COMMENTARIES
Opportunities for Public Health to Increase Physical Activity Among Youths Despite the well-known benefits of youths engaging in 60 or more minutes of daily physical activity, physical inactivity remains a significant public health concern. The 2008 Physical Activity Guidelines for Americans (PAG) provides recommendations on the amount of physical activity needed for overall health; the PAG Midcourse Report (2013) describes effective strategies to help youths meet these recommendations. Public health professionals can be dynamic change agents where youths live, learn, and play by changing environments and policies to empower youths to develop regularphysicalactivityhabits to maintain throughout life. We have summarized key findings from the PAG Midcourse Report and outlined actions that public health professionals can take to ensure that all youths regularly engage in health-enhancing physical activity. (Am J Public Health. 2015;105:421–426. doi: 10.2105/AJPH.2014.302325)
Katrina L. Piercy, PhD, RD, Joan M. Dorn, PhD, Janet E. Fulton, PhD, Kathleen F. Janz, EdD, Sarah M. Lee, PhD, Robin A. McKinnon, PhD, MPA, Russell R. Pate, PhD, Karin A. Pfeiffer, PhD, Deborah Rohm Young, PhD, Richard P. Troiano, PhD, and Risa Lavizzo-Mourey, MD, MBA
REGULAR PHYSICAL ACTIVITY has a myriad of health benefits for youths, many that are not related to body weight. In addition to increased cardiovascular and muscular fitness, strong evidence shows that physical activity can improve cardiovascular risk factors and metabolic health biomarkers, improve bone health, and contribute to favorable body composition.1 Moderate evidence indicates that physical activity benefits mental health and academic achievement.1---3
THE PROBLEM The 2008 Physical Activity Guidelines for Americans (PAG) recommends that youths get at least 60 minutes of physical activity every day for overall health benefits1; most should be of moderate to vigorous intensity. Data from the Centers for Disease Control and Prevention show that most US high school students are not getting the recommended amount of physical activity. In the seven days before the survey, more than 70% of students had not been active for 60 minutes each day, and 14% did not have a single day meeting the 60-minute recommendation.4 The public health community can help address the problem of inactivity and promote opportunities for physical activity where youths live, learn, and play. We have summarized the major strategies presented in the Physical Activity Guidelines for Americans
March 2015, Vol 105, No. 3 | American Journal of Public Health
Midcourse Report: Strategies to Increase Physical Activity Among Youth5 and identified actions public health professionals can take.
SOLUTIONS The US Department of Health and Human Services released the PAG Midcourse Report in 2013. A subcommittee of the President’s Council on Fitness, Sports, and Nutrition with expertise in physical activity completed the report. It describes evidence for 5 settings (schools, preschool and childcare centers, community, family and home, and primary care) where youths can be physically active (Figure 1). The subcommittee used a review of reviews approach to examine and synthesize findings from intervention strategies that were tested in various environments, and they summarized evidence as sufficient, suggestive, insufficient (emerging or no evidence), or evidence of no effect. The subcommittee defined sufficient evidence as consistent beneficial effects documented across studies and populations. Suggestive evidence described reasonably consistent evidence of effect but without evidence to make strong definite conclusions. Additional definitions and details are found in Table 2 of the PAG Midcourse Report.5 The subcommittee found sufficient or suggestive evidence for strategies to increase youths’ physical activity within the school, preschool, and childcare center and the built
environment settings. These strategies are our focus. Table 1 outlines the strategies for these settings as listed in the PAG Midcourse Report and presents opportunities for public health professionals to take action. We have described action steps for those working in public health to disseminate and implement solutions within these settings, potentially promising strategies that require additional research, and additional approaches to consider.
Effective Strategies Schools. Because of the amount of time youths spend in school, it is an optimal setting for students to be physically active. The reviews the subcommittee evaluated demonstrated sufficient evidence that implementing multicomponent physical activity programs in schools increases youths’ physical activity. Multicomponent programs include enhanced physical education ([PE]; e.g., increased lesson time, well-trained and qualified teachers, instruction that increases moderate- to vigorous-intensity physical activity), physical activity before and after school, and active transport (Table 1). A recent report from the Institute of Medicine3 supports these findings; provides recommendations for action at the national, state, district, and school levels; and suggests that a multilevel approach may be necessary to produce large-scale effects on school environments to support
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FIGURE 1—Sixty minutes or more a day: where kids live, learn, and play: Physical Activity Guidelines for Americans Midcourse Report, 2013.5
422 | Commentaries | Peer Reviewed | Piercy et al.
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TABLE 1—Strategies to Increase Physical Activity Among Youths and Potential Public Health Action: Physical Activity Guidelines (PAG) for Americans Midcourse Report, 2012 Strategies to Increase Physical Activity Among Youths
Potential Public Health Actions and Efforts to Support and Encourage School setting
Multicomponent Provide enhanced PE that increases lesson time, is delivered by well-trained specialists, and includes instructional practices that provide substantial moderate to vigorous
Quality professional development for PE teachers to enable increases in student moderate- tovigorous physical activity
physical activity. Provide classroom activity breaks.
Environmental changes to support organized physical activity opportunities during breaks or
Create activity sessions before and after school, including active transportation.
Integration of physical activity programs into the entire school curriculum
before and after school and increase availability of after-school activity space and equipment Build behavioral skills. Provide after-school activity space and equipment. PE Develop and implement a well-designed PE curriculum.
