THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 13 - DECEMBER 99

Can School PE Make Fitter Kids?

School physical education (PE), after years of relative neglect in favor of other subjects, is gaining new attention in the face of increasing obesity and inactivity among children. Educators and healthcare leaders are working to make PE more engaging, inclusive, and health-oriented. At the same time, they are stepping up efforts to ensure that all students have adequate instructional time in PE classes each week.

Enter the 'New PE'

In the early 1990s, an effort to update standards for all subjects taught in US schools led to a rethinking of school PE, says Judith C. Young, PhD, executive director of the National Association for Sport and Physical Education (NASPE), a group composed mostly of PE teachers and researchers on physical activity and exercise, based in Reston, Virginia. Two of the published educational standards for school PE address fitness and physical activity, she says. "There is a concerted effort to address the public health perspective in PE, based on our standards."

Observers are calling the curriculum changes "the new PE," which emphasizes lifetime physical activity and fitness instead of only sports competition and traditional calisthenics. For example, middle school students in Herndon, Virginia, use heart-rate monitors to measure their aerobic effort during 15-minute fitness runs (1). And in the St Paul area, some PE teachers are using popular activities such as rock-climbing and in-line skating to make PE more fun (2).

George Graham, PhD, a professor in the department of health and physical education at Virginia Tech in Blacksburg, Virginia, says the "new PE" is also a response to teaching methods—such as using exercise for punishment or picking teams—that seem to discourage many kids. "My view is that at about age 10, kids are making the decision about whether they're athletic or not," he says. "We need to find ways for all kids to succeed."

The more traditional PE classes that emphasize team sports are doing a disservice to competitive athletes as well, Graham adds. "Athletes need to get to know sports they can continue into adulthood. If you're a gymnast, you're not going to do gymnastics your whole life," he says.

The Impetus: Childhood Obesity

Recent national reports have made clear that children need to be more physically active and thus have strengthened the case for improving PE. According to the US Centers for Disease Control and Prevention (CDC) (3), the percentage of young people who are overweight has doubled in the past 30 years. The most recent figures (4) for adults show that from 1991 to 1998 the prevalence of obesity increased from 12% to 17.9%. The increase was seen in all age-groups, races, and educational levels. Further, the survey found that activity rates did not change substantially between 1991 and 1998.

In a recent survey (5) of more than 13,000 teenagers, only a third said they were moderately to vigorously active five or more times a week, the level usually cited in public health recommendations. The study found signs of greater inactivity among minority children. For example, the number of hours spent watching television each week was about 14.4 for white boys, 15 for Asian boys, 16.6 for Hispanic boys, and 20.8 for black boys. The pattern was similar for girls.

Steven J. Anderson, MD, clinical professor in the Department of Pediatrics at the University of Washington in Seattle, says his observations from a pediatric sports medicine practice seem to mirror national trends. "A small number of young athletes occasionally overdo it," says Anderson, who is chair of the American Academy of Pediatrics Committee on Sports Medicine and Fitness. Sedentary patients and families may use reports of injury or excesses to justify their own inactivity, he says.

How Much PE Is Enough?

Most children do not receive the amount of PE recommended by public health authorities, according to recent evidence. In 1996, the US surgeon general's report on physical activity and the CDC recommended that all students in kindergarten through grade 12 receive daily, quality physical education. However, a national survey (6) by NASPE a year later found that most states were not meeting this recommendation. The survey showed that:

• Illinois was the only state that mandated daily PE for students in all grades.
• State mandates for elementary PE ranged from 50 to 200 minutes a week. The mandates for middle school PE ranged from 55 to 275 minutes per week.
• Most high school students take PE for only 1 year, and 42 states allow high school students to opt out of PE for medical or religious reasons and to substitute varsity athletics, ROTC, or marching band for PE.

NASPE recommends that elementary school children receive at least 150 minutes of PE per week and that middle and high school students receive at least 225 minutes a week. The group also says that meeting PE standards should be a graduation requirement and that schools should not substitute other courses and activities for PE.

Some educators have resisted devoting more curriculum time to PE, fearing encroachment on academic work. However, a recent study (7) of 759 children who took achievement tests after three different PE interventions found that students in a health-related PE program did as well academically as students who spent half as much time each week in PE.

