Physical Activity for Children

EDUCATIONAL MODULE Vol. 11(6), June 2003

HYSICAL ACTIVITYFOR CHILDRENAND YOUTH

Canadians are gaining awareness of the healthbenefits of physical activity. Behaviour change mustfollow awareness, however, if patients are tocounter the health risks associated with sedentaryliving.

Physicians are continually challenged to identifyeffective and practical strategies to encourageongoing participation in physically active pursuitsparticularly when sedentary choices for recreationand leisure options are so popular.

To help family physicians facilitate positive changesin physical activity levels, this module will explorethe factors that influence physical activityparticipation, and will provide a set of practical toolsfor interacting with children and parents.

CASES

Case 1: Jamie B., age 4, male

Jamie is a healthy youngster who is in for a checkupand immunization update prior to starting school.[The following questions also could apply at earlierwell-child visits anytime from 2 years on.] How could you incorporate physical activityinto the anticipatory guidance provided at awell-care visit? How could you counsel Jamies parents aboutenhancing their childs recommended amountof physical activity?

Case 2: Farah W., age 8, female

Farahs mother has brought her in today, requestinga note that her daughter be allowed to take the busto school for medical reasons. Farah is a healthyyoungster who is doing well academically.

EDUCATIONAL MODULE Volume 11(6), June 2003

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Her mother is concerned because she has to walk onekilometre to school each way and is exhausted by thetime she gets home from school. The school boardprovides a bus for children who live more than onekilometre away, but will not provide it for Farah becauseshe lives within that boundary. Farahs mother alsoexpresses concern about her childs safety while walkingto and from school. How could you determine if Farah is getting therecommended amount of activity for her age?What strategies could help Farah become morephysically active?How could you address the mothers concernsabout Farahs walking to school?

Case 3: Rob S., age 13, male

Rob presents with a mild cold and complains aboutfeeling tired a lot of the time. As part of the exam, younotice that he is at the 95th percentile in height and 15kg above the 95th percentile in weight. On furtherenquiry, he appears to be sensitive about his size. Hismain form of physical activity is "gym", which occurstwice a week at school. Each gym period is 40 minuteslong and includes time for changing clothes, takingattendance, and setting out/striking equipment. Rob isalso having some problems in school performance.

How could you use this opportunity to initiate adiscussion with Rob about physical activity?How could you assist Rob in getting therecommended amount of activity for his age?How could you counter Robs reluctance tobecoming more active?

INFORMATION SECTION

Benefits of Physical Activity

1. In children and adolescents, daily physical activityhas many benefits. A variety of studies (Level 4evidence) have shown that it can: positively affect lean muscle mass and bone

density1,2

help decrease excess body fat3 and/or maintaina healthy body weight4,5

improve self-esteem and decrease anxiety,depression, and moodiness6,7

enhance academic performance8

2. Physical activity helps reduce resting blood pressurein children and adolescents with hypertension (Level4 evidence) and has been positively correlated with

a decrease in resting blood pressure in adults. 5,6,9

3. Because physical activity is correlated with lowerfasting insulin and greater insulin sensitivity inchildhood (Level 4 evidence), increasing physicalactivity levels may also reduce the risk of type 2diabetes in children.6,10

At this time, there are a limited number of large, high-quality studies by which to more definitively evaluateother effects of physical activity. 11

Role of Family Physicians

4. Family physicians are in a position to significantlyinfluence the physical activity levels of their youngpatients, and they will see more than 90% of youthsaged 5-17 years in their practice at least once in atwo-year period.12,13

5. The optimal time for broaching the subject ofphysical activity is during routine checkups or wellvisits. Secondary opportunities occur duringfollow-up appointments for injuries or illnesses,visits for chronic diseases (e.g. asthma), andphysical examinations before participation in sportsor camp programs. 13

6. Younger children rely heavily on parental supportand direction in becoming more physically active.Although physicians may have concerns aboutactively promoting physical activity with parents, aconsiderable majority of Canadian adults are eitheralready active, taking steps to become active, or ina period of relapse from activity.14 They are,therefore, likely to support initiatives to increase thephysical activity of their children.

Current Recommendations

7. Adult guidelines for physical activity are notnecessarily appropriate for children andadolescents.15 Adults frequently choose physicalactivity that is structured, highly organized, andoften continuous in nature. In contrast, childrensactivity is characterized by short bursts of activity,alternating with frequent short periods of rest.Given sufficient free time, children tend toaccumulate a greater volume of physical movementthrough active, unstructured play.15

8. Canadas Physical Activity Guides (Appendix 4)have tried to de-emphasize absolute values intime spent in physical activity and have taken theapproach of increasing accumulated time spent inphysical activity and decreasing accumulated


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screen time (e.g., television , computer, video).16

It is recommended, however, that at least 30minutes of active time each day be spent invigorous activities (such as running, basketball, orsoccer).17 For optimal health benefits, other studiessuggest as much as 2 to 2.5 hours per day of activeincidental play (NOT continuous play) for pre-schoolor elementary school children.6,18

Strategies for Promoting Physical Activity

For Physicians

9. Systematically Ask, Advise, Assist during routinevisits to raise the awareness of patients and parentsabout physical activity limits and/or lifestyle choices(a strategy devised originally for smokers).19 Usethe Ask phase to uncover what the patientconsiders an important benefit, and use thatinformation to drive the Advise and Assistphases.

Ask every patient about physical activitylevels and the personal benefits.

Advise on simple solutions to reducinginactivity.

