Physical Activity: Moving Toward Obesity Solutions: Workshop Summary (2015)

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Perspectives on Disparities in Physical Activity¹

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¹ These commentaries are reproduced here as submitted by the authors.

PHYSICAL ACTIVITY IN LATINO COMMUNITIES

Rebecca T. Adeigbe, M.S., and Amelie G. Ramirez, Dr.P.H., University of Texas Health Science Center at San Antonio, TX* April 2015

Latino health is increasingly synonymous with the future of U.S. health, yet the nation’s largest and still-growing minority group continues to live in communities with reduced access to health-promoting resources and safe, pedestrian-friendly built environments. Latinos’ higher rates of childhood and adult overweight/obesity relative to whites and blacks is often attributed to cultural influences, attitudes, and beliefs; however, community-level attributes are increasingly being associated with higher prevalence of obesity in Latino-predominant communities.

Latino communities across the country tend to have fewer parks, less access to recreational facilities, and unsafe and outdated street-scale infrastructure. Furthermore, Latinos tend to live in communities where crime rates are higher and perceived crime keeps Latinos and their children indoors.¹ Studies also have shown that Latino youth often attend schools with few recreational resources, have few opportunities for active play at and after school, and are less likely to participate in organized sports. Even with state active play policies, many schools struggle with implementation due to competing priorities and lack of resources or policy knowledge.²

In the face of these barriers, researchers, policy makers, health officials, and the public have identified families, communities, and schools as key areas to focus on to address Latino obesity. Through the work of programs such as Salud America! The Robert Wood Johnson Foundation Research Network to Prevent Obesity Among Latino Children—which works to showcase examples of grassroots-level healthy changes in Latino communities—culturally relevant evidence-based strategies and program have successfully improved built environments and increased activity opportunities in Latino communities.³

From a built environment perspective, shared-used agreements have been helpful at increasing accessibility to safe and free public places in Latino communities across the country. For example, large communities in

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The views expressed in this commentary are those of the authors and not necessarily of the authors’ organization or of the Institute of Medicine. The commentary is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine and is not a report of the Institute of Medicine or of the National Research Council.

* Participants in the activities of the IOM Roundtable on Obesity Solutions.

California and rural cities, like Alice, TX, have successfully implemented shared use agreements to improve access to schools and playgrounds with the support of passionate parents and community members.^4,5

In schools, culturally relevant structured school programs have demonstrated success in increasing physical activity among Latino children and their families. The Míranos! program in Head Start centers in San Antonio, TX, improved parents’, teachers’, and children’s knowledge of the benefits of healthy eating and physical activity.⁶ Utah researchers incorporated active video games in physical education (PE) classes and increased Latino youth activity.⁷ Providing Latina teens with the tools needed to advocate for change, city pools in New Britain, CT, were reopened and an out-of-school PE credit recovery program was implemented through the local YWCA.⁸

As strategies for improving physical activity become more innovative, it is critical to make them culturally relevant for Latinos. Despite the many physical activity barriers for Latinos, strategies showing promise for increasing physical activity in Latino communities tend to include community-level systems changes and active programming, but there are areas that can be better understood. As policy makers and public health experts develop strategies to improve the built environment and promote activity, doing so in Latino communities should begin with understanding the intended and desired use for public spaces and physical-activity oriented programs; that way, these efforts may be most effective for helping Latinos be and remain more active.

Rebecca T. Adeigbe, M.S., and Amelie G. Ramirez, Dr. P.H., are with the Institute for Health Promotion Research, University of Texas Health Science Center at San Antonio, TX.

References

1. Powell, L. M., et al. 2006. Availability of physical activity-related facilities and neighborhood demographic and socioeconomic characteristics: A national study. American Journal of Public Health 96(9):1676-1680.

2. Belansky, E. S., et al. 2009. Early impact of the federally mandated Local Wellness Policy on physical activity in rural, low-income elementary schools in Colorado. Journal of Public Health Policy 30(Suppl 1):S141-S160. doi: 10.1057/jphp.2008.50.

