Aimee Merkle-Scotland

DIET 3231W
Research Paper: Final Draft
May 5, 2018

Improving the neighborhood environment to increase physical activity in children

 According to the National Health and Examination Survey 2011-2012, more than

one-third of adults are obese, and one in six children between the ages of 2 and 19 years

old are obese.(Ogden C.L et al., 2015) For children and adolescents ages 2 to 20 years,

obesity is characterized as a Body Mass Index at the 95th percentile or greater according to

a child’s age and sex.(Ogden C L et al., 2015) Obesity in children increases the risk of

acquiring many comorbid conditions, such as Type 2 Diabetes Mellitus, Hypertension, and

Hyperlipidemia, for example.(Schuler & O'Reilly, 2017) Obesity is caused by a chronic

imbalance of between energy intake and expenditure. The concern today is that many

children are not getting sufficient activity, which increases the risk of energy

imbalance.(2018 Physical Activity Guidelines Advisory Committee, 2018)

Physical activity is important as it: builds and maintains skeletal and cardiovascular

strength and endurance; increases sensitivity to insulin, in turn decreasing blood glucose

levels; and releases serotonin to boost self-esteem. The recommendation for physical

activity for children is 60 minutes of daily moderate- to vigorous- intensity physical activity

(MVPA), with three of those days consisting of muscle-strengthening, bone-strengthening,

and vigorous intensity activity.(2018 Physical Activity Guidelines Advisory Committee,

2018) Examples of MVPA include walking briskly or with purpose, mopping or vacuuming,

or raking a yard. Whereas vigorous-intensity physical activity includes walking very fast,

running, carrying heavy groceries or other loads upstairs, shoveling snow by hand, mowing

grass with a hand-push lawn mower, or participating in an aerobics class.(2018 Physical

Activity Guidelines Advisory Committee, 2018) To achieve the aforementioned physical

activity guidelines, a child’s environment must be constructed in such a way to facilitate

this activity.
 This paper will explore the connection between physical activity and obesity,

focusing on the role that the neighborhood in which a child lives and how it influences the

amount they exercise. One barrier to a child’s ability to attain an adequate amount of

physical activity is their environment, specifically when the environment is perceived as

unsafe or lacks the facilities and programs necessary to facilitate and encourage physical

activity. A child’s environment includes their residence, neighborhood, school, and

community. To increase participation in physical activity and improve obesity rates

around the country, interventions should be multi-level following the social ecological

model: making policy changes, initiating school and community physical activity programs,

and helping families to adopt more active habits, in order to affect each individual child.

This paper will cover the following topics: general information about obesity and physical

activity, how a child’s environment affects the amount of physical activity they achieve, the

unsafe neighborhood and its effects on participation in physical activity, facilities and

programs that facilitate physical activity, and finally, modes of intervention.

The Relationship Between Physical Activity and Obesity

This section will examine evidence of associations between physical activity and

obesity in community-based studies. The research discussed in this section was uncovered

by exploring the research done by searching PubMed with the terms ‘“physical activity”

AND childhood obesity.’

Secondary data analysis of a large cross-sectional sample of U.S. children ages 11-18

(over 1300 children) revealed that children who did not engage in school-based physical

education(PE)-related physical activity were 1.6 times more likely to be obese compared
with those who met the national guidelines for weekly physical activity. In addition, the

analysis underscored the relationship between the duration of physical activity and the

BMI percentile among children. The children who participated in physical activity <112

minutes/week had a similar result as those getting no physical activity, supporting the

need for children to obtain 60 minutes per day to lower their risk of excessive adiposity.

Furthermore, more males than females participated in PE-related physical activity in the

average week; approximately 5% more males meet the national requirement of PE-related

physical activity than females.

Overall, the study discovered that 32.5% of middle and high school students do not

get any PE-based physical activity. (Hohensee & Nies, 2014) However, the study is not

without limitations. The use of a large data set does not allow for the addition of other

variables of interest. Similarly, missing data can only be estimated or excluded from the

data set, not regenerated. Specifically, in this study, age and race/ethnicity contained

missing data. Furthermore, the physical activity data collected included only PE-related

physical activity, and did not include physical activity during lunchtime or recess. Thus,

some children may not be meeting the physical activity requirements during PE, but they

may engage in physical activity during lunch or recess periods. Finally, collecting self-

reported data on physical activity duration and frequency may be a cognitive challenge for

children, resulting in misclassification or overestimation of physical activity. Nevertheless,

the physical activity is a factor that significantly affects BMI.

