Physical inactivity is a key determinant of health outcomes across the life span. A lack of activity increases the risk of heart disease, colon and breast cancer, diabetes mellitus, hypertension, osteoporosis, anxiety and depression, and other diseases. Recent studies have found that in terms of mortality the global population health burden of physical inactivity approaches that of cigarette smoking and obesity (Lee et al., 2012). Indeed, the prevalence of physical inactivity, along with this substantial associated disease risk, has been described as a pandemic (Kohl et al., 2012). Further, higher educational achievement and years of schooling are both markers and determinants of better health status, mainly as a result of education’s correlation with improved work and economic conditions, enhanced social psychological resources, and the ability to pursue a healthful lifestyle (Ross and Mirowsky, 1999). There is a long-held belief that health is an important determinant of educational performance, yet only recently has evidence begun to accumulate on a plausible physiologic pathway explaining the influence of one important health behavior—physical activity—on brain function and cognitive processes (see Chapter 4). These data increase confidence that improving physical activity and fitness may result in better school achievement and performance.
Although complete data are lacking, the best estimate in the United States is that no more than half of youth meet the current evidence-based guideline of at least 60 minutes of vigorous- or moderate-intensity physical activity daily (CDC, 2012). Moreover, the proportion of youth who meet this guideline declines with advancing age, so that younger children are more likely to do so than adolescents (Pate et al., 2002). Daily opportunities
for incidental physical activity also have declined for children and adolescents, as they have for adults, as the result of such factors as increased reliance on nonactive transportation, automation of activities of daily living, and greater opportunities for sedentary behavior. In addition, significant disparities in physical activity exist across racial/ethnic and socioeconomic lines (see Chapter 2).
The prevalence and health impacts of physical inactivity, together with evidence indicating its susceptibility to change, have resulted in calls for action aimed at increasing physical activity across the life span. A common belief is that, the earlier in life this important health behavior can be ingrained, the greater the impact will be on lifelong health. The question becomes, then, how physical activity among children and adolescents can be increased feasibly, effectively, and sustainably to improve their health, both acutely and throughout life. A recent report of the Institute of Medicine (IOM), Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation, singles out schools as “a focal point for obesity prevention among children and adolescents,” stating: “Children spend up to half their waking hours in school. In an increasingly sedentary world, schools therefore provide the best opportunity for a population-based approach for increasing physical activity among the nation’s youth” (IOM, 2012, p. 333).
Given the importance of physical activity to health in youth and increasing attention to its role in educational performance, coupled with the potential of schools to provide opportunities to be physically active, a 14-member ad hoc committee of the IOM was convened and charged to review the current status of physical activity and physical education in the school environment. The committee was also tasked with reviewing influences of physical activity and physical education on the short- and long-term physical health, cognition and brain health, and psychosocial health and development of children and adolescents. The committee was asked to make recommendations, as appropriate, regarding approaches for strengthening and improving programs and policies for physical activity and physical education in the school environment, including before, during, and after school. In doing so, the committee was expected to review the current status of physical activity and physical education in the school environment; review evidence on the relationship between physical activity, physical education, or physical fitness and physical, cognitive and brain, and psychosocial health and development; within a life-stage framework, consider the role of physical activity– and physical education–related programs and policies in the school environment in contributing to short- and
long-term health, health behaviors, and development (e.g., motor and cognitive development); recommend, as appropriate, strategic programmatic, environmental, and policy approaches for providing, strengthening, and improving physical activity and physical education opportunities and programs in the school environment, including before, during, and after school; and, as evidence was reviewed, identify major gaps in knowledge and recommend key topic areas in need of research.
Key Terms Used in This Report
Academic Learning Time (ALT)-physical education (PE): A measure used to assess quality physical education instruction. ALT-PE is the time in physical education class during which children are exposed to motor skill development, understanding of movement principles, attainment of health-enhancing levels of fitness, regular engagement in physical activity, socially responsible behaviors in physical activity settings, and an appreciation of the importance of engagement in physical activity.
Active transport: Modes of transportation to and from school that involve physical activity; includes primarily walking and biking.
Classroom physical activity: Opportunities for physical activity integrated into classroom lessons.
