Setting: School

The information in this brief is intended only to provide educational information.

The following provides a summary of findings from the CHOICES Learning Collaborative Partnership simulation model of an Active Recess policy in schools in Salt Lake County, UT to increase students’ physical activity levels during recess by installing playground markings, providing portable play equipment, and/or providing adult-led engaging activity options.

The Issue

Over the past three decades, obesity has nearly tripled in Utah.¹ In the United States, health care costs for treating obesity-related health conditions such as heart disease and diabetes were $147 billion in 2008.² Emerging prevention strategies directed at children show great promise for addressing this issue.³ Evidence shows that physical activity helps kids grow up at a healthy weight.

In Utah, only 19% of children meet the recommended 60 minutes of daily physical activity.⁴ Among all counties in Utah, Salt Lake County has the second highest rate of children with obesity.⁵ Recess periods during the school day typically last 10-15 minutes or more and are scheduled as isolated breaks or in association with lunch.^6,7 Elementary school children generally spend more time in recess than physical education weekly.⁸ Schools often lack resources that can encourage physical activity during recess such as supportive supervision, play facilities, and equipment.^9,10 On average, children spend less than 50% of recess time engaged in moderate-to-vigorous physical activity (MVPA).¹⁰

About Active Recess

We assumed that implementation would occur district-wide in public elementary and charter schools in the four school districts in Salt Lake County that provide recess but do not currently require the use of Active Recess strategies. Future grant funding would provide for installation of playground markings, provision of portable play equipment, and/or provision of adult-led engaging activities designed to increase students’ physical activity levels during school recess time. Playground markings would be installed for adult-led games that engage children in physical activity (e.g., four square, hop-scotch) and participating schools would receive portable playground equipment for use during recess time.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of implementing an Active Recess policy over 10 years (2017-2027) to costs and outcomes if the policy is not implemented. The approach assumes that no school is currently implementing Active Recess practices in these four districts, and 94% of these schools adopt Active Recess practices where all students benefit.

Implementing Active Recess is an investment in the future. By the end of 2027:

Conclusions and Implications

Every child deserves a healthy start in life. An Active Recess policy in Salt Lake County could help ensure that more kids have opportunities to be physically active during recess, no matter which school district they are in. Implementing a district-level policy in these Salt Lake County public elementary schools and charter schools would require an investment of $24 per student to provide the equipment and resources needed to increase physical activity levels during recess.

These results reinforce the importance of investing in prevention efforts to reduce the prevalence of obesity. This intervention would prevent 141 cases of childhood obesity in 2027 and provide the opportunity for 196,000 children to engage in active recess opportunities. For every $1.00 spent on implementing the Active Recess policy, $0.06 in health care costs would be saved. While not quantified in this analysis, there are also other positive benefits from physical activity related to cognition and academic performance that may also result in additional cost savings.¹¹

Evidence is growing about how to help children grow up at a healthy weight. Strategies such as Active Recess are laying the foundation for a healthier future by helping schools create environments that nurture healthy habits.

References

1. Utah Department of Health. (2018). Public Health Indicator Basied Information System (IBIS) Utah’s Public Health Data Resource, Health Indicator Report of Overweight or Obese. https://ibis.health.utah.gov/ibisph-view/indicator/view/OvrwtObe.UT_US.html
2. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs. 2009;28(5).
3. Gortmaker, S.L., Wang, Y.C., Long, M.W., et al. Three Interventions That Reduce Childhood Obesity are Projected to Save More Than They Cost to Implement. Health Affairs, 2015, 34(11), 1932–193
4. Utah Department of Health. (2018). Public Health Indicator Basied Information System (IBIS) Utah’s Public Health Data Resource, Health Indicator Report of Physical Activity Among Adolesents. https://ibis.health.utah.gov/ibisph-view/indicator/view/PhysActAdol.UT_US.html
5. Utah Department of Health. (2018). Public Health Indicator Basied Information System (IBIS) Utah’s Public Health Data Resource, Health Indicator Report of Obesity Among Children and Adolescents. https://ibis.health.utah.gov/ibisph-view/indicator/view/OvrwtChild.LHD.html
6. Parsad, B. & Lewis, L .Calories In, Calories Out: Food and Exercise in Public Elementary Schools, 2005, National Center for Education Statistics, U.S. Department of Education Report No. NCES 2006–057, (2006). https://nces.ed.gov/pubs2006/2006057.pdf. Accessed January 24, 2017.
7. Centers for Disease Control and Prevention. The Association Between School-Based Physical Activity, Including Physical Education, and Academic Performance. Atlanta, GA: U.S. Department of Health and Human Services; (2010). https://www.cdc.gov/ healthyyouth/health_and_academics/pdf/pa-pe_paper.pdf. Accessed January 24, 2017.
8. Robert Wood Johnson Foundation. Recess Rules: Why the Undervalued Playtime May Be America’s Best Investment for Healthy Kids and Healthy Schools. Princetown, NJ: Robert Wood Johnson Foundation; 2007.
9. National Association for Sport and Physical Education. Recess for Elementary School Students: A Position Paper, Council on Physical Education for Children Report, (2006). http://files.eric.ed.gov/fulltext/ED497155.pdf. Accessed January 24, 2017.
10. Stratton G. Promoting Children’s Physical Activity in Primary School: An Intervention Study Using Playground Markings. Ergonomics, 2000, 43(10), 538-1546.
11. 2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Washington, DC: U.S. Department of Health and Human Services, 2018. Accessed September 7, 2018