Assist with specific recommendations forphysical activity when asked.

10. Encourage young patients, where appropriate, to

be active during recess, at lunch, and immediatelyafter school hours and on weekends. This strategyhas been shown to be valuable in setting goodphysical activity patterns.20

11. Discuss with parents the time commitmentinvolved in assisting children to be more active andin providing transportation to appropriate sites forphysical activity such as a recreation centre; localpark; dance, martial arts, or gymnastics studio; orsports facility.21

12. Understand the influence of age, gender, andcultural background to help identify at-riskpopulations and set the stage for successfulinterventions that take into account differentcohorts: 22 young girls who are characteristically less active

than boys minority ethnic groups, where culturally-

appropriate opportunities may be an issue pre-adolescence, when physical activity levels

begin to drastically decline.

13. Physicians and their staff can demonstrate supportof healthy living and physical activity through 13 23: exhibiting posters which advertise community

events or recreation schedules leaving a supply of take-away copies of the

various Health Canada Physical Activityresources for Children and for Youth (seeAppendix 3) in the waiting room

leaving help yourself physical activityprescription pads (Appendices 5 and 6) in thewaiting room

arranging with community recreation sources todisplay their up-to-date brochures in the waitingroom

conspicuously posting a list of local day carecentres, recreation centres, or fitness facilitiesthat promote physical activity for children.6

displaying on office walls photographs ofphysicians and staff engaged in physical activityor local community fundraising initiatives

14. Consider wearing a pedometer as way to rolemodel the importance of physical activity. Itpotentially provides a bond between patient andphysician, particularly if the physician cancommiserate with the patient on challenges inmeeting the recommended 10,000 steps per day.(See Info point 26 and Patient Information Sheetfor more details on a pedometer). 24

15. Physicians can use their influence in communitiesto speak out strongly in favour of quality dailyphysical education (QDPE)6, especially if parentsfeel that school is the one safe place for childrenand youth to get some of the recommended dailyphysical activity.

For Parents

16. Parents are powerful physical activity role modelsfor their children 20, with studies showing a 30% to40% positive association with a childs beingactive25, particularly during the first decade of life.16

17. Parents should consider being physically activewith their children and families a top priority. 26


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18. A simple and effective way for parents to increasephysical activity among their children is to ensurethat they have time to play outdoors either duringthe day (for pre-school children) or after school.5,21

19. As many as 75% of children engage in inactivepursuits after school: doing homework, reading,watching television, or playing computer or videogames. These pursuits often add up to theequivalent of a full-time desk job (i.e., 40 hours perweek)! It has been shown that children and youthwho are not active after school, or are not involvedin community sports programs, are generallysedentary.21

20. While intrinsic motivation (e.g., having fun) iscrucial to ongoing participation, parents can useextrinsic motivators (such as calendars, daily logs,journals, or rewards) to nurture increased physicalactivity or a more active lifestyle. 20 Nearly half ofparents agree that being physically active for fun ispreferable to competition and winning for theirchildren.20

21. Therefore, activities that are selected to fosterconfidence, competence, and, most of all,enjoyment are critical in enticing children to bemore active.

22. Parents can take the following actions to improvephysical activity levels: create walking school buses 27, cooperatives

to supervise physical activity, and/or car poolsto share responsibility for transporting childrento or from activity programs.21

lobby with the school board for a greateremphasis on daily quality physical education(QDPE) 28 and a greater access to facilities forunstructured play during and after schoolhours.20 28 16

approach city hall about sidewalkmaintenance, the creation of safe cyclingroutes 21, the installation of lighting in

playgrounds16, and the building of newplaygrounds (per 20,000 people there are twiceas many golf courses as playgrounds) 29

arrange for a trained professional to superviseor monitor their childs exercise time eithersingly (if this is financially feasible) or as partof a group in a recreation centre.20

Table 1. Factors to consider in counseling aboutphysical activity

FACTORS ASSOCIATED WITH PHYSICAL ACTIVITY INCHILDREN AND YOUTH22

Children Youth (Variables can bedivided into twocategories)

time spent outdoors an inclination to be

physically active a healthy diet previous experience

with physicalactivity

access to bothfacilities andequipment

intention to bephysically active

Psychological andbehavioural: level of self-esteem

and perceivedcompetence

sensation seeking previous experience

with physical activity participation in

community sportsSocial/cultural andphysical environment parental support support from

significant others siblings who are

physically active opportunities to be

physically active

The following are associated with a negative effecton physical activity levels

perceived barriersto physical activity

depression inactive pursuits after

school and onweekends

Children

23. Children should naturally be more active thanadults.18 One of the ways for children to maintaina healthy balance of caloric intake and output is tobe physically active for at least 60 minutes perday.15

24. Children age 4 years to 12 years respond positivelyto activities that are FUN. They are more willing

Sample activities for parents to consider: Take your older child to the fitness centre with

you Get involved in a program for Moms/Dads

and Tots Help coach a sport team where your child is

involved Go swimming or hiking as a family on the

weekend Walk to school with the children


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to be involved in activities they enjoy and/orpersonally select, than in activities that theirparents may favour or think beneficial.21

Making activity seem fun for children,therefore, is a key to promoting participation.

