composite a b c
(2014)
-
Overweight/obesec
Baseline % correct Mean (SE)
10-month % correct Mean (SE)
Change %
Effect size
Baseline % correct Mean (SE)
10-month % correct Mean (SE)
Change %
72.54 (9.28)
69.67 (9.98)
2.87
0.83
0.71
51.87 (0.10)
68.10 (9.72)
16.24
0.26
0.01
83.35 (7.81)
87.01 (7.14)
3.67
0.73
0.10
81.90 (8.42)
87.01 (7.14)
5.11
0.65
0.14
66.57 (10.01)
82.67 (8.07)
16.10
0.23
0.37
72.81 (9.79)
82.67 (8.07)
9.87
0.44
0.24
74.97 (9.14)
78.33 (8.82)
3.36
0.79
0.08
72.80 (9.78)
91.33 (5.93)
18.53
0.13
0.50
82.62 (8.12) 54.59 (10.76) 58.15 (10.49)
91.34 (5.94) 87.03 (7.16) 73.98 (9.42)
8.71 32.44 15.83
0.39 0.03 0.28
0.26 0.74 0.34
72.82 (9.82) 68.30 (10.39) 54.57 (11.03)
91.34 (5.94) 95.67 (4.28) 82.67 (8.06)
18.51 27.36 28.09
0.13 0.04 0.05
0.50 0.78 0.62
70.78 (9.65)
86.42 (7.44)
15.64
0.22
0.39
72.81 (9.80)
87.01 (7.14)
14.19
0.26
0.36
58.76 (10.54) 6.55 (0.42)
60.93 (10.63) 7.84 (0.42)
2.17 1.29
0.88 !0.01
0.04 1.01
68.27 (10.32) 6.88 (0.39)
82.69 (8.09) 8.27 (0.39)
14.41 1.39
0.28 !0.01
0.34 1.10
p
Effect size
p
Adjusted for age and sex. Body mass index > 85th percentile for age and sex. Body mass index > 85th percentile for age and sex.
physical activity but not BMI. The authors emphasized a significant gap in effective obesity interventions for this population.44 Our last key finding was that Fit-2-PlayÔ participants significantly improved their knowledge of healthy lifestyle behaviors. Other studies have shown that an increase in nutrition knowledge results in increased vegetable and fruit consumption45 while others have seen no effect.46 Fit-2-PlayÔ does not serve a snack but does have water available at all times for consumption and that is encouraged among all participants. Strengths and limitations The main limitation of the study was not including a randomized no-treatment control group. While this study design is ideal it is not always feasible in communitybased programs such as this one. If resources can be focused on intervention and measurement fidelity rather than spreading staff and equipment across multiple control sites, this may be a more realistic approach to such efforts as this. However, the encouraging findings reported here justify implementing and supporting randomized longitudinal trials in future efforts. A second limitation is the small sample size that does not allow for within-disability (e.g. cognitive, intellectual) analysis, which leads to a third limitation; the broad spectrum of types of disabilities included in this study. However, all study participants here were functional and able to participate in Fit-2-PlayÔ at the same participatory level as those without disabilities. Additionally, this study may have introduced a healthy participant selection bias. Some parents who were not
interested in learning about health and wellness refused their child’s participation in the testing. Finally, home nutrition or physical activity habits were not assessed but are important components to monitor in future studies. Given the intersection of the current national economic climate and obesity crisis, it will be increasingly important to capitalize on existing resources such as our local, city, county, state, and national park systems to conduct prevention efforts. Recent studies show that among adults, parks play an important role in the ability of that community’s residents to be physically active and to maintain a normal body weight in large metropolitan areas.47 Our results here show promising outcomes among children with disabilities as well and suggest parks may be a bountiful resource in addressing the health consequences of the current childhood obesity epidemic that disproportionately affects those with disabilities.
Acknowledgments We would like to thank all of the children and their families who agreed to participate in this study. We would also like to thank all of our invaluable field staff ‘‘coaches’’ in the parks who implement Fit-2-PlayÔ on a daily basis. This research was partially funded by the Health Foundation of South Florida and the Aetna Foundation. References 1. Centers for Disease Control and Prevention. Disability and Obesity. Retrieved from: http://www.cdc.gov/ncbddd/disabilityandhealth/ obesity.html; Accessed 11.09.13.
ARTICLE IN PRESS K. Haney et al. / Disability and Health Journal 2. Reinehr T, Dobe M, Winkel K, Schaefer A, Hoffmann D. Obesity in disabled children and adolescents. Dtsch Arztebl Int. 2010;107(15): 268e275. 3. Centers for Disease Control and Prevention. Overweight and Obesity Among People With Disabilities. Retrieved from: http://www.cdc.gov/ ncbddd/disabilityandhealth/documents/obesityfactsheet2010.pdf; Accessed 11.09.13. 4. United States Department of Health and Human Services. Healthy People 2020. Retrieved from: http://www.healthypeople.gov/2020/ topicsobjectives2020/overview.aspx?topicid59; Accessed 13.06.13. 5. Rimmer JH, Rowland JL, Yamaki K. Obesity and secondary conditions in adolescents with disabilities: addressing the needs of an underserved population. J Adolesc Health. 2007 Sep;41(3):224e229. 6. Hinckson E, Curtis A. Measuring physical activity in children and youth living with intellectual disabilities: a systematic review. Res Dev Disabil. 2013;34(1):77e86. 7. United States Department of Health and Human Services. National Prevention Strategy. Washington, DC. http://www.surgeongeneral. gov/initiatives/prevention/strategy/; Accessed 13.09.13. 8. Rimmer JA, Rowland JL. Physical activity for youth with disabilities: a critical need in an underserved population. Dev Neurorehabil. 2008 Apr-Jun;11(2):141e148. 9. Afterschool Alliance. America After 3 pm. Retrieved from: http:// www.afterschoolalliance.org/AA3PM.cfm; 2010. Accessed 16.08.13. 10. McPherson A, Keith R, Swift J. Obesity prevention for children with physical disabilities: a scoping review of physical activity and nutrition interventions. Disabil Rehabil; 2013;1e15. Early Online. 