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the Salt Lake County Health Department through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only.

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The information in this brief is intended only to provide educational information.

This brief summarizes the findings from a CHOICES Learning Collaborative Partnership simulation model of statewide implementation of the Hawaii State Department of Education (DOE) “Active PE” Wellness Guideline that requires 50% of physical education (PE) class be dedicated to moderate-to-vigorous physical activity (MVPA).

The Issue

Every child deserves the opportunity to be healthy. Research shows that physical activity helps kids grow up at a healthy weight and reduces risk of future chronic disease.¹ If current trends continue in the United States, more than half of today’s children will have obesity at age 35.² Health care costs for treating obesity-related health conditions such as heart disease and diabetes were $147 billion in 2008.³ The best chance we have to make sure kids grow up to be healthy is while they are still growing.

Although participation in physical education (PE) can help students meet the national recommendation of 60 minutes of physical activity per day,¹ less than half of PE minutes are typically active.⁴ Hawaii DOE wellness guidelines say that elementary school students in DOE schools should receive at least 45 minutes of PE per week.⁵ The purpose of this study is to estimate the cost-effectiveness of implementing the Active PE guideline, which requires that at least 50% of PE time be spent in MVPA.

About Active PE

The hypothetical statewide implementation of the Active PE wellness guideline would include dissemination of the evidence-based program SPARK PE to elementary schools in Hawaii. SPARK is a widely used program that has been found to increase MVPA time in PE class.⁶

District PE Resource Teachers would receive professional development to become SPARK certified trainers, and then would train elementary PE teachers in subsequent years. All trained teachers would receive SPARK curricula and instructional materials, and all eligible schools would receive SPARK equipment. Implementation would include a state-level PE Educational Specialist to provide oversight and monitoring of policy implementation, as well as ongoing training and support for teachers and schools each year.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2017-2027) of the statewide implementation of the Active PE wellness guideline with the costs and outcomes associated with not developing a comprehensive plan to fully implement the guideline. We assumed that all designated PE specialists, who are employed in 65% of schools, would be trained in SPARK. In schools without a PE specialist, one general classroom teacher per grade would be trained. Using this approach, 58% of students in grades K-6 would benefit from this intervention.

Implementing Active PE is an investment in the future. By the end of 2027:

Conclusions and Implications

The statewide implementation of the Active PE guideline, using the evidence-based program SPARK, is projected to have a widespread reach and positive impact, at an investment cost that appears reasonable compared to alternative approaches for increasing physical activity among children.⁷ The intervention would reach 126,000 children and would cost $37.10 per child to implement over 10 years. We project that Active PE implementation would increase MVPA by nearly 3 minutes per PE class for each child. We estimate there will be 19 fewer cases of childhood obesity in the final year of the model as a result of implementation of the Active PE guideline.

If Hawaii DOE schools were able to offer 150 minutes per week for elementary school students,⁸ we project the health benefits for children to be even higher. MVPA would increase by over 9 minutes per week per child and 65 cases of childhood obesity would be prevented in the final year of the model.

SPARK training offers a professional development opportunity for teachers to learn new instructional strategies to foster a fun and enjoyable environment where children can gain lifelong skills to engage in physical activity.⁹ There are likely positive benefits from physical activity related to improved bone health, aerobic and muscular fitness, cognition and academic performance¹ that are not quantified in this analysis, but are important outcomes for children’s education and well-being.

