Effects of Physically Active Lessons on Movement Behaviors, Cognitive, and Academic Performance in Elementary Schoolchildren: ERGUER/Aracaju Project

in Journal of Physical Activity and Health

Background: To evaluate the effects of the introduction of physically active lessons on movement behaviors, cognitive, and academic performance in schoolchildren. Methods: This was a cluster-controlled trial. A total of 61 students from the second year of elementary school in a public school in Brazil made up 2 intervention classes (n = 34) with the introduction of physically active lessons and 2 control classes (n = 27). Sedentary behavior, physical activity, cognitive, and academic performance were evaluated in 3 moments, which were compared using models of generalized estimating equations. Results: The intervention was effective for reducing the standing time between the baseline and 3 months while increasing the walking time between baseline and 3 months and baseline and 9 months. There was a reduction in time in stationary activities and increased time in light physical activities between all moments. The intervention group increased their performance in the go/no go test, showing a smaller number of errors between the baseline and 3 months and baseline and 9 months, and a reduction in the test time between baseline and 3 months. No impact on students’ academic performance was observed. Conclusion: Physically active lessons improve movement behaviors and cognitive functions among elementary schoolchildren.

A high prevalence of sedentary behavior in children and adolescents has been identified around the world,1 including developing countries. A systematic review of 205 studies conducted with schoolchildren in Brazil reveals that less than half the young people met the recommendations of up to 2 hours of television a day.2 Sedentary behavior has been considered a risk factor for death from all causes and chronic noncommunicable diseases, regardless of the level of physical activity.3 Thus, international guidelines recommend limiting the time spent on sedentary behaviors to preserve the physical and mental health of children and adolescents,4,5 since high prevalence in the age group between 5 and 17 years are associated with worse body composition, cardiometabolic risk, antisocial conduct, low physical fitness, and low self-esteem.6

In this respect, the school environment has attracted interventions aimed at ensuring a reduction of sedentary behavior for being a place where children spend most of their time sitting, especially within classrooms. In Brazil, for instance, 64% of the daily school time for children is spent in sedentary behavior.7 On this account, specific frameworks to support school interventions for reducing sedentary behaviors have been developed and implemented in different parts of the world, mainly in developed countries.8,9 Among the types of intervention, physically active lessons have received special attention. These are characterized by incorporating physical activities into the regular curriculum for teaching subjects, stimulating learning without compromising class time.10,11

In addition to their potential to reduce sitting time, results of various studies also suggest that physically active lessons can improve on-task behavior during classes12 and academic performance.13 Norris et al 14 found, in a meta-analysis with data from 37 controlled clinical trials with primary or elementary children, significant improvements in lesson-time educational outcomes produced by physically active lessons. Improvements in other variables related to physical activity were also observed. Given the small number of studies with cognitive variables, the effects of physically active lessons on these variables are still inconclusive, and further studies are needed.14,15

However, besides the fact that most of the evidence from interventions in schools comes from developed countries where the school reality is different from countries like Brazil, research with experimental designs that identify if the effects of school interventions on indicators of physical activity and cognitive performance could be conclusive is still needed.15 Until now, especially scientific long-term studies on this subject are lacking. In addition, the results of interventions aimed at changing behaviors can be difficult to identify, especially if the assessment tools do not provide the necessary sensitivity to detect these possible changes.15 Jones et al16 observed that only 11 of 57 intervention studies to reduce sedentary behavior and increase physical activity included a measure of sitting time. In this sense, it is still necessary to observe through device-based measures the effectiveness of physically active lessons on sedentary behavior during school time.

Thus, we evaluated the effects of the introduction of physically active lessons in the classroom on movement behaviors (sedentary behavior and physical activity), cognitive functions, and academic performance in Brazilian elementary schoolchildren.

Methods

Participants and Study Design

This was a cluster-controlled trial with the introduction of physically active lessons in the classroom for 9 months. The sample was composed of 61 children from 4 classes in the second year of elementary school from a school in the municipal public school system in Aracaju, Sergipe (Northeast Brazil), selected for convenience. After the initial evaluation, 2 classes performed the intervention with physically active lessons, and the 2 other classes constituted the control group (traditional pedagogy—following the activities of the guide book, which students usually perform sitting at their desk and without incorporating any additional physical activity). Two additional evaluations were performed after 3 and 9 months of intervention (Figure 1). All children regularly enrolled in the 4 classes were invited to participate, but only those with authorization from parents or guardians by signing the term of responsibility were included. The study was approved by the Human Research Ethics Committee, Federal University of Sergipe (CAAE 86398418.0.0000.5546/Opinion Number: 2.587.676).