Training for teachers to better manage and organize PE classes
Enhance instructional strategies for PE. Provide teachers with appropriate training.
Inclusion of all youths by adjusting activities Specialized PE teachers to teach a PE curriculum that increases intrinsic motivation in students Multicomponent approaches that include PE
Active transportation
Support efforts to encourage the following:
Involve school personnel in intervention efforts.
Participation in walk or bike to school programs
Educate and encourage parents to participate with their children in active transportation
Community, school, parent, and law enforcement involvement
to school. Preschool and childcare center setting Provide portable play equipment on playgrounds and other play spaces. Provide staff with training in delivery of structured physical activity sessions for children and increase the time allocated for such sessions.
Training for teachers to incorporate physical activity into lessons and lead structured physical activity sessions
Integrate physically active teaching and learning activities into preacademic instructional
Educating parents about the benefits of physical activity
routines. Increase time that children spend outside.
Standards for incorporating regular physical activity every day Community setting
Built environment Improve the land use mix to increase the number of walkable and bikeable destinations in neighborhoods.
Partner with transportation and urban planning leaders to consider suitable locations for nonmotorized transportation, traffic-calming measures, and walkable destinations
Increase residential density so that people can use methods other than driving to reach
Educate policymakers about the associations between relevant aspects of the built
the places they need or want to visit.
environment and youths’ physical activity
Implement traffic-calming measures, e.g., traffic circles and speed bumps.
Encourage Complete Streets initiatives
Increase access to, density of, and proximity to parks and recreation facilities.
Systematically monitor community-built environments
Improve walking and biking infrastructure, e.g., sidewalks, multiuse trails, and bike lanes.
Encourage the use of Health Impact Assessments for relevant projects
Increase walkability of communities.
Aid in evaluating physical activity and other health outcomes related to relevant built environment improvements
Improve pedestrian safety structures, e.g., traffic lights. Increase vegetation, e.g., trees along streets. Decrease traffic speed and volume to encourage walking and biking for transportation. Reduce incivilities and disorders, e.g., litter and vacant or poorly maintained lots. Note. PE = physical education. We compiled potential public health actions from the findings of the review articles included in the PAG Midcourse Report.5
more physical activity. Other reports provide similar guidance.6---8 Some of these examples are enacted in states and school
districts. The 2012 School Health Policies and Practices Study9 documents that at least 50% of states reported distributing or providing
March 2015, Vol 105, No. 3 | American Journal of Public Health
materials on model policies or policy guidance or other materials to districts and schools on a variety of important topics such as PE
teacher certification or licensure, time requirements for PE, using fitness tests, physical activity outside PE and recess, and walking or
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biking to and from school. At the district level, 58.9% of elementary schools require recess. However, that leaves more than 40% of districts with no recess requirements, thus placing this important physical activity break at risk. Public health professionals can promote efforts to increase physical activity at the state level by doing the following: d
d
d
Support strong PE and activity policies that require districts and schools to provide more opportunities for students to engage in physical activity throughout the school year. Educate decision makers on the importance of enhancing statelevel requirements for teacher qualifications and training as well as total time dedicated to PE throughout the school year. Support efforts to require PE to be taught to all students every day in kindergarten through 12th grade.
Public health professionals can promote efforts to increase physical activity at the school district level by doing the following: d
d
d
Support efforts to expand or strengthen the physical activity component of their local wellness policy (schools participating in the federal school meal program are required to have a local wellness policy that includes physical activity goals). Provide quality professional development to PE teachers on implementing a comprehensive curriculum aimed at increasing moderate- to vigorous-intensity physical activity in PE classes. Convene and facilitate opportunities for schools to partner with local community resources to provide before- and after-school physical activity programs for students.
Public health professionals can promote efforts to increase physical activity in schools by doing the following: d
d
Continue to support PE teachers by providing them with research findings, training, tools, and instructional materials to deliver enhanced PE. Encourage schools to sign up to become an active school through the Let’s Move! Active Schools program,10 which provides schools with technical assistance and resources to develop, implement, and evaluate a multicomponent physical activity program.
School-based activity breaks are a low- to no-cost method of adding more activity to students’ school days and can be implemented with little or no equipment. Yet, only 11.8% of districts required that elementary schools provide regular physical activity breaks (i.e., physical activity outside PE class, including recess and classroom physical activity) during the school day.9 Only 10.8% of districts required this for middle schools and only 2.0% of districts required this for high schools.9 Finally, because of the promising nature of active transport to school and school-based activity breaks, government agencies and public health professionals can continue to support implementing safe routes to school, which enable students to walk or bike to and from school more safely. Preschool and childcare centers. Driven by a nationwide increase in obesity rates among children of preschool age (2---5 years),11 many states have reviewed, established, or upgraded their regulatory policies for physical activity and nutrition in childcare centers.12 Recently, the research community has given much more attention to
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identifying effective interventions for increasing physical activity through strategies applied in the 13---15
childcare setting.
