The Importance of Providing Opportunities for Health Behaviors during the School Day
- Globally, full-day preschool and an increased academic focus are rapidly becoming the norm, thus depriving children of opportunities to engage in physical activity (PA) [1]. Children are spending their time outside of the home in the school environment, which presents an opportunity for schools, administrators, teachers, and child care providers to educate children about the importance of participating in PA and making healthy eating choices. One such approach is called Whole School, Whole Community, Whole Child (WSCC) [2]. Figure 1 provides a framework to provide opportunities for 60 min of moderate-to-vigorous PA per day [3]. WSCC is ideal because it intertwines the desired outcome of academic success and prevalence of healthy behaviors, such as being regularly physically active and eating healthy. Particularly for youth, multicomponent approaches that include both school and family or community involvement have the most significant potential to make meaningful differences in the rate of PA participation [4]. Further, The Healthy Foods and Beverages in Schools campaign (Fig. 2) identifies smart snacks in school settings and opportunities in schools where healthy eating can be explained and practiced (classroom celebrations, events, and nonfood rewards). Overall, successful school interventions intended to increase PA and healthy eating include the following evidenced-based practice:
• Supportive administrators who are invested in improving student health
• Content-specific and ongoing professional development that increases teacher knowledge on PA and nutrition
• Effective use of school and classroom environment to engage students in PA opportunities across the school day
• Intentional teaching practices that embed routine PA across the school day
• Teacher champions that organize, support, and encourage a sustained culture of health
Fig. 1. The Whole School, Whole Community, Whole Child collaborative approach to learning and health [2].
Engaging youth in health leadership opportunities that provide them with a say and a voice
• Parental engagement that reinforces healthy eating and PA at home
• Community partnerships that support and extend the shared culture of health
• Evidenced-based curricula and data-driven instructional methods that support health behavior change in youth (i.e., SPARK, CATCH)
Public Health, Snap-ED, etc.) Social-ecological modes and theories like the Self-Determination Theory provide a framework for social systems supporting opportunities for children to build autonomy, relatedness, and competence. For example, during the school day, upper elementary school children before dancing to music in the classroom can predict how many steps per minute that they will take, whereas the same activity in early childhood might focus on having the child notice that their heart beats faster when dancing over sitting. Healthier children are better learners, because of the cognitive
benefits and improved brain health from individual PA sessions and regular PA participation over time [5], both structured and unstructured play, movement, physical education, recess, and sport should be integrated into the daily lives of children. Finally, the Centers for Disease Control and Prevention recommend that schools implement policies and practices to create a nutrition and PA environment that supports students in making healthy choices. When a school offers appealing, nutritious foods and
opportunities to be physically active, children not only learn about the importance of making healthy choices but also reduce health risks and improve readiness for learning.
References
1. Copeland KA, Khoury JC, Kalkwarf HJ: Childcare center characteristics associated with preschoolers’ physical activity. Am J Prev Med 2016;50:470–479.
2. ASCD and Centers for Disease Control and Prevention [CDC]: Whole School, Whole Community, Whole Child: A Collaborative Approach to Learning and Health. Alexandria/Atlanta, ACS/CDC, 2014. http://www.ascd.org/ASCD/pdf/siteASCD/ publications/wholechild/wscc-a-collaborative-approach.pdf or http://www.ascd.org/ programs/learning-and-health/wscc-model.aspx.
3. US Department of Health and Human Services: Physical Activity Guidelines for Americans, ed 2. Washington, US Department of Health and Human Services, 2018.
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5. Janssen I, LeBlanc AG: Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Int J Behav Nutr Phys Act 2010;7:40.
