Andrew Crotty

Diet 3231w
Cover Letter

In this paper I tried to provide overwhelming evidence that

1. Lack of MVPA contributes to obesity and overall poor health
2. Socio-ecological barriers interfere with MVPA attainment
3. Interventions can overcome said barriers

Core ideas were developed through extensive research

Transition from draft to final paper was fairly smooth
I feel the paper exceeds criteria
I proofread by reading aloud multiple times
I made all corrections at each stage of the paper and went over the
paper with you and made further corrections prior to submission

Identifying and Overcoming Factors

Adversely Influencing Moderate-toVigorous Physical Activity
Obtainment as Related to Obesity
in Adolescents

By,
Andrew Crotty

I.

Introduction
It is a general consensus that obesity is a major health concern, and a

pandemic in the world. In the United States and from the Behavioral Risk
Factor Surveillance System, the prevalence in adults ranges from as high as
>35% in West Virginia, Arizona, and Mississippi to between 20 and 25% in
California, Colorado, Massachusetts, and Vermont (figure 1). The rate of
obesity is on the rise. According to the National Health and Nutrition
Examination Survey, the national rate of obesity rate rose 1.5% from 2011 to
2014 (CDC 2014). Such evidence propels the need for action on factors that
contribute to or diminish the prevalence of obesity. Obesity is related to
energy imbalance, whereas caloric intake outweighs energy expenditure.
Acting on obesity starts with the younger generation, whom develop their life
long habits during their adolescent years.
Adolescents are significantly affected by obesity based on their obesity
rate, which is contributed to by the lack of efforts to lose weight and
excessive television viewing. Based on data from the United States, and the
High School Youth Risk Behavior Survey the rate of obesity in adolescents
has risen from 10.6% in 1999 to 13.7% in 2013 (HSYRBS 2013). Contributing
to this is the fact only 52.3% of adolescent claimed to be attempting to lose
weight. Another contributing factor is evident as 32.5% of adolescents report
watching television for over three hours daily. Energy imbalance can be

diminished in adolescents through promotion of physical exercise, and

therefore, increasing energy expenditure.
This paper will explore the hypothesis that lack of vigorous exercise
coupled with sedentary behavior is contributing to obesity in adolescents.
Low levels of vigorous activities result from a multitude of barriers at the
individual, community and policy levels. Barriers include factors such as:
individual-excessive screen time, perceived lack of time and energy,
community-lack of peer and educator support, neighborhood disorder; policylocal environmental policies to improve access to physical activity. Effective
interventions need to address these barriers on each level through the socioecological framework in order to effectively decrease the risk of adolescent
obesity and promote healthy growth development. Interventions discussed
include classrooms that are more active, neighborhood walkability, support
by physical education teachers, or physical education enhancements.
Interventions also could come at the policy level by improving neighborhood
walkability and promoting active commuting of students. This paper will
address the hypothesis by analyzing factors suspected of contributing to
limited physical activity, as related to obesity. Furthermore, it will analyze the
effectiveness of interventions that seek to overcome these barriers.

Figure 1: Prevalence of obesity in U.S. adults by state as of 2014 obtained

from the Behavioral Risk Factor Surveillance System, Center of Disease
Control. It demonstrates the overwhelming prevalence of obesity in this
country as it can be noted that the populations of some states are over 35%
obese.
II.) Rates of moderate to vigorous physical activity and sedentary behaviors
in teens
This section will highlight data from the Youth Risk Behavior
Surveillance System (YRBSS), which is a nationally representative of health
risk behaviors among adolescents. The surveillance system was designed to
determine the prevalence of health risk behaviors over time and the relative
prevalence between subpopulations based on surveys. An example of such a
factor is physical activity obtainment. A more specific factor in this category
is moderate-to-vigorous physical activity (MVPA), which negates data
regarding light to mild exercise.

