Kids Get Active

After-School Programs to the Rescue

By Deborah L. Vence

Is there such a thing as "recess" anymore? Recess, well, at least it used to be, the highlight of the school day. The bell would ring sometime after lunch, and all the children would dash out the school doors to engage in some form of playground amusement for 15 minutes, like playing tag, jumping rope or playing ball.

Unfortunately, this longstanding tradition is fading fast as more schools across the country are choosing to do away with recess as well as physical education classes, in some cases, in order to further children's academic achievement because of stricter educational requirements or simply because they don't have the money to keep PE teachers because of budget cuts.

Consequently, as traditional gym classes take a back seat and recess time is cut, the problem of childhood obesity carries on.

The fact is that childhood obesity in the United States has tripled in the past 30 years. The prevalence of obesity among children ages 6 to 11 years old increased from 6.5 percent in 1980 to 19.6 percent in 2008. Meanwhile, the prevalence of obesity among adolescents aged 12 to 19 years increased from 5 percent to 18.1 percent during those years, according to data from the Centers for Disease Control and Prevention (CDC) Web site.

Interestingly enough, part of the problem, experts believe, can be attributed to a lack of convenience to parks and recreation facilities. The point being that the closer children are to parks and recreation, the greater the chance they have at being leaner and healthier.

The Facts

For example, a 2009 study titled, "Childhood Obesity and Proximity to Urban Parks and Recreational Resources: A Longitudinal Cohort Study," by San Diego-based Active Living Research, a national program of the Robert Wood Johnson Foundation (RWJF) that supports research to identify environmental factors and policies that influence physical activity with a focus on active living related to youth in low-income and high-risk communities, proves that the proximity to parks and recreation resources has a lot to do with childhood obesity.

"The [close] proximity to both parks and public recreation [facilities] was associated with less weight gain over time," said Dr. James F. Sallis, professor of psychology at San Diego State University and director of Active Living Research.

The study, which originally was created to study asthma in children and the relationship with environmental variables and ultimately led to extensive research on childhood obesity, monitored children for eight years during which time height and weight data were surveyed actively.

"[Results showed] that proximity to both parks and public recreation were associated with less weight gain over time. This was pretty convincing and direct evidence between recreation resources and children's health as indicated by their weight gain. This links parks and recreation directly to childhood obesity and points to some solutions that children need access to parks and recreation facilities and programs," Sallis said.

The study involved research in 12 Southern California communities where 3,318 children between ages 10 and 18 were studied. Results showed that among boys at age 10, their average Body Mass Index (BMI) was 18.4 and 24.1 at age 18. Meanwhile, girls at age 10 had a BMI of 18.4 and 23.4 at age 18. The general characteristic of the study's communities comprised older central cities (Long Beach, Riverside), inner ring suburbs (San Dimas), suburbs (Lancaster, Mira Loma, Upland), distant exurbs (Lake Elsinore, Alpine) and rural/resort communities (Santa Maria, Atascadero, Lompoc, Lake Gregory). In addition, the mix of class and race/ethnicity comprised white, affluent and Latino, lower-income.

"One of the startling things is that there is a significant chunk of kids that have very bad geographical access [to recreation]," said Jennifer Wolch, Dean of the College of Environmental Design and William W. Wurster Professor of City and Regional Planning at UC Berkeley in Berkeley, Calif., who headed up the study. "One of the hypotheses [based on the study's results] was that with better access to park space, you might [not be at risk] for obesity. Parks are protective of obesity."

The results showed that park space within 500 meters of a child's home was inversely associated with BMI at age 18; that public recreational programs 10 kilometers or less from a child's home also warded off obesity; and that many children have poor access to public recreational programs. Meanwhile, nearly 20 percent said that they have no access within 10 kilometers and 36 percent have no access within 5 kilometers.

What's more, the study indicated that if all children had comparable access to recreational programs: 11.26 percent of boys would move from the overweight to normal weight category and 3 percent from obese to overweight; while 8.5 percent of girls would move from the overweight to normal weight category and almost 3 percent from obese to overweight.

Parks and Recreation Programs Do Work

To help fight the growing problem of childhood obesity, a camp program in the summer of 2009 proved to have enough muscle to sway a group of 96 kids in Milwaukee into eating healthier and exercising more.

