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Status and Trends of Physical Activity Behaviors and Related School Policies

Key Messages

•  Few children in the United States, probably no more than half, meet the currently recommended standard of at least 60 minutes of vigorous- or moderate-intensity physical activity daily.

o The proportion meeting the standard declines with age, with more elementary school children than middle and high school students achieving the goal. Boys are more likely than girls to meet the recommendation.

o During the past 30-40 years, probably even longer, the volume and intensity of daily physical activity among youth have gradually declined.

•  Given the large proportion of total waking hours spent at school and in school-related activities, remarkably little is known about students’ physical activity behaviors during school hours and during school-related after-school activities. Despite some excellent research and a few good public health surveillance systems, current monitoring of overall and school-related physical activity behaviors among



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2 Status and Trends of Physical Activity Behaviors and Related School Policies Key Messages • Few children in the United States, probably no more than half, meet the currently recommended standard of at least 60 minutes of v ­ igorous- or moderate-intensity physical activity daily. o  proportion meeting the standard declines with age, with The more elementary school children than middle and high school students achieving the goal. Boys are more likely than girls to meet the recommendation. o During the past 30-40 years, probably even longer, the volume and intensity of daily physical activity among youth have gradu- ally declined. • Given the large proportion of total waking hours spent at school and in school-related activities, remarkably little is known about students’ physical activity behaviors during school hours and during ­ school-related after-school activities. Despite some excellent research and a few good public health surveillance systems, current monitor- ing of overall and school-related physical activity behaviors among continued 35

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36 Educating the Student Body youth and school-related policies and practices that enable or impede those behaviors is inadequate. •  adequate description of the current status of and monitoring An of changes in students’ school-related physical activity behaviors currently is not possible. Public health and education surveillance and research need to be enhanced so that the impact of efforts to increase students’ physical activity can be monitored. • Policies are and will be important in creating an atmosphere in schools that enables, facilitates, and encourages children to be more physically active. Less clear are the factors that create an effective policy. An understanding is needed of what facilitators (e.g., funding, promotions, awards) and enforcers (e.g., less funding, job security) lead to policies that are fully implemented. A s discussed in further detail throughout this chapter, few children in the United States, probably no more than half, meet the currently recom- mended standard of at least 60 minutes of vigorous- or moderate-intensity physical activity daily (CDC, 2012b). In addition, the proportion meeting the standard declines with age, with more elementary school children than middle and high school students achieving the goal. Boys are more likely than girls to meet the recommendation. Finally, it can be said with reason- able certainty that during the past 30-40 years, probably even longer, the volume and intensity of daily physical activity among youth have gradually declined. It is also known that because children and adolescents spend so many hours at school, school-related physical activity must be a large contributor to overall physical activity among youth. Not known, however, is exactly how large the overall contribution is or the contribution of each segment of the school day—transportation to and from school, physical education, recess, classroom time, and before- and after-school activities. It is known that over the past 40 years the proportion of children walking and biking to school has declined substantially; otherwise, there are at best rough estimates of the current physical activity behaviors, recent changes, or long- term trends associated with each of these segments of the school day. Guidelines, recommendations, and policies from all levels of govern- ment (federal, state, district, local) and from various organizations (e.g.,

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Status and Trends of Physical Activity Behaviors and Related School Policies 37 National Association for Sport and Physical Education, American College of Sports Medicine) are known to influence youth’s school-related physical activity. Understood as well is that the strength of that influence is, in turn, affected by incentives and enforcements associated with those guidelines, recommendations, and policies (see Figure 1-3 in Chapter 1). What remains unclear is which guidelines, recommendations, policies, incentives, and enforcements are most influential in today’s social milieu. What should also be apparent is that, despite some excellent research and a few good public health surveillance systems, current monitoring of overall and school-related physical activity behaviors and school-related policies and practices that enable or impede those behaviors is inadequate. These deficiencies have arisen for several reasons. First, physical activity has only recently been acknowledged as a vital public health issue, so monitor- ing of the volume of physical activity at the population level is a recent objective with still insufficient priority. The Physical Activity and Health Branch of the Centers for Disease Control and Prevention (CDC) was not established until 1996, and the first formal federal-level physical activity guidelines were not published until 2008 (HHS, 2008). Second, physical activity is a notoriously difficult behavior to measure. Third, understanding of the types and amounts of physical activity relevant to health and health outcomes is still growing. The types and amounts of physical activity rec- ommended for children and adolescents have changed several times in the past 20 years, frustrating efforts to monitor trends. Fourth, information is scarce on prevalence and trends for policies that may enable (or inhibit) physical activity. Examples include school- and district-level policies on recess and training for physical education teachers, as well as community or neighborhood policies on active transport to and from school. Monitoring of policies and practices is improving but needs expansion and matura- tion. Finally, schools and school districts vary greatly in size, resources, environmental setting, urbanization, population characteristics, traditions, and policies. Summary assessments and measures may capture the national gestalt but omit important differences among subgroups. Physical Activity Versus Exercise Physical activity is defined as all human movement; it is done at some rate of energy expenditure in all settings and for many different p ­ urposes. Exercise is a subcomponent of physical activity that is done for the purpose of increasing physical fitness. Intensity (i.e., rate of energy expenditure) is an important descriptor of physical activity because dif- ferent intensities have different physiologic effects. Both physical activity and exercise encompass the full range of energy expenditure.

