• 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
activity throughout the day, including during physical education, recess, instructional classroom time, and before- and after-school opportunities.
• In addition to physical education, recess can provide an opportunity 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 lessons may contribute to reduced sedentary time during the school day and increase the amount of light- and moderate-intensity activity among students.
• Together, regular and quality physical education, recess, and physical activity in the classroom setting enable students to be more physically active during school hours and significantly contribute to recommended 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 outside 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 socioeconomic status. Additional research is needed to document any differential 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 interventions to fit the wide social and physical variations among schools.
An 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 increasing 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 interpreted with caution but not altogether discounted. Definitive evidence on effectiveness 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 making, which involves drawing on existing research and surveillance systems, is growing and is especially relevant to the study of the impacts and outcomes of the approaches presented in this chapter.
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 behavior within the school setting. Integrating students and key players such as school and administrative personnel with the school and classroom environments and all levels of policy may be the best way to influence sustainable changes in population-level physical activity behaviors.
According to a recently released report (HHS, 2013), multicomponent school-based approaches, which usually include enhanced physical education in conjunction with other forms of school-related physical activity,
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 evidence vary greatly (Salmon et al., 2007; Naylor and McKay, 2009; Craggs et al., 2011). Perhaps one of the most notable examples of a multicomponent intervention is the Child and Adolescent Trial for Cardiovascular
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 recognized, 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 careful 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.
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 component. 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 evidence 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 physical 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 community 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 activity 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 interventions 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
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 demonstrated 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 compared 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 compared with those who had not participated (Nader et al., 1999).
Such multicomponent, whole-of-school approaches for increasing physical 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 program champion; and adequate administrative support and resources, such as sufficient funding for materials and equipment.
(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 activity in youth often adhere to systems thinking and can be effective and sustained 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 disseminated to the fullest extent.
This section reviews programmatic and policy approaches for increasing 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.
Status and Trends
No national data are available concerning population-level trends over time in enrollment and daily attendance in physical education, overall physical activity in physical education classes, or the amount of time spent in vigorous- or moderate-intensity physical activity during physical education 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 moderate-intensity physical activity—far short of national recommendations—in physical education (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 patterns 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 significantly from 41.6 percent in 1991 to 25.4 percent in 1995, with no significant 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 percent 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
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 minutes 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 participation in physical education classes among high school students (Lowry et al., 2009).
All youth should engage in physical education and meet the recommended 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 socioeconomic 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 differences 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 physically 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,
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 lesson 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 during 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
a significantly higher amount of self-reported daily vigorous activity compared 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 control 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 likelihood 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 necessarily 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 adolescents to attain the recommended levels of daily vigorous- or moderate-intensity physical activity; the classes also do not reach the goal of 50 percent 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, immigration status, and socioeconomic status.
Students are more likely to meet physical education learning standards if taught by certified physical education teachers.
Similarly, other cross-sectional studies have documented significant associations between policies designed to increase physical activity and/or regulate physical education and greater frequency of physical education classes (from 2.0 days in 2004-2005 to 3.7 in 2006-2008), more time in structured physical activity and self-reported physical activity among students in middle schools (Barroso et al., 2009), and overall physical activity in female high school students nationwide (Cawley et al., 2007).
A systematic review of 13 studies concerning physical activity policies and legislation in schools (including physical education policies) found that the majority of the studies focused on policy implementation (Robertson-Wilson et al., 2012). To date, only a handful of studies have evaluated impacts of mandates requiring 150 minutes of physical education per week (Slater et al., 2012) on student activity levels (Cawley et al., 2007; Barroso et al., 2009).
Are Policies the Answer? Although state and local physical education mandates exist, they vary in content and scope and almost always lack adequate implementation and evaluation. A “top-down” federal-level mandate could help guide a collective effort in addressing the prevalence of childhood inactivity.
Impact on Other Outcomes
Fitness Physical fitness (such as aerobic capacity or maximal oxygen consumption [VO2max]) is a marker of successful interventions addressing physical activity (Dobbins et al., 2009). In a physical education intervention study in middle schools, Dorgo and colleagues (2009) observed that the experimental groups improved significantly on the six fitness measures used and showed greater improvements than the control group on most fitness measures at 9 and 18 weeks.
In the SPARK study, which aimed to increase physical activity in physical education classes, Sallis and colleagues (1997) found that, compared
with girls in the control condition, girls in the specialist-led condition were superior on abdominal strength, endurance, and cardiorespiratory endurance after the 2-year intervention period. Consistent with the findings presented above, a review of interventions focused primarily in school settings found good evidence that school-based physical activity interventions had positive effects on physical fitness (measured by VO2max) among adolescents aged 6-18 (Dobbins et al., 2009). Similarly, in an earlier systematic review, Kahn and colleagues (2002) concluded that strong evidence supports the effectiveness of school-based physical education in increasing physical fitness levels, as measured by aerobic capacity. Compliance with physical education policies appears to be important as well. In a cross-sectional observational study of elementary public schools in California, investigators found that school district compliance with state physical education policies was related to a greater likelihood of children being classified as meeting or exceeding fitness standards relative to students in districts that failed to comply with the physical education policy (Sanchez-Vaznaugh et al., 2012). The study also found that the favorable association between compliance with physical education policy and children’s fitness levels did not differ significantly by race/ethnicity, with all groups being more likely to be classified as meeting or exceeding fitness standards if they attended school in districts that complied with the state’s physical education policy; however, the level of the association was significant only among white and Hispanic children.
Evidence is limited concerning the effects of school-based physical activity and physical education interventions, including policies on physical activity and fitness levels, across subgroups of children based on gender, race/ethnicity, immigrant generation, or socioeconomic status.
Body mass index (BMI)/weight status The relationship between physical activity and children’s body weight has been studied in several reviews of school-based interventions designed to increase physical activity overall and during physical education in particular. Reviewing 25 school-based intervention studies that addressed diet or activity behaviors and used anthro-pometric outcomes, investigators found that 65 percent of the interventions were effective, reporting a statistically significant reduction in BMI and skinfold measures for at least one subgroup. The authors concluded that the majority of the reviewed obesity prevention interventions were effective and that physical education in schools is an example of a successful intervention (Doak et al., 2006). In a review of 17 studies concerning physical education in schools, however, investigators found no effects on BMI, although they identified some effects on skinfolds and percent body fat (Kahn et al., 2002). Effects of school-based physical activity interventions on BMI also were not observed in a review that included 14 studies, 10 of which
found no effect (Dobbins et al., 2009). And in a meta-analysis pertaining to prospective, randomized, and nonrandomized clinical trials of school-based physical activity interventions that lasted at least 6 months, no effects on BMI were found (Harris et al., 2009).