Developmentally appropriate physical activity: Physical activity that meets/includes the following criteria: (1) an orderly sequence of motor skills learning, (2) provisions for individual differences, (3) appropriate goal structures, and (4) ample learning time.
Exercise: Planned, structured, and repetitive activity designed to target a particular outcome (e.g., a component of fitness).
Extramural sports: Organized and supervised sports programs sanctioned by the school system that provide opportunities for competition outside the bounds of a particular school.
Intramural sports: Organized and supervised sports programs involving within-school teams and clubs that provide opportunities for all students to participate.
Moderate-intensity physical activity: Physical exertion that is equivalent to brisk walking. Such activities are usually performed at between 3.5 and 6.0 times resting metabolic rate.
Physical activity: Bodily movement that increases energy expenditure.
Physical activity breaks: Brief opportunities for physical activity provided throughout the day, such as during morning announcements.
Physical education: A planned sequential K-12 standards-based program of curricula and instruction designed to develop motor skills, knowledge, and behaviors of healthy active living, physical fitness, sportsmanship, self-efficacy, and emotional intelligence.
Physical fitness: A set of physiologic attributes that are either health related or skill related. Physical fitness is an adaptive physiologic state that varies with growth and maturity status and physical activity.
Recess: A regularly scheduled period within the school day for supervised physical activity and play.
Vigorous-intensity physical activity: Physical exertion that leads to sweating and heavy breathing, such as running, basketball, soccer, and swimming laps; usually performed at or above an intensity of 6.0 times resting metabolic rate.
Since before the early 1900s, schools have had a role in providing health care for youth (IOM, 1997). From the single school nurse performing inspections and injury treatment to the provision of screening, health education, and immunizations to today’s school-based health centers, schools have been important in providing health services to children. Throughout the history of school-based health care, access to children for large portions of the day has made schools practical and effective in providing these services (IOM, 1997). With the emergence of obesity as a key health threat for youth, schools are yet again being called on to take a lead role in the health of students.
As noted above, physical activity is an essential component of proximal and distal health indicators in youth (see Chapter 3). Recent efforts have led to an evidence-based guideline for physical activity in youth of at least 60 minutes per day, 7 days per week (Strong et al., 2005; Physical Activity Guidelines Advisory Committee, 2008) (see Box 1-1). Most of the 60 minutes per day should be spent in vigorous- or moderate-intensity activities. Further, vigorous physical activities, bone-strengthening activities, and muscle-strengthening activities should be included at least 3 days each week. Such activities should offer variety, be enjoyable, and be age appropriate.
Schools have long provided opportunities for physical activity to children and adolescents, most notably through physical education. Early school-based physical education efforts in the 19th century focused largely
Physical Activity Guidelines for Americans: Active Children and Adolescents
Children and adolescents should perform 60 minutes (1 hour) or more of physical activity daily.
Aerobic: Most of the 60 or more minutes per day should be either moderate- or vigorous-intensity aerobic physical activity and should include vigorous-intensity physical activity at least 3 days per week.
Muscle-strengthening: As part of their 60 or more minutes of daily physical activity, children and adolescents should include muscle-strengthening physical activity on at least 3 days of the week.
Bone-strengthening: As part of their 60 or more minutes of daily physical activity, children and adolescents should include bone-strengthening physical activity on at least 3 days of the week.
It is important to encourage young people to participate in physical activities that are appropriate for their age, that are enjoyable, and that offer variety.
SOURCE: HHS, 2008.
on hygiene, gymnastics, performance in sports and games, and (later) military readiness (IOM, 2012). A focus on physical education for health and fitness subsequently emerged, gradually taking hold in the middle of the 20th century (IOM, 1997). Quality school physical education has been recommended as an evidence-based strategy to increase physical activity among youth (Task Force on Community Preventive Services, 2005). Physical education thus has a long history of being a central foundation for health, development, and learning in schools.