Figure 1
Figure 1

—Flow of participants.

Citation: Journal of Physical Activity and Health 18, 7; 10.1123/jpah.2020-0604

Intervention

The intervention procedures are described following the Behavior Change Consortium guidelines.17

Design

The intervention began immediately after the initial assessment, which took place near the beginning of the 2018 school year (April 2018), was interrupted during school holidays (September 2018), and finished in January 2019 when the school year ended. The intervention consisted of the introduction of physically active lessons, carried out at least 3 times a week, 15 minutes per day, integrating movement with pedagogical content of the traditional subjects worked in the classroom (Portuguese, mathematics, history, geography, science, arts, and social studies). Physically active lessons were performed with the students standing, including body movements, for instance, and asking for the student to try to form, together with other students, a letter or a number with their bodies; perform board games and assemble puzzles in a standing position; perform choreography with music (illustrated examples of physically active lessons in Supplementary Figures 1 and 2 [available online]).

Delivery

In Brazil, in the early grades of elementary school, the classroom teacher is responsible for conducting all traditional subjects, except Physical Education. Therefore, 4 teachers participated in our study, 2 from the control group and 2 from the intervention group, who were responsible for carrying out the activities. All children regularly enrolled in the 2 intervention classes participated in the physically active lessons, as they were part of the teachers’ pedagogical strategy. However, only children with authorization from parents or guardians were evaluated. In the control classes, no activity was performed with physically active lessons and only children with authorization from parents or guardians were evaluated.

Training Providers

Classes are planned weekly according to the content of their curricular unit, which follows the guidebook and is the same between classes in the same series from the same education network. As teachers have the flexibility to adapt the content to the class level, starting from the object of knowledge with a focus on the skills that the students need to enhance, the physically active lessons should be linked to the content, and it was necessary to make the choice of the most appropriate activities for each class more flexible. For the development of these activities, the teachers could count on the continued commitment and support of a team of professionals from the Department of Education of the local university. The teachers of the intervention classes also started to attend weekly meetings to discuss the project implementation with the research team, sharing information about the activities performed. In order to avoid the contamination effect, specific information about the study and the intervention itself was only provided to the teachers of the intervention classes, who were advised not to share any information or material with teachers of the control classes.

Delivery of Treatment

In weekly meetings with the researchers, the teachers of the intervention classes gave feedback on the activities carried out and perceptions about the students’ motivation. In addition, student adherence to activities was observed by the intervention teachers themselves.

Instruments

Anthropometric measurements of body mass (in kilograms) and height (in meters) were collected at the school, using a WISO® portable scale (Crivitta Diagnóstica Ltda, São José-SC, Brazil) and Sanny® stadiometer (American Medical do Brasil Ltda, São Bernardo do Campo-SP, Brazil), with the children barefoot, in an orthostatic position, and with feet together (height). The body mass index was calculated from the results of these measures.

For movement behaviors, which are behaviors presented by the individual over 24 hours and are divided into sleep (in lying, reclining, or sitting positions), sedentary behavior (≤1.5 metabolic equivalents in lying, reclining, or sitting positions), and physical activity (>1.5 metabolic equivalents in standing, lying, reclining, sitting or other positions, and vigorous, moderate, or light intensities),18 we assessed sedentary behavior and physical activity during school hours through device-based measures.

The evaluation of sitting, standing, and walking time was performed using ActivPAL inclinometers (PAL Technologies Ltd, Glasgow, United Kingdom), validated for assessing posture and movement in children, including in classroom settings.19,20 The devices were programmed using ActivPAL software (version 7.2.38; PAL Technologies Ltd) to start the collection immediately after programming (with the time of 11 AM later adopted as the cut-off point for the closure of the collection), considering epochs of 15 seconds. The inclinometers fixed by tape on the anterior middle part of the child’s right thigh were placed at the beginning of the school shift and removed at the end of the shift (between 7 AM and 11 AM).

Physical activity was evaluated using ActiGraph accelerometers (model GT3X; ActiGraph, Pensacola, FL), validated for the assessment of physical activity levels in children.21,22 The devices were programmed using ActiLife software (version 6.8.1; ActiGraph) to start data collection at 7 AM and end at 11 AM, considering epochs of 1 second. The accelerometers were fixed on the right side of the body at the height of the iliac crest, using an elastic belt around the waist. The raw data of each child were collected and later reduced, considering the criteria of Choi et al23 for validating the time of use (with 20 min as a minimum period of consecutive zeros, windows of 5 min, and 1 min of peak tolerance counts) and the cutoff points of Evenson et al22 for categorizing physical activity levels. Each child wore the 2 devices for 4 days a week, consecutive or not, with data from at least 1 day being considered valid. The mean of all days of use was utilized to characterize each indicator in minutes, proportional to the time of use of the device.