Taken together, the evidence concerning the effects of school-based physical activity interventions and their observational associations with BMI, overweight, and obesity is inconsistent. While some studies document no effects on body weight, others report significant associations with measures of skinfolds and percent body fat, and some document significant relationships with BMI. There are several possible explanations for these inconsistent findings. First, body weight can increase among participants in physical activity interventions, as observed in a 4-year physical education intervention among students in elementary schools. In that study, students in the intervention experienced greater annual increases in fat mass compared with the controls (Lofgren et al., 2012). Additionally, physical activity/physical education interventions may not increase the frequency and intensity of physical activity sufficiently to have the desired impacts on children’s body weight (Dobbins et al., 2009). Moreover, interventions may not last long enough to have a measurable impact on children’s BMI, overweight, or obesity. The inconsistency in the evidence concerning the effects of physical education and physical activity on body weight among children and adolescents merits additional investigation. Future studies should be of longer duration and include programs that entail higher frequency and greater intensity of physical activity.
Cardiovascular disease outcomes A systematic review of 26 school-based physical activity interventions documents good evidence that they exerted positive effects on blood cholesterol (as measured in 7 studies), but there was no evidence of effects on systolic (measured in 10 studies) and diastolic (measured in 9 studies) blood pressure (Dobbins et al., 2009). In the CATCH intervention, investigators observed no significant differences in blood pressure or cholesterol measures between control and treatment groups (Luepker et al., 1996).
Physical education policies, if adequately worded and incorporating mechanisms for monitoring compliance, have the potential to increase physical activity levels among school-age children across the nation. As discussed in Chapter 5, however, only a few state policies require a specific number of minutes of physical activity in physical education (or during school), the language in many of these policies is not strong enough, and monitoring for policy compliance is lacking (Carlson et al., 2013).
Examining the impact of various physical activity opportunities during the school day on daily physical activity among youth, Bassett and colleagues (2013, p. 110) conclude that “policies mandating daily physical education may have the greatest impact on physical activity of U.S. youth.” Further, a study based on a nationally representative sample of elementary schools found that schools located in states with a policy requiring 150 minutes per week of physical education were 180 percent more likely to report having provided that many minutes per week of physical education relative to schools in states with no policy on physical education time (Slater et al., 2012). This study also documented a significant association between school district–level policies related to physical education time and a higher likelihood of schools providing 150 minutes of physical education per week.
A commonly cited barrier to implementing physical education to the recommended extent is lack of time during the school day. There is some evidence for the effectiveness of unique scheduling options that can overcome this barrier (see Chapter 5).
The body of evidence that has accumulated over the past two decades documents significant effects of school-based physical activity interventions on and associations of physical education policies with frequency and duration of physical activity, total activity, and levels of vigorous- or moderate-intensity physical activity among children and adolescents (Luepker et al., 1996; Nader et al., 1999; Gordon-Larsen et al., 2000; Kahn et al., 2002; Cawley et al., 2007; Barroso et al., 2009; Dobbins et al., 2009). Evidence concerning the associations between school-based physical activity interventions and BMI, overweight, and obesity is less clear, and these associations merit further investigation. Evidence is generally consistent that school-based physical activity interventions exert positive influences on fitness levels (Kahn et al., 2002; Dobbins et al., 2009) among students overall. However, there has been a paucity of research on the influence of compliance with physical education policy on students’ physical fitness levels (Sanchez-Vaznaugh et al., 2012) or whether this influence varies across race/ethnicity, gender, socioeconomic status, and locations. The lack of research in this area is due in part to the absence of data with which to study these questions. Data on the quality and quantity of physical activity
during physical education in schools are needed, especially for elementary and middle schools. Research also is needed to examine the effects of school-based physical activity interventions and physical education policies on physical activity and fitness levels across subgroups based on race/ethnicity, immigrant status, gender, and socioeconomic status.
Recess, as discussed in detail in Chapter 6, is a regularly scheduled break in the school day for unstructured play. The physical activity objectives for Healthy People 2020 (HHS, 2012) include increasing the number of states and school districts that require regularly scheduled recess in elementary schools and the proportion of school districts that require or recommend an appropriate length of time (20 minutes) for recess in elementary schools. The importance of providing recess during the school day is highlighted in a recent policy statement issued by the American Academy of Pediatrics (AAP) titled “The Crucial Role of Recess in School” (AAP, 2013).
A review by Salmon and colleagues (2007) found that school-based interventions focused on activity breaks such as recess were the most effective way to increase physical activity levels among youth. Thus, requiring and implementing daily recess is one of the most promising policies for increasing physical activity during the school day.
Status and Trends
Only 6 percent (3) of states have a strong law on recess—one that requires 20 minutes of recess daily. An additional 11 percent (5) of states have a weak law—one that suggests 20 minutes or requires fewer minutes of daily recess than the nationally recommended 20 minutes (Slater et al., 2012). At the local level, national data show that many students do not attend schools that meet the national recommendations for recess. As noted in Chapter 6, since the No Child Left Behind Act became law in 2001, nearly 40 percent of U.S. school districts have reduced or eliminated recess to free up time for core academic subjects (Zygmunt-Fillwalk and Bilello, 2005; Center for Public Education, 2008; McKenzie and Kahan, 2008; RWJF, 2010; Anderson et al., 2011; Basch, 2011). However, the Child Nutrition and WIC Reauthorization Act of 2004 requires all school districts to develop local school wellness policies by the 2006-2007 school year. These policies were to “include goals for nutrition education, physical activity and other school-based activities that are designed to promote student wellness in a manner that the local educational agency determines is appropriate (Child Nutrition and WIC Reathorization Act of 2004, Public Law 108-265, Section 204).” The act outlines specific nutrition-related
goals but includes no required physical activity–related components, such as physical education or recess. Although its language allows school districts the flexibility to develop individualized physical activity programs that accord with their existing schedules, it provides no direction or guidance for this wellness policy component.
The Healthy, Hunger-Free Kids Act of 2010 expands the scope of local wellness policies. Physical education teachers can now participate in policy development, but specific physical activity requirements are still lacking. Despite this lack of specificity regarding physical activity requirements, a recent survey of a nationally representative sample of elementary school administrators revealed that 70 percent of respondents’ schools provide at least 20 minutes of recess daily, although the schools with predominantly minority or low-income students are significantly less likely to do so (Slater et al., 2012). In addition, many local wellness policies address using or withholding physical activity, such as recess, as a punishment. During the 2008-2009 school year, 21 percent of elementary school districts prohibited this practice (Chriqui et al., 2010).
Impact on Physical Activity
Policies requiring daily recess breaks during the school day could both increase physical activity levels and reduce sedentary behavior. As noted in Chapter 2, no existing surveillance system tracks physical activity levels during recess over time. Nonetheless, numerous studies have shown a positive association between participating in recess and physical activity (Ridgers et al., 2005; Beighle et al., 2006; Tudor-Locke et al., 2006; Erwin et al., 2012). More specifically, Ridgers and colleagues (2005) found that children may accumulate up to 25 minutes of vigorous- or moderate-intensity physical activity during recess, and recess also can account for 14-44 percent of total school-day steps during school hours (Beighle et al., 2006; Tudor-Locke et al., 2006; Erwin et al., 2012). Howe and colleagues (2012) found a nearly 54 percent relative increase in vigorous- or moderate-intensity physical activity postintervention among youth participating in a 30-minute structured recess. In a recent review, Bassett and colleagues (2013) found that youth accumulate an average of 7 minutes of vigorous- or moderate-intensity physical activity during a 15-minute recess period and that infrastructure improvements, such as providing playground equipment, blacktop games, or loose equipment, could increase that time to an average of 12 minutes.