d
d
The sub-
committee found suggestive evidence that interventions in this setting can increase young children’s physical activity; specific strategies are outlined in Table 1. Several specific strategies for promoting physical activity in childcare settings were particularly promising. These included providing portable play equipment on playgrounds and other play spaces,13,14 training staff to deliver structured physical activity sessions,13,14 increasing the frequency with which such sessions are incorporated into the center schedule,13,14 integrating physically active teaching and learning activities into instructional routines,15 and increasing the time that children spend outside.16 Successful implementation of these strategies requires training preschool and childcare center staff members to deliver the recommended strategies and to incorporate them into the schedule on a consistent basis. Enhanced regulatory policies can play an important role in supporting the implementation of these strategies. Typically, preschools and childcare centers are regulated at the state level, and often it is the state’s social services agency that has primary responsibility. However, education and public health agencies also may play important roles. Public health professionals can increase physical activity opportunities in preschool and childcare centers by supporting efforts to do the following: d
Adopt policies that establish standards for delivery of strategies to promote physical activity.12
d
d
Monitor center compliance with physical activity standards. Provide relevant training for oversight boards, center directors, and the staff of childcare center. Training should focus on implementing specific strategies to increase children’s physical activity in classroom and free play settings. Link centers with community resources that support center compliance with physical activity standards. Provide materials to educate parents and other members of the public about the importance of physical activity to the health of children.
Built environment. Enhancing community environments to make it easier and safer for people to be physically active is a viable strategy to increase physical activity for all youths. The subcommittee found evidence suggesting that certain aspects of built environment design improved youths’ physical activity rates, for example, increasing land use mix and residential density to improve the number of local walkable and bikeable destinations and implementing traffic-calming measures (e.g., speed bumps) to reduce traffic speed (Table 1). Public health officials can play an important role in conducting outreach, forging partnerships, and helping leaders and agencies most responsible for the built environment: parks and recreation, transportation, and urban planning.17---25 Such partnerships can help ensure that health-related considerations and goals will be incorporated into built environment---related plans and changes. Societal shifts appear to be under way that support changes to the built environment to
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increase physical activity, such as increased interest in mixed-use developments, access and use of public transportation, and reduced car ownership.26---29 Beyond improvements in physical activity, relevant changes to the built environment may have additional benefits, such as improved air quality, increased livability and quality of life, and environmental sustainability. Public health professionals at local and state levels can promote efforts to increase physical activity within the built environment by doing the following: d
d
d
d
d
d
d
Document the epidemiology of noncommunicable diseases and other health outcomes associated with reduced physical activity by geographic area to inform priorities related to the built environment. Educate leadership and staff in relevant agencies on the links between design of the built environment, physical activity, and health. Establish, promote, and participate in interagency workgroups focused on the built environment and health. Understand non---health agency priorities and identify areas of mutual interest. Hire staff with formal training in disciplines related to the built environment, such as those with joint master’s degrees in urban planning and public health. Encourage interagency collaboration through short- or longterm staff assignments between agencies of health, planning, transportation, and parks and recreation. Identify other partners interested in promoting walkable and bikeable communities, such as those focusing on promoting economic growth, tourism, and environmental sustainability
d
d
and engage with those partners in relevant activities. Educate local authorities about the Environmental Protection Agency guidelines on school siting, which recommends locating schools within walkable and bikeable distances from youths.30 Partner on applications for built environment and health-funding opportunities and collaborate on the implementation and evaluation of funded projects.
Potentially Promising Strategies The subcommittee did not find sufficient evidence to make recommendations for the family and home or primary care settings. Nonetheless, the PAG Midcourse Report indicated that these settings present opportunities to promote physical activity for youths. When children are not at school or in childcare, they are most often at home. Youths develop physical activity values and behaviors in the home, and parents and caregivers control most of the resources that facilitate physical activity. To further the evidence in the home setting, it will be important to conduct observational and longitudinal studies to identify family strategies that influence physical activity throughout childhood and adolescence. Which interventions are effective for specific developmental periods and how interventions can be adapted to meet the often changing structures of families should be considered. Most children and adolescents see a health care provider at least annually. Inquiring about youths’ physical activity and related counseling is a measure of preventive health care quality in the Healthcare Effectiveness Data and
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Information Set performance assessment tool.31 A nationally representative survey of primary care providers found that, among pediatricians and family practice physicians who care for pediatric patients, nearly all patients (98%) were asked general questions about the amount of physical activity they engaged in, and two thirds (66%) were asked specific questions about duration, intensity, and type of physical activity.32 The Healthcare Effectiveness Data and Information Set requirement for health care settings and the apparent interest in physical activity by providers highlights the need for research to identify best practices in primary care provider counseling. Additional research needs in the primary care setting include how counseling can best be delivered. Intervention studies are needed to identify the most effective types of counseling for specific developmental periods, the optimal intensity and delivery modes, and what strategies can be effective for healthy youths and youths with chronic conditions.
Research Applications for Public Health Professionals In the PAG Midcourse Report, key knowledge gaps across all settings that need to be filled to advance youths’ physical activity were identified. Research priorities include extending the length of research and follow-up; studying a variety of demographic, geographic, health status, racial/ ethnic, and socioeconomic status groups; conducting longitudinal assessments; and evaluating policies and programs. Public health professionals who are involved with supporting, planning, and conducting research within these identified areas can further the
knowledge of “what works” in a variety of populations. In addition, those working in public health can play critical roles in translating and disseminating key strategies identified in the PAG Midcourse Report at the local level to provide increased opportunities for youths to be physically active.