To evaluate cognitive performance, 3 different computer-assisted tasks were selected following the 3 criteria: (1) their previous utilization with children of similar age of our sample,2426 (2) their availability on well-known repositories (PsyToolkit),27,28 and (3) their previous utilization in studies which evaluated the effects of physical activity over cognitive performance2931 and also because the selected tasks were easy to use by children of the age and socioeconomic conditions of our sample.

The executive functions evaluated were the following: (1) Inhibitory control uses the go/no go32 test, a well-known and widely used task to evaluate different developed conditions,33 which consists of the graphic presentation of various figures in the form of traffic lights where the colors green and red are randomly alternated (When the figure with the green traffic light appears, the child should press a computer key. When the red traffic light appears, the child should wait for the figure to change without pressing any key); (2) selective attention uses the visual search34 test, another well-known task,29 which consists in a set of the letter “T” which are present randomly distributed on the screen with different colors and some of them flipped (The child is instructed to press a computer key whenever at least a letter T appears in red and in its regular upright position. In any other case, the child must wait for the figure to change without pressing any key. This test studies selective attention among reaction time, inhibitory control, working memory, visual discrimination, oculomotor control, and object constancy); and (3) cognitive flexibility uses the mental rotation,35 another well-known task used to evaluated working memory and mental workload,36 a task whose objective is to find which stimulus matches another stimulus using mental rotation (The child is instructed to show the evaluator which of the 2 comparison stimuli matches with the sample one. This test also evaluates visual discrimination and spatial reasoning). The tests were translated from computerized versions available for PsyToolkit.27, 28

The children performed the tests in the order as previously described/outlined. For each test, 2 attempts were made in sequence—the first for familiarization of the student with this instrument and the second for evaluation. The tests were supervised by a blinded assessor. The total number of correct answers and the time spent to perform the tests (in milliseconds) were considered as indicators, except in the mental rotation test, as some children had difficulty handling the mouse to point to the figures, which compromised time, and for this reason, this indicator was excluded from the analyses.

Academic performance was evaluated through the mean grades obtained in the disciplines of Portuguese, mathematics, history, geography, science, arts, and social studies in tests designed, applied, and corrected individually by the teachers of each class. During the school year, each student performed 6 assessments in each subject. The first 2 grades were grouped, as well as the third and fourth grades, and the fifth and sixth grades, and the mean values were used in the comparison of the 3 evaluation moments with all subjects together.

Statistical Analyses

The data were analyzed in IBM SPSS Statistics for Windows (version 25.0; IBM Corp, Armonk, NY) by which descriptive analyses (mean, standard deviation, absolute, and relative frequencies) were performed to characterize the sample and to describe the variables in the baseline. The normality of the data was assessed using the Kolmogorov–Smirnov test. To compare the measures between the control and intervention groups in the baseline, a t test was performed for independent samples or the Mann–Whitney U, according to the data distribution, and were used a Bonferroni adjusted alpha to control the family-wise error rate. For comparison of categorical data (sex), the chi-square test was performed. Movement behaviors were analyzed with the percentage values in relation to the time of use of each device. Children with data from at least 1 moment of evaluation were included in the analyses. For the comparison of the 3 evaluation moments (baseline, 3 mo, and 9 mo) between the 2 groups (intervention and control), crude and adjusted models of generalized estimating equations were performed, with Bonferroni post hoc to identify the differences between the groups and considering a level of significance less than .05. In the adjusted models, we considered as covariate the baseline values (when groups were different), however, the covariates were maintained in the model only if they were significant (more details about the choice of covariates is provided in Supplementary Figure 3 [available online]). Cramer V equation was used to calculate the effect size, considering as small effect values up to 0.07, medium values above 0.07 and up to 0.21, and large values from 0.35.

Results

Participants

Table 1 presents the characteristics of the sample at baseline, as well as the comparison between groups. The control group presented an initial greater sitting time, while the time of using accelerometers and inclinometers and standing time was initially higher in the intervention group.