Other studies also have found that environmental changes at the school level can facilitate greater physical activity during recess. Access to play equipment, such as balls and jump ropes (Zask et al., 2001; Verstraete et al., 2006; Parrish et al., 2009; Willenberg et al., 2010), and low-cost environmental changes to blacktops (e.g., painted markings) (Stratton
and Mullan, 2005; Ridgers et al., 2007; Loucaides et al., 2009) have been shown to improve physical activity levels during recess. The presence of sports fields and adequate playground equipment also is associated with greater accumulation of vigorous- or moderate-intensity physical activity during recess (McKenzie et al., 2010; Ramstetter et al., 2010; Colabianchi et al., 2011; Saint-Maurice et al., 2011; Beighle, 2012; Martin et al., 2012).
Variations in physical activity during recess exist across individual-level factors, such as age, gender, and culture (Holmes, 2012), as well as across environmental factors. For example, numerous studies have shown that boys achieve higher rates of physical activity during recess than girls (Barfield et al., 2004; Beighle et al., 2006; Haug et al., 2010b; Brusseau et al., 2011; Ridgers et al., 2012). Evidence regarding the association between physical activity levels during recess and socioeconomic status is mixed (Ridgers et al., 2005), but as previously stated, evidence shows that less socioeconomically advantaged youth are less likely to receive daily recess (Slater et al., 2012). Finally, limited evidence shows no significant differences in children’s vigorous- or moderate-intensity physical activity levels across days or seasons; thus recess should provide a regular opportunity for physical activity year round (Ridgers et al., 2006). Box 7-3 summarizes evidence-based policy, programmatic, and environmental approaches for increasing physical activity during recess.
Impact on Other Outcomes
Weight and body mass index It is currently unknown whether policies requiring daily recess have a significant impact on weight, as research on this association is sparse. Nonetheless, limited evidence shows a significant relationship between increased weekly minutes of recess and lower BMI in children in grades 1-5 (Fernandes and Sturm, 2011; Miller, 2011).
Cognitive outcomes As discussed more thoroughly in Chapter 6, recent reviews of the literature suggest that daily recess policies can have a positive influence on academic performance (e.g., cognitive skills and attitudes, on-task behavior, organization, attendance, impulse control) (Siedentop, 2009; Trost, 2009; CDC, 2010; Beighle, 2012). Most of these studies showed enhanced learning due to greater classroom attentiveness and on-task behavior among students participating in recess. See the detailed discussion of the association between physical activity and academic performance in Chapter 4.
Other health outcomes Very little research has been conducted on the direct health benefits of providing recess breaks to students. Panksepp (2008) suggests a connection between lack of play and increased symptoms
of attention deficit hyperactivity disorder (ADHD). Recess breaks also provide students with the opportunity to develop social skills through peer interaction, as well as free time in which to role play (AAP, 2013). Thus, recess provides opportunities for social and emotional development of youth in addition to its potential to increase physical activity levels.
Evidence discussed in detail in Chapter 6 and summarized here indicates that implementing recess policies can have a positive impact on increasing both overall physical activity in youth and the amount of recess offered during the school day. As discussed in Chapter 2, strong physical activity–related state laws and local policies are associated with higher levels of implementation of physical activity opportunities at the school level. Existing evidence specific to state-level recess laws and local policies is mixed. Slater and colleagues (2012) found that weak state laws were associated with schools offering at least 20 minutes of daily recess; no association was found for strong state laws or strong or weak school district–level policies. However, the authors note that only three states have an existing strong state-level recess law and, as discussed above, school districts are not required to address recess in their wellness policies.
Evenson and colleagues (2009) examined the impact of a state law on school-based physical activity. They evaluated the impact of North Carolina’s Healthy Active Children Policy, which requires all children in kindergarten through 8th grade to receive at least 30 minutes of moderate to vigorous physical activity each school day. The policy allows school districts flexibility in meeting this requirement through physical education, recess, or other approaches. The authors found that elementary schools (69 percent) were most likely to meet the 30-minute daily requirement by offering daily recess.
In a study conducted among a nationally representative sample of Norwegian students, Haug and colleagues (2010a) found that schools with a written policy addressing physical activity and those offering organized noncurricular physical activity during the school day were most likely to report student participation in daily recess, although it is unclear whether these written policies contained strong or weak language. In contrast, in a random sample of low-income rural Colorado elementary schools, Belansky and colleagues (2009) found that the number of minutes of recess provided to students decreased after implementation of the federally mandated local wellness policy. The authors attribute this decline in recess minutes to the weak language of the policy. Finally, Turner and colleagues (2013) found an association between strong state and school district policies and the practice of withholding recess for behavior management or academic reasons. More
Evidenced-Based Policy, Programmatic, and Environmental Approaches for Increasing Physical Activity During Recess
Evidence shows that the following approaches can be used to increase levels of physical activity during recess:
• Provide organized sports activities that include adult supervisiona (Howe et al., 2012), such as the structured recess activities developed by Playworks. Playworks activities have been shown to significantly increase physical activity levels during recess while reducing the prevalence of playground injuries, bullying, and exclusionary behavior of children (RWJF, 2010). Unorganized but well-supervised play time also can be effective (Murray et al., 2013).
• Provide multiple recess breaks during the day to break up long stretches of sedentary behavior. Having more than one regularly scheduled recess break daily is associated with improved classroom behavior (Barroso et al., 2009).
• Schedule recess before lunch. Research has shown that, if youth play before they eat, they will consume more fruits and vegetables, drink
research is needed on how policies impact school practices, but existing evidence provides some support that strong state laws and local policies are more effective than weak ones.
The implementation of strong state laws and local policies and environmental interventions can be effective in increasing both the number of minutes of recess provided and physical activity during recess. Evidence shows that recess can provide another school-based opportunity in addition to physical education to increase physical activity in youth. Recess also is associated with improved classroom behavior. It is important to note that the primary focus of recess is to help youth develop social and emotional
more milk, and waste less food. Research also has shown that, if recess is offered before lunch, youth display better behavior and playground injuries are reduced (Getlinger et al., 1996; Bergman et al., 2004).
• Implement policies that prohibit withholding recess as a punishment for poor behavior or allowing students to complete schoolwork during recess. Students cannot be physically active during recess if they are not present.
• Implement policies requiring both the recommended number of physical education minutes and physical activity opportunities outside of physical education classes for every grade level. Currently, elementary schools that provide the nationally recommended 150 minutes of physical education weekly are less likely than other schools to provide 20 minutes of daily recess (Slater et al., 2012).
aEvidence on the issue of adult supervision is mixed. Evaluation of Playworks shows a positive association between adult supervision and increased physical activity during recess, but the review of Ridgers and colleagues (2012) shows that the evidence on this association is inconclusive. More research is needed to determine whether the association is with trained adult supervisors or adult participation in leading or encouraging organized games.
skills through unstructured, free play; using recess as a substitute for physical education is inappropriate.