Despite the effectiveness of quality physical education (whereby students have an opportunity to learn meaningful content with appropriate instruction and assessments) in increasing physical activity, challenges exist to its equitable and effective delivery. Fiscal pressures, resulting in teacher layoffs or reassignments and a lack of equipment and other resources, can inhibit the offering of quality physical education in some schools and districts. Schools may lack trained physical educators, and safety issues are associated with allowing children to play. Educators and policy makers may lack awareness and understanding of the potential for physical activity to improve academic achievement and the many ways in which physical activity can be and has been successfully incorporated into the school environment. The role of school physical education in providing physical activity for youth is further challenged by a demand for better standardized test scores by increasing classroom academic time and the ensuing policy pressures to do so. Nearly half of school administrators report cutting significant amounts of time from physical education, art, music, and recess to increase time in reading and mathematics since passage of the No Child Left Behind Act in 2001. These challenges have been cited as reasons why the percentage of schools offering physical education daily or at least 3 days each week declined dramatically in U.S. schools between 2000 and 2006 (GAO, 2012).
Children and adolescents engage in different types and patterns of physical activity as the result of a variety of factors, including age and access to resources. Exercise capacity in children and the activities in which they can successfully engage change in a predictable way across developmental periods. Young children are active in short bursts of free play, and their capacity for continuous activity increases as they grow and mature. In adults and likely also adolescents, improved complex motor skills allow for more continuous physical activity, although intermittent exercise offers much the same benefit as continuous exercise when the type of activity and energy expenditure are the same. While the health benefits of sporadic physical activity at younger ages are not well established, children require frequent opportunities for practice to develop the skills and confidence that promote ongoing engagement in physical activity. Physical education curricula are structured to provide developmentally appropriate experiences that
build the motor skills and self-efficacy that underlie lifelong participation in health-enhancing physical activity, and trained physical education specialists are uniquely qualified to deliver them.
In the best-possible scenario, however, physical education classes are likely to provide only 10-20 minutes of vigorous- or moderate-intensity physical activity per session. Physical education, then, although important, cannot be the sole source of the at least 60 minutes per day of vigorous- or moderate-intensity physical activity recommended to enhance the health of children and adolescents. Other ways to promote physical activity in youth must be systematically exploited to provide physical activity opportunities. Family, neighborhood, and community programs can be a source of such additional opportunities. Moreover, other school-based opportunities, including intramural and extramural sports programs, active transport to and from school, classroom physical activity breaks, recess, and before- and after-school programming, all can help youth accumulate the recommended 60 or more minutes per day of physical activity. Recent policy guidance from the National Association of State Boards of Education suggests such an integrated approach (NASBE, 2012).
Although family and community settings are helpful, schools provide a unique framework for physical activity opportunities because of the tremendous opportunity to contact many students multiple times. According to estimates of the U.S. Census Bureau, more than 51 million children aged 5-17 were enrolled in U.S. public schools in 2010; an additional 5.5 million were enrolled in U.S. private schools. Thus, an estimated 96-98 percent of the entire population in this age group was enrolled in an institutional school. Youth spend up to 7 hours each school day in school. Moreover, recent figures suggest that 15 percent of students across all grades attend an after-school program, and 38 percent of parents whose children do not attend such a program say their children would do so if they had access (Afterschool Alliance, 2009). These data, together with the role of schools in health promotion for youth, suggest that more can be done to leverage schools to help children meet the recommendation for at least 60 minutes per day of physical activity.
The committee recognized that, although physical education and physical activity in the school setting are primarily the responsibility of the education system, schools alone cannot implement the changes across systems required to achieve a healthy and educated future generation. Accomplishing these changes will demand systems approaches influenced by the social and cultural, economic, and physical environments, as well as the drivers of local, state, and national policies (see Figure 1-1).
FIGURE 1-1 Context for physical activity and physical education in the school environment.
Changes in a single venue or sector or at a single level or those that are uncoordinated are unlikely to be effective and will do little to effect long-term improvement. Interactions among and between the local school or district and eight additional sectors will be required to achieve the desired outcomes: (1) home and family; (2) transportation, land use, and community design; (3) volunteer and nonprofit community organizations; (4) business and industry; (5) parks, recreation, and sports; (6) neighborhood resources, including safety; (7) health care and public health; and (8) media and communications. These sectors traditionally have operated independently and have not communicated effectively. All, however, share a stake in and responsibility for working to change the conditions that pro-
mote the status quo of decreasing physical activity and increasing sedentary behavior among the nation’s youth.
