A Novel High-Intensity Short Interval Dance Intervention (THANDAV) for Non-Communicable Disease Prevention Tailored to Asian Indian Adolescent Girls

Abstract

Background:

A significant majority of adolescents from lower-middle-income countries do not meet recommendations for daily physical activity. THANDAV (Taking High-Intensity Interval Training [HIIT] ANd Dance to Adolescents for Victory over noncommunicable diseases [NCDs]) is a 10-minute dance intervention incorporating principles of HIIT. The present study evaluated the effect of THANDAV on cardiovascular risk factors and lifestyle behavior in Asian Indian adolescent girls.

Methods:

THANDAV was delivered as a 12-week pilot cluster randomized controlled trial (cRCT) in two schools, involving 108 schoolgirls aged 13 to 15 years in Chennai, India. The primary outcome was step counts, while secondary outcomes included metabolic, clinical, and lifestyle parameters. Focus group discussions and interviews were held to assess barriers to and acceptability of THANDAV intervention.

Results:

In the intention-to-treat analysis, the intervention group had significantly favorable changes in step counts (+1073 steps/day), skeletal muscle mass (+0.9 kg), body weight (−0.7 kg), body fat percentage (−2.0%), body mass index (−0.3 kg/m²), waist circumference (−1.0 cm), systolic (−4 mm Hg) and diastolic blood pressure (−4 mm Hg), resting heart rate (−3 bpm) and body fat mass (−1.7 kg), moderate -to-vigorous physical activity (+29.5 minutes/day), sleep (+46.4 minutes/day), sedentary time (−199.7 minutes/day), Adolescence Stress Scale (−6.6), and junk food consumption (−2.7) scores compared with controls. Qualitative interviews revealed that THANDAV routines were time-efficient, enjoyable, and easily fit into adolescents’ busy schedules enabling feasible engagement in active leisure time.

Conclusions:

THANDAV is a culturally acceptable HIIT-based dance intervention that improves leisure-time physical activity and reduces cardiometabolic risk in Asian Indian adolescent girls.

Trial Registration:

The trial is registered with the Central Trials Registry-India (CTRI/2020/02/023384; URL: https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=MzgyMTQ=&Enc=&userName=).

Keywords

adolescent girls dance diabetes HIIT physical activity technology

Introduction

India reports having 101 million individuals with diabetes¹ with escalating incidence reported in adolescence (14.2%).² Type 2 diabetes also occurs at younger ages in Indians compared with Caucasians.^3,4 Regular physical activity (PA) during adolescence helps control weight, improve flexibility and coordination, enhance cardiovascular and pulmonary fitness, and positively affects mood and self-esteem, and prevents type 2 diabetes (T2D) and cardiovascular disease (CVD).^5-7 Reaching 10 000 to 11 500 steps per day is linked to better cardiovascular fitness and overall health outcomes in adolescents.^8,9 However, nearly 80% of adolescents from lower-middle-income countries report insufficient PA.¹⁰ In India, around 25.2% of adolescents do not meet moderate-to-vigorous PA (MVPA) guidelines, with urban residents (38%) and girls (29.3%) being less likely to be active.¹¹

Factors such as limited access to recreational facilities, socioeconomic constraints, urbanization, cultural norms, and the pervasive influence of technology influence physical inactivity in adolescents.¹² Adolescent girls face specific personal, social, and environmental barriers to PA,^13,14 such as body image concerns, self-consciousness, lack of confidence, physical inability, discomfort with attire, societal disapproval, academic and family pressure, exercise not being considered “culturally acceptable,” lack of safe spaces, unfavorable weather conditions, and inadequate infrastructure in schools.

Addressing these barriers demands specific interventions tailored to unique sociocultural contexts. THANDAV (Taking High Intensity Interval Training [HIIT] ANd Dance to Adolescents for Victory over NCDs) is a 10-minute innovative HIIT-based dance routine that is a fun, culturally acceptable type of PA that takes minimal time and can be done at home. The high intensity and short duration of HIIT addresses the critical barrier of not having enough time for exercise.¹⁵ Youth have higher baseline fitness levels than adults, and the higher intensities of PA provided by HIIT are ideal to further improve their fitness.⁵

An initial study found that Asian Indian adolescent girls participating in the THANDAV intervention reached 80% of their maximum heart rate, sustained it for 10 minutes, and expended an average of 6.3 metabolic equivalents (METs), and found the activity enjoyable and socially acceptable.¹⁵ These findings suggested that THANDAV met HIIT norms and was suitable for Asian Indians. The present study was undertaken to evaluate the effects of the THANDAV intervention on step counts (using Fitbit Inspire 2), cardiometabolic risk factors and lifestyle behaviors among Asian Indian adolescent girls in a school setting. We also aimed to qualitatively assess the acceptability of, and the barriers to, the intervention through focus group discussions (FGDs) and key informant interviews (KIIs).

Methodology

Study Type and Design

This study employed a pre-post design within the framework of a cluster randomized controlled trial (cRCT) conducted in a pilot mode. Girls’ schools (n = 10) located across Chennai city (the largest metropolitan city of southern India), were targeted for participation. These schools were carefully chosen based on similarities in background, socioeconomic status (SES), and curriculum structure (matriculation schools). Of the ten schools, five schools showed interest in participation of which two were randomly chosen for the study and agreed to participate. The two consenting schools were then randomly allocated to either the intervention or control groups using the lottery method. Adolescent girls, aged 13 to 15 years studying in grades 7 to 9 (VII-IX) from these schools were recruited for the study in August 2022.