Table 1

Sample Characteristics and Comparison Between Intervention and Control Groups at Baseline

CharacteristicsAll

(N = 61)
Intervention

(n = 34)
Control

(n = 27)
P value
Sex    
 Female, %27 (44.3%)13 (38.2%)14 (51.9%).421
 Male, %34 (55.7%)21 (61.8%)13 (48.1%)
Age, y7.8 (0.6)7.7 (0.5)8.0 (0.7).010a
Weight, kg26.3 (5.1)25.3 (3.9)27.6 (6.2).100
Stature, m1.26 (0.06)1.25 (0.04)1.27 (0.07).380
BMI, kg/m216.5 (2.5)16.0 (2.1)17.0 (2.9).228a
Days of use    
 Accelerometers3.7 (0.7)3.6 (0.8)3.9 (0.4).057a
 Inclinometers3.7 (0.7)3.6 (0.8)3.9 (0.3).172a
Time of use    
 Accelerometers, min218.2 (9.9)222.0 (10.2)213.5 (7.2)≤.001
 Inclinometers, min204.9 (7.3)207.7 (7.9)201.4 (4.4)≤.001
Inclinometers data    
 Sitting time, %58.2 (14.1)49.4 (11.2)69.3 (8.3)≤.001
 Standing time, %28.0 (11.5)35.5 (9.0)18.7 (6.1)≤.001
 Walking time, %13.8 (4.2)15.1 (3.9)12.0 (3.9).003
Accelerometers data    
 Stationary time, %81.3 (5.5)80.4 (5.7)82.4 (5.3).166
 Light PA time, %14.0 (4.6)14.5 (4.7)13.2 (4.6).234a
 Moderate to vigorous PA time (%)4.7 (1.8)5.0 (2.0)4.3 (1.5).186a
Cognitive tests    
 Go/no go hits24.0 (1.3)23.6 (1.5)24.4 (0.9).016a
 Go/no go time, ms819.7

(215.7)
869.9

(199.7)
756.5 (222.1).040
 Visual search hits7.4 (1.8)7.1 (1.7)7.8 (1.8).159a
 Visual search time, ms3349.0 (1041.9)3489.4 (1113.1)3172.2 (935.0).241
 Mental rotation hits12.4 (1.5)12.1 (1.4)12.9 (1.6).070a
Academic performance (note)6.5 (1.6)6.2 (1.9)7.0 (1.1).036

Abbreviations: BMI, body mass index; PA, physical activity. Note: Values are presented as average (SD), except female and male—presented as frequency (%). %: proportional to the time of use. Bold indicates significance (P < .0025).

aVariables whose group average were compared using Mann–Whitney U test because they did not show normal distribution.

Intervention Analysis

Figure 2 shows the changes in the means of the variables evaluated in the 3 moments of evaluation, both in the control and intervention groups. Table 2 presents the differences in movement behaviors, cognitive and academic performance during the intervention in both groups, as well as the effect’s size.

Figure 2
Figure 2

—Changes in the means between 3 moments of evaluation in movement behaviors, cognitive, and academic outcomes, in intervention (lighter line, with triangles) and control (darker line with circles) groups. PA = physical activity. *P < .05 versus moments in intervention group; †P < .05 intervention versus control within the same moment; P < .05 versus moments in control group.

Citation: Journal of Physical Activity and Health 18, 7; 10.1123/jpah.2020-0604

Table 2

Differences Between Moments of Evaluation in Movement Behaviors, Cognitive, and Academic Performance in Intervention and Control Groups

Baseline vs 3 mo3 mo vs 9 moBaseline vs 9 mo
Variables/groupsInterventionControlInterventionControlInterventionControlGroup vs timeEffect size
Inclinometers data        
 Sitting time,a %1.7

