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Outdoor Play and its Association with a Healthy Body weight In

Children, and Considering Neighborhood Safety as an Indicator of
Levels of Physical Activity and Sedentary Behavior.

Allison Burke
Writing for Community Nutrition

Introduction
The increasing rate of childhood obesity in the U.S. and around the
world is a significant public health concern. According to analysis of data
from the National Health and Nutrition Examination Survey, the rates of
childhood obesity have doubled over the last 30 years (Ogden CL et al.
2014). Moreover, the prevalence of childhood obesity is greater in lowincome families according to the Pediatric Nutrition Surveillance System
findings in 2010 (Dalenius K 2010). According to this data, there was a 14.5%
prevalence of childhood obesity when the family income was between 51
and 100% of the federal poverty level, compared to 11.8% prevalence in
families whose income was between 151 and 185% of the federal poverty
level. The World Health Organization reports statistics retrieved from the
Final Report of the Commission on Ending Childhood Obesity of 2016. These
statistics state that childhood obesity rates are rapidly increasing,
specifically in low income and urban areas (World Health Organization 2015).
Many factors contribute to the childhood obesity pandemic or a chronic
imbalance between dietary intake and energy output, specifically physical
activity.
Figure 1

Barriers to physical activity in children include lack of sufficient

physical activity programs in school, the increasing trend to stay indoors and
have long periods of screen time, and lack of access to a park or recreational
center. In particular, socioeconomically disadvantaged children are at a
heightened level of risk of becoming obese, as they are more likely to be
affected by an energy imbalance resulting in weight gain. Environmental
factors such as food insecurity, poverty, and lack of transportation to grocery
stores can alter the quantity and quality of childrens diet. In addition, a lack
of access to safe areas for physical activity contributes to decreased energy
expenditure and increased adiposity in socioeconomically disadvantaged and
urban areas.
This paper will specifically focus on how access to safe, outdoor play
will increase moderate to vigorous physical activity and therefore decrease
susceptibility to childhood obesity. Increasing physical activity supports a
healthy weight in children. Children who lack access to outdoor play due to
neighborhood safety concerns have limited amounts of physical activity. The
specific hypothesis is that access to safe outdoor play will enhance a childs
physical health and promote a healthy BMI. Socioeconomic barriers to
outdoor play and neighborhood safety contribute to the increasing
prevalence of childhood obesity, specifically children living in urban areas
without access to appropriate and safe venues for play. Future initiatives
should focus on fostering a safe and conducive environment for children to
play outdoors. Programs that focus on increasing activity during the
commute to school, during the school day, and after school hours could have
an impact on childhood obesity by providing a safe outlet for outdoor play
and physical activity.
To address the hypothesis, this paper will discuss the relationship
between outdoor playtime and a childs willingness to partake in either
moderate or vigorous physical activity. The paper will also cover the
relationship between moderate, or vigorous activity and decreased BMI.
Furthermore, this paper will discuss the concept of neighborhood safety, as

this is a significant barrier to outdoor play for socio-economically

disadvantaged children living in urban areas. Lastly, the paper will discuss
current and future interventions aimed at increasing access to outdoor
playtime in the hopes that these interventions will promote a healthy weight
in children and have an impact upon the increasing rates of childhood
obesity in the United States.
Access to outdoor play and the relationship to time spent partaking
in moderate to vigorous physical activity
This section will assess whether or not children who have access to
outdoor play are more likely to partake in moderate to vigorous physical
activity (MVPA). The World Health Organization defines MVPA as an activity
that requires either a moderate or large amount of effort and will cause an
accelerated heart rate and/or rapid breathing (World Health Organization
2015). Activities that can be considered to provide MVPA include brisk
walking, dancing, and running, involvement in games and sports, and bicycle
riding. Recently, a group of researchers and stakeholders sought to create a
mission statement regarding the importance of outdoor play (Tremblay MS et
al 2015). The finalized position statement regarding outdoor play states,
access to active play in nature and outdoorswith its risks is
essential for healthy child development. [They] recommend increasing
childrens opportunities for self-directed play outdoors in all settings
at home, at school, in childcare, the community and nature3
The following articles in this section seek a relationship between access to
safe outdoor play and increased levels of moderate to vigorous physical
activity. The articles were found using PubMed and key search terms such as
moderate to vigorous physical activity, obesity, childhood, and outdoor play.
An observational study examined the associations between outdoor
playtime, physical activity, and sedentary behavior (Stone, M. R., & Faulkner,
G. E. 2014). The researchers found that boys who played less than <1hr per