Ethical Approval and Consent to Participate

The protocol was registered with the Clinical Trials Registry, India (CTRI/2020/02/023384) (https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=MzgyMTQ=&Enc=&userName=). The study was approved by the Institutional Ethics Committee (IEC) (Ref No: ECR/194/Inst/TN/2013/RR-24). Written informed consent and assent were obtained from parents and participants, respectively.

Sample Size Calculation

The sample size was calculated using the openEpi calculator, based on a 25.2% prevalence of physical inactivity¹⁶ in adolescents. Assuming THANDAV would improve the step count (primary objective) by 25% between the two groups, with 80% power and 5% significance, 43 participants per group were needed. Allowing for 10% dropout, the target sample size was 100 participants (around 50 per group).

Recruitment

The recruitment process in the study schools were as follows:

Screening camp and consent

All girls in both schools aged 13 to 15 years were invited to attend a health talk on the importance of PA at the school premises. At the end of the talk, the girls were informed about the study and provided with consent and assent forms. Those who submitted the signed consent and assent forms moved to the next step of the recruitment process.

ECG and fitness testing

This was done only in the intervention school so as to ensure participants’ suitability for engaging in high-intensity activities. A medical doctor assessed the participants’ past and current medical history. Participants underwent a fitness test which involved obtaining a baseline and follow-up electrocardiogram (ECG) using a portable machine after completing a one-minute run. Based on the results of the ECG and doctor consultation, the final set of participants were enrolled into the intervention.

Parent/participant webinar and final enrollment

All the recruited participants and their parents in both intervention and control schools were briefed by the principal investigators about the study protocol through webinars.

Set up of PA digital tracker

Both intervention and control group participants were provided with complimentary PA trackers (Fitbit Inspire 2) to monitor their step count. Participants installed the Fitbit app on their parent’s mobile phones ensuring synchronization with the devices. Participants received training on how to check their step counts, as well as the synchronization process. Participants were encouraged to wear their tracker every day, including days without intervention classes, to maintain continuous monitoring of PA.

Study Procedures and Data Collection

All measurements were recorded at baseline and at the end of second (after offline classes ended) and third month (at end of intervention) (Supplementary File 1).

Height was measured using a Seca stadiometer, and weight with a Tanita electronic scale. Waist circumference was measured with a non-elastic tape, and resting blood pressure (BP) using an OMRON machine (Hem7130-l-1). Body fat and muscle mass were assessed via InBody analyzer using Bioelectrical Impedance Analysis (BIA).

Dietary habits of the participants were assessed by evaluating the frequency of consumption of eight common snack items, including fast foods, savory Indian street foods, chips, Indian sweets, bakery items, chocolates, and ice creams. A junk food score (0-48) was calculated based on intake frequency, with higher scores indicating greater consumption.

The Adolescence Stress Scale (ADOSS)¹⁷ is a validated self-reported tool with 20 items designed for adolescents aged 10 to 17 years, addressing stressors across personal, academic, family, and social domains. The total score (maximum 60) is obtained by summing the responses to all items, excluding two positively phrased ones (items 3 and 12), which require reverse scoring. Higher scores indicate greater stress.

The Madras Diabetes Research Foundation Physical Activity Questionnaire for Children and Adolescents [MPAQ(c)], a reliable tool validated for Indian youth aged 10 to 17 years, was used to assess PA across various domains.¹⁸

Intervention group participants were also asked to provide feedback on the intervention at the post-intervention stage, including the practice frequency, usefulness of video tutorials, participation in online classes, interest in learning more routines, perceived impact on physical activity and health, and overall satisfaction with the program via a feedback form (Supplementary File 2).

Qualitative Evaluation

A focus group discussion was conducted with nine parents (two fathers and seven mothers), while individual interviews were conducted with seven participants of the intervention group to assess barriers and acceptability of the THANDAV intervention. Around 10% of the intervention group participants were recruited for the qualitative study based on their willingness to participate, and ability to provide diverse perspectives. FGD and interviews were conducted using specific guides, by a trained moderator/interviewer and an observer in a language familiar to all participants. Questions focused on exploring barriers, acceptability and overall feedback regarding the THANDAV intervention. The interview began with a round of introductions, an explanation of consent, and open-ended questions using an interview guide. FGD and interviews lasted approximately 40 to 60 minutes and were recorded using a voice recorder, with notes taken by the observer.

Intervention

THANDAV is a novel concept of PA which achieves HIIT through dance. The 10-minute THANDAV routine consists of four songs. Each song has a two-minute high-intensity component followed by a 30-second low-intensity component. This is repeated four times (4 songs) to form a single 10-minute routine. The dance routines include popular Indian film music, regional/folk songs and western music well-liked by adolescents in South Asia. This intervention was developed in collaboration with professional choreographers to ensure the ease and safety of the steps performed and was tested on 23 adolescent girls in an exercise physiology lab in Bengaluru, India, in 2019-2020.¹⁵

In the current study, participants had to attend 24 THANDAV sessions (2 per week) in the school premises. Classes were scheduled on different weekdays to accommodate school schedules, with a weekly make-up session on Saturdays for participants to cover missed classes, clarify doubts, and practice the routine. Each one-hour session, led by a professional dancer/ trainer, included a 10-minute warm-up, 40 minutes of THANDAV routine practice, and a 10-minute cool-down. Every week, the participants were taught a new song, culminating in a complete 10-minute routine by week four. This helped to gradually build stamina and fitness. Tutorial videos were shared via email for practice at home.

The first two months of sessions were conducted offline in a designated school hall for hands-on learning. However, because of the end-of-year academic and extra-curricular activities of the school, the intervention school could not give a dedicated time slot to deliver the third routine as part of the intervention. Hence, the third routine was delivered virtually using an online meeting platform (official private Zoom link). Parents and the participants were informed in advance about the online sessions, and necessary consents were taken. A similar pattern and weekly schedule were followed for the 8 online classes as for the offline classes (Supplementary File 3).

