The context. Mississippi has consistently ranked near the top of the list of states with the highest rates of children who are overweight or obese, according to both the National Survey of Children's Health and the Centers for Disease Control and Prevention's Youth Risk Behavior Survey.
In 2007, the Mississippi Legislature passed the Mississippi Healthy Students Act in an attempt to reverse this trend. The act mandates 150 minutes per week of health education instruction and 150 minutes per week of activity-based instruction for students in grades K–8; and the equivalent of one-half credit of health education and one-half credit of physical education for students in grades 9–12.
Many considered the Healthy Students Act a significant step forward. But, questions remain: Are Mississippi schools, especially those in the poor, rural northwest section of the state known as the Mississippi Delta complying with the law? What are the obesity levels among adolescents in the Delta? How does the built environment of schools in that impoverished area affect the weight of children?
Abigail Gamble, who received her doctorate from the University of Mississippi in May 2011, wanted to learn the answers.
A childhood struggle with weight forges a path. Growing up on Long Beach Island along the New Jersey shore, Abigail Gamble was part of a sports-minded family. Even though she played softball, field hockey and basketball, she struggled with her weight. "I was definitely an overweight child," she says. "And that condition followed me through high school and into college."
In 1997, Gamble enrolled at Rowan University in Glassboro, N.J., majoring in both elementary education and American studies. "I wanted to follow my grandmother's footsteps and be a social studies teacher," she says. Through playing field hockey for the university, however, Gamble got her first taste of an intense and extensive exercise program. "I began to see results in my body and I began to feel good," she says. "It changed my outlook." Gamble served as a personal trainer and group fitness instructor at the campus recreation center. "I decided I wanted a career that would help people who were overweight and obese live a healthy life," she says. "My own struggles led me down that path."
After graduating from Rowan, Gamble enrolled at the University of Mississippi School of Applied Sciences where she began her graduate studies in health promotion and served as a fitness graduate assistant in the university's Department of Campus Recreation. In addition to her assistantship responsibilities, Gamble says she also taught yoga, Pilates and spin classes.
A mentor and a grant. Gamble's advisor at "Ole Miss" was Jeffrey Hallam, Ph.D., professor of health promotion and director of the Center of Health Behavior Research. Hallam told his students about an opportunity to write a grant proposal to the Ole Miss Parents Association for an initiative that would improve student life on campus. Gamble took the challenge and wrote a proposal for an indoor cycling program. "It was my first stab at writing a grant," she says. "We got the program, so it was my first taste at success." Hallam's role as Gamble's mentor expanded when he enlisted her as a research assistant for several studies, including two funded by a Robert Wood Johnson Foundation (RWJF) program, Active Living Research: Building the Evidence to Prevent Childhood Obesity and Support Active Communities (ID#'s 059456 and 063348). See the description of her study on the program's website. Also see the Program Results for more information on the program.
"The main thing we did in those studies was to better define activity-friendly environments in rural settings," she says. It was while assisting Hallam, Gamble says, that she decided to pursue a doctorate in the hope that a career in research would allow her to help a greater number of people. "I wanted to have an impact on the lives of people who are overweight or obese," she says, "but on a population level rather than an individual one."
Coming from a shore town in New Jersey, Gamble admits that the lightly populated expanse of the Delta region was something of a culture shock. "Think about standing on the beach and looking out at the ocean," she says. "You stand at the crossroads of two country routes and look out at a sea of green fields." Culture shock would give way to curiosity and a fondness for the Delta. She brought a camera along on her study and photographed the region.
Making the connection with RWJF: a research project and a doctoral dissertation. By the summer of 2009, Gamble had finished her course work and was considering topics for her doctoral dissertation. Prompted by her work with Hallam, Gamble was intrigued by how the built environment of schools affects physical activity and childhood obesity. Through her work on her mentor's Active Living Research studies, Gamble found out that the program includes a component that provides up to $25,000 to help young researchers complete their doctoral dissertations. This support increases the number of new investigators in the field of active living and it adds to the evidence base of knowledge. Gamble decided to apply.
In January 2010, she received an Active Living Research dissertation grant for her study, "The Role of Policy and the Built Environment on Children's In-School Physical Activity in the Mississippi Delta." She had three objectives:
- Describe state, district and school level policy regarding physical activity and the built environment of elementary schools in the Mississippi Delta.
- Examine the relationship between the built environment, physical activity and weight status in children ages 6 through 11 years in the Mississippi Delta.
- Describe physical activities undertaken during structured physical education and during recess in children ages 6 through 11 years in the Delta region.
Between November 2009 and February 2010, Gamble collected anthropometric data, including Body Mass Index (BMI), waist circumference and waist-to-height-ratio (WtHR), on 1,136 children in 11 schools in the Delta. Between January and May 2010, she observed and recorded the students' leisure and structured activities. She also measured the quantity and quality of amenities, features and incivilities of each school's recreational resources. (See the PARA, Physical Activity Resource Assessment Instrument for more information.) In addition, she conducted in-depth interviews with state, district and school personnel.