Classroom Physical Activity
Classroom physical activity includes all activity, regardless of intensity, performed in the classroom during academic instruction, as well as breaks from instruction designed specifically for higher-intensity physical activity (see Chapter 6 for a detailed discussion). It includes time spent learning special topics (e.g., art, music) even if not taught by the usual classroom teacher and excludes physical education and recess even if conducted in the classroom by the usual classroom teacher.
A number of programs designed to increase classroom physical activity have been described, including ABC (Activity Bursts in the Classroom)
(Katz et al., 2010), The Class Moves (De Meij et al., 2010), Energizers (Mahar et al., 2006), Happy 10 (Liu et al., 2008), Instant Recess (Whitt-Glover et al., 2011), Kinder-Sportstudie KISS (Kriemler et al., 2010), Physical Activity Across the Curriculum (PAAC) (Donnelly et al., 2009), PLAY (Promoting Lifestyle Activity for Life) (Pangrazi et al., 2003), TAKE 10! (Kibbe et al., 2011), and Texas I-CAN! (Bartholomew and Jowers, 2011) (three of these programs are described in Box 7-4). The framework suggested for augmenting active school transport (Fesperman et al., 2008) also could be used for selecting and implementing a classroom physical activity program (see the section on facilitating active transport to school in Chapter 6). It is important to note that sufficient time to prepare and build support for the program is necessary.
Examples of Promising Programs for Increasing Classroom Physical Activity
TAKE 10! “is an evidence-based program that integrates physical activity, nutrition, and health concepts with academic lessons in elementary school classrooms, positively impacting both teachers and students. This program is effective in increasing physical activity levels in K-5th grade children” (Kibbe et al., 2011; http://www.take10.net [accessed February 1, 2013]).
Energizers are “classroom based physical activities that help teachers integrate physical activity with academic concepts”(http://www.eatsmartmovemorenc.com/Energizers/Elementary.html [accessed February 1, 2013]). In a 12-week study of 62 3rd and 4th graders at Grifton Elementary School, a team of East Carolina University researchers found that children were more attentive and on task after participating in physical activity (Mahar et al., 2006).
Physical Activity Across the Curriculum (PAAC) incorporated vigorous- and moderate-intensity physical activity into academic lessons delivered by elementary classroom teachers. After 3 years, students in classrooms averaging ≥75 minutes per week of PAAC activity had more favorable body mass index (BMI) scores (Donnelly et al., 2009).
Status and Trends
The committee found no information on trends in the volume of classroom physical activity and only one study providing an estimate of the proportion of the daily total step count accumulated during classroom time. A study of 6th-grade students near Phoenix, Arizona, using pedometers to measure physical activity found that about 20 percent of the daily step count during school hours occurred during instructional classroom time for both boys and girls (Tudor-Locke et al., 2006). Baseline levels of classroom physical activity are likely to vary by grade, race/ethnicity, sex, students’ socioeconomic status, subject, geographic location, and other factors.
Impact on Physical Activity
Although vigorous- or moderate-intensity physical activity is possible during normal classroom time, classroom physical activity is more likely to involve shifts from sedentary to light-intensity activities. Within the past decade, research has demonstrated that shifting the amount of time spent in sedentary activities (metabolic equivalent [MET] values ≤1.5) to light-intensity activities (MET values >1.5-<3.0) results in improved health outcomes for adults (e.g., Wijndaele et al., 2010, 2011; Grøntved and Hu, 2011; Matthews et al., 2012). Likewise, a qualitative review of 232 studies of children aged 5-17 found a dose-response relationship between more sedentary behavior and negative health outcomes, including unfavorable body composition and decreased fitness, lower scores for self-esteem and prosocial behavior, and decreased academic achievement (Tremblay et al., 2011). On the other hand, cohort studies that have controlled for vigorous-or moderate-intensity physical activity have yet to demonstrate a relationship between reductions in sedentary activity (which is the same as increases in light-intensity activity) and health or risk factor outcomes (Carson and Janssen, 2011; Ekelund et al., 2012). The implications of these findings are still being discussed and have not yet been explicated in current physical activity recommendations. Nonetheless, it appears prudent to assume that, while vigorous- or moderate-intensity physical activity may have more or unique physical (including brain) health and cognitive benefits for children, light-intensity physical activity is preferable to sedentary activity from both health and academic perspectives. Therefore, modifications that increase light-intensity activity in the classroom should be viewed as beneficial even though no change in the volume of vigorous- or moderate-intensity physical activity occurs.
Isolating the impact of classroom physical activity interventions on the overall physical activity of children and adolescents is a frustrating venture. Many efforts to increase classroom physical activity are imbedded within programs also designed to increase activity during physical education,
recess, and before- and after-school activities (Sallis et al., 2003; Simon et al., 2004; Verstraete et al., 2007; Naylor et al., 2008; Evenson et al., 2009; Kriemler et al., 2010). Evidence reviewed earlier on the effectiveness of multicomponent programs in increasing physical activity in youth (e.g., van Sluijs et al., 2007) suggests that increasing classroom physical activity may be a useful adjunct to broader programs but says nothing about whether classroom physical activity can actually be increased. Even programs in which classroom physical activity is the apparent centerpiece are commonly accompanied by efforts to provide children and their parents with information and encouragement to increase physical activity more widely. In addition, assessments of increased activity commonly focus on changes in vigorous- or moderate-intensity physical activity while discounting or ignoring increased light-intensity activity. Still, the existing scientific literature does suggest that increases in classroom physical activity can be achieved and are accompanied by increased overall physical activity.
Physical activity has been increased during classroom time by inserting scheduled breaks for physical activity (e.g., stretching, jumping jacks) (Ernst and Pangrazi, 1999; Pangrazi et al., 2003; Liu et al., 2008; Katz et al., 2010; Erwin et al., 2011; Whitt-Glover et al., 2011; Wadsworth et al., 2012) and by incorporating physical activity into academic sessions (e.g., physically active math or spelling games) (Mahar et al., 2006; Trost et al., 2008a; Donnelly et al., 2009; Grieco et al., 2009; Donnelly and Lambourne, 2011; Kibbe et al., 2011). Estimates of the increase in daily physical activity due to such interventions are modest, ranging from 700 to 1,000 steps per day (Mahar et al., 2006; Erwin et al., 2011). According to one report, physical activity breaks increased light-intensity physical activity by 50 percent and moderate-intensity physical activity by 16 percent (Whitt-Glover et al., 2011).
Just as environmental changes can increase physical activity during recess, changes to the physical classroom environment can facilitate physical activity (Sallis et al., 2003; Evenson et al., 2009). Examples of such changes include standing desks, physio ball chairs, balancing boards or balls, podiums with BOSU (BOth Sides Up) balls, juggling balls, medicine balls, exercycles on which students can read while riding, and desks on wheels so they can be easily rearranged (Disney, 2012). Examples of classroom space organized to provide room for students to be more physically active are provided in Chapter 5.
Impact on Other Outcomes
Benefits of increased classroom physical activity have frequently been noted, including improved academic achievement and cognitive performance, increased time on task, reduced BMI (Mahar et al., 2006; Liu et al.,
2008; Donnelly et al., 2009; Barr-Anderson et al., 2011; Kibbe et al., 2011; Whitt-Glover et al., 2011), and reduced use of medications for asthma and ADHD (Katz et al., 2010).