11. McKenzie TL, Sallis JF, Rosengard P. Beyond the stucco tower: design, development, and dissemination of the SPARK physical education programs. Quest. 2009;61:114e127. 12. Sallis JF, McKenzie TL, Alcaraz JE, Kolody B, Faucette N, Hovell MF. The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. Am J Public Health. 1997;87:1328e1334. 13. Alliance for a Healthier Generation. http://www.healthiergeneration. org/; Accessed 07.11.12. 14. Centers for Disease Control and Prevention. BMI - Body Mass Index: BMI for Children and Teens. Available at: http://www.provena.org/ documents/BMI/bmi-for-age.pdf; Accessed 08.10.13. 15. Pietrobelli A, Faith MS, Allison DB, Gallagher D, Chiumello G, Heymsfield SB. Body mass index as a measure of adiposity among children and adolescents: a validation study. J Pediatr. 1998;132(2): 204e210. 16. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med. 1992 Nov 5;327(19):1350e1355. 17. Brambilla P, Bedogni G, Moreno LA, et al. Crossvalidation of anthropometry against magnetic resonance imaging for the assessment of visceral and subcutaneous adipose tissue in children. Int J Obes (Lond). 2006 Jan;30(1):23e30. 18. Li C, Ford ES, Mokdad AH, Cook S. Recent trends in waist circumference and waist-height ratio among US children and adolescents. Pediatrics. 2006 Nov;118(5):e1390ee1398. 19. Taylor RW, Jones IE, Williams SM, Goulding A. Evaluation of waist circumference, waist-to-hip ratio, and the conicity index as screening tools for high trunk fat mass, as measured by dual-energy X-ray absorptiometry, in children aged 3-19 y. Am J Clin Nutr. 2000 Aug;72(2):490e495. 20. Katzmarzyk PT, Srinivasan SR, Chen W, Malina RM, Bouchard C, Berenson GS. Body mass index, waist circumference, and clustering of cardiovascular disease risk factors in a biracial sample of children and adolescents. Pediatrics. 2004;114(2):e198ee205. 21. Janssen I, Katzmarzyk PT, Srinivasan SR, et al. Combined influence of body mass index and waist circumference on coronary artery disease risk factors among children and adolescents. Pediatrics. 2005 Jun;115(6):1623e1630.
-
(2014)
-
7
22. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. Anthropometry procedures Manual. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/ nchs/data/nhanes/nhanes_07_08/manual_an.pdf; Accessed 08.10.13. 23. Bouchard C, Shephard RJ, Stephens T, Bouchard C, Sheppard RJ. Physical Activity, Fitness, and Health: The Model and Key Concepts. In: Bouchard C, Shephard RJ, Stephens T, eds. Physical Activity, Fitness, and Health. Champaign, IL: Human Kinetics Books; 1994:77e88. 24. The Presidential Youth Fitness Program. Physical Educator Resource Guide. http://www.presidentialyouthfitnessprogram.org/docs/Teacher %20guide%209-6.pdf; Accessed 08.10.13. 25. President’s Council on Physical Fitness and Sports. 1985 National School Population Fitness Survey. Washington, DC: US Department of Health and Human Services, Public Health Service, Office of the Assistant Secretary for Health; 1986. 26. Castro-Pi~nero J, Chillon P, Ortega FB, et al. Criterion-related validity of sit-and-reach and modified sit-and-reach test for estimating hamstring flexibility in children and adolescents aged 6-17 years. Int J Sports Med. 2009;30(9):658e662. 27. Fitnessgram Training Validity and Reliability. http://www.fitnessgram. net/txtrainers/validityreliability.pdf; Accessed 08.10.13. 28. Leger LA, Lambert J. A maximal multistage 20-m shuttle run test to predict VO2 max. Eur J Appl Physiol Occup Physiol. 1982;49(1): 1e12. 29. Mahoney JL, Lord H, Carryl E. An ecological analysis of after-school program participation and the development of academic performance and motivational attributes for disadvantaged children. Child Dev. 2005 Jul-Aug;76(4):811e825. 30. Choudhry S, McClinton-Powell L, Solomon M, et al. Power-up: a collaborative after-school program to prevent obesity in African American children. Prog Community Health Partnersh. 2011 Winter;5(4):363e373. 31. Salcedo Aguilar F, Martınez-Vizcaıno V, Sanchez Lopez M, et al. Impact of an after-school physical activity program on obesity in children. J Pediatr. 2010 Jul;157(1):36e42.e3. 32. Wiecha JL, Nelson TF, Roth BA, Glashagel J, Vaughan L. Disseminating health promotion practices in after-school programs through YMCA learning collaboratives. Am J Health Promot. 2010 JanFeb;24(3):190e198. 33. Madsen KA, Thompson HR, Wlasiuk L, Queliza E, Schmidt C, Newman TB. After-school program to reduce obesity in minority children: a pilot study. J Child Health Care. 2009 Dec;13(4):333e346. 34. Wiecha JL, Hannon C, Meyer K. A toolkit to promote fidelity to health promotion interventions in afterschool programs. Health Promot Pract. 2013 May;14(3):370e379. 35. Foster GD, Sundal D, McDermott C, Jelalian E, Lent MR, Vojta D. Feasibility and preliminary outcomes of a scalable, communitybased treatment of childhood obesity. Pediatrics. 2012 Oct;130(4): 652e659. 36. Schwartz RP, Vitolins MZ, Case LD, et al. The YMCA Healthy, Fit, and Strong Program: a community-based, family-centered, low-cost obesity prevention/treatment pilot study. Child Obes. 2012;8(6): 577e582. 37. Eriksson JG, Forsen T, Tuomilehto J, Osmond C, Barker DJ. Early adiposity rebound in childhood and risk of Type 2 diabetes in adult life. Diabetologia. 2003;46(2):190e194. 38. Freedman DS, Kettel Khan L, Serdula MK, Srinivasan SR, Berenson GS. BMI rebound, childhood height and obesity among adults: the Bogalusa Heart Study. Int J Obes Relat Metab Disord. 2001;25(4):543e549. 39. Guo SS, Huang C, Maynard LM, et al. Body mass index during childhood, adolescence and young adulthood in relation to adult overweight and adiposity: the Fels Longitudinal Study. Int J Obes Relat Metab Disord. 2000;24(12):1628e1635. 40. Williams SM, Goulding A. Patterns of growth associated with the timing of adiposity rebound. Obesity (Silver Spring). 2009;17(2): 335e341.
