Benefits of Physical Activity for Children

ABSTRACT

This paper focuses on children’s participation in physical activity and the benefits physical activity has on a child’s health. This paper suggests there is evidence that kids participating in physical activity is decreasing thus high body mass index in children is at a steady rise. This paper indicates that there is a need to identify the factors that play a role in children’s participation in physical activity throughout the day and the primary focus of physical activity should be encouraged during school hours. This study also focuses on the need of school wellness policies to help make sure that children are receiving adequate physical activity throughout the day, since most of their week is spent in school. The implications that physical activity plays on health in children cannot be ignored as it has been shown to help prevent some chronic diseases and improve mental health in children.

INTRODUCTION

A sedentary lifestyle has become a common theme in America. An increase in sedentary time means there is a decrease in physical activity (1).  Physical activity(PA) is an important factor in preventing against chronic diseases and obesity (2). It is understood and suggested that children should get at least sixty minutes of moderate to vigorous, physical activity daily (3). Due to media use like watching television, playing on their phones or computers, doing homework, or traveling/vacations promote a lot of sitting in a vehicle, thus, causing children to be more sedentary. In Europe and America, it is estimated that four to eight hours a day are spent being sedentary (3).

As children get older participation in extracurricular activities like sports becomes less, and the need for recess or gym class seems to not even be an option for most high school students. School wellness policies are a great way to implement physical activity for school age children and assess if they are getting enough physical activity throughout the day (4,5). It is evident that targeting school age children during school hours is the most efficient way to get children to exercise or participate in any sort of physical activity as they spend the majority of their day in school (2).

Not only can physical activity make a difference on body mass index of children, it can also help to improve a child’s self-esteem and help to improve symptoms of depression and anxiety in these young children (6). As obesity and mental health continue to be of importance in the adult population in America, healthcare professionals need to look at children and see how their adolescent years affect their health throughout their adult lives. This paper further illustrates the need to target and promote PA levels in children.

LITERATURE REVIEW

Physical Activity and Obesity

An increase in physical inactivity can be seen worldwide amongst parents and their children. It is known that parent’s habits or lifestyle can have an impact on their children’s way of life like eating habits and hobbies (1). In a prospective cohort study done in Poland by Anna Brzek and colleagues, observed 340 students and their parents and how often electronic devices were used. Their findings found that children’s physical activity was heavily dependent upon their parent’s active lifestyle. For example, if parents had a moderate active lifestyle it is expected that their child or their children would have a semi-active lifestyle. Not only do parents impact a child’s physical activity, but electronic devices. In the same study it was observed that children were on their electronic devices at least two to seven days a week and most of their free time was taken up by these electronic devices. It was seen in the study that children spent between 5-1620 minutes per week on their electronic device(s) and usually asked their parents for more time after their allotted time had expired (1).

Due to the use of electronic devices, some studies have looked at how to implement PA into these types of devices, and how effective it would be to have active or interactive type video games, that encouraged a child to get up and move while playing these video games (1,7). A study conducted by Ralph Maddison took a closer look at how physically active video games can make a difference in not only a child’s health but body mass index as well. This randomize control trial followed a group of children who were in a treatment group and children who were in a control group. The treatment group was given an upgraded hardware and gaming system to participate in the more active video games, whereas the control group continued using their normal gaming console with their standard games. Although this study showed very little differences between control and the treatment groups, this study is still worth bringing attention to. After the six-month period those who participated in the active video game intervention group saw a small decrease or difference in BMI and fat percentage and those that were in the control group showed no difference when using the usual non-active video games. The researchers of this study also noted that even though the difference was relatively small, this small change in BMI also showed that these active video games helped to slow weight gain, so children were able to grow into their height. There was no difference in groups among physical fitness, however this study showed that with the intervention group sedentary time did in fact decrease (7). This study shows that even minimal changes in a child’s everyday life like replacing a non-active video game with a more active video game can slow down weight gain and maybe help with weight loss.

Childhood obesity is becoming a public health issue. Data from a number of studies suggests that those who have a higher body mass index (BMI) during their childhood are likely to carry that same high BMI into adulthood (8,9).

In an observational cross-sectional study done in Northern India by Madhavi Bhargava and associates found that an overall 15.6% of children were overweight and 5.4% were obese (9). Both obesity and overweight were significantly associated with physical inactivity due to transportation to and from school, several missed chances to be active over lunch time, children not participating in household chores throughout the week, and excessive watching of television. This study suggests that more physical activity like sports and other recreational opportunities need to be encouraged in both home and school (9).