Risks of increased classroom physical activity include injuries. However, the literature includes no mention of injuries associated with classroom physical activity programs, and it is likely that any injuries that might occur would be minor.
Incorporating physical activity into daily classroom time either as part of academic lessons or as activity breaks is an emerging opportunity to enable students of all ages to be more physically active. The strategy may be especially useful in achieving a shift from sedentary to light-intensity physical activity.
Intramural/Extramural Sports and After-School Programs
Opportunities exist beyond the school day for increasing physical activity in youth. Sports and active after-school programs have the potential to make a significant impact on daily physical activity levels.
For more than a decade, the AAP has recommended youth sports as a means of obtaining physical activity as well as social benefits (Washington et al., 2001). Sports programs typically fall into two categories: intramural, or within schools, and extramural or interscholastic, or competition between schools (AAHPERD, 2013). The type and scope of each vary by school size (Landis et al., 2007) and location (Kanters et al., 2013), as well as the socioeconomic status of students (Edwards et al., 2012). Evidence shows benefits of participation in school sports for many aspects of health and well-being (see Chapter 6).
After-school programs are formal programs for school-age youth that operate outside of normal school hours for at least part of the year, are supervised or monitored by adults, and are intended to promote growth and development (Durlak et al., 2009). Roughly 6.5 million students attend after-school programs in the United States. Even after a steady increase over the past two decades, the number of such programs is predicted to grow as a result of shifting family demographics, such as higher numbers of single and employed mothers (Vandell et al., 2005). Although after-school programs vary greatly in availability, attendance, and implementation, they can provide both structured and unstructured opportunities for physical activity and can teach students the behavior and movement skills associated with lifelong participation in physical activity (Trost et al., 2008b).
Status and Trends
Sports programs are widespread in U.S. schools (see Chapter 6). Nearly 77 percent of middle and 91 percent of high schools offer at least one sport. Participation rates vary, but it is estimated that 33-55 percent of students participate in school sports programs (Lee et al., 2007).
Forty-eight percent of schools offer at least one intramural sport or physical activity club, with rates of participation and opportunities varying among elementary, middle, and high schools (Lee et al., 2007). More intramural sports are offered in middle than in high schools, but both offerings and participation in middle school intramural programs have been declining (Lee et al., 2007). Interscholastic sports are more common in high schools, and participation rates tend to decline from 9th to 12th grade (Landis et al., 2007). Overall, fewer girls than boys participate in school sports (Lee et al., 2007), and girls are less likely than boys to engage in vigorous-intensity physical activity during sports (CDC, 2012).
Participation in sports also varies by socioeconomic status and race/ethnicity (Johnston et al., 2007; CDC, 2012). Studies indicate fewer sports opportunities and lower participation in schools with a higher percentage of black and Hispanic students compared with schools with a majority of white students (Edwards et al., 2012). This finding is significant given that participation in school sports was shown to be a correlate of physical activity in black, Hispanic, and white middle school girls (Kelly et al., 2010).
According to the American Heart Association,
in recent years, there has been substantial interest in offering additional after-school activities to serve the needs of more students. For example, researchers at Stanford University are testing after-school ethnic and popular dance classes for girls in grades 2 to 5 and an after-school team sports program designed exclusively for overweight children in grades 4 and 5, a population that would not normally participate in sports teams. (Pate et al., 2006, p. 1219)
Nationwide, 8.4 million children in grades K-12 currently attend after-school programs averaging 8.1 hours per week, and 18.5 million others would attend if suitable programs were available (Smith, 2007; Afterschool Alliance, 2009; Kang and Weber, 2010) (see Chapter 6 for additional discussion). The Afterschool Alliance’s 2009 America After 3PM study revealed that an average of 67 percent of students participating in after-school programs qualify for free and reduced-price lunches, 14 percent are limited English proficient, and 11 percent have special needs/disabilities. Few studies have examined correlates of participation in physical activity within after-school programs.
Programs with more structure and supervision have been found to generate more physical activity among participants (Beets et al., 2012b). As with sports, Trost and colleagues (2008b) found that elementary-age boys were more likely than girls to engage in physical activity during after-school programs.
Impact on Physical Activity
The adoption of policies to provide sports programs in schools has great potential to increase physical activity among students (Kanters et al., 2013). This holds true for disparate populations, including rural, inner-city, and economically disadvantaged youth (Vandell et al., 2007; Edwards et al., 2012).
Although studies vary in methodology and population, evidence shows that involvement in sports enhances cardiovascular fitness (Beets and Pitetti, 2005) and increases the amount of time spent in vigorous- or moderate-intensity physical activity (Nelson et al., 2005, 2006; Coleman et al., 2008; Dodge and Lambert, 2009; Graham et al., 2011). In one study of sports involving boys aged 6-12, Wickel and Eisenmann (2007) found that participants averaged 110 minutes of vigorous- or moderate-intensity physical activity during a day in which they participated in a sport, compared with only 30 minutes on a nonsport day. Another study, by Leek and colleagues (2011), found that youth involved in soccer, baseball, or softball teams engaged in a mean of 45.1 minutes of vigorous- or moderate-intensity physical activity, with variation by sport. Participation in these programs thus appears to contribute to the overall recommendation of 60 minutes per day of vigorous- or moderate-intensity physical activity for youth. The authors note, however, that
enhanced policies could ensure sufficient physical activity during practices by emphasizing participation over competition, sponsoring teams for all skill levels across all ages, ensuring access by lower income youth with sliding scales for fees, increasing practice frequency, extending short seasons, using pedometers or accelerometers to monitor physical activity periodically during practices, providing coaches strategies to increase physical activity, and supporting youth and parents in obtaining adequate physical activity on non-practice days. (p. 298)
Although after-school physical activity programs are growing in number, their effectiveness in increasing physical activity among participants is unclear (Beets et al., 2009). Data are limited on physical activity levels in the after-school period (Trost et al., 2008b), which vary by program and the context in which the activity takes place (e.g., indoor versus outdoor, structured versus unstructured) (Trost et al., 2008b; Beets et al., 2009), as well as implementa-
tion and program content (Beets et al., 2009). However, a meta-analysis by Beets and colleagues (2009) found that after-school settings hold considerable promise for increasing physical activity in youth and that strategies designed to increase physical activity in these settings should include policies targeting staff training and ongoing technical support (Beets et al., 2012b).
Impact on Other Outcomes
Weight and body mass index Policies promoting sports in schools may help curb the childhood obesity epidemic. Students who participate in sports are less likely to be overweight or obese than those who do not participate (Salbe et al., 2002; Levin et al., 2003; Menschik et al., 2008; Drake, 2012). Involvement in sports also has been shown to improve dietary behaviors (French et al., 1994; Harrison and Narayan, 2003; Coleman et al., 2008). While it is intuitive that increasing physical activity through after-school programs would have a positive impact on weight status, there is no conclusive evidence of a temporal effect. Research does show, however, that the weight status of youth is an important moderator of physical activity in after-school settings. Trost and colleagues (2001, 2008a) found that overweight students enrolled in an after-school program were substantially less active than their nonoverweight counterparts during organized outdoor activities. More research is needed to understand the activity preferences of overweight children attending after-school programs.
