Nature Champions Healthcare providers prescribe the b enefits of Nature & Outdoor Activity

1. Nature ChampionsHealthcare providers prescribe the benefits of Nature & Outdoor Activity Physical and Mental Health Training for healthcare professionals Provided byGet Outdoors Florida! Coalition, Inc.

2. Nature Champions Sponsors • Tallahassee COPE Child Obesity Prevention Education -A community coalition to fight childhood obesity in Leon County • Funding provided by Florida Blue Foundation

3. “At the very moment the bond is breaking between the young and the natural world, a growing body of research links our mental, physical, and spiritual health directly to our association with nature – in positive ways.” Richard Louv Author of “Last Child in the Woods --Saving Our Children from Nature-Deficit Disorder”

4. Goal: This training will create Nature Champions among healthcare providers to connect children and families with nature for health benefits

5. Learning Objectives • Explain the evidence surrounding health and activity levels of children, particularly as they pertain to natural environments. • Explain the benefits of outdoor play on children’s physical and mental health. • Examine the role that natural environments have in improving outdoor physical activity for children. • Prescribe resources available to help your patients access the outdoors for health benefits.

6. The Challenge… • “Physical inactivity is the major public health issue in this country.” • “If we are going to survive as a nation, if we’re going to thrive as a nation, we really have to change that focus on sickness and illness to one of health, prevention and wellness.” Acting US Surgeon General Rear Admiral Boris Lushniak

7. Your Role… • “Health care professionals are on the front lines of the battle against obesity and metabolic disease. They are uniquely positioned to prompt change among individuals, families and society as a whole. That’s why we need to ensure that they have the tools to help their patients practice healthy lifestyles.” Donna Shalala, former Secretaryof Health and Human Services and President of the University of Miami

8. Learning Objective 1. Explain the Evidence Surrounding Health & Activity Levels of Children

9. Objective 1. Health & Activity Levels of Children National View Obesity • 16.9% of children ages 2-19 are obese (BMI ≥ 95 percentile)1 • 31.8% are overweight (BMI ≥ 85 percentile)2 • Overweight 5 year olds are 4 times more likely to become obese than normal weight children3 • Childhood obesity rates have tripled since 1980. Today, some 12.9 million American children are obese. 1 Ogden CL et al. JAMA 2014;311(8):806-814. 2 Ogden CL, et al. JAMA 2010;303(3):242-249. 3 Cunningham SA et al. NEJM 2014;370(5):403-11.

10. Objective 1. Health & Activity Levels of Children National View continued • 32% of youth at risk of being overweight • Prevalence of obesity increases as youth move into adolescence • 48% for boys and girls (ages 6-11) obtain 60 minutes of daily physical activity • 12% of boys and just over 3% of girls (ages 12-15) obtain 60 minutes of physical activity Ogden et al. 2008 Troiano et al. 2007

11. Objective 1. Health & Activity Levels of Children National View continued • Childhood obesity predicts adult morbidity • 80% of obese youth become obese adults1 • Related conditions • Type-2 diabetes, hypertension (HTN) • Metabolic syndrome 1Whitaker RC et al. NEJM 1997;337:869-73.

12. Objective 1. Health & Activity Levels of Children National View continued Obesity-Related Diseases • Type 2 diabetes mellitus (DM) • 5,089 children diagnosed with Type II DM each year1 • CDC estimates: 1 in 3 children born in 2000 will develop DM if present obesity trends are not reversed2 1CDC National Diabetes Statistics Report. June 10, 2014 2Narayan KN et al. JAMA 2003:290:1884-90.

13. Objective 1. Health & Activity Levels of Children National View continuedObesity-Related Diseases • Hypertension (HTN) • BMI <85th percentile: 2.6% of children with HTN • BMI ≥95th percentile: 10.7% with HTN1 1Sorof J et al. Pediatrics 2004;113:475-82.

14. Objective 1. Health & Activity Levels of Children Obesity-Related Diseases Cardiovascular disease • High cholesterol levels, abnormal glucose tolerance, and HTN in children1 • Overweight adolescents are at increased risk of coronary heart disease and early death 2 1Dietz W. Pediatrics 1998;101:518–25. 2Ludwig DS. NEJM 2007;357:2325–27.

15. Objective 1. Health & Activity Levels of Children National View continuedOther Medical Issues • Asthma • Overweight children are at increased risk for developing asthma, other respiratory problems1, asthma hospitalizations2 • Possible relationships between asthma and sedentary lifestyles, including lack of physical activity and television viewing3,4 1Schachter LM. Thorax 2001;56:4-8. 2 Bender B et al. Pediatrics, 2007;120:805-13. 3Rasmussen F. European Respiratory Journal 2000;16:866-70. 4Sheriff A, et al. Thorax 2009;64:321-5.

