Research and Professional Briefs
Diet and Physical Activity Patterns of
MAYA VADIVELOO, MS; LEI ZHU, MS; PAULA A. QUATROMONI, DSc, MS, RD
Childhood provides an opportunity for establishing
healthful lifestyle habits, yet little is known about diet
and physical activity patterns of elementary school-aged
children. A cohort of 35 boys and girls in grades 3 through
5 (mean age?9.5 years) was studied during the course of
the 2004-2005 school year, providing seasonal assess-
ments of diet and physical activity. Objectively measured
data included height, weight, and pedometer step counts.
Subjective data included seasonal 3-day diet diaries, a
food frequency questionnaire, and a physical activity
questionnaire. Participants were white, well-nourished,
and within the healthy range for body mass index for age.
Only three students (9%) were overweight and another
three were “at risk” for overweight. Food intake patterns
fell far below MyPyramid guidelines for average daily
servings of fruits and vegetables. High intakes of satu-
rated fat (average of 12% of calories) and sodium were
noted, along with inadequate fiber intakes. Snacks, des-
serts, and entrees that contributed most to calorie and
saturated fat intake were identified. Self-reported physi-
cal activity appears in line with recommendations, but
step counts fall short, particularly for girls and during
winter months. These findings identify targets for behav-
ioral and environmental interventions to reduce child-
hood obesity risks. Additional research involving more
diverse populations is warranted.
J Am Diet Assoc. 2009;109:145-151.
sity prevalence has more than doubled among preschool-
aged children and adolescents, and has more than tripled
among children ages 6 to 11 years (1-3). Approximately 9
million children older than age 6 years are classified as
overweight according to age- and sex-specific body mass
index (BMI; calculated as kg/m2) cut-points (1-3). Unfor-
tunately, youth does not spare children from the physical,
social, and emotional consequences of obesity, including
diabetes, dyslipidemia, hypertension, and metabolic syn-
There are many contributors to childhood obesity, man-
ifested by notable shifts in population demographics, life-
style behaviors, and environments at home, in the com-
munity, and in schools. Multiple forces contribute to the
imbalance between energy intake and energy expendi-
ture that influences weight gain (4). The importance of
establishing healthful nutritional practices in young chil-
dren is underscored by the fact that eating habits are
typically molded during early childhood (5). Only 2% of
school-aged children meet all of the recommendations of
the Food Guide Pyramid (6) and 16% do not meet any of
the guidelines (7). Some 20% of children and adolescents
meet the recommendation for fruit and vegetable intake
and even fewer drink at least 3 cups of milk daily (8).
Children also fall short of physical activity recommenda-
tions, with roughly one third of students active for at
least 60 minutes per day at least 5 days a week (8).
Moreover, 58% of students are exceeding the American
Academy of Pediatrics (AAP) guidelines (9) by spending
more than 2 hours a day watching television or playing
computer/video games (8).
Efforts to address childhood obesity include public
health goals to increase daily physical activity, decrease
sedentary behaviors, and establish healthful eating hab-
its (4). To inform effective interventions, a better under-
standing of the behaviors of school-aged children is
needed, yet relatively little research includes elementary
school students. Research examining this population
comes predominantly from large surveys (10-12) using
short-term, self-reported assessments methods that can
contribute to measurement error and imprecise estimates
of both diet and physical activity. While these data are
useful for generating new research hypotheses, more
comprehensive objective data are needed. Because ?20%
of US children who are either overweight or “at-risk”
have achieved that status by the time they enter middle
school (2,3,13), the elementary school years represent an
appropriate time to introduce behavioral interventions
revalence of childhood obesity has risen dramati-
cally in the United States, and is recognized as an
important public health threat. Since the 1970s, obe-
M. Vadiveloo is a research assistant and P. A. Quatro-
moni is an assistant professor, Department of Health
Sciences, Sargent College of Health and Rehabilitation
Sciences, Boston, MA. L. Zhu is a research assistant
and doctoral student, Department of Mathematics and
Statistics, Statistics and Consulting Unit, Boston Uni-
versity, Boston, MA.