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38 Educating the Student Body The purpose of this chapter is to describe the evidence supporting these general statements about the status and trends of the physical activity behav- iors of school-age children and adolescents, as well as the school-­elated r policies and practices that help determine those behaviors. Description of the status and trends of physical activity behaviors of youth requires, along the way, some discussion about the behaviors themselves, how they are mea- sured, and how the current recommendations came into being. Physical Activity Unless they take a nap or lie down to rest, all people are physically active from the time they get up in the morning until they go to bed at night. Physical activity is a necessary part of everything people do at home, work, or school; while going from place to place; and during leisure time. Few people in the United States, whether adults or children, expend a great deal of energy during physical activity, but they are always expending some. In the still-emerging field of physical activity and public health, physical activity is commonly defined as “any bodily movement produced by skeletal muscles that results in energy expenditure” (Caspersen et al., 1985, p. 126). Despite this straightforward definition, physical activity is a complex behav- ior with a wide variety of types and intensities. Types of physical activity may be categorized, for example, by type of movement (e.g., walking, skip- ping), by sport (e.g., soccer, badminton), by life context (e.g., at school, at home, during transportation), or by predominant physiologic effect (e.g., cardio­ espiratory conditioning, muscle strengthening). Regardless of the cat- r egorization scheme, physical activity operates through multiple physiologic pathways to influence many health outcomes. Although physical activity can be categorized and discussed in many ways, aerobic activities are the most common and have the broadest physiologic and health effects. Aerobic activities are commonly categorized as being of sedentary, light, moderate, or vigorous intensity based on the rate of energy expenditure (see Box 2-1). Status of physical activity behaviors AMONG YOUTH This section reviews what is known about the status of physical ­ ctivity a behaviors among youth, first for vigorous- or moderate-intensity activ- ity, next for sedentary or light-intensity activity, and finally for vigorous- or moderate-intensity activity during the school day. Vigorous- or Moderate-Intensity Physical Activity Vigorous- or moderate-intensity physical activity is important for normal growth and development (see Chapter 3), including maintenance

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Status and Trends of Physical Activity Behaviors and Related School Policies 39 BOX 2-1 Categories of Intensity of Physical Activity Categories of Absolute Rate of Energy Expenditure Aerobic activities are common and important. Such activities include walking, dancing, and playing soccer or basketball, all of which involve large muscle groups in rhythmic repetitive movement. Aerobic activities are performed at a pace that can be continued for more than a few minutes, and when done at higher-than-usual levels, improve the efficiency and capacity of the cardiorespiratory system (Powell et al., 2011). Aerobic activities have commonly been categorized based on the rate of energy expenditure, or intensity, at least in part because high rates of energy expenditure were known to be important for fitness training and were presumed necessary to reduce the risk of heart disease. Although energy expenditure can be measured in various units (e.g., kilocalories, milliliters of oxygen consumption), metabolic equivalents (METs) have become the method of choice in public health circles. One MET is the rate of energy expenditure while a person is at rest and is equivalent to an oxygen uptake of about 3.5 ml/kg body weight × min. Because METs take a person’s body weight into account, the MET rate for any given activity is similar for all individuals. For adults, for example, the MET rate while sitting at rest is 1.0, for cooking or food preparation is 2.0, for walking at 3 miles per hour is 3.5, and for running at 5 miles per hour is 8.3. Because of their smaller size, immature motor patterns, and other physiologic differences, children’s energy expenditure for most activities is slightly higher than that for adults (Torun, 1983). Despite these differences, adult MET values provide the best approximation of energy expenditure for children for most activities. The exceptions are walking and running, for which equations based on age and speed should be used (Ridley et al., 2008). Although rate of energy expenditure is a continuous variable, splitting the range into four categories has become standard (Pate et al., 2008) (see the table on the next page). This categorization scheme has facilitated conversation, epidemiologic analysis, surveillance, and public health recommendations. Although useful, the scheme and its arbitrary continued

