A Report to the President From the Secretary of Health and Human Services and the Secretary of Education

Executive Summary
Our nation’s young people are, in large measure, inactive, unfit, and increasingly overweight. In the long run, this physical inactivity threatens to reverse the decades-long progress we have made in reducing death from cardiovascular diseases and to devastate our national health care budget. In the short run, physical inactivity has contributed to an unprecedented epidemic of childhood obesity that is currently plaguing the United States. The percentage of young people who are overweight has doubled since 1980.

Enhancing efforts to promote participation in physical activity and sports among young people is a critical national priority.
Physical activity has been identified as one of our nation’s leading health indicators in Healthy People 2010, the national health objectives for the decade. Enhancing efforts to promote participation in physical activity and sports among young people is a critical national priority. That is why, on June 23, 2000, President Clinton issued an Executive Memorandum directing the Secretary of Health and Human Services and the Secretary of Education to work together to identify and report within 90 days on "strategies to promote better health for our nation’s youth through physical activity and fitness." The President concluded his directive: "By identifying effective new steps and strengthening public-private partnerships, we will advance our efforts to prepare the nation’s young people for lifelong physical fitness."

   To increase their levels of physical activity and fitness, young people can benefit from

* Families who model and support participation in enjoyable physical activity.
 

* School programs—including quality, daily physical education; health education; recess; and extracurricular activities—that help students develop the knowledge, attitudes, skills, behaviors, and confidence to adopt and maintain physically active lifestyles, while providing opportunities for enjoyable physical activity.
 

* After-school care programs that provide regular opportunities for active, physical play.
 

* Youth sports and recreation programs that offer a range of developmentally appropriate activities that are accessible and attractive to all young people.
 

* A community structural environment that makes it easy and safe for young people to walk, ride bicycles, and use close-to-home physical activity facilities.
 

* Media campaigns that help motivate young people to be physically active.
 

Strategies
The following strategies are all designed to promote lifelong participation in enjoyable and safe physical activity and sports.
 

1. Include education for parents and guardians as part of youth physical activity promotion initiatives.
2. Help all children, from prekindergarten through grade 12, to receive quality, daily physical education. Help all schools to have certified physical education specialists; appropriate class sizes; and the facilities, equipment, and supplies needed to deliver quality, daily physical education.
3. Publicize and disseminate tools to help schools improve their physical education and other physical activity programs.
4. Enable state education and health departments to work together to help schools implement quality, daily physical education and other physical activity programs

* With a full-time state coordinator for school physical activity programs.
 

* As part of a coordinated school health program.
 

* With support from relevant governmental and nongovernmental organizations.
 

5. Enable more after-school care programs to provide regular opportunities for active, physical play.
6. Help provide access to community sports and recreation programs for all young people.
7. Enable youth sports and recreation programs to provide coaches and recreation program staff with the training they need to offer developmentally appropriate, safe, and enjoyable physical activity experiences for young people.
8. Enable communities to develop and promote the use of safe, well-maintained, and close-to-home sidewalks, crosswalks, bicycle paths, trails, parks, recreation facilities, and community designs featuring mixed-use development and a connected grid of streets.
9. Implement an ongoing media campaign to promote physical education as an important component of a quality education and long-term health.
10. Monitor youth physical activity, physical fitness, and school and community physical activity programs in the nation and each state.

Implementation
Full implementation of the strategies recommended in this report will require the commitment of resources, hard work, and creative thinking from many partners in federal, state, and local governments; nongovernmental organizations; and the private sector. Only through extensive collaboration and coordination can resources be maximized, strategies integrated, and messages reinforced. Development or expansion of a broad, national coalition to promote better health through physical activity and sports is an important first step toward collaboration and coordination. A foundation to support the promotion of physical activity could complement the work of the coalition and play a critical role in obtaining the resources needed to help our young people become physically active and fit. The 10 strategies and the process for facilitating their implementation described in this report provide the framework for our children to rediscover the joys of physical activity and to incorporate physical activity as a fundamental building-block of their present and future lives.

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Promoting Physical Activity and Exercise Among Children

Liane M. Summerfield

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Introduction
     Physical inactivity has become a serious problem in the United States.  More than half of U.S. adults do not meet recommended levels of moderate physical activity, and one-fourth engage in no leisure time physical activity at all (Physical Activity, 1996). Inactivity is more prevalent among those with lower income and education, and, beginning in adolescence, affects females more than males (NIH, 1995; Physical Activity, 1996). A pattern of inactivity, also known as sedentism, begins early in life, making the promotion of physical activity among children imperative. This Digest discusses the importance of and ways to foster activity and exercise in children.
Why Is Physical Activity Important?
     Physical activity has been defined as "bodily movement produced by skeletal muscles that results in energy expenditure" (Pate, Pratt et al., 1995). There is no debate about the value of  physical exertion--regular physical activity has significant health benefits, and even modest increases in energy expenditure can have health-enhancing effects, including:

* Reduction in chronic disease risk--hypertension, type 2 diabetes,  high blood lipids, cardiovascular disease, and obesity. Even among children and adolescents, physical activity can prevent or delay the development of hypertension and can reduce blood pressure in those young people who already have hypertension (Physical Activity, 1996);
* Lowered risk of colon cancer;
* Increase in bone density;
* Reduction of anxiety, improvement in body image and mood;
* Development of physical fitness;
* Promotion of weight control through caloric expenditure. This benefit is of particular importance to children, who are experiencing the same epidemic of overweight as adults.

Childhood Obesity: A Cause for Concern
     More children today are overweight or obese than ever before. Overweight means that the individual weighs more than is recommended for a given height; when this excess weight is in the form of fat, health problems may develop. Obesity is an excess of body fat. In children obesity has been variously defined as

* >20% over the recommended weight for height;
* >85th percentile for Body Mass Index, which is calculated by dividing weight in kg by height in m2; or
* >25% of weight as fat for boys and > 30% of weight as fat for girls (Strategy Development, 1996).