The Youth Risk Behavior Survey reports that in 2013, out of 13,228
adolescent students, 52% do not attend physical education on at least one
day per week. This figure includes 57% of females and 46.7% of men (YRBS).
In accordance, females were less likely to participate in adequate moderate
to vigorous physical activity. In analysis of data, adolescents ability to be
active for at least 60 minutes per day on at least 5 days produced similar
results; 63% of females were unable to meet this exercise goal, while less
than 43% of males fell short.
According to the 2015 Dietary Guidelines, adolescents should engage
in 60 minutes of MVPA on at least three days of the week (DG 2015). Only
27.1% of students surveyed had participated in at least 60 minutes of
activity per day (CDC 2013). The comparison of the YRBSS and these
recommendations demonstrate a great discrepancy between exercise
recommendations and exercise obtainment, and therefore, obtainment of
MVPA.
By searching disparities youth physical activity in PubMed, 315
studies were discovered. The study reviewed was chosen due to its ability to
identify any disparities in physical activity over age, race, and gender
differences amongst adolescents.
A secondary analysis of NHANES revealed lower activity levels among
females, and adolescents relative to children (Gortmaker, Lee et al. 2012).
Race disparities in physical activity were also found. This secondary analysis
reviewed objective accelerometer data from the National Health and

Nutrition Examination Survey (NHANES). This data serves as a national

representative of activity in children and adolescents between the ages of six
to nineteen between the years of 2003 to 2004 and 2005 to 2006. The study
witnessed an increase in activity over the course of a year in separate data
sets of children, but not in data sets of adolescents. This evidence supports
the idea that physical activity levels decrease with age. It is also notable
that the increase in activity found in children overall wasnt present in African
American children when isolated. This evidence suggests a possible disparity
of physical activity obtainment among African American children. Females
were found to be less active than males in the age groups.
The study is limited by the use of two separate cross sectional
samples, which do not follow the same children. Another limitation is that the
accelerometers fail to accurately measure certain exercise such as swimming
or weight training. Despite these limitations, the nationally representative
NHANES holds valid in determination of risk factors in regards to failure to
reach physical activity recommendations. These data sets support a national
shortcoming of moderate to vigorous physical activity. They also
demonstrate a widespread prevalence of the issue amongst all adolescents.
However, they do show that females and African Americans are most likely to
lack adequate activity levels.
II.) Negative health effects associated with lack of moderate to vigorous
physical activity

This section will review data identifying shortcomings in physical

activity obtainment in adolescents with effects on health and well-being.
These data is a driving factor behind the formation of exercise guidelines and
efforts to greaten guideline adherence. By searching moderate to vigorous
physical activity" AND adolescents AND risk in the PubMed database, 62
results were uncovered. The study selected was singled out by its inclusion
of many physical health parameters in adolescents, our target subject group.
It was also determined as ideal due to the inclusion of data over the course
of 28 years. This signified significant insight towards long-term health related
implications.
A cohort study of 1,547,189 military men in Sweden uncovered
elevated BMI and lowered aerobic capacity were related to increased risk of
hypertension (Crump, Sundquist et al. 2016). The study was reviewed in
order to determine if lack of moderate to vigorous physical activity (MVPA)
could be related to effects on health. Hypertension affects 25% of adults
worldwide (Fields, Burt et al. 2004). Rates of this condition have increased
concurrently with obesity and prevalence of sedentary lifestyle. The rising
prevalence of hypertension is a great concern as it is associated with
increased risk of many cardiovascular diseases. This study served to
determine the effects of physical exercise on adiposity (assessed by BMI or
body mass index) in early life as it relates to hypertension in adulthood. The
researchers hypothesized both interactive and combined effects of BMI and
physical activity on hypertension rates in adulthood.

Various parameters of physical ability (e.g., aerobic capacity and

physical strength) and measured height and weight were obtained from 18year-old men at the Swedish Military Conscription Registry. Both the Swedish
Hospital Registry and the Swedish Outpatient Registry determined future
development of hypertension in the subjects over the following years. Followup assessments were used to determine changes in aerobic capacity,
muscular strength, BMI and blood pressure.
Low aerobic capacity was found to be associated with increased risk of
hypertension, even when adjusting for BMI and other variables, as seen in
figure 2. Furthermore, a high BMI greatly increased risk of hypertension an
elevated BMI (above 25) nearly doubled risk of hypertension from 7.4% of
the population to 14% among those classified as overweight. The
combination of elevated BMI with low aerobic capacity produced the largest
increase in risk. These data showed a 3.5 fold increase in risk in those with
both low aerobic capacity and high BMI.
This study suggests that attaining a normal adiposity and aerobic
capacity (associated with vigorous physical activity) greatly reduces the risk
of hypertension later in life. This study was limited by the fact that BMI and
fitness measurements were taken only at age 18 years, and were not
monitored over time. Another limitation was that BMI, which can be
misleading, was the only measure of adiposity used. Other limitations
included a suspected underreporting of hypertension, and changes in
diagnostic criteria that occurred during the study. It should also be noted that

upon follow up, the participants, at median age of 46 years at the end of the
follow up, were rather young relative to the age that high blood pressure
typically occurs.