3. Ramirez, A. G., et al. 2013. Salud America!: A national research network to build the field and evidence to prevent Latino childhood obesity. American Journal of Preventive Medicine 44(3 Suppl 3):S178-S185.

4. Salud America! 2013. Grassroots health group works with rural schools to open recreation spaces to public after school hours. Salud Am Salud Heroes. http://www.communitycommons.org/sa_success_story/grassroots-health-group-works-with-rural-schools-to-open-recreation-spaces-to-public-after-school-hours-sugary (accessed March 9, 2015).

5. Swanson, J., et al. 2013. Using shared use agreements and street-scale improvements to support physical activity among Latino youths. http://salud-america.org/sites/saludamerica/files/Active-Spaces-Research-Review.pdf (accessed November 3, 2014).

6. Yin, Z., et al. 2012. Míranos! Look at us, we are healthy! An environmental approach to early childhood obesity prevention. Child Obesity 8(5):429-439.

7. Gao, Z., et al. 2013. Video game-based exercise, Latino children’s physical health, and academic achievement. American Journal of Preventive Medicine 44(3 Suppl 3):S240-S246.

8. Hannay, J., et al. 2013. Combining Photovoice and focus groups: Engaging Latina teens in community assessment. American Journal of Preventive Medicine 44(3 Suppl 3):S215-S224.

Suggested Citation: Adeigbe, R. T., and A. G. Ramirez. 2015. Physical activity in Latino communities. Commentary, Institute of Medicine, Washington, DC. http://nam.edu/wp-content/uploads/2015/06/PAandLatinos.pdf.

PHYSICAL ACTIVITY IN OLDER PEOPLE

Loretta DiPietro, Ph.D., M.P.H., George Washington University* April 2015

Physiological function and resiliency decline with age, even among the most robust sectors of the older adult population. The degree to which this decline is attributable to true biological aging versus aging-related changes in lifestyle factors has been the focus of most research in this area. Nearly three decades ago, Walter Bortz first noted that many of the physiological changes ascribed to aging per se are similar to those induced by enforced inactivity, such as during prolonged bed rest, and he proposed that much of this functional dysregulation could be attenuated or even reversed with regular exercise.¹ Unfortunately, the modern-day lifestyle is characterized by a majority of time spent sedentary throughout the day. Older people may be especially vulnerable to the harmful effects of prolonged sitting due to a loss of physiologic reserve and the fact that they may spend up to 60-70 percent of their waking hours sitting or reclining. This has especially important consequences for aging, as increasing sedentary time may be displacing time spent in health-accruing lower intensity activities, which are the most prevalent physical activities reported among older people.

Physical activity of any intensity has consistently demonstrated a powerful counter effect on every risk factor associated with the prominent chronic diseases of older age.² Current activity level is more protective than past activity levels; however, cumulative lifetime patterns may be even more influential for risk reduction, especially for chronic diseases with a long latency period, such as cancer or osteoporosis. Moreover, the volume of physical activity necessary to prevent functional decline and to maintain health may be substantially lower than the amount needed to reverse an existing chronic condition. Thus, physical activity is far more cost-effective at the prevention (rather than curative) end of the public health spectrum, and this concept is emphasized repeatedly in the 2008 federal physical activity guidelines.³

Walking remains an important and prominent activity in older age.

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The views expressed in this commentary are those of the authors and not necessarily of the authors’ organization or of the Institute of Medicine. The commentary is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine and is not a report of the Institute of Medicine or of the National Research Council.

* Participants in the activities of the IOM Roundtable on Obesity Solutions.

Because walking is weight bearing, uses large muscle groups, can be sustained at lower and moderate intensities, and can improve maximal and submaximal physical functioning, its merits should be promoted among older people for meeting the physical activity guidelines of 150 minutes per week.³ In addition, the American College of Sports Medicine recommends a regular program of resistance, flexibility, and balance training 2 days per week to promote and maintain lean mass and to prevent falls.² Finally, the dosing and timing of the exercise bout has recently assumed investigative priority.

