Supporting Physical Education in Schools for All Youth

Abstract
This policy statement provides scientific evidence that schools are unique places where children should be engaged in physical activity. However, most school policies and programs are not supportive of physical activity in the school day, specifically physical education. Considering that 30.4% of youth are overweight or obese and that 76.8% do not meet the daily physical activity recommendations, and considering the benefits of physical activity with respect to increased ability to concentrate and learn, it is of the utmost importance to incorporate policies and programs that facilitate healthy engagement in physical activity in schools. Marginalized youth from low-income families, communities of color, immigrant communities, and others are disproportionately impacted by lack of supportive policies and programming. This policy statement calls for comprehensive and cooperative actions from the public health community, schools, administrators, researchers, and community members to increase physical activity opportunities through physical education in order to engage youth in at least 60 minutes of physical activity daily.

Relationship to Existing Policy Statements 

• APHA Policy Statement 20137: Improving Health and Wellness through Access to Nature
• APHA Policy Statement 20172: Supporting the Updated National Physical Activity Plan
• APHA Policy Statement 201515: The Role of Health Education Specialists in a Post-Health Reform Environment
• APHA Policy Statement 20079: Building a Public Health Infrastructure for Physical Activity Promotion
• APHA Policy Statement 9709: Promoting Public Health Through Physical Activity
• APHA Policy Statement 20044: Creating Policies on Land Use and Transportation Systems that Promote Public Health
• APHA Policy Statement 20058: Supporting the WHO Global Strategy on Diet, Physical Activity and Health
• APHA Policy Statement 200619: Urgent Call for a Nationwide Public Health Infrastructure and Action to Reverse the Obesity Epidemic
• APHA Policy Statement 20079: Building a Public Health Infrastructure for Physical Activity Promotion
• APHA Policy Statement 201514: Building Environments and a Public Health Workforce to Support Physical Activity Among Older Adults
• APHA Policy Statement 20121: Supporting the National Physical Activity Plan
• APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health

Problem Statement
Obesity is an important health issue among children in the United States. According to the 2019 National Health and Nutrition Examination Survey, 16.1% of U.S. youth are overweight and 19.3% are obese.[1] Moreover, racial, socioeconomic, and gender disparities exist in terms of risk factors associated with being overweight or obese. The chronic disease burden is consistent with the disproportionately high percentages of overweight and obese youth in racial minority and socioeconomically disadvantaged populations. According to data from the 2019 Youth Risk Behavior Surveillance System (YRBSS), 37.7% of Black youth and 38.8% of Hispanic youth are overweight or obese, as compared with just 27.7% of White youth.[2]

^Physical inactivity is a significant risk factor for obesity and other chronic conditions.[3] As the proportion of students who are overweight or obese has increased, so has inactivity. Empirical evidence suggests that physical activity may be used as a standalone strategy to decrease adiposity among children.[4] It is recommended that school-aged children and adolescents (6–17 years of age) engage in 60 minutes of physical activity seven days per week.[5] According to data from the 2019 YRBSS, 76.8% of youth do not meet the recommended amounts of physical activity.[2] The same data set indicates that adolescent girls, in particular, are at a higher risk for being inactive as they age; 84.6% of girls do not meet the physical activity guideline of 60 minutes per day seven days a week, as compared with 69.1% of boys.[2] In addition, inactive youth are more likely to be inactive as adults.[6] Starting physical activity early is essential to prevent inactivity in adulthood and older adulthood.

Physical activity provides benefits beyond physical health. For example, it is associated with a reduced risk for depression.[7] Trends for contemplating and making a plan for suicide are increasing among White, Hispanic, and Black youth, and there are racial and ethnic disparities in terms of mental health challenges among youth.[5] In 2019, 40.0% of Hispanic youth reported persistent feelings of sadness or hopelessness, as compared with 36.0% of White youth and 31.5% of Black youth.[5]

In addition to the long-term health benefits of child physical activity, there are numerous academic-related benefits, which the body of evidence continues to expand.[8] Extensive research has demonstrated strong positive correlations between physical activity and higher levels of physical fitness and academic achievement, educational attainment, academic performance, and brain functioning.[8–10] In fact, physical activity participation has both intermediate and long-term benefits with respect to academic performance. Research has shown that, immediately following engagement in physical activity, children have improved concentration on classroom tasks, which may potentially enhance learning.[8]