Address correspondence to: Paula A. Quatromoni,
DSc, MS, RD, Department of Health Sciences, Sargent
College of Health and Rehabilitation Sciences, Boston
University, 635 Commonwealth Ave, Boston, MA 02215.
Manuscript accepted: July 25, 2008.
Copyright © 2009 by the American Dietetic
© 2009 by the American Dietetic Association
Journal of the AMERICAN DIETETIC ASSOCIATION
(4). The purpose of this pilot study (KidSTEPS) is to use
a combination of age-appropriate objective and self-re-
ported assessment tools to describe the eating patterns
and physical activity habits of elementary school-aged
Children in grades 3 through 5 were recruited from two
partnering elementary schools in a single suburb of Bos-
ton, MA. Fliers were distributed in school in September
2004 and eligibility required only parental consent. Par-
ents contacted study personnel via e-mail and informed
consent was obtained by telephone with follow-up mail-
ings to obtain signed parental consent and student assent
forms. Study protocols were approved by the Boston Uni-
versity Institutional Review Board. Enrollment occurred
between September and November. Data collection was
initiated upon enrollment and continued through June
2005. Study materials were user-friendly, low-burden,
completed at home by children and their parents, and
exchanged by mail. Stamped envelopes were provided for
return of completed forms and small prize incentives (eg,
keychains, t-shirts) were given as rewards.
Children were assessed in three seasons: fall (October/
November), winter (January/February), and spring (May/
June). Parents completed a brief demographic question-
naire at baseline. All other information was collected in
each season, with the exception of the food frequency and
physical activity questionnaires as noted here. Each sea-
son, students were given a personalized KidSTEPS diary
that facilitated collection of information by integrating
assessment forms into a single booklet.
Height (in inches) and weight (in pounds) were mea-
sured by certified school nurses using district-wide clini-
cal protocols that comply with state regulations (14).
Nurses used existing equipment in their schools that is
calibrated annually (Detecto physician beam balance
scales, Webb City, MO; and Seca wall-mounted stadiom-
eters, Hanover, MD). Single measures were taken and
recorded to the nearest one-quarter inch for height and
one-half pound for weight. Anthropometric data were re-
corded by nurses in the KidSTEPS diary. BMI was com-
puted (15) and BMI-for-age was plotted on sex-specific
growth charts (16). Overweight was defined as BMI-for-
age ?95th percentile, and “at risk” was defined as values
?85th percentile but ?95th percentile (17).
A validated 152-item semi-quantitative youth food fre-
quency questionnaire (FFQ) (18,19) was completed at
home by children with their parents. FFQs were collected
in fall and spring seasons to assess long-term intake
patterns. Children reported how often they ate specific
foods during the past year. Response categories ranged
from “never/less than once per month” up to “5 or more
times per day.” Questionnaires were used to generate
estimates of food group intake and to identify foods that
were top contributors to key macronutrients in students’
diets. Questionnaires were reviewed for completeness,
open-ended responses were coded by trained research
assistants according to standard procedures of Channing
Laboratory (Boston, MA), and forms were optically
scanned to produce electronic data sets. All question-
naires were sufficiently complete for analysis; none were
excluded and no outliers were detected with respect to
reported food group intake.
There are many contributors to
childhood obesity, manifested by
notable shifts in population
demographics, lifestyle behaviors,
and environments at home, in the
community, and in schools.