Similar to some pharmacologic treatments, a smaller exercise dose repeated several times per day (particularly when it may be most effective, like after each meal or for breaking up sitting time) may provide greater overall benefits for health than the same dose performed prior to eating or than a single large dose performed once per day. This may be especially so if frailer people are more tolerant of smaller exercise doses and are better able to adhere to multiple frequencies of them on a regular basis.

Loretta DiPietro, Ph.D., M.P.H., is chair of the Department of Exercise Science at the Milken Institute School of Public Health, George Washington University, Washington, DC.

References

1. Bortz, W. 1982. Disuse and aging. Journal of the American Medical Association 248:1203-1208.

2. American College of Sports Medicine. 2009. Exercise and physical activity for older adults. Medicine and Science in Sports and Exercise 41:1510-1530.

3. Physical Activity Guidelines Advisory Committee. 2008. Physical Activity Guidelines Advisory Committee report, 2008. Washington, DC: U.S. Department of Health and Human Services.

Suggested Citation: DiPietro, L. 2015. Physical activity in older people. Commentary, Institute of Medicine, Washington, DC. http://nam.edu/wp-content/uploads/2015/06/PAandolderpeople.

PHYSICAL ACTIVITY FOR PEOPLE WITH DISABILITIES: HOW DO WE REACH THOSE WITH THE GREATEST NEED?

James H. Rimmer, Ph.D., University of Alabama at Birmingham/Lakeshore Foundation Research Collaborative* April 2015

The 25th anniversary of the Americans with Disabilities Act (ADA) this year is an opportune time for researchers, practitioners, and policy makers to begin thinking about addressing the high rates of physical inactivity among people with disabilities. Recent national estimates on rates of physical activity among Americans (2009-2012) found that more than 50 percent of adults with disability are not meeting the U.S. exercise guidelines of 150 minutes per week.¹ Achieving the U.S. recommended guidelines is far more challenging for many people with disabilities, particularly among those who have difficulty walking, are unable to walk due to some form of paralysis (e.g., spinal cord injury), or cannot walk for long periods due to pain and/or balance impairments (e.g., multiple sclerosis, stroke, rheumatoid arthritis, etc.). In general, people with physical disability are more likely to undertake less physical activity during any given day because of high rates of unemployment or underemployment.² They may be unable to walk outdoors (the most common form of physical activity in the general population) due to difficult terrain or safety issues. They may be unable to walk for periods long enough to accrue health benefits (i.e., 30 or more minutes).³ Transportation to and from community fitness facilities, parks, and recreation areas is often difficult to obtain, unavailable, or unaffordable,⁴ and many fitness facilities do not have accessible equipment, classes, and programs or trained staff who understand how to adapt programs and services for people with disabilities.^5-8 These barriers are often difficult to overcome for many people with disabilities and, when considered in the aggregate (i.e., most people report several barriers), pose substantial challenges to promoting higher rates of physical activity in this underserved population.

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The views expressed in this commentary are those of the authors and not necessarily of the authors’ organization or of the Institute of Medicine. The commentary is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine and is not a report of the Institute of Medicine or of the National Research Council.

* Participants in the activities of the IOM Roundtable on Obesity Solutions.

Reaching the Hardest to Reach

There is an urgent need to establish new models that integrate children and adults with a disability into the corpus of evidence-based programs and emerging new programs in physical activity.⁹ For long-term sustainable health improvements to occur, communities should provide people with disabilities with the necessary supports (e.g., transportation, trained staff, accessible information and facilities, universally designed exercise equipment, socially engaging physical activity environments) that will allow them to engage in self-managed physical activity with other community members.