Control Group

For the control group school, monthly lectures on healthy living were conducted for three months. Participants actively engaged in the sessions, seeking clarification on any queries they had. Each session lasted 60 minutes and covered various aspects of healthy living including guidance on healthy eating, strategies to increase PA, awareness on diabetes and NCDs and stress/time management. The session also included five minutes of simple stretching exercises.

Outcomes

The primary outcome of the study was daily step counts measured objectively through Fitbit Inspire 2. Weekly Fitbit reports were sent by the participants to research staff. Secondary outcomes included cardiometabolic risk factors such as body weight, body mass index (BMI), body fat, waist circumference, and BP. In addition, the study assessed lifestyle behavior changes, such as junk food consumption, stress scores, and self-reports of leisure time activity and sedentary behavior.

Data and Statistical Analysis

Data analysis was conducted by a biostatistician, utilizing a clean and anonymized dataset at the end of study. Statistical analysis was performed using SPSS software (Version 25), applying a two-sided test, and significance was set at p-values < 0.05. Analysis adhered to the intention-to-treat (ITT) principle (including data from all study participants). Patterns of missing data were thoroughly explored, and quality checks were implemented (including a double data entry procedure for every 10^th form). Regular backend checks were conducted and missing entries were updated from hard copy questionnaires.

During data analysis, data points with higher standard deviations from the baseline were scrutinized, cross-checked with raw data, and amended accordingly. For primary outcomes, where data were missing because of participants lost to follow-up, imputation was performed using the regression-based Multiple Imputation Generalized Estimating Equations (MI-GEE) method. Baseline characteristics were presented using means and standard error of mean for continuous variables and percentages and numbers for categorical data. The normality of data distributions was assessed visually through histograms. The unadjusted and adjusted differences in primary and secondary outcomes between intervention and control groups were determined using regression analysis, reporting coefficients and 95% confidence intervals.

The recordings of the qualitative FGDs and interviews were transcribed, and transcripts coded and analyzed for themes by a trained group of qualitative researchers. Both inductive and deductive approaches were used to derive codes and themes. The themes from the qualitative analysis data were further categorized based on theoretical framework used to understand and influence behavior change viz. the COM-B model (Capability, Opportunity, Motivation, and Behavior).¹⁹ By organizing themes under these domains, the model provides a comprehensive understanding of factors influencing behavior.

Results

Breakdown of Study Participants

A total of 137 students consented to screening across the intervention and control schools between August 2022 and February 2023. Fifty-nine students were screened in the intervention school and 78 in the control school. A total of 108 eligible students were successfully recruited into the study and completed baseline assessments (53 intervention; 55 control) (Figure 1).

Figure 1.

Study flow chart.

Baseline Characteristics

At baseline, there were no significant differences between the intervention and control groups except that intervention group participants were a few months younger compared with the control group (12.6 vs 13.0 years) (P < .05) (Supplementary File 4). Primary and secondary outcomes were adjusted for age in the pre-post analysis.

Effect of THANDAV Intervention on the Primary Outcome (Step Count)

Table 1 compares step count changes between intervention and control groups using the ITT approach. By the two-month intervention interval, the intervention group showed a significant increase in daily step count compared with the control group, with a significant interaction effect (effect size = 0.122, P = .010). At two months, the mean difference between the groups was 1125 steps/day (95% CI: 226 to 2023), which remained significant after adjusting for age. At the end of the program (third month) also, the intervention group showed improvements as compared with baseline, with a significant interaction effect (effect size = 0.074, P = .046) and a marked difference of 1073 steps/day between the groups (95% CI: 266 to 1880), after adjusting for age (Figure 2).

Table 1.

Mean Differences and Repeated Measures ANOVA of Daily Step Count Using the Intention-to-Treat Analysis (n = 108).

Group	Baseline step count (n = 108)Mean ± SEM	Baseline second month step count difference (n = 108)	Unadjusted difference between intervention and control (95% CI)	Adjusted difference between intervention and control (95% CI)	Baseline third month step count difference (n = 108)Mean ± SEM	Unadjusted difference between intervention and control (95% CI)	Adjusted difference between intervention and control (95% CI)
Intervention	4021 ± 270	1731 ± 305*	1254 (388, 2121)**	1125 (226, 2023)#	1495 ± 353*	1049 (274, 1824)**	1073 (266, 1880)#
Control	3844 ± 277	476 ± 312	1254 (388, 2121)**	1125 (226, 2023)#	324 ± 177	1049 (274, 1824)**	1073 (266, 1880)#
Time-intervention interaction effect Partial eta squared/effect size (p)	0.001 (0.794)	0.122 (0.01)	-	-	0.074 (0.046)	-	-
Overall intervention effect partial eta squared/effect size (p)	0.034 (0.05)

Significant difference from pre to post.

Significance between intervention and control.

Age adjusted significance between intervention and control.

Figure 2.

Mean step count per day across three time points.

Effect of THANDAV on the Secondary Outcomes

After two months’ offline THANDAV sessions, there were significant reductions in body weight (−1.2 kg), body fat (−2.0%), body fat mass (−0.6 kg), BMI (−0.3 kg/m²), waist circumference (−1.4 cm), systolic BP (−5 mm Hg), diastolic BP (−5 mm Hg), and resting heart rate (RHR) (−4 bpm), along with an increase in skeletal muscle mass (0.8 kg) in the intervention group compared with the control group (Table 2). These improvements were maintained after the third month (online sessions) (Figure 3).