It is recommended that schools provide 150 minutes of instructional physical education for elementary school children and 225 minutes for middle and high school students per week for the entire school year.[11] However, only Oregon and the District of Columbia have requirements that meet the recommendations for minutes of physical education.[12] Physical education requirements notably decrease after the fifth grade, which aligns with significant decreases in physical activity in youth. Only 8.7% of schools require physical education for 12th grade, as compared with 45.1% of schools for fifth grade.[13]

The lack of universal physical education requirements at all grade levels and the lack of funding dedicated to physical education facilitate inactivity. The median school physical education budget in the United States is just $764 per year,[12] which may further hinder schools from meeting physical education recommendations. Ohinmaa and colleagues suggested that grants, donations, and fundraising account for about half of all funding for school health.[14] Improving physical education policies nationwide has the potential to reduce overall health care costs by $60.5 million within 10 years.[15]

Students who attend physical education in school are two to three times more likely to be physically active outside of school and nearly twice as likely to be active in adulthood.[16] Furthermore, physical education has been shown to be an opportunity for students to gain many of their recommended minutes of physical activity, but many students do not attend or participate in these classes.[13] According to 2019 YRBSS data, about half of high school students attend physical education classes one or more days per week.[2] Therefore, targeting middle and high schools is uniquely important because a significant drop in physical education attendance and physical activity participation occurs between the seventh and 12th grades.[11]

Evidence-Based Strategies to Address the Problem 
Youth spend a significant portion of their time at school[17]; therefore, schools are one of the most important places for physical activity interventions.[18] According to the Society of Health and Physical Educators, schools should require physical education for students in kindergarten through grade 12.[19] Specifically, all students within secondary school (which includes middle school and high school) should achieve 225 minutes of physical activity per week, while students in primary school (which includes elementary school) should achieve 150 minutes per week.[19]

Current evidence-based strategies to increase physical activity among youth are described below.

Improving school-based physical education: According to the Community Preventive Services Task Force (CPSTF),[20] enhanced school-based physical education involves changing the curriculum and coursework for K–12th-grade students to increase the amount of time students spend engaging in moderate to vigorous physical activity (MVPA) during physical education classes. Enhanced school-based physical education is defined as increasing the amount of time students spend completing MVPA during physical education classes to at least 50% of class time.[20] The CPSTF specifically recommended improving physical education teaching strategies by (1) incorporating modified games and substituting sedentary games with active games and (2) including physical education lesson plans that incorporate fitness and circuit training activities.[20]

Lonsdale and colleagues highlighted effective strategies to increase MVPA, which included teacher professional learning focusing on class organization, management, and instruction and supplementing the usual physical education lessons with high-intensity activity (i.e., fitness infusion).[21] A systematic review of 14 studies showed that students who participated in enhanced school-based physical education classes engaged in 24% more MVPA.[21] Also, groups that received enhanced school-based physical education spent on average 53% of their time engaged in MVPA.[21] In addition, Zhou and Wang found that team games were reported to accumulate the most MVPA time, with movement-based activities (such as gymnastics and dance) having the highest amounts of MVPA and knowledge-based activities (i.e., lesson-based instruction) having the lowest amounts.[22] Implementation of enhanced school-based physical education aligns with the Healthy People 2030 objectives, which aim to increase the proportion of adolescents who meet current federal physical activity guidelines for aerobic physical activity and muscle-strengthening activity.[23]

It is important that physical education classes be taught by state‐licensed or state‐certified teachers who are endorsed to teach physical education. In a meta-analytic review, Hollis and colleagues found that youth were engaged in MVPA for an average of 44.8% of lesson time.[24] Low MVPA levels in physical education lessons could be the result of pedagogical characteristics often observed in typical lessons, such as stopping physical activity to provide instruction, observing demonstrations related to the activity, or organizing equipment or student groups.[25] An examination of time allotment in terms of lesson context revealed that 30% of lesson time was spent in game play, 29% in fitness, 20% in classroom management, 9% in knowledge-related activities, and 5% in skill-related activities.[15] Similar results were found in a study by Powell and colleagues in which the average length of physical education lessons was 35.3 minutes, with only 15 minutes of MVPA during physical education.[26] Results further demonstrated that 34% of the lesson was spent standing and 21.7% was spent sitting, with time sitting being directly linked to knowledge attainment.[26] 

