Physical Activity: Classroom-based Physically Active Lesson Interventions

CPSTF uses recently published systematic reviews to conduct accelerated assessments of interventions that could provide program planners and decision-makers with additional, effective options. The following published review was selected and evaluated by a team of specialists in systematic review methods, and in research, practice, and policy related to school-based physical activity interventions.

Norris E, van Steen T, Direito A, Stamatakis E. Physically active lessons in schools and their impact on physical activity, educational, health and cognition outcomes: a systematic review and meta-analysis. British Journal of Sports Medicine 2020;54:826-38.

The review included 42 studies (search period through April 2019), of which 34 were included in meta-analyses of physical activity, health, cognition, and education-related outcomes. The team also examined the subset of 18 intervention studies conducted in the United States and abstracted supplemental information about study, intervention, and population characteristics.

The CPSTF finding is based on results from the published review and meta-analyses, additional information from the subset of 18 studies conducted in the United States, and expert input from team members and CPSTF.

The U.S. Department of Health and Human Services recommends that young people ages 6 17 years participate in at least 60 minutes of physical activity daily (HHS 2018). Regular physical activity in childhood and adolescence improves strength and endurance, helps build healthy bones and muscles, helps control weight, improves cognitive function, reduces risk of depression, and may improve cardiovascular health (HHS 2018).

Schools have an important role in promoting and supporting daily and weekly physical activity among students. Classroom-based physical activity interventions can be used to supplement other school programs and policies to promote physical activity among students such as physical education programs, recess breaks, and active travel to school interventions (CDC 2018).

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The published systematic review included 42 studies, of which 34 were included in meta-analyses providing summary effect estimates as standardized mean differences. Interventions lead to the following student outcomes:

• Increased time spent in moderate-to-vigorous intensity physical activity over the school day
• Improved lesson-related educational outcomes
• Improved measurements of student attention to lesson content

The review did not find intervention effects on cognition or measures of physical fitness or body mass index.

A systematic review of economic evidence has not been conducted.

Based on results from the review, findings should be applicable to students in preschool, kindergarten, and elementary schools in the United States.

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• How do intervention effects vary by participant characteristics, including household income, parents’ level of education, and race/ethnicity in U.S. populations?
• How do intervention effects vary based on duration and frequency of physically active lessons during the school day?
• Do physically active lessons contribute to more students meeting recommendations for 60 minutes per day of moderate-to-vigorous intensity physical activity per day?
• What is the impact of classroom-based physically active lesson interventions on the following outcomes:
  • Cognitive functions
  • Physical fitness, including aerobic fitness, muscle strength and endurance, flexibility, and body composition
  • Other student health outcomes
• Are these interventions effective for older students in middle and high school settings?
• What are barriers to teacher and school adoption and sustained implementation?
• What are solutions to address barriers to teacher and school adoption and sustained implementation?
• How might physical activity breaks be tailored so they are developmentally appropriate, culturally relevant, and inclusive of students with disabilities?

• Study designs included group randomized controlled trials (27 studies), controlled before-after studies (14 studies), and prospective cohorts (1 study).
• Studies were conducted in the United States (18 studies), Australia (7 studies), the United Kingdom (5 studies), the Netherlands (4 studies), and Denmark (2 studies), and one study each came from China, Croatia, Ireland, Israel, Portugal, and Sweden.
• Most study interventions were implemented by teachers (32 studies). Many of them provided fully integrated active lesson plans (24 studies) or sample activities to be integrated into lessons (13 studies).
• Included studies most often evaluated students in primary school settings (29 studies) or preschool settings (10 studies). One study evaluated interventions among students in grades K-8, and two studies included students in grades 6-9.
• U.S. studies that reported information about race and ethnicity included students who self-identified as Black or African American (median of 10.9% from 9 studies), Hispanic or Latino (median of 13.1% from 7 studies), and Asian (median of 4.6% from 4 studies). Two studies were conducted in schools where a high proportions of students qualified for free (89%) or reduced-price (94%) lunch.