Table 2.

Effect of THANDAV Intervention on Cardiometabolic Risk Factors.

Variables	Group	Baseline (n = 108)Mean ± SEM	Baseline – second month difference (n = 108)Mean ± SEM	Unadjusted difference between intervention and control (95% CI)	Adjusted difference between intervention and control (95% CI)	Baseline – third month difference (n = 108)Mean ± SEM	Unadjusted difference between intervention and control (95% CI)	Adjusted difference between intervention and control (95% CI)
Body weight (kg)	Intervention	51.5 ± 2.0	–0.2 ± 0.5	–1.0 (–3.2, 0.9)	–1.2 (–2.6, 0.7)	0.8 ± 0.1*	–0.6 (–0.9, 0.2)	–0.7 (–1.1, –0.3)#
Body weight (kg)	Control	49.0 ± 1.5	0.8 ± 0.1	–1.0 (–3.2, 0.9)	–1.2 (–2.6, 0.7)	1.4 ± 0.1*	–0.6 (–0.9, 0.2)	–0.7 (–1.1, –0.3)#
Body fat (%)	Intervention	32.0 ± 1.5	–0.4 ± 0.4	–1.8 (–2.8, –0.7)**	–2.0 (–3.1, –0.9) #	0.3 ± 0.1	–1.6 (–2.6, –0.6)**	–2.0 (–3.0, –1.0)#
Body fat (%)	Control	29.6 ± 1.4	1.4 ± 0.3*	–1.8 (–2.8, –0.7)**	–2.0 (–3.1, –0.9) #	1.8 ± 0.2*	–1.6 (–2.6, –0.6)**	–2.0 (–3.0, –1.0)#
Body fat mass (kg)	Intervention	18.1 ± 8.9	0.4 ± 0.2	–0.4 (–0.9, 0.2)	–0.6 (–1.1, –0.1)#	1.2 ± 0.2*	–2.4 (–6.3, 1.4)	–1.7 (–2.9, –0.5)#
Body fat mass (kg)	Control	16.6 ± 7.9	0.8 ± 0.2*	–0.4 (–0.9, 0.2)	–0.6 (–1.1, –0.1)#	3.0 ± 0.5*	–2.4 (–6.3, 1.4)	–1.7 (–2.9, –0.5)#
Skeletal muscle mass (kg)	Intervention	16.5 ± 3.9	0.6 ± 0.1*	0.8 (0.3, 1.2)**	0.8 (0.3, 1.2)#	1.0 ± 0.2*	0.9 (0.3, 1.9)**	0.9 (–0.5, 1.9)
Skeletal muscle mass (kg)	Control	17.7 ± 4.2	–0.2 ± 0.1	0.8 (0.3, 1.2)**	0.8 (0.3, 1.2)#	–0.6 ± 0.4	0.9 (0.3, 1.9)**	0.9 (–0.5, 1.9)
BMI^a (kg/m²)	Intervention	21.4 ± 0.6	–0.1 ± 0.4	–0.1 (–1.2, 0.9)	–0.3 (–1.4, 0.8)	0.4 ± 0.06*	–0.2 (–1.4, 0.07)	–0.3 (–0.5, –0.03) #
BMI^a (kg/m²)	Control	20.7 ± 0.6	0.1 ± 0.3	–0.1 (–1.2, 0.9)	–0.3 (–1.4, 0.8)	0.6 ± 0.0.05*	–0.2 (–1.4, 0.07)	–0.3 (–0.5, –0.03) #
Waist circumference(cm)	Intervention	73.4 ± 1.4	–1.2 ± 0.8	–1.0 (–3.0, 0.9)	–1.4 (–3.5, 0.6)	–0.2 ± 0.3	–0.6 (–1.6, 0.4)	–1.0 (–2.0, –0.2)#
Waist circumference(cm)	Control	69.7 ± 1.3	–0.2 ± 0.6	–1.0 (–3.0, 0.9)	–1.4 (–3.5, 0.6)	0.5 ± 0.2	–0.6 (–1.6, 0.4)	–1.0 (–2.0, –0.2)#
Systolic BP^b (mm Hg)	Intervention	106 ± 12	–2 ± 1	–4 (–9, –1)**	–5 (–10, –1)#	–1 ± 1	–2 (–1, 6)	–4 (–8, –1)#
Systolic BP^b (mm Hg)	Control	104 ± 9	2 ± 1	–4 (–9, –1)**	–5 (–10, –1)#	1 ± 1	–2 (–1, 6)	–4 (–8, –1)#
Diastolic BP^b (mm Hg)	Intervention	72 ± 7	–1 ± 1	–3 (–7, –1)**	–5 (–8, –1)#	–3 ± 1*	–4 (–5, –2)**	–4 (–6, –2)#
Diastolic BP^b (mm Hg)	Control	70 ± 6	1 ± 1	–3 (–7, –1)**	–5 (–8, –1)#	1 ± 1	–4 (–5, –2)**	–4 (–6, –2)#
Resting heart rate (bpm)	Intervention	82 ± 8	–3 ± 2*	–5 (–9, –0.6)**	–4 (–9, –0.06)#	–1 ± 1	–4 (–12, –1)**	–3 (–11, –1)#
Resting heart rate (bpm)	Control	83 ± 9	2 ± 1	–5 (–9, –0.6)**	–4 (–9, –0.06)#	3 ± 1*	–4 (–12, –1)**	–3 (–11, –1)#

Abbreviations: PI, post intervention; CI, confidence interval.

Body mass index.

Blood pressure.

Significant difference from pre to post.

Significance between intervention and control.

Age-adjusted significance between intervention and control.