A Systems Approach
A challenge in current efforts to address the problem of physical inactivity among youth has been an unbalanced attention to individualized behavior change strategies instead of a true public health approach that requires systems thinking (Kohl et al., 2012) (see Box 1-2 for a definition of systems thinking). A systems approach posits that schools may act as a focal point but alone cannot accomplish the task of increasing and sustaining physical activity in youth because multiple systems and sectors in society influence the adoption of an active healthy lifestyle. A systematic review of recent obesity prevention interventions (Krishnaswami et al., 2012) found a significant correlation between engagement with the community and intervention outcomes. Capacity building, needs assessments, dissemination
What Is Meant by Systems Thinking?
A systems approach
• explicitly designs strategies to focus on interactions and interconnections (integration) between and among different sectors in the community and between individuals and their community environment;
• accounts for the context and characteristics of a community in planning intervention strategies in order to see the whole picture so that intended and unintended consequences of strategies can be recognized and the strategies altered if required;
• utilizes a multidisciplinary approach, including community experts, to determine the interactions among systems and sectors necessary to develop feasible interventions that will be sustainable (persistence of changes made and ongoing adoption of new ones) and scalable (capable of being brought to scale to impact many settings) and have reach across cultural and language population subgroups.
of results, and durable partnerships among different sectors can improve health outcomes.
Increasing societal demand for and ingraining values that support a healthier environment and population requires direct engagement and alignment of the priorities of multiple sectors, including those displayed earlier in Figure 1-1. A systems approach in public health requires identifying key actors that can effect change. Within the local education sector, the actors that can influence physical activity and physical education opportunities for children and adolescents include school board members, superintendents, principals, administrators and coordinators of curricular areas and evaluation, school physical education and pupil services, security, and transportation programs. Parent-teacher organizations and school health advisory councils also are part of a systems perspective on the problem.
To capture the systems perspective on increasing physical activity among children and adolescents, it is important to recognize that efforts must go beyond physical education curricula or physical activity programs per se (see Figure 1-2). Components of an intervention should explicitly and directly impact elements of the support infrastructure (at both the school and community levels) that enables high-quality physical education and meaningful opportunities for physical activity throughout the school day. Investments in the support infrastructure should ensure that its elements are well aligned and integrated (i.e., work synergistically) to achieve the goals of school curricula and programs. In addition, opportunities for physical activity throughout the school day should be cohesively designed to bring about a culture of active living and the value of wellness. Finally, the support infrastructure should enable accountability of physical education cur-
FIGURE 1-2 Integrated/coordinated approach to increasing physical activity among children and adolescents in the school environment before, during, and after school.
NOTE: PA = physical activity; PE = physical education.
ricula and physical activity programs. In turn, these curricula and programs should be monitored and evaluated to inform iterative improvements to the overall system.
As part of its systems approach, the committee acknowledged that much of what happens in the school setting is part of an overall system of policies and regulations at multiple levels (see Figure 1-3). The center of interest is students’ physical activity opportunities and experiences. Such opportunities include physical education, intramural and extramural sports, active transport to and from school, classroom physical activity, recess, before- and after-school programs, and other types of breaks. These opportunities and experiences are influenced by a series of federal guidelines, state laws, district policies, and school and classroom policies and practices. The impact of this set of guidelines, laws, policies, and practices is influenced in part by any accompanying assistance or incentives and by whether means of enforcement are in place. In other words, guidelines, laws, and policies
FIGURE 1-3 Influence of policy level and strength of implementation on student experience.
NOTE: Arrow weight indicates no implementation, weak implementation, and strong implementation (thin to thick); box shade indicates no law or policy, weak law or policy, and strong law or policy (light to dark).
are more likely to be properly implemented if there are aids and rewards (e.g., funding, training) for doing so and penalties (e.g., less funding, less job security) for not doing so. The varying strengths of influence are depicted in Figure 1-3 by the varying thicknesses of the arrows exiting each level of influence (i.e., federal, state, district, school, classroom). Figure 1-3 also acknowledges other influences, such as other and sometimes competing policies issuing from the same organizational level; competing interests; or a lack of funding, personnel, or space. The arrows veering toward the empty space at the edges of Figure 1-3 indicate that at every level there is likely to be slippage. One study found, for example, that seven of eight high schools in Mississippi and Tennessee had entirely avoided implementation of new state legislation designed to increase levels of physical activity and improve the quality of physical education in high schools. The main barriers to implementation at these schools were the priority given to standardized testing, subordination of physical education to varsity sports, resource constraints, and policy overload (Amis et al., 2012).