While evidence is growing about how to help children achieve a healthy weight, there is currently not one single strategy that will reverse the obesity epidemic on its own. Active PE is one evidence-based strategy that can benefit the majority of students and can be incorporated into a comprehensive plan to address childhood obesity. Leaders at the state level should use the best available evidence to select strategies to help children be more active.

References

1. 2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Washington, DC: U.S. Department of Health and Human Services, 2018. Accessed September 7, 2018.
2. Ward ZJ, Long MW, Resch S, Giles CM, Cradock AL, Gortmaker SL. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. New England Journal of Medicine. 2017; 377(22): 2145-2153.
3. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs. 2009;28(5).
4. Institute of Medicine. Educating the Student Body: Taking Physical Activity and Physical Education to School. Washington, DC: National Academies Press; 2013.
5. Hawaii State Department of Education. Hawaii State Department of Education Wellness Guidelines. Retrieved from: http://www.hawaiipublicschools.org/DOE%20Forms/Health%20and%20Nutrition/Wellness-Guidelines-Implementation-Checklist.pdf. Accessed 12 April 2018.
6. Sallis JF, McKenzie TL, Alcaraz JE, Kolody B, Faucette N, & Hovell MF. The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. Sports, Play and Active Recreation for Kids. American Journal of Public Health. 1997; 87(8), 1328-1334.
7. Cradock AL, Barrett JL, Kenney EL, Giles CM, Ward ZJ, Long MW, … & Gortmaker SL. Using cost-effectiveness analysis to prioritize policy and programmatic approaches to physical activity promotion and obesity prevention in childhood. Preventive Medicine. 2017; 95, S17-S27.
8. Society of Health and Physical Educators (SHAPE). Physical Education Guidelines. Retrieved from: https://www.shapeamerica.org/standards/guidelines/peguidelines.aspx. Accessed 13 April 2018.
9. McKenzie TL, Sallis JK, & Rosengard P. Beyond the stucco tower: Design, development, and dissemination of the SPARK physical education programs. Quest. 2009;61(1), 114-127.

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the Hawaii Department of Health (MDH) through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. Funded by The JPB Foundation. Results are those of the authors and not the funders.

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The information in this brief is intended only to provide educational information.

This brief summarizes findings from a CHOICES Learning Collaborative Partnership (LCP) simulation model and cost-effectiveness analysis of the expansion of Safe Routes to School (SRTS) initiatives in elementary and middle schools in Minnesota. SRTS aims to help children safely walk and bicycle to school through infrastructure improvements, education, and promotional activities.

The Issue

Research shows that physical activity helps kids grow up at a healthy weight and reduces the risk of future chronic disease;¹ however, the majority of kids do not get enough daily physical activity.² Without action, a majority of today’s children will have obesity at age 35³ with substantial financial implications as the costs for treating obesity-related health conditions such as heart disease and diabetes can total over $3 billion per year in Minnesota.⁴

Every child deserves the opportunity to be healthy, and all kids need opportunities to be physically active, no matter where they live or where they go to school. Over recent decades, the declining rates of using physically active transportation modes like walking and bicycling to school may have contributed to lower than recommended levels of physical activity among youth.⁵ In Minnesota, only 12.3% of students walk or bicycle to school.⁶ However, SRTS initiatives are an effective strategy to increase physical activity by promoting safe walking and bicycling opportunities.⁷

About Safe Routes to School

Minnesota SRTS initiatives are supported by a combination of state and federal transportation funding. This analysis assumes a continued allocation of $1 million per biennium to support the implementation of SRTS initiatives in Minnesota, in addition to a one-time increase of $6 million in state funding. As a portion of these state funds could be used as a match to leverage $2.6 million in additional federal funding, this investment would increase total funding support by $8.6 million. The expanded funding would support individual SRTS project implementation costs for infrastructure, planning and construction, and state program administration, including increased time in program coordination and project selection.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2017-2027) of expanding SRTS in one biennium with the costs and outcomes associated with not expanding the program. Based on prior program expenditures, we estimated that 96 schools would implement a new SRTS program with the increase in state and leveraged federal funds. Additional research suggests that 5.5% of Minnesota’s students would shift from cars to active travel modes after SRTS implementation,⁶ a 45% increase in the current active transportation mode share in Minnesota. This shift would result in some projected cost savings due to reduced vehicle use for school transportation trips.