Three-day food records were collected from participants
in each of three seasons for the purpose of estimating
daily nutrient intake. Children and their parents were
instructed to record the child’s food and beverage intake
on 2 weekdays and 1 weekend day in the KidSTEPS
diary. Days of the week specified for record-keeping were
randomly assigned across cohort members and were
guaranteed to be nonconsecutive. Portion sizes were es-
timated using household measures, food-specific portion
size information from food packages, and serving size
information obtained from the school foodservice man-
ager. Completed diaries were returned by mail and re-
viewed by trained staff. Parents were contacted and
probed for missing information, food preparation details,
or missing portion details. The foodservice manager pro-
vided recipe, ingredient, and serving size details for
school lunch items. Food records were coded by trained
university-based research staff using the Nutrition Data
System for Research (NDS-r version 5.0, database 35,
2004) developed by the Nutrition Coordinating Center at
the University of Minnesota (20) to generate nutrient
intake estimates exclusive of micronutrients from multi-
vitamin/mineral supplements. Data files were reviewed
by investigating the top 10% and bottom 10% of daily
intake estimates for total calories and macronutrients to
correct or verify any extreme nutrient outliers.
Physical activity was assessed by self-report using a val-
idated, youth seasonal activity questionnaire (21,22) com-
pleted in fall and spring seasons. Like the FFQ, this
instrument was scanned by Channing Laboratory (Bos-
ton, MA) to generate a data set that was devoid of outli-
ers. The questionnaire lists 18 physical activities, 8 inac-
tive pursuits like reading and doing homework, and
queries participation in team sports. This instrument
minimizes the overestimation of highly seasonal activi-
ties by asking respondents to report their frequency of
participation in each season of the previous year (23).
Children also wore pedometers for 7 consecutive days in
each season. A 7-day monitoring protocol was shown to
provide reliable estimates of usual physical activity in
children (24). Students entered daily pedometer counts
into activity logs in the KidSTEPS diaries, with parental
assistance as needed.
January 2009 Volume 109 Number 1
Nutrient estimates represent an average of 9 days of food
record data (3 days/season). Food group intake was de-
rived from the spring FFQ to coincide with nutrient esti-
mates from food records kept during the same time frame
(the 2004-2005 school year). Foods that contributed the
most to total energy and saturated fat intakes in the
cohort were determined from FFQ data. Pedometer, an-
thropometric, demographic, and behavioral data (such as
multivitamin/mineral supplement use) were keyed and
verified using duplicate entry procedures. The Statistical
Analysis System (SAS/STAT Software, version 8.2, 2001,
SAS System for Windows, SAS Institute Inc, Cary, NC)
was used to generate descriptive statistics and two-sam-
ple t-tests compared data across sexes.
RESULTS AND DISCUSSION
Thirty-five children enrolled and completed baseline data
collection. The cohort was almost exclusively white
(n?34), with one minority participant who was Asian
American. At the close of data collection, 32 children
(91%) remained in the study, with reasons for drop-out
related to burden of the diet assessment protocols. Chil-
dren who dropped out of the study were no different from
those who completed the study with respect to demo-
graphic characteristics, BMI, or baseline physical activ-
ity. Participants were between the ages of 8 and 10 years
with a mean age of 9.5 years. Most students (n?15) were
in the fourth grade. The study group was predominantly
female (n?24) and most were within the healthy range
for weight. In this sample, 26 students (82%) had a BMI-
for-age in the desired range, three (9%) were at risk for
overweight, and three others were overweight. About half
of participants (n?17) took a multivitamin/mineral sup-
plement, with only 10 reporting daily use.
The dietary profiles of elementary school-aged children in
this sample (Table 1) were relatively consistent with rec-
ommendations of the Dietary Guidelines for Americans
2005 (25). Children consumed 54% of calories from car-
bohydrate, 15% from protein, and 33% from fat, on aver-
age. According to Institute of Medicine recommendations
(26-30), diets appeared adequate in folic acid, iron, and
vitamins C and D from food sources (exclusive of multi-
vitamin/mineral supplements). However, diets fell short
of target intakes for fiber and calcium with children meet-
ing only 50% and 70% of the recommendations, respec-
tively. Both boys and girls consumed more saturated fat
and sodium in their diets than what is recommended by
the Institute of Medicine (30,31). The difference in mean
energy intake between sexes approached statistical sig-
nificance, and boys consumed more fiber, iron, calcium,
folic acid, and sodium than girls (P?0.05).
