Visual Aids for Sunscreen Application: A mixed methods study.

BACKGROUND: Consumers routinely underapply sunscreen, and this may be because they misinterpret application quantity directions on sunscreen labels. U.S. labels use ambiguous terms such as "apply generously" to communicate application quantity. Visual aids may be helpful to consumers to determine proper application quantity. PURPOSE: To examine sunscreen application practices and sunscreen quantity visual aid preferences. METHODS: Sets of five GIFs and five static images were created corresponding to five quantities of sunscreen. Participants extracted their typical-use sunscreen quantity from a pre-measured tube and answered questions about their estimation process and use of labeled instructions. Participants then identified their typical-use sunscreen quantity in response to three stimuli: teaspoons, images, and GIFs and reported their preferred format. RESULTS: No participants reported using the label directions for application quantity to inform their sunscreen use. The GIF-based visual aid for sunscreen application quantity (44%) was preferred over image-based (40%) or teaspoon-based (16%) versions (p = .0249). Addition of a GIF demonstration to clarify application quantity was reported as highly helpful. CONCLUSION: Consumers have difficulty determining the appropriate quantity of sunscreen to use and labeling does not influence their application quantity. A QR code incorporating an image or GIF demonstration of proper sunscreen quantity could be useful to sunscreen consumers.

Cross-sectional Association between Walking and Sunburn: A Potential Trade-off between Cancer Prevention and Risk Factors.

BACKGROUND: The positive association between physical activity and sunburn is a health behavior trade-off between the health benefits of physical activity and increased risk of skin cancer. PURPOSE: We assessed walking, which is a common source of physical activity, and the prevalence of sunburn. METHODS: This research used the 2015 National Health Interview Survey of adults (N = 26,632), age ≥ 18 years. We defined four exclusive categories of walking: (a) those who reported not walking; (b) only transportation (to get some place, such as work, a store, or public transit stop); (c) only leisure (such as for fun, relaxation, or exercise); and (d) both categories. We estimated the adjusted prevalence of sunburn by walking category and separately for walking duration; we stratified by gender and sun sensitivity. RESULTS: The adjusted sunburn prevalence was not different between walking categories for women, but it was for men. Specifically, prevalence was lower for men who reported not walking, 34.1% (95% confidence interval [CI]: 32.2%-36.1%) compared to 38.8% (95% CI: 36.5%-41.2%) who walked for both purposes (p = .003). Walking duration was not associated with sunburn prevalence. CONCLUSION: We could not determine whether sunburn occurred during walking trips because the questions were not asked as such. However, the results suggest that walking, unlike leisure-time physical activity (such as exercise, sports, or physically active hobbies), may not generally be associated with sunburn, except for the higher sunburn prevalence for men who walked for both leisure and transportation purposes.

The harmonizing effect of Smart Snacks on the association between state snack laws and high school students' fruit and vegetable consumption, United States-2005-2017.

Despite national guidelines recommending daily fruit and vegetable (FV) consumption, intake of FV among adolescents is low. Over the past 10-15 years, state and federal laws have reduced the availability of junk foods in schools. This study examined the association between state snack laws and high school (HS) student FV consumption. The overall sample included 99,785 HS students (outcome samples ranged from 96,209-97,328) included in the Youth Risk Behavior Survey (YRBS). National Cancer Institute Classification of Laws Associated with School Students' data for 2004-2016 were lagged on to 2005-2017 YRBS data. Separate analyses examined the state law-youth FV consumption relationship pre- and post-federal Smart Snacks standards (effective school year 2014-2015). Analyses were conducted between 2018 and 2020. Overall, state laws were associated with any vegetable, salad, and other vegetable consumption. The relationship between state laws and vegetable consumption primarily occurred pre-Smart Snacks. Pre-Smart Snacks, state laws were associated with higher odds of youth consumption of any vegetable, salad, carrots, and other vegetables (all compared to students in states without snack laws). The only association post-Smart Snacks was between strong state laws and salads. This study illustrates the important role that standards restricting the availability of junk foods in schools can have on increasing student vegetable consumption. Given current efforts to roll-back federal school meal standards, findings from this study illustrate how federal standards harmonized the patchwork of state laws that existed prior to Smart Snacks and the important role that consistent national standards can play in supporting student consumption of vegetables.

Associations between ultraviolet radiation, tree cover and adolescent sunburns.