(−2.5 to 6.0)
−1.7

(−5.2 to 1.8)
−2.2

(−6.0 to 1.7)
3.0

(−1.5 to 7.5)
−0.4

(−4.4 to 3.5)
1.3

(−3.1 to 5.7)
0.0940.39
 Standing time,a %−4.1*,**

(−8.1 to −0.06)
1.5

(−1.4 to 4.4)
0.7

(−2.8 to 4.2)
−3.3

(−7.1 to 0.4)
−3.4

(−7.2 to 0.4)
−1.8

(−4.8 to 1.1)
0.0230.50
 Walking time, %2.3*,**

(0.4 to 4.3)
0.2

(−1.5 to 1.9)
1.5**

(−0.3 to 3.4)
0.2

(−1.7 to 2.2)
3.9*,**

(2.1 to 5.6)
0.4

(−1.7 to 2.5)
0.0090.56
Accelerometers data        
 Stationary time, %−3.8*

(−6.6 to −0.9)
−1.4

(−4.1 to 1.2)
−8.8*,**

(−11.2 to −6.4)
−5.5*

(−8.3 to −2.7)
−12.6*,**

(−15.9 to −9.2)
−7.0*

(−9.8 to −4.0)
0.0080.56
 Light PA time, %2.7*

(0.4 to 4.9)
0.8

(−1.6 to 3.1)
6.8*,**

(5.0 to 8.5)
4.2*

(1.9 to 6.4)
9.4*,**

(6.9 to 12.0)
5.0*

(2.8 to 7.1)
0.0040.60
 Moderate to vigorous PA time,bcd %1.1

(−0.05 to 2.2)
0.6

(0.01 to 1.3)
2.0

(1.1 to 2.9)
1.3

(0.08 to 2.5)
3.1

(1.9 to 4.3)
1.9

(0.7 to 3.2)
0.2670.29
Cognitive tests        
 Go/no go hits0.8*,**

(0.2 to 1.3)
0.04

(−0.5 to 0.6)
0.05

(−0.4 to 0.5)
−0.2

(−0.9 to 0.5)
0.8*

(0.1 to 1.5)
−0.2

(−0.8 to 0.5)
0.0290.48
 Go/no go time, ms−154.4*,**

(−236.6 to −72.2)
23.1

(−91.8 to 138.0)
59.0

(−59.0 to 177.0)
36.0

(−115.4 to 187.3)
−95.5

(−224.2 to 33.2)
59.0

(−64.1 to 182.2)
0.0050.59
 Visual search hits0.1

(−0.9 to 1.2)
0.3

(−1.0 to 1.7)
0.4

(−0.6 to 1.4)
−0.9

(−2.2 to 0.4)
0.5

(−0.4 to 1.5)
−0.6

(−2.0 to 0.8)
0.1180.37
 Visual searchb,c time, ms−544.7

(−978.2 to −111.2)
−390.5

(−862.7 to 81.6)
−62.6

(−371.8 to 246.5)
−113.9

(−584.5 to 356.7)
−607.3

(−1021.5 to −193.2)
−504.4

(−854.5 to −154.4)
0.8360.11
 Mental rotationb,d hits−0.8

(−1.7 to 0.2)
−1.6

(−2.3 to −1.0)
1.3

(0.4 to 2.2)
1.7

(1.1 to 2.3)
0.6

(−0.3 to 1.4)
0.1

(−0.7 to 0.8)
0.2130.32
Academic performance−0.2**

(−0.5 to 0.1)
0.2

(−0.02 to 0.4)
0.2**

(−0.2 to 0.6)
0.3

(−0.1 to 0.7)
−0.03**

(−0.4 to 0.3)
0.5*

(0.03 to 0.9)
0.0150.52

Abbreviation: PA, physical activity. Note: Values of the differences between the moments described in absolute values with 95% confidence interval. Effect sizes for Cramer’s V.

aAdjusted by baseline value. bP < .05 adding the 2 groups between baseline and 3 months. cP < .05 adding the 2 groups between baseline and 9 months. dP < .05 adding the 2 groups between 3 months and 9 months.

*P < .05 versus moments. **P < .05 intervention versus control within the same moment.

The sitting time, despite demonstrating reductions between 3 and 9 months and between the baseline and 9 months, did not show a significant difference in the group versus time interaction. Both standing and walking time presented significant group versus time interaction, with differences in the intervention group, which presented reduced standing time between baseline and 3 months and increased walking time between baseline and 3 months and baseline and 9 months.

Among the accelerometer variables, both stationary and light physical activity demonstrated significant group versus time interaction, while moderate to vigorous physical activity only demonstrated differences between the moments. The stationary time presented reductions in both groups. In the intervention group differences were found between all moments, and in the control group there were differences between 3 and 9 months and baseline and 9 months. However, at 3 and 9 months, the differences between groups were significant (P = .016 and P < .001, respectively). Regarding light physical activity, increases were observed in both groups. In the intervention group, differences were observed between all moments, and in the control group, differences were found between 3 and 9 months and baseline and 9 months. There were also differences between the groups at 3 and 9 months (P = .022 and P < .001, respectively).

Regarding the executive functions tests, increases in the number of correct answers were found in the intervention group for the go/no go test between baseline and 3 months and baseline and 9 months, with group versus time interactions (baseline to 3 mo: P = .004; baseline to 9 mo: P = .09). In addition, a reduction in the test time between baseline and 3 months was observed. The other executive functions tests did not present a significant difference between groups. Academic performance presented a significant interaction between groups versus time, with the differences identified only in the control group with increases between 3 and 9 months.

About the effect size, only the variables moderate to vigorous physical activity time, visual search time, and mental rotation hits the values were considered medium. In all other variables, the values were large. Only in the variables in which the group versus time interaction was significant ranged from .48 in the go/no go hits to .60 in light physical activity time.