25. Regular positive feedback from parents as well asphysicians help children stick with their physicalactivity prescription or program.15

26. Pedometers are simple to use, inexpensive, andself-motivating devices to get older childreninvolved in their own activity levels. 30 a. The following range of steps has been

suggested in the literature based on a 5-daypedometer program.30: 12,000 to 16,000 steps as a goal for

children 8-10 years;3 11,000 to 12,000 steps for

adolescents 14 to 16 years old.30

b. The disadvantage is that they do not provideintensity levels of exercise. 30

27. Other self-monitoring tools that children couldcreate and/or use, include: a personal log sheet for recording activity

levels, designed by children themselves usingtheir computer skills

the poster-sized Health CanadaPhysical Activity Chart with colourfulstickers available at no charge throughthe Health Canada website(http://www.healthcanada.ca/paguide) orby calling 1-888-334-9769.

Youth/adolescents

28. Adolescents might be enticed into being moreactive by experimenting with less traditional kindsof activities (e.g. rock climbing, skateboarding,street or hip hop dancing, or kayaking) available inthe community, through school or municipalrecreation departments.31

29. Youth involved in organized sports, in contrast withyouth not so involved, expend more energy inmoderate to vigorous activities and spend less timewatching television than their less active peers.32

30. Physicians may be able to engage adolescents insetting goals and objectives for the Lets GetActive prescription by acknowledging their growingdesire for independent decision making.31

THE BOTTOM LINE Seize available opportunities to promote

physical activity (at well-care visits, duringvisits for follow-up or for minor problems).

Take advantage of the waiting room to activelypromote physical activity.

Encourage kids to be active outdoors afterschool and on weekends.

Involve parents both as role models andfacilitators of physical activity for their children.

CASE COMMENTARIES

Case 1: Jamie B., age 4, male

How could you incorporate physical activity intothe anticipatory guidance provided at a well-carevisit?

Anticipatory guidance has been a traditional part of well-baby and well-child care. Until recently, evidence wasnot necessary for physicians to encourage parents toensure play time for children as it was taken for grantedthat children would play and be active. Sadly, this is nolonger the case.

Making a personal notation about physical activity underthe heading of Education and Advice on the RourkeBaby Record, Guide I I I , (avai lable athttp://www.ctfphc.org) of young patients, can serve as areminder to inquire about physical activity at well-carevisits.

In provinces where funding does not cover well-carevisits up to the age 5 years, physicians will need to takeadvantage of visits for other reasons in order tointroduce the topic of physical activity (Info point 5).The following Talking Tips, modeled after Ask,Advise, Assist, could be helpful in a discussion with thechild and parents (Info point 9). (See Appendix 1 forother interview question samples)


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Talking Tips Is your child involved in active play on most, if

not all, days of the week? Would you say that the total length of time

accumulated in active play adds up to at least2 hours per day?

In the past 6 months, has your child beeninvolved in community physical activityprograms (such as swimming or childrensgymnastics or Tee ball)?

How much television do you allow your childto watch each day?

What active things do you do together as afamily?

Do you believe your child is active enough tobe healthy?

Adapted from Patrick, 2001 6

Depending upon the maturity level of the child, thephysician might choose to directly ask the young patienta couple of questions about physical activity levels. How could you counsel the parents aboutenhancing Jamies physical activity level?

Try to determine the level of importance that the parentsplace on physical activity and their willingness to workwith their children at increasing physical activity. Thisinformation will influence the guidance that you provide.

Advise Jamies parents that, for children this age, it isreasonable to expect as much as 2 to 2.5 hours per dayof active play for optimal growth and development. Thisplay, however, usually is incidental and intermittentrather than planned or structured (Info point 7) by justallowing Jamie to play outdoors for at least part of theday (Table 1. Factors to consider in counseling aboutphysical activity, page 4) and encouraging doingactivities he enjoys and finds fun (Info point 24).

If neighbourhood safety is an issue, Jamies parentscan form a block cooperative whereby parents rotateresponsibility for a group of children in the home yard.Alternatively, this same cooperative can take turnsgetting a group of children to preschool or localactivities, either by walking the children to and from thecentre or facility, or by providing transportation (Infopoint 22). Provide Jamies parents with brochures ofcommunity activities, programs, and services(preferably available in your waiting room) (Info point13) and suggest that they contact one of theparticipating organizations about suitable programming.If the cost of programs is a concern, suggest that

Jamies parents investigate municipal programs orofferings of not-for-profit organizations like YMCAs orYWCAs, where subsidized programs and services areavailable.

Case 2: Farah W., age 8, female

How could you determine if Farah is getting therecommended amount of activity for her age?

The patient requesting support for something that is notnecessarily medical always represents a difficultsituation. Frequently, it will require some exploration ofthe issues to understand both the child and the parentspoints of view as well as some tact and provision ofinformation.

If Farahs mother seems concerned about a medicalcondition causing the exhaustion, it may be necessary,at some time, to perform a physical examination and/orother testing to provide reassurance. Address otherbarriers to physical activity that might be causingconcern for both Farah and her mother.

When illness has been ruled out, then Farah could beasked for more information about her daily activityhabits.

Talking Tips What kinds of activities do you and friends

do? How much time each day do you spend in

physical education at school? Do you belong to any sports teams either at

school or in the community? What do you do after school? What kinds of activities do you do with your

family (brothers and sisters)? How much time do you spend watching

television, surfing the net, or playing videogames?

(See Appendix 1 for more suggestions)

If it appears that Farah participates on school teams, isactive at recess, and has numerous lessons (violin,ballet, gymnastics, piano, swimming) throughout theweek, counsel Farahs mother about the benefit ofunstructured time and creative play.

