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3
Physical Activity
GOALS:
• Increase physical activity in young children.
• Decrease sedentary behavior in young children.
• elp adults increase physical activity and decrease
H
sedentary behavior in young children.
O ver the past 20 years, society has changed in multiple ways that have reduced
the demand for physical activity and increased the time spent in sedentary
pursuits. These trends have been evident even in the youngest children. It is well
documented that many children under age 5 fail to meet physical activity guide-
lines established by expert panels (NASPE, 2009). The relationships among weight
status, physical activity, and sedentary behavior are not yet fully understood in
young children, but the limited research on this issue is growing. Some evidence
suggests that higher levels of physical activity are associated with a reduced risk of
excessive weight gain over time in young children (Janz et al., 2005, 2009; Moore
et al., 2003), and similar evidence is more extensive for older children and adults
(Hankinson et al., 2010; Riddoch et al., 2009). Additional prevention-oriented
research to study the relationship between physical activity and risk of excessive
weight gain over time in children is important.
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Increasing physical activity and reducing sedentary behavior are logical
and accepted strategies for maintaining energy balance and preventing excessive
weight gain. Recent evidence-based publications from government agencies, often
developed using recommendations from scientific panels, affirm the importance
of physical activity in reducing the risk of excessive weight gain. For example, the
Dietary Guidelines for Americans 2010 (USDA and HHS, 2010) counsels that for
Americans 2 years of age and older, “Strong evidence supports that regular partici-
pation in physical activity also helps people maintain a healthy weight and prevent
excess weight gain.” The Surgeon General’s Vision for a Healthy and Fit Nation
(HHS, 2010) argues that “physical activity can help control weight, reduce risk
for many diseases (heart disease and some cancers), strengthen your bones and
muscles, improve your mental health, and increase your chances of living longer.”
The 2008 Physical Activity Guidelines for Americans (HHS, 2008a), targeted to
children over 6 years of age and adults, states, “Regular physical activity in chil-
dren and adolescents promotes a healthy body weight and body composition.”
This chapter thus presents policy and practice recommendations aimed at
increasing physical activity and decreasing sedentary behavior in young children.
Specifically, the recommendations in this chapter are intended to (1) increase
young children’s physical activity in child care and other settings, (2) decrease
young children’s sedentary behavior in child care and other settings, and (3) help
adults adopt policies and practices that will increase physical activity and decrease
sedentary behavior in young children. Each of these recommendations includes
potential actions for its implementation. Recommendations for infants are includ-
ed in an effort to highlight the need to begin obesity prevention practices in early
life. The recommendations in this chapter target child care regulatory agencies,
child care providers, early childhood educators, communities, colleges and univer-
sities, and national organizations for health and education professionals, urging
them to collectively adopt policies and practices that will promote physical activity
and limit sedentary behavior in young children.
GOAL: INCREASE PHYSICAL ACTIVITY IN YOUNG CHILDREN
Recommendation 3-1: Child care regulatory agencies should require child
care providers and early childhood educators to provide infants, toddlers,
and preschool children with opportunities to be physically active throughout
the day.
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For infants, potential actions include
• providing daily opportunities for infants to move freely under adult supervi-
sion to explore their indoor and outdoor environments;
engaging with infants on the ground each day to optimize adult-infant inter-
•
actions; and
• providing daily “tummy time” (time in the prone position) for infants less
than 6 months of age.
For toddlers and preschool children, potential actions include
• providing opportunities for light, moderate, and vigorous physical activity
for at least 15 minutes per hour while children are in care;
• providing daily outdoor time for physical activity when possible;
• providing a combination of developmentally appropriate structured and
unstructured physical activity experiences;
• joining children in physical activity;
• integrating physical activity into activities designed to promote children’s
cognitive and social development;
• providing an outdoor environment with a variety of portable play equip-
ment, a secure perimeter, some shade, natural elements, an open grassy area,
varying surfaces and terrain, and adequate space per child;
• providing an indoor environment with a variety of portable play equipment
and adequate space per child;
• providing opportunities for children with disabilities to be physically active,
including equipment that meets the current standards for accessible design
under the Americans with Disabilities Act;
• avoiding punishing children for being physically active; and
• avoiding withholding physical activity as punishment.
Rationale
With adequate supervision and a secure perimeter, infants should be provided
time each day to move freely and explore their surroundings. Physical activity
may facilitate the achievement of gross motor milestones (Slining et al., 2010) and
provides opportunities to expend energy (Li et al., 1995; Wells et al., 1996a,b).
Research examining physical activity in infants is scarce, and even defining physi-
cal activity for infants is challenging. Thus, based on limited information, promot-
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ing opportunities for movement such as reaching, creeping, crawling, cruising, and
walking may be the most effective way to increase energy expenditure in children
less than 1 year of age.
Although evidence in this area is limited, physical activity in infancy may
help control excessive weight gain and maximize infants’ developmental potential.
Obesity has been linked to lower levels of fitness and motor skills in older chil-
dren (Cawley and Spiess, 2008; Frey and Chow, 2006; Graf et al., 2004; Mond et
al., 2007; Okely et al., 2004; Shibli et al., 2008; Slining et al., 2010). Obesity in
infancy in particular may delay the achievement of gross motor milestones (Shibli
et al., 2008; Slining et al., 2010), and infants who attain motor milestones at later
ages may be less physically active later in childhood (Slining et al., 2010).
Adults can help facilitate physical activity in infants by engaging with them
on the floor or ground and encouraging exploration and free movement. Infants
should spend some of this time in the prone position for supervised “tummy time”
to help them attain motor milestones (Jennings et al., 2005; Kuo et al., 2008).
In designing indoor and outdoor spaces for children’s physical activity,
attention increasingly is being paid to the developmental needs of toddlers and
preschoolers (Trost et al., 2010; Ward et al., 2010), but much less attention has
been paid to infants. For example, research is emerging on what characteristics of
the physical environment are associated with more movement in children over 36
months of age, but little is known on this subject for children under 36 months of
age.