Milwaukee Recreation Services coordinated a nine-week trial of the Säjai Foundation's Wise Kids program, which is designed to teach children between the ages of 6 and 11 about healthy living. The study was conducted by Säjai Foundation, Penn State University and the National Recreation and Park Association (NRPA) in 49 U.S. cities.

"We partnered with the NRPA, and we were able to offer grants to 49 different agencies running the Wise Kids program across the country. Milwaukee was selected as one of the sites. We ran the Wise Kids program with about 100 kids," said Melissa Hanson, CEO and president of Säjai Foundation, a national nonprofit organization based in Hamel, Minn., that is committed to working with local communities to educate children about how to live a healthier life.

Cecelia Edmond, Wise Kids supervisor for Milwaukee Recreation, added that the program was designed to help kids to understand the process of choosing the right food, and how certain foods cause them to gain weight.

"A lot of the schools don't have PE teachers and all of that anymore, due to funding cuts. So, [in some cases], a lot of physical education teachers have two schools [they teach at]," Edmond said.

Wise Kids program activities entailed, in part, teaching children how to eat healthier. One of the activities had participants cutting up vegetables to make a salad.

"In the Wise Kids program, kids do everything from learning to read [nutrition labels], to an activity called sugar scientists where they actually read labels to find the grams of sugar then measure that amount of sugar in teaspoons into a test tube so they can see for themselves how much it is. The activity is really exciting for them," Hanson said. "They also make posters, play games like Food Pyramid Bingo and try to plan a healthy meal for home or 'make-over' a restaurant menu to include healthy options or physical activity suggestions."

"In terms of physical activity in Wise Kids, they do everything from games like Sharks and Minnows to using pedometers to playing soccer with a beach ball. The goal is to be active for 30 minutes each session and we recommend that they meet two times per week. At 30 minutes, they are halfway to the 60-minute-a-day goal," she said.

In the Wise Kids Outdoors program, kids are outdoors the majority of each session doing things like greening up an area, hiking on scavenger hunts, digging for worms, looking for critters and even learning about geocaching, orienteering and reading maps. Some kids even practice setting up a tent or build a fort, Hanson explained.

"Most times, they are outside exploring and/or being active for up to 45 to 60 minutes as they learn about environmental stewardship and nature around them," she added.

And, the impact of the program has been encouraging. Survey results indicated that children in Milwaukee who participated in the program are exercising more often on their own and making healthier choices about food. Also, they are spending less time watching television and playing computer games.

"The kids just embraced [the program] wholeheartedly," Hanson said.

For example, after participating in the Wise Kids program, children ate breakfast more often and spent more time in physical activity and less time on the computer, watching TV or playing video games.

Further evidence showed that there was a 30 percent change in the number of children who said they enjoyed eating fast food, such as hamburgers and French fries; a 14 percent change in the number of children who said they like to eat fruits and vegetables; a 16 percent change in the number of children who said in the last week they did eat fruits and vegetables; an 18 percent change in the number of children who said they like eating breakfast. Also, 100 percent of program participants said they were definitely or somewhat interested in learning more about healthy living at the end of the program; and 100 percent of parents said their children enjoyed the Wise Kids program all or most of the time.

Besides Milwaukee, the state of Oregon initiated a pilot project last year—called the Portland Rx Play project—to help fight childhood obesity.

The project, the lead researcher for which is Dr. Stewart Trost, an associate professor at Oregon State University's Department of Nutrition and Exercise Science, evaluates the effectiveness of an innovative childhood obesity prevention model that combines clinician-based physical activity counseling and prescriptions with referrals to physical activity programs offered by local parks and recreation departments.

"If you look at what we've been doing from a research standpoint, the childhood obesity figures that come out of the CDC are still pretty high. Even though we might be [considered] No. 1 [in the country as having the lowest childhood obesity rate], we don't think we're doing that well," said Randall S. Rosenberger, associate professor in the Department of Forest Ecosystems and Society at Oregon State University in Corvallis, Ore., who helped research the 2008-2012 Oregon Statewide Comprehensive Outdoor Recreation Plan [SCORP] report.