In conclusion, a significant proportion of physical education instruction time is spent on classroom management, instruction, and transitional periods. While these periods are necessary, they detract from the overall time youth spend participating in MVPA. It is, therefore, recommended that all physical education courses be taught by qualified individuals who have received formal training in physical education pedagogy. SHAPE America has specifically recommended that physical education be taught by an endorsed state‐licensed or state‐certified teacher.[11] This educational licensure or certification requirement would ensure that the physical education curriculum used in schools is appropriate and maximizes the time students spend engaging in MVPA while also aligning with national and/or state physical education standards for K–12 physical education.[11] 

Increasing the frequency of physical education: Scientific evidence has shown that increasing the frequency of physical education can improve overall physical activity among youth. Research indicates that only 25.9% of high school students attend physical education classes five days per week.[5]  Findings from the School Health Policies and Practices Study showed that less than 4% of elementary and middle schools require physical education or similar activity every day throughout the school year.[18] Moreover, less than 9% of middle schools require physical education at least three days per week.[18] Physical education instruction for high school students decreased from 29.9% in 2017 to 25.9% in 2019.[5]

The benefits of regular physical activity are well documented and include improvements in bone and muscle development, cardiorespiratory fitness, and weight control; reduced symptoms of depression and anxiety; and reduced risks of heart disease, cancer, type 2 diabetes, and hypertension.[3] Research has demonstrated that physical activity throughout the school day is associated with better school performance.[8] Healthy People 2030 objectives highlight the importance of increased physical activity through improved physical education in both public and private school systems. Specifically, the Educational and Community-Based Programs workgroup aims to increase the proportion of adolescents who participate in daily school-based physical education.[7]

Reduction or removal of waivers, substitutions, and exemptions for physical education: Another important strategy to increase school-based MVPA is the reduction or removal of waivers, substitutions, and exemptions for physical education. According to the Shape of the Nation 2016 report, 30 U.S. states allow student exemptions from physical education classes, and 31 states allow students to substitute activities such as marching band, cheerleading, drill team, or intramural sports for physical education credit.[12] SHAPE America issued a position statement according to which school districts and schools should not allow waivers or exemptions from physical education class time or credit requirements.[11] Specifically, SHAPE firmly asserted that all students should be required to complete physical education courses and that state, district, and school policies should not allow substitutions, waivers, or exemptions for physical education courses, class time, or credit requirements. By allowing waivers, substitutions, and exemptions for physical education, schools and districts eliminate opportunities for students to be active at a time when physical activity levels are at an all-time low among youth.[11] As mentioned, schools offer a unique setting to teach children the value of physical activity as well as a structured, supervised environment in which children can learn the necessary skills to encourage lifelong physical activity.[11]

Culturally tailored physical education: Multiple organizations have reported the need to ensure culturally tailored physical education for all populations, especially marginalized populations such as minority racial, ethnic, and cultural groups; girls and women; refugees; people experiencing homelessness; LGBTQ+ (lesbian, gay, bisexual, transgender, queer or questioning) populations; and others.[27,28] The United Nations Educational, Scientific and Cultural Organization’s Guidelines for Policy-Makers on Quality Physical Education stated the need for and importance of providing physical education for minority groups. According to the guidelines, (1) curricula should be flexible and adaptable for all groups, (2) teachers should be professionally qualified and capable of providing physical education for all students, and (3) school policies and practices should provide appropriate infrastructure, faculties, equipment, and teaching material for all students.[28]

Lastly, it is recommended that teachers have access to resources such as community health workers who can provide culturally specific guidance on physical education. Community health workers are particularly effective because of the cultural and linguistic connections they have with the communities they serve.[29] Providing culturally appropriate physical education may increase physical activity,[30] decrease obesity,[31] and improve the overall health of minority groups by increasing social support, promoting healthy lifestyles, and increasing knowledge of disease prevention.[32]