Adults are responsible for creating the spaces in which infants move. The
characteristics of these spaces theoretically can affect energy expenditure and
obesity risk by influencing infants’ movements. However, data are lacking with
which to link any physical characteristics of indoor or outdoor spaces to infant
movement or body weight. Recommendations on the characteristics of spaces
for infants that would prevent obesity are based on what is known about how to
alter indoor environments to facilitate the achievement of gross motor milestones
(Abbott and Bartlett, 2001; Bower et al., 2008). The magnitude or direction of the
association among gross motor skills, movement, and body weight in infancy has
not been elucidated. It is plausible, however, that the creation of indoor and out-
door spaces that support the achievement of motor milestones will facilitate move-
ment and increase the possibility that infants can maintain a healthy body weight.
Infants are intrinsically motivated to explore their environments to obtain
the visual, auditory, and tactile sensory input that fosters their cognitive and social
development (Bushnell and Boudreau, 1993). Infants will generally approach and
Early Childhood Obesity Prevention Policies
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interact with objects that elicit their attention. An infant’s attention and interac-
tion will often be sustained if the objects have sensory properties that produce
positive reinforcement. To explore the environment that is beyond arm’s reach,
infants must develop the locomotor skills of rolling, creeping, crawling, or walk-
ing. The development of these skills can be enhanced by the sensory properties
of surfaces on which infants are placed and by the presence of stable objects they
can use for pulling up to a standing position or stepping with support (cruising)
(Metcalfe and Clark, 2000). While infants are developing verbal language, they
also rely on movement to communicate with others. Motor movement, therefore,
is elicited in infants not just by the objects in their environments but also by their
interactions with adults.
Broad consensus exists that young children should engage in substantial
amounts of physical activity on a daily basis. In older children and adolescents,
research has demonstrated a relationship between higher levels of physical activ-
ity and reduced risk for development of overweight and other physiologic indica-
tors of elevated cardio-metabolic risk (HHS, 2008b). The 2008 Physical Activity
Guidelines for Americans includes the recommendation that school-age youth
engage in at least 60 minutes of moderate to vigorous physical activity per day
(HHS, 2008a).
Very little research has been conducted on the relationship between physi-
cal activity and health in infants. Some, but limited, research has been undertaken
on the relationship between physical activity and body weight in toddlers and
preschoolers. Nonetheless, the prevalence of overweight and obesity clearly has
increased in these children (Ogden et al., 2010), and expert panels frequently
have recommended that increased physical activity be targeted as one strat-
egy for reducing the prevalence of obesity among children in these age groups
(IOM, 2005; Strong et al., 2005). Some expert panels have recommended that
2- to 5-year-old children engage in 2 or more hours of physical activity per day
(NASPE, 2009); however, these recommendations have not been based on dose-
response studies of the effect of physical activity on health outcomes. A rationale
for those guidelines is that toddlers and preschoolers need substantial amounts of
physical activity to develop the fundamental motor patterns that underlie efficient
and skilled human movement (Clark, 1994; Williams and Monsma, 2007).
Toddlers and preschoolers, as compared with older children, clearly tend to
be highly physically active. Several studies have examined levels of light, moder-
ate, and vigorous physical activity in young children using accelerometry as an
objective measure. Differing accelerometer cut-points used by researchers to dis-
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30
Minutes per Hour
25
20
15
10
5
0
d
d
d
d
d
d
c
a
b
c,
c,
c,
c,
c,
c,
Studies
FIGURE 3-1 Synthesis of studies examining levels of total minutes of physical activity per hour
(light, moderate, and vigorous) in awake children (3 to 5 years old).
NOTES:
aActiGraph accelerometer, used cut-point from Pate (Pate et al., 2006).
bActiGraph accelerometer, used cut-point from Sirard (Sirard et al., 2005).
Figure 3-1, revised, PMS 370C
cActiGraph accelerometer, used cut-point from Reilly (Reilly et al., 2003).
dMedian.
tinguish the threshold for light physical activity likely contribute to the different
estimates of physical activity reported. Nonetheless, these studies demonstrate
that children aged 3–5 are physically active (sum of light, moderate, and vigorous
activity) for an average of about 15 minutes per hour of observation (Figure 3-1).
This finding corresponds to approximately 3 hours of physical activity across a
period of 12 waking hours. If this documented median is taken as a reasonable
standard (e.g., those below the median should increase to that level), toddlers and
preschoolers should be physically active for at least 3 hours per day. To adhere to
that guideline, child care facilities should ensure that toddlers and preschoolers are
active for at least one-quarter of the time they spend in the facility. For example,
children spending 8 hours per day in care should be provided opportunities to be
active for at least 2 hours.
Findings from physical activity interventions in the home and child care set-
tings provide evidence of successful strategies to increase young children’s physi-
cal activity levels. Three family-based interventions demonstrated positive effects
Early Childhood Obesity Prevention Policies
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(Cottrell et al., 2005; Klohe-Lehman et al., 2007; Sääkslahti et al., 2004). Cottrell
and colleagues (2005) conducted a 4-week family physical activity intervention
that included pedometers (for parents and children) and information on physical
activity. Children in the intervention group significantly increased their steps per
day relative to children in the control group (Cottrell et al., 2005). The other two
studies used parental reports of children’s physical activity and found that young
children had higher physical activity levels at the end of the intervention (Klohe-
Lehman et al., 2007; Sääkslahti et al., 2004).
Some studies suggest that structured physical activity sessions implemented
in child care settings can be effective in increasing physical activity levels among
preschool-age children (Eliakim et al., 2007; Trost et al., 2008; Williams et al.,
2009). Trost and colleagues (2008) conducted an RCT to test the effectiveness
of an 8-week “move and learn” activity curriculum in the child care setting. This
curriculum incorporated physical activity into 10-minute curriculum lessons in
math, social studies, science, language arts, and nutrition education (Trost et al.,
2008). During classroom time, children in the intervention group engaged in sig-
nificantly more moderate to vigorous physical activity than children in the control
group during weeks 5–8, and more vigorous physical activity during weeks 7 and
8 (Trost et al., 2008). When classroom and outdoor time were combined, levels
of moderate to vigorous physical activity were similar between the two groups
with the exception of weeks 7 and 8, when children in the intervention group
had higher levels of moderate to vigorous physical activity (Trost et al., 2008). In
the study by Williams and colleagues (2009), teachers in nine Head Start centers
implemented a 10-week intervention consisting of 10-minute classroom physical
activities (Animal Trackers). These activities effectively increased the amount of
time children spent in structured physical activity, for a total of 47 minutes per
week (Williams et al., 2009). Finally, Eliakim and colleagues (2007) conducted a
group RCT that included a physical activity program for preschool children. The
14-week intervention included 45-minute sessions of circuit training and endur-
ance activities 6 days per week. At the conclusion of the intervention, children in
the intervention group had made significantly more overall steps per day, steps
during school, and steps after school compared with children in the control group
(Eliakim et al., 2007).