ENERGIZING PUBLIC HEALTH ACTION Together, the PAG and the PAG Midcourse Report provide the scientific basis for how much physical activity youths need and successful strategies to increase physical activity among youths. Public health professionals have tremendous opportunities for increasing physical activity rates of youths and helping them establish lifelong healthy habits. The PAG Midcourse Report provides specific, evidence-based strategies, and we have outlined opportunities for action by public health professionals, as summarized in Table 1. Within schools, preschool and childcare centers, and built environment settings, the strategies have been tested and are ready for widespread implementation and dissemination. Public health professionals are urged to collaborate with stakeholders across multiple sectors to promote and encourage physical activity opportunities where youths live, learn, and play. j
About the Authors Katrina L. Piercy is with the Office of Disease Prevention and Health Promotion, US Department of Health and Human Services, Rockville, MD. Joan M. Dorn, Janet E. Fulton, and Sarah M. Lee are with the US Department of Health and Human Services, Centers for Disease Control and Prevention, Atlanta, GA. Kathleen F. Janz is with the Department of Health and Human Physiology, University of Iowa, Iowa City. Robin A. McKinnon and
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Richard P. Troiano are with the US Department of Health and Human Services, National Institutes of Health, Bethesda, MD. Russell R. Pate is with the Department of Exercise Science, University of South Carolina, Columbia. Karin A. Pfeiffer is with the Department of Kinesiology, Michigan State University, East Lansing. Deborah Rohm Young is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA. Risa Lavizzo-Mourey is with the Robert Wood Johnson Foundation, Princeton, NJ. Correspondence should be sent to Katrina L. Piercy, 1101 Wootton Parkway, Suite LL100, Rockville, MD 20852 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This commentary was accepted September 11, 2014.
Contributors K. L. Piercy led the overall conceptualization, organization, writing, and review of the commentary. J. M. Dorn, J. E. Fulton, K. F. Janz, S. M. Lee, R. A. McKinnon, R. R. Pate, K. A. Pfeiffer, D. Rohm Young, and R. P. Troiano were involved in the conceptualization, writing, review, and editing of the commentary. R. Lavizzzo-Mourey was involved in the development and review of the commentary.
Acknowledgments The authors acknowledge and thank Anne Brown Rodgers for her review of the commentary.
Human Participant Protection There were no human participants involved in the research reported in this commentary and therefore institutional review board approval was not needed.
References 1. US Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Washington, DC; 2008. 2. Centers for Disease Control and Prevention. The Association Between School Based Physical Activity, Including Physical Education, and Academic Performance. Atlanta, GA: US Department of Health and Human Services; 2010.
3. Institute of Medicine. Educating the Student Body: Taking Physical Activity and Physical Education to School. Washington, DC: National Academies Press; 2013. 4. Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States 2011. MMWR Surviell Summ. 2011;61(4):1---162. 5. US Department of Health and Human Services. Physical Activity Guidelines for Americans Midcourse Report: Strategies to Increase Physical Activity Among Youth. Washington, DC; 2012. 6. Centers for Disease Control and Prevention. School health guidelines to promote healthy eating and physical activity. MMWR Surviell Summ. 2011;60 (RR---5):1---76. 7. Centers for Disease Control and Prevention. School-Based Obesity Prevention Strategies for State Policymakers. Atlanta, GA: US Department of Health and Human Services; 2010. 8. Waters E, de Silva-Sanigorski A, Hall BJ, et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2011;7(12):1---214. 9. Lee SM, Nihiser AJ, Fulton JE, Borgogna B, Zavacky F. Physical education and physical activity. In: Centers for Disease Control and Prevention, ed. Results from the School Health Policies and Practices Study 2012. Atlanta, GA: Centers for Disease Control and Prevention; 2012. 10. SHAPE America and the Alliance for a Healthier Generation. Let’s Move Active Schools. 2014. Available at: http://www. letsmoveschools.org. Accessed February 22, 2014. 11. Centers for Disease Control and Prevention; National Center for Health Statistics. National Health and Nutrition Examination Survey Data 2005---2008. Hyattsville, MD: US Department of Health and Human Services; 2010. 12. American Academy of Pediatrics; American Public Health Association; National Resource Center for Health and Safety in Child Care and Early Education. Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs. Elk Grove Village, IL; 2011. 13. Ward DS, Vaughn A, McWilliams C, Hales D. Interventions for increasing
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physical activity at child care. Med Sci Sports Exerc. 2010;42(3):526---534.
Physical Activity and Health in Design. New York: City of New York; 2010.
14. Kreichauf S, Wildgruber A, Krombholz H, et al. Critical narrative review to identify educational strategies promoting physical activity in preschool. Obes Rev. 2012;13(suppl 1):96---105.
24. Bruton CM, Bocarro JN, Henderson KA, Casper JM, Kanters KA. Physical activity and health partnerships among park and recreation departments in North Carolina. J Phys Act Health. 2011;29 (2):55---68.