Discussion

Our results demonstrated that the introduction of physically active lessons was able to reduce the time spent by children on stationary activities and that even with a reduced sample size, it was possible to obtain reasonable values of effect size for the group comparisons. Physically active lessons also contributed to the improvement in some executive functions, such as the inhibition of responses (go/no go test), even without effects on academic performance by now. To our knowledge, this study is the first to assess the effects of the introduction of physically active lessons in elementary school classrooms, in a school belonging to a region of low socioeconomic status, in a middle-income country, using objective measures for evaluating posture and physical activity, in addition to assessing executive functions and academic performance.

Inclinometers data demonstrated that the intervention was effective in increasing the time walking in the intervention group at the 2 evaluated moments. However, this increase could not be explained by the reduction in sitting time because, despite the decreases observed in the intervention group, these were not significant. It was found that the substitution of behavior was due to the standing time, as a reduction was observed in the first 3 months of intervention. It is worth mentioning that the students in the intervention classes already presented less time sitting in the classroom at the baseline (49.4% vs 69.3%). Furthermore, these results suggest that the intervention proposed by the teachers consists of activities whose characteristics seem to stimulate the students to stand up and to do light physical activities. This way, these learning activities may have contributed more to the reduction in stationary activities (such as sitting still or standing quietly) than reduction in sitting time itself.

Other studies have also used ActivPAL to assess the effectiveness of interventions to decrease sitting time in elementary school students. While some studies demonstrated significant differences in the reduction in sitting time, concomitant to the increase in standing and walking time,37,38 another study corroborates our findings, demonstrating positive effects of the intervention even without differences in this variable.39 However, the comparison with these studies is limited by the large variety in sample size and intervention time and because the other studies mainly used standing desks as a form of intervention.

In relation to the accelerometer data, stationary time decreased in both the intervention group and in the control group, where there may have been a contamination effect, as they were from the same school. Despite this, the differences between the groups at evaluation moments 3 and 9 months indicate that the magnitude of the changes was greater in the intervention group, demonstrating the positive effect of introducing physically active lessons on this variable. In addition, there was an increase in light physical activity but no change in moderate to vigorous physical activity. These results were expected since the intervention teachers were instructed to replace the children’s sitting time with activities that could be performed inside the classroom itself. Having in mind the space limitation and the infrastructure of the classroom might have led the teachers to choose learning activities that provoked only light physical activity.

The introduction of active intervals in the classroom or physically active lessons can be efficient to replace sedentary time with physical activity; however, the intensity will be light or moderate to vigorous depending on the design, duration, and intensity of the interventions, which vary greatly between subjects.8 Thus, our findings corroborate previous studies, which demonstrated the effectiveness of classroom interventions to increase the level of general physical activity10 but without changes in the level of moderate to vigorous physical activity.15

However, most studies use only the accelerometer as a device for assessing sedentary behavior,14,16 and there are some limitations in the interpretation of these data. Despite presenting acceptable reliability and validity for physical activity in pediatric populations,40,41 accelerometers overestimate sedentary behavior among school time and longitudinal data when compared to inclinometers because of the limitation of detecting postures.42 On the other hand, inclinometers enabled more accurate identification of total sitting time in the school context,19 but they have not been well validated for assessment of various intensities of physical activity in children. In this way, our findings advance with complementary information from both devices of physical activity and sedentary behavior.

Among the cognitive performance, we observed positive effects of the intervention only in the go/no go test, both in relation to the increase in the number of correct answers, as well as the reduction in the time to perform the test. The go/no go paradigm is used to evaluate inhibitory response,32 an important executive function related to self-regulating behavior, and to the ability to suspend an unwanted response.43 Moreover, inhibition is also related to another relevant executive function, working memory, through which the individual is able to mentally retain information to work with later.44 Other executive functions may have been stimulated, but due to the type of tests used, based on psychological theories—which evaluate constructs from different parts of the brain—and not on imaging tests, they could not be measured individually.45

The mechanisms by which physical activity improves cognitive performance are explained by neurobiological, psychosocial, and behavioral pathways.46 One of the main mechanisms theorizes that the energy metabolism generated by physical activity influences the brain-derived neurotrophic factor system, which in turn is responsible for neuroplasticity in the hippocampus, the brain region responsible for learning and memory.47 However, the evidence is more robust in relation to the benefits of moderate to vigorous physical activity, more specifically aerobic activities, requiring further studies that associate the improvement in cognitive function with the increase in light physical activity or reduction in sedentary behavior.45 In the case of physically active classes, these effects could also be associated with further mechanisms/mediators. When the teacher asks the children to get up and move around the classroom, this is because the movement is part of the pedagogical strategy, which is why we consider that the effect of these activities could be small in terms of the physical movement but not in terms of cognition.