Two examples of environmental interventions in the child care setting had
positive outcomes (Benjamin et al., 2007; Hannon and Brown, 2008). Hannon
and Brown (2008) tested the effect of activity-friendly equipment on the play-
ground, which was set up as an obstacle course. Children had significantly
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increased the percentage of time spent in light (+3.5 percent), moderate (+7.8
percent), and vigorous (+4.7 percent) physical activity and significantly decreased
the percentage of time spent in sedentary behavior (–16 percent) postintervention
(Hannon and Brown, 2008). Benjamin and colleagues pilot-tested an environmen-
tal intervention in 19 child care centers. The intervention consisted of a director’s
self-assessment, action planning, continuing education workshops, technical assis-
tance, and reassessment (Benjamin et al., 2007). At the conclusion of the 6-month
intervention period, the intervention centers had improved by approximately 10
percent based on the director’s self-assessment (Benjamin et al., 2007). In a larger
trial involving 84 child care centers, however, a similar intervention had no signifi-
cant impact on physical activity (Ward et al., 2008).
Young children should be provided with daily opportunities to be active
outdoors when possible. Research has demonstrated that young children are more
active outdoors than indoors (Brown et al., 2009; Klesges et al., 1990; Sallis et
al., 1993). For example, Brown and colleagues (2009) found that only 1 percent
of preschoolers’ indoor time consisted of moderate to vigorous physical activ-
ity, as compared with 17 percent of their outdoor time (Brown et al., 2009).
Yet although young children are more active when outside, the potential exists
to increase preschoolers’ physical activity levels further during outdoor play.
Realizing this potential may require more training of adults in how to encourage
children’s movement. Some evidence suggests that allowing more outdoor time for
unstructured play may alone be insufficient to increase young children’s physical
activity levels (Alhassan et al., 2007).
Several strategies have been identified to increase young children’s physi-
cal activity levels in outdoor settings. First, large playgrounds, particularly those
with open space, are significantly associated with increased physical activity lev-
els (Boldemann et al., 2006; Brown et al., 2009; Cardon et al., 2008; Dowda et
al., 2009). For example, Dowda and colleagues (2009) found that preschoolers
engaged in more moderate to vigorous physical activity in preschools with larger
playgrounds compared with children in preschools with smaller playgrounds
(Dowda et al., 2009). Second, providing portable playground equipment, such as
balls or wheeled toys, significantly increases young children’s physical activity lev-
els (Brown et al., 2009; Cardon et al., 2008; Dowda et al., 2009). Third, evidence
indicates that young children are more active in outdoor spaces with less fixed
equipment (Bower et al., 2008; Brown et al., 2009; Dowda et al., 2009). Finally,
outdoor spaces with trees, shrubbery, and broken ground are positively associated
with physical activity in young children (Boldemann et al., 2006). (In this study,
Early Childhood Obesity Prevention Policies
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“broken ground” refers to spaces with clusters of trees present, rather than wide
open spaces.)
Although the literature is limited with respect to how to increase moderate
to vigorous physical activity while young children are indoors, doing so is impor-
tant because children tend to be inactive while indoors. Bower and colleagues
(2008) found that providing such opportunities was positively associated with
moderate to vigorous physical activity (r = 0.50) and negatively associated with
sedentary behavior (r = –0.53).
Physical activity also can be incorporated into activities designed to pro-
mote children’s cognitive and social development. Indeed, active learning has been
shown to promote cognitive development (Burdette and Whitaker, 2005; Bushnell
and Boudreau, 1993). Therefore, including training on the benefits of physical
activity and how to promote active play and provide a positive environment for
such play is advisable for child care providers.
Recommendation 3-2: The community and its built environment should pro-
mote physical activity for children from birth to age 5.
Potential actions include
• ensuring that indoor and outdoor recreation areas encourage all children,
including infants, to be physically active;
• allowing public access to indoor and outdoor recreation areas located in
public education facilities; and
• ensuring that indoor and outdoor recreation areas provide opportunities for
physical activity that meet current standards for accessible design under the
Americans with Disabilities Act.
Rationale
Physical activity provides children with opportunities to expend energy. As dis-
cussed under the previous recommendation, although research on the relation-
ship between physical activity and the control of excessive weight gain among
young children is limited, evidence suggests that higher levels of physical activ-
ity are associated with a reduced risk of excessive weight gain. The importance
of active play for children to promote their physical, cognitive, and emotional
development is well established, and such play may help prevent overweight
and obesity during early childhood and later in adult life (Berntsen et al., 2010;
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Burdette and Whitaker, 2005; Dwyer et al., 2009; Ginsberg et al., 2007; Janz et
al., 2002). Children at all ages need indoor and outdoor spaces that provide them
with opportunities to play and be physically active. To promote physical activity,
however, facilities need to be accessible, safe, and well designed to prevent seri-
ous injuries to young children. Adults and caregivers may limit young children’s
playing in outdoor spaces and recreational parks for fear that they will be injured
if playground surfaces and equipment are not safe or developmentally appropriate.
The Public Playground Safety Handbook issued by the Consumer Product
Safety Commission (CPSC, 2010) offers detailed guidelines for the design of
playgrounds and the selection of equipment and surfacing materials to ensure the
safety of children. The commission also has guidelines for separating play areas
for children of different age groups to avoid injuries during play and for designing
pathways to prevent older, more active children from running into younger chil-
dren with slower movements and reactions. These guidelines form the basis for the
National Health and Safety Performance Standards (AAP et al., 2002) for out-of-
home child care, which include detailed standards for a number of outdoor play
area features, including size and capacity, as well as specifications for playground
equipment. State and local enforcement of national standards for outdoor play-
grounds and recreational facilities is key to providing young children (infants, tod-
dlers, and preschoolers), under the supervision of their caregivers, with increased
opportunities to be physically active outside of their homes or child care settings.