Within this framework, six concurrent steps are recommended. First, from a research perspective, adapted versus reinvented (which is much costlier and less generalizable) evidence-based physical activity strategies and programs established on the general population must be adapted and tested on people with disabilities in real-world settings. Second, disability and non-disability service providers must work together to form inclusive health coalitions that represent the physical activity needs of community members with disabilities. Third, programs that successfully promote inclusion in physical activity across policies, systems, and environments must be captured, translated, and disseminated to other organizations and communities using technology to readily and effectively connect to key stakeholders. Fourth, policies must be established that require staff training in physical activity inclusion for people with disabilities in all sectors (e.g., schools, workplaces, health care facilities, fitness centers). Fifth, health care providers must be trained and encouraged to counsel people with disabilities on appropriate and effective strategies for increasing physical activity. Sixth, university-based exercise science programs must add additional content across the curriculum in disability and physical activity and recommend to students that they obtain an entry-level certification sponsored by the American College of Sports Medicine (Certified Inclusive Fitness Trainer) that will increase their knowledge in accommodating people with disabilities in their programs.

James H. Rimmer is director of the University of Alabama at Birmingham/Lakeshore Foundation Research Collaborative.

References

1. Carroll, D., et al. 2014. Vital signs: Disability and physical activity—United States, 2009-2012. Morbidity and Mortality Weekly Report 63(18):407-413.

2. Brucker, D. L., and A. J. Houtenville. 2015. People with disabilities in the United States. Archives of Physical Medicine and Rehabilitation 96(5):771-774.

3. Clarke, P., et al. 2008. Mobility disability and the built environment. American Journal of Epidemiology 168:506-513.

4. Krahn, G., et al. 2015. Persons with disabilities as an unrecognized health disparity population. American Journal of Public Health 105:S198-S206.

5. Rimmer, J. H., et al. 2004. Physical activity participation among persons with disabilities: Barriers and facilitators. American Journal of Preventive Medicine 26(5):419-425.

6. Stuifbergen, A., et al. 1990. Barriers to health promotion for individuals with disabilities. Family and Community Health 13:11-22.

7. Phillips, M., et al. 2009. An exploratory study of physical activity and perceived barriers to exercise in ambulant people with neuromuscular disease compared with unaffected controls. Clinical Rehabilitation 23:746-755.

8. Rimmer, J. H., et al. 2000. Barriers to exercise in African American women with physical disabilities. Archives of Physical Medicine and Rehabilitation 81(2):182-188.

9. Drum, C., et al. 2009. Guidelines and criteria for the implementation of community-based health promotion programs for individuals with disabilities. American Journal of Health Promotion 24(2):93-101.

Suggested Citation: Rimmer, J. H. 2015. Physical activity for people with disabilities: How do we reach those with the greatest need? Commentary, Institute of Medicine, Washington, DC. http://nam.edu/wp-content/uploads/2015/06/PAandDisabilities.pdf.

DISPARITIES IN PHYSICAL ACTIVITY AMONG LOW-INCOME AND RACIAL/ETHNIC MINORITY COMMUNITIES: WHAT CAN WE DO?

Wendell C. Taylor, Ph.D., M.P.H., University of Texas Health Science Center at Houston, TX* April 2015

Eliminating disparities related to physical activity (PA) among low-income and racial/ethnic minority communities (hereinafter referred to as “high-priority groups”) is a complex, dynamic, and multifaceted challenge that requires complex, dynamic, and multifaceted solutions. First, we need to conduct more comprehensive and accurate assessments of PA in order to develop a clearer picture of PA patterns among high-priority groups. To accomplish this goal, self-report assessments of PA should be complemented with more objective and sensitive measures of PA, such as accelerometers, smartphone applications, and wearable technology devices.¹ Self-report assessments also should measure PA across multiple activity domains, including household, transportation, workplace, and recreation/leisure. Sedentary behavior as it relates to PA, weight status, and other health outcomes should be included in these assessments.² Furthermore, ecological momentary assessments with repeated and random sampling of PA and sedentary behavior in real time in natural environments should be conducted to minimize recall bias and maximize ecological validity.