 Further evidence of the negative association of physical activity and obesity is

provided in the International Study of Childhood Obesity, Lifestyle and the Environment

(ISCOLE) study.(Katzmarzyk et al., 2015) The sample was at least 500 children ages 9 to

11 per site, from 12 multinational sites. The data collection was cross-sectional and

included lifestyle behaviors including sleep duration, time spent doing moderate to

vigorous physical activity, and dietary intake patterns. The analysis revealed that

participation in moderate to vigorous physical activity was associated with significantly

lower odds of obesity, in boys and girls, and independent of sleep, TV watching, diet

patterns, and demographic variables (Table 2, Model 2). Of these additional lifestyle

variables, MVPA was associated with the

greatest reduction in odds of obesity

(Table 2).(Katzmarzyk et al., 2015)

 As discussed throughout this section, physical activity associates in large studies

with decreased risk of obesity. Improved factors that encourage or facilitate physical

activity participation in the environment can reduce the risk of obesity. It is not only

important for cardiovascular and skeletal strength and endurance, but it is also crucial for

energy balance, which is the basis of childhood obesity.

How a Child’s Neighborhood Affects their Physical Activity

This section will present regression, observational, and cross-sectional studies to

discuss the correlation between a child’s physical environment and their opportunity for

physical activity. The physical environment is defined as the characteristics of the physical

context in which a child spends their time, such as their school and neighborhood. It

includes features of urban design, traffic density and speed, distance and design of places of

physical activity, crime, safety, and weather condition.(Davison & Lawson, 2006)

A regression study using a large, population-based sample of middle and high school

students (mean participant age 14.5 years) in Minneapolis/St. Paul, MN, examined the

associations between adolescent BMI and 22 neighborhood characteristics including access

to food sources, access to recreational places, opportunities for physical activity, perceived

safety, and neighborhood sociodemographic. Controlling for individual characteristics of

the sample, a higher BMI was significantly associated with a lower proportion of

park/recreation land and the perception of being unsafe during the day and night in both

boys and girls. Similarly, convenient access to unhealthy foods and lack of safe space for

outdoor recreation in neighborhoods significantly correlated to a greater BMI z-score in

both boys and girls. The researchers formed six clusters of neighborhoods, two of high SES,
one median SES, and three of low SES. These six clusters demonstrated the complexity of

the neighborhood environment, and contrary to the researcher’s hypothesis, all three low-

SES clusters contained high land use for parks/recreation or were in proximity to

recreational facilities. The limitations of this study include that this study is not necessarily

generalizable, as all participants were drawn from schools within just one metropolitan

area.(Wall et al., 2012)

While each individual factor identified in the previous study is a contributing factor

in impacting the physical activity achieved within a neighborhood, the following study

looks at the neighborhood affect as a whole and its role in preventing or facilitating

physical activity participation. A study done as part of the Greenville Healthy

Neighborhoods Project (GHNP) collected information on residents’ perspectives on

physical activity participation within low-income, African American neighborhoods. The

data was collected through the formation of 8 focus groups meeting for semi-structured

sessions of 60-90 minutes in Greenville, South Carolina. The focus groups discussed

benefits to being physically active, neighborhood factors associated with physical activity

participation, and suggestions to increase neighborhood physical activity participation.

The sample included 76 residents with mean age 61.5 years, in which 72% was female, and

95% was Black. The participants were able to describe various benefits of physical activity,

and identified safety concerns as often inhibiting physical activity. They were also able to

recognize that seeing others engage in neighborhood physical activity influenced others to

participate in both physical and social activity. The residents demonstrated that they

viewed their neighborhoods as prime settings for physical activity and had many

suggestions for increasing their incidences of MVPA. The residents communicated that
implementing a walking track, walking groups, and cleaning up the neighborhood would all

greatly impact the participation of PA in the neighborhood. While the results from the

focus groups were promising, there were several limitations to the study. To begin, the

participants were primarily gathered based on convenience, individuals within each

neighborhood president’s social network. This may have not provided the many other

valuable perspectives from other members in the neighborhoods. Finally, the participant

sample was fairly homogenous with respect to income, education, and race/ethnicity.