Implementing Safe Routes to School in Minnesota is an investment in the future. By the end of 2027:

Conclusions and Implications

Over 46,000 students in Minnesota would benefit from safer transportation environments. Investing in SRTS initiatives helps children accumulate the recommended levels of physical activity; on average, those who start walking or bicycling to school engage in 47 more minutes of physical activity during the school week. We also estimate 6 fewer cases of obesity in 2027 as students shift to more physically active travel. There are likely positive benefits from physical activity related to improved bone health, aerobic and muscular fitness, cognition and academic performance¹ that are not quantified in this analysis, but are important outcomes for children’s education and well-being.

The 10-year total intervention implementation costs, including projected cost savings due to reduced vehicle use, are estimated to be $6,550,000. In Minnesota, one-third of SRTS implementation costs could be offset by savings associated with reduced vehicle travel that include $607,000 in environment-related cost savings. Additionally, families whose students start walking or bicycling and thus drive less for school transportation trips could average $985 in savings over 10 years.

Strategic SRTS initiatives may reduce the risk of pedestrian and bicycle injury.⁸ We estimated that there is a 78% probability that the SRTS program as conceptualized for Minnesota would not result in additional injuries, even though more students may be walking or bicycling than in the past. Additionally, we estimate that there is a 66% probability that the SRTS program in Minnesota could prevent injury-related healthcare costs. Investing in SRTS projects that make walking and bicycling to school safer and easier opens opportunities for those families who want to allow their child to walk or bicycle but cannot because of safety concerns.⁹

These multiple benefits reinforce the importance of investing in effective strategies that promote accessible, safe, and convenient walking and bicycling options to improve the health of our students and the environments of our local communities.

References

1. 2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Washington, DC: U.S. Department of Health and Human Services, 2018. Accessed September 7, 2018.
2. Child and Adolescent Health Measurement Initiative. 2016-2017 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by Cooperative Agreement U59MC27866 from the U.S. Department of Health and Human Services, Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA MCHB). Retrieved [02/08/2019] from www.childhealthdata.org. CAHMI: www.cahmi.org.
3. Ward Z, Long M, Resch S, Giles C, Cradock A, Gortmaker S. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. New England Journal of Medicine. 2017; 377(22): 2145-2153.
4. Trogdon JG, Finkelstein EA, Feagan, W,  Cohen JW. State- and payer-specific estimates of annual medical expenditures attributable to obesity. Obesity. 2012; 20(1), 214-220.
5. McDonald, NC. Active transportation to school: trends among US schoolchildren, 1969–2001. American Journal of Preventive Medicine. 2007; 32(6), 509-516
6. Pelletier J. (2018). Minnesota Student Travel Tally Data from 2011-2015. [Unpublished Raw data].
7. McDonald C, Steiner RL, Lee C, Smith TR, Zhu X, & Yang Y. Impact of the Safe Routes to School Program on Walking and Bicycling, Journal of the American Planning Association. 2014; 80:2, 153-167
8. DiMaggio C, Li G. Effectiveness of a safe routes to school program in preventing school-aged pedestrian injury. Pediatrics. 2013; 131(2), 290-296.
9. McDonald NC, Aalborg AE. Why Parents Drive Children to School: Implications for Safe Routes to School Programs, Journal of the American Planning Association. 2009; 75:3, 331-342, DOI: 10.1080/01944360902988794

 The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the Minnesota Department of Health (MDH) through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. Funded by The JPB Foundation. Results are those of the authors and not the funders.

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The information in this brief is intended for educational use only.

This brief provides a summary of the CHOICES Learning Collaborative Partnership simulation model in Washington of a potential Active Recess program in public elementary schools to increase students’ physical activity levels during recess via installation of playground markings, provision of portable play equipment, and/or provision of structured activities.

The Issue

Over the past three decades, more and more people have developed obesity.¹ Health care costs for treating obesity-related health conditions such as heart disease and diabetes were$147 billion in 2008.² Emerging cost-effective prevention strategies directed at children show great promise for addressing this issue.³ Evidence shows that physical activity helps kids grow up at a healthy weight.

In Washington, 98% of schools serving elementary grades provide at least one daily recess.⁴ Recess is typically allocated in bouts of 10-15 minutes or more as isolated breaks and/or in association with lunch.^5,6 Elementary school children generally spend more time in recess than physical education weekly.⁷ Schools often lack resources that encourage physical activity among children including supervision, play facilities, and equipment.^8,9 On average, children spend less than 50% of recess engaged in moderate-to-vigorous physical activity.⁹

About Active Recess

Implementation of this voluntary school-level intervention would occur in public elementary schools in Washington that provide recess but not Active Recess strategies. It would include installation of playground markings, provision of portable play equipment, and/or provision of structured activities designed to increase students’ activity levels during school recess time. Through grant proposals, school personnel and parent volunteers would support creation of playground markings for structured games for the children to be physically active (e.g., four square, hop-scotch) and each participating school would receive portable playground equipment to be used during recess time.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of Active Recess over 10 years (2015-2025) with costs and outcomes associated with not implementing the program. The approach assumes that 90% of children attend schools without an Active Recess program, and 100% of these schools adopt Active Recess practices where all students benefit.