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40 Educating the Student Body BOX 2-1 Continued cut-points have become rigid, obscuring the fact that rate of energy expenditure is a continuous variable and cut-points are arbitrary. Categories of Intensity of Physical Activity Range of Metabolic Equivalents Category (METs) Examples of Activities Sedentary Activity ≤1.5 METs Sleeping, lying down, sitting, watching television Light-Intensity >1.5-<3.0 METs Standing; walking slowly; Activity everyday activities such as getting dressed, making a bed, cooking Moderate-Intensity ≥3.0-<6.0 METs Walking, table tennis, ball- Activity room dancing Vigorous-Intensity ≥6.0 METs Running at various speeds, Activity shoveling snow, mowing the lawn while walking with a hand mower of healthy body composition, and reduces the likelihood of acquiring risk factors for the development of chronic diseases later in life. The currently recommended dose of physical activity for children and adolescents is at least 60 minutes of vigorous- or moderate-intensity physical activity per day, with vigorous physical activity on at least 3 of those days (Strong et al., 2005; PAGAC, 2008). In 2005 a panel was convened by the CDC specifically to consider the physical activity needs of children and adolescents (6-18 years of age). The

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Status and Trends of Physical Activity Behaviors and Related School Policies 41 Relative Rate of Energy Expenditure The rate of energy expenditure expressed in METs, kilocalories, or kilo- joules is an absolute measure of intensity. For all people, higher rates of energy expenditure require a greater level of effort, and the above categorical terms for the commonly used categories—sedentary, light, moderate, vigorous—reflect that fact. For most healthy and reasonably fit youth and adults, the categorical terms and the individual’s perceived level of effort closely align. Older and unfit persons, however, require a greater relative, or perceived, level of effort to accomplish a given physi- cal activity (see the table below). For example, a healthy person with the capacity to expend energy at a rate of 12 METs feels as though he or she is performing vigorous activity when jogging (MET level above 7), whereas an older or unfit person with a capacity of only 5 METs feels as though he or she is performing vigorous activity when walking (MET level of 3-4). Recognizing that level of fitness determines the rate of energy at which physical activity can be performed is important when planning programs to improve the fitness of any individual or group. Relative Intensity of Activity for Younger and Fit Persons and for Older and Unfit Persons Younger and Fit Older and Unfit Relative Intensity (12 MET capacity) (5 MET capacity) Light <3.2 METs <1.8 METs Moderate 3.2-7.5 METs 1.8-3.3 METs Vigorous ≥7.6 METs ≥3.4 METs SOURCE: Adapted from Table D-1 in PAGAC, 2008. panel reported beneficial effects of regular physical activity on muscular health, cardiovascular health, adiposity, blood pressure, blood lipid levels, self-concept, anxiety, depressive symptoms, and academic performance. The optimal dose was more difficult to determine for at least two reasons (see also Box 2-2). First, different health outcomes accrue from different doses. Second, research demonstrates a positive dose response rather an ideal dose. The panel concluded, however, that “school-aged youth should participate every day in 60 minutes or more of moderate to vigorous physi-