Average daily intakes of fruits and vegetables were
markedly low; children consumed half or less of the
amount recommended by the US Department of Agricul-
ture’s MyPyramid (32). In contrast, intake of milk, yo-
gurt, and cheese approached recommended levels, yet
only boys’ average intakes met the guideline. While it is
promising that children in this cohort were close to meet-
ing the milk equivalent recommendation, it is important
to promote consumption of these foods wisely. In this
school-aged sample, milk was the biggest contributor to
both total calories and saturated fat intake, suggesting
that availability and promotion of low-fat and nonfat milk
deserves extra effort. In fact, many items commonly of-
fered in school cafeterias as either lunch entrees or snack
foods were found to be important contributors to calorie
and saturated fat intake in this cohort, namely ice cream
treats; chips; macaroni and cheese; fried foods, including
chicken nuggets; meatballs; and other entrees made with
cheese. This observation was made previously in a high
school population (33) and substantiates the need for
healthier menu offerings in school foodservice beginning
at the elementary level.
Sex differences in dietary intake in this cohort were
relatively few. According to the Institute of Medicine
guidelines, active boys and girls between the ages of 9
and 13 should consume 2,000 to 2,600 and 1,800 to 2,200
calories, respectively (30). Reported energy intakes in our
cohort are slightly lower than these targets, but are not
likely the result of substantial measurement error, given
the 9 days of food records collected during the year. None-
theless, our estimates of intake are comparable with the
limited body of research among this age group showing
that boys tend to consume more calories than girls (10)
and children between the ages of 6 and 11 years eat, on
average, 2,100 kcal/day, with 33% of calories from fat and
11.5% of calories from saturated fat (10). Research sug-
gests that children’s diets are also high in sodium (10,11).
Finally, low fruit and vegetable intake in school-aged
children may represent an important precursor to adoles-
cent behavior, because only one in five high school stu-
dents reportedly eats five or more servings of fruits and
vegetables daily (8). Without diligent efforts, these unde-
sirable food and nutrient intake patterns that begin as
early as elementary school will likely persist throughout
Physical Activity Patterns
According to self-reports from the activity questionnaires,
elementary school-aged students in this cohort met the
AAP guidelines for physical activity (34) by engaging in a
mean of 1.8 hours of daily activity (Table 2). They accu-
mulated, on average, almost 11,000 steps per day. Simul-
taneously, both boys and girls were spending an average
of 4 hours per day engaging in inactive pursuits including
television, video games, computer media, and recre-
ational reading. While television viewing and video, com-
puter, and handheld games were not distinguished from
inactivity associated with pleasure reading and home-
work in this analysis, it is possible that the proportion
that was screen time exceeded AAP recommendation of
fewer than 2 hours per day (9).
While children in this sample appear reasonably active
based on self-reported activity data, objectively measured
pedometer counts fall short of public health recommen-
dations for children. Whereas 10,000 steps per day is
advocated as a target for health promotion among adults
(35), the 2001-2002 President’s Challenge Physical Activ-
ity and Fitness Awards Program (36) recommends that
children accumulate more; specifically 11,000 steps (for
January 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION
girls) to 13,000 steps (for boys) at least 5 days a week.
More recently, targets ranging from 12,000 up to 16,000
steps per day have been suggested for girls and boys,
respectively (37,38). KidSTEPS participants were chal-
lenged to meet these goals, with boys logging an annual
average of 12,839 steps and girls accumulating only 9,822
steps on average. In fact, boys logged considerably more
steps than girls in each season. The sex discrepancy was
least pronounced during the spring season, when both
groups appeared to be the most active. In general, step
counts were notably higher during the fall and spring
seasons, whereas levels dropped to below recommended
targets in the winter among both sexes. Sustaining phys-
ical activity during winter months and inclement weather
requires special efforts and creative innovation.