Figure 3.

Comparison of anthropometric and clinical parameters across three time points.

After the second month, the intervention group showed a significant increase in leisure MVPA (15.4 minutes/day), sleep (33.3 minutes/day), and a decrease in sedentary time (−115.0 minutes/day), stress (−5.1 on ADOSS), and junk food consumption (−2.5) compared with the control group. These changes further improved after the third month (Table 3, Figure 4).

Table 3.

Effect of THANDAV Intervention on Lifestyle Parameters.

Variables	Group	Baseline (n = 108)Mean ± SEM	Baseline – second month difference (n = 108)Mean ± SEM	Unadjusted difference between intervention and control (95% CI)	Age adjusted difference between intervention and control (95% CI)	Baseline – third month difference (n = 108)Mean ± SEM	Unadjusted difference between intervention and control (95% CI)	Adjusted difference between intervention and control (95% CI)
Leisure MVPA^a minutes/day	Intervention	33.1 ± 6.0	17.0 ± 5.8	15.2	15.4	15.6 ± 7.2*	31.8 (13.0, 50.7) **	29.5 (9.9, 49.0)#
Leisure MVPA^a minutes/day	Control	37.0 ± 3.9	1.9 ± 4.4	(0.7, 29.6)**	(0.3, 30.4)#	–15.6 ± 3.9	31.8 (13.0, 50.7) **	29.5 (9.9, 49.0)#
Leisure sedentary minutes/day	Intervention	322.4 ± 17.4	–36.2 ± 20.3*	–117.0 (–185.4 –48.5)**	–115.0 (–186.4, –43.7) #	–68.6 ± 22.6*	–189.5 (–264.8, –	–199.7 (–277.9, –
Leisure sedentary minutes/day	Control	351.1 ± 9.8	80.8 ± 27.6*	–117.0 (–185.4 –48.5)**	–115.0 (–186.4, –43.7) #	120.9 ± 30.2*	114.3)**	121.6)#
Sleep minutes/day	Intervention	467.9 ± 7.0	14.5 ± 11.5	29.2	33.3	18.0 ± 10.4	45.2	46.4
Sleep minutes/day	Control	482.1 ± 0.4	–14.6 ± 13.1	(5.6, 64.0)**	(2.8, 69.5)#	–27.1 ± 15.0	(8.7, 81.7)**	(8.4, 84.5)#
ADOSS^b	Intervention	17.4 ± 7.7	–6.4 ± 1.2*	–6.6	–5.1	–6.8 ± 1.2*	–7.4 (–10.3, –4.4)**	–6.6 (–9.6, –3.6)#
ADOSS^b	Control	16.3 ± 8.9	0.2 ± 0.8	(–9.5, –3.7)**	(–7.9, –2.3)#	0.5 ± 0.7	–7.4 (–10.3, –4.4)**	–6.6 (–9.6, –3.6)#
Junk food consumption score	Intervention	25.9 ± 6.5	–6.2 ± 1.2*	–2.9	–2.5	– 5.1 ± 1.0*	–3.9	–2.7
Junk food consumption score	Control	23.7 ± 6.3	–3.3 ± 1.1	(–05, 6.3)	(–6.0, 1.0)	–1.2 ± 1.3	(–7.2, –0.5)**	(–6.1, –0.7)

Abbreviations: PI, post intervention; CI, confidence interval.

Moderate vigorous physical activity.

ADOlescence Stress Scale.

Significant difference from pre to post.

Significance between intervention and control.

Age-adjusted significance between intervention and control.

Figure 4.

Comparison of lifestyle parameters across three time points.

Participant feedback collected through a semi structured survey (Figure 5) indicated the intervention classes increased motivation to adopt a fitter lifestyle, brought about favorable health changes, and improved PA. While some participants mentioned academic pressure as a barrier, the majority said they were happy and satisfied with THANDAV lessons and would recommend them to others. In addition, a considerable proportion of respondents said that offline and video tutorials (74.5%) were equally beneficial.

Figure 5.

Participants’ feedback about THANDAV classes.

The qualitative analysis of the FGD data identified five major themes described in Table 4. Overall, participants shared that engaging in THANDAV left them feeling energetic, which significantly boosted their stamina.

Table 4.

Themes From the THANDAV FGD (Participants and Parents).