day outdoors were more likely to be obese. However, the relationship

between adiposity and amount of time spent outdoors did not hold true. The
researchers analyzed 856 children from both low socioeconomic status (SES)
and high SES neighborhoods. The researchers followed a cohort of 856
children whose parents categorized their afterschool outdoor play as <1
hour/day, 1-2 hours/day, or >2 hours per day on schooldays and weekends.
They used multivariate analysis of variance to analyze whether the level
outdoor play predicted the level of MVPA and obesity while controlling for
age, sex, and time spent sedentary. As shown in Table 1, the category of
time outside did not greatly affect the time spent participating in moderate
to vigorous physical activity (MVPA), there was one exception. The group of
boys who played for <1 hour per day were more likely to be obese than were
the boys who played outside for >2 hours per day (p= 0.023).
Table 1. Comparison between % of participants who were overweight or
obese indicates that 39.1% of boys who had low levels of outdoor play were
obese compared to only 20% of boys who had high amounts of outdoor play.
Additionally, the time spent partaking in MVPA did not vary significantly
across groups.
Table 1

The above table corresponds to the amount of time (low, medium, high) spent outdoors and
variables including BMI, % obese, and level of MVPA and is separated based on gender.

Outdoor play environment and greater access to green space and play
equipment associates with greater MVPA among young children according to
an observational study (Nicaise, V et al 2011). This involved 51 preschoolers
in southern California. Researchers examined levels of unstructured outdoor
play. Unstructured outdoor play was any time spent outdoors during the
school day in which adult supervisors were not instructing or guiding the
children to partake in a particular activity. The researchers followed this
cohort of students and tracked their level of MVPA during 204 observation
periods that corresponded to the preschool recess. From the analysis,
geographical and social environment played a significant role in engaging
preschoolers in MVPA. Researchers compared level of activity between a
cement amphitheater playground and an open green-space park area.

Children were between 3.4 and 4.9 times more likely to engage in physical
activity when using green space. In addition, the researchers found that
children were more likely to engage in physical activity if they were either
alone or with one other child. Lastly, researchers noticed a relationship
between weight status and level of activity. Overweight children were 3.2
times less likely to engage in MVPA than their healthy weight counterparts.
Consistently, a systematic review of 28 studies aimed to determine the
level of evidence in the relationship between access to outdoor playtime and
physical activity, fitness and sedentary behavior. Many of the previous
studies had only been observational; therefore pooling and comparing results
from different studies strengthen the relationship between these variables at
establishing a more concrete relationship between outdoor play and physical
activity, cardiorespiratory fitness, musculoskeletal fitness, and sedentary
behavior (Gray, C et al. 2015).
Table 2

Table 3

Table 4

Overall, the researchers analyzed a cumulative sample of 13,798

children between the ages of 3 and 12. Regarding the relationship between
time spent outdoors and habitual physical activity in children, all 16
observational studies assessed indicated that more time spent outdoors was
correlated with more time being habitually physically active. However as the
Table 2 notes, the quality of evidence is low due to a high risk of bias. This
stems from not knowing the accelerometer cut points and not controlling for
confounding variables such as age and sex. In table 3, the relationship
between outdoor time and acute physical activity has a moderate quality of
evidence. This evidence indicates that children are more likely to be
physically active (engaging in MVPA) when outdoors compared to indoors.
Seven cross sectional studies and one longitudinal studies reported the
association between outdoor time being a better predictor for MVPA than
time spent indoors. There was no serious risk of bias in this association, as
evidenced by the second table in the series. Lastly as seen in Table 4 more

