INTRODUCTION

Standardized testing and academic achievement scores have become a staple of evaluation not only for students but also for schools. Well-intended societal and financial pressures to help our students and schools succeed have led to a unilateral focus on sedentary classroom learning activities. However, this has come at a cost to our children. In order to provide this increased teaching time that was perceived to be necessary to properly educate students, subsequent cuts to nonacademic areas, particularly those involving physical activity such as physical education (PE) and recess, have been extensive across the country. In fact, since the No Child Left Behind act was passed in 2001, 44% of school administrators reported cutting significant time from PE and recess in order to increase time spent in reading and math (64). In spite of this, a growing body of literature seems to indicate that an opposite approach should likely be instituted.

In an attempt not to interchange the words exercise and physical activity, it should be made clear that exercise is a form of physical activity that is planned, structured, and done to improve at least one aspect of physical fitness like strength, flexibility, or aerobic endurance. Meanwhile, PE, although with a focus on physical activity, is a formalized course taught by professionals to provide the skills and knowledge needed to establish and sustain an active lifestyle.

BACKGROUND

Two topics identified as focus areas for Healthy People 2010 were 1) physical activity and fitness and 2) nutrition and overweight (29,30,72). However, despite their allotted level of significance, not only were the decade goals set forth not met, the status of the obesity epidemic is also worsening (31,75). What is more, this is not just an American issue but rather a global threat (34). Childhood and youth physical inactivity has been identified as a clear worldwide concern (25). In fact, 5.3 million deaths across the world were attributed to physical inactivity alone in 2007 (37).

Over the past 20 years, the percentage of youth considered overweight has more than tripled (approximately 18% aged 6 to 19) with additional evidence depicting that life habits form early, with 80% of overweight youth later becoming adults who are obese (29,30,72). In addition, over half of adults and approximately one-third of high school–aged children do not participate in recommended levels of physical activity that equate to provide general health benefits (16,17,21–23,29,30,36,38,62,68,72).

These statistics are of great concern because of the medical implications to which physical inactivity and obesity can lead. Obesity is now the most common chronic disease in childhood (10). Furthermore, the average body mass index (BMI) among youth has increased from 21.3 to 24.1 kg·m−2 since 1963 and type 2 diabetes mellitus, once rare, now represents 45% of all cases of diabetes among youth (39). Links to many chronic diseases exist and include such illnesses as hypertension, dyslipidemia, diabetes, coronary heart disease, stroke, osteoarthritis, sleep apnea, and even some cancers (15,26,46). We will examine in this article whether cognition and academic achievement also should be added to this list.

Obviously, attempting to address this epidemic does not come cheap. Financially, in the year 2000, it was estimated that the total cost of obesity in the United States was $117 billion, with $61 billion from medical expenses (29,30,72). Meanwhile, direct health care costs from physical inactivity were estimated at over $76 billion for the same year. It is expected that by 2018, these same medical-related expenses will cost the United States $344 billion, an astonishing 21% of the health care spending for our country (70). These figures do not even begin to address the associated issues of quality of life, morbidity, or mortality. In fact, poor diet coupled with lack of exercise is the second leading risk factor for death and its distance behind tobacco use is dramatically shrinking (45).

SIGNIFICANCE

Admittedly, obesity is a multifactorial disease, as nutrition and screen time (television, video games, computer) also affect an individual’s level of physical activity and weight (5,19,20,55). Nonetheless, current recommendations from the U.S. Centers for Disease Control and Prevention (CDC) and its Division of Nutrition, Physical Activity, and Obesity call for at least 60 min of activity every day of the week for those aged 6 to 17 years (73). The American College of Sports Medicine, the American Heart Association, the American Medical Society for Sports Medicine, the CDC, and the Department of Health and Human Services all support and have distinct guidelines for adults and children regarding physical activity and public health (2–4,27,28,41,57). However, as of 2013, only 27.1% of high school students participated in at least 60 min·d−1 of physical activity on all 7 d of the week (11). The intimate relationship between physical activity and obesity is not a new concept, and with one in three kids now considered overweight or obese, there is a need for a society-wide approach to treating childhood obesity.