Psychosocial outcomes Policies favoring school sports programs can influence factors in students that play a role in their success as adults, including competence (Anderson et al., 2009; Greenleaf et al., 2009), self-concept and self-esteem (Harrison and Narayan, 2003; Dishman et al., 2006), and body image (Greenleaf et al., 2009) (see Chapter 3). Involvement in sports also confers unique psychosocial benefits that protect adolescents against suicide (Taliaferro et al., 2011) and depressive symptoms (Dishman et al., 2006; Johnson and Taliaferro, 2011). In addition, participation in sports may enhance school connectedness, social support, and bonding among friends and teammates (Weintraub et al., 2008). There are developmental benefits as well; involvement in school sports may enhance initiative, goal setting, and emotional control (Gould and Carson, 2008), along with general well-being (Greenleaf et al., 2009).
Other health outcomes Sports programs may help reduce the risk of alcohol, tobacco, and illicit drug use in students (Forman et al., 1995; Harrison and Naryan, 2003; Kulig et al., 2003; Lisha and Sussman, 2010; Nkansah-Amankra et al., 2011). Studies also point to a reduced risk for violence
(Garry and Morrissey, 2000) and sexual behavior (Taliaferro et al., 2011) among student athletes.
In addition to the policies discussed in Chapter 6, the development, use, and maintenance of school facilities have a major impact on opportunities for both school sports and after-school programs. A study by Kanters and colleagues (2013) found that the majority of school sports fields are underutilized, suggesting opportunities for increased programming. Joint or shared use with community facilities holds promise as well (see the discussion of joint- or shared-use agreements later in this chapter).
Do Policies Matter? Policies for after-school programs that outline the percentage of time to be dedicated to physical activity are being implemented. Because of variation in the scope and content of these policies and the lack of surveillance of their implementation, their outcomes, beneficial effects, and feasibility are largely unknown.
School sports and active after-school programs offer the potential to increase physical activity among youth. More research is needed to define specific factors that increase the effectiveness of such programs and ways in which they can be tailored and implemented in varied school settings across the United States. Consideration of equity in sports and after-school programs is especially important as the quality and scope of these opportunities vary tremendously by district.
Active transport or active commuting to school includes walking, cycling, and the use of other human-powered modes of transportation (e.g., skateboarding); it also includes using public transportation or being driven to a point closer to school and walking the rest of the way. The major focus of this discussion is on walking and cycling the full distance between home and school. (See the detailed discussion of active transport to school in Chapter 6.)
Programs to increase walking and cycling to school include changes in site selection regulations for new/remodeled schools, infrastructure improvements (e.g., sidewalk improvements, overpasses, traffic calming), safety initiatives (e.g., crossing guards, school speed zones), educational campaigns, “walking school buses,” and others (see Chapter 6 for more detailed discussion). The committee could find no empirical evaluations of changes in active transport to school due to relocation of schools from the edge of communities to the center. Evaluations of state and federal programs designed to increase the proportion of students walking or cycling to school provide some evidence of success1 (Staunton et al., 2003; Boarnet et al., 2005; Buliung et al., 2011; Hinckson and Badland, 2011; Mendoza et al., 2011a,b).
As discussed in Chapter 6, safety is a major concern among parents who do not want their children to walk or bike to school. Funding for infrastructure (e.g., building sidewalks, installing traffic calming structures) or to hire staff (e.g., crossing guards) can make areas near schools safe for children to walk or bike to school. From 2005 through 2012, the U.S. Department of Transportation provided state departments of transportation with about $1 billion for Safe Routes to School projects. These funds benefited about 13,000 schools—13 percent of eligible schools in the country (USDOT, 2012). The new transportation bill, Moving Ahead for Progress in the 21st Century (MAP-21), allows states to spend the money they receive to enable students to walk and bike to school more safely, but dedicates no funds specifically for that purpose.
Place Matters Residents of neighborhoods with close proximity to schools and greater connectivity of pathways walk and cycle to school more than residents of neighborhoods with low proximity and connectivity (Saelens et al., 2003; Duncan and Mummery, 2005).
Support from a variety of community organizations also is possible. Pedestrian advocacy groups (e.g., WalkBoston, Pedestrians Educating Drivers About Safety [Atlanta], PedNet [Missouri]) are likely to be supportive, as are some health groups concerned about conditions such as diabetes, obesity, and heart disease. Two groups likely to be willing to help promote active school transport and prevent associated traffic mishaps are local emergency department physicians and local chapters of the AAP. In Miami
1 A U.S. Department of Transportation Fact Sheet provides two more examples but includes no explanation of how the information was obtained (USDOT, 2012).
TABLE 7-1 Percentage of Students Who Usually Walk or Bike to School, 2009
|Miles from School||Elementary Schools (%)||Middle Schools (%)|
SOURCE: McDonald et al., 2011.
a program led by providers of hospital emergency room care has offered educational programs on pedestrian and bicycle safety and on infrastructure changes to enhance safety (Gillian et al., 2004).
Status and Trends
The prevalence of walking or bicycling to school among American school-aged children declined from 42 percent in 1969 to 13 percent in 2001 (McDonald, 2007) (see Figure 2-11 in Chapter 2). Among children who live within 1 mile of their school, the prevalence has fallen from 86 percent to 50 percent. There is a strong and inverse relationship between distance to school and the prevalence of active transport (see Table 7-1) (McDonald, 2008). During the past 40 years, but especially in the 1970s and 1980s, new schools were likely to be built away from residential neighborhoods. As a result, fewer students now live close enough to school to walk (McDonald, 2008). Today only about one-third of students live within a mile of their school (Martin et al., 2007). In some areas, the proportion is much lower; in Georgia, for example, only an estimated 10-15 percent of students live close enough to walk (Falb et al., 2007). The proportion varies widely among schools, however, so that active transport programs for some schools could have a major impact. The shift from placing new schools in residential areas to placing them in sparsely populated areas at the edge of communities is responsible for about half of the decline in active transport since 1969; changes in demographics and social norms and an increase in the proportion of special-focus schools (e.g., science, arts) account for the other half of the decline.
Impact on Physical Activity
Recent systematic reviews have found that students who walk or bike to school are more physically active than students who do not (Davison et al., 2008; Lee et al., 2008; Faulkner et al., 2009). A few studies have
estimated the difference in minutes of daily vigorous- or moderate-intensity physical activity between children and adolescents who walk to school and those who are driven. Basset and colleagues (2013) estimate that walking or biking to school adds an average of 16 minutes per day of vigorous- or moderate-intensity physical activity. According to other estimates, the figure ranges from 2 to 24 minutes per school day (Sirard et al., 2005; van Sluijs et al., 2009; Owen et al., 2012; Saksvig et al., 2012). Not surprisingly, the excess minutes are greater among students who walk or bike longer distances than among those who walk or bike shorter distances (van Sluijs et al., 2009).