Abstract
Today, children are less active than previous generations leading to an increased prevalence of morbidity associated with physical inactivity. Globally, full-day preschool is rapidly becoming the norm. Thus, the amount of time that a child spends outside the home is an opportunity for schools and teachers to educate children about the importance of participating in physical activity and making healthy eating choices. One approach to comprehensively offer opportunities for physical activity and healthy eating is called Whole School, Whole Community, Whole Child, which intertwines academic success and promotion of healthy behaviors. Particularly for adolescent children, multicomponent approaches that include both school and family or community involvement have the most significant potential to make meaningful differences in the rate of physical activity participation. For young children, teacher training, resources, and equipment are needed to achieve equity across programs and schools, because these are predictors of physical activity participation. Further, school policies, administrative support, modeling by teachers, and the use of cues and incentives can have a positive effect. The purpose of this paper is to describe the benefits of contemporary, evidence- based models for providing opportunities for health behaviors in school from early childhood to adolescence.
Introduction
The World Health Organization (WHO) [1] asserts that unlike the previous generations, children today are mostly physically inactive. Alarmingly, young children exhibit low levels of physical activity that is far below the daily recommendation of 3 h of playtime for children under 5 years of age, and 60 min of moderate-to-vigorous physical activity for children aged 5–17 years. Such deficits occur because opportunities to move have been replaced with sedentary time [2]. Research suggests that Brazilian children (n = 485, mean age 10 years) spent approximately 56% of their waking hours in sedentary behavior (e.g., watching television) and only 2% of the time in vigorous physical activity [3]. The lack of time spent in moderate-to-vigorous physical activity was inversely
related to body composition in boys, while girls were negatively impacted by a lack of time in vigorous physical activity and the amount of time spent in sedentary behavior. Since sedentary behaviors by themselves were not related to body composition, these findings suggest that even low-intensity physical activity may have some health benefits over sedentary time. Physical activity only accounts for a portion of the modifiable behaviors involved in the prevention of excessive weight gain, and the risk for overweight or obesity, tooth decay, and juvenile diabetes during childhood, and
cardiovascular disease and some cancers in later life. Establishing healthy eating patterns in young children (aged 3–4 years) is critical because micronutrients are required for brain development, and fewer than 1 in 10 adolescents eat the recommended amount of fruit and vegetables each day [4]. Unhealthy eating is further compounded by the consumption of sugar-sweetened beverages [5] and the fact that childhood obesity rates among minority groups are disproportionately higher than among non-Hispanic white children [6]. Given the prevalence of physical inactivity and unhealthy eating, the purpose of this paper is to describe the benefits of contemporary, evidenced-based models providing opportunities for health behaviors in school from early childhood to adolescence.
Key Findings among the Research
Globally, full-day preschool is rapidly becoming the norm, meaning 3- and 4-year-old children are joining children aged 5–18 years, who already spend 6 h a day in schools. The amount of time a child spends outside of the home is an opportunity for schools and teachers to educate children about the importance of participating in physical activity and making healthy eating choices; however, with the school curriculum already filled with academic requirements, little time is reserved for addressing such content and providing opportunities to participate.
Physical Activity in All Schools
Despite the known benefits of physical activity participation, across the world, physical inactivity is on the rise as technology has infiltrated daily tasks that require thus less energy expenditure than in previous generations who were needed to engage in manual labor for survival. The daily efficiency of transportation, employment, and education has been maximized through screen time and other conveniences. The current context may be placing children in a position where they are trading their active play and physical activity for time watching television or using a tablet, phone, or computer [7]. This is problematic, as screen time has been found to diminish the healthy development of the whole child, whereas physical activity has been found to promote it. Physical activity in early childhood is often facilitated through structured
and unstructured play [8]. Structured or guided play, known as play with a purpose [9], provides specific and planned activities that are tied to a given learning outcome. Unstructured play, also known as free play, provides the young child with opportunities to interact and explore their environment in a productive way that also engages social and emotional elements [10]. Physical activity guidelines indicate that young children should be engaging in ongoing physical activity throughout the day that includes both structured and unstructured play [2].