"Some of the research in the last SCORP report did put preference points on counties that had an increasing obesity rate with lack of outdoor recreation opportunities, though it was not directed at youth in particular," Rosenberger said.

"To me, what I've seen, Oregon patterns pretty much mirror the rest of the nation. With lower obesity rates here, I don't know of scientific evidence that explains why that is the case. But, there is a lot of biking, hiking and camping [in Oregon]. Physical activity or inactivity isn't necessarily the culprit for childhood obesity. There's a combination of factors. Childhood obesity is all over the place," he added.

The idea for the pilot program originated, in part, when Kaiser Permanente, an Oakland, Calif.-based integrated managed care organization, approached the Oregon Parks and Recreation Department (OPRD) about its interest in putting together a community outreach program to address childhood obesity.

"It was with Kaiser in 2008 that our initial conversations began. They told us that physicians didn't have the time to follow through. They didn't have the time in the consultation and with the parents to give them information or the resources to follow up afterward," said Terry Bergerson, outdoor recreation planner for Oregon Parks and Recreation.

"There is no evidence-based program for dealing with childhood obesity associated with parks and recreation. And, we wanted to take a look at that and see if there was a possibility in starting a pilot project to lead to the creation of an evidence-based program. There's a greater likelihood that it would be accepted in a medical community in Oregon and maybe even across the country," Bergerson said.

Planning for the Portland Rx Play project began in the fall of 2008 when the OPRD staff began working in the Portland metropolitan area to develop a project addressing a recommendation in the SCORP report that identified a need for Oregon's recreation providers to work with the medical community to get recreation participation information into medical offices and physicians' physical activity referrals.

OPRD's role in the Portland Rx Play project has been to identify key partners, provide overall project management and fund the pilot project research component. Current project partners include Portland Parks and Recreation, Kaiser Permanente, Legacy Health System, Clarendon-Portsmouth School Health Center, Multnomah County Health Department, and the Oregon Health and Science University.

Also, in planning the project, other models across the country were looked at, including the parks and recreation department in San Diego, and New Zealand, which stood out the most, Bergerson noted, with its green prescription program, which is a referral given by a doctor or nurse to a patient, with exercise and lifestyle goals written on it.

The site for Oregon's pilot program is at University Park Community Center in Portland.

"Transportation is tricky in getting kids involved on a regular basis. What we did was identify University Park Community Center in Portland as the central location," Bergerson said. "That's because seven months out of the year, because of the rain, you are talking about indoor activities, especially during the school year. The community center became the central place to funnel kids to."

To be included in the Portland Rx Play Pilot Project, children must be between the ages of 6 and 12, reside in the north Portland area, have a BMI greater than or equal to the 85th percentile for their age and sex (overweight or obese) and have a clinician's approval to engage in moderate physical activity. The results of the pilot study will be used to conduct a randomized trial with a larger group to test the effectiveness and potential public health impact of the approach.

Though data collection still is ongoing, Bergerson said results have been promising.

"So far, we found out that the University Park Community Center received 19 prescriptions from medical providers. Six families have signed up for a few classes, three families are interested in the walking club and nonscheduled activity," he said. "Initial indications [show that] things are working out okay."

After-School Fitness

Fitness programs offered after school also can be a great way for children to kick-start a healthier lifestyle.

Now considered to be the most cost-effective health and wellness program for children in the country, based on a recent study by Cornell University, CATCH—which stands for Coordinated Approach to Child Health—is an after-school recreation program for children in kindergarten through fifth grade. The CATCH program brings schools, families and communities together to teach children how to be healthy for a lifetime. Healthy behaviors are reinforced through a coordinated approach—in the classroom, in the cafeteria, in physical education, at home and after school.

"CATCH was funded by NIH back in the late '80s to be an intervention to reduce cardiovascular disease. The CDC wanted to see if there would be a school-based intervention," said Kathy Chichester, campaign manager for CATCH.

"That original school-based study turned into CATCH—a program that can change behaviors, and [the types of] meals served in schools. The after-school program was designed for after-school implementation in an after-school market. The after-school piece today consists of physical activity and a nutrition component," she said.