As mentioned, the rise in overweight and obese children is a worldly problem in both developed and underdeveloped countries. There are reported to be 43 million children who are considered overweight or obese and 35 million of that 43 million are children from developing countries. Furthermore, an additional 92 million were found to be at risk of becoming overweight or obese (10). This incessant rise of obesity in children is likely because there has been a drastic change in both nutrition and physical activity patterns, worldwide prevalence of children who are either overweight or obese has grown from 4.2% in the 1990s to 6.7% in 2010, it is speculated that this trend will continue to rise and reach 9.1% in 2020. It is more alarming that this trend is not only seen in older children, but pre-school aged children as well, thus indicating how important it is to encourage PA in young children (11). An increase in overweight and obesity in children can be attributed to a high intake of sugar-sweetened beverages, more screen time, inadequate sleep, and high rates of physical inactivity (11).

In a cross-sectional study done by Trost and colleagues, they compared patterns of physical activity in obese and non-obese children in middle school. A total of 133 children who were non-obese were entered in the study along with 54 obese children, all children were in the sixth grade. This study used NHANES to determine obesity, they determined obesity by specific race, age, and gender in the 95^th percentile range for body mass index. Over a seven-day period objective measurement of physical activity were collected for by using an accelerometer. Both moderate daily physical activity and vigorous daily physical activity was collected. Not only were daily physical activity measurements collected, but a cumulative of the weekly PA as well. The children did a self-report, for self-efficacy of PA, questions were asked about influences of their social life for PA, how they thought the outcomes of PA were, what they observed for PA levels in their parents and peers, how much access they had to exercise equipment at home, if they were involved in any PA in the community like sports, and lastly they were asked on how much time they spent watching tv or engaged in video games. In general, the results of this study showed that obese children had a lot lower physical activity level in both vigorous and moderate activity levels compared to non-obese children. Along with lower PA obese children had lower self-efficacy for PA, they were also less likely to be involved in PA in community sport programs, lastly this cross-sectional study found that obese children were more likely to report that the male figure in their life (father or guardian) was physically active (12).

It is evident that these studies show a need for further increase in PA in younger children to help prevent against childhood obesity.

Physical Activity and Health

There are several studies that suggest that PA not only helps a person lose and maintain weight, but that PA may help prevent against diseases and improve mental health.  A meta-analysis study done by Soyeon Ahn and Alicia L. Fedewa found that there was indeed a relationship between increased participation in physical activity and reduction of mental health illness like depression, anxiety, and emotional disturbance in children. The study conducted by Ahn and Fedewa found in both randomized control trials and non-randomized control trials, that with the increase in exercise or PA children had higher self-esteem(6). In a systematic review conducted by Ekeland, Heian, and Hagen looked at how PA can improve children’s self-esteem. They found that indeed exercise does help to improve a child’s self esteem at least for short-term as they did not find any studies that included long-term follow-up (13).In a cross-sectional study conducted by M. Rodriquez-Ayllon and colleagues found that there is a relationship between muscular strength and psychological distress. Thus, suggesting that obese and overweight adolescents with greater muscle strength had less psychological distress (14).

In a systematic review done by Janssen and LeBlanc, found in three studies where sixty to ninety minutes of exercise was prescribed weekly, and saw significant improvements in at least one symptom of depression, during an exercise program that was eight to twelve weeks. These reviewers looked at a case control study, where a there was two treatment groups one with a moderate intensity exercise program and one with a high intensity exercise program, and these groups were compared to a control group that had no exercise. They found that those who participated in the high intensity program had an improvement on depression scores (15). All these reviews and cross-sectional studies indicate a need to further strengthen the evidence of the benefits of PA to a child’s mental well-being.

Physical activity not only plays a vital role in mental health of children, but in several other health aspects. For instance in the same systematic review done by Janssen and LeBlanc found that even just 10 minutes of exercise done two to three days a week can have a moderate effect on a child’s bone mineral density (15). In another systematic review done by Julian-Almarcegu and colleagues, looked at cross-sectional as well as experimental studies and found that not only did calcium play a vital role in bone mineral density development, but physical activity plays a crucial role as well. They concluded that both calcium and physical activity helped to develop bones during growth outside of pubertal stages(16). Thus, indicating that children should participate in a decent amount of physical activity throughout their life.