Implementing Active Recess in Washington is an investment in the future. By the end of 2025:

Conclusions and Implications

Every child deserves a healthy start in life. This includes ensuring that all kids have the same opportunities to be physically active during recess, no matter where they live or where they go to school. A state-level program in Washington to assist public elementary schools invest in equipment and resources to increase physical activity during recess may be a cost-effective strategy for reducing obesity at $23.30 per child. This intervention would prevent 955 cases of childhood obesity in 2025 and provide the opportunity for over 1 million children to engage in active recess opportunities. There are also likely positive benefits from physical activity related to cognition and academic performance which are not quantified in this analysis, but may result in additional cost savings.^10,11,12

For every $1.00 spent on implementing the Active Recess intervention, we would save $0.10 in health care costs. These results reinforce the importance of investing in prevention efforts to reduce the prevalence of obesity. Shortchanging prevention efforts can lead to more costly and complicated treatment options in the future. Introducing small changes to school-aged children can inform healthy habits that carry into adulthood.

Evidence is growing about how to help children achieve a healthy weight. Interventions such as Active Recess are laying the foundation for a healthier future by helping schools create environments that nurture healthy habits. Leaders at the federal, state, and local level should use the best available evidence to help children eat healthier diets and be more active.

References

1. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in Obesity Among Adults in the United States, 2005 to 2014. JAMA, 2016;315(21), 2284-91.
2. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs. 2009;28(5).
3. Gortmaker SL, Claire Wang Y, Long MW, Giles CM, Ward ZJ, Barrett JL, Kenney EL, Sonneville KR, Afzal AS, Resch SC, Cradock AL. Three Interventions That Reduce Childhood Obesity Are Projected to Save More Than They Cost to Implement. Health Affairs, 34, no. 11 (2015):1304-1311.
4. Howard K & Rakoz L. Survey Regarding Recess Periods for Elementary School Students: Report to the Legislature. Office of Superintendent of Public Instruction, Dec 2009. http://www.k12.wa.us/LegisGov/2009documents/RecessPeriodsforElementarySchoolStudents.pdf
5. Parsad B & Lewis L .Calories In, Calories Out: Food and Exercise in Public Elementary Schools, 2005, National Center for Education Statistics, U.S. Department of Education Report No. NCES 2006–057, (2006). https://nces.ed.gov/pubs2006/2006057.pdf. Accessed January 24, 2017.
6. Centers for Disease Control and Prevention. The Association Between School-Based Physical Activity, Including Physical Education, and Academic Performance. Atlanta, GA: U.S. Department of Health and Human Services; (2010). https://www.cdc.gov/healthyyouth/health_and_academics/pdf/pa-pe_paper.pdf. Accessed January 24, 2017.
7. Robert Wood Johnson Foundation. Recess Rules: Why the Undervalued Playtime May Be America’s Best Investment for Healthy Kids and Healthy Schools. Princetown, NJ: Robert Wood Johnson Foundation; 2007.
8. National Association for Sport and Physical Education. Recess for Elementary School Students: A Position Paper, Council on Physical Education for Children Report, (2006). http://files.eric.ed.gov/fulltext/ED497155.pdf. Accessed January 24, 2017.
9. Stratton G. Promoting Children’s Physical Activity in Primary School: An Intervention Study Using Playground Markings. Ergonomics, 2000, 43(10), 538-1546.
10. Lees C & Hopkins J. Effect of Aerobic Exercise on Cognition, Academic Achievement, and Psychosocial Function in Children: A Systematic Review of Randomized Control Trials. Prev Chronic Dis, 2013, 10, E174.
11. Fedewa AL & Ahn S. The Effects of Physical Activity and Physical Fitness on Children’s Achievement and Cognitive Outcomes: A Meta-Analysis. Res Q Exerc Sport. 2011, 82(3), 521–535.
12. IOM. Educating the Student Body: Taking Physical Activity and Physical Education to School. Washington, DC: National Academies Press; 2013.

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