Figure 1-3 also suggests that monitoring (surveillance) of federal guidelines, state laws, district policies, and school and classroom policies, plus related incentives and enforcements, is important. Monitoring of students’ physical activity opportunities and experiences is essential because they represent the ultimate outcome of importance, and barriers may have derailed implementation (Amis et al., 2012).
A systems approach demands analysis of existing and potential practical program and policy interactions among the sectors and individuals outlined above, interactions that are necessary for the optimal impact on physical activity. A process of aligning priorities among disparate sectors should lead to new types of intersectoral interactions. These new interactions can potentially produce greater synergistic effects than independent within-sector efforts. Such synergies can in turn allow for opportunities to pool and share resources. For example, synergies that lead to combining efforts in the education and transportation sectors may be more likely to create a sustainable and effective program that promotes active transportation to and from school than such a program implemented only within the education sector. Developing these approaches in a place-based framework will allow for tailoring interventions, taking into account the strengths and constraints, cultural and demographic characteristics, and resources of each local context. The outcomes achieved must be sustainable (persistence of changes made and ongoing adoption of new ones) and scalable (diffusion across settings) and have reach across population subgroups.
Early in this study the committee formulated a set of principles that guided its deliberations and its consideration of recommendations:
• Instilling lifelong physical activity in children and adolescents is crucial to the current and future health of the nation, and its long-term benefits should be recognized.
• Systems thinking is needed to develop recommendations for improving physical activity and physical education opportunities in schools in the context of children’s and adolescents’ development, family, home, culture, and community. Unintended consequences, accelerants, barriers, and other factors should be considered.
• Disparities in physical activity and physical education opportunities exist, and their elimination should be a priority in any recommendations for school-based efforts.
• The committee should consider all types of school environments in formulating its recommendations.
• The committee should consider student diversity, including gender, culture, religion, education, resources, and physical ability, in developing its recommendations.
• The committee should consider the practicality of implementation and existing school resources in making its recommendations. In addition, it should consider the challenges and barriers faced by policy makers, principals, teachers, parents/guardians, students, and other stakeholders.
• The committee should base its recommendations on the best-available scientific evidence and promising approaches.
The committee developed a conceptual framework for its work plan and its deliberations (see Figure 1-4). In this framework, the proximal and distal outcomes of most interest for this study are measures of academic performance and indicators of health and development in youth. Leading to these two ultimate outcomes of interest are several layers of determinants, programs, and intermediate outcomes reviewed by the committee. At the base of Figure 1-4 are key supports for the multiple programmatic and policy approaches to improving physical activity and physical education in schools.
Although the central programmatic approach to physical activity in schools remains the physical education curriculum, the committee conceptualized multiple additional opportunities, including intramural and
FIGURE 1-4 Conceptual framework for physical activity and physical education in the school environment.
NOTE: The framework applies to all opportunities for physical activity and physical education on K-12 school campuses before, during, and after school, including before- and after-school programming.
aFor example, professional development/credentials, staffing, class size, class/program length and frequency, curricula/instructional materials, equipment, supervision, use of class time (vigorous- and moderate-intensity physical activity), use of technology.
bEach approach can occur before, during, or after school.
extramural sports, active transport to and from school, classroom physical activity, before- and after-school programs, recess, and other types of breaks. (Although the framework applies to all opportunities for physical activity and physical education on K-12 school campuses before, during, and after school, including onsite preschool and after-school programming, summer was not considered independently.)
Factors affecting a program’s impact toward achievement of the ultimate outcomes include the quality (fidelity) of implementation, the scalability of the program (its ability to move beyond an individual school or class to affect a broader population of schools and youth), and the reach of the program—whether it is available to all students and is unaffected by potential disparities. Finally, the committee believed that sustainability was a critical factor to consider, an issue that is central to the systems thinking that guided its deliberations.