(Child et al., 2017)

A cross-sectional study looked at the relationship between the physical

environment and physical activity for transport by looking at the potential moderating

effect of parent participation in walking and cycling. The study had a sample of 677

children with their parents across low and high SES areas. The mean age was 11.5 years of

age. 23% of the children were overweight and 6.2% were obese. Overall, 45% of children

walked the dog with a parent and 52.1% walked with a parent for fitness (at least once or

twice a month). There was no parent or child demographic differences between children

whose family was involved in co-participation when walking and cycling compared with

children who did not participate. Four factors were identified as having a positive

association on the number of incidences a child and parent participate in walking or cycling

in a week: the density of intersections, number of sport options available within 800m, and

the population density. In addition, parent accompanied walking and cycling were

significant positive associations of the frequency of a child’s walking and cycling trips. The

findings are pictured below in table 2. The limitations of this study include the use of

cross-sectional data, which means that the observed associations cannot be interpreted in
terms of causality. Furthermore, the study relied on parent reports on the frequency of

physical activity and thus may be overestimated. A final limitation is that this study only

examined a limited amount of physical environments were studied, so other factors such as

crime-related variables and the presence of nature were not examined. Regardless, this

study identified valuable associations in physical activity in the physical environment, in

which parent-child co-participation is associated with a higher frequency of walking and

cycling trips in the neighborhood. The study also indicated the connection identified by

previous research that the more parents co-participate with their children, the parents and

children have an increased confidence in the child’s ability to navigate traffic on their own,

increasing their frequency of using physical activity for transport. (Ghekiere et al., 2015)

The studies analyzed in this section the factors influencing an individual’s ability to

participate in MVPA within their neighborhood. The neighborhood can be used for walking

and cycling, a convenient mode of physical activity important for social interaction and

transport. The presence of green space and recreational facilities within a neighborhood

also associates with a lower BMI. These findings can help to guide future childhood obesity
interventions by encouraging the focus on parent encouragement and facilitating outdoor

physical activity in the neighborhood environment.

Physical Activity Participation and Safety

This section will discuss the correlation between the actual measures of safety and

perceived safety in a neighborhood relative to the reported levels of physical activity in

children. The research discussed in this section was uncovered by PubMed Searching using

the terms: “built environment” AND “physical acvitity” AND children.

In a meta-analysis analyzing 16 publications identifying the association between

perceived safety from crime, objectively-measured crime, and physical inactivity. The

review indicated a small but significant association between perceived safety from crime

and physical activity, indicating that feeling safe in the neighborhood has a 27% greater

odds of achieving higher physical activity. Figure 2 is a forest plot that demonstrates the

odds ratios of the included studies, analyzing physical activity participation in areas

relating to perceived safety from crime. Similarly, those living in areas with higher police-

reported crime have a 20% reduced odds of achieving higher levels of physical activity.

Other factors relating to safety and physical activity participation were identified but not

analyzed, including the income level of the country studied, age, gender, and racial/ethnic

minorities. However, this meta-analysis was limited by the small number of published

studies, impacting the extent to which it could analyze other factors identified that might
influence physical activity previously mentioned. (Rees-Punia, Hathaway, & Gay, 2017)

A systematic review and meta-analysis were conducted of longitudinal studies

including prospective and retrospective cohort studies studying weight-related behaviors

including physical activity, sedentary behavior and diet and BMI in which the participants

were 17 years or younger. The meta-analysis was performed to estimate the pooled effect

size of neighborhood safety on each outcome and behavior. Table 4 summarizes the

modeling results from the meta-analysis. A finding from the meta-analysis is that living in

unsafe neighborhoods was found to be associated with a modest (but statistically

significant) increase in BMI z-score and a reduction in weekly PA duration among children.