Neighborhoods and communities can affect children’s opportunities to be
physically active through the provision of parks, open spaces, and playgrounds
(AAP, 2009). In communities where these venues are limited, opportunities to use
public school facilities can also be explored (IOM and NRC, 2009). Numerous
reviews have examined the links between the built environment, including the
availability of parks and playgrounds, and the physical activity of adults (Floriani
and Kennedy, 2008; Kaczynskl and Henderson, 2008), and researchers have
increasingly been interested in assessing the impact of the built environment
on children’s, including preschoolers’, physical activity (Davison and Lawson,
2006). Thus, various surveys, assessment tools, and measurement approaches
have been developed and used to evaluate the link between the quality of outdoor
playgrounds for young children (under age 5) and their physical activity levels
(Brown et al., 2006; Cosco et al., 2010; DeBord et al., 2005; Saelens et al., 2006).
Behavioral mapping is one approach used to explore the relationship between
a number of physical attributes, such as open areas, sand play, ground surface,
play equipment, and pathways, and levels of physical activity (sedentary, light,
Early Childhood Obesity Prevention Policies
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and moderate to vigorous physical activity) among children in a preschool set-
ting (Cosco et al., 2010). Communities and local governments can benefit from
the growing evidence and expertise in designing outdoor playgrounds and other
areas to further help young children develop their gross motor skills and be physi-
cally active. Landscape architects and designers, environmental psychologists, and
specialists can provide technical assistance and knowledge of how to design play-
grounds using behavioral mapping methods and other science-based approaches to
enhance the physical attributes of parks and playgrounds and attract young chil-
dren to play and be active (see Box 3-1).
Among older children, those with disabilities appear to be at higher risk for
developing obesity than those without disabilities (Chen et al., 2010; Rimmer et
al., 2010). The cause of this increased risk is unclear, but lower levels of physical
activity and higher levels of sedentary behavior may be one explanation, particu-
larly for the subset of children with physical disabilities (Maher et al., 2007; Steele
et al., 1996). To increase opportunities to be physically active for children with
disabilities, both indoor and outdoor spaces for young children’s physical activity
Box 3-1
Behavioral Mapping: A New Approach to Link Outdoor Design with
Physical Activity Levels
Behavioral mapping is a method that combines direct observation of the physical attributes of a loca-
tion, such as a playground, with measurement of the physical activity behaviors of individuals. This
mapping approach is based on two concepts: behavior settings (ecological units that are composed of
people, physical components, and behavior) and affordance (perceived properties of an environment).
The approach was recently used to investigate the relationship between different layouts, designs, and
equipment locations in preschool outdoor playgrounds and the perceptions and abilities of preschool-
ers with respect to playing and being physically active. Behavioral mapping is a promising method
for assessing not only the physical characteristics of recreational areas and playgrounds but also the
impact of climate and seasonality on the year-round physical activity of children, as well as possible dif-
ferences based on race and ethnicity in children’s perceptions and use of these behavior settings.
SOURCE: Cosco et al., 2010.
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activity level (r = 0.40) and the percentage of time children spent in moderate to
vigorous physical activity (r = 0.35) and negatively associated with the percentage
of time children spent in sedentary behavior (r = –0.35) (Bower et al., 2008). In
addition, training in physical activity was positively associated with more teacher
behavior supportive of physical activity (r = 0.48) (Bower et al., 2008).
A major examination of issues related to training of employees in child
care and child development centers with regard to physical activity and nutrition
was undertaken in the state of Delaware (Gabor et al., 2010). Training needs and
recommendations for future training activities were studied through an extensive
series of focus group discussions. Child care providers acknowledged the need for
more training opportunities, technical assistance, and resources. Specifically, child
care center directors stated that child care providers and early childhood educators
needed more ideas and resources for structured physical activities, especially those
that are linked to the development of gross motor skills. In addition, child care
providers preferred a hands-on training approach for learning how to incorporate
structured activities into the child care setting.
Several national organizations have made recommendations regarding train-
ing in the provision of physical activity programs for child care providers and
early childhood educators (AAP et al., 2010; Benjamin, 2010; McWilliams et
al., 2009). Training opportunities also should be provided for special education
teachers who have specific responsibility, under the Individuals with Disabilities
Education Act, for working with children with disabilities.
There are resources available to assist caregivers with ways to encourage
physical activity in young children. Information can be found at the following
websites, among others:
• National Association for Sport and Physical Education: http://www.naspe
info.org
• National Association for the Education of Young Children: http://www.
naeyc.org/
Adults control where and how children under age 5 spend their time. These
decisions influence the variety, frequency, and intensity of children’s movement
experiences and thus their motor development, energy expenditure, and body
weight. For example, whether an awake infant in the home is spending time con-
strained in a car seat or prone and moving freely on the floor may have implica-
tions for that infant’s gross motor development, movement, and energy expendi-
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ture. Whether a toddler or preschooler at home spends time watching television
or playing outdoors may have similar implications. These decisions about alloca-
tion of time across activities also affect children’s cognitive, social, and emotional
development. Thus it is the cumulative impact of decisions made by adults that
shapes the development of the bodies and minds of young children.
Of all the adults who make decisions about activities for infants, toddlers,
and preschoolers, it is parents (or guardians) who have the greatest influence
because children at this age still spend the majority of their time in their parents’
care. This is true even for children in full-day child care or preschool. Therefore,
how children spend the time they are with their parents and the nature of the
physical environment in the home are two key leverage points for preventing obe-
sity from birth to age 5. Parents establish the household policies and practices in
these two areas. Therefore, for public policy to affect these areas, it must reach
parents.
Parents seek advice in raising their children from those they trust. Outside of
friends and family, the professionals they often trust include the following: health
care providers; child care providers; early childhood educators; and those work-
ing in home visiting programs, the Special Supplemental Nutrition Program for
Women, Infants, and Children (WIC), and U.S. Department of Agriculture (USDA)
Cooperative Extension programs. These professionals function within institutions,
programs, and professional organizations that can develop policies and practices
that influence the content and frequency of professionals’ communication with
parents on a number of issues affecting children’s physical activity.
The first two goals of this chapter involve recommendations designed to
alter settings outside the home by changing physical environments and the ways
adults in those settings interact with children and allocate children’s time across
activities. It would be ideal for parents to implement many of these same recom-
mendations at home. Parents can be aided in this effort by the professionals from
whom they already seek advice about parenting. For parents to be receptive to this
advice, they must feel encouraged by these professionals rather than blamed, and
the advice must be practical and compatible with the parents’ values. Messages
about physical activity and sedentary behavior also must be consistent across
settings—from the pediatrician’s office, to the WIC clinic, to the child care center.