16. Objective 1. Health & Activity Levels of Children National View continuedOther Medical Issues • Vitamin D Deficiency • 9% of US children are vitamin D deficient • 61% are insufficient1 • Physical activity may be associated with vitamin D levels2 • ¹Kumar J, et al. Pediatrics 2009;124:e362-70 • ²Ohta H, et al. J Bone Miner Metab 2009;27:682-8

17. Objective 1. Health & Activity Levels of Children Other Medical Issues • Mental Health – ADHD/ADD • Variable estimates, but prevalence is increasing • National Health Interview Survey estimates 9% of US children with ADHD/ADD3 • Impairs school performance and socialization; may persist into adulthood • ³Pastor PN, et al. Vital Health Stat 2008;10:237

18. Objective 1. Health & Activity Levels of Children Active vs. Sedentary Lifestyle • Physical activity reduces risk for • Coronary artery disease, HTN • Diabetes, osteoporosis, colon cancer1 • The US is shifting to a sedentary lifestyle1 • Physical activity in adulthood begins in childhood • 40% of adults report NO leisure physical activity¹ • Kids learn by watching their parents ¹ Center for Health Statistics. Health, United States, 2007 with Chartbook on Trends in the Health of Americans. 2007.

19. Objective 1. Health & Activity Levels of Children Obesity & Physical Activity • Nationwide shift in physical activity • Active teens become active adults • In 2011, only 29% of HS students met recommended level of physical activity1 ¹CDC. Youth risk behavior surveillance 2011. MMWR 2012; 61(4):35-36

20. Objective 1. Health & Activity Levels of Children Obesity & Physical Activity • Growth in electronic media • 31% played video or computer games >3 hours on an average school day1 • Average child watches 3 hours TV daily2 • 7.5 hours per day spent with all forms of e-media (TV, Internet, chats, games, etc)3 ²AAP, Committee Public Ed. Pediatrics 2001;107:423-6 ³Rideout VJ et al. Kaiser Family Foundation Report. 2010

21. Obesity & Physical Activity • Objective 1. Health & Activity Levels of Children • Growth in electronic media • 32% of 2-7 year-olds & 65% of 8-18 year-olds have TVs in bedrooms¹ • Time spent in front of TV or computer = time not spent being physically active ¹ Roberts DF et al. Henry J Kaiser Family Foundation Report, 1999. ² Juster FT et al. Changing Times of American Youth: 1981-2003. University of Michigan, 2004. ³ Dillon S. Schools cut back subjects to push reading and math. New York Times March 26; 2006.

22. Objective 1. Health & Activity Levels of Children Diabetes Rates • Incidence based on 2008-2009 for Type 2 Diabetes in 10-19 year olds was 24/100,000. Highest in American Indians at 28.9/100,000; Afro-Americans 26.7; Hispanic 17.2; and non-Hispanic whites 4.51 • Girls are 1.7 times more likely than boys to develop Type 2 Diabetes2 (CDC SEARCH for Diabetes 1 Youth Study) http://graphs.net/type-2-diabetes-in-children-stats.html, Aug. 2014

23. Objective 1. Health & Activity Levels of Children • Florida’s Obesity Rates by County

24. Objective 2. Explain the benefits of outdoor play on children’s physical and mental health

25. Objective 2. Benefits of outdoor play National View • Estimated 25% loss of play time and 50% loss in an unstructured outdoor activity.1 • No Child Left Behind 2001 • Increased time for reading and math • But at the expense of physical education.2 ¹ JusterFT et al. Changing Times of American Youth: 1981-2003. University of Michigan, 2004. ² Juster Dillon S. Schools cut back subjects to push reading and math. New York Times March 26; 2006.

26. Outdoor play and obesity study Objective 2. Benefits of outdoor play • Study linking positive impacts of time outdoors on obesity • More outdoor activity for children and teens may improve physical fitness • Youth spending most of their after school time outdoors more likely (2.8 times) to achieve recommended daily minimum of 60 minutes for moderate-to-vigorous physical activity • Youth active outdoors had healthier hearts and lungs than those not active Source: Baskin, Liza. Outdoor Time is Associated with Physical Activity, Sedentary Time, and Cardiorespiratory Fitness in Youth. The Journal of Pediatrics, Elsevier Health Sciences, July 10, 2014.