BACKGROUND: Sunburn is the strongest risk factor for melanoma and non-melanoma skin cancers. Adolescent sunburns are related to higher risk of developing melanoma later in life. Little is known about the association of sunburns and shade, particularly tree cover, around adolescent homes and schools. This linkage study assessed associations of adolescent self-reported sunburns with ambient ultraviolet radiation (UV) and tree cover. METHODS: We analyzed a U.S. national sample of parent-child dyads (n = 1333) from the 2014 Family Life, Activity, Sun, Health, and Eating (FLASHE) study conducted by the National Cancer Institute. The outcome was adolescent sunburns reported for the previous 12 months. GIS buffers around geocoded home and school addresses were used to summarize UV and tree cover. A sensitivity analysis assessed different UV measures and tree cover buffer distances. Logistic regression models estimated the adjusted odds of any sunburns for five models: (1) no environmental variables; (2) spatial variables of latitude and longitude; (3) UV; (4) tree cover; and, (5) a combined model with UV and tree cover. Covariates included common sunburn-related items such as sun protective behaviors, socio-demographics, and latitude. Model residuals were assessed for spatial dependency and clustering. RESULTS: Overall, 44% of adolescents reported any sunburns in the previous 12 months. For the bivariate associations, lower categories of UV were associated with any reported sunburns (p-trend = 0.002). Home tree cover was not associated with any reported sunburns (p-trend = 0.08), whereas schools with lower categories of tree cover were associated with sunburns (p-trend = 0.008). The adjusted odds of any sunburns by UV tertiles, as a linear tread, was 0.89 (0.76-1.05) (p = 0.17); school tree cover was: 0.91 (0.78-1.07) (p = 0.25). Neither UV nor tree cover, in a combined model, were significant. Sensitivity analyses resulted in the optimal buffer size of 200 m for summarizing tree cover. Spatial dependence of residuals was not significant and clustering was significant for about 6% or less of the sample in each model. CONCLUSIONS: We did not find significant relationships between UV or tree cover and adolescent sunburns, when adjusted by sunburn-related covariates. Better contextual data about where sunburns occurred is needed to identify environmental correlates of sunburn.

Adolescent Physical Activity at Public Schools, Private Schools, and Homeschools, United States, 2014.

INTRODUCTION: Physical activity overall and during school-related opportunities among homeschool adolescents are poorly documented. METHODS: We used data from the National Cancer Institute's Family Life, Activity, Sun, Health, and Eating (FLASHE) study, a national sample of parent-child dyads. We examined reported frequency of physical activity in middle-school and high-school respondents (N = 1,333). We compared the overall physical activity by school type (ie, public school, private school, and homeschool), compared school-related contexts (eg, recess, physical education [PE] class), and tested for level of physical activity by school for those reporting PE. RESULTS: Middle-school homeschool adolescents reported less physical activity during school hours compared with public school, but not private school, adolescents. Physical activity was not different by school type for out of school or weekends. Physical activity of high-school homeschool adolescents was not different from that of high-school adolescents at traditional schools; homeschool adolescents in both middle and high school reported less physical activity in PE compared with public and private school adolescents. Other school-related contexts of physical activity were not different by school type. More homeschool students reported not having PE (middle school, 54.8%; high school, 57.5%) compared with public (middle school, 18.7%; high school, 38.0%) or private schools (middle school, 13.5%; high school, 41.5%). CONCLUSION: Homeschool adolescents in middle school reported less physical activity compared with middle-school adolescents in traditional schools during school hours, likely because of having fewer PE classes and less physical activity during PE.

Skin cancer interventions across the cancer control continuum: A review of experimental evidence (1/1/2000-6/30/2015) and future research directions.

While the general efficacy of skin cancer interventions have been reviewed, employing the cancer control continuum would be useful to identify research gaps at specific cancer control points. We characterized the intervention evidence base for specific behavioral targets (e.g., tanning, sun protection, screening) and clinically related targets (e.g., sunburn, skin exams, cancers) at each point in the cancer control continuum. The review included articles published from 1/1/2000-6/30/15 that had an experimental design and targeted behavioral intervention in skin cancer (e.g., specific behaviors or clinically related targets). The search yielded 86 articles, including seven dissemination studies. Of the 79 non-dissemination studies, 57 exclusively targeted primary prevention behaviors, five exclusively targeted screening, 10 targeted both detection and prevention, and eight addressed cancer survivorship. Among prevention studies (n=67), 29 (43%) targeted children and 38 (57%) targeted adults. Of the 15 screening studies, nine targeted high-risk groups (e.g., men aged ≥50 years) and six targeted the general population. Although research has focused on skin cancer prevention, empirically validated interventions are still needed for youth engaged in indoor tanning and for behavioral interventions to pursue change in clinically relevant targets. Research must also address detection among those at highest risk for skin cancer, amelioration of emotional distress attendant to diagnosis and treatment, and survivorship concerns. We discuss essential qualities and opportunities for intervention development and translational research to inform the field.