In addressing its charge, the committee identified more than 1,000 articles and reports from the peer-reviewed published literature and from organizations relevant to physical education, physical activity, and health. The focus of the literature review was on gathering available evidence on (1) the influences of physical activity and physical education on the short-and long-term physical, cognitive and brain, and psychosocial health and development of children and adolescents and (2) potential physical activity and physical education policies and programs.
The literature search strategy generated search terms based on the committee’s conceptual framework. The initial search strategy paired the terms physical education and physical activity with terms related to themes, including academic achievement, brain development, classrooms, disparities, fitness, intra- and extramural sports, joint-use agreements, mental health, out-of-school time, policy, psychosocial health, recess, sedentary activity, school financing, somatic growth, transport, and weight. Searches were typically limited to U.S. populations and to children and adolescents, with the exception of studies examining the long-term and adult health benefits of childhood activity. See Appendix B and the references in Chapters 2 through 7 for more details on the methodology used and the evidence identified.
A Whole-of-School Approach
School and community policy and regulatory environments impact both the health and learning of children and youth. The “healthy schools” and “healthy communities” initiatives in various countries around the
world, following guidance from the World Health Organization, have placed major emphasis on attempting to create school and community environments that support both physical and psychosocial health (Samdel and Rowling, 2013). In the United States, local “wellness policies” have been mandated for schools receiving U.S. Department of Agriculture support for food and nutrition programs. Recently, these policies have been strengthened, leading to potential new systems of accountability for how healthy the school environment is for both children and staff (Belansky et al., 2009; Schwartz et al., 2009).
Early in its deliberations, the committee defined a whole-of-school approach for physical activity and physical education. In this approach, each opportunity for physical activity that can be tied to school grounds and facilities can be considered together. As seen in Figure 1-5, such an approach can realistically be expected to provide nearly the full 60 minutes or more of recommended health-enhancing physical activity on school days. Figure 1-5 also reflects the description of programmatic and policy approaches in the committee’s conceptual framework (see Figure 1-4).
The committee recommends a whole-of-school approach to physical activity promotion. Under such an approach, all of a school’s components and resources operate in a coordinated and dynamic manner to provide access, encouragement, and programs that enable all students to engage in vigorous- or moderate-intensity physical activity 60 minutes or more each day. A whole-of-school approach encompasses all segments of the school day, including travel to and from school, school-sponsored before-and after-school activities, recess and lunchtime breaks, physical education,
FIGURE 1-5 Comprehensive approach to school-wide physical activity promotion.
SOURCE: Beets, 2012. Reprinted with permission from Michael Beets.
and classroom instructional time. Beyond the resources devoted to quality daily physical education for all students, other school resources, such as classroom teachers, staff, administrators, and aspects of the physical environment, are oriented toward physical activity. Intramural and extramural sports programs are available to all who wish to participate, active transportation is used by substantial numbers of children to move from home to school and back again, recess and other types of breaks offer additional opportunities for physical activity, and lesson plans integrate physical activity as an experiential approach to instruction.
A whole-of-school approach encompasses all people involved in the day-to-day functioning of the school, including students, faculty, staff, and parents. It creates an atmosphere in which physical activity is appreciated and encouraged by all these groups. School buildings, outdoor grounds and playgrounds, indoor and outdoor equipment, and streets and pathways leading to a school from the surrounding neighborhood encourage and enable all persons to be more physically active. Moreover, a school is part of a larger system that encompasses community partnerships to help these goals be realized.
Development of Recommendations
The committee’s approach to developing its recommendations was informed by the systems approach and guiding principles outlined above. A consensus process was used to develop and review the overarching recommendations presented in Chapter 8. In addition, committee members discussed areas for research that, if pursued, would advance the field of physical activity and physical education in schools to further the evidence base.
The remainder of this report is organized into seven chapters. Chapter 2 describes the status and trends of physical activity behaviors and related school policies. Chapters 3 and 4, respectively, describe health and development outcomes and academic and cognitive outcomes associated with physical activity and physical education. Chapter 5 provides an overview and discussion of physical education programs and policies in schools, including what a quality program looks like. Chapter 6 presents an overview and discussion of physical activity programs and policies in schools. Chapter 7 summarizes the evidence for the effectiveness of physical activity and physical education programs and policies. Finally, Chapter 8 provides the committee’s recommendations. Appendix A is a glossary of acronyms and terms used in the report, Appendix B provides a detailed description of the study’s methodology, Appendix C provides a summary of data extracted from the
National Association of State Boards of Education’s State School Health Policy Database, Appendix D contains the agenda for workshops held to inform the committee’s deliberations, and Appendix E presents biographical sketches of the committee members.