Adaptive physical education: According to the Physical Activity Guidelines for Americans, children and adolescents with disabilities are more likely to be inactive than those without disabilities.[7] It is recommended that children and adolescents with disabilities still aim to meet the key guideline of 60 minutes of physical activity every day when possible. If youth are unable to participate in the physical activities or durations needed to meet the key guidelines, it is recommended that they be as active as possible and avoid being inactive.[7]

Youth with disabilities should work with health care professionals or physical activity specialists to learn about the types and amounts of physical activity appropriate for them.[7] The Adapted Physical Education National Standards were developed to ensure that physical education for children with disabilities be delivered by a qualified adapted physical educator. According to these standards,  physical education teachers should use sound teaching practices to ensure the inclusion and representation of all skill and ability levels.[33] Specifically, master physical educators should be well prepared to provide knowledge acquisition as well as physical activity opportunities for all abilities to create active and healthy lifestyles for all students. In addition, the standards outline high expectations for a physically active lifestyle. Lastly, it is expected that master physical educators will maintain a stimulating, productive learning environment that holds all students to the highest expectations for a physically active lifestyle.[33]

Conclusion: In conclusion, schools are the ideal and recommended setting for the promotion of physical activity among youth, and physical education is the primary vehicle through which to achieve this objective in schools.[34] Improving the quality and quantity of physical education courses will give youth more opportunities to attain the recommended amount of physical activity each day. Reducing physical education waivers would ensure that youth are not exploiting a loophole in the system. Advocating for culturally tailored physical education and adaptive physical education would foster an inclusive environment in which all children are able to be physically active and healthy.

Opposing Arguments/Evidence 
Few would disagree that physical activity and time spent engaged in physical education are important for youth development and overall health. The primary opposing arguments tend to stem from the poorly designed physical education curriculum and the time taken away from other subjects amid increased pressure to raise standards and scores in subjects such as math, science, and English. As a result, time allocated to physical education and the perceived importance of physical education lessons have been reduced. 

However, there is a substantial amount of evidence that physical activity can help improve academic achievement, including overall grades and standardized test scores.[34] In a systematic review of 43 articles and 50 studies, the Centers for Disease Control and Prevention (CDC) determined that physical activity has a positive impact on cognitive skills, attitudes, and academic achievement.[34] Specifically, physical activity enhanced concentration and attention and improved classroom behavior.[34] The review also showed that increasing time during the school day for physical activity does not appear to take away from overall academic performance.[34]  Therefore, the CDC recommended that schools increase the amount of time students spend in physical education or consider adding components to increase the quality of physical education classes.[34] As highlighted in the evidence-based strategies to improve school-based MVPA, the CPSTF recommended use of enhanced physical education, including improved physical education teaching strategies, by incorporating modified, more active games and physical education lesson plans that involve fitness and circuit training activities.[20]

Alternative Strategies
Enhancing, encouraging, and maintaining physical education class duration and quality are vital to the health and well-being of children, particularly in terms of their physical activity behaviors. However, there are several alternative strategies to increase the physical activity of youth that should be considered in conjunction with retaining the importance of physical education.

Before- and after-school physical activity programs: According to the World Health Organization, after-school activities are a key avenue to supplement youth MVPA levels.[35] After-school physical activity could include physical activity clubs, intramural programs, informal play on school grounds, physical activity in school-based before- and after-care programs, and interscholastic sports.[18] Mayorga-Vega and colleagues found that physical activity that took place after school hours achieved 36% of the recommended 60 minutes of MVPA per day.[36] However, adolescents still reported a higher level of MVPA during physical education classes than during school recess and after-school programs.[36]

Only about 26% of the nation’s public and private schools provide access to their physical activity spaces and facilities for all individuals outside of normal school hours. In addition, a steady decline has been observed in provision of access to physical activity facilities during nonschool hours.[37] Therefore, schools can further encourage physical activity by opening up their facilities for community use.[18]

Increasing active transportation to and from school: According to the CPSTF, walking or bicycling to and from school provides children and adolescents with an opportunity to be physically active most days of the week.[38] Interventions such as the Safe Routes to School program could increase active transportation to and from school and reduce pedestrian and bicycle injury rates. However, there is not enough evidence to show that school travel leads to increases in students’ overall daily physical activity.[38]