ARTICLE IN PRESS 8
K. Haney et al. / Disability and Health Journal
41. Whitaker RC, Pepe MS, Wright JA, Seidel KD, Dietz WH. Early adiposity rebound and the risk of adult obesity. Pediatrics. 1998;101(3):E5. 42. Lee DC, Sui X, Church TS, Lavie CJ, Jackson AS, Blair SN. Changes in fitness and fatness on the development of cardiovascular disease risk factors hypertension, metabolic syndrome, and hypercholesterolemia. J Am Coll Cardiol. 2012;59(7):665e672. 43. Heller T, Sorensen A. Promoting healthy aging in adults with developmental disabilities. Dev Disabil Res Rev. 2013;18:22e30. 44. Oppewal A, Hilgenkamp T, Wijck R, Evenhuis H. Cardiorespiratory fitness in individuals with intellectual disabilities - A review. Res Dev Disabil. 2013 October;34(10):3301e3316.
-
(2014)
-
45. Wright K, Norris K, Newman Giger J, Suro Z. Improving healthy dietary behaviors, nutrition knowledge, and self-efficacy among underserved school children with parent and community involvement. Child Obes. 2012;8:347e356. 46. Evans CE, Christian MS, Cleghorn CL, Greenwood DC, Cade JE. Systematic review and meta-analysis of school-based interventions to improve daily fruit and vegetable intake in children aged 5 to 12 y. Am J Clin Nutr. 2012;96:889e901. 47. West ST, Shores KA, Mudd LM. Association of available parkland, physical activity, and overweight in America’s largest cities. J Public Health Manag Pract. 2012;18:423e430.
Disability and Health Journal
-
(2014)
-
www.disabilityandhealthjnl.com
Brief Report
Park-based afterschool program to improve cardiovascular health and physical fitness in children with disabilities Kanathy Haney, M.S., B.S.W.a, Sarah E. Messiah, Ph.D., M.P.H.a,b,*, Kristopher L. Arheart, Ed.D.a,b, Eric Hanson, M.P.A.c, Allison Diego, M.P.A.c, Jack Kardys, M.S.M.c, Kevin Kirwin, M.P.A.c, Renae Nottage, B.A.c, Shawn Ramirez, B.S.c, Gabriel Somarriba, D.P.T.b, and Lucy Binhack, B.A.c a
b
Department of Epidemiology and Public Health Sciences, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA Department of Pediatrics, Division of Pediatric Clinical Research, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA c Miami Dade Department of Parks, Recreation and Open Spaces, Miami, FL, USA
Abstract Background: Children with disabilities are more likely to be overweight or obese and less likely to engage in physical activities versus their peers without disabilities. Objective: The effect of a structured afterschool program housed in a large county parks system on several obesity-related health outcomes among children with disabilities was examined. Methods: Children/adolescents with a developmental and/or intellectual disability ages 6e22 (N 5 52, mean age 13.7 years) who participated in an afterschool (either 2010e2011 or 2011e2012 school year) health and wellness program called Fit-2-PlayÔ were assessed. Pre-post comparison of outcome variables (mean height, weight, waist/hip/midarm circumference, fitness tests, and a 9-item health and wellness knowledge assessment) via general linear mixed models analysis was conducted to evaluate the effectiveness of the program for normal and overweight/obese participants. Results: Normal weight participants significantly improved pre-post mean number of push-ups (9.69e14.23, p 5 0.01) and laps on the PACER test (8.54e11.38, p ! 0.01) and the overweight/obese group significantly improved the number of sit ups (7.51e9.84, p ! 0.01) and push ups (4.77e9.89, p ! 0.001). Pre-post mean health and wellness knowledge composite scores significantly improved for all participants ( p ! 0.01). Conclusions: Parks-based afterschool programs can be effective community resources for instilling physical health in both normal weight and overweight/obese children with disabilities. More studies are needed to ascertain whether community-based afterschool health and wellness programs can be implemented and sustained across this population. Ó 2014 Elsevier Inc. All rights reserved. Keywords: Disability; Children; Obesity; Prevention; Physical activity
The Centers for Disease Control and Prevention (CDC) reports that obesity is 38% higher in children with disabilities compared to their peers without disabilities.1e3 Moreover, individuals with disabilities are less likely to engage in physical activities, are exposed to more screen time, and have a worse overall health status as a result versus their peers without disabilities.4e6 As such, Healthy People
There are not conflicts of interest to report for any authors. The work presented here has not been previously published or presented. * Corresponding author. Department of Pediatrics, Division of Pediatric Clinical Research, University of Miami Leonard M. Miller School of Medicine, Batchelor Children’s Research Institute, Room 541, 1580 NW 10th Avenue, Miami, FL 33130, USA. Tel.: þ1 305 243 1943; fax: þ1 305 243 8475. E-mail address: [email protected] (S.E. Messiah). 1936-6574/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2014.02.006
20204 and the National Prevention Strategy7 among others8 recommend including individuals with disabilities in health promotion programs to decrease their overall health risks. The afterschool setting can provide an alternative setting for obesity prevention and wellness activities with potential for significant impact since 8 million children attend afterschool programs in the US.9 Historically, children with disabilities have not been fully represented in afterschool programs that specifically promote physical and mental health yet would likely benefit from such programs. Few studies in the literature specifically focus on outcomes of afterschool health and wellness programs designed for children with disabilities.10 Thus, we report here the anthropometric, physical fitness and health and wellness knowledge outcomes of an afterschool program among a diverse sample of children with disabilities.
ARTICLE IN PRESS 2
K. Haney et al. / Disability and Health Journal
Methods Design A pilot, single arm, pre-post 10 month (length of one school year) study was conducted. Fit-2-PlayÔ is managed by the Miami-Dade County Department of Parks, Recreation and Open Spaces (MDCPROS) and takes place every afternoon from 2 pm to 6 pm. Sample All students had to provide their individual education plans (IEPs) to document they were currently receiving special services for their disability in school and therefore qualified for the same program in the afterschool setting. The children included in this analysis had a range of known disabilities including attention deficit hyperactivity disorder (n 5 8), autism (n 5 19), cerebral palsy (n 5 1), Down syndrome (n 5 3), physical (n 5 1), learning (n 5 1), intellectual (n 5 7), cognitive (n 5 6), lead poisoning at birth (n 5 1), PVR natal stoke (n 5 1), speech issues (n 5 3), and severe asthma (n 5 1).