Skin cancer interventions across the cancer control continuum: Review of technology, environment, and theory.

The National Cancer Institute's Skin Cancer Intervention across the Cancer Control Continuum model was developed to summarize research and identify gaps concerning skin cancer interventions. We conducted a mapping review to characterize whether behavioral interventions addressing skin cancer prevention and control from 2000 to 2015 included (1) technology, (2) environmental manipulations (policy and/or built environment), and (3) a theoretical basis. We included 86 studies with a randomized controlled or quasi-experimental design that targeted behavioral intervention in skin cancer for children and/or adults; seven of these were dissemination or implementation studies. Of the interventions described in the remaining 79 articles, 57 promoted only prevention behaviors (e.g., ultraviolet radiation protection), five promoted only detection (e.g., skin examinations), 10 promoted both prevention and detection, and seven focused on survivorship. Of the 79 non-dissemination studies, two-thirds used some type of technology (n=52; 65.8%). Technology specific to skin cancer was infrequently used: UVR photography was used in 15.2% of studies (n=12), reflectance spectroscopy was used in 12.7% (n=10), and dermatoscopes (n=1) and dosimeters (n=2) were each used in less than 3%. Ten studies (12.7%) targeted the built environment. Fifty-two (65.8%) of the studies included theory-based interventions. The most common theories were Social Cognitive Theory (n=20; 25.3%), Health Belief Model (n=17; 21.5%), and the Theory of Planned Behavior/Reasoned Action (n=12; 15.2%). Results suggest that skin cancer specific technology and environmental manipulations are underutilized in skin cancer behavioral interventions. We discuss implications of these results for researchers developing skin cancer behavioral interventions.

Muscular Grip Strength Estimates of the U.S. Population from the National Health and Nutrition Examination Survey 2011-2012.

The purposes of this study were to use the National Health and Nutrition Examination Study (2011-12) data to determine nationally representative combined handgrip strength ranges and percentile information by sex and age group, examine trends in strength across age by sex, and to determine the relative proportion of children and adults falling into established health benefit zones (HBZ). Results indicate that mean strength was greater among men than women and increased linearly for children and in a quadratic fashion among adults for both sexes. Grip strength peaked in the 30- to 39-year age group for both men (216.4 lbs) and women (136.5 lbs) with subsequent age groups showing gradual decline, p < 0.0001. Relative and absolute increases in grip strength were greater for men than for women, but relative decrease from peak strength was less among women than men. Although absolute strength was greater among men than women, HBZ data indicated that a higher percentage of men than women overall and at each age group fell into the needs improvement zone, with differences particularly pronounced during adolescence and older adulthood. These data provide the first nationally representative population estimates of combined handgrip strength and percentile information from childhood through senescence and suggest consideration of HBZ information in conjunction with grip strength to improve surveillance data interpretation and intervention planning.

The association between demographic and behavioral characteristics and sunburn among U.S. adults - National Health Interview Survey, 2010.

OBJECTIVE: To examine the association between demographic and behavioral characteristics and sunburn among U.S. adults. METHOD: We used 2010 National Health Interview Survey data (N=24,970) to conduct multivariable logistic regressions examining associations with having 1 or more sunburns in the past year and having 4 or more sunburns in the past year. RESULTS: Overall, 37.1% of adults experienced sunburn in the past year. The adjusted prevalence of sunburn was particularly common among adults aged 18-29years (52.0%), those who repeatedly burn or freckle after 2weeks in the sun (45.9%), whites (44.3%), indoor tanners (44.1%), those with a family history of melanoma (43.9%), and those who are US-born (39.5%). Physical activity, alcohol consumption, and overweight/obesity were positively associated with sunburn (all P<0.001); sun protection behaviors were not significantly associated with sunburn (P=0.35). Among those who were sunburned in the past year, 12.1% experienced 4 or more sunburns. CONCLUSION: Sunburn is common, particularly among younger adults, those with a more sun-sensitive skin type, whites, those with a family history of melanoma, the highly physically active, and indoor tanners. Efforts are needed to facilitate sun-safety during outdoor recreation, improve the consistency of sun protection practices, and prevent sunburn, particularly among these subgroups.