The improvement in cognitive function also seems to be associated with better academic performance.44 However, our results, despite showing a beneficial effect of the intervention on inhibition and working memory, had no effect on students’ academic performance so far. One of the reasons for this result may have been the use of tests that were designed, applied, and corrected by the teachers of each class, according to personal criteria, and the nonuse of standardized tests. Although it is widely demonstrated that academic performance has a positive relationship with physical activity, including thorough physically active lessons in the classroom,10,48 review studies8,15 concluded that the evidence is weak or inconclusive, and that the positive effects of an intervention on students’ academic performance can only be demonstrated if the tests are progressive.

The results identified in the present study showed the potential effects of behavioral changes over a period of 9 months of physically active lessons. The minimum time required to implement sustainable school-based interventions has been discussed, and there is still no consensus in the literature. While a minimum period of 18 weeks has already been indicated as necessary to produce long-term behavioral changes,49 according to Fullan et al,50 the minimum time for behavioral change to be incorporated into the school routine can vary between 3 and 5 years. However, strategies that provide teachers with the tools for organizing and systematizing activities seem to be effective for continuity and long-term sustainability.51 In the ERGUER/Aracaju project, we involve teachers in the construction and organization of activities, and throughout the school year, they participate in conversations with researchers about the implementation of activities. However, to verify the sustainability of the effects found, the intervention is going to be continued, and further evaluations will be carried out.

Our study presents some limitations that should be taken into account. First, the lack of standardized academic performance tests and the adaptation of cognitive tests to the computer may have compromised the accuracy of the measurements. Regarding the cognitive tests, it is important to emphasize that we do not use validate battery tests because in Brazil there are few validated tests for neuropsychological evaluation and their use in our research could invalidate future clinical evaluation that for any reasons the children who participated in our research may need to conduct. In this sense, we opted for tasks that were not part of batteries but that are widely used in research with similar objectives and sample characteristics. Second, the lack of class randomization may have created a bias in the selection of teachers and students. Third, there was no control over the activities that students performed outside of school and in physical education classes (which included both practical and theoretical classes). Fourth, due to the absence of recess at school (only snack break), students may have demonstrated a different pattern of behavior in relation to schools that have an active break. In addition, in relation to the intervention fidelity, stronger control of the dose of the activities delivered was not possible, given that the observation of the classes would be invasive and could affect the behavior of the teachers and children. However, in addition to the training and materials provided to the teachers of the intervention classes, they were followed weekly and provided information about the activities delivered.

Conclusion

We conclude that the introduction of physically active lessons in the classroom reduces stationary behaviors, increasing light physical activity and improving some domains of cognitive function. These findings extend the current literature, which is based on developed countries, to different educational systems and low-income contexts and encourage the creation of political initiatives to incorporate physically active classes into elementary education in these contexts.

Acknowledgments

The authors gratefully acknowledge the contribution of all who participated, especially school principal Mauro Santos, coordinator Betânia, and the teachers Valdeci, Wedyne, Amanda, and Ana Paula, as well as the Municipal Secretariat of Education of Aracaju. The authors thank everyone who helped with data collection, especially Jaqueline Rodrigues, Larissa Gandarela, Graziele Santana, Elondark Machado, Winston Almeida, Pedro Divino, Marcos Melo, Beatriz Nóia, and Themyres Gabriele. The authors also would like to thank the professors Dr Roberto Jerônimo, Dr Thayse Gomes, and Dr David Ohara for their collaboration in the manuscript. The authors thank the International Society of Behavioral Nutrition and Physical Activity for supporting the wider project through the Pioneer Scholarship Grant. The authors also thank the Laboratory of the Study and Research Group in Metabolism, Nutrition, and Exercise (GEPEMENE) from Londrina State University for lending the devices (accelerometers and inclinometers) to this study. This work was supported by the National Council of Scientific and Technological Development (CNPq/Brazil) (Process 423706/2018-7).

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Barboza and E.C.M. Silva are with the Postgraduate Program in Physical Education, Federal University of Sergipe, Sao Cristovao, Brazil. Schmitz is with the Department of Education, Federal University of Sergipe, Sao Cristovao, Brazil. Tejada is with the Department of Psychology, Federal University of Sergipe, Sao Cristovao, Brazil. Oliveira is with the Postgraduate Program in Education, Tiradentes University (UNIT), Aracaju, Brazil. Sardinha is with the Exercise and Health Laboratory, CIPER, Faculdade de Motricidade Humana, Universidade de Lisboa, Lisboa, Portugal. D.R. Silva is with the Department of Physical Education, Federal University of Sergipe, Sao Cristovao, Brazil.

Barboza (leite.lu@gmail.com) is corresponding author.
  • View in gallery

    —Flow of participants.