-
(2014)
-
sessions are conducted weekly (and biweekly some weeks) on Fridays in the place of homework hour. Children are typically grouped by age for all activities. Outcome measures University of Miami faculty and staff members trained all parks field staff (coaches with physical education backgrounds) on appropriate anthropometric, blood pressure and physical fitness data collection methods and techniques. In turn, parks staff conducted all pre-and post data collection on-site and data were uploaded to a shared database. Additionally, MDCPROS bachelor and master’s level recreation directors with education backgrounds in health and wellness and exercise physiology oversaw on-site measurement procedures and collection of all pre-and post data to ensure measurement fidelity.
Description of program
Anthropometric measures Weight was collected on calibrated scales (Seca Model 869, Seca North America East Medical Scales & Measuring Devices, Hanover, MD). Children did not wear their shoes, were asked to empty their pockets, and only wore light clothing (e.g. shorts, t-shirt). Height was measured using a stadiometer (Seca 217 Mechanical Telescopic, Seca North America East Medical Scales & Measuring Devices, Hanover, MD). Body mass index (BMI) was calculated as weight (kilograms) divided by height (meters)2 and was then converted to an age-and sex-adjusted percentile and z score.14 BMI has been shown to be a reliable and valid measure of both total body fat and percent of body weight as fat among children in previous studies.15e17 Waist circumference18 and its relationship to both height19 and hip circumference19 are simple, yet valid surrogate measures of cardiometabolic disease risk (e.g. cardiovascular disease and/or type 3 diabetes).20,21 Waist, hip and midarm circumferences were measured with a tape measure (Gulick model 1098990, Mabis, Jesup, GA). Waist circumference was measured in the horizontal plane at a point marked just above the right ileum on the midaxillary line at minimal respiration.22
The Fit-2-PlayÔ curriculum is comprised of (1) Sports, Play and Active Recreation for Kids (SPARK)11 an evidenced-based12 outcome oriented structured active recreation for children with a focus on developing and improving motor skills, movement knowledge, social and personal skills and (2) EmpowerMe4Life, a health and wellness education curriculum grounded in the American Heart Association’s scientific recommendations in promoting heart-healthy lifestyles.13 Children are exposed to the Fit-2-PlayÔ program and curriculum on a daily basis after homework is completed. Park ‘‘coaches’’ introduce different physical activities for at least 1 h each afternoon. Health and wellness education
Physical fitness Physical fitness refers to those components of fitness that have a relationship with health such as (1) cardiorespiratory fitness, (2) musculoskeletal fitness, and (3) motor fitness.23 The following components of the validated President’s Council on Exercise’s standardized testing protocol were used to test physical fitness.24,25 Flexibility was assessed with the modified sit and reach test (Novel Products Flex Tester sit-and-reach box model 00004, Rockton, IL) that has recently been validated for hamstring and low back flexibility in both children and adolescents.26
Participants Mean age of the entire sample was 13.7 years old (64.7 years), 75% of the sample were boys and the majority selfidentified as Hispanic (65%), followed by non-Hispanic Black/African American (23%), and non-Hispanic White (12%). At baseline/pre-test, 48% of the sample was normal weight, 13% were overweight, and 38% were obese (Table 1). Procedures Parents of children ages 5e24 who participated were asked to sign a consent form for their child to participate in the pre-post test measurements to evaluate the Fit-2-PlayÔ program (N 5 52; out of a total of 172 total participants with disabilities). The study was approved by the University of Miami Institutional Review Board.
ARTICLE IN PRESS K. Haney et al. / Disability and Health Journal
-
(2014)
-
3
Table 1 Baseline characteristics of 52 participants with developmental disabilities, 2010e2011 or 2011e2012 school year Entire sample (N 5 52) Normal weighta (N 5 25)
Gender Boys Girls Ethnicity Hispanic Non-Hispanic Black or African American Non-Hispanic White Age, yr Weight, kg Weight, percentile Weight, z score Height, cm Height, percentile Height, z score BMId, kg/m2 BMId percentile BMId z score Waist circumference, cm Hip circumference, cm Waist-to-hip ratio, % Waist-to-height ratio, % Midarm circumference, cm Biceps skinfold (mm) Triceps skinfold (mm) Subscapular skinfold (mm) Suprailiac skinfold (mm) Sum of thicknesses of four skinfolds (mm)
Overweight/obeseb (N 5 27)
n (%)
n (%)
n (%)
39 (75) 13 (25)
21 (84) 4 (16)
18 (67) 9 (33)
34 (65) 12 (23) 6 (12) Mean (SD) 13.7 55.9 69.2 0.5 151.7 49.8 0.2 23.5 70.5 0.8 77.7 89.3 87.1 51.3 24.4 13.0 19.4 13.8 14.9 54.7
(4.7) (24.0) (32.9) (2.2) (17.8) (35.9) (1.8) (6.9) (33.2) (1.7) (18.3) (17.1) (10.5) (10.7) (6.7) (7.5) (10.1) (7.8) (9.6) (29.8)
16 (28) 7 (64) 2 (8) Range (minemax)
18 (67) 5 (19) 4 (14) Mean (SD)c
Mean (SD)c
(6.5e22.4) (21.5e130.2) (0.0e100.0) (9.5 to 3.4) (106.1e184.7) (0.0e100.0) (4.7 to 5.2) (14.8e42) (0.0e99.9) (4.1 to 2.9) (53.1e121.4) (55.5e129.3) (65.3e130.3) (34.0e73.3) (13.6e45.0) (3.0e35.0) (6.0e48.7) (4.0e34.7) (5.0e36.7) (20.3e123.5)
13.6 42.5 44.8 0.8 152.0 50.5 0.3 17.9 42.5 0.6 64.9 80.2 81.1 42.8 20.6 8.8 13.8 11.1 9.6 42.4
13.8 68.3 91.8 1.8 151.5 49.2 0.0 28.7 96.5 2.0 89.4 97.4 92.5 59.1 28.0 17.5 25.4 18.4 22.2 75.2
e e
e e
(4.3) (13.7) (30.8) (2.3) (18.8) (32.9) (1.7) (2.5) (27.5) (1.5) (11.0) (11.9) (5.5) (5.1) (4.0) (5.8) (7.1) (6.7) (6.5) (24.2)
(5.1) (25.0) (11.9) (0.8) (17.1) (39.0) (1.9) (5.5) (3.4) (0.5) (15.6) (17.1) (11.0) (8.2) (6.7) (6.6) (9.4) (7.6) (8.3) (27.5)
n (%) Obese (>95th BMId percentile) Overweight (85th < BMId percentile ! 95th) a b c d
20 (38.46) 7 (13.46)
e e
Body mass index (BMI) ! 85th percentile for age and sex. Body mass index (BMI) > 85th percentile for age and sex. Adjusted for age and sex. Body mass index.