Cross-sectional examination of physical and social contexts of episodes of eating and drinking in a national sample of US adults.

OBJECTIVE: The current study characterizes associations between physical and social contexts of self-reported primary episodes of eating/drinking and sociodemographic and obesity-related variables in US adults. DESIGN: Multinomial logistic regression was used to analyse a nationally representative sample of adults from the 2006-2008 American Time Use Survey. Models identifying physical (where) and social (whom) contexts of primary eating/drinking episodes at the population level, controlling for demographic characteristics, weight status and time of eating, were conducted. SETTING USA SUBJECTS: A nationally representative sample of US adults (n 21 315). RESULTS: Eating/drinking with immediate family was positively associated with age (OR = 1·15 (95 % CI 1·04, 1·27) to 1·23 (95 % CI 1·09, 1·39)), education level (OR = 1·16 (95 % CI 1·03, 1·30) to 1·36 (95 % CI 1·21, 1·54)), obesity (OR = 1·13 (95 % CI 1·04, 1·22)), children in the household (OR = 3·39 (95 % CI 3·14, 3·66)) and time of day (OR = 1·70 (95 % CI 1·39, 2·07) to 5·73 (95 % CI 4·70, 6·99)). Eating in the workplace was negatively associated with female gender (OR = 0·65 (95 % CI 0·60, 0·70)) and children in the household (OR = 0·90 (95 % CI 0·83, 0·98)), while positively associated with non-white status (OR = 1·14 (95 % CI 1·01, 1·29) to 1·47 (95 % CI 1·32, 1·65)) and time of day (OR = 0·25 (95 % CI 0·28, 0·30) to 5·65 (95 % CI 4·66, 6·85)). Women (OR = 0·80 (95 % CI 0·74, 0·86)), those aged >34 years (OR = 0·48 (95 % CI 0·43, 0·54) to 0·83 (95 % CI 0·74, 0·93)) and respondents with children (OR = 0·69 (95 % CI 0·63, 0·75)) were less likely to eat in a restaurant/bar/retail than at home. Overweight and obese respondents had a greater odds of reporting an episode of eating in social situations v. alone (e.g. immediate family and extended family; OR = 1·13 (95 % CI 1·04, 1·22)) and episodes occurring in restaurant/bar/retail locations (OR = 1·12 (95 % CI 1·03, 1·23) to 1·14 (95 % CI 1·05, 1·24)). CONCLUSIONS: Findings underscore the multidimensional nature of describing eating/drinking episodes. Social and physical contexts for eating/drinking and their demographic correlates suggest opportunities for tailoring interventions related to diet and may inform intervention targeting and scope.

The association of soda sales tax and school nutrition laws: a concordance of policies.

OBJECTIVE: The current research examined the association between state disfavoured tax on soda (i.e. the difference between soda sales tax and the tax on food products generally) and a summary score representing the strength of state laws governing competitive beverages (beverages that compete with the beverages in the federally funded school lunch programme) in US schools. DESIGN: The Classification of Laws Associated with School Students (CLASS) summary score reflected the strength of a state's laws restricting competitive beverages sold in school stores, vending machines, school fundraisers and à la carte cafeteria items. Bridging the Gap (BTG) is a nationally recognized research initiative that provided state-level soda tax data. The main study outcome was the states' competitive beverage summary scores for elementary, middle and high school grade levels, as predicted by the states' disfavoured soda tax. Univariate and multivariate analyses were conducted, adjusting for year and state. SETTING: Data from BTG and CLASS were used. SUBJECTS: BTG and CLASS data from all fifty states and the District of Columbia from 2003 to 2010 were used. RESULTS: A higher disfavoured soda sales tax was generally associated with an increased likelihood of having strong school beverage laws across grade levels, and especially when disfavoured soda sales tax was >5 %. CONCLUSIONS: These data suggest a concordance between states' soda taxes and laws governing beverages sold in schools. States with high disfavoured sales tax on soda had stronger competitive beverage laws, indicating that the state sales tax environment may be associated with laws governing beverage policy in schools.