15. Nixon CA, Moore HJ, Douthwaite W, et al. Identifying effective behavioural models and behaviour change strategies underpinning preschool- and schoolbased obesity prevention interventions aimed at 4---6-year-olds: a systematic review. Obes Rev. 2012;13(suppl 1):106--117. 16. Bower JK, Hales DP, Tate DF, Rubin DA, Benjamin SE, Ward DS. The childcare environment and children’s physical activity. Am J Prev Med. 2008;34(1):23--29. 17. Bors P, Dessauer M, Bell R, Wilkerson R, Lee J, Strunk SL. The Active Living by Design national program: community initiatives and lessons learned. Am J Prev Med. 2009;37(6, suppl 2):S313--S321. 18. Mowen AJ, Baker BL. Park, recreation, fitness, and sport sector recommendations for a more physically active America: a white paper for the United States national physical activity plan. J Phys Act Health. 2009;6(suppl 2):S236--S244. 19. US Department of Transportation. Research and Innovative Technology Administration. Metropolitan Area Transportation Planning for Healthy Communities. Washington, DC; 2012. 20. Coordinating Committee and Working Groups for the Physical Activity Plan. US National Physical Activity Plan. 2010. Available at: http://www. physicalactivityplan.org. Accessed September 13, 2012. 21. Centers for Disease Control and Prevention. Recommended Community Strategies and Measurements to Prevent Obesity in the United States: Implementation and Measurement Guide. Atlanta, GA: US Department of Health and Human Services; 2009. 22. Office of the Surgeon General. National Prevention Strategy. Washington, DC: US Department of Health and Human Services; 2011. 23. City of New York. New York City Active Design Guidelines: Promoting
25. Rube K, Veatch M, Huang K, et al. Developing built environment programs in local health departments: lessons learned from a nationwide mentoring program. Am J Public Health. 2014;104 (5):e10---e18. 26. US PIRG Education Fund Frontier Group. A New Direction: Our Changing Relationship With Driving and the Implications for America’s Future. Washington, DC: US PIRG Education Fund Frontier Group; 2013. 27. Doherty PC, Leinberger CB. The next real estate boom: how housing (yes, housing) can turn the economy around. 2010. Available at: http://www. washingtonmonthly.com/features/2010/ 1011.doherty-leinberger.html. Accessed November 9, 2014. 28. Kuhnimhof T, Armoogum J, Buehler R, Dargay J, Denstadli JM, Yamamoto, T. Men shape a downward trend in car use among young adults—evidence from six industrialized countries. Transp Rev. 2012;32(6):761---779. 29. Rubertino MJ. A volunteer nurse (RN) program: creating a successful strategy to improve customer service in today’s cost containment environment. Ohio Nurses Rev. 2014;89(3):12---13. 30. US Environmental Protection Agency. School citing guidelines. 2011. Available at: http://www.epa.gov/ schools/siting/downloads/School_ Siting_Guidelines.pdf. Accessed July 15, 2014. 31. National Committee for Quality Assurance. Summary table of measures, product lines and changes. In: National Committee for Quality Assurance, ed. Healthcare Effectiveness Data and Information Set (HEDIS). Technical Specifications for Health Plans. Vol. 2. Washington, DC; 2009. 32. Huang TT, Borowski LA, Liu B, et al. Pediatricians’ and family physicians’ weight-related care of children in the U.S. Am J Prev Med. 2011;41(1):24---32.
American Journal of Public Health | March 2015, Vol 105, No. 3
Opportunities for Public Health to Increase Physical Activity Among Youths Despite the well-known benefits of youths engaging in 60 or more minutes of daily physical activity, physical inactivity remains a significant public health concern. The 2008 Physical Activity Guidelines for Americans (PAG) provides recommendations on the amount of physical activity needed for overall health; the PAG Midcourse Report (2013) describes effective strategies to help youths meet these recommendations. Public health professionals can be dynamic change agents where youths live, learn, and play by changing environments and policies to empower youths to develop regularphysicalactivityhabits to maintain throughout life. We have summarized key findings from the PAG Midcourse Report and outlined actions that public health professionals can take to ensure that all youths regularly engage in health-enhancing physical activity. (Am J Public Health. 2015;105:421–426. doi: 10.2105/AJPH.2014.302325)
Katrina L. Piercy, PhD, RD, Joan M. Dorn, PhD, Janet E. Fulton, PhD, Kathleen F. Janz, EdD, Sarah M. Lee, PhD, Robin A. McKinnon, PhD, MPA, Russell R. Pate, PhD, Karin A. Pfeiffer, PhD, Deborah Rohm Young, PhD, Richard P. Troiano, PhD, and Risa Lavizzo-Mourey, MD, MBA
REGULAR PHYSICAL ACTIVITY has a myriad of health benefits for youths, many that are not related to body weight. In addition to increased cardiovascular and muscular fitness, strong evidence shows that physical activity can improve cardiovascular risk factors and metabolic health biomarkers, improve bone health, and contribute to favorable body composition.1 Moderate evidence indicates that physical activity benefits mental health and academic achievement.1---3
THE PROBLEM The 2008 Physical Activity Guidelines for Americans (PAG) recommends that youths get at least 60 minutes of physical activity every day for overall health benefits1; most should be of moderate to vigorous intensity. Data from the Centers for Disease Control and Prevention show that most US high school students are not getting the recommended amount of physical activity. In the seven days before the survey, more than 70% of students had not been active for 60 minutes each day, and 14% did not have a single day meeting the 60-minute recommendation.4 The public health community can help address the problem of inactivity and promote opportunities for physical activity where youths live, learn, and play. We have summarized the major strategies presented in the Physical Activity Guidelines for Americans
March 2015, Vol 105, No. 3 | American Journal of Public Health
Midcourse Report: Strategies to Increase Physical Activity Among Youth5 and identified actions public health professionals can take.