Theme	Outcome	Interpretation
Physical activity Routine before THANDAV/ Preferred form of physical activity/ Awareness about HIIT	Participants listed various forms of physical activity they were involved in before THANDAV. These included dancing, badminton, tennis, and basketball. However, very few people were regularly engaging in these activities. The remaining participants did not engage in any physical activity. Parents reported cycling, playing, and dancing as the most preferred form of physical activity and only a single parent had heard of HIIT before.	All the participants had an irregular physical activity routine, mostly due to a lack of time, space, and motivation. Parents were dissatisfied with the quantity of physical exercise their children were engaging in, but they also felt helpless. “I don’t think she ever did something called fitness activity.”—Parent of Participant 1
Reasons to join THANDAV	Liking for dance, consciousness about physical image, entertainment, fun and spending time with friends were listed as the top most reason to join THANDAV by the participants. Amongst other reasons listed by parents were; for fitness, new experience, group activity, girls undergoing physical changes/puberty, love for music and dance and easy accessibility as it was being conducted within the school premises.	In India, dance has traditionally been an important part of culture. Participants cherished dancing and spending time with their friends. While parents cited opportunity for fitness and ease of accessibility as additional incentives of THANDAV program. “School life is very boring. There is too much sitting and learning, THANDAV broke that monotony.”—Parent of Participant 2 “My child is very social and does not like to do things when she is alone. So, THANDAV gave her a perfect opportunity to do physical activity as there was a group of people, music, and dance.”—Parent of Participant 1
Experience with THANDAV	All the participants reported a positive experience with THANDAV. Participants described their experience as enjoyable and fun filled. They loved the sessions with choreographer and the video tutorial. Parents felt that their kids were more energetic and passionate about this type of physical activity and were more conscious about their diet.	Participants felt more energetic and enjoyed working as a team with their friends. Participant 11 said that “To be honest it is great physical activity and learning from a choreographer was awesome”. Parents felt that the THANDAV routine helped their children increase stamina and were happy that they could practise at home with help of video tutorial. Parent of participant 3 said, “Dance is happiness for my child, so THANDAV is happiness for my child.” “THANDAV is great and very energetic. To be honest, it is great physical activity.”—Participant 8 “I want THANDAV class frequency to be increased to 4 classes per week.”—Participant 12 “I love THANDAV and would like to continue learning more dance routines.”—Participant 4 “I have recommended THANDAV to my classmates.”—Participant 6
Challenges faced while learning and practicing	Only a few participants reported having trouble picking up some dance moves and mild cramps while learning THANDAV dance routine. Challenges faced during online sessions included inadequate network access and a lack of space for dancing during class.	Most of the participants were able to overcome the difficulties they encountered while learning the THANDAV routine because they discovered that practicing reduced their cramps and fatigue and that watching the video tutorial helped them review the dance moves, they had trouble picking up. Parents reported that the video dance tutorial was very helpful and motivated the children to practise dance at home. “My daughter loves THANDAV and practises daily. She thoroughly enjoyed THANDAV and is very fit now as well.”—Parent of Participant 4 “THANDAV gives them a break from their routine. Also, the video tutorial is very useful and helps them practise at home.”—Parent of Participant 7
Changes in lifestyle; benefits and recommendations	Lifestyle changes brought in by THANDAV included-being physically more active, awareness about health and consciousness about healthy foods, heart rate and daily step count. Participants reported that after learning THANDAV routine their flexibility and stamina improved. Additionally, the THANDAV routine helped them lose weight and regularize their menstrual cycle. It gave them a break from their monotonous routine and they recommended THANDAV to friends and family. Recommendations included-add latest and regional songs, teach new loops, reach out to large number by making it apart of school curriculum. Most of the parents and participants preferred offline mode of the classes.	THANDAV was positively embraced by everyone. It inspired individuals to be more health conscious and physically active. Parent of participant 9 said that “School life is very boring. There is too much sitting and learning, THANDAV gives them a break”. “My stamina in physical activity like cycling and walking has improved.”–Participant 5

Parents shared their dissatisfaction with the limited PA their children engaged in school or at home before joining THANDAV, many reporting that they felt helpless about the situation. They highlighted how the program not only helped participants feel more energetic but also encouraged them to enjoy exercising alongside friends.

Themes from the qualitative analysis were further categorized applying the COM-B framework. Each COM-B domain further categorized the themes into two main factors—barriers (challenges of PA) and acceptability (how THANDAV helped overcome the challenges) which have been detailed in Table 5.

Table 5.

Factors Influencing Barriers and Acceptability of THANDAV Based on the COM-B Model of Behavior Change.

COM-B Domain		Themes
CAPABILITY	Barrier	Irregular Physical Activity Routine: Difficulty in maintaining a consistent exercise routine due to various factors such as motivation and discipline.
		Lack of Time and Space: Constraints in scheduling time for physical activity and having adequate space to perform it.
		Lack of Motivation: Difficulty in finding the drive or interest to engage in physical activity regularly.
	Acceptability	Cultural Acceptance of Dance: Dance is a traditional and culturally valued activity in India, making it an acceptable and enjoyable form of physical activity for many.
OPPORTUNITY	Barrier	Hectic School Schedule: The demanding nature of schoolwork and exams limits the time and energy available for physical activities.
		Physical Changes/Puberty: Adolescents may face physical and emotional changes during puberty that make participating in physical activities challenging.
	Acceptability	Sessions with a Choreographer: Access to professional guidance and choreography increases the appeal and engagement in the activity.
		Video Tutorials for Home Practise: The availability of video resources allows students to practise and engage in physical activity at their convenience.
		Group Activity and Social Engagement: Participating in a group setting with peers, especially in a school environment, fosters social connections and makes the activity more enjoyable.
		Love for Dance and Music: An inherent interest in dance and music motivates participation and engagement in the activity.
		Accessibility within School Premises: Conducting activities within the school makes participation more convenient and removes logistical barriers.
MOTIVATION	Barrier	Cramps and Fatigue: Physical discomfort such as cramps and fatigue during and after dancing can demotivate participants.
		Inadequate Network Access for Online Classes: Poor internet connectivity can hinder participation in online dance sessions, leading to frustration and disengagement.
		Lack of Private Space for Dancing at Home: Limited privacy at home can make it challenging to practise dance routines freely.
	Acceptability	Increased Stamina and Energy through THANDAV: Improvements in their physical endurance and energy levels motivate continued engagement.
		Enjoyment of Teamwork and Socializing: Working together with friends in a team setting enhances the enjoyment of the activity.
		Reduction in Cramps and Fatigue: Regular practise of THANDAV helps in alleviating physical discomfort, further encouraging participation.
		Improved Flexibility and Stamina: Physical benefits such as improved flexibility, stamina, and even weight loss are motivating factors.
		Regularized Menstrual Cycle: Health benefits, such as a more regular menstrual cycle, is a powerful motivator.
		Break from Monotony: The activity provides a refreshing change from regular study routine, making it more appealing.
		Cherished Time with Friends: The social aspect of dancing with friends adds a significant motivational factor.