The finding, however, did not illustrate an association between these results and the risk of

childhood overweight and obesity. Children living in unsafe neighborhoods were found to

be associated with a significantly higher BMI by 0.018 standard deviations when compared

with their counterparts living in safe neighborhoods. Similarly, children living in unsafe

neighborhoods were associated with a decrease in the duration of weekly MVPA compared
with their counterparts living in safe neighborhoods. That said, unsafe neighborhoods were

not significantly associated with overweight or obesity in children. The limitations to this

study may explain the limited influence the safety of a child’s neighborhood has on weight-

related behaviors and outcomes. To begin, the effect of the safety of the neighborhood may

be over-shadowed by the direct effect of another factor such as the neighborhood food

environment. In addition, truly understanding the difference between different

neighborhood safety levels often requires surveying geographically and socioeconomically

diverse residential groups, which is not typically viable in these studies. Finally, the

measures on neighborhood safety were often not standardized and predominantly relied

on self-report, resulting in a potential for underestimating the association between the

safety of a neighborhood and a child’s PA. (An, et al., 2017)

 An observational prospective cohort study, Neighborhood Impact on Kids, analyzed

a cohort of 6-11 year olds living in San Diego, CA to examine individual factors related to

weight, physical activity, and nutrition behaviors. Neighborhoods were given ratings

calculated based on the presence or absence of contributors to the perception of safety in

the neighborhood including: graffiti, liquor/alcohol stores, abandoned buildings or lots,

lighting, and litter to name a few. The City of San Diego’s police reported crime data was

then discussed and assessed for its association with participation in MVPA. From the

analysis, only police-reported crimes were associated with lower total MVPA. The

children’s MVPA was significantly lowered by 0.01 minute for each additional police-

reported crime in the neighborhood. Children living in the neighborhoods with the lowest

reported crimes had the highest total and neighborhood MVPA. There were limitations to

the study. To begin, all police-reported crimes were included, including those which may

not have an impact on children’s physical activity, such as fraud, for example. There is

evidence that the type of crime plays a role in affecting MVPA in children. Another

limitation is the generalizability of the findings; the sample was primarily non-Hispanic
white, and all were able bodied children ages 6-11 living in a single US city.(Kneeshaw-

Price et al., 2015)

The final study analyzed the associations between parent-perceived neighborhood

safety and encouragement and child outdoor physical activity participation in low-income

children. The target population in this study lived in low-income areas and included

children eligible for Medicaid. Of the participants in this study, more than half of the

children were overweight or obese, and less than half (47%) of the parents were physically

active. The study identified that perceived neighborhood safety was significantly

associated with parent’s encouragement for boys physical activity; however, no significant

association was observed among girls. In both the adjusted and unadjusted models,

children have increased reported outdoor physical activity with parents that encourage

their child. Similarly, girls whose parents encouraged outdoor physical activity had higher

odds of reported physical activity. With regards to neighborhood safety, children’s

reported outdoor physical activity was greater when parent’s perceived their

neighborhood as safe. The figure of table 4 below demonstrates the unadjusted model of

parental perceived neighborhood safety and reported outdoor physical activity. This study

used both parent-reported and child-reported physical activity, and indicated that there

were discrepancies between the parent and child reports of physical activity participation.

The study had several limitations including a high nonresponse rate of around 10%,

resulting in a reduced sample size. In addition, the study may not be “adequately powered”

for all the research questions of interest. That said, the findings in this study can be used to
increase children’s participation in physical activity by educating parents the importance of

encouraging their children to participate in physical activity outside. (Nicksic et al., 2018)

The studies analyzed in this section identify the complex relationship between

perceived safety and physical activity, in which the effect of safety is not very large, though

it is significant. In terms of future childhood obesity intervention efforts, cleaning up

neighborhoods to make them appear safer would be a valuable effort that would positively

impact physical activity participation, but should not be prioritized as a critical component

of intervention strategies.

Modes of Intervention: Facilities and Programs that Facilitate PA

This section was uncovered by PubMed Searching using the terms ‘”physical

activity” AND childhood obesity’ looking for interventions and analyses of physical activity
in schools and other community programs aimed to increase physical activity. The socio-

ecological model emphasizes the importance of multiple levels of organization that interact

and influence an individual.(Schuler & O'Reilly, 2017) To expand, habits and behaviors

formed at the individual level are influenced by policies and programs within the family,

the neighborhood, at school, within the community, and because of policies set by town,

state, and federal governments. As a result, methods of intervention strategies should be

implemented at each of these levels to have an effect on the amount of daily physical

activity achieved by each individual child and, in turn, affecting overall obesity rates in

children.