Recess: Recess is defined as a regularly scheduled period during the school day for physical activity and play that are monitored by trained staff or volunteers.[13] Recess has been directly related to increased physical activity, improved memory, improved attention, improved concentration, decreased classroom disruptive behavior, improved social and emotional development, and academic achievement.[8,39–41] It is recommended that elementary, middle, and high school students have a minimum of 20 minutes of daily recess.[39] The CDC has further recommended that recess and physical education be separate, distinct physical activity opportunities, which creates separate times for skill acquisition (physical education) and active play (recess).[39] Also, the CDC has recommended that schools provide students with adequate, designated, and safe spaces, facilities, equipment, and supplies for both indoor and outdoor recess (e.g., playground markings, physical activity zones, activity cards).[39] Lastly, students should not be excluded from recess for disciplinary reasons or academic performance because such practices promote negative reinforcement.[39]

Classroom-based physical activity: Classroom-based physical activity, including single physical activity sessions, may increase student attention, concentration, and memory; increase motivation and enjoyment of learning; and reduce behavior issues.[8,40] Classroom-based physical activity integration may include physically active lessons, physical activity before a test, physical activity breaks, energizers, brain boosters, and active classrooms (a teaching technique that intentionally blends physical activity into academic lessons to satisfy the learning outcomes of the classroom without sacrificing time spent engaging in physical activity).[8,40,42] Further guidance by the CDC and other national organizations includes providing teachers with ongoing professional development to integrate physical activity into planned academic instruction as a means of reinforcing academic concepts.[40]

Action Steps
Increasing physical activity among school-aged children is a vital investment in the health and well-being of youth in the United States. Increasing physical activity at this critical age has the potential to build healthier, happier young adults. Schools should support physical activity through culturally appropriate, high-quality physical education. Schools; local, state, and federal education agencies; public health departments; policymakers; and researchers should address the following objectives relevant to public health priority setting in order to advance school-based physical activity programming and activities:

1. Federal agencies should develop national policies on physical education that are consistent with the larger national strategies to increase physical activity among youth.
2. Federal and state governments should increase funding for schools to implement high-quality physical education programming
3. State and local education departments should improve physical education requirements to provide the opportunity for 60 minutes of MVPA each school day.
4. Policymakers at state and local education departments should be made aware of the importance of physical education provided by schools.
5. Schools should require that all physical education teachers be appropriately credentialed to deliver culturally appropriate, high-quality physical education.
6. Schools should solicit involvement and expertise from state and local public health departments and physical activity researchers on culturally specific, evidence-based strategies to improve school-based physical education.
7. Principals and superintendents of schools should develop action plans to improve physical education for all of their students. Youth should have the opportunity to engage in 60 minutes of physical activity during the school day.
8. Principals and superintendents should reduce or eliminate policies allowing waivers for physical education. Waivers should be considered on a case-by-case basis.
9. Schools and school districts should engage in collaborative efforts to share the results of successfully implemented physical education programs.
10. Schools and researchers should collaborate in studying physical activity among diverse youth who have been traditionally understudied and systematically underserved. Furthermore, researchers should be encouraged to develop innovative programs for youth in school settings that promote physical activity for all.
11. Greater diversity in programming should be implemented in schools so that youth can be exposed to a variety of activities that those of all abilities and cultures might enjoy.
12. Youth, families, community members, and local organizations should advocate to their school districts and legislative bodies for culturally appropriate, high-quality physical education in their local schools.
13. Public health departments should partner with and support physical education teachers and programs. This support should include school-based physical activity in community health assessments and community health improvement plans highlighting the importance of physical activity in preventing chronic disease and providing mental and cognitive benefits.