A few studies have assessed the impact of a walking school bus intervention. Two studies found that the proportion of children actively commuting to school increased and that accelerometer-measured physical activity was higher among students at intervention schools than those at comparison schools (Heelan et al., 2009; Mendoza et al., 2011b). A third study found no differences between intervention and comparison schools (Sayers et al., 2012).
Impact on Other Outcomes
Evidence that students using active transport have lower BMIs is suggestive but inconsistent (Davison et al., 2008; Lee et al., 2008; Faulkner et al., 2009; Lubans et al., 2011). Active transport also is thought to enhance neighborhood social capital and social interactions among children and to promote independent mobility (Collins and Kearns, 2001; Kearns et al., 2003).
Benefits of walking or biking to school also include reduced use of automobiles and school buses and the associated reductions in air pollution, fuel consumption, and traffic congestion. A simulation study estimated that, compared with locations where few to no students could walk or bike to a neighborhood school, locations where active transport was feasible would see a 15 percent reduction in noxious emissions (EPA, 2003). Enabling more students to walk or bike to school could substantially reduce the cost of busing. One school reportedly is saving $49,000 per year in busing costs after improving the safety of active transport with new sidewalks, crosswalks, and signage (USDOT, 2012). Infrastructure improvements such as new or repaired sidewalks benefit not just students but all pedestrians.
Some evidence suggests that favorable school district and/or state policies increase the likelihood of implementation of “walking school buses” (Turner et al., 2012).
For students who live close enough to school, active transport is an important source of vigorous- or moderate-intensity physical activity. Substantial evidence shows that students who walk or bike to school are more physically active than those who do not. Enabling students to walk or bike to school provides a number of environmental and economic benefits as well. Evidence that environmental, safety, and educational interventions increase the proportion of students who walk or bike to school is suggestive but limited in volume and quality.
The Environment and Physical Activity
The discussion to this point has focused primarily on how different segments of the school day, such as physical education class or recess, and the policies that affect them can influence physical activity behaviors. Also important is the physical environment in which the various segments of the day take place and the policies that shape it.
As in communities generally, the built environment of a school plays a role in access to opportunities for physical activity. In particular, policies supporting adequate space for leisure-time or after-school active programming may decrease overall sedentary time. McKenzie and colleagues (2000) used an objective measure of the outdoor environment during leisure time in a middle school setting. They found that few students took advantage of opportunities to be physically active during leisure time at school, and they recommend policies and environmental manipulations (e.g., supervision, equipment, structured programs) to attract more adolescents, especially girls, to existing activity areas.
Equally important is the location of schools. School siting policies at the state or local level can dictate the size of schools, the distance between homes and schools, and general school locations. Not only do these factors impact the ability to commute actively to and from school (McDonald and Aalborg, 2009), but a school’s location in relation to facilities for physical activity may encourage such activity. In a study by Trilk and colleagues (2011), 12th-grade girls who attended schools with at least five facilities for physical activity within the designated parameter reported more physical activity per day than girls in schools with fewer than five such facilities. In addition, girls who attended rural schools surrounded by at least five such facilities reported about 12 percent more physical activity per day than girls who attended rural schools with fewer than five such facilities nearby. The authors conclude that the number of facilities for physical activity surrounding the area should be considered when school siting decisions are made.
On school grounds, age-appropriate equipment and outdoor space that are safe and attractive enable and encourage children and adolescents to participate in active play (see Chapter 6). Walkways can encourage walking during breaks and before and after school.
The indoor environment is important as well. The presence of gymnasiums and other open spaces enables active play. As discussed above, mobile desks, standing chairs, physio balls, and other equipment can encourage higher levels of energy expenditure in the classroom. Building guidelines that specify stairwell placement, classroom design, and building flow also have the potential to increase the volume of physical activity during the school day (Zimring et al., 2005; Cohen et al., 2008; Nicoll and Zimring, 2009; McGann, 2013).
Just as the work environment is a factor in employee health, a school’s physical environment plays an important role in student health—including sedentary behavior. Tremblay and colleagues (2011) find that “there is a large body of evidence from all study designs which suggests that decreasing any type of sedentary time is associated with lower health risk in youth aged 5-17 years.” Similarly, Kwon and colleagues (2012) note that “breaks in sedentary time notably decrease during childhood and adolescence. During school hours, boys and girls have fewer breaks in sedentary time than during any other period of weekday or weekend days” (p. 1075).
School policies encouraging an environment that promotes physical activity and decreases sedentary time are promising obesity prevention strategies (McKenzie et al., 2000; Leung et al., 2012). In some children, changes in sedentary behaviors may be important to modify energy balance and prevent obesity (Epstein et al., 2004, 2006). A recent review indicates that, even considering the varied and limited methodologies of intervention studies, evidence suggests the effectiveness of strategies designed to reduce overall sedentary behavior among children and adolescents (Leung et al., 2012). However, much of the existing research consists of studies within the home, neighborhood, or community environment (Robinson, 1999; Epstein et al., 2006; Robinson and Borzekowski, 2006; Leung et al., 2012; Tandon et al., 2012). Few studies examine interventions that entailed modifying school physical environments and policies to support regular physical activity and improved dietary practices (Simon et al., 2004; Newton et al., 2010; Leung et al., 2012). New research is being conducted on the association between the school environment and healthy eating (Huang, 2013), with plans to expand the focus to encompass physical activity and reduction of sedentary behavior. Healthy eating design guidelines are being developed for elementary schools to promote indoor environments that are spatially organized to be conducive to learning and health.
Joint- or Shared-Use Agreements
Joint- or shared-use agreements entail “two or more entities—usually a school and a city or private organization—sharing indoor and outdoor spaces like gymnasiums, athletic fields and playgrounds. The concept is simple: share resources to keep costs down and communities healthy” (Joint Use, 2009, p. 1).
Such agreements are one policy strategy that communities and schools can use to provide schools with additional or alternative opportunities for physical activity. They may be a particularly important strategy for providing structured physical activity programs during summer months and other out-of-school time. The agreements can be formal or informal and are designed to encourage shared use of facilities for both physical activity– related and other kinds of programs.
Joint-use agreements have been promoted by a number of national organizations (McCambridge et al., 2006; Solomon et al., 2009; Leadership for Healthy Communities, 2010; National Physical Activity Plan, 2010; White House Task Force on Childhood Obesity, 2010; HHS, 2012) as a way to provide access to existing neighborhood physical activity facilities for communities, such as rural or low-income areas, that may have few or no such facilities available to them. Shared use of existing facilities is also more cost-effective than building new structures in resource-poor areas. Despite the promise of this strategy, however, and the significant attention and promotion it has received at the national level, little is known about its effectiveness in increasing physical activity.
Status and Trends
In a survey conducted with a nationally representative sample of public and nonpublic elementary, middle, and high school administrators in 2000 and again in 2006, researchers found that two-thirds of schools allowed youth sports teams to use school facilities outside of school hours (Evenson et al., 2010). A significantly lower percentage, however, allowed community-sponsored youth programs, open gyms, and adult sports programs (see Table 7-2). Results were similar across the survey years (2000 and 2006), with no appreciable changes noted in facility availability across groups.