In a cross-sectional study done by Ekelund and colleagues found that both increased or high levels of PA and cardiorespiratory fitness can decrease risks for certain metabolic factors. Their study consisted of two defined age ranges, nine to ten-year old and fifteen to sixteen-year-old boys and girls from three different regions in Europe for a total of 1,709 children participating in the study. This study looked at the independent relationships of bPA and cardiorespiratory fitness and the metabolic factors of interest. These metabolic factors of interest were, blood pressure, fasting glucose, waist circumference, insulin, levels of HDL-cholesterol, and triacylglycerol level (17). After the data analyses adjusted for the waist circumference, there was a strong association between cardiorespiratory fitness and metabolic risks with a confidence interval of (-0.08, -0.02), however after the confounding factor of waist circumference was adjusted for, total PA remained the same with a confidence of (-0.10, -0.05), still indicating significance. These results suggest that PA and cardiorespiratory fitness do in fact affect metabolic risk factors in several different ways (17).  The benefits of PA for children is undeniable, the key is being able to reach out to these children, and being able to successfully encourage them to participate in PA.

Physical Activity in Schools

Not only does PA play an important role in preventing obesity, mental health, and other diseases, but it has been shown to help improve cognitionand academic achievement.Sedentary behaviors have been shown to increase children’s BMI and other health risk factors. To target many children of different socioeconomic backgrounds schools are the best place to start in helping to implement the breaking up of time being sedentary and increasing physical activity during the day(2). There is evidence that suggests that as students get older they are at a greater risk of increased sedentary time and physical activity decreasing. To better understand this relationship Kerli Mooses and associates did a cross sectional study that looked at sedentary behaviors, sedentary time, and physical activity in different schools, ages, and subjects. In this study they observed nearly 6,363 school lessons/classes all forty-five minutes long. The average moderate to vigorous activity during these class periods remained less then 2.2 minutes per class in all levels of school and age. In grades 1-3 the time that students went without physical activity was 36% at a maximum and in grades 7-9 the longest time without any physical activity was 73% of the school day. This long sedentary time is unfavorable to both health and academic success. There is a need for physical activity interventions to focus on breaking up sedentary time and making physical activity more prominent throughout the day is needed in all subject matters and all age groups, but especially in older grades. (2).

School wellness policies are a good strategy in implementing and improving PA within schools. The creation of school wellness policies is complex and not well understood but are created to help fight against childhood obesity and physical inactivity. One example of a school wellness policy is one implemented in Georgia in 2009. Georgia’s General Assembly adopted the Student Health and Physical Education (SHAPE) Act. SHAPE requires an annual assessment of fitness for public schools for all students enrolled in a physical education course in grades one through twelve (4).

Furthermore, in a randomized control trial done in fifty middle school students showed that being enrolled in a gym class that focused primarily on fitness helped decrease body mass index (BMI). This study was carried out by Aaron L. Carrel, MD and colleagues, they found middle school children who were above the 95^th percentile BMI for their current age and then were randomized into a lifestyle and fitness focus group and then were compared to a gym class of normal standards for nine months. The children had lab work to look at their fasting glucose and insulin levels, evaluation of their body composition which was done utilizing the dual energy absorptiometry, and lastly their maximum consumption of oxygen using a treadmill. These evaluations were done at the beginning and end of the school year.  Not only did the study show that there was improvement of fat loss by using the lifestyle and fitness focused gym class (p<.04), it also showed improvement in these children with their fasting insulin levels (p<.02), and lastly those enrolled in the treatment group had greater cardiovascular fitness(p<.001). The results from this study suggests that minor and consistent differences in a student’s gym class can make a big difference in that of a child’s health(5).

In a cluster randomized control trial done in Switzerland, there were great implications that a school program for physical activity helped to reduce adiposity in children who participated in the program. This study took 28 classes from a total of 15 elementary schools, and the 498 students were randomly put into an intervention group or control group. The intervention group received a physical activity program that had a multitude of components to the program; they had 5 physical education lessons, short breaks for activity, and had homework that included physical activity. After the data was controlled for sex and age, the results suggested that those who were in the intervention group showed a decrease in adiposity, assessed by four skinfolds, they also had an increase in aerobic fitness, there was no significant change in the intervention group in overall daily physical activity, quality of their psychological well-being, or their physical quality of life (18). Through school wellness policies, and these studies show that including more PA in school is beneficial for children.

RESEARCH GAPS

More research needs to be done in the school setting between age groups as it is quite apparent that sedentary time increases with age. Since kids spend most of their day at school and are not required to take a physical education class every year or partake in any sports school is an easier place to target all kids of all backgrounds to improve physical activity on all levels. More studies like the one done by Mooses and associates are needed to further understand where sedentary time takes place during the school day. It is hard to implement physical activity during all class subjects, but even having the students stand or walk around the classroom would be beneficial opposed to sitting all day during hour long class periods.