Discussion

In this study, we show that THANDAV helped to improve step counts (using Fitbit Inspire 2), leisure time PA, and sleep, while reducing cardiometabolic risk factors, sedentary behavior, stress and junk food consumption in Asian Indian adolescent girls. The FGDs and KIIs revealed that THANDAV was a culturally acceptable, fun, and time-efficient PA intervention, which adolescents wanted to be engaged with long term.

Increasing sedentary behavior among children and adolescents,²⁰ coupled with unhealthy dietary and lifestyle factors, contributes to early metabolic risks and sets a trajectory for diabetes and other noncommunicable diseases (NCDs) in adulthood. Even in childhood and adolescence, the prevalence of NCDs such as obesity, hypertension, and T2D is steadily rising in India.^6,7,^21-23 Adolescents with lower step counts, especially those with high screen time,²⁰ are more prone to being overweight or obese.¹²

HIIT is an effective approach for enhancing PA and improving cardiometabolic health in adolescents. A large cross-sectional study found that increased activity intensity, rather than duration, correlated with reduced cardiometabolic risk and BMI in children (4-18 years).²⁴ A 3-month HIIT intervention in schoolchildren (mean age = 10.7 years) improved aerobic fitness and showed notable reductions in peripheral and central systolic BP.²⁵ A systematic review and a cluster RCT indicated that short-term, school-based HIIT programs significantly improved physical fitness²⁶ and step count in adolescent girls.²⁷ Other HIIT-based studies reported significant improvements in body composition, strength, and PA levels among adolescents.²⁸

Our findings support the impact of HIIT interventions in young people. The study participants who engaged in a novel form of HIIT (THANDAV) showed significant improvements in total daily step count compared with those in the control group.

Wearable technology such as Fitbit play a crucial role in chronic diseases (especially diabetes and CVDs) prevention, management, and behavioral health.²⁹ Though most commonly used to track step-counts, these digital trackers are also used to track sleep, heart rate, food, and structured physical activity. By facilitating real-time monitoring and personalized care, wearables help engage the user through a positive feedback loop and thus contribute to better management of health.²⁹ Integrating wearable technology like Fitbit with exercise-based interventions like THANDAV has the potential to transform behavior and optimize health outcomes.

Dance has been shown to be a culturally engaging form of PA, increasing adherence and enjoyment, particularly in South Asian women and girls who may be less inclined toward traditional sports.^15,30 Research on dance interventions in children and adolescents highlight improvements in physical outcomes like balance, agility, and emotional well-being.^31,32 However, most of these studies have been done in children with special needs. A systematic review underscored the therapeutic and health-promoting effects of dance for children and adolescents, emphasizing its potential as an alternative therapy for medical conditions and a viable PA modality.³³ The present study helps fill a gap in research on the effects of dance as a form of PA in the south Asian population.

Combining dance with HIIT is a novel concept that offers a culturally relevant, enjoyable, and effective solution to improve fitness among Indian adolescents.¹⁵ HIIT improves glucose control, enhances insulin sensitivity, and lowers insulin resistance thereby, reducing the risk of T2D.³⁴ It strengthens cardiovascular health by lowering blood pressure, improving cholesterol, and decreasing heart disease risk.³⁴ In addition, HIIT aids weight management by burning calories and preventing obesity, a key risk factor for T2D and other NCDs.³⁵ Such a fusion of dance with HIIT not only addresses physical inactivity contributing to NCD risk, but also provides a structured, fun outlet for stress relief and social interaction, creating a sustainable, health-promoting lifestyle.^15,30 This combined approach offers a promising strategy to combat the growing NCD burden in South Asian populations.³⁰ THANDAV was found to be popular among young Scottish girls, during a pilot test conducted at the University of Dundee. Young girls, who had never been exposed to Indian music or dance enjoyed learning and performing THANDAV as part of a two-hour workshop, suggesting its potential applicability beyond South Asia.

Data on school-going children in India found 42.7% of children had sleep problems,³⁶ 31.2% had inconsistent sleep schedules, and 28% did not receive adequate sleep.³⁷ We showed a significant increase in sleep minutes for those students who participated in the intervention.

The THANDAV intervention adopted both offline and online formats, each offering distinct benefits and limitations. Offline classes effectively increased step counts, while online sessions helped sustain these gains, showcasing the hybrid (both online and offline) model’s potential for scalable dissemination. Offline sessions allowed for better engagement, direct interaction, and higher attendance rates, while the online format offered flexibility and adaptability for busy adolescent schedules (Supplementary File 3). Since October 2023, the research team has been conducting regular free of charge THANDAV classes for women and adolescent girls in a hybrid format and one can join the classes by registering themselves on the THANDAV website (details available @thandav.in). Various dissemination workshops along with the regular classes have helped the THANDAV intervention to successfully reach over 10 000 women and girls as of date.

The qualitative interviews showed the THANDAV intervention helped to foster a buddy system, bringing out positive behavior change among peers. Hence, integrating THANDAV into school settings^33,38 has many advantages. The program can be implemented as part of the physical education curriculum, as an extra-curricular program after school, or even as a peer-led group activity. However, it holds the potential to expand beyond students to include teachers, school staff and parents, thus creating an inclusive, wellness- and fitness-focused environment for the adolescents. This aligns well with the 2022 India Report Card on PA that emphasized the need for a national PA strategy for children and adolescents, addressing gender inequities through educational campaigns and improving physical literacy, focusing on schools as ideal platforms to implement PA promotion programs.¹¹ Collaboration among schools, local governments, and health authorities is essential for national scaling, with potential expansion to include women teachers and parents as both facilitators and beneficiaries.

