EDUCATING THE
STUDENT BODY

Taking Physical Activity and
Physical Education to School

Committee on Physical Activity and Physical Education
in the School Environment

Food and Nutrition Board

Harold W. Kohl III and Heather D. Cook, Editors

INSTITUTE OF MEDICINE
            OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

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EDUCATING THE STUDENT BODY Taking Physical Activity and Physical Education to School Committee on Physical Activity and Physical Education in the School Environment Food and Nutrition Board Harold W. Kohl III and Heather D. Cook, Editors

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THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee respon- sible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Grant No. 69449 between the National Academy of Sciences and the Robert Wood Johnson Foundation. Any opinions, findings, conclu- sions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that pro- vided support for the project. International Standard Book Number-13:  0-978-0-309-28313-7 International Standard Book Number-10:  0-309-28313-2 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2013 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2013. Educating the student body: Taking physical activity and physical education to school. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general wel- fare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engi­ neers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its con- gressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences ­ in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The C ­ ouncil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON PHYSICAL ACTIVITY AND PHYSICAL EDUCATION IN THE SCHOOL ENVIRONMENT HAROLD W. KOHL III (Chair), Professor of Epidemiology and Kinesiology, School of Public Health, Division of Epidemiology, Human Genetics and Environmental Sciences, Michael & Susan Dell Center for Healthy Living, University of Texas Health Science Center-Houston, and Department of Kinesiology and Health Education, University of Texas at Austin Darla M. Castelli, Associate Professor, Department of Kinesiology and Health Education, University of Texas at Austin Ang Chen, Professor, Department of Kinesiology, University of North Carolina, Greensboro Amy A. Eyler, Assistant Professor, George Warren Brown School of Social Work, Program of Public Health, Washington University, St. Louis, Missouri Scott Going, Interim Department Head and Professor, Department of Nutritional Sciences, and Director, Center for Physical Activity and Nutrition, University of Arizona, Tucson Jayne D. Greenberg, District Director, Physical Education and Health Literacy, Miami-Dade County Public Schools, Miami, Florida Charles H. Hillman, Professor, Departments of Kinesiology and Community Health, Psychology, and Internal Medicine, Affiliate of the Neuroscience Program, Division of Nutritional Sciences, and the Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign Philip R. Nader, Professor Emeritus of Pediatrics, Department of Pediatrics, School of Medicine, University of California, San Diego Kenneth E. Powell, Retired Chief, Chronic Disease, Injury, and Environmental Epidemiology Section, Division of Public Health, Georgia Department of Human Resources, Atlanta Leah E. Robinson, Associate Professor, Department of Kinesiology, Auburn University, Alabama Emma Sanchez-Vaznaugh, Assistant Professor, Health Education Department, San Francisco State University, California Sandy Slater, Research Assistant Professor, Institute for Health Research and Policy, University of Illinois at Chicago Nicolas Stettler, Senior Managing Scientist, Health Sciences Center for Chemical Regulation and Food Safety, Exponent, Washington, DC v

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Gail Woodward-Lopez, Associate Director, Dr. Robert C. and Veronica Atkins Center for Weight and Health, University of California, Berkeley Study Staff Heather del valle cook, Study Director Lynn Parker, Scholar Emily Ann Miller, Program Officer (until January 2013) SARAH ZIEGENHORN, Research Assistant (from January 2013) Allison Berger, Senior Program Assistant anton L. bandy, Financial Associate geraldine kennedo, Administrative Assistant linda D. Meyers, Director, Food and Nutrition Board Consultant TERRY T-K HUANG, Professor and Chair, Department of Health Promotion, Social and Behavioral Health College of Public Health, University of Nebraska Medical Center, Omaha vi

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Andy Bindman, University of California, San Francisco James F. Bogden, National School Boards Association Catherine L. Davis, Georgia Regents University Russell R. Pate, University of South Carolina Stephen J. Pont, Seton Healthcare Family, Dell Children’s Medical Center of Central Texas, University of Texas Southwestern, Austin Programs Judith E. Rink, University of South Carolina Stephen W. Sanders, University of South Florida Cary R. Savage, University of Kansas Medical Center Mark B. Stephens, Uniformed Services University of the Health Sciences Katherine T. Thomas, University of North Texas, Denton vii

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viii Reviewers Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the report’s conclu- sions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Connie M. Weaver, Purdue University, and Caswell A. Evans, Jr., University of Illinois at Chicago. Appointed by the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface P o hysical activity is central to health, and its importance clearly extends beyond its role in achieving energy balance to prevent and treat ­ besity and overweight. Adequate daily physical activity improves cardio­ vascular health, metabolic health, brain and mental health, and musculo­ skeletal health—benefits that recent research shows are gained across the life span. Important emerging research has further focused on the association between physical activity in youth and academic achievement. Clinical and public health guidelines indicate that youth need a mini- mum of 60 minutes per day of vigorous- or moderate-intensity physical activity to optimize health and development. Because many youth spend a substantial amount of time in school, this report focuses specifically on the role schools can play in increasing physical activity among youth and providing opportunities to meet these guidelines. This role falls squarely within schools’ long-standing tradition of providing access to health-related services such as health screenings, nutrition programs, and immunizations. The assumption that school-based physical education can provide enough physical activity for children and adolescents has recently been challenged on a variety of fronts. First, the 60 minutes per day of physical activity that is health enhancing is nearly impossible to achieve through physical education, even with the highest-quality physical education cur- riculum. Second, quality physical education must include time for teaching activities and lessons that may not be physically active. Third, political and economic pressures on education systems to improve standardized test scores have had the unintended consequence of reducing or eliminating physical education curricula and thus students’ opportunities for physical ix