Structured play and movement opportunities in early childhood have been associated with cognitive and learning benefits. Research indicates that inhibition, or the ability to filter out classroom distractions to complete the task at hand, is significantly and positively influenced by physical activity regardless of intensity, suggesting that movement by itself enhances the young child’s neural processing efficiency [11]. Further, physical activity that enhances gross motor coordination has been found to positively influence working memory and attention [12]. Classroom-based physical activity in the preschool setting has also been found to improve self-regulation and, in doing so, has improved academic readiness, or the young child’s preparedness to take in new information [8, 13].
Among children in elementary school, single sessions of physical activity have
been associated with increased cognitive performance [14], and regular participation has led to increased physical fitness [15], working memory [16], and inhibitory control [17]. Behaviorally, research supports the notion that the more movement a young child is provided, the more self-regulated [18] and attentive [19] they will be.
School Nutrition and Healthy Eating
While we know that physical activity participation is on the decline, other factors like unhealthy eating and low socioeconomic status also influence health [20]. Nutrient-dense, well-balanced meals are essential for proper growth, immunity, physical and cognitive development, health, and well-being. Eating patterns as a whole, i.e., the combinations of food and drinks that children consume, can impact body weight and the attainment of essential nutrients. Although the consumption of healthy eating, like fruits and vegetables, has long been a societal concern, changes in how foods are constructed, preserved, and prepared, like adding sugar to fruit drinks, have increased the risk for obesity. Although the WHO recommends that grown children limit intake of added sugars to 6 teaspoons per day or 5% of the total energy expenditure, consumption is influenced by the child’s age and level of physical activity participation [21]. For example, in children 3 years of age, this would translate to less than 3 teaspoons. Globally, children and adolescents have consistently consumed more
than 10% of their total calories from added sugars over the past 20 years. Also, research shows that children who consume the highest percentages of total calories
from added sugars tend to consume the lowest amounts of nutrient-dense foods such as fruits and vegetables. All food and beverage choices matter as the appropriate caloric levels help to achieve healthy body weight, meet the nutrient needs of growing bodies, and reduce the risk of chronic diseases. School-based interventions targeting healthy eating are most effective when paired with physical activity outcomes, when they provide accessibility to healthy food options, and when they restrict access to unhealthy food options [22]. Approaches that are customizable and focus on both the micro- (i.e., child) and macrosystems (i.e., school policies) [23] have the highest potential for impact; however, sometimes unintended consequences lead to new inequalities linked to socioeconomics. A clustering of factors increases the health risk. Specifically, television watching for more than 1 h per day was associated with the consumption of fast foods, sweets, chips, and pizza, and reduced consumption of fruits and vegetables [24]. Moreover, this phenomenon was most prevalent among low socioeconomic families. To further our understanding, there needs to be increased scientific rigor among studies examining this phenomenon, e.g., in vulnerable minority populations.
Discussion
The intersectionality of socioecological systems identifies areas of overlap where
a policy, e.g., to ban fried foods from school, could have both upstream and downstream effects. If french fries were replaced with fresh fruit, and recess was
Whole School, Whole Community, Whole Child
“Health and education affect individuals, society, and the economy and, as such, must work together whenever possible. Schools are a perfect setting for collaboration” [26]. The WSCC intertwines academic success and prevalence of healthy behaviors, such as being regularly physically active and eating healthy. Models like WSCC identify points of intervention, provide justification for professional development for teachers and provision of resources, and help to develop strategies for overcoming barriers. In early childhood, the dosage and quality of the physical activity are dependent on the site. Several studies have investigated barriers to physical activity in child care settings citing issues ranging from lack of staff support and training to lack of space and resources [25]. In elementary and secondary schools, physical activity at school and healthy eating programs are often plagued by a lack of administrator support, school
policies, teacher professional development, and few adults modeling healthy
behaviors [27].