In a cross-sectional analysis identifying the relationship between school

environment and physical health, 649,442 total Taiwanese students grades 7 to 9 across

urban and rural settings were studied. Schools were analyzed for their facilities and their

location (rural versus urban). The analysis indicated that the students performed better

on the physical fitness tests attended schools with more space for physical activity. Boys in

schools with access to a sports field performed better on the fitness tests then those

without access. Girls with access to sports fields had significantly higher endurance,

explosive power, and cardiorespiratory ability than those who didn’t have access to sports

field. Table 3 below demonstrates the aforementioned findings. (Lo et al., 2017)
 Another study analyzed the longitudinal relationship between community programs

and policies to prevent childhood obesity and BMI in children, the Healthy Communities

Study, included a probability-based sample of 102 communities and community-based

programs and policies (CPPs), to determine the relationship between BMI in children and

the intensity of the CPP. A total of 9681 CPPs were identified and characterized through

interviews with 10-14 key informants per community and supplemented with reviews of

reports. Each CPP was given intensity score based on the behavior change strategy,

duration, reach, and other dimensions like target behavior and the sector through which it

was delivered. A higher score was given to programs that reached a greater proportion of

the community, that were ongoing, and that modified policies or access, barriers and

opportunities as opposed to those that provided information and enhanced skills. The

scores given were low (0.1), medium (0.5), or high (1) for each of the dimensions, and a
weighted score was averaged over the three dimensions then summed to create an annual

intensity score for the program. BMI data was collected from pediatric health care

providers of families and by trained field data collection personnel during at home visits.

Linear mixed effects models were used to assess longitudinal relationships between

the CPP intensity scores and childhood BMI, with adjustments made for correlation among

participants from within the same school/community and repeated measures on children.

The relationship between BMI and CPP intensity differed significantly with a child’s grade

in school, race, ethnicity, family income and parental education, but did not differ

significantly as a function of child gender or parental employment status. Likewise, the

relationship between BMI and CPP intensity also differed significantly by community

race/ethnicity, but not by region, urbanity, or community income. The relationship was

also significantly different for children in grades K-2 and 6-8, but not for grades 3-5.

The parameter that captured the relationship between the CPP intensity and

childhood BMI demonstrates that if a community at the minimum observed CPP intensity

score was instead at the maximum observed CPP score, the children were predicted to have

BMIs of about 1.6 BMI units smaller. The finding that higher CPP scores are associated with

lower BMI in a large diverse sample of US children suggests that community programs

aimed to decrease childhood obesity over the past 10 years had a beneficial effect.

However, there were no statistically significant differences in the CPP intensity scores

based on community sociodemographic characteristics. Other limitations include

limitations in recall for the documentation of CPPs, which affected the intensity scores of

CPPs further back in time. Another important limitation of this study is due to the methods
used to recruit children and key informants within the same school, factors related to non-

involvement could not be assessed. (Strauss et al., 2018)

The articles reviewed in this section identify programs that are beneficial for

facilitating physical activity. Physical education and space for participating in physical

activity in schools is a central part of encouraging physical activity in children. Likewise,

community programs work to create an environment of encouraging healthy behaviors

within a neighborhood, affecting the family and the child to increase their participation in

physical activity.

Modes of Intervention: Policies

This section was uncovered using the framework described in the early article by

Heath et al. The article explores the effects and efficacy of interventions implemented to

change physical activity participation within neighborhoods. In addition to land use, the

article demonstrates the relationship existing between the built environment, funding

availability, infrastructural support, and mediating factors including: increased numbers of

people residing within walking distance of shopping, work, and school; improved

connectivity of streets and sidewalks; and preservation or creation of greenspace and

improved aesthetic qualities of the built environment. (Heath et al., 2006)

A retroactive case study done by Heelan, et al. evaluated a community intervention

strategy implemented in schools in a small town in a rural Mid-western community

(Kearney, NE), to increase participation in physical activity. The interventions

implemented include body mass index screening, a healthier school meal program, a new

physical education program, and a comprehensive school physical activity program. The
study revealed a 2.5% absolute decrease in obesity from 2006 to 2012. These findings

were in contrast with the 2.5% absolute increase in obesity prevalence documented by the

NHANES national data, indicating that the decrease in obesity in Mebane, NC was related to

the intervention strategies implemented and not a result of a nationwide declining trend.