Muscular endurance was evaluated by the sit-up test. Subjects performed as many complete sit-ups as they could during a 60 s timed period. Muscular strength was assessed by maximal right angle push-up. When instructed, each subject performed as many complete pushups until volitional exhaustion. Absolute values were recorded.27 Aerobic fitness was assessed with a timed 400 m run and the PACER test. The PACER (Progressive Aerobic Cardiovascular Endurance Run) is a valid, multistage fitness test adapted from the 20-m shuttle run test.28 The test is progressive in intensity with the objective to run as many laps as possible. In the 400 m run, children were instructed to run a lap as fast as possible and their time was recorded.27 Push-ups, sit ups, and the PACER test practice typically occurs once every month during the school year in addition to the daily SPARK activities. Quarter mile run practice occurs approximately twice a month.
Health and wellness knowledge Health and wellness knowledge was assessed using the EmpowerMe4Life13 9-item scale. Specifically, participants were asked 7 true/false and 2 multiple choice questions at both pre-and post-test about nutrition and physical activity choices. Individual and total of all 9 items (composite score) were analyzed as outcomes measures. No psychometric property data are available at this time for this pre-post assessment tool. Statistical analyses Means and standard deviations were generated for all continuous data (age, anthropometric measures) and categorical data (gender, ethnicity) are reported as frequencies and percentages. All outcome measures were dichotomized by weight status: normal weight (BMI ! 85th percentile for age and sex) and overweight/obese participants (BMI > 85th percentile for age and sex).14 For those
ARTICLE IN PRESS 4
K. Haney et al. / Disability and Health Journal
participants who were older than age 20, the 20 year old age-and sex-adjusted percentiles were applied. Normally distributed outcome variables including BMI z score, hip circumference, waist circumference, midarm circumference, waist-hip ratio, sit and reach test, 400 m run, and the health and wellness composite scores were analyzed with a general linear mixed model to generate means and standard errors. Outcomes with a binary distribution which are the correct responses for the health and wellness knowledge items are presented as percent and standard error. Data with a Poisson distribution including sit-ups, push-ups and the pacer test are presented as means and standard errors. Both types of data are analyzed with a generalized linear mixed model. All models included fixed effects for BMI group, time, and the interaction of group and time. When appropriate, covariates for age, sex, and ethnicity were included to control for their possibly confounding effects. For example, all physical fitness variables were adjusted for age and sex. A random intercept was included with parks as a subject to account for between park variation, and another random effect is included for the repeated measure time with participants nested within parks to account for the nesting of participants within parks. Contrasts were used to determine the significance of the change over time in each group and the significance of the difference between groups in the changes. The link function for binary data was the logit, and for Poisson data was the natural logarithm. The 0.05 significance level determined statistical significance. SAS 9.3 (SAS Institute, Inc., Cary, NC) was used for all analyses. Results Anthropometrics BMI z score did not significantly change for the normal weight (0.63 to 0.39) or overweight/obese group (1.99e1.81) over the study period. Similarly, there were no significant changes in other anthropometric measures for both groups from pre- to post-test (Table 2). Physical fitness Both groups improved in all physical fitness tests. Specifically, among the overweight/obese group the mean number of sit ups significantly improved from 7.5 at baseline to 9.8 repetitions at follow up ( p ! 0.01, effect size [ES] 5 0.21), mean number of push-ups significantly improved from 4.8 to 9.9 repetitions at follow up ( p ! 0.001, ES 5 0.46). The normal weight group significantly improved their mean number of push-ups from 9.7 at baseline to 14.2 at follow up ( p 5 0.01, ES 5 0.37) as well as the mean number of laps on the pacer test (8.54e11.38, p ! 0.01, ES 5 0.26) (Table 2). Health and wellness knowledge Both weight groups significantly improved their health and wellness knowledge from baseline to post-test
-
(2014)
-
assessment (mean overall composite change 6.55e7.84 questions correct in the normal weight group ( p ! 0.01, ES 5 1.01) and 6.88e8.27 questions correct in the overweight/obese group ( p ! 0.01, ES 5 1.10)). Several individual items saw similar statistical improvement (Table 3). Discussion We report here multiple key findings that have direct implications for the current childhood obesity epidemic and it’s health related consequences that both disproportionately affect children and adolescents with disabilities. Results show that both normal weight and overweight/ obese children with disabilities who participated in the Fit-2-PlayÔ afterschool program significantly improved fitness levels and nutrition knowledge over the school year. The afterschool setting has remained relatively understudied as an alternative to school-based intervention efforts and among pediatric populations with disabilities in particular.29 Those studies that have occurred in schoolbased and YMCA afterschool settings among children who do not have disabilities show that this time of day