If you have determined that Farahs current level ofactivity is insufficient to achieve the necessary healthbenefits, provide Farahs mother with information on the


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amount of physical activity that is normal and healthy foran 8-year-old.(Appendix 4)

Note that if Farah takes 12 to 15 minutes to walk toschool (a reasonable, moderate pace), her totalaccumulated walking time would be 25 to 30 minutes.The daily walk to school, then, is less than the optimalrecommendation of moderate accumulated activity perday including 15-minute individual bouts of exerciseand Farah should consider increasing her daily physicalactivity by 30 minutes (Appendices 4 and 5 and Infopoint 8).

What strategies could help Farah become morephysically active?

Ask Farah and her mother to consider purchasing apedometer to determine if Farah is getting an adequateamount of physical activity. Provide Farah and hermother with a Pedometer Exercise Prescription(Appendix 7) and information about how to obtain a freebooklet on pedometers (available from the AlbertaCentre for Active Living, Appendix 3, # 9). Theprescription and booklet will explain the purpose ofpedometers as well as how to undertake and record thistype of exercise. Encourage Farahs mother to walk andplay with her daughter and oversee her chart-keepingactivities as a means for providing vital support andmotivating feedback (Info point 25). As is appropriatefor an 8-year-old, the pedometer results will provideinformation on the volume of Farahs daily activity butnot the intensity (Info point 26). The idea behind thestrategy is simply to get Farah more active by engagingher in a self-monitoring, quantifiable measure to charther progress. As an alternative strategy, help Farah choose one or twoactivities that she really enjoys doing and that can bedone after school or on weekends. Provide her with aCall to Action prescription (Appendix 5), and check offthe activity preferences and the recommended increaselevels, that you have determined in prior discussion.Also refer Farah and her mother to recreation activitiesbrochures (preferably available in the waiting room) andsuggest they investigate some of the communityrecreation programs that might interest Farah, such asswimming, dancing, after-school clubs, martial arts, ormartial arts alternatives (Info point 24). These activitiescan be used to fulfill the goal activity requirements in theprescription. Farah and her mother can considerparticipating in these activities together (Info point 17).Often organizations like the YWCA will have combinedclasses for parents and children.

How could you address the mothers concernsabout Farahs walking to school?

If Farahs mother is concerned about her child walkingalone to school, she could organize a neighbourhoodparent cooperative (as in Case 1) and create a walkingschool bus (Appendix 3) where a group of youngsterswalk together to and from school, perhaps accompaniedby a parent who works from home (a great way toincrease the physical activity level of the parent at thesame time). Perhaps Farah could walk to school withother children who live in her neighbourhood. If there isa concern that is not related to physical capability (forexample, bullies on the way to school, taunting),another child may be having a similar problem. AskFarahs mother if she would consider telephoninganother mother to explore this possibility.

Case 3: Rob S., age 13, male

How could you use this opportunity to initiate adiscussion with Rob about physical activity?

Here is another opportunity to Ask, Assist, and Advise.During Robs examination, brief discussion on hiscurrent physical activity level might open withSometimes fatigue and lack of energy can actually bethe result of not enough physical activity. Describe forme your activity during a typical day. What activities doyou prefer?. The written prescription could recommendthat, until the cold abates, Rob bundle up and do two10-minute sessions of light activity each day in thefresh air (like walking or bike riding) until his return visitin 2 weeks. Remind him about his personalresponsibility for getting better (Info point 30).

An intervention during an unrelated visit is typicallybrief, simply an awareness-raising or planting-of-the-seed for a follow-up visit in a couple of weeks (Infopoint 5). To ensure that Rob returns to see you,schedule a follow-up appointment to discuss the resultsof a throat swab or blood work, and Robs progress onthe written prescription. This is an opportune time inRobs life to intervene because physical activity levelsdrop drastically between grades 7 and 11, and it iseasier to keep adolescents participating in physicalactivity than it is to overcome the inertia of inactivity.

How could you assist Rob in getting therecommended amount of activity for his age?


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Talking Tips Including your physical education classes,

how much time did you spend in physicalactivity in the last 2 days (the last week?)

What do you and your friends usually doduring your free time?

What do you generally do when you gethome from school?

How much time do you spend watchingtelevision, surfing the net, or playcomputer/video games each day?

What kinds of activities do you do as afamily?

A couple of quick questions will provide a roughpicture of Robs current physical activity levels.

Rob needs to add 30 minutes daily to his activity levelsand decrease his screen time by 30 minutes (Info point8 and Appendix 4). Health Canada stronglyrecommends vigorous activity for at least 30 minutes ofthis daily total. As an ultimate goal for fitness after 5months, Rob might aim at 3 or more weekly sessions ofcontinuous moderate or vigorous activity lasting at least20 minutes each session (Appendix 4).

To engage Rob in taking responsibility for his physicalactivity, suggest that he explore sports (such asbasketball or football) where his size is an advantage.He also could experiment with less traditional andcurrently cool physical activity options such as rockclimbing, skateboarding, or kayaking (Info point 28).

Robs present size also perfectly suits a supervisedresistance training program, where extra mass isadvantageous. Supervised resistance training programsare available through the YMCA or YWCA, MunicipalRecreation Centres, Public Health Department, or localcommercial fitness centres. Rob can select from theprograms and services offered in the brochures in thewaiting room (Info point 13). As suggested in the Dareto Be Active prescription (Appendix 6), Rob can trackhis activity on a computer chart or journal that hedesigns for himself, in a daily logbook, or on a schoolday planner. Request that Rob bring his personal trackrecord with him to the next visit so that you mightdiscuss the results of his prescription and his reactionto it (Info point 30). The success that he will experiencewill positively affect his self-esteem and improve bothhis perception of, and his actual, body image (Info point1). These activities might also appeal to Robs friends,so that they could participate as a group, an importantconcept (support from significant others) in promotingphysical activity at this age (Table 1. Factors to considerin counseling about physical activity, page 4).