Figure 2: The relationship between adiposity (BMI) and the probability of

hypertension by percentile of aerobic capacity among a cohort of men
followed over 28 years (Crump, Sundquist et al. 2016).
IV.

Barriers to MVPA among teens

In acknowledgement of the negative health effects associated with

lack of physical activity, it becomes crucial to understand barriers

contributing to this shortcoming. Original research on barriers to MVPA in
adolescents was researched with PubMed database searching for vigorous
physical activity barriers with the search limited to title and adolescents.
The search resulted in the uncovering of 150 articles. The first article
reviewed was ideal due to its insight on implications of neighborhood

environment on various health parameters in adolescents. The following

study was chosen due to its systematic approach in uncovering data
examining the role of support systems in physical activity. Another study was
chosen to provide data in gauging the role of screen-based media in regards
to physical activity obtainment.
From a cross-sectional study of 101 adolescents, perceived
neighborhood disorder was associated with lower rates of physical activity.
The researchers targeted African American adolescents (Dulin-Keita, Kaur
Thind et al. 2013), who have higher rates of being overweight or obese than
Caucasian adolescents (41.2% vs 30% in 2010 according to NHANES). This
data reinforces the risk associated with African Americans in regards to
physical activity obtainment previously mentioned. In addition, African
American adolescents are less likely to meet MVPA recommendations
(NHANES 2010). The researchers questioned whether perceived
neighborhood physical and social disorder contribute to the large declines in
physical activity in African Americans across adolescence. They hypothesized
that disordered neighborhood environments would discourage physical
activity due to fear of crime along with the lack of resources that promote
physical activity
The convenience sample of African American adolescents was
evaluated for health parameters such as BMI and physical activity levels
using surveys along with accelerometers. The surveys allowed for
neighborhood conditions to be self reported while the accelerometers served

to determine physical activity. In conjunction with data from the

accelerometers, participants also kept logs of physical activity in order to
further validate the obtained data. Perceived disorder was characterized by
reporting of observable indicators such as crime, vandalism, and abandoned
buildings.

From the analysis, the largest percentage of overweight adolescents

lived in the top quartile of perceived neighborhood disorder. Perceived
disorder was also correlated with decreased physical activity. Adolescents
from neighborhoods that are perceived as disordered were less likely to be
physically active. These same individuals are also more likely to be
overweight. Limitations of the study include the fact that the sample size
was relatively small at 101 adolescents. Also, the duration of the study may
not have been representative of accelerometer data that would have been
obtained over the course of a year. Regardless of limitations, these data
suggest that community based interventions to decrease obesity should take
into consideration neighborhood perceptions along with their physical
activity outcomes (Dulin-Keita, Kaur Thind et al. 2013).
Beyond the perceived safety of the environment, another barrier of
MVPA in adolescence is lack of perceived support according to a crosssectional study on roughly 1200 adolescents. Furthermore, females were
found to have the greatest lack of MVPA as a result of the absence of
support.

The sample was gathered from adolescents enrolled in schools in

Kosovo. The number of male and female participants was relatively similar,
as selected through random sampling. The data collection occurred with
through the administration of an anonymous questionnaire. The data
collected included self-reported levels of MVPA, anthropometric data, and
perceived support systems in PE.
From the analysis of the survey, MVPA was heavily influenced by
teachers support during PE. Conversely, it was also indicated that lack of
support from PE teachers resulted in low MVPA. It was found that support
from classmates significantly affected MVPA in the same manner. It was also
noted that girls of this age group experienced a less MVPA in correlation with
lowered levels of support. This is likely attributed to by traditional roles in
society whereas males are praised for physical ability and females may be
valued based on other skill sets while discouraged in attributes related to
physical ability. This study is limited by its approach in covering one small
geographic area where cultural norms may differentiate from other areas.
Regardless of limitations, it is apparent that interventions require a
supportive environment for adolescent girls may be effective in overcoming
barriers presented by traditional roles in society (Bronikowski, LaudanskaKrzeminska et al. 2015).
Another apparent barrier is screen based media (SBM) usage. From a
cross-sectional survey of 14,818 American and 7,266 Canadian adolescents,
it was determined that SBM was negatively associated with physical activity.