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42 Educating the Student Body BOX 2-2 Dose of Physical Activity The dose of physical activity, sometimes referred to as volume or amount, is a function of the type, frequency, duration, and intensity of the ­ ctivity. a Until recently, benefits appeared to derive almost exclusively from vigorous- or moderate-intensity physical activity, and almost all epide- miologic, clinical, and intervention research focused on that intensity range. Evidence derived from that research indicated that, for both adults and youth, health benefits are more closely related to the total dose of v ­ igorous- or moderate-intensity physical activity than to any of the com- ponents of dose (i.e., type, frequency, duration, intensity) (PAGAC, 2008). Research has consistently demonstrated an inverse relationship between the dose of regular vigorous- or moderate-intensity physical activity and a wide variety of adverse health outcomes (e.g., heart disease, diabetes, functional limitation, depressive symptoms) (PAGAC, 2008). Dose of vigorous- or moderate-intensity physical activity has been mea- sured in a variety of ways, including minutes per week, kilocalories or kilojoules of energy expenditure, or even miles or minutes of running per week. A method frequently used to describe the dose of vigorous- or moderate-intensity physical activity is to multiply the time spent in the activity by its metabolic equivalent (MET) value (see Box 2-1). For exam- ple, running at 5 miles per hour (about 8 METs) for 20 minutes provides a dose of 160 MET minutes. Accelerometers permit estimates of the total dose of physical activity ­ performed in a day regardless of intensity (see also Box 2-3). By estimat- ing intensity for every minute, accelerometers can provide an estimate of the total dose of vigorous- or moderate-intensity physical activity. Accelerometers are not yet able to “know” exactly what type of physical activity is being performed (e.g., cycling, stair climbing, raking, sweep- ing) and as a result may over- or underestimate the rate of energy expenditure. Nevertheless, the products are improving rapidly, and their capability to measure sedentary and light-intensity as well as vigorous- or m ­ oderate-intensity activities makes them an increasingly valuable tool. The inverse relationship between dose of vigorous- or moderate-intensity physical activity and reduced risk of adverse health outcomes clearly demonstrates that larger doses provide more health benefits. Selecting a single dose to recommend has been more difficult, especially for youth,

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Status and Trends of Physical Activity Behaviors and Related School Policies 43 because less research is available on this question, and the pattern of the dose-response curve is less well established (PAGAC, 2008). A composite of the findings for adults from 10 studies of regular physi- cal activity and all-cause mortality indicates a curvilinear relationship, with the risk of mortality decreasing as the dose of regular vigorous- or moderate-intensity physical activity increases (PAGAC, 2008; Powell et al., 2011) (see the figure below). Four points are worth noting about the dose-response curve. First, there is no lower threshold for benefit; some vigorous- or moderate-intensity physical activity is preferable to none. Second, the slope is steepest at the left side of the curve, suggesting that the most rapid reduction in risk occurs when the least physically active people become slightly more active. Third, there is no obvious best dose, making a range of doses (e.g., 150-300 minutes per week of vigorous- or moderate-intensity physical activity for adults) as in the current U.S. guidelines (PAGAC, 2008) preferable to a single dose. Fourth, at levels of activity commonly achieved in the general population, there is no upper threshold above which risk ceases to decline, although the rate of decline decreases. No Lower Threshold for Benefit 1 Steep Early Slope No Upper Threshold Relative Risk 0.5 Risk reduction for some No Obvious “Best” Amount conditions accrues more rapidly and for others more slowly 0 0 1 2 3 4 5 6 7 Hours/Week of Moderate- to Vigorous-Intensity Physical Activity Risk of all-cause mortality by hours per week of vigorous- or moderate- intensity physical activity. Figure for Box 2-2.eps SOURCE: Adapted from PAGAC, 2008. The available evidence indicates that the dose-response curves for the beneficial effect of regular vigorous- or moderate-intensity physical activ- continued

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44 Educating the Student Body BOX 2-2 Continued ity on the risk for type 2 diabetes, hip fracture, cardiovascular disease, coronary heart disease, stroke, depression, dementia, breast cancer, and colon cancer are similarly shaped (PAGAC, 2008) but with slightly differ- ent slopes (Powell et al., 2011); insufficient data are available with which to prepare similar dose-response curves for other health outcomes. Risk reduction accrues more rapidly for diabetes and hip fracture and less rap- idly for breast and colon cancer. Risk reduction for cardiovascular disease, depression, and dementia appears to be quite similar to the curve for all-cause mortality. These differences are not surprising given the wide variety of physiologic pathways through which regular physical activ- ity produces its various health benefits. The shape of the dose-response curve and the differences in the slopes of the curves for different health outcomes demonstrate the difficulty of identifying a specific dose or even a range of doses of vigorous- or moderate-intensity physical activity that should be recommended. cal activity that is enjoyable and developmentally appropriate” (Strong et al., 2005, p. 736). In 2008 the Physical Activity Guidelines Advisory Committee also reviewed the scientific evidence relating to physical activity and the health of children and adolescents (PAGAC, 2008). That commit- tee confirmed the benefits reported by the previous panel. The committee also agreed that it is difficult to select a minimal or optimal dose of physi- cal activity for youth but reaffirmed the recommendation for 60 minutes or more per day of vigorous or moderate physical activity. The committee further commented that weekly activity should include some vigorous activ- ity on at least 3 days and some activities to strengthen muscles and bones. Available information indicates that relatively few youth achieve a daily dose of at least 60 minutes of vigorous- or moderate-intensity physical activity. Information on the proportion of youth who are vigorously active on 3 or more days per week is not available. However, about 10 percent of middle and high school students responding to the Youth Risk Behavior Survey (YRBS), conducted by the CDC and state health departments, self-reported that on no days in the previous week did they spend at least 60 minutes doing vigorous- or moderate-intensity physical activity, about 50 percent reported doing so on at least 5 days, and about 30 percent

