Physical Education
Perhaps because schools have been unable to provide sufficient time and resources for students to meet all the objectives of standard PE, the concept of “health-related PE” has been promoted.28,29 A major goal of health-related PE is the development of lifelong physical activity. As such, the priority for PE is seen as providing opportunities for students to engage in enjoyable physical activity, to become physically fit, and to learn generalizable motor and behavioral skills.30
A number of carefully designed studies that incorporated health-related PE concepts and used physical activity in PE classes as the primary outcome have been conducted in the United States.31–33 In most of these, PE was one component of a multidisciplinary and multifaceted intervention package. These studies moved beyond the focus on knowledge and attitudes that characterized earlier health behavior change studies and used behavioral models from social psychology as the theoretical underpinning for changing behaviors, including physical activity. Many also focused on a Coordinated School Health Program model, so that multiple environmental components and policies supported a topic addressed in the classroom.21,34,35 In addition, the school-based research field advanced to using more robust research designs, selection of more appropriate theoretical models, improved measurement approaches, and more appropriate analysis strategies for the multiple health behaviors and multiple component programs being implemented. Studies that adopted these approaches to promotion of physical activity in schools included the Child and Adolescent Trial for Cardiovascular Health (CATCH),37,38 Go for Health,27,39 Lifestyle Education for Activity Program (LEAP),40,41 Middle School Physical Activity and Nutrition (M-SPAN),42,43 Pathways,44 Sports, Play, and Active Recreation for Kids (SPARK),45,46 and Trial of Activity for Adolescent Girls (TAAG).24,47 Several comprehensive reviews summarize many of these studies.32,33,48,49
The majority of physical activity intervention studies have been conducted at the elementary school level and have involved grades 3, 4, 5, and 6 in some combination.32,48,49 Most of these studies were designed to intervene on multiple cardiovascular disease behavioral risk factors—primarily physical activity, sedentary behaviors, and dietary behaviors. Most involved changes to PE, the classroom health curriculum, and the food service program and included some family, community, and policy change components. In most, existing school staff were trained to implement the interventions, although the Stanford Adolescent Heart Health Program was implemented by project staff from outside the school, and SPARK was implemented by both outside PE specialists and school staff who were trained in the intervention.46,50 Some programs increased both the number of minutes and the proportion of lesson time that students were vigorously active in PE classes.38,45 For example, without a modification to either the frequency or the duration of lessons, moderate-to-vigorous physical activity during PE increased from 37% to 52% in CATCH intervention schools.38
Middle school studies include M-SPAN, Planet Health, and the Oslo Youth Study. In the M-SPAN intervention schools, moderate-to-vigorous physical activity in PE classes increased by 18%.42 The results of Planet Health showed that the prevalence of obesity was reduced among girls, but not boys, as compared with controls, and that a reduction in TV-watching predicted a change in obesity.51,52 The Oslo Youth Study addressed multiple cardiovascular health behaviors and used multiple intervention components in grades 5 and 7, with follow-up in grade 7 and at 12 years after the intervention. Results showed an increase in knowledge and in frequency of vigorous physical activity, which persisted to the 12-year follow-up for boys but not for girls.53 Fitness also was increased for boys in the intervention group. TAAG, a national multisite randomized intervention study, is currently under way at 6 sites across the country. It is testing a school and community multicomponent intervention designed to prevent the decline in physical activity in middle school girls.47
Only a few studies have tested programs designed to promote physical activity in high school students. The Stanford Adolescent Heart Health Program was a curriculum-based program designed to improve physical activity, nutrition, smoking, and stress behaviors. Students in the intervention schools reported significant knowledge gains and increases in regular exercise.50,54 Positive treatment effects also were observed for BMI, skinfolds, and resting heart rate. LEAP was a comprehensive physical activity intervention designed to change the instructional program and school environment to increase support of physical activity for ninth-grade girls. LEAP focused on 6 components of the Coordinated School Health Program model: PE, health education, school environment, school health services, faculty/staff health promotion, and family/community involvement. After the 1-year intervention, the prevalence of vigorous physical activity was significantly higher in the LEAP intervention schools than in the control schools.40 Other high school studies that addressed physical activity through multiple component interventions include the Australia School Project55 and Slice of Life.56 The Class of 89 Study,57 which was part of a larger community study, had multiple intervention components and addressed multiple cardiovascular health behaviors. It involved grades 6 to 12, with follow-up through grade 12. The results showed smaller declines in physical activity for intervention students, with the most significant effect on girls. The study also showed that physical activity tracks during youth (ie, high activity at one age is associated with high activity at an older age).
Most of the interventions to date have focused on increasing physical activity during the school day. It is possible that students who increase their physical activity levels during the school day may compensate by decreasing out-of-school physical activity. Additional research is needed to clarify the relationship between in-school and out-of-school activity. In addition, it has not yet been demonstrated that school-based interventions can reduce BMI or the prevalence of overweight.
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