27. Objective 2. Benefits of outdoor play • Time spent outdoors usually equates to increased physical activity1 • Study among 10-12 year olds2 • For every hour spent outside, physical activity increased by 27 minutes/week • Prevalence of overweight was 27-41% lower among those spending more time outdoors 1Burdette HL, et al. Arch Pediatr Adol Med 2004;159:46-50. 2Cleland V, et al. Int J Obesity 2008;32:1685-93.

28. Objective 2. Benefits of outdoor play • Spending time outside raises levels of Vitamin D, helping protect children from future bone problems, heart disease, diabetes and other health issues.1 • Outdoor play increases fitness levels and builds active, healthy bodies, an important strategy in helping the one in three American kids who are obese get fit.2 1American Academy of Pediatrics. “Many Children have suboptimal Vitamin D Levels,” Pediatrics. October 26, 2009. 2CDC’s National Center Chronic Disease Prevention and Health Promotion. Division of Adolescent and School Health. Childhood Obesity. 20 Oct. 2008.

29. Parks & Physical Activity Objective 2. Benefits of outdoor play • Proximity of residence predicts park use and physical activity • Those living < 1 mile away were more likely to use the park and had 38% more exercise sessions than those living farther away Cohen DA, et al. Amer J Pub Health 2007;97:509-14

30. Nature as a Restorative Mechanism Objective 2. Benefits of outdoor play • Randomly assigned post-surgery patients to either rooms facing a brick wall or with views of nature • Those facing nature had shorter post-operative hospital stays, fewer negative comments from nurses, and took less analgesics • Viewing nature alone may aid in the path of recovery Ulrich RS. Science, 1984;224:420–421.

31. Childhood Stress and Nature Objective 2. Benefits of outdoor play • Nature appeared to act as a buffer to decrease stress in rural children • Lower levels of stress noted with increased exposure to natural environments • Nature exposure effect especially pronounced for children with highest levels of stressful events • Higher nature exposure associated with positive self-worth Wells NM & Evans GW. Environment and Behavior 2003;35:311-330.

32. Physical Activity in Natural Environments Objective 2. Benefits of outdoor play • Positive effects on mood and blood pressure • Synergistic health effects between physical activity and exposure to nature (“green exercise”) • Intervention: Subjects ran on treadmill while shown 4 different themes of pictures • Rural pleasant, urban pleasant, rural unpleasant, urban unpleasant photographs Pretty J et al. Internat J Environ Health Res 2005;15:319-37.

33. Physical Activity in Natural Environments Objective 2. Benefits of outdoor play • Results: the rural and urban pleasant nature pictures showed a significant reduction in blood pressure and a more positive effect on mood than exercise alone • Participants in rural pleasant group had largest blood pressure reduction Pretty J et al. Internat J Environ Health Res 2005;15:319-37.

34. Objective 2. Benefits of outdoor play • Outdoor exercise brings more positive effects on mental wellbeing than exercising indoors • 11 trials comparing mental wellbeing after a short walk or run outdoors and indoors • 9 of 11 trials showed improved mental wellbeing following outdoor exercise • Outdoor exercise associated with revitalization, decreases in tension, confusion, anger, depression, and increased energy • Greater intent to repeat outdoor activity • Coon JT et al. Environ Sci Technol 2011.

35. Effects of Nature on ADD/ADHD Objective 2. Benefits of outdoor play • Does contact with nature improve inattentiveness? • Survey of parents compared child’s symptoms when engaging in various settings • Indoor setting– windowless room • Natural outdoor setting– park, farm, outdoor neighborhood public space Taylor AF et al. Environment and Behavior 2001;33:54-77.

36. Effects of Nature on ADD/ADHD Objective 2. Benefits of outdoor play • Outcome measure were 4 inattentive symptoms • Inability to stay focused on unappealing tasks • Inability to complete tasks • Inability to listen and follow directions • Being easily distracted Taylor AF et al. Environment and Behavior 2001;33:54-77.

37. Effects of Nature on ADD/ADHD Objective 2. Benefits of outdoor play • Findings • Activities in natural settings were helpful in reducing inattentive symptoms • As tree cover in the setting increased, inattentive symptoms decreased Taylor AF et al. Environment and Behavior 2001;33:54-77.

38. Effects of Nature on ADD/ADHD Objective 2. Benefits of outdoor play • Nationwide study examined if “green” settings reduced symptoms of ADHD • Compared green outdoor after-school/weekend activities to activities in built indoor/outdoor settings • Findings: “green outdoor activities reduced symptoms significantly more than did activities conducted in other settings, even when matched across all settings” • Critique: Not randomized, not controlled, “green activities” are not uniformly defined Kuo FE & Taylor AF. Amer J Pub Health 2004;94:1580-86.