There is a lot of room for more randomized control trials, prospective cohort studies, and even case control studies to be conducted on how PA affects a child’s mental health. While going through the literature there were very few studies available that investigated the role physical activity may play on the mental health and self esteem of children. This is an important area to investigate as there is such a need as mental health and mental health disorders continue to become more prevalent as time continues to pass.

PRACTICE GUIDELINES FOR HEALTHCARE PROFESSIONALS

One-third of adults in the United States had obesity and at least another 33.6% of adults were considered overweight in 2012 (19). This high population with overweight and obesity in the United States has a negative impact on health. Individuals who are obese are at a greater risk for developing chronic diseases such as certain forms of cancer, cardiovascular disease,  and type 2 diabetes (20,21). Obesity has a great bearing on not only health but even medical costs(22), thus making the importance of reducing the obesity rates in the United States a public health issue. It is the position of the Academy of Nutrition and Dietetics that to have positive effect in overweight and obese adult individuals, will require the implementation and maintenance of a healthy lifestyle that influence not only dietary behaviors, but physical activity behaviors as well (23). Physical activity has been proven to help prevent chronic diseases. Regardless of these findings physical activity in Americans remains inadequate and therefore obesity in America remains high (24).

As future health care professionals we need to identify where the problem lies. As mentioned early physical inactivity is high among children, as they would rather spend time on electronic devices opposed to exercising. For health care professionals it is important to understand why physical activity is not happening at a young age as these habits carry over into adulthood. We need to reach out the parents of the children and speak volumes on to how detrimental this can be not only on the children presently, but as they continue to grow into adults. More importantly as future dietitians we not only need to encourage parents and children to exercise, but we need to teach them the importance of a well-balanced nutrient diet, to help decrease the magnitude in which obesity is affecting the young population.

Health care professionals need to take this research and implement it into the school districts to help make sure these types of gym programs are available for schools and not just hoping kids will join extracurricular activities, like sports to help increase exercise. School wellness policies are becoming better understood and regulated, but more research needs to be done, to make sure all schools are on the same page and no one slips through the cracks. Not only should school wellness policies incorporate physical activity, but healthy food options for children to have during school hours. Along these lines healthcare professionals, like Registered Dietitians, should go in and teach these kids about nutrition in simple terms that they can understand, and explain to them, why adequate fruits and vegetable intake is important, and answer any nutrition related questions that these children may have. We must be advocates for these children to help them better understand their body and their health.

CONCLUSION

This research further strengthens the fact that children’s physical inactivity is alarming, and we need to find ways to improve fitness in young children. Researchers are targeting schools as their primary contact with these children to help encourage exercise, since most of their day is spent inside the school’s four walls. There are studies out there that prove that a focus more on lifestyle changes and fitness in gym class can help children lose body fat and increase cardiovascular function (5). It is evident that by increasing children’s physical activity we are not only improving a child’s physical appearance, by helping children lose body fat and helping to prevent certain disease, but physical activity also helps children improve their mental well-being. Although further research needs to be done in this area there is strong evidence to suggest that PA can increase a child’s self-esteem and may help decrease symptoms of depression and/or anxiety(6). Even the smallest increases in physical activity can make huge differences in the health of these children! By forming healthy habits early, these habits just may follow these children throughout their entire lives, resulting in a healthier America overall.

REFERENCES

1. Brzek A, Strauss M, Przybylek B, Dworrak T, Dworrak B, Leischik R. How does the activity level of the parents influence their children’s activity? The contemporary life in a world ruled by electronic devices. Arch Med Sci 2018;14(1):190-98 doi: 10.5114/aoms.2018.72242[published Online First: Epub Date]|.

2. Mooses K, Magi K, Riso EM, Kalma M, Kaasik P, Kull M. Objectively measured sedentary behaviour and moderate and vigorous physical activity in different school subjects: a cross-sectional study. BMC Public Health 2017;17(1):108 doi: 10.1186/s12889-017-4046-9[published Online First: Epub Date]|.

3. Hoffmann B, Kettner S, Wirt T, et al. Sedentary time among primary school children in south-west Germany: amounts and correlates. Arch Public Health 2017;75:63 doi: 10.1186/s13690-017-0230-8[published Online First: Epub Date]|.

4. Lyn RS, Sheldon ER, Eriksen MP. Adopting State-Level Policy to Support Physical Activity Among School-Aged Children and Adolescents: Georgia’s SHAPE Act. Public Health Rep 2017;132(2_suppl):9S-15S doi: 10.1177/0033354917719705[published Online First: Epub Date]|.