Though most states aren't meeting public health recommendations, NASPE is hoping a major funding bill will pass Congress and move more states toward compliance. The proposed Physical Education for Progress (PEP) Act would provide $400 million over the next 5 years to initiate, expand, and improve school PE programs. The bill was introduced in May by Sen Ted Stevens (R-AK). More information on the PEP bill can be found on NASPE's Web site: http://www.aahperd.org/naspe/naspe-whatsnew.htm#pep. NASPE projects that the bill could be voted on anytime between now and December 2000.

The Effectiveness of PE

Long-term effects of daily physical education have been hard to measure because studies depend on recall, but a recent report provides some clues. Canadian researchers (8) compared a group of 147 men and women who received daily PE during grade school in the early 1970s with matched controls. They found that women who had daily PE were more likely to be physically active as adults than women who didn't have daily PE. Among men, those who had daily PE were less likely to smoke than those who did not have daily PE.

Researchers have investigated other health effects of school PE. In 1996, Shephard and Lavallee (9) evaluated the impact of an enhanced PE program (5 additional hours of class taught by a specialist) on the lung volumes (forced vital capacity and forced expiratory volume in 1 second) of primary school children. They found that students in the enhanced PE classes during the 6-year study period had greater lung volumes than controls who took the standard PE class.

Though other interventions exist for promoting childhood activity, such as after-school programs or self-directed workouts, Graham says many kids don't have access to such programs or to safe exercise environments. "PE is the best hope we have," he says.

What Physicians Can Do

Young and Graham have several tips for physicians who want to promote PE to their patients and support PE programs in their communities.

Learn about local programs. Talk to patients and parents to find out what local PE programs are like. NASPE has published a list of appropriate and inappropriate PE practices (table 1) (10).

Table 1. Examples of Appropriate and Inappropriate Physical Education Practices
Component	Appropriate Practice	Inappropriate Practice
Curriculum	Goals and objectives that are appropriate for all children and that balance and enhance cognitive, motor, affective, and physical fitness development	Developed goals lacking; curriculum based primarily on teacher background or preference
Concepts of fitness	Children learn how physical fitness contributes to a healthy lifestyle	Children are required to participate but are not taught why
Physical fitness tests	Used to help children understand, improve, and maintain physical fitness	Used to qualify children for rewards or because required by school district or state; used without adequate conditioning
Adapted with permission from Council on Physical Education for Children: Developmentally appropriate physical education practices for children: a position stand of the National Association for Sport and Physical Education. Reston, Virginia, National Association for Sport and Physical Education, 1999

Be aware of PE standards. Graham recommends that physicians become familiar with the most recent guidelines for a quality PE program. Educational standards for PE are available on the NASPE Web site at http://www.aahperd.org/naspe/publicationsnationalstandards.htm.

Ask young patients about PE. "Have conversations about PE with all kids, not just the ones who are obese," says Young. "Physicians are respected authorities—parents and kids will listen to them."

Identify kids who are obese. It's not always obvious when a child is too fat, Young says. She notes that kids who have very low lean body mass in proportion to their fat mass may be considered obese.

Support the PEP bill. Write letters to US senators and representatives asking them to sign on as cosponsors of the PEP bill (Senate Bill 1159) or otherwise support it. E-mail links to US Senators can be found at http://www.senate.gov/contacting/index.cfm; Web and e-mail links to US Representatives can be found at http://www.house.gov/house/MemberWWW.htm.

Lisa Schnirring
Minneapolis

References

1. Samuels CA: Gym class shapes up for a new generation. Washington Post 1999;Apr 12:A1
2. Fukushima R: P.E. makeover. St Paul Pioneer Press 1999;Sept 13:8E
3. Guidelines for school and community programs to promote lifelong physical activity among young people: Centers for Disease Control and Prevention. MMWR 1997;46(RR-6):1-36
4. Mokdad AH, Serdula MK, Dietz WH, et al: The spread of the obesity epidemic in the United States, 1991-1998. JAMA 1999;282(16):1519-1522
5. Gordon-Larsen P, McMurray RG, Popkin BM: Adolescent physical activity and inactivity vary by ethnicity: the National Longitudinal Study of Adolescent Health. J Pediatr 1999;135(3):301-306
6. National Association for Sport and Physical Education: Shape of the Nation. Reston, Virginia, National Association for Sport and Physical Education, 1997
7. Sallis JF, McKenzie TL, Kolody B, et al: Effects of health-related physical education on academic achievement: project SPARK. Res Q Exerc Sport 1999;70(2):127-134
8. Trudeau F, Laurencelle L, Tremblay J, et al: Daily primary school physical education: effects on physical activity during adult life. Med Sci Sports Exerc 1999;31(1):111-117
9. Shephard RJ, Lavallee H: Effects of enhanced physical education on lung volumes of primary school children. J Sports Med Phys Fitness 1996;36(3):186-194
10. Council on Physical Education for Children: Developmentally appropriate physical education practices for children: a position stand of the National Association for Sport and Physical Education. Reston, Virginia, National Association for Sport and Physical Education, 1999