Finally, professionals can empower parents to change children’s environ-
ments and activities outside the home to encourage physical activity and decrease
sedentary behavior. Parents need the support of professionals to advocate for these
changes in their communities, especially in settings where their children receive
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child care and early childhood education. Parents’ expression of their opinions
can change the indoor and outdoor environments in all these settings, the ways in
which nonparental adults interact with their children, and the kinds of activities
their children engage in while away from home.
REFERENCES
AAP (American Academy of Pediatrics). 2009. The built environment: Designing communi-
ties to promote physical activity in children. Pediatrics 123:1591-1598.
AAP, APHA (American Public Health Association), and National Resource Center for
Health Safety in Child Care and Early Education. 2002. Caring for Our Children:
National Health and Safety Performance Standards; Guidelines for Out-of-Home Child
Care Programs, 2nd ed. Elk Grove Village, IL: AAP and Washington, DC: APHA.
AAP, APHA, and National Resource Center for Health Safety in Child Care and Early
Education. 2010. Preventing Childhood Obesity in Early Care and Education. http://
nrckids.org/CFOC3/PDFVersion/preventing_obesity.pdf (accessed October 22, 2010).
Abbott, A. L., and D. J. Bartlett. 2001. Infant motor development and equipment use in
the home. Child: Care, Health and Development 27(3):295-306.
Alhassan, S., J. R. Sirard, and T. N. Robinson. 2007. The effects of increasing outdoor
play time on physical activity in Latino preschool children. International Journal of
Pediatric Obesity 2(3):153-158.
Benjamin, S. E. 2010. Preventing Obesity in the Child Care Setting: Evaluating State
Regulations. http://cfm.mc.duke.edu/wysiwyg/downloads/State_Report-NC.pdf
(accessed October 22, 2010).
Benjamin, S. E., A. Ammerman, J. Sommers, J. Dodds, B. Neelon, and D. S. Ward. 2007.
Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC): Results
from a pilot intervention. Journal of Nutrition Education and Behavior 39(3):142-149.
Berntsen, S., P. Mowinckel, K. H. Carlsen, K. C. Lødrup Carlsen, M. L. Pollestad
Kolsgaard, G. Joner, and S. A. Anderssen. 2010. Obese children playing towards an
active lifestyle. International Journal of Pediatric Obesity 5(1):64-71.
Bialocerkowski, A. E., S. L. Vladusic, and C. Wei Ng. 2008. Prevalence, risk factors,
and natural history of positional plagiocephaly: A systematic review. Developmental
Medicine and Child Neurology 50(8):577-586.
Black, H. 2009. Back sleeping can flatten babies’ heads. Nursing New Zealand
(Wellington, N.Z.: 1995) 15(8):4.
Boldemann, C., M. Blennow, H. Dal, F. Martensson, A. Raustorp, K. Yuen, and U. Wester.
2006. Impact of preschool environment upon children’s physical activity and sun expo-
sure. Preventive Medicine 42(4):301-308.
Early Childhood Obesity Prevention Policies
76
OCR for page 77
Bower, J. K., D. P. Hales, D. F. Tate, D. A. Rubin, S. E. Benjamin, and D. S. Ward. 2008.
The childcare environment and children’s physical activity. American Journal of
Preventive Medicine 34(1):23-29.
Brown, W. H., K. A. Pfeiffer, K. L. McIver, M. Dowda, M. J. C. A. Almeida, and R. R.
Pate. 2006. Assessing preschool children’s physical activity: The observational system
for recording physical activity in children-preschool version. Research Quarterly for
Exercise and Sport 77(2):167-176.
Brown, W. H., K. A. Pfeiffer, K. L. McIver, M. Dowda, C. L. Addy, and R. R. Pate. 2009.
Social and environmental factors associated with preschoolers’ nonsedentary physical
activity. Child Development 80(1):45-58.
Burdette, H. L., and R. C. Whitaker. 2005. Resurrecting free play in young children:
Looking beyond fitness and fatness to attention, affiliation, and affect. Archives of
Pediatrics and Adolescent Medicine 159(1):46-50.
Bushnell, E. W., and J. P. Boudreau. 1993. Motor development and the mind: The potential
role of motor abilities as a determinant of aspects of perceptual development. Child
Development 64(4):1005-1021.
Cardon, G., E. Van Cauwenberghe, V. Labarque, L. Haerens, and I. De Bourdeaudhuij.
2008. The contribution of preschool playground factors in explaining children’s physi-
cal activity during recess. International Journal of Behavioral Nutrition and Physical
Activity 5:11.
Cawley, J., and C. K. Spiess. 2008. Obesity and skill attainment in early childhood.
Economics and Human Biology 6(3):388-397.
Chen, A. Y., S. E. Kim, A. J. Houtrow, and P. W. Newacheck. 2010. Prevalence of obesity
among children with chronic conditions. Obesity 18(1):210-213.
Clark, J. 1994. Motor development. In Encyclopedia of Human Behavior, edited by V. S.
Ramachandran. San Diego, CA: Academic Press.
Cliff, D. P., A. D. Okely, L. M. Smith, and K. McKeen. 2009. Relationships between fun-
damental movement skills and objectively measured physical activity in preschool chil-
dren. Pediatric Exercise Science 21(4):436-449.
Cosco, N. G., R. C. Moore, and M. Z. Islam. 2010. Behavior mapping: A method for link-
ing preschool physical activity and outdoor design. Medicine and Science in Sports and
Exercise 42(3):513-519.
Cottrell, L., E. Spangler-Murphy, V. Minor, A. Downes, P. Nicholson, and W. A. Neal.
2005. A kindergarten cardiovascular risk surveillance study: Cardiac-kinder. American
Journal of Health Behavior 29(6):595-606.
Cowan, S., and S. Bennett. 2009. Pursuing safe sleep for every baby, every sleep, in every
place they sleep. Nursing New Zealand (Wellington, N.Z.: 1995) 15(6):12-13.
CPSC (U.S. Consumer Product Safety Commission). 2010. Public Playground Safety
Handbook. http://www.cpsc.gov/cpscpub/pubs/325.pdf (accessed June 3, 2011).