Mention information resources available to Rob throughthe Physical Activity Guide and provide Rob with a copyof the Lets Get Active Magazine for Youth (Appendix3). The baseline recommendations for his Dare to beActive! prescription (Appendix 6) will be determinedfrom the answers Rob gives to your questions about hisphysical activity habits and preferences. If timepermits, a couple of quick anthropometricmeasurements (e.g. waist, chest, and upper arm) wouldprovide a measurable benchmark for comparison atRobs follow-up appointment in a month, the typicallength of time that it takes to adopt or discard a potentialhabit.

How could you counter Robs reluctance tobecoming more active?

Anticipate resistance from Rob. He might say he getsplenty of physical activity during school physicaleducation classes. Discuss with him that the activityprovided at school is meant only as a supplement to thephysical activity he gets at home and through otheractivities.

Rob might better understand the relationship betweenphysical activity and his current size if he actually seesthe chart showing the percentile comparison of heightand weight. With an explanation of the percentileresults, he might begin to understand the need tobalance out his weight and his height so that they bettermatch and that increasing physical activity in thepresence of his already healthy diet should help createthis balance (Info point 23). This is a good opportunityto explore Robs poor self-image.

Rob may mention that transportation to and fromactivities is an issue. The waiting room literature willprovide low-cost activity opportunities available atcommunity centres or municipal facilities. Suggest thatRob pick up a copy of interesting brochures andrecommend that he discuss his transportation issue withhis parents. You could offer to call his parents toreinforce your prescription recommendation, raise theissue of transportation and suggest his parents considerlinking with other parents to create a car pool orhelping Rob choose activities in a facility that is withinwalking distance for Rob (Table 1. Factors to considerin counseling about physical activity, page 4).

The Foundation for Medical Practice Education,volume 11(6):1-8, June 2003

Production of this document has been madepossible by a financial contribution from the


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Population Health Fund, Health Canada. The viewsexpressed herein do not necessarily represent theofficial policies of Health Canada.

The Foundations module team would like toacknowledge, with thanks, the PBSG group facilitated byDr. Garth Verbonac, Surrey, British Columbia, who pilot-tested this educational module.

We encourage you to direct your questions andcomments to the clinical discussion bulletin boardon our website: www.fmpe.org

While every care has been taken in compiling the informationcontained in this module, the Program cannot guarantee itsapplicability in specific clinical situations or with individual patients.Physicians and others should exercise their own independentjudgement concerning patient care and treatment, based on thespecial circumstances of each case.Anyone using the information does so at their own risk and releasesand agrees to indemnify The Foundation for Medical PracticeEducation and the Practice Based Small Group Learning Programfrom any and all injury or damage arising from such use.

Authors: Francine Lemire, CCFP, FCFPFamily PhysicianMississauga, Ontario

J.W. Mackie, FACSM,DipSports Med, CCFPFamily PhysicianVancouver, British Columbia

Storm Russell, PhDPsychologistWakefield, Quebec

Reviewers: Oded Bar-Or, MD, FACSMProfessor of PediatricsHamilton, Ontario

Maureen F. Kennedy, MD,CCFP, MSc Exercise Medicine,Dip. Sport Med.Director, Fitness MDCalgary, Alberta

Medical Editor: Richard Russek, MD, CCFPFamily PhysicianCambridge, Ontario

Associate Editor: Lynda Cranston, Hons BAHamilton, Ontario

Medical Writer/ Dawnelle Hawes, BA, BKin, MEdResearcher: Hamilton, Ontario


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LEVELS OF EVIDENCE

Level ofEvidence

Therapy/Prevention Prognosis Diagnosis

1a Systematic review or meta-analysis of well-designed randomized trials using explicitcriteria for inclusion and includingadequately large total numbers

Systematic review (with homogeneity) ofinception cohort studies or a CDR(clinical decision rule or guide) validatedin different populations

Systematic review (with homogeneity) ofLevel 1 diagnostic studies; or a clinicaldecision rule validated in different clinicalcentres

1b Large randomized trials with clear-cutresults (and low risk of error)

Individual inception cohort study with$80% follow-up

Study with independent blind comparisonof an appropriate spectrum of consecutivepatients

1c All or none case-series All or none case-series Absolute positive specificity (rules indiagnosis) or negative sensitivity (rulesout)

2a Systematic review or meta-analysis of well-designed randomized trials using explicitcriteria for inclusion but still with moderaterisk of error (e.g., often with subgroupanalysis).Systematic review of cohort studies withhomogeneity

Systematic review (with homogeneity) ofretrospective cohort studies or untreatedcontrol groups in RCTs

Systematic review (with homogeneity) ofdiagnostic studies at 2b level

2b Small RCT with moderate to high risk oferror [low power]:a. Trial with high false-positive ()errorinteresting positive trend that is not statistically significant.b. Trial with high false-negative () erroranegative trial that could not exclude thereal possibility of a clinically importantbenefit or difference because of smallnumbers.Individual well-designed cohort study

Retrospective cohort study or follow-up ofuntreated control patients in an RCT orCPG not validated in a test set