Second, given the current social stratifications in Western societies, we need to consider justice principles, which include environmental justice, green justice, and social justice. Historically, high-priority groups have been disproportionately affected by injustices in these three areas. In terms of environmental justice, high-priority groups tend to live in communities deprived of health-promoting resources; thus, there is an inequality in the availability of PA resources.³

In this area, the goal is to develop and promote PA-friendly built environments (e.g., safe and walkable neighborhoods and access to recreation facilities) in all communities, especially those of color and low income.^4,5 In terms of green justice (i.e., natural environments), high-priority groups

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The views expressed in this commentary are those of the authors and not necessarily of the authors’ organization or of the Institute of Medicine. The commentary is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine and is not a report of the Institute of Medicine or of the National Research Council.

* Participants in the activities of the IOM Roundtable on Obesity Solutions.

generally lack access to parks where they can be active, play, and learn about the environment.^6,7 To help address this inequality, the National Park Foundation launched Every Kid in a Park, an initiative to get all fourth graders and their families to national parks and other federal lands by giving them free admission for a full school year. In this area, the goal is to maximize the opportunities for all communities, particularly those of color and low income, to experience and enjoy the outdoors.⁷ In terms of social justice, high-priority groups are adversely affected by various social factors, including poverty; inequitable education; lack of housing, jobs, and economic development; income inequalities; and stress associated with discrimination, racism, and poverty.⁸ These factors increase social isolation and depression, all of which are associated with decreased PA. In this area, the goal is to eliminate social disadvantages in order to increase PA levels for all communities, with those for high-priority groups increasing at a faster rate.

Third, we need to understand how high-priority groups adapt to and function in the surrounding community. The recently developed Community Energy Balance Framework (CEB) can help to achieve this objective.⁹ According to CEB, researchers, practitioners, and community organizers working with high-priority groups should contextualize their food- and PA-related sociocultural perspectives by accounting for relevant historical, political, and structural contexts. Importantly, the health consequences of cultural-contextual stressors and accommodating these stressors are emphasized. For intervention development, CEB identifies several factors and elements in three broad domains: cultural-contextual influences, intervention settings and agents, and intervention targets.⁹ Also, emerging evidence identifies social capital as a correlate of PA patterns in high-priority groups, so PA intervention programs should incorporate social capital indicators into their designs.^10,11

In conclusion, there is no single, simple strategy for eliminating PA-related disparities among high-priority groups. We need innovative, comprehensive, and multifaceted strategies emanating from community-based participatory approaches and theoretical frameworks.^12,13 The ultimate goal is to have health-promoting environments and the motivation to take full advantage of PA-friendly opportunities for all segments of society.¹⁴

Wendell C. Taylor, Ph.D., M.P.H., is associate professor of health promotion and behavioral sciences at the School of Public Health at the University of Texas Health Science Center at Houston, TX.

References

1. Whitt-Glover, M., et al. 2009. Disparities in physical activity and sedentary behaviors among U.S. children and adolescents: Prevalence, correlates, and intervention implications. Journal of Public Health Policy 30(Suppl 1):s309-s334.

2. Taylor, W., et al. 2015. Sedentary behavior, body mass index, and weight loss maintenance among African American women. Ethnicity & Disease 25(1):38-45.

3. Gordon-Larsen, P., et al. 2006. Inequality in the built environment underlies key health disparities in physical activity and obesity. Pediatrics 117(2):417-424.

4. Taylor, W., et al. 2006. Environmental justice: Obesity, physical activity, and healthy eating. Journal of Physical Activity & Health 3(Suppl 1):s30-s54.

5. Taylor, W., et al. 2008. Obesity, physical activity, and the environment: Is there a legal basis for environmental injustices? Environmental Justice 1(1):45-48.