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Status and Trends of Physical Activity Behaviors and Related School Policies 45 reported meeting the recommended 7 days (CDC, 2012b) (see Figure 2-1). In a different ongoing national survey of 8th-, 10th-, and 12th-grade stu- dents—Monitoring the Future—fewer than half of students reported doing 60 or more minutes of vigorous activity every or almost every day (Delva et al., 2006). Results from surveys measuring physical activity with accelerometers and including younger children similarly suggest that few children, espe- cially older ones, meet the currently recommended volume of vigorous- or moderate-intensity physical activity. A study of accelerometer-measured physical activity among students in central Massachusetts found that almost all students in grades 1-6, but fewer than one-third of high school students, performed at least 60 minutes of vigorous- or moderate-intensity physical activity at least 5 days per week (Pate et al., 2002) (see Figure 2-2); the proportion of students meeting the 7-day recommendation would, of course, be lower. Also worth noting is that for high school students in this study, the accelerometer-estimated prevalence is about half the self-reported estimated prevalence for the same dose among students responding to the YRBS (see Figure 2-1). (See Box 2-3 on measuring physical activity.) Results of other surveys confirm the decline in vigorous- or moderate- intensity physical activity with age (Nader et al., 2008; Troiano et al., 2008). Figure 2-3 displays the mean number of minutes of vigorous- or m ­ oderate-intensity physical activity per day rather than the proportion who 60 50 40 Percentage 30 Middle School Students High School Students 20 10 0 No Days/wk 5 Days/wk 7 Days/wk FIGURE 2-1  Percentage of middle and high school students reporting they engaged in no days, 5 days, or 7 days per week of 60+ minutes of vigorous- or moderate-intensity ­physical activity. Figure 2-1.eps NOTE: The middle school estimate is the mean of 15 statewide surveys; the high school esti- mate is based on a nationwide sample. SOURCE: CDC, 2012b.

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86 Educating the Student Body (McCullick et al., 2012). Moreover, although elementary, middle, and high school students report meeting the national recommendation for minutes per week or per day of physical education, this may not be true in actual- ity. On the school schedule, the minutes allotted for physical education may be presented and reported, but the actual number of minutes in which students are engaged in physical education remains undocumented. Nor is it clear whether the time allotted for physical education was canceled or shortened on a weekly basis because of assemblies, disciplinary actions, or other school activities. Seldom are time allocations for physical educa- tion enforced or are schools held accountable for policy enforcement. Overall, policies requiring increased physical education and physical activity at school each day have the potential to affect large numbers of children and adolescents and are an effective strategy for promoting regular physical activity. However, external and internal barriers to policy imple- mentation need to be considered, as is highlighted by a recent study (Amis et al., 2012) finding that priority given to standardized testing and varsity sports over physical education, as well as insufficient resources and inunda- tion with new policy requirements, serve as barriers to successful implemen- tation of strong policies on physical activity. These findings are supported by results of a study conducted with California school board members (Cox et al., 2011), who cited most frequently as barriers to policy implementa- tion a lack of adequate funding; limited time during the school day; and competing priorities, such as core curriculum classes and standardized test- ing. (See the discussion of these issues in Chapters 5 and 6.) Existing evidence also shows some grade-level, racial/ethnic, and socio- economic disparities in participation in physical education across secondary schools (i.e., grades 8-12). Johnston and colleagues (2007) conducted a national study of 504 middle/junior high and high schools from a repre- sentative sample of geographic (urban/rural) and regional locations. The overall requirement for participation in physical education was found to drop sharply from 8th to 12th grade—87 percent in 8th grade, 47 percent in 10th grade, and 20 percent in 12th grade. The evidence also indicates a significant decrease in the minutes per week of physical education—from 172.3 minutes per week in 8th grade, to 163.9 minutes in 10th grade, to 88.6 minutes in 12th grade. The number of days per week on which stu- dents in 8th, 10th, and 12th grades receive physical education also was found to decline from 3.5 to 2.7 to 1.4 days, respectively. From 8th to 12th grade, moreover, the percentage of students taking physical education was found to be lower in schools attended by Hispanic students than in those attended by white students; no significant differences were found for African American students (Johnston et al., 2007). Johnston and colleagues also found that schools with a greater percentage of stu- dents of higher socioeconomic status were more likely to require students