Any of: Independent blind or objectivecomparison; Study performed in a set of non-consecutive patients, or confined to anarrow spectrum of study individuals (orboth), all of whom have undergone boththe diagnostic test and the referencestandard; A diagnostic CDR not validated in a testset

2c Audit or Outcomes Research Audit or Outcomes Research

3a Systematic review of case-control studieswith homogeneity

Prospective or retrospective cohort studyof adequate size, but with somelimitations in methodology

Systematic review with homogeneity of 3bstudies

3b Individual well-designed case-control study Study with independent blind comparisonof an appropriate spectrum, but thereference standard was not applied to allstudy patients; Non-consecutive study

4 Case-series; Cohort and case-control studies that lackdefined comparison groups and/or did notmeasure interventions & outcomes insimilar and appropriate ways

Poor quality prognostic cohort studies inwhich sampling was biased ormeasurement of outcomes achieved in


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11. Evidence for Policy and Practice (EPPI-Centre). Young people and physical activity: a systematic review of research onbarriers and facilitators. Information and Co-ordinating Centre, editor. 1-186. 2001. London, UK, Social Science ResearchUnit; University of London. Accessed on Jan. 10, 2003 at : http://eppi.ioe.ac.uk

12. Craig CL, Russell SJ, Cameron C. Physical activity and the media. What messages are Canadians receiving? 1998 mediastudy: an inmedia analysis 1998. Canadian Fitness and Lifestyle Research Institute1998 Capacity Study

13. Sallis JF, Prochaska JJ, Taylor WC. A review of correlates of physical activity of children and adolescents. Med Sci SportsExerc 2000; 32(5):963-975. PMID:10795788

14. Canadian Fitness and Lifestyle Research Institute. 2001 Physical Activity Monitor. The data for the North: Interim report.2001 Physical Activity Monitor 2002. Accessed at: http://www.cflri.ca

15. Corbin CB, Pangrazi RP. Guidelines for Appropriate Physical Activity for Elementary School Children. 2003 Update.National Association for Sport and Physical Education 2002; Position Statement. Council for Physical Education for Children(COPEC). Accessed on Jan.7 at http://www.aahperd.org/naspe

16. Bar-Or O. Physical Activity in Children and Youth - Practice Based Small Group Learning Program. 23-4-2003. PersonalCommunication

17. Health Canada. Teacher's Guide to physical activity for youth 10-14 years of age. Canada's Physical Activity Guide toHealthy Active Living 2002. Accessed online at http://www.healthcanada.ca/paguide or 1-888-334-9769

18. Epstein LH, Paluch RA, Kalakanis LE, Goldfield GS, Cerny FJ, Roemmich JN. How much activity do youth get? Aquantitative review of heart-rate measured activity. Pediatrics 2001; 108(3):E44. PMID:11533362

19. Pipe A. Get active about physical activity. Ask, advise, assist: get your patients moving. Can Fam Physician 2002; 48:13-13.


12

PMID:11852603

20. Canadian Fitness and Lifestyle Research Institute (CFLRI). Helping Children to Be Active. The Research File 1999;Reference No. 99-02.

21. Sallis JF, Pate RR. Determinants of youth physical acitivity: FITNESSGRAM Reference Guide. The FITNESSGRAMReference Guide 2001. Accessed at: http://www.cooperinst.org

22. Canadian Fitness and Lifestyle Research Institute (CFLRI). Influences on Children's Activity. The Research File 2001;Reference No. 01-01.

23. Royal Australian College of General Practitioners TR. Putting prevention into practice. A guide for the implementation in thegeneral practice setting (Green Book), 1st edition ed. Melbourne, Australia: RACPG, 1998. Accessed on Feb. 13, 2003 at http://www.racgp.org.au

24. Stapleton S. Fat chance: How physicians can help patients lighten their load. The directions are clear: Eat your vegetables. Drink water. Exercise regularly. Still the numbers on the scale go up. How can doctors get patients to comply?amednews.com The Newspaper for America's Physician. 18-11-2002. Accessed on Nov. 11, 2002 at http://www.ama-assn.org

25. Sallis JF, Prochaska JJ, Taylor WC, Hill JO, Geraci JC. Correlates of physical activity in a national sample of girls and boysin grades 4 through 12. Health Psychol 1999; 18(4):410-415. PMID:10431943

26. Kennedy M. Physical Activity in Youth and Children. 11-4-2003. Personal e-mail Communication.

27. Canadian Fitness and Lifestyle Research Institute (CFLRI). Active & Safe Travel to School. The Research File 2001;Reference No. 01-09.

28. Sallis JF, Conway TL, Prochaska JJ, McKenzie TL, Marshall SJ, Brown M. The association of school environments withyouth physical activity. Am J Public Health 2001; 91(4):618-620. PMID:11291375

29. Crotty MT. Parents advised to find balance between TV viewing, Video Games, Computers, Homework and Physical Activityfor Children. National Heart Alliance press release . 2001. Accessed on Apr, 2003 athttp://www.irishheart.ie/news/NHApressrelease.htm

30. Tudor-Locke C. Taking steps toward increased physical activity: Using pedometers to measure and motivate. ThePresident's Council on Physical Fitness and Sports Research Digest 2002; Series 3(No. 17). Accessed on: Jan, 2003 athttp://www.indiana.edu/~preschal

31. Rowland TW. Adolescence: A 'Risk Factor' for Physical Inactivity. Research Digest (President's Council on Physical Fitnessand Sports) 1999; Series 3(No. 6). Accessed on Dec. 20, 2002 at http://fitness.gov/activity

32. Katzmarzyk P.T., Malina RM. Contribution of organized sports participation to estimated daily energy expenditure in youth.Pediatric Exercise Science 1998; 10(378):386.