     When the percent fat definition is used, data indicate that 11% of 6-11 year olds and 14% of 12-17 year olds are obese (Strategy Development, 1996), double the prevalence of 30 years ago (CDC, 1996).  This is of particular concern because body weight and overfatness in children are significant cardiovascular disease risk factors, and the risk tracks into adolescence and young adulthood if not checked in childhood. In addition, obese children often experience exclusion from social groups and low self-esteem.

     Particularly detrimental to health is central (abdominal) body fat, which is linked to cardiovascular disease and diabetes. Studies examining the relationship between physical activity and abdominal fat suggest that those who are more active are less likely to deposit fat in the abdominal area (NIH, 1995). Physical activity is thus a key element in the prevention and treatment of both chronic disease and obesity.

How Much Physical Activity Is Enough?
     Health benefits can be derived simply from becoming more physically active, but the greatest benefits come from engaging in planned and structured exercise. Cardiovascular risk factors can be reduced and physical fitness enhanced with low to moderate levels of physical activity (40-60% of a person's maximal aerobic capacity) (Blair & Connelly, 1996). And, low- to moderate-intensity activity is less likely than vigorous exercise to cause musculoskeletal injury and sudden heart attack death during exercise (a very rare occurrence even for vigorous exercisers), while it is more likely to promote continued adherence to activity (Blair & Connelly, 1996; NIH, 1995).
     Current recommendations state that children and adults should strive for at least 30 minutes daily of moderate intensity physical activity (Pate, Pratt et al., 1995). An alternate approach that may be equally beneficial would be to engage in 5- (Blair & Connelly, 1996) to 10-minute (NIH, 1995) bouts of moderate intensity activity throughout the day, for a total accumulation of at least 30 minutes for adolescents and adults and 60 minutes for children (Pangrazi, Corbin, & Welk, 1996). Walking briskly or biking for pleasure or transportation, swimming, engaging in sports and games, participating in physical education, and doing tasks in the home and garden may all contribute to accumulated physical activity.
     Children and adults who already engage in regular activity may benefit from more vigorous activity. The specific amount of energy expenditure needed by children to decrease their risk of cardiovascular disease is not known; for adults, approximately 3 kcals/kg of body weight/day has been recommended (Zwiren, 1993).  Weight in pounds can be converted to kg by dividing by 2.2. Thus, a 140-pound person (140/2.2 = 63.6 kg) should expend about 192 kcals/day (63.6 X 3).
How Can We Promote Physical Activity among Young People?
     Quality Daily Physical Education
     In addition to being physically active, children need to learn fundamental motor skills and develop health related physical fitness (cardiovascular endurance, muscular strength and endurance, flexibility, and body composition). Physical education, provided at school, is an ideal way to encourage activity and develop fitness among children and, for many children, will be their only preparation for an active lifestyle. For this reason, the Centers for Disease Control and Prevention (CDC), the National Association for Sport and Physical Education (NASPE), and the American Heart Association all recommend comprehensive daily physical education for children K-12.
     Over the years, state requirements for daily physical education have eroded, and today no states currently have such a requirement (Healthy People, 1995). Not surprisingly, only a quarter of high school students participate in daily physical education, and only 19% of high school students are active for at least 20 minutes a day during physical education class (Physical Activity, 1996). The recent School Health Policies and Programs Study (SHPPS), conducted by CDC, determined that just 47% of middle/junior high schools and 26% of high schools require at least 3 years of physical education (Pate, Small et al., 1995).
     Physical education offers many benefits: development of motor skills needed for enjoyable participation in physical activities; promotion of physical fitness; increased energy expenditure; and promotion of positive attitudes toward an active lifestyle. Evidence also exists that physical education may enhance academic performance, self-concept, and mental health (Allensworth, Lawson, Nicholson, & Wyche, 1997).
     Other Ways to Incorporate Activity into Schools
     In addition to physical education, schools can promote physical activity in a variety of other ways (much of this is based on CDC, 1997):

* Promote collaboration between physical education and classroom teachers. For example, physical education teachers might provide ideas for "fitness breaks" to classroom teachers, where 5-minute aerobic activities could be used to break up the school day.
* Provide extracurricular physical activity programs. Interested teachers and parents might be encouraged to establish developmentally appropriate clubs and/or intramural activities of a competitive and noncompetitive nature. Walking clubs, in-line skating, jumping rope, water aerobics, and intramural swim teams provide a few examples.
* Coordinate physical activities with community agencies. Schools might allow use of school facilities by community agencies that sponsor physical activity programs, facilitate training programs for volunteer youth coaches, invite community groups to an "activity fair" for students in the school gymnasium, or provide a listing of community physical activity resources to students.
* Encourage and enable parental involvement in physical activity. Parental activity level is very important in promoting activity among children. Schools can help encourage activity in parents by sending home activity homework that parents and children do together, recruiting parent volunteers for physical education classes, and sponsoring parent-child activity programs at school.
* Provide physical and social environments that encourage and enable physical activity. For example, schools might allow access to facilities before and after school hours and during vacation periods, encourage teachers to provide time for unstructured physical activity during recess and during physical education class, and help school personnel to serve as active role models by enabling and encouraging their own participation in physical activity.

Conclusion
     Inactive adults have twice the mortality of adults who are at least somewhat active (Blair & Connelly, 1996). Schools that promote physical activity may have a significant impact on reducing childhood obesity, chronic disease, and, ultimately, adult mortality. Insofar as physical activity has been associated with increased academic performance, self-concept, mood, and mental health, the promotion of physical activity and exercise may also improve quality of life.