  • View in gallery

    —Changes in the means between 3 moments of evaluation in movement behaviors, cognitive, and academic outcomes, in intervention (lighter line, with triangles) and control (darker line with circles) groups. PA = physical activity. *P < .05 versus moments in intervention group; †P < .05 intervention versus control within the same moment; P < .05 versus moments in control group.

  • 1.

    LeBlanc AG, Katzmarzyk PT, Barreira TV, et al. . ISCOLE Research Group. Correlates of total sedentary time and screen time in 9-11 year-old children around the world: the international study of childhood obesity, lifestyle and the environment. PLoS One. 2015;10(6):e0129622. PubMed ID: 26068231 doi:10.1371/journal.pone.0129622

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Silva KS da, Bandeira A da S, Santos PC dos, Malheiros LEA, Sousa ACFC de, Filho VCB. Systematic review of childhood and adolescence sedentary behavior: analysis of the Report Card Brazil 2018. Braz. J. Kinanthrop. Hum. Perform. 2018;20(4):415445. doi:10.5007/1980-0037.2018v20n4p415

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3.

    Stamatakis E, Ekelund U, Ding D, Hamer M, Bauman AE, Lee I-M. Is the time right for quantitative public health guidelines on sitting? A narrative review of sedentary behaviour research paradigms and findings. Br J Sports Med. 2019;53(6):377382. PubMed ID: 29891615 doi:10.1136/bjsports-2018-099131

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    American Academy of Pediatrics. Committee on Public Education. American Academy of Pediatrics: children, adolescents, and television. Pediatrics. 2001;107(2):423426.

    • Search Google Scholar
    • Export Citation
  • 5.

    World Health Organization. Guidelines on Physical Activity, Sedentary Behaviour and Sleep for Children under 5 Years of Age. Geneva: World Health Organization; 2019. http://www.ncbi.nlm.nih.gov/books/NBK541170/. Accessed November 30, 2019.

    • Search Google Scholar
    • Export Citation
  • 6.

    Carson V, Hunter S, Kuzik N, et al. . Systematic review of sedentary behaviour and health indicators in school-aged children and youth: an update. Appl. Physiol. Nutr. Metab.. 2016;41(6 suppl)(3):S240S265. PubMed ID: 27306432 doi:10.1139/apnm-2015-0630

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    da Costa BGG, da Silva KS, George AM, de Assis MAA. Sedentary behavior during school-time: sociodemographic, weight status, physical education class, and school performance correlates in Brazilian schoolchildren. J Sci Med Sport. 2017;20(1):7074. PubMed ID: 27374756 doi:10.1016/j.jsams.2016.06.004

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8.

    Daly-Smith AJ, Zwolinsky S, McKenna J, Tomporowski PD, Defeyter MA, Manley A. Systematic review of acute physically active learning and classroom movement breaks on children’s physical activity, cognition, academic performance and classroom behaviour: understanding critical design features. BMJ Open Sport Exerc Med. 2018;4(1):e000341. PubMed ID: 29629186 doi:10.1136/bmjsem-2018-000341

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Daly-Smith A, Quarmby T, Archbold VSJ, et al. . Using a multi-stakeholder experience-based design process to co-develop the Creating Active Schools Framework. Int J Behav Nutr Phyl Activ. 2020;17(1):13. doi:10.1186/s12966-020-0917-z

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Martin R, Murtagh EM. Effect of active lessons on physical activity, academic, and health outcomes: a systematic review. Res Q Exerc Sport. 2017;88(2):149168. PubMed ID: 28328311 doi:10.1080/02701367.2017.1294244

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Vazou S, Webster CA, Stewart G, et al. . A systematic review and qualitative synthesis resulting in a typology of elementary classroom movement integration interventions. Sports Med—Open. 2020;6(1):1. PubMed ID: 31907711 doi:10.1186/s40798-019-0218-8

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12.

    Norris E, Dunsmuir S, Duke-Williams O, Stamatakis E, Shelton N. Physically active lessons improve lesson activity and on-task behavior: a cluster-randomized controlled trial of the “virtual traveller” intervention. Health Educ Behav. 2018;45(6):945956. PubMed ID: 29562763 doi:10.1177/1090198118762106

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Bedard C, St John L, Bremer E, Graham JD, Cairney J. A systematic review and meta-analysis on the effects of physically active classrooms on educational and enjoyment outcomes in school age children. PLoS One. 2019;14(6):e0218633. PubMed ID: 31237913 doi:10.1371/journal.pone.0218633

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    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. Br J Sports Med. 2020;54(14):826838. PubMed ID: 31619381 doi:10.1136/bjsports-2018-100502

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