33. Health Canada. Canada's Physical Activity Guide for Children. Canada's Physical Activity Guide to Healthy Active Living2002. Accessed online at http://www.healthcanada.ca/paguide or 1-888-334-9769

34. Health Canada. Canada's Physical Activity Guide for Youth. Canada's Physical Activity Guide to Healthy Active Living 2002.Accessed online at: http://www.healthcanada.ca/paguide or 1-888-334-9769

Appendix 1. SAMPLE INTERVIEW QUESTIONS, INFANT TO ADOLESCENT

Sample interview questions that might be asked during a routine health exam of an infant (5 yrs) or anadolescent (>11 yrs) (adapted from Patrick, 2002) 6

For the childDo you think physical activity is important? Why? (or whynot?) Do you think you are in good shape?Do you do something physically active most days of theweek? What time of day are you most active? (e.g. after school,after supper, on the weekends?)What physical activities do you really enjoy doing? Whichones do you really dislike doing?Do you participate in physical activities as a family? (forexample, walking, biking, hiking, skating, swimming, orrunning?)How much time each day do you spend watching televisionor DVDs or playing computer games?

For the parentDoes your child regularly participate in physicalactivity (for example on most, if not all, days of theweek?)How does your child spend his/her after school hours?What are your childs favourite physical activities?What physical activities does your child dislikeparticipating in?How much time each day do you allow your child towatch television, play video games, or watch movies?Are you physically active as a family?How might you help your child become more active?

Appendix 2

Characteristics of Childrens Physical Activity15

Children are naturally more active than adolescents or adults.Activities need to be of short duration to maintain a young childs attention.Children seek concrete reasons for consistently being active not abstract reasons such as health.Children learn skills by being physically active and in mastering these skills, increase in self-confidence.Self-efficacy has a strong association with later in life adherence to a physically active lifestyle.Skills learned in childhood will sustain leisure activities during adulthood.High intensity activities may be discouraging for some children.Although inactive children tend to become inactive adults, the opposite is not necessarily true.

Appendix 3. RESOURCES

Free resources for children and youth

1. Health Canada. These resources are colourful and age-appropriate. Available to everyone(1-888-334-9769) or at http://www.healthcanada.ca/paguide

For school-age children (ages 6-9) For Youth (ages 10-14)

Gotta Move! Interactive magazine for childrenPhysical Activity Guide for Children (single page)Physical Activity Chart & Activity Stickers

Lets Get Active! Interactive Magazine for Youth Physical Activity Guide for Youth (single page)

Helpful free resources for Parents2. Health Canada

(1-888-334-9769) or at http://www.healthcanada.ca/paguideFamily Guide to Physical Activity for ChildrenFamily Guide to Physical Activity for YouthHelping your children become more physically active: Tips for parents and caregivers (fact sheet) athttp://www.hc-sc.gc.ca

3. Caring for Kids. http://www.caringforkids.cps.ca or telephone 1-613-526-9397Child health information from Canadian Paediatric Experts. Excellent resource on a wide variety of child- andteen-rearing topics, such as:Promoting good television habitsKeeping kids safe.Health active living.

4. Go for Green. http://www.goforgreen.caActive and Safe Routes to School: brochure: activities one can start in the communityDid you know? A childs ability to assess potential traffic dangers: Fact Sheet (the Canadian Institute of ChildHealth- CICH)Walking/Cycling School Bus: brochure: practical tips and advice for starting.

5. Safe Kids Canada http://www.safekidscanada.ca Provides information on safety aspects for children under 5 years and a variety of other safety issues includingwinter, water, and playground safety.

6. Caring for Kids Canadian Paediatric Society http://www.caringforkids.cps.ca

7. Keep Kids Healthy Free pediatricians guide for all kinds of parenting issues http://www.keepkindshealthy.com

Parenting Tips for newborn through adolescence including Fitness and Exercise Guide

8. Kids Health American Academy of Family Physicians http://www.kidshealth.org also http://www.familydoctor.org helpful tips on a variety of topics from exercise to preventing abductions, frombicycle safety to weight management.The Parent Package http://www.ama-assn.org/ama/upload/mm/39/parentinfo.pdfA series of online booklets providing parents with information about their adolescents on 15 different topicsincluding: PHYSICAL ACTIVITY, injuries, violence prevention, cigarettes, alcohol, illicit drugs, depression, sex,HIV/AIDS, nutrition, making responsible choices, growth and development, and vaccinations

9. PedometersFor information: Watch Your Step: Pedometers and Physical Activity. WellSpring, 2003, Vol. 14(2) published bythe Alberta Centre for Active Living. (8 pgs.) Available free of charge at (780) 4276949 (toll-free in Alberta only: 1-800-661-4551) or online at http://www.centre4activeliving.ca/Publications/WellSpring/index.htm

How to effectively use your pedometer! Step by step guide and Q & A. http://www.pedometer.com (Mar., 2003)

-Available at local sporting goods stores, the Running Room or fitness equipment stores

-Bally Kids Go the Distance Pedometer, $14.99, currently available through Avon catalogues, also online auctionsat http://cgi.ebay.com (Mar., 2003)

Pokemon, Pikachu 2,website information http://www.amazon.co.uk

-A variety of pedometers (including Pokemon, Pikachu 2) available online through http://half.ebay.com/ orhttp://pages.ebay.ca/index.html (type in pedometer). Lots of choices, including a wristwatch option.