77
Physical Activity
OCR for page 78
Davison, K. K., and C. T. Lawson. 2006. Do attributes in the physical environment influ-
ence children’s physical activity? A review of the literature. International Journal of
Behavioral Nutrition and Physical Activity 3(19).
DeBord, K., L. L. Hestenes, R. C. Moore, N. G. Cosco, and J. R. McGinnis. 2005.
Preschool Outdoor Environment Measurement Scale-Poems. Winston Salem, NC:
Kaplan, Inc.
Dowda, M., R. R. Pate, S. G. Trost, M. J. Almeida, and J. R. Sirard. 2004. Influences of
preschool policies and practices on children’s physical activity. Journal of Community
Health 29(3):183-196.
Dowda, M., W. H. Brown, K. L. McIver, K. A. Pfeiffer, J. R. O’Neill, C. L. Addy, and R.
R. Pate. 2009. Policies and characteristics of the preschool environment and physical
activity of young children. Pediatrics 123(2):e261-e266.
Dwyer, G. M., L. A. Baur, and L. L. Hardy. 2009. The challenge of understanding and
assessing physical activity in preschool-age children: Thinking beyond the framework of
intensity, duration and frequency of activity. Journal of Science and Medicine in Sport
12(5):534-536.
Eliakim, A., D. Nemet, Y. Balakirski, and Y. Epstein. 2007. The effects of nutritional-
physical activity school-based intervention on fatness and fitness in preschool children.
Journal of Pediatric Endocrinology and Metabolism: JPEM 20(6):711-718.
Fisher, A., J. J. Reilly, L. A. Kelly, C. Montgomery, A. Williamson, J. Y. Paton, and S.
Grant. 2005. Fundamental movement skills and habitual physical activity in young chil-
dren. Medicine and Science in Sports and Exercise 37(4):684-688.
Floriani, V., and C. Kennedy. 2008. Promotion of physical activity in children. Current
Opinion in Pediatrics 20(1):90-95.
Frey, G. C., and B. Chow. 2006. Relationship between BMI, physical fitness, and motor
skills in youth with mild intellectual disabilities. International Journal of Obesity
30(5):861-867.
Gabor, V., K. Mantinan, K. Rudolph, R. Morgan, and M. Longjohn. 2010. Challenges and
Opportunities Related to Implementation of Child Care Nutrition and Physical Activity
Policies in Delaware: Findings from Focus Groups with Child Care Providers and
Parents. http://www.cshelwa.org/Resources/DelawareFocusGroup-FullReport-FIN.pdf
(accessed October 21, 2010).
Garrett, M., A. M. McElroy, and A. Staines. 2002. Locomotor milestones and babywalk-
ers: Cross sectional study. British Medical Journal 324:1494.
Early Childhood Obesity Prevention Policies
78
OCR for page 79
Ginsburg, K. R., D. L. Shifrin, D. D. Broughton, B. P. Dreyer, R. M. Milteer, D. A.
Mulligan, K. G. Nelson, T. R. Altmann, M. Brody, M. L. Shuffett, B. Wilcox, C.
Kolbaba, V. L. Noland, M. Tharp, W. L. Coleman, M. F. Earls, E. Goldson, C. L.
Hausman, B. S. Siegel, T. J. Sullivan, J. L. Tanner, R. T. Brown, M. J. Kupst, S. E. A.
Longstaffe, J. Mims, F. J. Wren, G. J. Cohen, and K. Smith. 2007. The importance
of play in promoting healthy child development and maintaining strong parent-child
bonds. Pediatrics 119(1):182-191.
Graf, C., B. Koch, E. Kretschmann-Kandel, G. Falkowski, H. Christ, S. Coburger, W.
Lehmacher, B. Bjarnason-Wehrens, P. Platen, W. Tokarski, H. G. Predel, and S.
Dordel. 2004. Correlation between BMI, leisure habits and motor abilities in child-
hood (CHILT-project). International Journal of Obesity Related Metabolic Disorders
28(1):22-26.
Hamilton, M. T., D. G. Hamilton, and T. W. Zderic. 2007. Role of low energy expenditure
and sitting in obesity, metabolic syndrome, type 2 diabetes, and cardiovascular disease.
Diabetes 56(11):2655-2667.
Hankinson, A. L., M. L. Daviglus, C. Bouchard, M. Carnethon, C. E. Lewis, P. J.
Schreiner, K. Liu, and S. Sydney. 2010. Maintaining a high physical activity level over
20 years and weight gain. Journal of the American Medical Association 304(23):
2603-2610.
Hannon, J. C., and B. B. Brown. 2008. Increasing preschoolers’ physical activity intensities:
An activity-friendly preschool playground intervention. Preventive Medicine 46(6):
532-536.
HHS (U.S. Department of Health and Human Services). 2008a. 2008 Physical Activity
Guidelines for Americans. http://www.health.gov/paguidelines/guidelines/default.aspx
(accessed October 20, 2010).
HHS. 2008b. Physical Activity Guidelines Advisory Committee Report 2008. http://www.
health.gov/paguidelines/committeereport.aspx (accessed October 21, 2010).
HHS. 2010. The Surgeon General’s Vision for a Healthy and Fit Nation. Rockville, MD:
HHS.
Hu, F. B., T. Y. Li, G. A. Colditz, W. C. Willett, and J. E. Manson. 2003. Television watch-
ing and other sedentary behaviors in relation to risk of obesity and type 2 diabetes mel-
litus in women. Journal of the American Medical Association 289(14):1785-1791.
IOM (Institute of Medicine). 2005. Preventing Childhood Obesity: Health in the Balance.
Washington, DC: The National Academies Press.
IOM and NRC (National Research Council). 2009. Local Government Actions to Prevent
Childhood Obesity Balance. Washington, DC: The National Academies Press.
Jackson, D. M., K. Djafarian, J. Stewart, and J. R. Speakman. 2009. Increased television
viewing is associated with elevated body fatness but not with lower total energy expen-
diture in children. American Journal of Clinical Nutrition 89(4):1031-1036.
79
Physical Activity
OCR for page 80
Jago, R., T. Baranowski, J. C. Baranowski, D. Thompson, and K. A. Greaves. 2005.
BMI from 3-6 y of age is predicted by TV viewing and physical activity, not diet.