SOLUTIONS The US Department of Health and Human Services released the PAG Midcourse Report in 2013. A subcommittee of the President’s Council on Fitness, Sports, and Nutrition with expertise in physical activity completed the report. It describes evidence for 5 settings (schools, preschool and childcare centers, community, family and home, and primary care) where youths can be physically active (Figure 1). The subcommittee used a review of reviews approach to examine and synthesize findings from intervention strategies that were tested in various environments, and they summarized evidence as sufficient, suggestive, insufficient (emerging or no evidence), or evidence of no effect. The subcommittee defined sufficient evidence as consistent beneficial effects documented across studies and populations. Suggestive evidence described reasonably consistent evidence of effect but without evidence to make strong definite conclusions. Additional definitions and details are found in Table 2 of the PAG Midcourse Report.5 The subcommittee found sufficient or suggestive evidence for strategies to increase youths’ physical activity within the school, preschool, and childcare center and the built
environment settings. These strategies are our focus. Table 1 outlines the strategies for these settings as listed in the PAG Midcourse Report and presents opportunities for public health professionals to take action. We have described action steps for those working in public health to disseminate and implement solutions within these settings, potentially promising strategies that require additional research, and additional approaches to consider.
Effective Strategies Schools. Because of the amount of time youths spend in school, it is an optimal setting for students to be physically active. The reviews the subcommittee evaluated demonstrated sufficient evidence that implementing multicomponent physical activity programs in schools increases youths’ physical activity. Multicomponent programs include enhanced physical education ([PE]; e.g., increased lesson time, well-trained and qualified teachers, instruction that increases moderate- to vigorous-intensity physical activity), physical activity before and after school, and active transport (Table 1). A recent report from the Institute of Medicine3 supports these findings; provides recommendations for action at the national, state, district, and school levels; and suggests that a multilevel approach may be necessary to produce large-scale effects on school environments to support
Piercy et al. | Peer Reviewed | Commentaries | 421
COMMENTARIES
FIGURE 1—Sixty minutes or more a day: where kids live, learn, and play: Physical Activity Guidelines for Americans Midcourse Report, 2013.5
422 | Commentaries | Peer Reviewed | Piercy et al.
American Journal of Public Health | March 2015, Vol 105, No. 3
COMMENTARIES
TABLE 1—Strategies to Increase Physical Activity Among Youths and Potential Public Health Action: Physical Activity Guidelines (PAG) for Americans Midcourse Report, 2012 Strategies to Increase Physical Activity Among Youths
Potential Public Health Actions and Efforts to Support and Encourage School setting
Multicomponent Provide enhanced PE that increases lesson time, is delivered by well-trained specialists, and includes instructional practices that provide substantial moderate to vigorous
Quality professional development for PE teachers to enable increases in student moderate- tovigorous physical activity
physical activity. Provide classroom activity breaks.
Environmental changes to support organized physical activity opportunities during breaks or
Create activity sessions before and after school, including active transportation.
Integration of physical activity programs into the entire school curriculum
before and after school and increase availability of after-school activity space and equipment Build behavioral skills. Provide after-school activity space and equipment. PE Develop and implement a well-designed PE curriculum.
Training for teachers to better manage and organize PE classes
Enhance instructional strategies for PE. Provide teachers with appropriate training.
Inclusion of all youths by adjusting activities Specialized PE teachers to teach a PE curriculum that increases intrinsic motivation in students Multicomponent approaches that include PE
Active transportation
Support efforts to encourage the following:
Involve school personnel in intervention efforts.
Participation in walk or bike to school programs
Educate and encourage parents to participate with their children in active transportation
Community, school, parent, and law enforcement involvement
to school. Preschool and childcare center setting Provide portable play equipment on playgrounds and other play spaces. Provide staff with training in delivery of structured physical activity sessions for children and increase the time allocated for such sessions.
Training for teachers to incorporate physical activity into lessons and lead structured physical activity sessions
Integrate physically active teaching and learning activities into preacademic instructional
Educating parents about the benefits of physical activity
routines. Increase time that children spend outside.
Standards for incorporating regular physical activity every day Community setting
Built environment Improve the land use mix to increase the number of walkable and bikeable destinations in neighborhoods.
Partner with transportation and urban planning leaders to consider suitable locations for nonmotorized transportation, traffic-calming measures, and walkable destinations
Increase residential density so that people can use methods other than driving to reach
Educate policymakers about the associations between relevant aspects of the built
the places they need or want to visit.
environment and youths’ physical activity
Implement traffic-calming measures, e.g., traffic circles and speed bumps.
Encourage Complete Streets initiatives
Increase access to, density of, and proximity to parks and recreation facilities.
Systematically monitor community-built environments
Improve walking and biking infrastructure, e.g., sidewalks, multiuse trails, and bike lanes.
Encourage the use of Health Impact Assessments for relevant projects
Increase walkability of communities.