can successfully promote health and wellness30e34 and even treat obesity successfully.35,36 The Fit-2-PlayÔ afterschool program described here includes parks that offer both exclusive and immersion programs for children with disabilities so all participants can benefit from the opportunity to develop not only better physical health but social relationships with their peers. Although there was a decrease in BMI z score in the overweight/obese group over the school year, it did not reach statistical significance. Nevertheless, this finding is encouraging because if normal childhood growth trajectories can be maintained (e.g. not gaining abnormal weight) among children with disabilities who historically struggle more with their weight versus their peers without disabilities, the risk of later onset overweight and obesity decreases.37e41 Our next key findings showed that both weight groups significantly improved in several physical fitness tests. Some have suggested that being physically fit can eliminate the health risks of being overweight, especially in terms of heart health. In adults, how fitness and fatness uniquely contribute to overall health is controversial,42 and few studies are available on the associations of changes in fitness and fatness with the development of cardiometabolic disease risk factors, with even fewer studies available in pediatric populations and very few in children with disabilities. Healthy aging adults with developmental disabilities have been shown to gain fitness benefit from interventions focusing on physical activity and healthy behaviors but more long term studies are needed to determine their effects on cardiovascular disease risk.43 In a recent review article of 34 physical fitness studies among children with mixed disabilities, it was found that 18 programs improved
Table 2 Change in anthropometric and physical fitness measurements over the 2011e2011 or 2011e2012 school year Normal weightb (N 5 25) p
Effect size
Primary end point BMI z score 0.63 Secondary end pointsd Hip circumference, cm 80.44 Waist circumference, cm 64.48 Mid-arm circumference, cm 20.19 Waist-to-hip ratio 80.30 Waist-to-height ratio 42.89 Baseline
(0.22)
0.39 (0.23)
0.24 (0.59 to 0.10)
0.16
0.40
(2.44) (2.55) (1.17) (1.73) (1.56)
79.51 (2.46) 65.60 (2.57) 20.42 (1.18) 82.65 (1.74) 43.58 (1.57) 10-month
0.93 (1.67 1.11 (3.36 0.23 (1.59 2.35 (5.95 0.69 (2.19 Change
0.47 0.05 0.32 0.53 0.74 0.22 0.19 0.37 0.36 0.32 Effect size
c d
80.40 14.64 14.23 11.38 18.90 226.19
(3.07) (2.22) (2.85) (1.87) (1.50) (34.09)
3.07 2.32 4.54 2.84 0.34 25.87
0.31 0.07 0.01 !0.01 0.73 0.29
0.41 0.29 0.37 0.26 0.10 0.36
83.96 7.51 4.77 4.76 21.06 230.36
(2.11) (2.21) (1.02) (1.52) (1.35)
(2.85) (1.06) (0.95) (0.75) (1.28) (27.40)
96.81 (2.12) 88.98 (2.22) 27.47 (1.02) 91.57 (1.53) 58.39 (1.36) 10-month 80.94 9.84 9.89 5.97 21.37 218.89
(2.93) (1.35) (1.79) (0.91) (1.28) (27.46)
p
Effect size
0.18 (0.14 to 0.51)
0.27
0.30
0.55 0.21 0.37 0.53 0.71
0.65 0.85 0.56 0.75 0.32
0.11 0.18 0.04 0.09 0.22 Effect size
(1.86 to (1.93 to (0.91 to (2.83 to (0.72 to Change 3.01 2.33 5.12 1.22 0.32 11.47
2.96) 2.34) 1.67) 3.89) 2.15) p
0.29 !0.01 !0.001 0.07 0.73 0.29
0.29 0.21 0.46 0.16 0.10 0.19
-
b
(3.00) (1.86) (1.96) (1.41) (1.47) (34.39)
97.37 89.19 27.84 92.11 59.11 Baseline
1.81 (0.22)
Change (95% CI)
(2014)
a
83.45 12.32 9.69 8.54 19.24 200.32
3.53) 1.13) 1.13) 1.24) 0.82) p
1.99 (0.22)
10-month Mean (SE)
-
Fitness test, meana (SD)d Pulse Sit ups (number) Push ups (number) Pacer test (laps) Sit-and-reach (cm) 400 m run (seconds)
to to to to to
Baseline Mean (SE)
Change represents difference between baseline and 10-month mean percent. Body mass index ! 85th percentile for age and sex. Body mass index > 85th percentile for age and sex. Adjusted for age and sex.
ARTICLE IN PRESS
Changea (95% CI)
K. Haney et al. / Disability and Health Journal
10-month Mean (SE)
Baseline Mean (SE)
Overweight and obesec (N 5 27)
5
ARTICLE IN PRESS 6
K. Haney et al. / Disability and Health Journal
-
Table 3 Change in nutrition knowledge over the 10-month school year Normal weightb
Test items/variablesa Being physically active is only for athletes It is healthy to eat fruits and vegetables at every meal Fruits and vegetables are full of nutrients and vitamins It is good to exercise an hour a day Watch TV instead of exercise I should limit the amount of TV How does being physically active help your body Identify the activity that is most physically active Identify the bad drink Overall composite a b c
(2014)
-
Overweight/obesec
Baseline % correct Mean (SE)
10-month % correct Mean (SE)
Change %
Effect size
Baseline % correct Mean (SE)
10-month % correct Mean (SE)
Change %
72.54 (9.28)
69.67 (9.98)
2.87
0.83
0.71
51.87 (0.10)
68.10 (9.72)
16.24
0.26
0.01
83.35 (7.81)
87.01 (7.14)
3.67
0.73
0.10
81.90 (8.42)
87.01 (7.14)
5.11
0.65
0.14
66.57 (10.01)
82.67 (8.07)
16.10
0.23
0.37
72.81 (9.79)
82.67 (8.07)
9.87
0.44
0.24
74.97 (9.14)
78.33 (8.82)
3.36
0.79
0.08
72.80 (9.78)
91.33 (5.93)
18.53
0.13
0.50
82.62 (8.12) 54.59 (10.76) 58.15 (10.49)
91.34 (5.94) 87.03 (7.16) 73.98 (9.42)
8.71 32.44 15.83
0.39 0.03 0.28
0.26 0.74 0.34
72.82 (9.82) 68.30 (10.39) 54.57 (11.03)
91.34 (5.94) 95.67 (4.28) 82.67 (8.06)
18.51 27.36 28.09
0.13 0.04 0.05
0.50 0.78 0.62
70.78 (9.65)
86.42 (7.44)
15.64
0.22
0.39
72.81 (9.80)
87.01 (7.14)
14.19
0.26
0.36
58.76 (10.54) 6.55 (0.42)
60.93 (10.63) 7.84 (0.42)
2.17 1.29
0.88 !0.01
0.04 1.01
68.27 (10.32) 6.88 (0.39)
82.69 (8.09) 8.27 (0.39)
14.41 1.39
0.28 !0.01
0.34 1.10
p
Effect size
p
Adjusted for age and sex. Body mass index > 85th percentile for age and sex. Body mass index > 85th percentile for age and sex.