Feasibility of a Physical Activity Index in Clinical Practice: Perspectives of Providers and Cancer Patients.

Physical activity is a common clinical recommendation for cancer survivors, yet the use of clinical tools to counsel patients is understudied. We developed an integrated Physical Activity Index to assist with this task. The purpose of this project was to conduct interviews to assess the feasibility and clinical utility of the Physical Activity Index from both provider and patient perspectives. Our findings indicate that a Physical Activity Index may be a useful tool to facilitate productive patient-provider communication about physical activity goals.

Change in school nutrition-related laws from 2003 to 2008: evidence from the school nutrition-environment state policy classification system.

OBJECTIVES: We examined state laws affecting the school food environment and changes in these laws between 2003 to 2008. METHODS: We used the Westlaw legal database to identify state-codified laws, with scoring derived from the updated School Nutrition-Environment State Policy Classification System, obtained from the Classification of Laws Associated With School Students Web site. RESULTS: States significantly changed their school nutrition laws from 2003 to 2008, and many increased the stringency of the laws targeting competitive foods (snacks and entrées sold in competition with the school meal) and beverages sold in school and for in-school fundraising. Many states enacted laws that mandated the establishment of a coordinating or advisory wellness team or council. Stronger laws were enacted for elementary grades. We found tremendous variability in the strength of the laws and plenty of room for improvement. CONCLUSIONS: State law governing school nutrition policies significantly changed from 2003 to 2008, primarily affecting the competitive food environment in schools. The extent to which changes in school nutrition laws will lead to desired health outcomes is an area for additional research.

Association between state physical education (PE) requirements and PE participation, physical activity, and body mass index change.

OBJECTIVE: To determine if state physical education (PE) laws are associated with student physical education attendance and physical activity (PA), and whether physical education and competitive food laws, in conjunction, are associated with lower BMI change. METHOD: State laws regarding physical education time requirements and competitive foods in 2003 and 2006 were classified as strong, weak, or none, based on codified law ratings obtained from the Classification of Laws Associated with School Students. Laws were linked to student data on PE attendance and physical activity (8th grade, Spring 2007) and BMI change (5th-8th grade, 2004-2007), obtained from the Early Childhood Longitudinal Study (n=5510 students in 40 states). RESULTS: Girls reported 0.31 more days of activity (95% CI: 0.02, 0.61) and were more likely to attend physical education ≥ 3 days/week (74.1% versus 52.1%, difference=22.0, 95% CI: 2.1, 42.0) if they resided in states with strong physical education laws compared to no physical education laws. Weak physical education laws had modest associations with PE and activity, and there was no evidence that weak laws reduce BMI gain regardless of competitive food laws. CONCLUSION: Strong physical education laws with specific time requirements may increase physical education attendance and activity in girls. There is insufficient evidence that physical education laws reduce student weight gain.

Sun protection behavior: health impact, prevalence, correlates and interventions.

Sun protection behavior can reduce skin cancer risk. This paper provides an overview of skin cancer risk and the complex behavioral options for sun protection, along with a narrative review of research on determinants of, and interventions to promote, sun protection. Gaps and opportunities for future research are also outlined. Evidence supports the effectiveness of sunscreen use, ultraviolet (UV) protection clothing, and shade seeking. However, these behaviors are complex and are often performed in ways that are inadequate for sun protection. Most research examining and targeting determinants of sun protection behavior has focused on sunscreen use, to the exclusion of other strategies, and has largely ignored the complexity of even sunscreen use. Most research and interventions are theory- driven, drawing on social cognitive constructs, but also considering self and social identity and emotion. Multilevel perspectives considering context, environment, policies, and other structural contexts have also been applied to sun protection behavior, but there is a need to combine psychological constructs with factors at other levels to optimize predictive models and intervention effectiveness. Effective sun protection effectively involves complex behaviors and perceived and actual tradeoffs that should be considered, in combination with multilevel determinants, in research predicting and promoting sun safety.

Consumers pay attention to ingredients on the front of a label: an eye tracking study.