6. Taylor, W., et al. 2007. Environmental justice: A framework for collaboration between public health and parks and recreation fields to study disparities in physical activity. Journal of Physical Activity & Health 4(Suppl 1):s50-s63.

7. Floyd, M., et al. 2009. Measurement of park and recreation environments that support physical activity in low-income communities of color: Highlights of challenges and recommendations. American Journal of Preventive Medicine 36(4 Suppl):S156-S160.

8. Day, K. 2006. Active living and social justice: Planning for physical activity in low-income, Black, and Latino communities. Journal of the American Planning Association 72(1):88-99.

9. Kumanyika, S., et al. 2012. Community energy balance: A framework for contextualizing cultural influences on high risk of obesity in ethnic minority populations. Preventive Medicine 55(5):371-381.

10. Broyles, S., et al. 2011. Integrating social capital into park use and active living framework. American Journal of Preventive Medicine 40(5):522-529.

11. Franzini, L., et al. 2010. Neighborhood characteristics favorable to outdoor physical activity: Disparities by socioeconomic and racial/ethnic composition. Health & Place 16(2):267-274.

12. Taylor, W., et al. 2007. Changing social and built environments to promote physical activity: Recommendations from low-income, urban women. Journal of Physical Activity & Health 4(1):54-65.

13. Blacksher, E., and G. Lovasi. 2012. Place-focused physical activity research, human agency, and social justice in public health: Taking agency seriously in studies of the built environment. Health & Place 18:172-179.

14. Taylor, W., et al. 2012. Environmental audits of friendliness toward physical activity in three income levels. Journal of Urban Health 89(2):296-307.

Suggested Citation: Taylor, W. C. 2015. Disparities in physical activity among low-income and racial/ethnic minority communities: What can we do? Commentary, Institute of Medicine, Washington, DC. http://nam.edu/wp-content/uploads/2015/06/PAandHighPriority.pdf.

INVESTING IN NATIVE COMMUNITY-LED STRATEGIES TO IMPROVE PHYSICAL ACTIVITY

Donald Warne, M.D., M.P.H., North Dakota State University, and Olivia Roanhorse, M.P.H., Notah Begay III Foundation* April 2015

Native Americans represent approximately 1 percent of the U.S. population, but account for some of the worst health outcomes related to preventable chronic diseases (diabetes, heart disease, cancer, alcoholism) than any other racial or ethnic group. In considering the risk factors for these diseases, Native American people have among the highest rates of obesity, with many children experiencing obesity rates two to three times greater than other racial/ethnic populations. But this was not always the case. Only in the last half of the 20th century have the documented cases of diabetes rates in Native communities increased so drastically.¹

From a public health perspective, the policies, systems, and environment have had a significant impact on rates of obesity. For example, the environment in many Native communities drastically changed over the past 200 years, shifting from traditional hunting and gathering or farming subsistence cultures to forced relocation and reservations, leading to sedentary lifestyles and dependence on federal government food programs. These drastic generational changes to the environment, culture, and language, and the connection to land and food, have had a direct impact on the health of Native American people.

Native American communities disproportionately lack access to safe places to exercise and for children to play. Families and communities face a variety of barriers to being physically active, such as limited access to parks and recreation facilities, dirt roads with little to no walkable areas, stray dogs, and gang violence. Physical activity has always been an integral part of Native American life and history from running for endurance and speed valued for hunting, to running as a spiritual connection.

Native peoples are well aware of the research that links social determinants of health to the health of a community (level of educational attain

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The views expressed in this commentary are those of the authors and not necessarily of the authors’ organization or of the Institute of Medicine. The commentary is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine and is not a report of the Institute of Medicine or of the National Research Council.