The observation that boys were more active than girls
is consistent with other research (39-42) and suggests the
importance of targeting activity interventions differently
to girls to achieve high rates of participation. In addition,
research suggests that interventions should encourage
specifically more vigorous physical activity. In fact, the
majority of youth participate in moderate physical activ-
ity, whereas ?3% engage in vigorous activity three or
more times per week (39,43).
While the activity findings are promising, observations
about the average time spent inactive warrant attention.
Research suggests that physical activity declines through-
out adolescence and is often replaced with less-active pur-
suits (44). Inactivity, particularly inactivity associated
with television-watching and video or computer games,
may be related to development of unhealthful eating and
snacking patterns (45,46), including excess fat consump-
Table 1. Dietary intakes of elementary school-aged participants in KidSTEPS compared to recommended intake levels, with food sources of
key macronutrients identified
at the 2,000-calorie
Boys (n?8)Girls (n?24)
Total fat (%)
Saturated fat (%)
Trans fat (g)
Folic acid (DFE)c
4™™™™™™™™™™™™™™™ mean?standard deviation ™™™™™™™™™™™ 3
Top contributors to calories and saturated fat in children’s dietsd
Total caloriesMilk, peanut butter sandwich, poultry, ice cream, beef, yogurt, cold cereal, spaghetti w/sauce, pasta,
Peanut butter sandwich, spaghetti w/ sauce, pizza, macaroni and cheese, turkey sandwich, tacos,
bologna sandwich, cheeseburger, French toast, grilled cheese sandwich
Potato chips, corn chips, crackers, nuts, pretzels, popcorn, nachos, chicken noodle soup
Ice cream, fruit punch, chocolate chip cookies, frozen yogurt, popsicles, chocolate, soda, cake, other
candy, graham crackers
Milk, ice cream, beef, cheese, butter, poultry, peanut butter sandwich, macaroni and cheese, fried
foods eaten away from home, meatballs
Calories from mixed dishes
Calories from snack foods
Calories from desserts and
aRecommended intake levels for energy and food groups were estimated for the average KidSTEPS participant who was 9.5 years old, based on the US Department of Agriculture Food
Guide amount at the 2,000 calorie-level for a moderately-active to active boy or girl ages 9-13 (25); for micronutrients, Dietary Reference Intakes are shown for males and females
ages 9-13 years (26-31). Recommended fiber intake is 14 g/1,000 kcal, representing 28 g/day at a 2,000-calorie intake level (30). There is no specific recommendation for trans-fat
intake other than to keep intake as low as possible (25).
bNutrient intake estimated from a series of 3-day food records collected in each of three seasons (fall, winter and spring), for a total of nine dietary records per child.
cDFE?dietary folate equivalent. 1 DFE?1 ?g food folate (26).
dDerived from the Youth/Adolescent Questionnaire (18,19).
eMilk equivalents include milk, yogurt and cheese.
*P?0.05 for differences in intake between sexes.
January 2009 Volume 109 Number 1
tion (47) and low fruit and vegetable intake (48). Because
elementary school-aged children in this sample may al-
ready exceed AAP recommendations (9) for screen time,
this trend may become problematic as adolescence ap-
proaches. In fact, some of the observed dietary traits may
already reflect the unhealthful patterns that can develop
with excess screen time.
The hypothesis that obesity risk behaviors cluster to-
gether is well-supported in the literature. In a recent
study, nearly 80% of 11- to 15-year-olds had more than
one risk factor related to poor diet and physical activity
(49). Moreover, children who are the most sedentary are
reportedly less likely to undertake physical activity and
consume adequate servings of fruits and vegetables (50).