Schools remain an important setting in which to promote national health objectives, including lifetime physical activity, which many have recognized as one of the keys to healthy living (1,24,33,44,56,58,60,68). It is generally believed that those who choose to exercise regularly also tend to adopt other positive health habits and vice versa (50–53). In addition, a prospective study carried out for close to 30 years involving more than 3500 boys and girls in six age cohorts between 3 and 18 years old showed that not only do physical activity habits develop very early in childhood but they also track at a moderate or high level over time from youth to adulthood (63).

Opportunities for participation on sports teams and othe r modes of vigorous activity may vary by setting, but PE is available almost uniformly. This wide-ranging presence allows PE to be uniquely positioned as an important public health tool. Unfortunately, there is a great amount of disparity among state-, district-, and even school-level opportunities for and enforcement of PE requirements. In 2013, only 29% of students overall attended PE daily (11). A breakdown from 2006 reveals that 4% of elementary schools, 8% of middle schools, and 2% of high schools offered daily PE in all grades (8). Meanwhile, only 53.6% of high school students had PE at least 1 d·wk−1 (8). In addition, only 57% elementary schools had recess as part of the school day (8). Bergeron (6) makes a noteworthy point that participation alone is not enough and in order to meet recommended levels of activity, programs need to have opportunities for all students to practice or play hard. In other words, we need to maximize the time and involvement for all.

Children spend a large portion of their day in school, and many of the lifestyle and behavior choices associated with obesity develop during the school age years (18). School policies can address meals, physical activity, and health education. Children are less likely to participate in physical activity in the absence of adult supervision (61). School programs can create expectations for regular physical activity that may persist into adulthood. It is important that health-related fitness in general be emphasized over activities that require specific athletic abilities (24). This can occur at school in PE classes or in combination with other opportunities such as after-school programs.

As part of moving forward in this aim, we need to reincentivize schools to offer PE. However, we need to know what to fix before we can offer solutions, and therefore, it is necessary to also identify the additional barriers as to why PE is decreasing in schools outside of the drive for higher test scores on school performance measures. Major issues affecting the delivery of quality PE in schools surround a qualified workforce as well as curriculum regulations. For example, challenges include a decrease in the amount of time allocated to PE, the number of trained staff, the amount of training provided for PE teachers, and the spending on resources required to deliver PE.

Several studies over time have demonstrated that evidence-based PE programs increased physical activity by as much as 18%; however, adoption remains limited (42). In an attempt to evaluate why, over 150 elementary schools were surveyed across the country (42). The results showed that teachers in adopter schools were more satisfied with PE program outcomes and had greater involvement in teacher evaluation and program decision making. Compared with teachers, principals were generally more satisfied with their schools’ PE program outcomes, did not share the same perceptions of PE barriers, but also demonstrated a general lack of PE program familiarity. Therefore, efforts should target both administrators and PE teachers, while increasing knowledge for principals may be important in addressing some of the teacher perceptions regarding barriers to PE.

Another area of need is the recognition of PE as an important topic on the curriculum. Historically, PE tends to be marginalized in the hierarchy of school curricula compared with academic subjects. Correspondingly, it receives lower prestigious esteem from educators and therefore is not appreciated for its potential to contribute to the educational experience and overall well-being of children. PE cannot be viewed solely as recreation.

A related barrier is the issue of professional development and the lack of opportunities and support for PE teachers. Previous political and educational mandates have placed a focus on areas that teachers and schools are held publicly accountable for — language and numbers. As a result, efforts to improve practice habits in the area of PE have suffered. The quality of teaching is also affected when nonspecialist teachers or appropriately trained individuals are given the task of leading PE. This situation allows for programs that lack structure and systematic goals, therefore contributing to the perceived low status and value of PE. To borrow a phrase from coaching, the mentality of “just rolling the balls out” does not work. Skill development and learning for life-long health habits need to be properly taught and evaluated. Programs need to be planned, developmentally appropriate, have progression and sequencing in mind, and engage students. As mentioned previously, you cannot have only the “good” or “interested” players participating.