Aid in evaluating physical activity and other health outcomes related to relevant built environment improvements
Improve pedestrian safety structures, e.g., traffic lights. Increase vegetation, e.g., trees along streets. Decrease traffic speed and volume to encourage walking and biking for transportation. Reduce incivilities and disorders, e.g., litter and vacant or poorly maintained lots. Note. PE = physical education. We compiled potential public health actions from the findings of the review articles included in the PAG Midcourse Report.5
more physical activity. Other reports provide similar guidance.6---8 Some of these examples are enacted in states and school
districts. The 2012 School Health Policies and Practices Study9 documents that at least 50% of states reported distributing or providing
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materials on model policies or policy guidance or other materials to districts and schools on a variety of important topics such as PE
teacher certification or licensure, time requirements for PE, using fitness tests, physical activity outside PE and recess, and walking or
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biking to and from school. At the district level, 58.9% of elementary schools require recess. However, that leaves more than 40% of districts with no recess requirements, thus placing this important physical activity break at risk. Public health professionals can promote efforts to increase physical activity at the state level by doing the following: d
d
d
Support strong PE and activity policies that require districts and schools to provide more opportunities for students to engage in physical activity throughout the school year. Educate decision makers on the importance of enhancing statelevel requirements for teacher qualifications and training as well as total time dedicated to PE throughout the school year. Support efforts to require PE to be taught to all students every day in kindergarten through 12th grade.
Public health professionals can promote efforts to increase physical activity at the school district level by doing the following: d
d
d
Support efforts to expand or strengthen the physical activity component of their local wellness policy (schools participating in the federal school meal program are required to have a local wellness policy that includes physical activity goals). Provide quality professional development to PE teachers on implementing a comprehensive curriculum aimed at increasing moderate- to vigorous-intensity physical activity in PE classes. Convene and facilitate opportunities for schools to partner with local community resources to provide before- and after-school physical activity programs for students.
Public health professionals can promote efforts to increase physical activity in schools by doing the following: d
d
Continue to support PE teachers by providing them with research findings, training, tools, and instructional materials to deliver enhanced PE. Encourage schools to sign up to become an active school through the Let’s Move! Active Schools program,10 which provides schools with technical assistance and resources to develop, implement, and evaluate a multicomponent physical activity program.
School-based activity breaks are a low- to no-cost method of adding more activity to students’ school days and can be implemented with little or no equipment. Yet, only 11.8% of districts required that elementary schools provide regular physical activity breaks (i.e., physical activity outside PE class, including recess and classroom physical activity) during the school day.9 Only 10.8% of districts required this for middle schools and only 2.0% of districts required this for high schools.9 Finally, because of the promising nature of active transport to school and school-based activity breaks, government agencies and public health professionals can continue to support implementing safe routes to school, which enable students to walk or bike to and from school more safely. Preschool and childcare centers. Driven by a nationwide increase in obesity rates among children of preschool age (2---5 years),11 many states have reviewed, established, or upgraded their regulatory policies for physical activity and nutrition in childcare centers.12 Recently, the research community has given much more attention to
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identifying effective interventions for increasing physical activity through strategies applied in the 13---15
childcare setting.
d
d
The sub-
committee found suggestive evidence that interventions in this setting can increase young children’s physical activity; specific strategies are outlined in Table 1. Several specific strategies for promoting physical activity in childcare settings were particularly promising. These included providing portable play equipment on playgrounds and other play spaces,13,14 training staff to deliver structured physical activity sessions,13,14 increasing the frequency with which such sessions are incorporated into the center schedule,13,14 integrating physically active teaching and learning activities into instructional routines,15 and increasing the time that children spend outside.16 Successful implementation of these strategies requires training preschool and childcare center staff members to deliver the recommended strategies and to incorporate them into the schedule on a consistent basis. Enhanced regulatory policies can play an important role in supporting the implementation of these strategies. Typically, preschools and childcare centers are regulated at the state level, and often it is the state’s social services agency that has primary responsibility. However, education and public health agencies also may play important roles. Public health professionals can increase physical activity opportunities in preschool and childcare centers by supporting efforts to do the following: d
Adopt policies that establish standards for delivery of strategies to promote physical activity.12
d
d
Monitor center compliance with physical activity standards. Provide relevant training for oversight boards, center directors, and the staff of childcare center. Training should focus on implementing specific strategies to increase children’s physical activity in classroom and free play settings. Link centers with community resources that support center compliance with physical activity standards. Provide materials to educate parents and other members of the public about the importance of physical activity to the health of children.
Built environment. Enhancing community environments to make it easier and safer for people to be physically active is a viable strategy to increase physical activity for all youths. The subcommittee found evidence suggesting that certain aspects of built environment design improved youths’ physical activity rates, for example, increasing land use mix and residential density to improve the number of local walkable and bikeable destinations and implementing traffic-calming measures (e.g., speed bumps) to reduce traffic speed (Table 1). Public health officials can play an important role in conducting outreach, forging partnerships, and helping leaders and agencies most responsible for the built environment: parks and recreation, transportation, and urban planning.17---25 Such partnerships can help ensure that health-related considerations and goals will be incorporated into built environment---related plans and changes. Societal shifts appear to be under way that support changes to the built environment to
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increase physical activity, such as increased interest in mixed-use developments, access and use of public transportation, and reduced car ownership.26---29 Beyond improvements in physical activity, relevant changes to the built environment may have additional benefits, such as improved air quality, increased livability and quality of life, and environmental sustainability. Public health professionals at local and state levels can promote efforts to increase physical activity within the built environment by doing the following: d
d
d
d
d
d
d
Document the epidemiology of noncommunicable diseases and other health outcomes associated with reduced physical activity by geographic area to inform priorities related to the built environment. Educate leadership and staff in relevant agencies on the links between design of the built environment, physical activity, and health. Establish, promote, and participate in interagency workgroups focused on the built environment and health. Understand non---health agency priorities and identify areas of mutual interest. Hire staff with formal training in disciplines related to the built environment, such as those with joint master’s degrees in urban planning and public health. Encourage interagency collaboration through short- or longterm staff assignments between agencies of health, planning, transportation, and parks and recreation. Identify other partners interested in promoting walkable and bikeable communities, such as those focusing on promoting economic growth, tourism, and environmental sustainability
d
d
and engage with those partners in relevant activities. Educate local authorities about the Environmental Protection Agency guidelines on school siting, which recommends locating schools within walkable and bikeable distances from youths.30 Partner on applications for built environment and health-funding opportunities and collaborate on the implementation and evaluation of funded projects.