References
1. Fryar CD, Carroll MD, Afful J. Prevalence of overweight, obesity, and severe obesity among children and adolescents aged 2–19 years: United States, 1963–1965 through 2017–2018. Available at: https://www.cdc.gov/nchs/data/hestat/obesity-child-17-18/overweight-obesity-child-H.pdf. Accessed October 20, 2021.
2. Centers for Disease Control and Prevention. 2019 Youth Risk Behavior Survey Questionnaire. Available at: www.cdc.gov/yrbs. Accessed October 20, 2021. 
3. Centers for Disease Control and Prevention. Division of Nutrition, Physical Activity, and Obesity at a glance. Available at: https://www.cdc.gov/chronicdisease/resources/publications/aag/dnpao.htm. Accessed October 20, 2021.
4. Laframboise MA, Degraauw C. The effects of aerobic physical activity on adiposity in school-aged children and youth: a systematic review of randomized controlled trials. J Can Chiropractic Assoc. 2011;55(4):256–268.
5. Center for Disease Control and Prevention. High School YRBS 2019. Available at: https://nccd.cdc.gov/youthonline/App/QuestionsOrLocations.aspx?CategoryId=C06. Accessed October 20, 2021.
6. Lounassalo I, Salin K, Kankaanpaa A, et al. Distinct trajectories of physical activity and related factors during the life course in the general population: a systematic review. BMC Public Health. 2019;19:1.  
7. U.S. Department of Health and Human Services. Physical activity guidelines for Americans. Available at: https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf. Accessed October 20, 2021.
8. Castelli DM, Glowacki E, Barcelona JM, Calvert HG, Hwang J. Active education: growing evidence on physical activity and academic performance. Available at: https://activelivingresearch.org/sites/activelivingresearch.org/files/ALR_Brief_ActiveEducation_Jan2015.pdf. Accessed October 20, 2021.
9. Kari JT, Pehkonen J, Hutri-Kähönen N, Raitakari OT, Tammelin TH. Longitudinal associations between physical activity and educational outcomes. Med Sci Sports Exerc. 2017;49(11):2158–2166.
10. Kohl HW, Cook HD. Physical activity, fitness, and physical education: effects on academic performance. Available at: https://www.ncbi.nlm.nih.gov/books/NBK201501/. Accessed October 20, 2021.
11. Society of Health and Physical Educators. The essential components of physical education. Available at: https://www.shapeamerica.org/uploads/pdfs/TheEssentialComponentsOfPhysicalEducation.pdf. Accessed October 20, 2021.
12. Society of Health and Physical Educators (2016). 2016 shape of the nation: status of physical education in the U.S. Available at: https://www.shapeamerica.org//advocacy/son/2016/upload/Shape-of-the-Nation-2016_web.pdf. Accessed October 20, 2021.
13. Springboard to Active Schools. Keep recess in schools. Available at: https://www.cdc.gov/healthyschools/physicalactivity/pdf/Recess_Data_Brief_CDC_Logo_FINAL_191106.pdf. Accessed October 20, 2021.
14. Ohinmaa A, Langille JL, Jamieson S, Whitby C, Veugelers PJ. Costs of implementing and maintaining comprehensive school health: the case of the Annapolis Valley Health Promoting Schools program. Can J Public Health. 2011;102(6):451–454.
15. Barrett JL, Gortmaker SL, Long MW, et al. Cost effectiveness of an elementary school active physical education policy. Am J Prev Med. 2015;49(1):148–159.
16. Physical Activity Council. (2017). 2017 participation report. Available at: http://s3.amazonaws.com/ustaassets/assets/822/15/papc_study.pdf. Accessed October 20, 2021.
17. Synder TD, de Brey C, Dillow SA. Digest of education statistics. Available at: https://files.eric.ed.gov/fulltext/ED580954.pdf. Accessed October 20, 2021.
18. Centers for Disease Control and Prevention. School Health Policies and Practices Study, 2014. Available at: https://www.cdc.gov/healthyyouth/data/shpps/pdf/shpps-results_2016.pdf. Accessed October 20, 2021.
19. Society of Health and Physical Educators. A-Z of social justice physical education. Available at: https://www.shapeamerica.org/uploads/pdfs/2020/publications/joperd/The-A%E2%80%93Z-of-Social%20Justice-Physical-Education-P1.pdf. Accessed October 20, 2021. 
20. Community Preventive Services Task Force. Annual report to Congress: 2013. Available at: https://www.thecommunityguide.org/content/tffrs-physical-activity-interventions-increase-active-travel-school. Accessed October 20, 2021.
21. Lonsdale C, Rosenkranz R, Peralta L, et al. A systematic review and meta-analysis of interventions designed to increase moderate-to-vigorous physical activity in school physical activity lessons. Prev Med. 2013;56:152–161.