Sunscreen is an important part of skin cancer prevention. The Food and Drug Administration (FDA) proposed numerous changes to sunscreen labeling including adding active ingredients to the front of a label. The purpose of the study was to identify and describe differences in attention between current label formatting and the proposed label formatting. Forty-seven participants were interviewed. Participants were presented with mock sunscreen labels that resembled current labeling or labeling based on the proposed FDA rule. While reading the labels, eye movements were recorded. Participants spent 12.3 s longer looking at the front of the proposed rule-compliant label than they did on the front of the current label. They spent the longest time reading the directions (13-14 seconds) compared with other areas. Placing active ingredients on the front of a label in relatively large font makes it more likely consumers will look at the information.

Sunscreen offers important protection against sunburn and skin cancer. In many instances, it is not as effective as it could be. Possible reasons include not applying it frequently enough or failing to understand instructions on the label. The FDA has proposed making changes to sunscreen labeling to increase its effectiveness. This includes adding active ingredients on the front of a label. Previous research has shown that adding active ingredients to the front of a label does not help consumers remember the ingredients. It is possible that consumers are not paying attention to/reading the ingredients when placed on the front label. Using eye tracking hardware, we tracked where 47 participants were looking as they read labels that either had active ingredients or did not have them. We found that the participants looked longer at the front label when the ingredients were on the front. This shows that consumers do pay attention to important information (e.g., active ingredients) on the front of a label. Given these results, and based on previous research that shows consumers have trouble remembering active ingredients, we recommend using the front label space for other types of important information, such as instructions for use.

Associations Between College/University Physical Activity Requirements and Student Physical Activity.

Background: Most U.S. college students do not meet physical activity guidelines. Physical activity requirements (PAR) are a proposed solution for increasing undergraduate physical activity. Purpose: To determine whether college/university PAR are associated with undergraduates' self-reported physical activity. Methods: Undergraduate students (N = 383,632) attending colleges and universities taking part in the American College Health Association-National College Health Assessment II survey (2015-2019) self-reported physical activity and demographics. Using websites and course catalogs, researchers coded schools to indicate binary PAR status. Bayesian Hierarchical Logistic Regression was used to determine the percentage of students meeting physical activity guidelines; interactions between PAR status and student characteristics (sex, BMI) were examined. Results: PAR status was positively associated with percent of students meeting physical activity guidelines (PAR: 43.3%, without: 40.5%; difference score 95% Highest Density Interval [HDI; 1.0, 4.5]). A greater percentage of students attending schools with PAR, versus without, met physical activity guidelines across all categories of sex and weight. However, the positive relationship between PAR status and physical activity was stronger among male students (PAR: 46.7%, without: 43.2%; 95% HDI [1.6, 5.4]) compared to female students (PAR: 39.9%, without: 37.9%; 95% HCI [0.2, 3.8]), and among students with underweight (PAR: 39.2%, without: 35.5%; 95% HDI [1.2, 6.3]) or obesity (PAR: 37.1%, without: 33.7%; 95% HDI [1.4, 5.3]) compared to normal weight (PAR: 49.3%, without: 47.4%; 95% HDI [0.1, 3.7]) or overweight (PAR: 47.5%, without: 45.5%; 95% HDI [0.1, 4.0]). Conclusions: PAR are associated with meeting physical activity guidelines, particularly among college/university students with underweight or obesity.

The association of state law to physical education time allocation in US public schools.

OBJECTIVES: We examined whether public schools in states with specific and stringent physical education (PE) laws, as assessed by the Physical Education-Related State Policy Classification System (PERSPCS), available on the Classification of Laws Associated with School Students (C.L.A.S.S.) Web site, reported more weekly PE time in the most recent School Health Policies and Programs Survey (SHPPS). METHODS: Schools (n=410) were grouped by their state's PERSPCS time requirement scores (none, nonspecific requirement, or specific requirement). Average weekly school-level PE was calculated using the SHPPS-reported PE minutes. Weighted analyses determined if PE minutes/week differed by PERSPCS group. RESULTS: Schools in states with specific requirement laws averaged over 27 and 60 more PE minutes/week at the elementary and middle school levels, respectively, compared with schools within states with nonspecific laws and over 40 and 60 more PE minutes per week, respectively, compared with elementary and middle schools in states with no laws. High school results were nonsignificant. CONCLUSIONS: Public health guidelines recommend at least 60 minutes of daily physical activity for children, and PE may further this goal. Strong codified law with specific time requirements for PE may be an important tool contributing toward adequate PE time and daily physical activity recommendations.