outdoor time associated with a lower amount of time per day spent being
sedentary. However, the third table in this series indicates a low quality of
evidence. Only two studies were included, and there was a high risk of bias.
The studies in this review were all observational, and therefore cannot
provide a high-quality level of evidence in relating the variables. However,
benefits of the study included that most used objectives measures such as
pedometers, accelerometers and GPS, to report levels of activity.
In summary of this section, across all publications, researchers have
found that more time spent outdoors is associated with increased time being
active, however some studies have concluded that the environment has to
be conducive to physical activity. This presents a challenge to children living
in urban socioeconomic areas as they may lack neighborhood security and
access to appropriate green space and play equipment to promote activity.
Increasing Physical Activity is Associated with Decreases in
Childrens BMI
The next question to consider is whether increases in physical activity
has an effect on the body composition and adiposity of children. The
following studies were found using PubMed including search terms Physical
Activity Child/Children/Childhood Obesity Body Composition and
BMI.
An observational study of a cohort of 2810 preschoolers in the Head
Start program found that providing access to outdoor physical activity during
the school day decreased the childs risk of developing obesity by 42% and
on average reduced total BMI by 0.18 points. (Ansari, A. et al 2015). Data
were gathered from 3-4 year old children who were enrolled in the Head Start
program, a government-funded preschool program for socioeconomically
disadvantaged children. The researchers stratified for initial BMI at the
beginning of the year, time spent outdoors at home, and neighborhood
safety. The preschool teachers were asked to categorize the time their class
spent outdoor within five-minute intervals. The childrens heights and

weights were taken four times throughout the year (twice during each term).
Overall, the researchers found that for every 1 minute increase in time spent
outdoors was associated in a 1% decrease in risk of becoming obese
indicated by an odds ratio (OR= 0.99). As shown in table 5, children who
had high levels of outdoor play had an overall decrease of 0.18 BMI points
more than children who had low levels of outdoor play at school. Children
who experienced the largest reduction in BMI based high levels of outdoor
play at school were those who were obese at the beginning of the school
year, those who lived in unsafe neighborhoods, and those who were less
active at home.

While this study displays a relationship between outdoor playtime,

increased physical activity, and decreased body mass index values, it is only
observational and therefore cannot establish a cause and effect relationship.
Another observational study looked at the relationship between physical
activity and obesity rates in Oregon.
While the previous study focused on preschool aged children, another
observational study conducted in rural Oregon schools found that more time
spent at school participating in MVPA was significantly associated with a
lower BMI z-score in a sample of 1482 for children between the ages of 6 and
11(Gunter, K. et al 2015). The data reflects mostly socioeconomically
disadvantaged children. For a school to be chosen for this study, more than
half of the students needed to qualify for free or reduced lunch. The children

used pedometers throughout the school day to track total physical activity
and moderate to vigorous activity. In comparing the group means, Total PA
and MVPA was higher in boys than in girl participants and on average higher
in younger participants. Total physical activity was not significantly
associated with BMI z-scores across all children. However, healthy weight
children had higher significantly higher rates of MVPA than did the obese
children independent of age or sex (p value <0.001). While healthy weight
children also had higher rates of MVPA than overweight children, the data
wasn't statistically significant (p value = 0.18). The above findings suggest
an increased need for interventions specifically targeting young girls to
increase levels of physical activity. However, this was another observational
study and therefore cannot establish a cause and effect relationship on its
own. As another limitation, this study looked primarily at rurally located
children and this does not take into consideration the different resources and
disadvantages that are presented to children living in urban areas.
The previous two studies only established a correlation between
physical activity and BMI. In comparison, a nonrandomized control trial
examined if a causal relationship existed between physical activity and BMI
(Li, X. et al 2014). Specifically, the trial sought to determine the effectiveness
of physical activity interventions in the school setting in decreasing BMI. A
sample of 921 children between 7 and 15 were allocated to control and
intervention groups. The intervention group received a 12-week program of
physical education, afterschool physical activities, and home physical
activities as well as education on overall health for both participants and
their parents. The control group maintained their usual daily health practices.
Researchers assessed BMI, skinfolds, and duration of moderate to vigorous
physical activity, and blood glucose levels at the start and end of the 12week program. After the 12-week program, the intervention group had a
0.43 kg/m2 smaller average BMI than the control group. There were also
significantly larger decreases in skinfolds as well as fasting blood glucose
levels. In addition, the intervention group had longer average duration of