Student Access to Healthy Foods and Beverages at School
As part of the WSCC, the Foods and Beverages in Schools Campaign (Fig. 2) encourages
teachers to provide healthy snacks at school, model healthy behaviors,
and take advantage of healthy eating teaching opportunities [28]. The goals of
this program include providing access to clean drinking water at no cost, providing
2 healthy school meals per day, integrating nutrition education into the
school curriculum, and limiting access to unhealthy foods and beverages before,
during, and after school. Particularly for children and adolescents, multicomponent approaches that include both school and family or community involvement have the most significant potential to make meaningful differences in the rate of physical activity
participation [3]. In early childhood, training teachers is a priority so that they can work toward acceptance of physical activity as a normative practice. When there was portable physical activity equipment, low use of technology, and large playground/activity spaces, children were less sedentary and spent more time in moderate-to-vigorous physical activity. These findings suggest that intentional modifications of the child care environment can promote increased physical activity. Specifically, teachers need to learn how to offer physical activity opportunities across the day. In elementary and secondary education, where children and adolescents have more agency, we might be guided by the Self-Determination Theory (SDT) to develop educational materials to support opportunities to be physically active and consume healthy snacks and meals.
From a social cognitive perspective, SDT is commonly used to explain engagement
and disengagement behaviors as intrinsic and extrinsic constructs of motivation [29]. Intrinsically motivated children play and move for enjoyment and satisfaction. Realistically, though, children sometimes need to be incentivized by offering
them items of interest, such as rewards, to extrinsically motivate children to participate.
SDT is grounded in 3 essential human psychological needs for competence, autonomy, and relatedness. These needs provide a fundamental source of mental energy for social behaviors manifested through human interactions in environments like classrooms, gymnasiums, and playgrounds [30]. Competence is the perception that one can complete a given task. Feelings of competence reflect satisfaction that often results from one’s ability to produce the desired outcome and to demonstrate mastery. While autonomy is defined as the degree to which indi-
viduals perceive themselves as the origin or source responsible for the initiation of
the behavior, relatedness is the extent to which individuals feel connected to others through activities and their sense of belonging both to their community and other individuals. The application of SDT to school-based interventions allows us to differentiate between goals and self-regulatory processes like health behaviors. The
underlying assumptions of the SDT are (a) a school/parent-initiated environment can influence the formation of motivational regulations and (b) motivational regulations
have cognitive, affective, and behavioral outcomes. These assumptions are behaviorally carried out as self-regulation.
Implications
supporting regular participation in physical activity and healthy eating (Table 1). Administrators need to invest in children’s health and the training of teachers to provide opportunities for physical activity before, during, and after school, as healthier children are more ready to learn. By financing professional development for teachers and securing the resources necessary for implementing the WSCC framework, there is a potential for children to learn how to make healthy choices. Administrators can establish an expectation for building a health-enhancing school climate. From this health-first perspective, teachers, once trained, are positioned to be both practitioners and health promoters [31]. Pedagogical steps for increasing the potential for healthy decision-making, based on the SDT, would suggest the following evidenced-based practices. First, teachers could provide educational experiences wherein children learn about the importance of their health and how to make healthy choices. Teachers need to differentiate activities for varying abilities so that everyone can be optimally challenged at his or her own level and achieve success. Next, teachers need to praise students for the effort they put into the learning processes rather than just for the outcomes. In other words, teachers should create a mastery climate focused more on the acquisition of decision making skills and self-regulation. Since health behaviors are organic, continual, positive feedback can help children to improve their competence.
Table 1 summarizes these strategies and outlays the benefits for children and adolescents. Physical education can be an ideal place for increasing relatedness,
as there is often more time compared to classroom experiences dedicated to practice and gameplay. Cooperative and team activities are opportunities for relatedness to emerge. Having affiliation and being connected to school or a class like physical education can be a powerful predictor of student engagement.
A relatively novel approach is to include the students’ voices and give them a say in the development of authentic learning experiences. Student choice increases perceived control over their own health behaviors. During physical education, there was a positive association between perceived competence and self regulation [30]. If students are capable of applying self-regulation strategies, in theory, they should be able to develop and maintain the motivation to carry out healthful living. When teachers utilize these strategies, there are typically positive learning outcomes for children and adolescents.
Conflict of Interest Statement
The authors declare no known conflicts of interest.
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