Finally, the most important finding in this case study was that the highest dose score was

calculated for the physical activity intervention portion which ranged from a 5.6-9.7% in

physical activity due to its high reach and the strength of the strategy. The study did have

some limitations, however. The study did not evaluate changes in the environment outside

of the school setting that could influence a child’s weight status over time. In addition, the

dose was assessed at the end of the study period and reflects an estimation of

implementation at the end of six years, instead of throughout the six years. Finally, while

the study is a promising indicator of different interventions that can be made within the

school setting alone to decrease obesity rates, the findings are not generalizable.(Heelan, et

al., 2015)

The American Heart Association published an article discussing the idea of shared

recreation spaces based on research done analyzing physical activity habits in America. In

this article, the organization proposes a policy allowing school recreation facilities (such as

sports fields and playground spaces) as a way to provide convenient and economical

spaces for communities. This involves opening school grounds and even some school

buildings during non-school hours for the use of all members of the community. The

shared use can be in the form of a formal, written contract, or an informal agreement

between the school or district and the individuals or organizations wishing to use the

property. The challenges to this policy include: providing adequate funds necessary to
maintain the school facilities for extra hours, establishing the coordination and

communication among the various individuals and organizations wishing to use the

property, and ensuring protection from liability, crime, and other damaging risks that could

affect the school’s ability to function during the normal school hours. (Young et al., 2014)

This section discussed various approaches of policies that can be implemented to

increase physical activity participation to reduce a child’s risk of childhood obesity.

Policies can be implemented at each level of the social ecological model: policy within

schools, communities, towns, and even up to the county, state, and national level. Each of

these levels impact a child’s experience within their neighborhood and their family, and in

turn will impact the child, thus demonstrating the importance of policies as a method of

obesity intervention.

Connecting to Other Influences on Childhood Obesity

The following section was uncovered through the presentation of other research

being performed in the field of childhood obesity. As mentioned throughout this paper,

childhood obesity is caused by a number of factors. While physical activity is a significant

factor influencing a child’s BMI, many other factors also significantly impact adiposity and

are discussed in this section.

One of factor that impacts a child’s risk of obesity is sleep. Decreased sleep

duration is significantly associated with increased BMI. Furthermore, having a later

bedtime is also associated with higher obesity risk. When a child is lacking in sleep, they

will have increased energy consumption following the sleep restriction. Thus, sleep
indirectly impacts a child’s energy imbalance, which is the basis for obesity as discussed in

this paper. (Miller et al., 2015)

Another factor that impacts a child’s risk of obesity is the presence of food outlets in

the physical environment. Unhealthy food outlets include but are not limited to fast food

restaurants and convenience stores. A cross-sectional analysis performed in England

identified a significant positive association between the density of unhealthy food outlets

and the prevalence of overweight and obesity in children. The analysis compared the

association in children ages 4-5years old and ages 10-11 years old, and found that the

correlation is greater in the older group, with over a 3.5% difference between the age

groups. (Cetateanu & Jones, 2014)

Inadequate sleep duration and the presence of unhealthy food outlets in the physical

environment are two factors significantly associated with an increased risk of overweight

and obesity in children, as they both affect a child’s energy balance.

Conclusion

Energy imbalance is the main cause of childhood obesity. This imbalance can be a

result of inadequate physical activity, lack of sleep, or excessive intake of energy-dense

food options due to the presence of unhealthy food outlets in the neighborhood, or many

other mediating factors. Increasing physical activity participation in children has life-long

health benefits in addition to reducing their risk of overweight and obesity. The

environment in which a child is raised can either hinder their ability to be physically active,

or can be one that encourages physical activity throughout the community. To successfully

facilitate participation in moderate- to vigorous- intensity physical activity in children,

interventions should be made at each level in the social ecological model: individual, family,

neighborhood and school, community, and policy levels, both state and federal.
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