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Status and Trends of Physical Activity Behaviors and Related School Policies 87 to take physical education and actually have students take it than schools with a greater percentage of students of lower socioeconomic status. These findings suggest that differences do exist in the provision of physical educa- tion across grades, race/ethnicity, and socioeconomic status in secondary schools. In general, however, data on differences in the percentage of stu- dents taking physical education by race/ethnicity and socioeconomic status are sparse. Thus while it is important that schools closely examine and address such disparities, there is also a need to examine these disparities more closely. Summary Few children in the United States, probably no more than half, meet the guideline of at least 60 minutes of vigorous- or moderate-intensity physi- cal activity daily. The reason this statistic cannot be more specific is that different measurement methods yield different estimates. Some consistent patterns can be reported, however. The proportion meeting the guideline declines with age, with more elementary school children than middle and high school students achieving the goal, and boys are more likely than girls to meet the guideline regardless of whether the information is self-reported or derived from objective measurement with accelerometers or pedometers. There are no consistent patterns across different racial/ethnic or socio­ economic groups, although fewer data are available with which to examine these issues. One can also say with reasonable certainty that over the past 30-40 years, probably even longer, the volume and intensity of daily physi- cal activity among youth have gradually declined. During about half of their waking hours, youth engage in activities with low rates of energy expenditure—1.5 METs or less—commonly called sedentary activities. Evidence is clear for adults and is accumulating for children that shifting time spent in sedentary activities to even light-intensi- ty physical activity is beneficial from a health perspective. Remarkably little information exists about the physical activity ­ behaviors of students during school hours or in school-related activities. Even the nation’s best public health surveillance systems do not obtain that information. Aside from a few good one-time surveys of physical activity during physical education classes, little information is available on students’ physical activity during the school day or in after-school programs. This lack of information is surprising given that school-related physical activ- ity must be a large component of the overall volume of physical activity among youth and that vigorous- or moderate-intensity physical activity is vital to students’ healthy growth and development and is associated with improved academic performance and classroom behavior (see Chapters 3 and 4). Substantial evidence exists that the volume of student’s vigorous- or

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88 Educating the Student Body moderate-intensity physical activity can be increased through daily physical education, recess, classroom physical activity, active transport to school, and before- and after-school activities (see Chapter 6). State- and district-level policies related to physical activity have the potential to exert a positive influence on the physical activity behaviors of large numbers of children and adolescents. Evidence that such policies have not only potential but actual influence is emerging. Also emerging is evi- dence of slippage between the intent and implementation of these policies, such that their ultimate impact is commonly less, sometimes appreciably so, than expected. The factors that create an effective policy are still being elucidated. Policies that include required reporting of outcomes, provision of adequate funding, and easing of competing priorities appear to be more likely to be effective, as well as implemented, compared with policies that lack these features. Further evaluation of policies on physical activity and physical education is needed to fully understand their impact in changing health behavior. Monitoring of state and district policies has improved over the past decade. In general, the number of states and districts with policies per- taining to physical education has increased, although many such policies remain weak. For example, most states and districts have policies regard- ing physical education, but few require daily physical education or a mini- mum number of minutes of physical education per week. Although some comprehensive national guidelines exist, more are needed to define quality standards for school-based physical activity policies so that more uniform programs and practices can be created across states, school districts, and ultimately schools. An important need going forward will be augmentation of the few monitoring systems that exist for school-related physical activity behaviors. It is important to know not only how much vigorous- or moderate-intensity physical activity youth are performing but also how much of that activity is taking place in each segment of the school day (i.e., physical education, recess, classroom, transport to and from school, school-related before- and after-school activities). The YRBS, the NHANES, and Monitoring the Future provide much useful information but not enough about physical activity during and related to school. Such national surveys are not designed to provide local or even state estimates. State departments of education, local school districts, and state and local health departments will need to collaborate to provide adequate monitoring. Finally, in addition to improved monitoring of physical activity behav- iors, there is a need for augmented monitoring of physical activity–related guidelines, policies, and practices at the federal, state, and local levels. Surveillance of both student behavior and policy is necessary.

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