* Participants in the activities of the IOM Roundtable on Obesity Solutions.

ment, poverty, access to health services, etc.). For example, poverty leads to dependence on federal government food programs such as the Food Distribution Program on Indian Reservations or “commodity foods”). In addition, due to the remote nature of many Native communities, access to healthy food choices is a challenge due to the cost of transporting fresh fruits and vegetables and other perishable foods. As a result, food access is typically limited to preserved and packaged foods that can be transported and stored inexpensively. These foods are typically not the healthiest choices, and are not consistent with traditional healthy diets.

Using this lens, we can approach solutions and strategies to address the root causes of obesity. Understanding these social and environmental changes impacting Native people requires an understanding of their history and treatment in this country as well as how this history over hundreds of years has impacted and drastically changed Native communities, their environment, and their health. Understanding this context will help inform strategies and solutions that will shed light on the foundational inequities facing Native people and build on their resiliency and inherent strength.

Despite these significant challenges, there are numerous positive and promising Native-led strategies to increase physical activity in Native communities. For example, some tribes in the Northeast are working to bring back leg wrestling, which in previous times would help create strong, agile men. Also in the Northeast, traditional games like lacrosse are being promoted as part of children’s daily physical activity. In the Midwest, canoeing was not only a way to get around a land full of streams and lakes, but it also provided a means for fishing and collecting wild rice, a staple of many Midwestern tribes’ diets. In the Southwest, several Pueblo and Navajo chapters are returning to their roots as long-distance runners. Runners played a critical role for the Pueblos, not only for entertainment and keeping their people strong and healthy, but also as an intricate piece of the 1680 Pueblo revolt. Long-distance runners were tasked with sharing communication throughout the Pueblo villages for when and how the revolt would take place.² In addition, many Native communities are embracing the concept of food sovereignty and regaining traditional food systems. These efforts need to be evaluated, highlighted, and shared with other Native communities to expand the evidence base of promising practices in obesity prevention and to promote health in Native communities.

Donald Warne, M.D., M.P.H., is director of the Master of Public Health Program, chair of American Indian Public Health, and Mary J. Berg Distinguished Professor of Women’s Health at North Dakota State University. Olivia Roanhorse, M.P.H., is director of Native Strong: Healthy Kids,

Healthy Futures at the Notah Begay III Foundation and a member of the Roundtable on Obesity Solutions.

References

1. Will, J. C., et al. 1997. Diabetes mellitus among Navajo Indians: Findings from the Navajo Health and Nutrition Survey. Journal of Nutrition 127:10.

2. Nobokov, P. 1987. Indian running: Native American history and tradition. Santa Fe, NM: Ancient City Press.

Suggested Citation: Warne, D., and O. Roanhorse. 2015. Investing in Native community-led strategies to improve physical activity. Commentary, Institute of Medicine, Washington, DC. http://nam.edu/wp-content/uploads/2015/06/PAandNativeCommunities.pdf.

INCREASING MOVEMENT TO PROMOTE HEALTH AND LEARNING IN EARLY CHILDHOOD

Robert C. Whitaker, M.D., M.P.H., and Jeffrey S. Gehris, Ph.D., Temple University* April 2015

Public support is increasing for the investment in pre-kindergarten (pre-K) education for 3- and 4-year-olds.¹ If physical activity is going to be an integral part of pre-K education, changes are needed in the training of early childhood educators and in the physical environments of pre-K programs. When teachers are trained and motivated to move with children throughout the school day and have the spaces to do so, both children and teachers can benefit. Frequent movement is developmentally appropriate for preschool children, promotes health and learning, and can also improve the physical and mental health of teachers.