International Journal of Obesity 29(6):557-564.
Janz, K. F., S. M. Levy, T. L. Burns, J. C. Torner, M. C. Willing, and J. J. Warren. 2002.
Fatness, physical activity, and television viewing in children during the adiposity
rebound period: The Iowa bone development study. Preventive Medicine 35(6):
563-571.
Janz, K. F., T. L. Burns, and S. M. Levy. 2005. Tracking of activity and sedentary behav-
iors in childhood: The Iowa Bone Development Study. American Journal of Preventive
Medicine 29(3):171-178.
Janz, K. F., S. Kwon, E. M. Letuchy, J. M. Eichenberger Gilmore, T. L. Burns, J. C. Torner,
M. C. Willing, and S. M. Levy. 2009. Sustained effect of early physical activity on body
fat mass in older children. American Journal of Preventive Medicine 37(1):35-40.
Jennings, J. T., B. G. Sarbaugh, and N. S. Payne. 2005. Conveying the message about opti-
mal infant positions. Physical and Occupational Therapy in Pediatrics 25(3):3-18.
Kaczynskl, A. T., and K. A. Henderson. 2008. Parks and recreation settings and active liv-
ing: A review of associations with physical activity function and intensity. Journal of
Physical Activity and Health 5(4):619-632.
Kelly, L. A., J. J. Reilly, D. M. Jackson, C. Montgomery, S. Grant, and J. Y. Paton. 2007.
Tracking physical activity and sedentary behavior in young children. Pediatric Exercise
Science 19(1):51-60.
Klesges, R. C., L. H. Eck, C. L. Hanson, C. K. Haddock, and L. M. Klesges. 1990. Effects
of obesity, social interactions, and physical environment on physical activity in pre-
schoolers. Health Psychology 9(4):435-449.
Klohe-Lehman, D. M., J. Freeland-Graves, K. K. Clarke, G. Cai, V. S. Voruganti, T. J.
Milani, H. J. Nuss, J. M. Proffitt, and T. M. Bohman. 2007. Low-income, overweight
and obese mothers as agents of change to improve food choices, fat habits, and physical
activity in their 1-to-3-year-old children. Journal of the American College of Nutrition
26(3):196-208.
Kordestani, R. K., and J. Panchal. 2006. Neurodevelopment delays in children with defor-
mational plagiocephaly. Plastic and Reconstructive Surgery 118(3):808-809; author
reply 809-810.
Kuo, Y. L., H. F. Liao, P. C. Chen, W. S. Hsieh, and A. W. Hwang. 2008. The influence
of wakeful prone positioning on motor development during the early life. Journal of
Developmental and Behavioral Pediatrics: JDBP 29(5):367-376.
Li, R., L. O’Connor, D. Buckley, and B. Specker. 1995. Relation of activity levels to body
fat in infants 6 to 12 months of age. Journal of Pediatrics 126(3):353-357.
Maher, C. A., M. T. Williams, T. Olds, and A. E. Lane. 2007. Physical and sedentary activ-
ity in adolescents with cerebral palsy. Developmental Medicine and Child Neurology
49(6):450-457.
Early Childhood Obesity Prevention Policies
80
OCR for page 81
McKinney, C. M., M. L. Cunningham, V. L. Holt, B. Leroux, and J. R. Starr. 2009. A case-
control study of infant, maternal and perinatal characteristics associated with deforma-
tional plagiocephaly. Paediatric and Perinatal Epidemiology 23(4):332-345.
McWilliams, C., S. C. Ball, S. E. Benjamin, D. Hales, A. Vaughn, and D. S. Ward. 2009.
Best-practice guidelines for physical activity at child care. Pediatrics 124(6):1650-1659.
Metcalfe, J. S., and J. E. Clark. 2000. Sensory information affords exploration of posture
in newly walking infants and toddlers. Infant Behavior and Development 23(3-4):
391-405.
Mildred, J., K. Beard, A. Dallwitz, and J. Unwin. 1995. Play position is influenced by
knowledge of SIDS sleep position recommendations. Journal of Paediatrics and Child
Health 31(6):499-502.
Mond, J. M., H. Stich, P. J. Hay, A. Kraemer, and B. T. Baune. 2007. Associations between
obesity and developmental functioning in pre-school children: A population-based
study. International Journal of Obesity 31(7):1068-1073.
Montgomery, C., J. J. Reilly, D. M. Jackson, L. A. Kelly, C. Slater, J. Y. Paton, and S.
Grant. 2004. Relation between physical activity and energy expenditure in a representa-
tive sample of young children. American Journal of Clinical Nutrition 80(3):591-596.
Moore, L. L., D. Gao, M. L. Bradlee, L. A. Cupples, A. Sundarajan-Ramamurti, M. H.
Proctor, M. Y. Hood, M. R. Singer, and R. C. Ellison. 2003. Does early physical activ-
ity predict body fat change throughout childhood? Preventive Medicine 37(1):10-17.
NASPE (National Association for Sport and Physical Education). 2009. Active Start: A
Statement of Physical Activity Guidelines for Children from Birth to Age 5, 2nd ed.
Reston, VA: NASPE.
Ogden, C. L., M. D. Carroll, L. R. Curtin, M. M. Lamb, and K. M. Flegal. 2010.
Prevalence of high body mass index in U.S. children and adolescents, 2007-2008.
Journal of the American Medical Association 303(3):242-249.
Okely, A. D., M. L. Booth, and T. Chey. 2004. Relationships between body composition
and fundamental movement skills among children and adolescents. Research Quarterly
for Exercise and Sport 75(3):238-247.
Oliver, M., G. M. Schofield, and G. S. Kolt. 2007. Physical activity in preschoolers:
Understanding prevalence and measurement issues. Sports Medicine 37(12):1045-1070.
Pate, R. R., M. J. Almeida, K. L. McIver, K. A. Pfeiffer, and M. Dowda. 2006. Validation
and calibration of an accelerometer in preschool children. Obesity 14(11):2000-2006.
Pfeiffer, K. A., M. Dowda, K. L. McIver, and R. R. Pate. 2009. Factors related to objec-
tively measured physical activity in preschool children. Pediatric Exercise Science
21(2):196-208.
Preiser, W. F. E., and E. Ostroff, eds. 2001. Universal Design Handbook. New York:
McGraw-Hill.