Potentially Promising Strategies The subcommittee did not find sufficient evidence to make recommendations for the family and home or primary care settings. Nonetheless, the PAG Midcourse Report indicated that these settings present opportunities to promote physical activity for youths. When children are not at school or in childcare, they are most often at home. Youths develop physical activity values and behaviors in the home, and parents and caregivers control most of the resources that facilitate physical activity. To further the evidence in the home setting, it will be important to conduct observational and longitudinal studies to identify family strategies that influence physical activity throughout childhood and adolescence. Which interventions are effective for specific developmental periods and how interventions can be adapted to meet the often changing structures of families should be considered. Most children and adolescents see a health care provider at least annually. Inquiring about youths’ physical activity and related counseling is a measure of preventive health care quality in the Healthcare Effectiveness Data and
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Information Set performance assessment tool.31 A nationally representative survey of primary care providers found that, among pediatricians and family practice physicians who care for pediatric patients, nearly all patients (98%) were asked general questions about the amount of physical activity they engaged in, and two thirds (66%) were asked specific questions about duration, intensity, and type of physical activity.32 The Healthcare Effectiveness Data and Information Set requirement for health care settings and the apparent interest in physical activity by providers highlights the need for research to identify best practices in primary care provider counseling. Additional research needs in the primary care setting include how counseling can best be delivered. Intervention studies are needed to identify the most effective types of counseling for specific developmental periods, the optimal intensity and delivery modes, and what strategies can be effective for healthy youths and youths with chronic conditions.
Research Applications for Public Health Professionals In the PAG Midcourse Report, key knowledge gaps across all settings that need to be filled to advance youths’ physical activity were identified. Research priorities include extending the length of research and follow-up; studying a variety of demographic, geographic, health status, racial/ ethnic, and socioeconomic status groups; conducting longitudinal assessments; and evaluating policies and programs. Public health professionals who are involved with supporting, planning, and conducting research within these identified areas can further the
knowledge of “what works” in a variety of populations. In addition, those working in public health can play critical roles in translating and disseminating key strategies identified in the PAG Midcourse Report at the local level to provide increased opportunities for youths to be physically active.
ENERGIZING PUBLIC HEALTH ACTION Together, the PAG and the PAG Midcourse Report provide the scientific basis for how much physical activity youths need and successful strategies to increase physical activity among youths. Public health professionals have tremendous opportunities for increasing physical activity rates of youths and helping them establish lifelong healthy habits. The PAG Midcourse Report provides specific, evidence-based strategies, and we have outlined opportunities for action by public health professionals, as summarized in Table 1. Within schools, preschool and childcare centers, and built environment settings, the strategies have been tested and are ready for widespread implementation and dissemination. Public health professionals are urged to collaborate with stakeholders across multiple sectors to promote and encourage physical activity opportunities where youths live, learn, and play. j
About the Authors Katrina L. Piercy is with the Office of Disease Prevention and Health Promotion, US Department of Health and Human Services, Rockville, MD. Joan M. Dorn, Janet E. Fulton, and Sarah M. Lee are with the US Department of Health and Human Services, Centers for Disease Control and Prevention, Atlanta, GA. Kathleen F. Janz is with the Department of Health and Human Physiology, University of Iowa, Iowa City. Robin A. McKinnon and
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Richard P. Troiano are with the US Department of Health and Human Services, National Institutes of Health, Bethesda, MD. Russell R. Pate is with the Department of Exercise Science, University of South Carolina, Columbia. Karin A. Pfeiffer is with the Department of Kinesiology, Michigan State University, East Lansing. Deborah Rohm Young is with the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA. Risa Lavizzo-Mourey is with the Robert Wood Johnson Foundation, Princeton, NJ. Correspondence should be sent to Katrina L. Piercy, 1101 Wootton Parkway, Suite LL100, Rockville, MD 20852 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This commentary was accepted September 11, 2014.
Contributors K. L. Piercy led the overall conceptualization, organization, writing, and review of the commentary. J. M. Dorn, J. E. Fulton, K. F. Janz, S. M. Lee, R. A. McKinnon, R. R. Pate, K. A. Pfeiffer, D. Rohm Young, and R. P. Troiano were involved in the conceptualization, writing, review, and editing of the commentary. R. Lavizzzo-Mourey was involved in the development and review of the commentary.
Acknowledgments The authors acknowledge and thank Anne Brown Rodgers for her review of the commentary.
Human Participant Protection There were no human participants involved in the research reported in this commentary and therefore institutional review board approval was not needed.
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