Through this study, Gamble hopes to more clearly define the role of the school built environment and school policies mandated by the Healthy Students Act on in-school physical activity of children in the Delta. With this information, she hopes that school administrators and program coordinators will be better equipped to identify key points for intervention.
Results. Gamble found that 47.1 percent of children ages 6 through 11 in the Delta are overweight or obese (which means a BMI greater than the 85th percentile for age and sex), with nearly 30 percent obese (BMI greater than the 95th percentile for age and sex). Some 109 children, most of them between ages 9 and 11, had body mass indexes of 30 or above, readings that are considered obese based on adult standards.
Measurements of children's WtHR indicated that a large number of them carried much of their excess weight around their abdomens. According to Gamble, students whose weight is concentrated in the abdominal area are at even higher risk for weight-related chronic diseases like diabetes and heart disease. "So, not only are they overweight or obese based on BMI standards," Gamble says, "but there is actually an imminent health risk because they're carrying most of their weight in their midsection."
Gamble concluded that the problem of childhood obesity in the Mississippi Delta was considerable. But she wanted to know more: Were the Delta schools implementing the Healthy Students Act? Did the built environment of the schools in the study have any impact on the problem?
Although support of the Healthy Students Act is nearly unanimous among parents, according to findings from an RWJF-funded study conducted by the Center for Mississippi Health Policy (Grant ID# 064636), less than half of the parents questioned in that study knew of any specific changes the policy brought to the schools.
Gamble found gaps in local staff understanding of the state mandates created by the Act. "The physical education instructors I interviewed didn't know what the Healthy Students Act was," she says. "School administrators in low-income districts face monetary, academic and spatial barriers that are difficult to overcome," Gamble adds. And, many administrators give priority to academic concerns over physical education or physical activity even though, she says, "There is evidence out there that says, if we provide kids with physical activity, it's not going to hinder their academic performance," Gamble says. "That information needs to be clearly conveyed to the administrators so they can take comfort in knowing that giving kids a 15 or 20 minute recess each day is not going to take away from their academic performance."
Finally, Gamble found that the built environment varied widely from school to school in the Delta. While there were a similar number of indoor and outdoor recreational resources present at each school, the size and capacity of each resource varied. In the poorer districts, some schools were in disrepair and had limited space. Two schools did not have a gymnasium and had to use a regular classroom for physical education; another had students from kindergarten through high school sharing the same gymnasium. A (relatively) wealthier district had ample indoor and outdoor space to accommodate recess and physical education opportunities.
Although prior studies suggest improving the quality of amenities and features of physical activity resources as a means to increase student's in-school physical activity, Gamble's findings are somewhat different: "It appears that children need a place to be active and the opportunity (through policy) to be active," she says.
Gamble observed that when the overweight children in her study have the opportunity to engage in unstructured moderate to vigorous physical activity (MVPA), they are among the most active of all the students. Gamble believes that the 150 minutes per week mandated by the Mississippi Healthy Students Act for physical activity in schools would go a long way in the battle against childhood obesity in the Delta. "If the [Mississippi] Healthy Students Act was habitually enforced," she says, "the children of my study would likely use the time to be active and subsequently experience the myriad of health benefits that regular exercise affords."
After receiving her doctorate, in May 2011, Gamble accepted a job with the Mississippi State Department of Health working for the Delta Health Collaborative on a five-year project examining cardiovascular disease in Delta residents that is funded by the Centers for Disease Control and Prevention.
RWJF perspective. RWJF's Board of Trustees authorized Active Living Research in July 2000 and re-authorized it in October 2007. Findings from research funded by the program are used to inform nutrition and physical activity policies and influence decisions regarding the design of the built environment. Active Living Research has increasingly focused on reversing the rise of childhood obesity, particularly in lower-income and racial/ethnic minority communities in which childhood obesity levels are highest.
Active Living Research teams are required to be transdisciplinary, involving investigators from multiple disciplines and backgrounds who work together across traditional disciplinary boundaries. Active Living Research investigators represent more than 20 different disciplines (e.g., public health, urban planning, architecture, behavioral science, exercise science, transportation, sociology, political science).
"In addition to building an evidence base to guide physical activity policy and community design, Active Living Research is developing a vibrant, new transdisciplinary field and diverse network of researchers," says C. Tracy Orleans, Ph.D., RWJF distinguished fellow and senior scientist.
"ALR [Active Living Research] has had a huge impact in terms of influence," says Celeste Torio, Ph.D., RWJF Research and Evaluation program officer and program officer for Active Living Research, "and not just with policy-makers but with research investigators as well. The research is very innovative and something policy-makers can use, it's not something you just put on the shelf and forget about."
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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