22. Zhou Y, Wang L. (2019). Correlates of physical activity of students in secondary school physical education: a systematic review of literature. BioMed Res Int. 2019;2019:4563484.  
23. U.S. Department of Health and Human Services. Healthy People 2030 physical activity objectives. Available at: https://health.gov/healthypeople/objectives-and-data/browse-objectives/physical-activity. Accessed October 20, 2021.
24. Hollis JL, Sutherland R, Williams AJ, et al. A systematic review and meta-analysis of moderate-to-vigorous physical activity levels in secondary school physical education lessons. Int J Behav Nutr Phys Act. 2017;14(1):52.  
25. Fairclough SJ, Stratton G. A review of physical activity levels during elementary school physical education. J Teach Phys Educ. 2006;25(2):240–258.  
26. Powell E, Woodfield LA, Nevill AM, Powell AJ, Myers TD. ‘We have to wait in a queue for our turn quite a bit’: examining children’s physical activity during primary physical education lessons. Euro Phys Educ Rev. 2019;25(4):929–948.
27. Society of Health and Physical Educators. National PE standards. Available at: https://www.shapeamerica.org/standards/pe/. Accessed October 20, 2021. 
28. United Nations Educational, Scientific and Cultural Organization. Guidelines for policy makers: quality physical education. Available at: https://en.unesco.org/inclusivepolicylab/sites/default/files/learning/document/2017/1/231101E.pdf. Accessed October 20, 2021.
29. Haughton J, Ayala G, Burke K, Elder J, Montanez J, Arrendondo E. Community health workers promoting physical activity. J Ambul Care Manage. 2015;38(4):309–320.
30. Hovell MF, Mulvihill MM, Buono MJ, et al. Culturally tailored aerobic exercise intervention for low-income Latinas. Am J Health Promotion. 2008;22(3):155–163.
31. Falbe J, Cadiz AA, Tantoco NK, Thompson HR, Madsen KA. Active and healthy families: a randomized controlled trial of a culturally tailored obesity intervention for Latino children. Acad Pediatr. 2015;15(4):386–395.  
32. Joo JY, Liu MF. Culturally tailored interventions for ethnic minorities: A scoping review. Nurs Open. 2021;8(5):2078–2090.
33. APENS. Adapted Physical Education National Standards. Available at: https://apens.org/national_standard.html. Accessed October 20, 2021.
34. Centers for Disease Control and Prevention. The association between school based physical activity, including physical education, and academic performance. Available at: https://www.cdc.gov/healthyyouth/health_and_academics/pdf/pa-pe_paper.pdf. Accessed October 20, 2021. 
35. World Health Organization. School policy framework: implementation of the WHO global strategy on diet, physical activity and health. Available at: https://www.who.int/dietphysicalactivity/SPF-en-2008.pdf. Accessed October 20, 2021. 
36. Mayorga-Vega D, Saldias MP, Viciana J. Comparison of moderate-to-vigorous physical activity levels between physical education, school recess and after-school time in secondary school students: an accelerometer-based study. Kinesiology. 2017;49(2):242–251.  
37. U.S. Department of Health and Human Services. Healthy People 2020. Physical activity objectives. Available at: https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity/objectives. Accessed October 20, 2021. 
38. Community Guide. Physical activity: interventions to increase active travel to school. Available at: https://www.thecommunityguide.org/content/tffrs-physical-activity-interventions-increase-active-travel-school. Accessed October 20, 2021. 
39. Centers for Disease Control and Prevention and Society of Health and Physical Educators. Strategies for recess in schools. Available at: https://www.shapeamerica.org/uploads/pdfs/recess/SchoolRecessStrategies.pdf. Accessed October 20, 2021. 
40. Centers for Disease Control and Prevention. Strategies for classroom physical activity in schools. Available at: https://www.cdc.gov/healthyschools/physicalactivity/pdf/classroompastrategies_508.pdf. Accessed October 20, 2021.
41. Zavacky F, Michael SL. Keeping recess in schools. J Phys Educ Recreation Dance. 2017;88(5):46–53.  
42. Bedard C, St. John L, Bremer E, Graham JD, Cairney J. A systematic review and meta-analysis on the effects of physically active classrooms on educational and enjoyment outcomes in school age children. PLoS One. 2019;14(6):1–19.