physical activity but not BMI. The authors emphasized a significant gap in effective obesity interventions for this population.44 Our last key finding was that Fit-2-PlayÔ participants significantly improved their knowledge of healthy lifestyle behaviors. Other studies have shown that an increase in nutrition knowledge results in increased vegetable and fruit consumption45 while others have seen no effect.46 Fit-2-PlayÔ does not serve a snack but does have water available at all times for consumption and that is encouraged among all participants. Strengths and limitations The main limitation of the study was not including a randomized no-treatment control group. While this study design is ideal it is not always feasible in communitybased programs such as this one. If resources can be focused on intervention and measurement fidelity rather than spreading staff and equipment across multiple control sites, this may be a more realistic approach to such efforts as this. However, the encouraging findings reported here justify implementing and supporting randomized longitudinal trials in future efforts. A second limitation is the small sample size that does not allow for within-disability (e.g. cognitive, intellectual) analysis, which leads to a third limitation; the broad spectrum of types of disabilities included in this study. However, all study participants here were functional and able to participate in Fit-2-PlayÔ at the same participatory level as those without disabilities. Additionally, this study may have introduced a healthy participant selection bias. Some parents who were not
interested in learning about health and wellness refused their child’s participation in the testing. Finally, home nutrition or physical activity habits were not assessed but are important components to monitor in future studies. Given the intersection of the current national economic climate and obesity crisis, it will be increasingly important to capitalize on existing resources such as our local, city, county, state, and national park systems to conduct prevention efforts. Recent studies show that among adults, parks play an important role in the ability of that community’s residents to be physically active and to maintain a normal body weight in large metropolitan areas.47 Our results here show promising outcomes among children with disabilities as well and suggest parks may be a bountiful resource in addressing the health consequences of the current childhood obesity epidemic that disproportionately affects those with disabilities.
Acknowledgments We would like to thank all of the children and their families who agreed to participate in this study. We would also like to thank all of our invaluable field staff ‘‘coaches’’ in the parks who implement Fit-2-PlayÔ on a daily basis. This research was partially funded by the Health Foundation of South Florida and the Aetna Foundation. References 1. Centers for Disease Control and Prevention. Disability and Obesity. Retrieved from: http://www.cdc.gov/ncbddd/disabilityandhealth/ obesity.html; Accessed 11.09.13.
ARTICLE IN PRESS K. Haney et al. / Disability and Health Journal 2. Reinehr T, Dobe M, Winkel K, Schaefer A, Hoffmann D. Obesity in disabled children and adolescents. Dtsch Arztebl Int. 2010;107(15): 268e275. 3. Centers for Disease Control and Prevention. Overweight and Obesity Among People With Disabilities. Retrieved from: http://www.cdc.gov/ ncbddd/disabilityandhealth/documents/obesityfactsheet2010.pdf; Accessed 11.09.13. 4. United States Department of Health and Human Services. Healthy People 2020. Retrieved from: http://www.healthypeople.gov/2020/ topicsobjectives2020/overview.aspx?topicid59; Accessed 13.06.13. 5. Rimmer JH, Rowland JL, Yamaki K. Obesity and secondary conditions in adolescents with disabilities: addressing the needs of an underserved population. J Adolesc Health. 2007 Sep;41(3):224e229. 6. Hinckson E, Curtis A. Measuring physical activity in children and youth living with intellectual disabilities: a systematic review. Res Dev Disabil. 2013;34(1):77e86. 7. United States Department of Health and Human Services. National Prevention Strategy. Washington, DC. http://www.surgeongeneral. gov/initiatives/prevention/strategy/; Accessed 13.09.13. 8. Rimmer JA, Rowland JL. Physical activity for youth with disabilities: a critical need in an underserved population. Dev Neurorehabil. 2008 Apr-Jun;11(2):141e148. 9. Afterschool Alliance. America After 3 pm. Retrieved from: http:// www.afterschoolalliance.org/AA3PM.cfm; 2010. Accessed 16.08.13. 10. McPherson A, Keith R, Swift J. Obesity prevention for children with physical disabilities: a scoping review of physical activity and nutrition interventions. Disabil Rehabil; 2013;1e15. Early Online. 11. McKenzie TL, Sallis JF, Rosengard P. Beyond the stucco tower: design, development, and dissemination of the SPARK physical education programs. Quest. 2009;61:114e127. 12. Sallis JF, McKenzie TL, Alcaraz JE, Kolody B, Faucette N, Hovell MF. The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. Am J Public Health. 1997;87:1328e1334. 13. Alliance for a Healthier Generation. http://www.healthiergeneration. org/; Accessed 07.11.12. 14. Centers for Disease Control and Prevention. BMI - Body Mass Index: BMI for Children and Teens. Available at: http://www.provena.org/ documents/BMI/bmi-for-age.pdf; Accessed 08.10.13. 15. Pietrobelli A, Faith MS, Allison DB, Gallagher D, Chiumello G, Heymsfield SB. Body mass index as a measure of adiposity among children and adolescents: a validation study. J Pediatr. 1998;132(2): 204e210. 16. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med. 1992 Nov 5;327(19):1350e1355. 17. Brambilla P, Bedogni G, Moreno LA, et al. Crossvalidation of anthropometry against magnetic resonance imaging for the assessment of visceral and subcutaneous adipose tissue in children. Int J Obes (Lond). 2006 Jan;30(1):23e30. 18. Li C, Ford ES, Mokdad AH, Cook S. Recent trends in waist circumference and waist-height ratio among US children and adolescents. Pediatrics. 2006 Nov;118(5):e1390ee1398. 19. Taylor RW, Jones IE, Williams SM, Goulding A. Evaluation of waist circumference, waist-to-hip ratio, and the conicity index as screening tools for high trunk fat mass, as measured by dual-energy X-ray absorptiometry, in children aged 3-19 y. Am J Clin Nutr. 2000 Aug;72(2):490e495. 20. Katzmarzyk PT, Srinivasan SR, Chen W, Malina RM, Bouchard C, Berenson GS. Body mass index, waist circumference, and clustering of cardiovascular disease risk factors in a biracial sample of children and adolescents. Pediatrics. 2004;114(2):e198ee205. 21. Janssen I, Katzmarzyk PT, Srinivasan SR, et al. Combined influence of body mass index and waist circumference on coronary artery disease risk factors among children and adolescents. Pediatrics. 2005 Jun;115(6):1623e1630.