The main goal of pre-K and other early childhood education programs, such as Head Start, is to prepare children for elementary school. Efforts to increase young children’s physical activity are more likely to be implemented and sustained if they align with that goal. Therefore, movement needs to be promoted on the basis of its benefits for learning, not just for health. Movement can improve academic performance by developing cognitive functions, such as the ability to sustain and shift attention, remember information, and inhibit impulses.^2,3

Social and emotional learning can also be enhanced when children move together because this develops additional brain functions, such as locating one’s body in relation to others and interpreting and responding to non-verbal cues.⁴ When teachers move with children, it may enhance teacher–child relationship quality,⁵ which can also support learning.⁶ Finally, outdoor activity, which is associated with more energy expenditure than indoor activity,⁷ may also increase children’s cognitive stimulation because outdoor environments are more variable and complicated than indoor environments.⁸ Interventions have already been developed that emphasize the links between moving and learning by integrating physical activity into the teaching of academic concepts.^9,10

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The views expressed in this commentary are those of the authors and not necessarily of the authors’ organization or of the Institute of Medicine. The commentary is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine and is not a report of the Institute of Medicine or of the National Research Council.

* Participants in the activities of the IOM Roundtable on Obesity Solutions.

Teachers may also be motivated to support children’s physical activity if teachers find that moving with children improves their own physical and mental health. For children to learn well, their teachers must be healthy, and the health of early childhood educators has much room for improvement.¹¹ The early childhood education program must be viewed as the educators’ worksite, and the same level of support must be given to the teachers’ health and well-being as to the children’s learning. Integrating movement into early learning helps physical activity become part of the culture of learning and health at the school and workplace.

To integrate movement and learning, classroom teachers need training, and preschools require space and equipment that afford safe and enriching movement experiences.^5,12 All of this requires funding. Funding is most likely to follow from changing policy in two areas: (1) requirements for teacher certification and (2) requirements for program certification and quality rating.¹³ Degree-conferring programs that credential early childhood educators should require training in several areas: children’s gross motor development, the integration of movement experiences into academic learning, children’s safety during movement, and the development of the teacher’s own movement skills. Technical assistance to existing early childhood educators must address these same topics along with providing guidance about suitable equipment and space for both indoor and outdoor movement experiences. This training may need to come from experts in the physical education of young children. Program certification and quality rating should depend on indoor and outdoor space requirements and the availability of equipment and practices that support physical activity and gross motor development. These costs cannot be shifted onto the teachers, who are already poorly paid,¹⁴ or to the low-income families whose children may benefit most from these changes. As support grows for public pre-K investment, there is an opportunity to position physical activity as part of this investment because movement is necessary for learning and for the health of young children and teachers.

Robert C. Whitaker, M.D., M.P.H., is professor of public health and pediatrics and Jeffrey S. Gehris, Ph.D., is associate professor of kinesiology at Temple University.

References

1. Jones, J. M. 2014. In the United States, 70 percent favor federal funds to expand pre-K education: Americans view preschool education as less important than other education levels. Gallup, Inc. http://www.gallup.com/poll/175646/favor-federal-funds-expand-preeducation.aspx (accessed March 13, 2015).

2. Becker, D. R., et al. 2014. Physical activity, self-regulation, and early academic achievement in preschool children. Early Education and Development 25(1):56-70.

3. Diamond, A. 2013. Executive functions. Annual Review of Psychology 64(1):135-168.

4. Lobo, Y. B., and A. Winsler. 2006. The effects of a creative dance and movement program on the social competence of Head Start preschoolers. Social Development 15(3):501-519.

5. Gehris, J. S., et al. 2015. Teachers’ perceptions about children’s movement and learning in early childhood education programmes. Child: Care, Health, and Development 41(1):122-131.

6. Pianta, R. C. 1999. Enhancing relationships between children and teachers. Washington, DC: American Psychological Association.

7. Hinkley, T., et al. 2008. Preschool children and physical activity: A review of correlates. American Journal of Preventive Medicine 34(5):435-441.

8. Fjørtoft, I. 2004. Landscape as Playscape: The effects of natural environments on children’s play and motor development. Children, Youth and Environments 14(2):21-44.

9. Fox, M. K., et al. 2010. Efforts to meet children’s physical activity and nutritional needs: Findings from the I Am Moving, I Am Learning implementation evaluation: Final report. Washington, DC: Administration for Children and Families, U.S. Department of Health and Human Services.

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