Field Notes

Tracking a 'Rhino' Through a Marathon
Costumes are a fixture at the London Marathon, where many runners wear strange outfits to publicize a cause or just to entertain. This year, two researchers with an interest in cardiovascular loading and adaptation saw an opportunity to answer a scientific question: What kind of cardiac stress does wearing a 16-kg rhinoceros suit place on a marathon runner? The experiment was described in the October issue of the British Journal of Sports Medicine.

The 24-year-old female research subject had run the London Marathon the previous year. She prepared for the rhino-suit experiment by training in heavy clothing in warm conditions, and she planned to carefully remain well-hydrated during the race. She finished the race "in good spirits" with a time of 4 hours and 35 minutes. Her average heart rate during the race was 181 beats per minute, and her blood pressure at the end of the race was the same as baseline.

The researchers said the experiment shows that endurance exercise in hot conditions requires careful planning and adequate training, and that young, well-trained persons can maintain high heart rates for extended periods without adverse effects.

An On-Site Brain Injury Detector?
A portable device that screens patients for brain damage is under development for the US Army by scientists at the US Department of Energy's Oak Ridge National Laboratory in Oak Ridge, Tennessee.

A press release from the laboratory stated that the device uses a range of ultrasound frequencies to evaluate a head injury. Ultrasound imaging is usually of limited use in brain imaging because the sound waves have difficulty penetrating the skull. However, scientists have found that lower-frequency waves are better able to penetrate the skull.

The device will not replace computed tomography and surgically implanted sensors in the clinical setting, the press release said, but it is expected to provide physicians a noninvasive, portable way to monitor patients. Testing of the prototype device began this year.

Why Many Working Women Don't Exercise
The Cigna Corporation in Philadelphia has an on-site fitness center, but few women were using it. To find out why, Cigna asked the Melpomene Institute to investigate. The results were detailed in a press release from the Melpomene Institute, a St Paul-based organization that researches and publishes on women's physical activity topics.

Responses from the 750 women who were surveyed indicated that the main obstacles to work-site exercise were lack of time due to work and family commitments, lack of motivation, self-consciousness in a physical activity setting, and lack of energy and discipline. Women who used the fitness center three or more times a week reported fewer obstacles, suggesting that commitment and support can help women overcome most obstacles to regular physical activity.

Survey respondents suggested several ways for corporations to support activity programs for women:

• Survey employees about their interests, activities, and preferred times for classes.
• Institute a walking program, which does not require special skills or equipment. Offer incentives for specific distances.
• Offer a seminar on how to be active with children. Hold a family event such as a hike or a bike trip.

Orthopedists Question Perthes Disease Rating
Orthopedic surgeons from the University of Iowa in Iowa City are questioning the reliability of a classification system that predicts long-term outcomes in children who have Legg-Calvé-Perthes disease. The disease is a circulatory disruption in the upper femur that leads to deformation of the femoral head.

Their study, published in the September issue of The Journal of Bone and Joint Surgery, examined how nine orthopedic surgeons used the Stulberg system to evaluate the radiographs of skeletally mature patients who had been treated for Legg-Calvé-Perthes disease.

The authors found marked inter-rater variances that did not depend on experience level. Researchers also confirmed their suspicion that having the raters meet to discuss classification definitions would influence ratings.

In a press release from the University of Iowa, researcher Stuart Weinstein, MD, study coauthor and professor of orthopedic surgery, said the system should not be entirely discounted. "Intuitively, it has some validity, but I think the whole classification system needs to be looked at," he said. "Perthes disease is a three-dimensional deformity, and these classifications are based on two-dimensional radiographs. In the future we need to have other more sophisticated methodologies to determine anatomic outcome."