Unhealthful dietary patterns appear to proliferate during
the years between elementary and high school, with far
fewer high school students consuming enough daily serv-
ings of fruits and vegetables (12). In a nationwide survey
of ?4,000 students, the proportion who fell short of phys-
ical activity guidelines increased dramatically by 28 per-
centage points between elementary and high school, with
63% of high school students not meeting the criteria for
physical activity (12). While behavioral research demon-
strates that unhealthful behaviors travel together, it also
suggests that healthier behaviors are similarly correlated
(51,52). This evidence underscores the need for integrated
intervention strategies and environmental changes to effec-
tively moderate obesity-related risk behaviors.
This descriptive research is preliminary and is limited by
the cohort’s small sample size, unequal sex distribution
with few male participants, and relative homogeneity
with respect to demographic characteristics. Yet the com-
bination of multiple self-reported, seasonal, and objective
measures of diet and physical activity reduces measure-
ment error and strengthens our behavioral assessments.
It should be noted that for apparent differences between
boys and girls that do not reach statistical significance,
one explanation may be lack of analytical power given the
small sample size. Self-selection bias is possible because
children who participated may have had activity and
dietary patterns that were different, and possibly health-
ier, than those who did not enroll. This source of bias may
explain why most participants were within the healthy
BMI range, which limits the generalizability of findings
to overweight children. Nonetheless, areas for improve-
ments in diet and physical activity were clearly identified
even within this selective cohort, suggesting that sub-
stantial risk may remain undefined in the general popu-
Elementary school–aged children have diet and physical
activity patterns that warrant attention, additional
study, and targeted intervention in order to impact child-
hood obesity risks. Food and nutrition professionals and
educators should work to foster healthful eating behav-
iors in elementary schools and facilitate physical activity
opportunities that effectively involve girls and students
in general who are challenging to engage. Specific efforts
to increase intakes of fruits, vegetables, dietary fiber, and
calcium appear important, as are efforts to reduce con-
sumption of saturated fat and sodium in home, school,
and snack environments. Continued emphasis on the pro-
motion of daily physical activity is appropriate, and cre-
ative strategies that sustain activity during winter
months are needed.
This work was supported by funds from the Dudley Allen
Sargent Research Fund, Sargent College of Health and
Rehabilitation Sciences at Boston University.
The authors gratefully acknowledge the contributions
of the school nurses, school administrators, teachers, par-
ents, and children who participated in the KidSTEPS
Table 2. Mean daily pedometer step counts and self-reported physical activity of elementary school-aged participants in KidSTEPS, compared
to recommendations for physical activity
Boys (n?8)Girls (n?24)
4 ™™™™™™™™™™™™™ mean?standard deviation ™™™™™™™™™™™™™ 3
Time spent in physical activityd(h/day)
Time spent in inactivitye(h/day)
13,000 for boysb
11,000 for girlsb
aAverage of pedometer step counts logged over 7 consecutive days per season.
bRecommendations for children, set by the 2001-2002 President’s Challenge Physical Activity and Fitness Awards Program (36).
cAverage of pedometer step counts logged over 7 consecutive days in each of three seasons (21 days total).
dSelf-reported time spent in various physical activities and sports, from the Seasonal Youth/Adolescent Activity Questionnaire (21-23).
eSelf-reported time spent doing inactive tasks like playing computer games, reading, or watching television; from the Seasonal Youth/Adolescent Activity Questionnaire (21-23).
fRecommendation is to limit “screen time” specifically to no more than 2 hours per day (9). This makes the comparison with the estimate of time spent in inactivity as defined by the
Seasonal Youth/Adolescent Activity Questionnaire (21-23) less direct because reading is included in that tool’s estimate of inactive time.
January 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION
project. Special thanks to Research Assistants Danielle
Duggan, Katie Kirkpatrick, Annie Paquette, Eva Mallis,
Helen Wei, and Mimi Borkan. Thanks to Winning Moves
Games, Inc of Danvers, MA and the Barnes & Noble
Bookstore at Boston University for the games and prizes
donated as incentive gifts for study participants.
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January 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION