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The Effectiveness of Physical Activity and Physical Education Policies and Programs: Summary of the Evidence

Key Messages

•  Regular and quality physical education can help children and adolescents achieve the recommended amount of daily vigorous-or moderate-intensity physical activity and improve fitness and potentially body mass index (BMI). Quality monitoring systems are crucially needed to enable monitoring and evaluation of these important outcomes.

•  Recommended levels of vigorous- or moderate-intensity physical activity for youth are more likely to be achieved and sustained in the school setting if students, administrators, teachers, and supportive policies and environments are integrated.

•  Recommended levels of vigorous- or moderate-intensity physical activity for children and adolescents are more likely to be achieved in schools where the physical environment, the school’s programs, and the school’s staff all facilitate greater amounts of physical



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7 The Effectiveness of Physical Activity and Physical Education Policies and Programs: Summary of the Evidence Key Messages • Regular and quality physical education can help children and a ­ dolescents achieve the recommended amount of daily vigorous- or moderate-intensity physical activity and improve fitness and potentially body mass index (BMI). Quality monitoring systems are ­ rucially needed to enable monitoring and evaluation of these c important outcomes. • Recommended levels of vigorous- or moderate-intensity physical activity for youth are more likely to be achieved and sustained in the school setting if students, administrators, teachers, and supportive policies and environments are integrated. • Recommended levels of vigorous- or moderate-intensity physical activity for children and adolescents are more likely to be achieved in schools where the physical environment, the school’s programs, and the school’s staff all facilitate greater amounts of physical continued 311

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312 Educating the Student Body activity throughout the day, including during physical education, recess, instructional classroom time, and before- and after-school opportunities. •  addition to physical education, recess can provide an opportunity In for students to engage in vigorous- or moderate-intensity physical activity and has been shown to improve classroom behavior. • Disparities in access to quality physical education exist, particularly for Hispanic students and those of lower socioeconomic status. • Physical activity during classroom time or activity breaks during l ­essons may contribute to reduced sedentary time during the school day and increase the amount of light- and moderate-intensity a ­ ctivity among students. • Together, regular and quality physical education, recess, and physical activity in the classroom setting enable students to be more physi- cally active during school hours and significantly contribute to recom- mended levels of vigorous- or moderate-intensity physical activity. • Opportunities exist for increasing physical activity outside of normal school hours, including active transport to and from school and active after-school and sports programs. These programmatic efforts can further contribute to the daily recommended levels of vigorous- or moderate-intensity physical activity among students for whom such programs are available and accessible in the school setting. • Schools can be rich resources for joint-use agreements that facilitate physical activity programming for students in their community out- side of school time. • Research is limited on the effectiveness of physical education, recess, classroom physical activity, and before- and after-school programs across subgroups based on race/ethnicity and immigrant and socio- economic status. Additional research is needed to document any d ­ ifferential effects of these approaches among these subgroups. • Even though sufficient evidence exists to support augmenting student physical activity during school hours and at school-related after- school activities, important questions remain about tailoring interven- tions to fit the wide social and physical variations among schools.

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The Effectiveness of Physical Activity and Physical Education Policies and Programs 313 A n effective or promising approach for increasing physical activity in youth is one that both has theoretical underpinnings and has been investigated through methodologically sound qualitative or quantitative research. The type of research and evidence relating to strategies for increas- ing physical activity in schools varies tremendously by program or policy components. As suggested by the L.E.A.D. (Locate Evidence, Evaluate It, Assemble It, and Inform Decisions) framework, developed to guide decision making on obesity prevention, evidence should be evaluated against criteria for assessing quality that are appropriate and established for this type of evidence (IOM, 2010). All research findings should be considered in light of their strengths and limitations, including internal and external validity, where appropriate and relevant. This chapter presents a summary of available evidence on and provides examples of effective and promising approaches for increasing physical activity in schools. It is important to note that a lack of favorable research findings concerning the influence of a program or policy must be interpret- ed with caution but not altogether discounted. Definitive evidence on effec- tiveness may be limited by the novelty of the approach, gaps in surveillance, or the lack of feasibility of using “gold standard” study designs to examine certain issues. For example, use of a randomized controlled design to study the effects of a new physical education policy at the state level may not be feasible. At the same time, however, the field of evidence-based policy mak- ing, which involves drawing on existing research and surveillance systems, is growing and is especially relevant to the study of the impacts and out- comes of the approaches presented in this chapter. SYSTEMS APPROACHES: MULTICOMPONENT PROGRAMS AND INTERVENTIONS Strategies for promoting behavioral change need to take account of the complex interactions between individuals and the settings in which they spend their time. While ecological models for health promotion encompass the individual, social, and policy levels, a systems approach (discussed in detail in Chapter 1) focuses on the dynamic interactions among various factors at those levels. A systems approach to increasing physical activity in children and adolescents can help address the complexity of this behav- ior within the school setting. Integrating students and key players such as school and administrative personnel with the school and classroom envi- ronments and all levels of policy may be the best way to influence sustain- able changes in population-level physical activity behaviors. According to a recently released report (HHS, 2013), multicomponent school-based approaches, which usually include enhanced physical educa- tion in conjunction with other forms of school-related physical activity,

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314 Educating the Student Body are effective in increasing physical activity among students (see Box 7-1). Although systematic reviews of the literature identify evidence for the promise of such approaches, the context for and generalizability of this evi- dence vary greatly (Salmon et al., 2007; Naylor and McKay, 2009; Craggs et al., 2011). Perhaps one of the most notable examples of a multicom- ponent intervention is the Child and Adolescent Trial for Cardiovascular BOX 7-1 The ENERGY Project The aim of the ENERGY (EuropeaN Energy balance Required to prevent excess weight Gain among Youth) project is to develop a theory- and evidence-based multicomponent intervention promoting the adoption or continuation of behaviors that can lead to a healthy energy balance (available online at http://www.projectenergy.eu/flash.html; accessed March 1, 2013). This program also includes a component called UP4FUN, a 6-week school-based project to reduce and break up time spent sitting in school and at home. The preliminary findings of the ENERGY project suggest that increased breaks in sedentary behavior can be achieved through a school- and home-based intervention. An intervention must take certain circumstances into consideration: national and cultural traditions and social disparities need to be recog- nized, along with variations in family structure, ethnicity, and education levels. All of these factors may influence the opportunity for intervention and the intervention’s form and content. For this reason, it is valuable to involve the intended participants—especially teachers, parents, and youth themselves—in an intervention’s development. The most successful interventions tend to combine dietary behavioral change with increased physical activity and reduced sedentary behavior instead of focusing on only one of these behaviors. Failed interventions did not combine educational with environmental change strategies, did not involve the family and home environment, and did not conduct care- ful pretesting before larger-scale implementation. Multifaceted school- based programs with an active physical education component have been shown to be most cost-effective. SOURCE: Brug et al., 2010, 2012.

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The Effectiveness of Physical Activity and Physical Education Policies and Programs 315 Health (CATCH). This 3-year rigorously designed randomized controlled intervention included improvements in physical education classes, a health promotion curriculum, and food service changes, as well as a family com- ponent. Results indicated more intense physical activity during physical education classes and more daily vigorous physical activity in intervention groups compared with controls (Luepker et al., 1996). (See Box 7-2 for a more detailed description of this intervention.) In a recent review, van Sluijs and colleagues (2007) found strong evi- dence for the effectiveness of multicomponent school-based interventions including family or community components (Craggs et al., 2011). With increasing recognition of the importance of these integrated approaches, programs such as Playful City USA (Kaboom, 2013) and Playworks (www. playworks.org) are being launched as national campaigns to promote phys- ical activity. Playful City USA is a national recognition program honoring cities and towns that make play a priority and use innovative programs to get children active, playing, and healthy. Playful City USA designees map local play spaces; complete a needs assessment; and develop an action plan that identifies a minimum of three policies, programs, or initiatives aimed at increasing access to play at school, in neighborhoods, and through com- munity engagement. In 2012, 213 cities and towns in 41 different states earned Playful City USA recognition. Playworks is another program promoting physical activity through integrative means. The Playworks mission is to improve the health and well-being of children by increasing opportunities for physical activ- ity and safe, meaningful play at recess and throughout the school day. Trained adult program coordinators go to low-income schools, where they enhance recess and play to make both a positive experience that helps students and teachers get the most out of every learning opportunity throughout the school day. This program has the potential to enhance not only physical activity but also classroom learning and social culture (see Chapter 4). The interest in and prevalence of these multicomponent programs for increasing child and adolescent physical activity are growing. As has been brought to light by reviews of these interventions, well-developed evaluation methodology is needed to strengthen the evidence base for their effectiveness. Cost-effectiveness is another important feature of these interventions. Growing evidence indicates that population-level environmental interven- tions are a more cost-effective preventive health measure than interventions targeting individuals, although more research is needed in this area (Choski and Farley, 2012). As discussed in Chapter 1, schools, where children spend the majority of their waking hours, are important locations for obesity prevention activities, such as those designed to increase physical activity

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316 Educating the Student Body BOX 7-2 CATCH: An Example of a Multicomponent Coordinated School Health Promotion Program The Child and Adolescent Trial for Cardiovascular Health, or CATCH, was a “controlled clinical trial that entailed a multicomponent, multiyear coordinated school health promotion program designed to decrease fat, saturated fat and sodium in children’s diets; increase physical activity; and prevent tobacco use” (Perry et al., 1990). CATCH included school environmental modifications related to food consumption, physical activity, and tobacco use. For physical activity, a whole-of-school approach was used (see the discussion of this approach in Chapter 1). Physical education teachers were instructed to increase the involvement of children and to provide for vigorous- or moderate- intensity physical activity for at least 50 percent of class time. The CATCH classroom curriculum outside of physical education used social cognitive theory to target 3rd- to 5th-grade students and focused on multiple health behaviors, including eating habits, physical activity, and cigarette smoking. CATCH also incorporated family- and home-based programs to complement in-school activities (Perry et al., 1990). The trial was carried out in 1991-1994 in 96 schools (56 intervention sites, 40 control sites) in four states (California, Louisiana, Minnesota, and Texas) and included more than 5,100 students with diverse cultural and ethnic backgrounds. By the time it was completed, CATCH had dem- onstrated sustainable changes in dietary and physical activity behaviors. With respect to physical activity outcomes, students who participated in the intervention were more physically active during physical education classes and participated in more physical activity outside of school com- pared with students in the control schools (Luepker et al., 1996). Further sustainability was demonstrated after the main CATCH trial ended. The CATCH students were studied 3 years following the intervention. With no continued CATCH intervention, the students who had participated in the trial maintained lower fat intakes and higher levels of physical activity com- pared with those who had not participated (Nader et al., 1999). Such multicomponent, whole-of-school approaches for increasing physi- cal activity can be successfully sustained with key elements in place. Osganian and colleagues (2003) studied the schools in the original trial and concluded that sustainability was enhanced by staff training; a pro- gram champion; and adequate administrative support and resources, such as sufficient funding for materials and equipment.

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The Effectiveness of Physical Activity and Physical Education Policies and Programs 317 (Story et al., 2009). The World Health Organization, the American Heart Association, and the Centers for Disease Control and Prevention (CDC) all have called on schools to assume a leadership role in promoting physical activity among children and adolescents. Recent research by Aryana and colleagues (2012) shows the need to target obesity prevention strategies at an early age. This study tracked changes in California students’ physical fitness, including body mass index (BMI), during 5th, 7th, and 9th grades. While the researchers found that school-based physical activity can have some effect on reducing obesity rates, they continued to find increased obesity rates in incoming 5th-grade study participants. Several studies also point to the importance of physical activity in obesity interventions. Findings of both Skinner and colleagues (2012) and a new Australian study led by Richard Telford (Telford et al., 2012) show that obese youth consume the same amount of calories as their normal-weight counterparts, suggesting that increased physical activity in youth may be crucial in reducing obesity prevalence. Likewise, Stallmann- Jorgensen and colleagues (2007) indicate that a lack of vigorous physical activity, rather than excess calorie intake, is related to body fat in youth. These findings highlight the need to target physical activity interventions and policies at all youth. Even though multicomponent approaches to increasing physical activ- ity in youth often adhere to systems thinking and can be effective and sus- tained over time, they are complex, and barriers to their implementation and sustainability are numerous. Indeed, physical activity interventions and initiatives in school are more often defined by a single focus, such as a policy or a curriculum. These singular programmatic and policy approaches within schools are increasing in prevalence, as indicated in Chapters 5 and 6. The next section summarizes the evidence on such approaches and their outcomes. As demonstrated by variations in the space devoted to each approach, many of these approaches have not been evaluated or dissemi- nated to the fullest extent. Programmatic/Policy Approaches and Their Outcomes This section reviews programmatic and policy approaches for increas- ing physical activity in the school setting and their outcomes. Examined in turn are physical education, recess, classroom physical activity, intra- and extramural sports and after-school programs, active transport, the role of the environment in physical activity, and joint- or shared-use agreements.

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318 Educating the Student Body Physical Education Status and Trends No national data are available concerning population-level trends over time in enrollment and daily attendance in physical education, overall p ­ hysical activity in physical education classes, or the amount of time spent in vigorous- or moderate-intensity physical activity during physical educa- tion ­lessons among students in elementary and middle schools. However, research pertaining to children in elementary and middle schools documents insufficient physical education opportunities. One study of elementary schools across 10 U.S. localities found that the schools offered an average of two physical education lessons per week lasting 33 minutes each; children in this study received 25 minutes per week of vigorous- or ­ oderate-intensity m physical activity—far short of national recommendations—in physical edu- ­ cation (Belsky et al., 2003). And among middle and high school adolescents who participated in Wave I of the Adolescent Health Study in 1993, only 21.3 percent reported participating in physical education on one or more days per week (Gordon-Larsen et al., 2000). The CDC has collected national data on physical education among high school students over the past two decades through the Youth Risk Behavior Surveillance System (YRBSS). These data reveal disconcerting pat- terns as well. Among high school students during the period 1991-2007, enrollment and daily attendance in physical education classes and being physically active during these classes fell short of the objectives of Healthy People 2010 (Lowry et al., 2001, 2005, 2009). Specifically, in 1991, 48 percent of high school students were enrolled in physical education, with no significant changes between 1991 and 2003 (Lowry et al., 2001, 2005). Moreover, daily attendance at physical education classes declined signifi- cantly from 41.6 percent in 1991 to 25.4 percent in 1995, with no signifi- cant changes between 1995 and 2007 (Lowry, 2005, 2009). In addition to enrollment and attendance, the quantity of physical activity during physical education classes is crucial. In 1991, only 36.8 per- cent of high school students were physically active in physical education classes; although the percentage was slightly higher in 2003 (39.2 percent), there were no significant changes between 1991 and 2003. Further, no significant changes were observed from 1999 to 2007 (Lowry et al., 2009). Although physical education may be offered, high schools do not always require students to take it; these variations appear to follow grade lines. From 2004 to 2007, 88 percent of 8th graders, 48 percent of 10th graders, and only 20 percent of 12th graders attended schools that required physical education in their grade (O’Malley et al., 2009). The average weekly minutes spent by high school students in physical education classes

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The Effectiveness of Physical Activity and Physical Education Policies and Programs 319 also varies across grade levels—according to a national study, declining from 172 minutes in 8th grade to 164 minutes in 10th, down to 89 min- utes by 12th grade, with the overall decrease being statistically significant (Johnston et al., 2007). The available national data indicate that between 1991 and 2007 no significant progress was made toward increasing par- ticipation in physical education classes among high school students (Lowry et al., 2009). Disparities All youth should engage in physical education and meet the recom- mended 60 or more minutes per week of vigorous- or moderate-intensity physical activity, regardless of geographic region, school attended, grade level, or individual-level characteristics. In addition to the overall troubling physical education participation patterns described above, a number of studies have documented disparities by race/ethnicity, socioeconomic status, and gender. Race/ethnicity and socioeconomic status  Using national data from the Monitoring the Future and Youth, Education, and Society studies, Johnston and colleagues (2007) observed that, among 8th graders, Hispanic youth attended schools in which smaller proportions of students were required to take physical education relative to schools attended by white youth. Compared with schools attended by white students, those attended by Hispanic students had a significantly smaller percentage actually taking physical education in 8th and 12th grades. Further, students of lower socio- economic status were less likely to attend schools that required physical education. Racial/ethnic and socioeconomic disparities in physical activity and physical education may be driven by multiple factors, including dif- ferences in student-level socioeconomic status and school-level resources such as funding, equipment, and facilities. Fernandes and Sturm (2010) found that unavailability of facilities, such as gymnasiums, was a potential barrier for school physical activity programs and was a greater problem in urban, high-minority, and high-enrollment schools. Gymnasium availability in schools also was associated with an additional 8.3 minutes of physical activity weekly overall and at least an additional 25 minutes for schools in humid climate zones. Gender  Participation in physical education and time spent being physi- cally active in physical education classes differ by gender. Consistent with national data, participation in physical education was found to be higher in boys (66 percent) than girls (59 percent) among California adolescents (Diamant et al., 2011). Moreover, based on national data from the YRBSS,

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320 Educating the Student Body high school girls spent more minutes per week in active physical education (37 minutes) than boys (26.9 minutes). The investigators concluded that physical education increased girls’ overall physical activity levels (Cawley et al., 2007). In direct observations of physical education classes in elementary schools across various U.S. localities, investigators noted that boys spent more time in physical education engaged in vigorous- or moderate-intensity physical activity than girls, although there were no gender differences in les- son length or number of minutes of physical education (Belsky et al., 2003). Nevertheless, girls reported that physical education was their largest source of physical activity (14.3 percent), followed by lunchtime (11.7 percent) and recess (8.3 percent); among boys, lunchtime represented the largest single source of physical activity at school (13.4 percent), followed by physical education (12.7 percent) and recess (9.5 percent) (Brusseau et al., 2011). Impact on Physical Activity Physical education programs and policies can shape the quantity and quality of physical activity among students across schools (Slater et al., 2012). Studies using direct observations of physical activity have found large variations in the amount of vigorous- or moderate-intensity physical activity performed by students during their physical education classes: a range of 9-48 percent (Pate et al., 2011). A number of school-based intervention studies have targeted physical education classes as a focus for increasing vigorous- or moderate-intensity physical activity in young children; many of these studies have included other intervention components, such as environmental changes. In the CATCH intervention study, involving children in elementary schools, an increase in the intensity of physical activity in physical education classes during the intervention was observed in the intervention schools compared with the control schools. Compared with control students, moreover, those in the intervention schools reported significantly more minutes of daily vigorous activity (Luepker et al., 1996). In the Sports, Play, and Active Recreation for Kids (SPARK) intervention, also comprising elementary schools, vigorous- or moderate-intensity physical activity increased dur- ing physical education among 4th graders (Sallis et al., 1997). The SPARK intervention also showed that students who received physical education from specialists had the highest percentage of class time (40 percent) in vigorous- or moderate-intensity physical activity, compared with those who received physical education from trained teachers (33 percent) and controls (18 percent) (Sallis et al., 1997). In a follow-up of the CATCH study, while participants were in 8th grade, investigators observed that the intervention students maintained

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The Effectiveness of Physical Activity and Physical Education Policies and Programs 321 a significantly higher amount of self-reported daily vigorous activity com- pared with control students; however, the intervention-control differences declined over time (13.6 minutes in grade 5, 11.2 minutes in grade 6, 10.8 minutes in grade 7, and 8.8 minutes in grade 8) (Nader et al., 1999), highlighting the need for longer-term school-based interventions. Further, in an intervention for girls aged 11-12 designed to increase vigorous- or moderate-intensity physical activity during physical education lessons, the experimental group engaged in more of such activity than the con- trol group and had more opportunities for skill practice (Fairclough and Stratton, 2005). Cross-sectional studies also have documented that participation in daily school physical education programs is associated with an increased likeli- hood of engaging in vigorous- or moderate-intensity physical activity among middle and high school adolescents nationwide (Gordon-Larsen et al., 2000). Moreover, participating in physical education was associated with engaging in an additional 18 minutes per week of overall physical activity, even after adjusting for age, gender, race, and income, among adolescents in California (Diamant et al., 2011). One study, using cross-sectional data from the National Survey of Children’s Health, found that, although there was no significant association between schools requiring physical education and levels of physical activity in the sample overall, such an association did exist for girls (Kim, 2012), suggesting that physical education may be particularly important for increasing physical activity in girls. Consistent with results from the above studies, several reviews (Dobbins et al., 2009; Kriemler et al., 2011; Pate et al., 2011; Heath et al., 2012) have concluded that school-based interventions increased vigorous- or moderate-intensity physical activity during physical education (Pate et al., 2011); duration of physical activity (Dobbins et al., 2009) (not neces- sarily only in physical education); physical activity overall (Heath et al., 2012); and physical activity in school, out of school, and overall (Kriemler et al., 2011). Effects of school-based interventions on the quantity and quality of physical activity are favorable, as are the positive associations documented in observational studies. However, studies involving direct observations of physical activity during physical education classes provide strong evidence that the classes do not provide sufficient activity to enable children or ado- lescents to attain the recommended levels of daily vigorous- or moderate- intensity physical activity; the classes also do not reach the goal of 50 per- cent of class time spent in such activity (Pate et al., 2011). Further, there is a dearth of research concerning intervention effects and observational associations of school-based programs and the quantity and quality of physical activity across subgroups based on race/ethnicity, gender, immigra- tion status, and socioeconomic status.