5. Carrel A, Clark R, Peterson S, Nemeth B, Sullivan J, Allen D. Improvement of Fitness, Body Composition, and Insulin Sensitivity in Overweight Children in a School-Based Exercise Program. Arch Pediatr Adolesc Med 2005;159:963-68

6. Ahn S, Fedewa AL. A meta-analysis of the relationship between children’s physical activity and mental health. J Pediatr Psychol 2011;36(4):385-97 doi: 10.1093/jpepsy/jsq107[published Online First: Epub Date]|.

7. Maddison R, Foley L, Ni Mhurchu C, et al. Effects of active video games on body composition: a randomized controlled trial. Am J Clin Nutr 2011;94(1):156-63 doi: 10.3945/ajcn.110.009142[published Online First: Epub Date]|.

8. Deckelbaum JR, Williams LC. Childhood Obesity: The Health Issue. Obesity Research 2001;Vol. 9

9. Bhargava M, Kandpal SD, Aggarwal P. Physical activity correlates of overweight and obesity in school-going children of Dehradun, Uttarakhand. Journal of Family Medicine and Primary Care 2016;5:564-68

10. Mekonnen T, Tariku A, Abebe SM. Overweight/obesity among school aged children in Bahir Dar City: cross sectional study. Ital J Pediatr 2018;44(1):17 doi: 10.1186/s13052-018-0452-6[published Online First: Epub Date]|.

11. Latorre-Roman PA, Mora-Lopez D, Garcia-Pinillos F. Effects of a physical activity programme in the school setting on physical fitness in preschool children. Child Care Health Dev 2018 doi: 10.1111/cch.12550[published Online First: Epub Date]|.

12. Trost S, Kerr L, Ward D, Pate R. Physical activity and determinants of physical activity in obese and non-obese children. International Journal of Obesity 2001;21:822-29

13. Ekeland E, Heian F, Hagen KB. Can exercise improve self esteem in children and young people? A systematic review of randomised controlled trials. Br J Sports Med 2005;39(11):792-8; discussion 92-8 doi: 10.1136/bjsm.2004.017707[published Online First: Epub Date]|.

14. Rodriguez-Ayllon M, Cadenas-Sanchez C, Esteban-Cornejo I, et al. Physical fitness and psychological health in overweight/obese children: A cross-sectional study from the ActiveBrains project. J Sci Med Sport 2018;21(2):179-84 doi: 10.1016/j.jsams.2017.09.019[published Online First: Epub Date]|.

15. Janssen I, LeBlanc AG. Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Interanational Journal of Behavioral Nutrition and Physical Activity 2010;7(40)

16. Julian-Almarcegui C, Gomez-Cabello A, Huybrechts I, et al. Combined effects of interaction between physical activity and nutrition on bone health in children and adolescents: a systematic review. Nutr Rev 2015;73(3):127-39 doi: 10.1093/nutrit/nuu065[published Online First: Epub Date]|.

17. Ekelund U, Anderssen SA, Froberg K, et al. Independent associations of physical activity and cardiorespiratory fitness with metabolic risk factors in children: the European youth heart study. Diabetologia 2007;50(9):1832-40 doi: 10.1007/s00125-007-0762-5[published Online First: Epub Date]|.

18. Kriemler S, Zahner L, Schindler C, et al. Effect of school based physical activity programme (KISS) on fitness and adiposity in primary schoolchildren: cluster randomised controlled trial. BMJ 2010;340:c785 doi: 10.1136/bmj.c785[published Online First: Epub Date]|.

19. Ogden C, Carroll M, Fryer C, Flegal K. Prevalence of Obesity Among Adults and Youth: United States, 2011–2014. NCHS Data Brief 2015;219

20. Hurt RT, Kulisek C, Buchanan LA, McClave S. The Obesity Epidemic: Challenges, Health Initiatives, and Implications for Gastroenterologists. Gastroenterology & Hepatology 2010;6(12)

21. Visscher TL, Seidell JC. The Public Health Impact of Obesity. Annu. Rev. Public Health 2001;22:355-75

22. van Baal PHM, Polder JJ, de Wit AG, et al. Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure. PLoS Med 2008;5(2) doi: 10.1371/journal. pmed.0050029[published Online First: Epub Date]|.

23. Raynor HA, Champagne CM. Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults. J Acad Nutr Diet 2016;116(1):129-47 doi: 10.1016/j.jand.2015.10.031[published Online First: Epub Date]|.

24. 7^Kaushal N, Rhodes R. The home physical environment and its relationship with physical activity and sedentary behavior: A systematic review. Prev. Med., 2014:221-37.