The terms “physical activity” and “physical education” are not interchangeable. Being active is different from educating students about body management, motor skills, fitness, and health. An effective PE teacher provides opportunities not only for activity but also learning. The role of physical activity is undeniable; however, physical activity in and of itself does not create a physically educated person who builds lifelong health habits through the potential for lower risk of injury and greater degrees of motor skill development as well as movement and performance capabilities. Enjoyment, comfort, and competence are key factors for any of us wanting to do something regularly. The promotion of PE in school requires the proper understanding of its value and contribution to the development of the whole child. Efforts to improve this with evidence are critical and involve all stakeholders in both the academic and exercise worlds. PE teachers should want their students to be competent and excel in exercise-related skills for life just like what academic subject teachers envision for their students with regard to math, science, and language.

This is a multifaceted issue as seen in a survey of 115 PE teachers that revealed that the majority of perceived barriers were institutional in nature as previously discussed (budget constraints, scarce resources, time constraints, absence of professional development, lack of facilities and equipment, low-priority placement, absence of performance measures); it also was revealed that two-thirds of teachers recognized their own difficulties in engaging students when teaching as a potential obstacle to student participation (35). Teachers self-reported low levels of confidence or interest in teaching, inability to provide safely planned and structured lessons, previous personal negative experiences in PE, and the lack of training, knowledge, expertise, or qualifications to provide PE as barriers. They also felt that a student’s participation was influenced by either their own (45%) low level of interest or by that of their peers (62%). It is no surprise that changes in behavior appear to be more successful when done at lower grade levels, with PE teachers reporting a trend of lower fitness levels in students as they got older. Other possible solutions on the student side include promoting positive peer interaction that encourages and supports activity, empowering students by increasing their roles and responsibilities, offering elective topics, nontraditional sports or activities, and innovative approaches to traditional sports or activities. On the teacher side, a clear area of need is providing continuing education opportunities for PE teachers in their specialty and making sure to provide appropriate training to generalist teachers with the responsibility of also teaching PE if specialists are not available in your school. Having an awareness of the possible barriers is an important first step in order to make change in regard to PE teaching, curriculum design, teacher training, and adolescent participation.

Every human being should have a fundamental right of access to PE and sports. Many international and domestic policies highlight the role of athletics as a key component of child development and, as stated in the United Nations Convention on the Rights of the Child, serve to do so along with the associated aspects related to sport, play, and recreation, such as the right to participate, the right to freedom of expression, and the right to be involved “freely in cultural life and the arts” (71). Therefore, particular attention should be paid to additional barriers that limit or even prevent participation in physical activity and sport for often neglected populations worldwide such as females and those with disabilities. This stance allows for sport, recreation, and play to be considered not only as a necessary part of child and youth development (a “needs-based” perspective) but also one in which sport, recreation, and play are considered as entitlements (a “rights-based” perspective). As so simply and exquisitely stated by the Exercise is Medicine® campaign, if exercise was a pill, we would all take it and prescribe it.

The groundbreaking Shape of the Nation Report provides recommendations regarding what is felt to be the critical elements of a quality PE program (50). These include the following: 1) PE is delivered by certified/licensed PE teachers; 2) adequate time is provided at every grade (K–12), 150 min·wk−1 in elementary school and 225 min·wk−1 in middle and high school; 3) all states set minimum standards for student learning and achievement; 4) successful completion of PE be a requirement for high school graduation; and 5) follow positive PE pledge developed by National Association for Sport and Physical Education in 2004. It also is stressed that this system be promoted and supported by families and the community through encouragement, accountability, and resources.

DISCUSSION

The health benefits of exercise are clear. Extending fitness beyond the physical and to the mental is the next public health challenge for sports medicine professionals. Exercise has been shown to have many positive effects on the brain, with an even greater effect seen on developing brains in children.