This was based on survey responses in regards to physical activity and SBM
use occurring in a typical week (Iannotti, Kogan et al. 2009).
Through analysis of these various studies it becomes abundantly clear
that socio-ecological factors can attribute to the inability of adolescents to
maintain an active lifestyle. The research also clarifies that it is improbable
that lack of physical activity is resulting from a sole barrier. Rather,
diminished activity can be occurring due to a multitude of factors in
combination of one another.
V. Interventions directed at increasing MVPA
This section will review data analyzing interventions designed to
overcome socio-ecological barriers hindering MVPA obtainment. Research
involved PubMed a search with the term vigorous physical activity while
restricting to meta-analysis. This search uncovered 45 articles. Metaanalyses selected were those demonstrated a high level of data quality and
that thoroughly determined the relative abilities of interventions in
promoting MVPA in adolescents.
A meta-analysis of 14 studies revealed that interventions can be
successful in increasing the amount of time spent in MVPA (Lonsdale,
Rosenkranz et al. 2013). These results are depicted in Figure 3. The
generalized types of intervention included teaching strategy, fitness infusion,
and other interventions. Teaching strategy interventions require alteration of

teaching strategies, typically in physical education instructors. On the other

hand, fitness infusion interventions focus on incorporation of skillful games
that involve high levels of activity. Fitness infusion interventions were found
to be effective, as three out of four studies reviewed produced this result.
However the success rates of participants in these studies had great
variability. Overall, teaching strategy interventions were determined to be
very effective. Specifically, two of the studies were seen to be extremely
successful.

Figure 3: This forest plot was obtained from the study, A systematic review
and meta-analysis of interventions designed to increase moderate-tovigorous physical activity in school physical education lessons. It serves to
reiterate findings of success in regards to increases of physical activity as
result of interventions.
A successful infusion intervention involved 86 adolescents is
demonstrated in one study, which was included in the meta-analysis. The
results of this study suggest that incorporating intervals of MVPA into skill

practice of games. This meant that physical education werent only

concentrated on skill development, they now thoughtfully involved MVPA
whenever implementation was possible. It was found that this adjustment
effectively increased MVPA obtainment without diminishing skill
development. The study was limited by its sample size of only 86 students.
Regardless of limitations, the study may suggest the implication of a
practical strategy allowing increase in MVPA among adolescents.
The most successful of the teaching strategy interventions included in
the meta-analysis was a randomized control trial that involved 221
adolescent females. This study was especially crucial, as it targeted the
group of adolescents at highest risk, African American females, whom were
83% of the 221 participants. The study compared the effects of an eightmonth physical intervention in PE class to a normal PE class. The main
findings of this study were that the intervention based teaching strategy
resulted in a large increase in MVPA during PE. The intervention group also
had a sharp decrease in time spent watching TV, whereas the control did not.
The study was limited by only focusing on one gender, and furthermore, on
mainly one race of adolescents at a single grade level (ninth). These results
suggest that teaching strategy interventions could increase MVPA in
adolescents (Lonsdale, Rosenkranz et al. 2013).
Since the publication date of the meta-analysis, further studies have
been conducted to support prior findings. By once again searching vigorous
physical activity in the PubMed database the study, An intervention to

improve the physical activity levels of children: Design and rationale of the
Active Classrooms cluster randomized controlled trial was uncovered.
This cluster randomized control study is currently underway and
consists of an eight-week classroom based intervention directed at
increasing MVPA students. Subjects are the students of randomly selected
primary schools in Ireland. The outcome will be measured in change of time
spent performing MVPA. The intervention itself is targeted at increasing
classroom-based physical activity. The findings of this study will be crucial in
determining the effectiveness of incorporation of physical activity into the
classroom setting in regards to raising MVPA (Martin, Murtagh 2015b).
Another meta-analysis that has since been completed has found that
walking to and from school could contribute significantly to MVPA obtainment
in school aged children (4-19 years old). The meta-analysis reviewed studies
that used objective data in the form of heart rate monitoring, or
accelerometry to quantify active commuting in the form of walking and its
effect on MVPA. The study aimed to determine whether activiley
communiting to school, in the form of walking, could significantly contirbute
MVPA to the lives of school aged children. The samples analyzed included
3422 children along with 2600 adolescents from studies in Europe and the
United States.
The MVPA accumulated during the day when adolescents commuted
actively was increased by an average of 13 minutes per day. For those who
actively commuted, the analysis showed the commute contibuted 36% of