A 2003-2004 report about a pilot study of an after-school adaptation of the CATCH elementary school program called the CATCH Kids Club (CKC), evaluated 16 Texas after-school programs—eight in El Paso and eight in Austin. Evaluation involved direct observation of moderate to vigorous physical activity [MVPA] during play time, self-reported food intake and physical activity and focus group interviews with after-school program staff.

The results revealed that students responded well to physical activity and snack components and were less interested in the five-module education component. Routine staff training was a key variable in achieving proper implementation; the ideal would be a full day with repeated follow-up model teaching visits. The results of the physical education component suggest it is feasible, effective and ready for larger-scale evaluation or dissemination.

The physical activity component of the pilot study had four main objectives: involvement of students in at least 30 minutes of daily physical activity; involvement of students in MVPA for at least 40 percent of daily physical activity time; providing students with many opportunities to participate and practice skills in physical activities that could be carried over into other times of the day and maintained later in life; and, finally, providing students with a variety of enjoyable physical activities.

"There is evidence that is showing student behaviors can be changed about physical activity," Chichester said.

Pre- and post-testing has shown that kids are moving more and changing behaviors—since the CATCH program was implemented. There are take-home letters and activities to do with their family members in English and Spanish. This is the goal of the program—several of the lessons have family activities to take home after the program, Chichester added.

Meanwhile, a program that began in March 2009 at Stamford Hospital in Stamford, Conn., now will be partnered with the Stamford YMCA to help fight childhood obesity.

Dr. Madhu Mathur from Stamford Hospital created the program called Kids' Fitness and Nutrition Services, or Kids' FANS, which is geared toward giving children instruction on how to make healthy lifestyle choices and essentially battle childhood obesity. Through regular meetings with a pediatrician, nutritionist, exercise instructor and social worker, children are taught how to make healthier food and lifestyle choices.

"A certified trainer will be running fitness classes for the kids at the YMCA this year, and the hospital is providing a nutritionist to work with the kids in the public school system. After-school transportation is provided to the YMCA," said Tim Dudics, marketing and membership director for the Stamford Family YMCA.

The program with the YMCA, which will begin this fall, will enable children who are enrolled in Stamford Hospital's after-school wellness program to join the YMCA after their 12-week session with medical and fitness professionals at the Tully Health Center ends.

Political Influence

The U.S. Department of Health and Human Services recommends that children get at least 60 minutes of physical activity every day—yet another reason why recess and physical education classes are so important.

Nancy Somerville, CEO of Washington-based American Society of Landscape Architects [ASLA], said her organization is an advocate of increasing kids' access to play and recreation areas and parks.

"It's important for communities to be designed to provide safe access. Advocacy on the legislative front, the Urban Revitalization and Livable Communities Act (URLC) and the No Child Left Inside Act haven't passed yet. They were introduced during the last Congress, but that's another piece of legislation that both gets them outdoors so they have recreational opportunities and provides environmental opportunities," Somerville said.

The URLC Act came about a number of years ago—out of the Urban Parks and Recreation Recovery Act, UPARR—which essentially was federal aid to help cities to restore existing parks, keep them upgraded or create new ones, with a focus on the urban areas.

"In a lot of ways, the URLC Act picks up where that left off. We're better informed. We know now more than we did 10 years ago about the link between community design and access to parks and obesity for children and people of any age group," she said.

"Legislation really takes off on the critical nature of that need. Ten or 20 years ago, when the UPARR legislation was not continued and it died, the attitude among public policy makers was that it's nice, but not critical. The data we know now about physical exercise and access to the outdoors is that it's a necessity; it's not a luxury," Somerville added.

In addition, Complete Streets legislation currently is being adopted across the country and making its way through Congress, and is critical to providing opportunities that incorporate walking and biking into daily activities.

"Complete Streets is about planning for bicycles, alternative forms of transportation, when you are defining and designing neighborhoods," she said.

Somerville added, "All of the research shows that human beings are hard wired to respond to nature. We are more productive if we get out in the landscape or look out into a place that's landscaped. Research has shown that people in the hospital heal faster and have shorter stays if their window looks out on an area that's landscaped. We're calmer, everything about our physiology responds better to the great outdoors."

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