How Physical Activity Affects the Brain (59,69) Taken from: CDC (8) Cognitive skills and motor skills appear to develop through a dynamic interaction. Research has shown that physical movement can affect the brain’s physiology by increasing the following: Cerebral capillary growth

Blood flow

Oxygenation

Production of neurotrophins

Growth of nerve cells in the hippocampus (center of learning and memory)

Neurotransmitter levels

Development of nerve connections

Density of neural network

Brain tissue volume These physiological changes may be associated with the following: Improved attention

Improved information processing, storage, and retrieval

Enhanced coping

Enhanced positive affect

Reduced sensations of cravings and pain

It appears that the physical act of movement has an actual effect on brain physiology. It is hypothesized that the neurophysiological changes that occur in the brain as a result of physical activity explain the positive influence that physical fitness has on academic performance (12). More specifically, changes in vascularity lead to increased oxygen saturation and glucose delivery, promotion of angiogenesis, and improved cerebral blood flow to areas related to cognition, alertness, and focus. In fact, a 3-month exercise program can increase blood flow to memory and learning centers by up to 30% (54). In addition, increased levels of neurotransmitters such as serotonin and norepinephrine expedite information processing while the increase of neurotrophins such as brain-derived neurotrophic factor (BDNF) stimulates brain cell growth and neurogenesis. It is postulated that this results in improved short-term memory, faster reaction times, and higher levels of creativity. An increased ability to learn and capacity for knowledge may occur as BDNF causes the brain’s nerve cells to branch out, join together, and communicate in new ways.

Finally, changes in specific gene expression allows for an accentuation in brain plasticity. Evidence from mouse models is mirrored in imaging studies in children, as those who are aerobically challenged versus sedentary controls show increased brain growth up to twice as large particularly in the executive control, memory, and learning centers of the basal ganglia and hippocampus, allowing for better attention and complex thinking (74).

In 2010, the CDC published an extensive review of the literature evaluating the association between academic performance and a variety of settings for school-based physical activity (8). Outcome measures for academic performance included cognitive skills and attitudes (attention, concentration, memory, verbal ability), academic behaviors (conduct, attendance, time on task, homework completion), and academic achievement (standardized test scores, grades). Overall, of the 50 studies that met inclusion criteria, 50.5% showed a positive association, 48% did not show any significance, and only 1.5% had a negative association, which was similar to what would be expected to occur by chance alone. It is important to note that all studies were assigned equal weight and there was no ranking based on methodology.

The CDC findings (8) revealed substantial evidence that physical activity can help improve academic achievement, including grades and standardized test scores. Physical activity also impacted cognitive skills and attitudes as well as academic behavior, all of which can play a role in improving overall academic performance specifically by improving concentration, attention, and classroom behavior. Taking a closer look at the results by activity type reveals the following:

1) School-based physical education: increased time in PE appears to have one or more positive relationships with academic achievement. No studies showed negative association.

2) Recess: having recess showed positive relationship with attention, concentration, and/or on-task class behavior. Also seen was one or more positive associations with cognitive skills, attitudes, and academic behavior. A secondary gain in social skills was seen occurred as well. Again, no negative associations existed.

3) Classroom physical activity: this is a distinct entity from PE and recess where short physical activity breaks (5 to 20 min) occur during class time or physical activity is introduced into the actual lesson plan. A positive association was displayed with regard to cognitive skills, attitudes, academic behavior, and achievement. There were no negative associations.

4) Extracurricular physical activity: this includes interscholastic sports and after-school programs. All studies had one or more positive association with academic performance.

Furthermore, there was no significant difference in the results by grade level (secondary school slightly better than elementary), gender, race, or ethnicity. Of all the studies examined, 86% had a positive association with academic behavior, suggesting that addressing this skill set may be the leading strategy for a variety of reasons. In the end, what is clear is that increasing or maintaining dedicated time for physical activity, regardless of the setting, may help and certainly does not hurt academic performance.