81
Physical Activity
OCR for page 82
Proctor, M. H., L. L. Moore, D. Gao, L. A. Cupples, M. L. Bradlee, M. Y. Hood, and R.
C. Ellison. 2003. Television viewing and change in body fat from preschool to early
adolescence: The Framingham Children’s Study. International Journal of Obesity
Related Metabolic Disorders 27(7):827-833.
Reilly, J. J., J. Coyle, L. Kelly, G. Burke, S. Grant, and J. Y. Paton. 2003. An objective
method for measurement of sedentary behavior in 3- to 4-year olds. Obesity Research
11(10):1155-1158.
Reilly, J. J., D. M. Jackson, C. Montgomery, L. A. Kelly, C. Slater, S. Grant, and J. Y.
Paton. 2004. Total energy expenditure and physical activity in young Scottish children:
Mixed longitudinal study. Lancet 363(9404):211-212.
Riddoch, C. J., S. D. Leary, A. R. Ness, S. N. Blair, K. Deere, C. Mattocks, A. Griffiths, G.
Davey Smith, and K. Tilling. 2009. Prospective associations between objective measures
of physical activity and fat mass in 12-14 year old children: The Avon Longitudinal
Study of Parents and Children (ALSPAC). British Medical Journal 339:b4544.
Riley, B. B., J. H. Rimmer, E. Wang, and W. J. Schiller. 2008. A conceptual framework for
improving the accessibility of fitness and recreation facilities for people with disabilities.
Journal of Physical Activity and Health 5(1):158-168.
Rimmer, J. H., K. Yamaki, B. M. Lowry, E. Wang, and L. C. Vogel. 2010. Obesity and
obesity-related secondary conditions in adolescents with intellectual/developmental dis-
abilities. Journal of Intellectual Disability Research 54(9):787-794.
Robinson, S. 2010. Deformational plagiocephaly delays motor skill development in
6-month-old infants. Journal of Pediatrics 157(3):514-515.
Sääkslahti, A., P. Numminen, P. Salo, J. Tuominen, H. Helenius, and I. Välimäki. 2004.
Effects of a three-year intervention on children’s physical activity from age 4 to 7.
Pediatric Exercise Science 16(2):167-180.
Saelens, B. E., L. D. Frank, C. Auffrey, R. C. Whitaker, H. L. Burdette, and N.
Colabianchi. 2006. Measuring physical environments of parks and playgrounds:
EAPRS instrument development and inter-rater reliability. Journal of Physical Activity
and Health 3(Suppl. 1):S190-S207.
Sallis, J. F., P. R. Nader, S. L. Broyles, C. C. Berry, J. P. Elder, T. L. McKenzie, and J. A.
Nelson. 1993. Correlates of physical activity at home in Mexican-American and Anglo-
American preschool children. Health Psychology 12(5):390-398.
Shibli, R., L. Rubin, H. Akons, and R. Shaoul. 2008. Morbidity of overweight (≥85th per-
centile) in the first 2 years of life. Pediatrics 122(2):267-272.
Sirard, J. R., S. G. Trost, K. A. Pfeiffer, M. Dowda, and R. R. Pate. 2005. Calibration and
evaluation of an objective measure of physical activity in preschool children. Journal of
Physical Activity and Health 2(3):345-357.
Slining, M., L. S. Adair, B. D. Goldman, J. B. Borja, and M. Bentley. 2010. Infant over-
weight is associated with delayed motor development. Journal of Pediatrics 157(1):20-
25 e21.
Early Childhood Obesity Prevention Policies
82
OCR for page 83
Steele, C., I. Kalnins, J. Jutai, J. Bortolussi, and W. Biggar. 1996. Lifestyle health
behaviours of 11- to 16-year-old youth with physical disabilities. Health Education
Research 11:173-186.
Strong, W. B., R. M. Malina, C. J. Blimkie, S. R. Daniels, R. K. Dishman, B. Gutin,
A. C. Hergenroeder, A. Must, P. A. Nixon, J. M. Pivarnik, T. Rowland, S. Trost,
and F. Trudeau. 2005. Evidence based physical activity for school-age youth.
Journal of Pediatrics 146(6):732-737.
Thein, M., J. Lee, V. Tay, and S. Ling. 1997. Infant walker use, injuries and motor
development. Injury Prevention 3:63-66.
Trost, S. G., B. Fees, and D. Dzewaltowski. 2008. Feasibility and efficacy of a “move
and learn” physical activity curriculum in preschool children. Journal of Physical
Activity and Health 5(1):88-103.
Trost, S. G., D. S. Ward, and M. Senso. 2010. Effects of child care policy and environ-
ment on physical activity. Medicine and Science in Sports and Exercise 42(3):
520-525.
USDA (U.S. Department of Agriculture) and HHS. 2010. Dietary Guidelines for
Americans 2010. http://www.healthierus.gov/dietaryguidelines (accessed January
12, 2011).
Ward, D. S., S. E. Benjamin, A. S. Ammerman, S. C. Ball, B. H. Neelon, and S. I.
Bangdiwala. 2008. Nutrition and physical activity in child care. Results from an
environmental intervention. American Journal of Preventive Medicine 35(4):
352-356.
Ward, D. S., A. Vaughn, C. McWilliams, and D. Hales. 2010. Interventions for
increasing physical activity at child care. Medicine and Science in Sports and
Exercise 42(3):526-534.
Wells, J. C., T. J. Cole, and P. S. Davies. 1996a. Total energy expenditure and body
composition in early infancy. Archives of Disease in Childhood 75(5):423-426.
Wells, J. C., M. Stanley, A. S. Laidlaw, J. M. Day, and P. S. Davies. 1996b. The rela-
tionship between components of infant energy expenditure and childhood body
fatness. International Journal of Obesity and Related Metabolic Disorders
20(9):848-853.
Williams, C. L., B. J. Carter, D. L. Kibbe, and D. Dennison. 2009. Increasing physi-
cal activity in preschool: A pilot study to evaluate animal trackers. Journal of
Nutrition Education and Behavior 41(1):47-52.
Williams, H., and E. Monsma. 2007. Assessment of gross motor development in
preschool children. In The Psychoeducational Assessment of Preschool Children,
edited by B. N. Bracken. Hillsdale, NJ: Lawrence Erlbaum.
83
Physical Activity
OCR for page 84