Effectiveness Review

• Logic Model
• Text Description

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on the following published systematic review:

Norris E, van Steen T, Direito A, Stamatakis E. Physically active lessons in schools and their impact on physical activity, educational, health and cognition outcomes: a systematic review and meta-analysis. British Journal of Sports Medicine 2020;54:826-38.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

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Grieco LA, Jowers EM, Errisuriz VL, Bartholomew JB. Physically active vs. sedentary academic lessons: a dose response study for elementary student time on task. Preventive Medicine 2016; 89:98 103.

Have M, Nielsen JH, Ernst MT, Gejl AK, Fredens K, et al. Classroom-based physical activity improves children’s math achievement – A randomized controlled trial. PLoS One 2018;13:e0208787.

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Blog Post

Health.gov: Reaching Kids Where They Are Classroom-Based Interventions to Increase Physical Activity

Effectiveness Review

Refer to the existing systematic review for information about the search strategy:

Norris E, van Steen T, Direito A, Stamatakis E. Physically active lessons in schools and their impact on physical activity, educational, health and cognition outcomes: a systematic review and meta-analysis. British Journal of Sports Medicine 2020;54:826-38.

Centers for Disease Control and Prevention. Strategies for Classroom Physical Activity in Schools. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2018.

Norris E, van Steen T, Direito A, Stamatakis E. Physically active lessons in schools and their impact on physical activity, educational, health and cognition outcomes: a systematic review and meta-analysis. British Journal of Sports Medicine 2020;54:826-838

U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. Washington, DC: U.S. Department of Health and Human Services; 2018.

The following considerations for implementation are drawn from studies included in the existing evidence review, the broader literature, and expert opinion.

• Classroom-based physically active lessons may provide additional minutes of moderate-to-vigorous intensity physical activity to the school day, which could help students achieve the recommended 60 minutes of daily physical activity.
• Interventions should be used in addition to, not instead of, other school programs and policies to promote physical activity among students. These may include recess breaks and the following CPSTF-recommended interventions:
  • Interventions to increase active travel to school (2016)
  • Enhanced school-based physical education (2013)
  • Combined nutrition and physical activity interventions in schools (2018)
• CPSTF recommendations support the priorities of CDC’s Healthy Schools Guidance and Comprehensive School Physical Activity Program Framework. CDC provides the following program and intervention guidance:
  • Increasing Physical Education and Physical Activity: A Framework for Schools (2017)
  • Strategies for Classroom Physical Activity in Schools (2018)
• Most of the included studies evaluated interventions implemented by teachers. The interventions provided training for teachers, and most also provided resources such as integrated lesson plans, and videos or web links to classroom appropriate exercises and dance routines.
• Investigators in included studies noted several advantages of physically active lesson interventions including retention of classroom time for instruction, teacher flexibility to fit active lessons into the classroom schedule, and modest resource requirements. CPSTF notes that scalability may depend on development of, or access to, integrated lessons and activities that support daily or regular use.
• Advantages of classroom-based physical activity break interventions include the following:
  • Retention of classroom time for educational instruction
  • Teacher flexibility to fit breaks into the classroom schedule
  • Low resource requirements
  • Scalability
• Identified factors related to implementation and sustained use of physically activity lesson interventions include:
  • Teacher time required to integrate activity into lesson plans on a daily or regular basis in the absence of packaged active lessons
  • Support that teachers receive from school administrators
  • Level of buy-in and comfort level from the school system
  • Resources, time, and spaces available
  • Goals of individual classes or courses
• Several publicly available resources provide implementation guidance:
  • Classroom Energizers (Eat Smart Move More) is a resource guide from North Carolina public schools that instructs on classroom-based physical activity integrated with academic concepts.
  • Move for Thought is an integrated physical activity strategy for learning in primary school classrooms.
  • Active Academics offers classroom teachers practical physical activity ideas that can be integrated into regular classroom content areas.
  • Springboard to Active Schools provides professional development, technical assistance, and tools and resources for promoting physical activity in the classroom.
  • Active Schools provides information on implementing physical activity in the classroom, including links to activity ideas and webinars and trainings for classroom teachers.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Increase the proportion of adolescents who do enough aerobic physical activity — PA-06
• Increase the proportion of children who do enough aerobic physical activity — PA-09