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354 Educating the Student Body Erwin, H. E., M. G. Abel, A. Beighle, and M. W. Beets. 2011. Promoting children’s health through physically active math classes: A pilot study. Health Promotion Practice 12(2):244-251. Erwin, H., M. Abel, A. Beighle, M. P. Noland, B. Worley, and R. Riggs. 2012. The contri- bution of recess to children’s school-day physical activity. Journal of Physical Activity and Health 9(3):442-448. Evenson, K. R., K. Ballard, G. Lee, and A. Ammerman. 2009. Implementation of a school-based state policy to increase physical activity. Journal of School Health 79(5):231-238. Evenson, K. R., F. Wen, S. M. Lee, K. M. Heinrich, and A. Eyler. 2010. National study of changes in community access to school physical activity facilities: The school health policies and programs study. Journal of Physical Activity and Health 7(1):20. Fairclough, S., and G. Stratton. 2005. Improving health-enhancing physical activity in girls’ physical education. Health Education Research 20(4):448-457. Falb, M. D., D. Kanny, K. E. Powell, and A. J. Giarrusso. 2007. Estimating the propor- tion of children who can walk to school. American Journal of Preventive Medicine 33(4):269-275. Faulkner, G. E. J., R. N. Buliung, P. K. Flora, and C. Fusco. 2009. Active school transport, physical activity levels and body weight of children and youth: A systematic review. Preventive Medicine 48(1):3-8. Fernandes, M., and R. Sturm. 2010. Facility provision in elementary schools: Correlates with physical education, recess, and obesity. Preventive Medicine 50(Suppl):S30-S35. Fernandes, M. M., and R. Sturm. 2011. The role of school physical activity programs in child body mass trajectory. Journal of Physical Activity and Health 8(2):174-181. Fesperman, C. E., K. R. Evenson, D. A. Rodríguez, and D. Salvesen. 2008. A compara- tive case study on active transport to and from school. Preventing Chronic Disease 5(2):A40. Forman, E. S., A. H. Dekker, J. R. Javors, and D. T. Davison. 1995. High-risk behaviors in teenage male athletes. Clinical Journal of Sport Medicine 5(1):36-42. French, S. A., C. L. Perry, G. R. Leon, and J. A. Fulkerson. 1994. Food preferences, eat- ing patterns, and physical activity among adolescents: Correlates of eating disorders symptoms. Journal of Adolescent Health 15(4):286-294. Garry, J. P., and S. L. Morrissey. 2000. Team sports participation and risk-taking behav- iors among a biracial middle school population. Clinical Journal of Sport Medicine 10(3):185-190. Getlinger, M. J., V. Laughlin, E. Bell, C. Akre, and B. H. Arjmandi. 1996. Food waste is reduced when elementary-school children have recess before lunch. Journal of the American Dietetic Association 96(9):906. Gillian, A., M. Stephen, A. Castelblanco, S. Colston, M. Thomas, A. Weiss, J. Nelson, and R. Duncan. 2004. WalkSafe: A school-based pedestrian safety intervention program. Traffic Injury Prevention 5(4):382-389. Gordon-Larsen, P., R. G. McMurray, and B. M. Popkin. 2000. Determinants of adolescent physical activity and inactivity patterns. Pediatrics 105(6):e83. Gould, D., and S. Carson. 2008. Life skills development through sport: Current status and future directions. International Review of Sport and Exercise Psychology 1(1):58-78. Graham, D. J., M. Schneider, and S. S. Dickerson. 2011. Environmental resources moder- ate the relationship between social support and school sports participation among adolescents: A cross-sectional analysis. International Journal of Behavioral Nutrition and Physical Activity 8:34.

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