daily MVPA on schooldays. Similar results were found in the studies involving
children, whereas they gained and average of 17minutes of MVPA per school
day. These results emphasize the importance of commuting actively to
obtainment of MVPA in adolescents and children.
All studies used were rated as high quality, meaning the meta-analysis
presents a high level of evidence. However, the study could be limited by its
lack of inclusiveness (only 13 studies) due to strict criteria. An example of
this is the fact that no studies were used that were carried out prior to 2004,
this was to keep the information recent and relevant. Regardless of
limitations, this study demonstrates a direct correlation to increased MVPA as
a result of active commuting. This suggests intervations such as policy
adjustment or promotion of active commuting could likely be succesful
interventions in regards to increasing MVPA in adolescents (Martin, Boyle et
al. 2016).
In the context of the ability for pupils to obtain physical activity by
actively commuting to school, perceived neighborhood disorder is taken
under consideration. It has been determined that neighborhood disorder
negatively influences MVPA, therefore making it intuitive that it has this
same effect upon students willingness to actively commute to school. With
this in mind, policies have intervened in hopes of establishing routes to
school that are perceived as safe for students to walk. The Safe Routes to
School National Partnership is a non-profit that advances policy change that
increases neighborhood walkability in terms of students safely traveling to

school. This is accomplished through promoting safe infrastructure, physical

activity, and healthy living. It represents an occurrence where interventions
at the community level are brought on through actions leading to policy
change.
In incorporation of outside research further captivating the entire
social-ecological model and its implication in MVPA, a successful intervention
on grade-school children was analyzed. This was incorporated realizing that
interventions altering the personal factors of health and education at an
early age may enhance outcomes in the futures of the soon to be
adolescents. The randomized control included an intervention group of 127
boys and 121 girls from the third grade (Sacchetti, Ceciliani et al 2013). This
group participated in a two year long enhanced physical education program
targeted improving physical abilities and decreasing daily sedentary
behavior. The control group of 129 boys and 121 girls experienced a
traditional physical education curriculum over the two years. The physical
activity habits of participants were effectively improved in those participating
in the enhanced physical education program. It was also effective in
decreasing sedentary activities in these participants. Both of these results
were less notable in the control group. Regardless of the fact this age group
isnt part of the target adolescent audience, it shows an effective behavioral
change in children. It was be good a study could verify if these results can be
replicated in an adolescent population. It would also be advantageous to

further monitor participants to see if behavior change is ongoing or

temporary.
VI. Conclusion
This paper explored the hypothesis that lack of vigorous exercise
contributes to the risk of obesity in adolescents. Low levels of vigorous
activity result from a multitude of barriers at the individual, community, and
policy levels. And lastly, effective interventions must follow the socioecological framework to work past these barriers. In ability to provide a
comprehensive conclusion, these components will be individually addressed
in verification of each confirmed component of this hypothesis.
The abundance of data uncovered supported the idea that lack of
exercise is apparent in adolescents and is related to weight gain that can
result in adverse health effects. It found that the lack of exercise is related to
cardiovascular disease such as hypertension.
Research also verified the statement that low levels of vigorous activity
result from a multitude of barriers at the individual, community, and policy
levels. Inisght towards the role of neighborhood disorder in negatively
affecting activity levels in teens exemplifies a barrier to physical activity at
the community and environmental levels. Furthermore, environment was
seen attributing in the context of hindering physical activity again in data
that found lack of support by peers and teachers negatively affected activity
levels. Itd be good if research had been exaimined to determine if this trend
exsisted at the individual level. However, the data analyzed is sufficient to

conclude that factors of the socio-ecological model can in fact serve as

barriers in regards to physical activity obtainment.
Research generated a large basis of support for the statement that
interventions that follow the socio-ecological framework can work past these
barriers to physical activity obtainment in adolescents. An instance of this
occurance at both the policy and environmental levels are policies that
promote active commuting to schools. This trend continues in the behavioral
setting of school whereas teaching strategy interventions successfully
increased physical activity levels. It was further determined that effective
interventions can also work through the behavioral setting of enhanced
physical education in younger children, however, it is currently unclear if the
results could be replicated in adolescents. This could be determined through
future research. Itd also be good if the data from the current eight week
active classroom study previously mentioned was available for analysis but
this wont happen until the results are published.
Overall, there wasnt much discrepencies amongst these data in
regards to verifying the hypothesis. It was fully supported by every aspect of
research and provides an insightful strategy towards how action may be
taken to increase MVPA in adolescents, and strive towards reducing the
chronic energy imbalance that contributes to obesity in this population and
the nation as a whole. It is therefore advised that physical education
programs are enhanced and policies promoting improvement of

neighborhood environment are adopted in compliance with other actions

taken to reduce the risk of obesity in adolescents.

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