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x Preface activity. Therefore, the purpose of this report is to highlight the central need not only to provide quality physical education for all youth but also to implement other evidence-informed methods schools can use to help all children and adolescents attain a minimum of 60 minutes of vigorous- or moderate-intensity physical activity per day to improve health, develop- ment, and academic performance. Many different constituents—including federal, state, district, and school administrators; teachers; parents; and all those interested in the health, development, and academic achievement of youth—must be reached with the message that such a whole-of-school approach to physical activity is needed. Many people contributed to the successful completion of this project. First, the committee thanks Tina Kauh and the Robert Wood Johnson Foundation for supporting the study and the development of this report. The committee also wishes to thank participants in a public workshop held in September 2012 to gather expert opinion on this topic from leaders in the field: Michael Beets, Ph.D.; Becky Ciminillo; Don Disney, M.S., M.A.; Joseph Donnelly, Ed.D.; Erin Donoghue, M.Ed.; David Dzewaltowski, Ph.D.; Gillian Hotz, Ph.D.; Dolly Lambdin, Ed.D.; Melissa Maitin- Shepard, M.P.P.; Noreen McDonald, Ph.D.; Thomas McKenzie, Ph.D.; Lisa Perry, M.Ed; Shellie Pfohl, M.S.; Abby Rose, M.Ed., M.A.; and Jennifer A. Weber, M.P.H., R.D. In addition, in December 2012, Katrina L. Butner, Ph.D., spoke with the committee during an open session, and we would like to thank her for her time. I am most grateful to the volunteer expert committee members who so graciously gave time from their busy schedules to contribute to the comple- tion of this task over such a short time period. The efforts of each member were extraordinary. Further, I appreciate the extensive consultative ­ uidance g from Terry T-K Huang, Ph.D., M.P.H., C.P.H., of the University of Nebraska Medical Center. Dr. Huang’s understanding of systems thinking helped shape the committee’s approach and this report in an innovative way. This work could not have been completed without the outstanding support and guidance of the dedicated Institute of Medicine (IOM) staff, including Heather Del Valle Cook, study director; Lynn Parker, scholar; Emily Ann Miller, program officer; Sarah Ziegenhorn, research assistant; Allison Berger, senior program assistant; Sarah Sliwa, Christine Mirzayan Science and Technology Policy Fellow; and Linda Meyers, director of the IOM Food and Nutrition Board. Finally, the report greatly benefited from the copyediting skills of Rona Briere. I am grateful to each of these indi- viduals for their patience and focus during the study process. Harold W. Kohl III, Chair Committee on Physical Activity and Physical Education in the School Environment

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Contents SUMMARY 1 1 INTRODUCTION 15 Purpose of This Study, 16 Background and Study Context, 18 Study Approach, 21 Overview of the Report, 31 References, 32 2 STATUS AND TRENDS OF PHYSICAL ACTIVITY BEHAVIORS AND RELATED SCHOOL POLICIES 35 Physical Activity, 38 Status of Physical Activity Behaviors Among Youth, 38 Trends in Physical Activity Behaviors Among Youth, 63 State and Local Policies on School-Based Physical Activity, 69 Summary, 87 References, 89 3 PHYSICAL ACTIVITY AND PHYSICAL EDUCATION: RELATIONSHIP TO GROWTH, DEVELOPMENT, AND HEALTH 97 Physical Health, 101 Psychosocial Health, 130 Mental Health, 132 xi

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xii Contents Summary, 139 References, 141 4 PHYSICAL ACTIVITY, FITNESS, AND PHYSICAL EDUCATION: EFFECTS ON ACADEMIC PERFORMANCE 161 Physical Fitness and Physical Activity: Relation to Academic Performance, 163 The Developing Brain, Physical Activity, and Brain Health, 175 Limitations, 185 Summary, 186 References, 187 5 APPROACHES TO PHYSICAL EDUCATION IN SCHOOLS 197 Physical Education in the Context of Schooling, 199 Importance of Physical Education to Child Development, 215 Characteristics of Quality Physical Education Programs, 219 Policies That Affect the Quality of Physical Education, 234 Barriers to Quality Physical Education and Solutions, 240 Summary, 248 References, 249 6 APPROACHES TO PHYSICAL ACTIVITY IN SCHOOLS 259 Sedentarism in Schools, 261 Opportunities to Increase Physical Activity in the School Environment, 264 Summary, 300 References, 302 7 THE EFFECTIVENESS OF PHYSICAL ACTIVITY AND PHYSICAL EDUCATION POLICIES AND PROGRAMS: SUMMARY OF THE EVIDENCE 311 Systems Approaches: Multicomponent Programs and Interventions, 313 Programmatic/Policy Approaches and Their Outcomes, 317 Summary, 347 References, 350 8 RECOMMENDATIONS 365 Recommendations, 366 Future Research Needs and Areas for Additional Investigation, 377

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Contents xiii APPENDIXES A Acronyms and Glossary 381 B Methodology 395 C State Legislative Policies on Physical Education and Physical Activity 397 D Workshop and Panel Public Sessions 477 E Committee Member Biographical Sketches 481

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