moderate to vigorous physical activity per day. Limitations of this study

include the fact that it was not randomized and therefore the results may
have been skewed. The research did indicate that increasing physical activity
led to a slightly smaller BMI the intervention group at the end of the trial.
These individuals may have already been more apt to partake in physical
activity and experience weight reduction.
In summary of this section, the above 3 studies support that increasing
physical activity will in turn predispose a child to a more healthy weight. As
childhood obesity rates increase, it is important to consider that providing
access to an outdoor play environment fosters increasing physical activity in
children. That physical activity, in turn, can promote reductions in BMI and
promote maintenance of healthy weight in children. However, to address the
relationship between outdoor play and healthy weight it is important to
consider potential barriers, such as neighborhood safety, to accessing
outdoor play.
Relationship between neighborhood safety of urban and
socioeconomic disadvantaged areas and outdoor play
A potential factor that inhibits access to outdoor play is the
neighborhood environment. While school programs may provide a safe area
for physical activity, the home environment must do the same. Children
living in socioeconomically disadvantaged areas may be subject to a lack of
neighborhood safety and security, which in turn can decrease levels of
outdoor play and physical activity. Here you need to tell the read how you
uncovered the references.
An observational study in Europe involving 3,469 children between 5
and 6 years found (Hrudey, E et al 2015) that neighborhood characteristics
such as socioeconomic status, availability of green space, and demographic
distribution plays a smaller role in predicting children's percent body fat than
the children's social environment, such as peer and parental behaviors. The

study used data from the ABCD longitudinal cohort. Socioeconomic status
was determined using status scores set by the Social and Cultural Plan
Bureau, and neighborhood safety was ranked using the Dutch Housing
Questionnaire. The study included other questions regarding prenatal and
postnatal health. Researchers used a mixed linear regression model to
interpret the relationship between the neighborhood environment and child
adiposity. Overall, the maternal health characteristics were a stronger
indicator for children's adiposity than socioeconomic status or neighborhood
safety.
In agreement, the Early Childhood Longitudinal Study identified that
parental perceptions of neighborhood safety can influence whether or not
children are allowed to spend unsupervised periods of time outdoors. In this
student researchers sought to find the effect of parental perceptions of
neighborhood safety in their children's BMI (Datar, A et al 2013). The
researchers found that perceived neighborhood safety did not significantly
influence a child's percent body fat or BMI but did have an impact on time
spent sedentary and physically active. This 9 year long longitudinal study
examined over 19,000 United States children between kindergarten and
eighth grade. Parents were asked to rank the safety of their neighborhood as
"very safe," "somewhat safe" or "not at all safe" during the 9 years. The
parents were interviewed 4 times when their children were in kindergarten,
third grade, fifth grade, and eighth grade. The researchers stratified for
gender, race, maternal education level as well as the level of "urbanicity" of
the neighborhood environment. The researchers asked the parents to specify
if their home was located in an urban area, city, or town.
From the analysis, unsafe neighborhoods significantly increased the
children's time spent sedentary watching TV as shown in Figure 2. Also
shown in figure 2, unsafe neighborhoods significantly decreased the time
spent partaking in physical activity. In addition, neighborhood safety did not
have a significant impact on BMI or % obese as shown in Figure 3.

The following graphs represent the effect of neighborhood safety on

physical activity, sedentary behaviors, BMI percentile and % obese.
Figure 2

Figure 3

e dark gray bar indicates children who lived in a neighborhood their parents
thought to be very safe. The light gray bar represents children who lived in
somewhat safe or not at all safe neighborhood

Th

In conclusion, neighborhood safety has less of an impact on

BMI than expected, but does play a significant role in time spent
either active or sedentary. While the first study mentions that
neighborhood safety and socioeconomic status do play a small role
in predicting BMI, other factors such as maternal health and parental
behaviors are a far more significant predictor of a childs BMI. In
contrast the second study the mentioned that although
neighborhood safety influences the amount of time spent outdoors,
the increase time spent outdoors wasnt met with an increase in BMI
or % body fat. However, BMI is not an absolute measure for
evaluating childhood obesity, therefore future research should aim to
look at other factors when comparing neighborhood safety and risk
of obesity.