Afterschool Alliance. 2009. America after 3pm: The most in-depth study of how America’s children spend their afternoons. Washington, DC: Afterschool Alliance.
Amis, J. M., P. M. Wright, B. Dyson, J. M. Vardaman, and H. Ferry. 2012. Implementing childhood obesity policy in a new educational environment: The cases of Mississippi and Tennessee. American Journal of Public Health 102(7):1406-1413.
Beets, M. W. 2012. Before- and after-school physical activity programs including intra-and extramural sports: Challenges and opportunities. Presented at the Workshop on Physical Activity and Physical Education in Schools: Perspectives on Successes, Barriers, and Opportunities, September 20, Washington, DC.
Belansky, E. S., N. Cutforth, E. Delong, C. Ross, S. Scarbro, L. Gilbert, B. Beatty, and J. A. Marshall. 2009. Early impact of the federally mandated local wellness policy on physical activity in rural, low-income elementary schools in Colorado. Journal of Public Health Policy 30(Suppl 1):S141-S160.
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IOM (Institute of Medicine). 1997. Schools & health: Our nation’s investment. Washington, DC: National Academy Press.
IOM. 2012. Accelerating progress in obesity prevention: Solving the weight of the nation. Washington, DC: The National Academies Press.
Kohl, H. W., C. L. Craig, E. V. Lambert, S. Inoue, J. R. Alkandari, G. Leetongin, and S. Kahlmeier. 2012. The pandemic of physical inactivity: Global action for public health. Lancet 380(9838):294-305.
Krishnaswami, J., M. Martinson, P. Wakimoto, and A. Anglemeyer. 2012. Community-engaged interventions on diet, activity, and weight outcomes in U.S. schools: A systematic review. American Journal of Preventive Medicine 43(1):81-91.
Lee, I. M., E. J. Shiroma, F. Lobelo, P. Puska, S. N. Blair, and P. T. Katzmarzyk. 2012. Effect of physical inactivity on major non-communicable diseases worldwide: An analysis of burden of disease and life expectancy. Lancet 380(9838):219-229.
NASBE (National Association of State Boards of Education). 2012. A school health policy guide: Fit, healthy, and ready to learn. In Chapter D: Policies to promote physical activity and physical education, 2nd ed., edited by J. F. Bogden, M. Brizius, and E. M. Walker. Arlington, VA: NASBE.
Pate, R. R., P. S. Freedson, J. F. Sallis, W. C. Taylor, J. Sirard, S. G. Trost, and M. Dowda. 2002. Compliance with physical activity guidelines: Prevalence in a population of children and youth. Annals of Epidemiology 12(5):303-308.
Physical Activity Guidelines Advisory Committee. 2008. Physical Activity Guidelines Advisory Committee report. Washington, DC: HHS.
Ross, C. E., and J. Mirowsky. 1999. Refining the association between education and health: The effects of quantity, credentials, and selectivity. Demography 36(4):445-460.
Samdel, O., and L. Rowling, eds. 2013. The implementation of health promoting schools: Exploring the theories of what, why and how. London and New York: Routledge.
Schwartz, M. B., A. E. Lund, H. M. Grow, E. McDonnell, C. Probart, A. Samuelson, and L. Lytle. 2009. A comprehensive coding system to measure the quality of school wellness policies. Journal of the American Dietetic Association 109(7):1256-1262.
Strong, W. B., R. M. Malina, C. J. Blimkie, S. R. Daniels, R. K. Dishman, B. Gutin, A. C. Hergenroeder, A. Must, P. A. Nixon, J. M. Pivarnik, T. Rowland, S. Trost, and F. Trudeau. 2005. Evidence based physical activity for school-age youth. Journal of Pediatrics 146(6):732-737.
Task Force on Community Preventive Services. 2005. Physical activity. In The guide to community preventive services: What works to promote health?, edited by S. Zaza, P. A. Briss, and K. W. Harris. Atlanta, GA: Oxford University Press. Pp. 80-113.