Manoj Sharma, MBBS, CHES, Ph.D. Associate Professor, University of Cincinnati

1. Developing and testing aninstrument to evaluate childhood obesity prevention behaviors based on social cognitive theory Manoj Sharma, MBBS, CHES, Ph.D. Associate Professor, University of Cincinnati Donald I. Wagner, HSD Professor, University of Cincinnati Session 4190, Board 1, November 7 (T), 2:30 pm

2. Background • Since 1980 the prevalence of overweight has doubled for children and tripled for adolescents • The national health care expenditures related to overweight and obesity in adults are estimated between $98 billion to $129 billion • In the Healthy People 2010 Report, the goal for reducing overweight and obesity in children and adolescents is aimed at 5 percent from the 1988-94 baseline of 11 percent

3. Problems with Childhood Obesity • The Bogalusa Heart Study found that by age 10 years, 60% of overweight children have at least one biochemical or clinical cardiovascular risk factor and 25% have more than two • Childhood obesity is associated with several short term medical consequences such as adverse blood lipid profile, altered glucose metabolism, obstructive sleep apnea and long term effects such as higher risk of hypertension, diabetes, cardiovascular disease, gall bladder disease, and osteoarthritis in adulthood

4. Public health strategies to combat childhood obesity • Promoting breastfeeding • Limiting television viewing • Encouraging physical activity • Increasing fruit and vegetable intake • Controlling portion size • Limiting soft drink consumption

5. Purposes of this study • The purpose of this study was to develop and test an instrument that reified the constructs of expectations, self-efficacy and self control for four common behaviors modulated in childhood obesity prevention programs, namely: • television viewing • physical activity • fruit/vegetable intake • water consumption. • Secondarily, to examine the extent to which selected social cognitive theory constructs (expectations, self-efficacy, and self control) can predict the four behaviors of: • Daily moderately intense physical activity of 30 minutes • Limiting television viewing to two hours per day • Increasing water consumption to eight glasses per day • Increasing fruit and vegetable intake to five or more servings per day in upper elementary children.

6. Methodology • Design: Cross-sectional • Study conducted in December 2004 • Institutional Review Board (IRB) permission from the University was obtained • Parental permission was obtained • Child’s assent obtained before filling the questionnaire

7. Instrumentation • A 52-item scale was developed and validated for face and content validity by a panel of six experts in a two round process • Administered to 159 fifth graders • Confirmatory factor analysis confirmed one factor solution for each of the components measuring outcome expectations, outcome expectancies and self-efficacy for each of the four behaviors • Cronbach’s alpha and test-retest reliability coefficients for all the subscales were found to be over 0.70

8. Demographics of the sample • Age: • 69.9% - 10 yr olds • 27.9% - 11 yr olds • 2.2% - 12 yr olds • Gender: • 47% - boys • 53% - girls • Ethnicity: • 64.7% - Caucasian • 22.8% - African American • 2.2% - American Indian • 7.4% - Other race

9. Previous exposure • Exposure to sessions about healthy eating in school : • 68.4% - 3 or more • 19.1% - 2 • 5.9% - 1 • 5.9% - None • Exposure to sessions about engaging in physical activity or exercise at home: • 69.9% - 3 or more • 14.0% - 2 • 9.6% - 1 • 5.9% - None

10. Means and standard deviations of behavioral variables

11. Means and standard deviations of SCT variables for exercise

12. Means and standard deviations of SCT variables for TV watching

13. Means & standard deviations of SCT variables for drinking water

14. Means & standard deviations of SCT variables for fruits/veg.

15. Final regression model for exercising(adjusted R2 0.072)

16. Final regression model for TV watching(adjusted R2 0.055)

17. Final regression model for water drinking(adj. R2 0.091)

18. Final regression model for fruits/veg.(adj. R2 0.137)

19. Main conclusions • In the case of physical activity, the number of sessions of physical education (p<0.026) and self-efficacy for exercising (p<0.026) were significant predictors • In the case of watching TV, the number of times taught about healthy nutrition (p<0.03) and self control for watching less than two hours of TV (p<0.04) were significant predictors.

20. Main conclusions…2 • In the case of drinking water, the only significant predictor was expectations for drinking eight or more glasses of water (p<0.001). • In the case of fruit and vegetable consumption, the only significant predictor was self-efficacy to eat five or more servings of fruits and vegetables (p<0.0001).

21. Implications for Practice • More health education programs in upper elementary children are needed that promote: • Daily moderate intensity physical activity of 30 minutes • Limit television viewing to two hours per day • Increase water consumption to eight glasses per day • Increase fruit and vegetable intake to five or more servings per day • Social cognitive theory (SCT) - excellent framework to design such interventions • SCT interventions can be implemented by health and physical education teachers

22. Implications for Practice…2 • Self-efficacy can be built through using credible role models. • Boosted by focusing on specific tasks, breaking down complex tasks into simple steps, inculcating participatory practice that leads to mastery • To influence self control, students must be encouraged to set goals to accomplish desired behaviors and reward themselves upon accomplishing the goal. • More needs to be done with regard to understand behavioral determinants of childhood obesity and designing and evaluating behavior change interventions

23. Limitations • The study did not use random selection of subjects which introduced sampling bias • One-day recall was employed to measure the primary dependent variables. While it offers advantage in accuracy of recall it may not accurately depict the typical day for the participant • The instrument was all self-report and that too introduces measurement bias. However, the instrument was read to the participants to account for varying levels of readability and reduce measurement bias. • The design of this study was cross-sectional and as such nothing can be said about temporality of association