Interventions to increase neighborhood safety and their potential

impact on decreasing rates of childhood obesity
While there is currently limited evidence to suggest that neighborhood
safety plays a large role in influencing a childs BMI, interventions aimed at
creating a safe environment to foster outdoor play could still promote
physical activity and a healthy weight in children.
To combat the issue of a lack of physical space, the Childrens Hospital
at Montefiore Joining Academics and Movement (CHAM JAM) intervention was
implemented in urban elementary schools in the Bronx, New York (Reznik M,
2015). This intervention was meant to combat the issues that prevent
children living in highly urban areas from being physically active during the
school day. A randomized controlled trial sought to determine the
effectiveness of this program in increasing physical activity. The CHAM JAM
intervention includes teachers playing a 10-minute track on an audio CD that
instructs children on performing physical activity. Teachers should play the
track 3 times a day for a total of 30 minutes. The study found that

implementing the intervention significantly increased the number of steps

taken per day (p=0.0048), independent of gender, BMI, and baseline
physical activity level. The study analyzed 988 kindergarten and first grade
students from four schools. Two schools were randomly assigned to the
intervention group and two schools were randomly assigned to the control
group. The intervention group utilized the CHAM JAM tapes, while the control
group followed their usual physical activity plan. The study sought to provide
an outlet for students to be physically active despite going to school in an
unsafe area that lacked physical space to promote outdoor play.
Interventions focused on school commute
The walking school bus is an intervention that focuses on optimizing
time commuting to and from school by actively commuting (Mendoza JA,
2011). Actively commuting refers to either walking or cycling to a
destination. By providing an adult supervised commute, the walking school
bus program hopes to increase the amount of time spent partaking in MVPA.
This randomized clinical control trial sought to determine the effect that
active commuting had on childrens physical activity levels. The study found
that by implementing the walking school bus program, a group of fourth
grade students physical activity and time actively commuting both
increased significantly. The study chose eight schools in Houston Texas to
participate in the trial. The schools student populations were largely black or
Hispanic. In addition, more than 75% of the schools population had to
qualify for free and reduced school lunch. The eight schools were randomly
assigned to the intervention or control group. The intervention group
implemented a walking program for fourth graders, while the control group
maintained their usual transportation services. Within the intervention group,
two adult staff members would supervise 8-12 children walking home. The
children had to live within a 1-mile radius of the school to qualify. This was a
five-week program. The researchers collected information on daily levels of
MVPA and active commuting at time one and after the five-week program at
time two. The intervention group of children increased their time spent

actively commuting from 23.8% at time one to 54% at time two. In

comparison, the control groups time spent actively commuting decreased
from 40.2% to 32.6%. In addition, the intervention group increased their
MVPA by an average of seven minutes per day.
Conclusion
To review, this paper examined how access to safe outdoor play will
enhance a childs physical health and promote a healthy BMI. Socioeconomic
barriers to outdoor play and neighborhood safety contribute to the increasing
prevalence of childhood obesity, specifically children living in urban areas
without access to appropriate and safe venues for play. In conclusion, a
general shift towards time spent indoors being sedentary has contributed to
the rise in childhood obesity. Children who have access to safe outdoor play
are more likely to engage in MVPA and therefore achieve a healthy weight
status. While little evidence suggests that neighborhood safety plays a direct
role in contributing to the childhood obesity epidemic, studies have
suggested that a lack of perceived neighborhood safety impacts the amount
of time spent engaging in MVPA. Future interventions should focus on how to
improve access to outdoor play and time spent partaking in MVPA during the
school commute, during school hours, and during afterschool extracurricular
activities.
The issue surrounding childhood obesity needs to be addressed from a
socio ecological framework. To improve the weight status of the children
across the US, interventions must address barriers to the individual and
community. Individual barriers could be a lack of motivation to be physically
active, or the influence of parents or peer behaviors. Barriers to the
community include lack of access to a safe venue such as a park or
recreational center. Also, a lack of suitable walking space for children due to
violence or vehicle traffic pose an issue for physical activity. In addition to
individual and community-focused interventions, policy level interventions
could make an impact. Legislature to mandate a minimum amount of time

spent outdoors during the school day could have a huge impact on childhood
obesity by providing access to outdoor play. One systematic review and meta
analysis found that by providing children with interventions (which promoted
increased time spent in MVPA) spent 24% of the lesson time engaging in
MVPA compared to children who followed their schools regular physical
education pattern (Ogden, CL 2014). By implementing more effective
strategies during the school day, the school commute, and by providing
afterschool activities, which promote MVPA, the energy imbalance that
contributes to childhood obesity could improve. In addition, by keeping the
socio-ecological model in mind and addressing interpersonal, intrapersonal,
institutional, community, and policy-based interventions through
interventions, the epidemic of childhood obesity may be reversed.

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