A systematic review of randomized controlled trials lends additional support and demonstrated that all included studies had a generally positive impact on children’s cognition and psychosocial function (40). Although the effect was minimal in many studies, there was no negative impact seen even in cases where time in the school curriculum was reassigned from sedentary classroom teaching to aerobic physical activity. Executive functioning tasks, such as thinking and problem solving, which are used for controlling impulsivity and staying focused and motivated, were the most affected. Moreover, a recently published randomized controlled trial of over 220 school-aged kids showed that those with 60 min of daily after-school aerobic activity performed better on tests of focus and cognitive flexibility switching between tasks while maintaining speed and accuracy (32).

Much of the literature focuses on the general pediatric population, but Davis examined the impact of activity and cognition specifically in overweight kids. His results revealed that with 40 min·d−1 of aerobic exercise, executive function also was improved in this group (13). A second study of overweight and obese children several years later showed that 13 wk of aerobic exercise was linked to improved math skills as well as increased bilateral prefrontal cortex activity that is associated with executive function (14). There also was improved accuracy and reaction times on concentration and attention tasks with higher aerobic fitness levels.

Nevertheless, some scientists and administrators suggest that despite the large volume of information, evidence from population-based studies remains weak. Critiques include a lack of control of confounders, such as parental education and socioeconomic status, and a limited look at the degree to which different types of exercise, i.e., strength, speed, agility, or aerobic training, matter. Additional alternative theories that have been proposed include the belief that motivated students may strive for achievement in both academic and physical fitness, that physical fitness is associated with better health, which may contribute to academic achievement, and that activity may improve attention and behavior in the classroom as well as overall mental health, confidence, and self-esteem, which can all positively affect academic achievement. In addition, regular exercise can alleviate stress, anxiety, and depression, all factors that can negatively affect school performance.

A recent study attempted to address some of these concerns by controlling for age, parental education, socioeconomic status, and BMI (65). During an evaluation of children aged 9 to 11 years who underwent a play-based program of two sessions per week lasting 90 min and one 150 min session per week, academic achievement scores (core subject grades) were positively related to fitness levels using a variety of fitness markers. Cardiorespiratory fitness had an odds ratio (OR) of 3.06, speed and agility had an OR of 4.25, while strength did not have a significant association. It also demonstrated that physical fitness is more closely related to academic achievement than obesity, and therefore, focus should be on fitness as opposed to weight control in school programs.

Questions that remain to be answered based on the lack of research include the impact of type, duration, and intensity of exercise, the role of dose-response, and whether improvements are maintained or decline when physical activity ceases.

Some strategies that have been proposed to help students meet national recommended physical activity goals without distracting from academic achievement involve either increasing the amount of time or increasing the quality of time (56). For example, spending more days per week or extended class time on physical activity and/or ensuring classes are staffed by trained instructors and increasing active time while decreasing time spent on inactivity. In fact, “FUNterval,” a program consisting of brief, multiple, high-intensity bouts of interval exercise throughout the day to meet daily physical activity requirements for second- and fourth-grade students showed reduced off-task behaviors like fidgeting or inattentiveness in the classroom (43). It was shown to be most effective in those with high rates of such behavior, perhaps revealing not only a generalized preventive component but a treatment role for these afflicted students. “FUNterval” is 4 min in duration and took place within a scheduled 10-min break from sedentary classroom activities on alternating days for 3 wk and was compared with a break of 10 min that did not include physical activity.

The use of technology, such as pedometers or heart rate monitors, also can aid in ensuring that appropriate levels of exertion and fitness are being reached. Teachers also need to be challenged to be creative and incorporate physical activity as well as activity breaks into learning plans. Administrators in turn need to be challenged to support physical activity in school and to maintain sports programs. The National Association for Sport and Physical Education goes on to recommend that all pre-K through grade 12 schools implement a comprehensive school physical activity program, which includes quality PE; physical activity before, during, and after school, including recess and other physical activity breaks; extracurricular, noncompetitive physical activity clubs; interscholastic sports; and walk- and bike-to-school initiatives (49). However, it remains important to note that any implemented activity plans need to be age appropriate and enjoyable and must offer variety for the participants to achieve maximum and sustained success. Like exercise and organized sports, free and unstructured play is good for the brain as well.