-
(2014)
-
7
22. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. Anthropometry procedures Manual. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/ nchs/data/nhanes/nhanes_07_08/manual_an.pdf; Accessed 08.10.13. 23. Bouchard C, Shephard RJ, Stephens T, Bouchard C, Sheppard RJ. Physical Activity, Fitness, and Health: The Model and Key Concepts. In: Bouchard C, Shephard RJ, Stephens T, eds. Physical Activity, Fitness, and Health. Champaign, IL: Human Kinetics Books; 1994:77e88. 24. The Presidential Youth Fitness Program. Physical Educator Resource Guide. http://www.presidentialyouthfitnessprogram.org/docs/Teacher %20guide%209-6.pdf; Accessed 08.10.13. 25. President’s Council on Physical Fitness and Sports. 1985 National School Population Fitness Survey. Washington, DC: US Department of Health and Human Services, Public Health Service, Office of the Assistant Secretary for Health; 1986. 26. Castro-Pi~nero J, Chillon P, Ortega FB, et al. Criterion-related validity of sit-and-reach and modified sit-and-reach test for estimating hamstring flexibility in children and adolescents aged 6-17 years. Int J Sports Med. 2009;30(9):658e662. 27. Fitnessgram Training Validity and Reliability. http://www.fitnessgram. net/txtrainers/validityreliability.pdf; Accessed 08.10.13. 28. Leger LA, Lambert J. A maximal multistage 20-m shuttle run test to predict VO2 max. Eur J Appl Physiol Occup Physiol. 1982;49(1): 1e12. 29. Mahoney JL, Lord H, Carryl E. An ecological analysis of after-school program participation and the development of academic performance and motivational attributes for disadvantaged children. Child Dev. 2005 Jul-Aug;76(4):811e825. 30. Choudhry S, McClinton-Powell L, Solomon M, et al. Power-up: a collaborative after-school program to prevent obesity in African American children. Prog Community Health Partnersh. 2011 Winter;5(4):363e373. 31. Salcedo Aguilar F, Martınez-Vizcaıno V, Sanchez Lopez M, et al. Impact of an after-school physical activity program on obesity in children. J Pediatr. 2010 Jul;157(1):36e42.e3. 32. Wiecha JL, Nelson TF, Roth BA, Glashagel J, Vaughan L. Disseminating health promotion practices in after-school programs through YMCA learning collaboratives. Am J Health Promot. 2010 JanFeb;24(3):190e198. 33. Madsen KA, Thompson HR, Wlasiuk L, Queliza E, Schmidt C, Newman TB. After-school program to reduce obesity in minority children: a pilot study. J Child Health Care. 2009 Dec;13(4):333e346. 34. Wiecha JL, Hannon C, Meyer K. A toolkit to promote fidelity to health promotion interventions in afterschool programs. Health Promot Pract. 2013 May;14(3):370e379. 35. Foster GD, Sundal D, McDermott C, Jelalian E, Lent MR, Vojta D. Feasibility and preliminary outcomes of a scalable, communitybased treatment of childhood obesity. Pediatrics. 2012 Oct;130(4): 652e659. 36. Schwartz RP, Vitolins MZ, Case LD, et al. The YMCA Healthy, Fit, and Strong Program: a community-based, family-centered, low-cost obesity prevention/treatment pilot study. Child Obes. 2012;8(6): 577e582. 37. Eriksson JG, Forsen T, Tuomilehto J, Osmond C, Barker DJ. Early adiposity rebound in childhood and risk of Type 2 diabetes in adult life. Diabetologia. 2003;46(2):190e194. 38. Freedman DS, Kettel Khan L, Serdula MK, Srinivasan SR, Berenson GS. BMI rebound, childhood height and obesity among adults: the Bogalusa Heart Study. Int J Obes Relat Metab Disord. 2001;25(4):543e549. 39. Guo SS, Huang C, Maynard LM, et al. Body mass index during childhood, adolescence and young adulthood in relation to adult overweight and adiposity: the Fels Longitudinal Study. Int J Obes Relat Metab Disord. 2000;24(12):1628e1635. 40. Williams SM, Goulding A. Patterns of growth associated with the timing of adiposity rebound. Obesity (Silver Spring). 2009;17(2): 335e341.
ARTICLE IN PRESS 8
K. Haney et al. / Disability and Health Journal
41. Whitaker RC, Pepe MS, Wright JA, Seidel KD, Dietz WH. Early adiposity rebound and the risk of adult obesity. Pediatrics. 1998;101(3):E5. 42. Lee DC, Sui X, Church TS, Lavie CJ, Jackson AS, Blair SN. Changes in fitness and fatness on the development of cardiovascular disease risk factors hypertension, metabolic syndrome, and hypercholesterolemia. J Am Coll Cardiol. 2012;59(7):665e672. 43. Heller T, Sorensen A. Promoting healthy aging in adults with developmental disabilities. Dev Disabil Res Rev. 2013;18:22e30. 44. Oppewal A, Hilgenkamp T, Wijck R, Evenhuis H. Cardiorespiratory fitness in individuals with intellectual disabilities - A review. Res Dev Disabil. 2013 October;34(10):3301e3316.
-
(2014)
-
45. Wright K, Norris K, Newman Giger J, Suro Z. Improving healthy dietary behaviors, nutrition knowledge, and self-efficacy among underserved school children with parent and community involvement. Child Obes. 2012;8:347e356. 46. Evans CE, Christian MS, Cleghorn CL, Greenwood DC, Cade JE. Systematic review and meta-analysis of school-based interventions to improve daily fruit and vegetable intake in children aged 5 to 12 y. Am J Clin Nutr. 2012;96:889e901. 47. West ST, Shores KA, Mudd LM. Association of available parkland, physical activity, and overweight in America’s largest cities. J Public Health Manag Pract. 2012;18:423e430.