39. Effects of Nature on ADD/ADHD Objective 2. Benefits of outdoor play • Children completed a series of puzzles designed to create mental fatigue • Children with ADHD guided through 20 minute walk in three different environments • Children next completed tests of concentration and impulse control • Concentration significantly better after a walk in the park, compared to two other settings Taylor AF Kuo FE. J Atten Disord 2009;12:402

40. Nature Aiding Childhood Development Objective 2. Benefits of outdoor play AAP Clinical Report: importance of play in a child’s social, emotional, cognitive, and physical development • Benefits of play – develop healthier cognition, a more developed imagination, dexterity, emotional strength, and physical strength • Play builds active healthy children • Advice for pediatricians: children should get free unstructured play outside Ginsburg KR, et al. Pediatrics, 2007;119:182-191.

41. Objective 2. Benefits of outdoor play • Children who spend more time outdoors are less likely to be overweight by 27-41% • Exposure to nature can reduce stress levels by as much as 28% in children • A 20 minute walk in nature can help children with attention deficit hyperactivity disorder Source: www.neefusa.org/health

42. Objective 2. Benefits of outdoor play • Study with adults showed walking in nature, compared to walking in an urban environment, had significant increases in memory span • Positive impact for individuals with major depressive disorder (MDD) • Effect for children not studied • Berman MG et al. Interacting with Nature Improves Cognition and Affect for Individuals with Depression, • J Affect Disorders 2012 November; 140 (3): 300-305

43. Effects of Nature on ADD/ADHD Objective 2. Benefits of outdoor play • An estimated 4.4 million children in the US suffer from Attention / Hyperactivity Disorder (ADHD) • Children with ADHD who play regularly in green play settings have milder symptoms than children playing in built or indoor settings Faber T and Kuo FE, could Exposure to Everyday Green Spaces Help treat ADHD? Evidence from Children’s Play Settings. Applied Psychology: Health and Well-Being 3:281-303.

44. Effects of Nature Objective 2. Benefits of outdoor play • Memory performance and attention span improved by 20% after one hour interacting with nature (University of Michigan 2008) • 50% boost in creativity after 4 days interacting with nature – increase in endorphins (University of Kansas 2012) Louv R AARP Bulletin 2012

45. Effects of Nature on ADD/ADHD Objective 2. Benefits of outdoor play • Autism Society: Autism Spectrum Disorders • Occur in 1 of 88 births • 1% of children ages 3-17 • Autistic children who spend time in natural environments found to have increased attention and improved behavioral temperament www.asla.org

46. Objective 3. Examine the role that natural environments have in improving physical activity in children.

47. Objective 3. Examine natural environments Proximity to Parks and Impacts on Health • The relationship between physical activity and access to parks differs depending on adolescents’ socio-demographic, housing, and neighborhood characteristics. Parks may be particularly important for promoting physical activity among urban adolescents. • Access to safe parks positively associated with regular physical activity and negatively associated with inactivity for adolescents in urban areas, but not rural areas. Physical Activity Among Adolescents; When Do Parks Matter? (Susan H. Babey, PhD, Theresa A. Hastert, MPP, Hongjian Yu, PhD, E. Richard Brown, PhD)

48. Proximity to Parks and Impacts on Health Objective 3. Examine natural environments Children with better access to parks and recreational resources are less likely to experience significant increases in attained BMI Source: Wolch J, Jerrett M, Reynolds K, McConnell R, Chang R, Dahmann N, Brady K, Gilliland F, Su JG, Berhane K. Childhood obesity and proximity to urban parks and recreational resources: a longitudinal cohort study (2010).

49. Prescribing Exercise Objective 3. Examine natural environments • Swedish study measured effectiveness of issuing 6,300 physical activity referrals over two years • Half of the patients reached reported increased physical activity at three months and 12 months¹ • Program in Spain recruited 4,000 physically inactive patients and provided exercise referrals to half • Six months later, patients who received the referrals were more active² ¹ Leijon et al. Scand J Med Sci Sports 2009;19:627-36. ² Grandes et al. Arch Intern Med 2009;169:694-701

50. Prescribing Exercise Objective 3. Examine natural environments • Copenhagen study: living a short distance from a garden or park linked to less stress and lower body mass index • Risk for asthma in children lowered in low income children living near higher tree density areas (US) Miller D A Prescription for Nature