Currently, the CDC makes the following recommendations regarding physical activity in youth (9). Aerobic activity, such as brisk walking (moderate) or running (vigorous) should make up the majority of the 60 min·d−1 or more of physical activity. At least three of the days should reach vigorous levels. Muscle strengthening, such as gymnastics, push-ups, or playing on the jungle gym, and bone strengthening, such as jumping rope or running, should occur at least 3 d·wk−1. Younger kids should reach these goals mostly from free play, while adolescents can be introduced to more structured activity, workouts, and sports. However, it is important to recognize that some is better than none, and more, without overdoing it, is better than some.

Emerging research, however, is beginning to provide us with better answers with regard to how much and what type of physical activity children actually need. Myer and Faigenbaum (47) raise the crucial point that current recommendations for physical activity in children focus on quantitative time spent on selected health-related components of fitness (aerobic and muscular endurance, flexibility, and muscular strength) and overlook the importance of qualitative factors such as motor skill acquisition and development, socialization, and enjoyment of exercise early in life. They go on to explain that the level of brain development and neuroplasticity occurring at this age, before and during early adolescence, which are a critical period of time to learn, develop and reinforce fundamental motor skills such as agility, balance, coordination, reaction time, and power. This is key as those who are not exposed as children to these types of structured activities via participation in PE or a diverse set of youth sports may never reach their motor skill potential and thereby not have the tools, confidence, or perceived pleasure to sustain physical fitness for life.

The generic physical activity recommendations similar to those referenced previously from the CDC without specific advice on the type of exercise, sets, and repetitions fall short for health care providers as well as the youth to whom they provide care attempting to institute a plan of action. This lack of clarity leads to noninitiation or lack of continuation due to boredom or reduced skill competence. Therefore, a critical next step is to construct a well-described, developmental exercise strategy that integrates both health-related and skill-related fitness components to create an effective program that is enjoyable, challenging, and stimulating to both the mind and body. As a result, this is likely an ideal approach to positively influence compliance and attitudes toward play, sports, and exercise throughout childhood and into adolescence and adulthood.

One approach that seems to have great promise involves integrative neuromuscular training (48). Present models involve well-trained and highly knowledgeable pediatric exercise specialists teaching motor skills and other age-related exercises in a game-play environment that is fun, safe, challenging, and engaging. Continued development of a system that allows for expansion of this level of education and service into our schools on a wide-scale level seems like a logical next step in order to increase access and effective delivery.

CONCLUSIONS

As discussed at the Global Summit on the Physical Activity of Children, this is not a one-step solution by one group. It will require contributions and collaboration from a variety of sectors (sports and recreation, education, fitness, transportation, early childhood development, public health, and medical sectors) addressing a variety of issues (physical activity, sedentary behavior, active transportation, active play, organized sport, family, and peers) in a variety of settings (home, school, community, investment, and policy) (66). There also is clearly room for work across the board and the globe as demonstrated by the Global Matrix of Grades as compiled by Tremblay et al. (67).

Most Americans live in an environment that promotes inactivity and increased food intake. The capacity for treatment of obesity and its sequelae are limited, highlighting the need for improved preventative efforts. In order to be successful, a multifaceted and sustainable approach is required. Leaders and resources must come from our schools, health care organizations, government agencies, and community services in order not only to halt but also to reverse the obesity epidemic. Part of this strategy must provide healthful options and opportunities that are accessible to all.

Schools remain a critical piece to this challenge particularly as ties to academic achievement are discovered. The evidence from future research can be used to effect policy change, gain support and funding for physical activity programs at schools and in the community, change national and global lifestyle habits, reduce the medical and financial burden, and improve the overall quality of life. As Burgeson (7) implores, “Physical activity comes in many forms, and there is something for everyone. Physical activity must be a regular part of everyday life, as commonplace and important for good health as brushing one’s teeth. Quality PE and health education programs provide the foundation for healthy, active lifestyles that support all learning and help ensure success in future pursuits.”