More recent research conducted in 2009, which surveyed a national sample of school principals in underserved communities, also found that nearly 70 percent of principals reported that their school recreational facilities were open to the public outside of school hours for either unsupervised or supervised use (Spengler et al., 2011). Finally, in a study conducted in 2010, researchers examined and coded joint-use agreement policies collected in a national sample of 157 school districts during the 2009-2010
TABLE 7-2 Weighted Percent of Community Access to Indoor or Outdoor School Facilities for Physical Activity Use in 2000 and 2006 Among Schools with Any Indoor or Outdoor Physical Activity Facilities
|2000 (N = 911)||2006 (N = 981)|
|Weighted Percent||Standard Error||Weighted Percent||Standard Error||p-Valuea|
|Outside of school hours or when school is not in session, do children or adolescents use any of this school’s physical activity facilities for:|
|. . . community-sponsored sports teams?||66.9||2.3||68.9||2.0||0.52|
|. . . community-sponsored classes/lessons?||31.4||2.1||33.5||2.1||0.49|
|. . . community-sponsored supervised “open gym” or “free-play”?||37.6||2.2||40.5||2.2||0.36|
|Outside of school hours or when school is not in session, do adults who are not school employees adults use any of this school’s physical activity facilities for:|
|. . . community-sponsored sports teams?||52.6||2.4||47.6||2.0||0.11|
|. . . community-sponsored classes/lessons?||26.3||2.0||23.3||1.7||0.24|
|. . . community-sponsored supervised “open gym” or “free-play”?||27.9||2.1||30.9||2.3||0.33|
|Can children or adults in the community use any of this school’s outdoor physical activity and athletic facilities without being in a supervised program?|
|. . . Yes||66.6||2.2||66.7||2.1||0.98|
|. . . . . . If yes, can they use it:|
|. . . . . . . . . before school?||70.4||2.5||71.4||2.9||0.78|
|. . . . . . . . . after school?||93.7||1.1||94.4||1.2||0.67|
|. . . . . . . . . in the evening?||96.6||0.8||95.3||1.2||0.34|
|. . . . . . . . . on the weekend?||97.3||0.8||96.0||1.1||0.35|
|. . . . . . . . . during school vacation?||96.6||0.9||95.2||1.2||0.36|
ap-value is obtained from Wald chi-square test to examine changes between 2000 and 2006.
SOURCE: Evenson et al., 2010. Reprinted with permission.
school year (Chriqui et al., 2012). They found that 93 percent of the sampled school districts had an existing joint-use agreement, with 81 percent of the agreements specifically allowing for recreational use of school grounds. However, results also showed that agreements lacked specificity in identifying which types of facilities could be used or what community groups had access to the school grounds (Chriqui et al., 2012).
Impact on Physical Activity and Other Health Outcomes
Little research has examined the impact of joint-use policies on physical activity among youth. The committee identified only one study that evaluated the impact of a newly enacted joint-use agreement. Results of this study showed that the agreement enabled more than 1,000 community members to participate in 900 class sessions (Maddock et al., 2008). However, the study did not examine physical activity levels in class participants before or after implementation of the agreement. Another study, conducted by Van Acker and colleagues (2012), examined barriers and facilitators for providing physical activity–related after-school programs and found that having an agreement to use school facilities was positively associated with the presence of an after-school program. Likewise, Durant and colleagues (2009) found that opening school playgrounds outside of school hours was associated with increased physical activity and reduced screen time/sedentary behavior.
Because so little research has been conducted on the impact of joint-use agreements on physical activity behavior, it remains unclear what specific components should be included in such agreements to facilitate increased physical activity. Unknown, for example, is whether informal (open gym) or formal (organized sports) programs are preferable, when facilities should be available for public use (weekdays, weekends, holidays), what hours are important (after school or evenings), and which facilities (indoor or outdoor) should be made available.
Joint-use agreements as a means of increasing access to available school settings for physical activity are a promising strategy for increasing physical activity. However, further research is needed to determine the impact of such agreements on physical activity. Additional research also is needed to determine whether simply making school facilities available is effective in increasing physical activity levels in youth or whether supervision and more structured/formal programs are needed to produce this result.
Many examples exist of effective and promising strategies for increasing vigorous- or moderate-intensity physical activity in schools (see Table 7-3). The most thorough yet often most difficult to implement are multicomponent interventions designed to increase physical activity using a systems approach that entails both school and community strategies. For strategies with a singular focus, the evidence is most robust for interventions involving physical education. Physical education can increase overall physical activity, increase the intensity of physical activity, and potentially influence BMI/weight status in children and adolescents. However, the lack of consistent surveillance of physical activity levels during physical education classes (especially in elementary and middle schools) impedes monitoring and evaluation of progress toward increasing physical activity through physical education in schools across the nation.
Beyond physical education, opportunities for increasing physical activity are present both in the classroom and, for elementary schools, during recess. Classroom physical activity and other strategies designed to reduce sedentary time in the school setting hold promise for increasing overall physical activity among children and adolescents, yet isolating their impact is complex, and they often are met with resistance from key stakeholders. Recess is a nationally recommended strategy for increasing physical activity, and evidence indicates that participating in recess can increase vigorous- or moderate-intensity as well as light-intensity physical activity and improve classroom behavior. However, this strategy currently is not being implemented in sufficiently high doses to make a major impact.
Effective and promising strategies beyond the school day also exist, including after-school programming and sports teams, as well as active transport to and from school. School sports and after-school programming offer important physical activity opportunities in the school setting, but access and implementation vary greatly. Formal policies also are needed to specify physical activity standards for after-school programs. Evidence shows that children who walk or bike to school are more physically active than those who do not. Successful active transport interventions address policy and infrastructure barriers.
Also associated with the school environment are agreements between schools and communities to share facilities as places to be physically active. Although this is a relatively new research topic, these joint-use agreements can provide youth with additional opportunities for out-of-school physical activity. Further research is needed on the utilization of facilities resulting from these agreements and their impact on physical activity.
For both single- and multicomponent strategies, evidence on effective programs and policies is limited by the lack of quality surveillance and a
TABLE 7-3 Examples of Effective and Promising Single-Component Approaches to Increase Physical Activity in Youth
• Physical education requirements
— Quality curriculum
— Required minutes of vigorous- or moderate-intensity physical activity
— Monitoring and enforcement
— Elimination of exemptions
• Teacher certification
• Class size restrictions
• Adequate environment, facilities, and equipment
• Integrated curriculum
• Fitness testing and reporting
Classroom Physical Activity/Reduction of Sedentary Behavior
• Active learning lessons
• Activity breaks during lessons
• Environmental modifications (e.g., standing desks)
• Modified sitting (e.g., balls)
• Recess requirements/policy
— Not taken away for punishment
School Sports/After-School Programs
— Low cost
— Transportation provided
• Program criteria
• Educational programs
• Infrastructure improvements
— School (e.g., bike racks)
— Community (e.g., sidewalks)
— Allowing access
— Reducing liability
• Increased awareness
NOTE: As discussed in the text, multicomponent interventions with a whole-of-school focus that include two or more of these single-component approaches have the potential to be more effective and sustainable in increasing vigorous- or moderate-intensity physical activity in youth.
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