Strengths and Limitations

This study has several strengths, including the novel culturally tailored intervention, schools randomized to condition, school setting, high retention rates and a personal activity tracker (Fitbit Inspire 2) providing an objective primary outcome measure. Qualitative interviews of participants and their parents helped us better understand their perceptions regarding the intervention and its pros and cons. Use of a hybrid model for the intervention provides scope for scalable dissemination. Basing dance routines on the familiar Bollywood/Indian film music/album/folk songs, made THANDAV not only unique and interesting but also relatable and enjoyable for the participants.

We also acknowledge several limitations. Having only two clusters limit the generalizability of the study findings due to a higher intraclass correlation coefficient (ICC). However, as mentioned in the “Methods” section, this cRCT design was conducted in pilot mode to manage the logistics and coordination challenges of implementing this novel program in a school setting. With these positive results and a better understanding of the “know-how” of implementing THANDAV in a school setting, we plan to scale-up this cRCT across cities in the future. The second limitation in the research study was that the third dance routine had to be taught virtually owing to unforeseen circumstances that prevented it being taught in person, as described earlier. Moreover, although the two schools were randomized into the two arms, a purposive sampling technique was used to select the schools that came into the final pool as the study required requisite permissions and buy-in from the participating schools to conduct the program. Potential inaccuracy of Fitbit devices, particularly concerning variations in skin tone (especially darker skin tones), may affect sensor readings.³⁹ Fitbit step count accuracy has also been questioned.⁴⁰ These technological limitations should be considered when interpreting the study findings.

Conclusion

The present study highlights that THANDAV is a culturally appropriate, time efficient, and fun physical activity intervention which improves leisure time PA and reduces cardiometabolic risk in Asian Indian adolescent girls. The intervention is adaptable to a hybrid delivery model, assuring scalability. THANDAV if sustained over time could be a positive step toward NCD prevention in Asian Indian women.

Supplemental Material

sj-docx-1-dst-10.1177_19322968251332925 – Supplemental material for A Novel High-Intensity Short Interval Dance Intervention (THANDAV) for Non-Communicable Disease Prevention Tailored to Asian Indian Adolescent Girls

Supplemental material, sj-docx-1-dst-10.1177_19322968251332925 for A Novel High-Intensity Short Interval Dance Intervention (THANDAV) for Non-Communicable Disease Prevention Tailored to Asian Indian Adolescent Girls by Ranjit Mohan Anjana, Sharma Nitika, Narayanaswamy Jagannathan, Deenadayalan Vinothini, Kanniyappan Yuvarani, Viswanathan Mohan, Rajendra Pradeepa, Colin N. A. Palmer, Melissa O’Shea, Shifalika Goenka, Ranjini Manian, Amrita Karthik Raj, Shiny Surendran, Ranjit Unnikrishnan, James F. Sallis and Harish Ranjani in Journal of Diabetes Science and Technology

Footnotes

Acknowledgements

We extend our sincere gratitude to the students and administration of Sacred Heart Matriculation Higher Secondary School and Good Shepherd Matriculation Higher Secondary School, Chennai, India, for their participation and support in this study. We are also grateful to the THANDAV field team led by Mr Pandiyan for their efforts in ensuring the classes ran smoothly. We also thank the RAACK Dance Academy, Chennai, India who are our partners and were responsible for choreography, tutorials, and delivering THANDAV in school. SG is supported by NIHR Global Health Research Centre for Multiple Long-Term Conditions using UK aid from the UK Government (NIHR203257).

Abbreviations

ADOSS, Adolescence Stress Scale; BIA, bioelectrical impedance analysis; BMI, body mass index; BP, blood pressure; COM-B, Capability, Opportunity, Motivation, and Behavior; cRCT, cluster randomized trial; CVD, cardiovascular disease; ECG, electrocardiogram; FGDs, focus group discussions; HIIT, high-intensity interval training; ICC, intraclass correlation coefficient; IEC, Institutional Ethics Committee; ITT, intention to treat; KIIs, key informant interviews; METs, metabolic equivalents; MI-GEE, multiple imputation generalized estimating equations; MPAQ(c), Madras Diabetes Research Foundation Physical Activity Questionnaire for Children and Adolescents; MVPA, moderate-to-vigorous physical activity; NCDs, non-communicable diseases; PA, physical activity; SES, socioeconomic status; T2D, type 2 diabetes; THANDAV, Taking High-Intensity Interval Training ANd Dance to Adolescents for Victory over noncommunicable diseases..

Author Contributions

Conceptualization and methodology by RMA and HR. Data curation by SN and NJ. Drafts of the paper have been reviewed and edited by all authors. NJ, HR, SN, and RMA have directly accessed and verified the underlying data reported in the manuscript. All authors have read and approved the final version of the article and agree with the order of presentation of the authors.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The award was jointly funded by the Department of Health and Social Care (DHSC), the Foreign, Commonwealth & Development Office (FCDO), Department for International Development (DFID), the Medical Research Council (MRC), the National Institute for Health Research (NIHR), and the Wellcome, UK (Grant No. MR/T003626/1). The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The views expressed in this publication are those of the author(s) and not necessarily those of the funder.

ORCID iDs

Ranjit Mohan Anjana

Sharma Nitika

Narayanaswamy Jagannathan

Deenadayalan Vinothini

Kanniyappan Yuvarani

Viswanathan Mohan

Rajendra Pradeepa

Melissa O’Shea

Ranjit Unnikrishnan

James F. Sallis

Harish Ranjani

Data Sharing

The de-identified data sets analyzed during this study are available from the corresponding author on reasonable request.

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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