Helpful resources, tools, fact sheets for physicians

10. Evidence-base Resource Sheets. Canadian Task Force on Preventive Health Care (CTFPHC)http://www.ctfphc.orgRourke Baby Records

11. Put Prevention into Practice (PPIP) Agency for Healthcare Research and Quality (AHRQ)http://www.ahcpr.gov contains physician preventive care fact sheets, charts, and reminder postcards

12. Putting Prevention into Practice The Royal Australian College of General Practitioners (RACPG)a monograph on the implementation of preventive care in practice with helpful and practical appendiceshttp://www.racgp.org.au

Appendix 4

Comparison of activity guidelines: Physical activity for children and youth

Guidelines for Appropriate Physical Activity for Elementary School Children. Corbin & Pangrazi, 2003 15

Children (elementary school age)15 Adolescents (ages 11-21 years)15

It is recommended that children get at least 60 minutesand up to several hours daily of accumulated activityappropriate for age and skill level on all, or most, daysof the week.

For optimal ongoing health benefits, 50% of childrensactivities should occur in 15- minute bouts (or more),alternating with brief periods of rest.

Children who spend excessive time watching television,playing computer games, or surfing the net, areunlikely to meet the minimum physical activityguidelines above

A minimum of 30 to 60 minutes of accumulatedphysical activity

3 or more sessions per week of activities that arecontinuous in nature, lasting 20 minutes or more at amoderate to vigorous intensity

Physical Activity Guidelines from Health Canada for Children and Youth (aged 6-14 years)33,34 (See PatientInformation Sheet for prescription)

An increase of 30- 90 minutes daily of physical activity accumulated in 5- to 10-minute bouts of activity A minimum of 30 minutes daily (as part of the total above activity, not in addition to it) should be spent in vigorous

activity such as running, basketball, or soccer A subsequent decrease of 30 to 90 minutes daily of sedentary activities

Patient Information Sheet (Appendix 5)

LL Call to ACTION!Activity prescription for 6 to 10 year-olds

Name: _________________________ Phase (circle mth of intervention)1 2 3 4 5

What is itCalled?

What Can I Do? How Often ? How Much MORE should I do?

ENDURANCE:

Activities thatuse ENERGY!

GG riding your bikeGG swimmingGG playground (swings, slides)GG walking (quickly)GG tobogganing, winter playGG skating (relaxed)GG ballet or dance class (relaxed)

Every day Increase your playtime by:9920 minutes (Phase/Mth 1)9930 minutes (Phase/Mth 2)9940 minutes (Phase/Mth 3)9950 minutes (Phase/Mth 4)9960 minutes (Phase/Mth 5)

ENDURANCE:

HIGH ENERGYactivities!

GG riding your bike (for a longtime)

GG skating, inline skatingGG soccerGG running, joggingGG basketball, volleyballGG energetic dancing GG hockeyGG high energy ballet or dance

class GG _______________

Every day Increase your very active play by:9910 minutes (Phase/Mth 1)9915 minutes (Phase/Mth 2)9920 minutes (Phase/Mth 3)9925 minutes (Phase/Mth 4)9930 minutes (Phase/Mth 5)

DECREASE TIME AT

Sitting Activities

GG sitting in front of the TVGG sitting doing computer gamesGG sitting playing video gamesGG surfing on the internetGG ________________

Every day Decrease your sitting-in-front-of-a-screen time:9920 minutes (Phase/Mth 1)9930 minutes (Phase/Mth 2)9940 minutes (Phase/Mth 3)9950 minutes (Phase/Mth 4)9960 minutes (Phase/Mth 5)

Adapted from: Green Prescription, Hillary Commission, Ministry of Health, Wellington, NZ,, Canadas Physical Activity Guide forAdapted from: Green Prescription, Hillary Commission, Ministry of Health, Wellington, NZ,, Canadas Physical Activity Guide forChildren, 2002, with information from the Canadian Fitness and Lifestyle Research Institute 2001 Physical Activity MonitorChildren, 2002, with information from the Canadian Fitness and Lifestyle Research Institute 2001 Physical Activity Monitor

Put a sticker on your poster or fridge calendar every time you follow all the doctors suggestions fromthe chart above.

Bring your finished calendar or poster to your doctor by the following date:_________, 2003

Doctors Signature: _______________________ Date: __________

Feel Free to Copy this Sheet


LL Dare to be ACTIVE!Dare to be ACTIVE!Physician-Patient Physical Activity Contract for YouthPhysician-Patient Physical Activity Contract for Youth

Name of participant: _____________________________ Phase (mth of intervention)1 2 3 4 5

What Can I Do? How Often? How Long Do I Do It?

ENDURANCE:

ModerateActivitiesthat useenergy

GG brisk walking (to the mall, to yourfriends, to school)

GG bike ridingGG swimmingGG exercising at homeGG skateboarding (stop & start)GG supervised weight trainingGG bowlingGG baseball, softballGG Alpine skiing

Every day Increase your moderate physicalactivity by:

9920 minutes (Phase/Mth 1)9930 minutes (Phase/Mth 2)9940 minutes (Phase/Mth 3)9950 minutes (Phase/Mth 4)9960 minutes (Phase/Mth 5)

ENDURANCE:

VigorousHigh energyactivities

GG running, joggingGG bicycling (brisk & continuous)GG basketball, volleyball GG dancing (fast)GG inline skating, boarding (snow or

skate) (continuous)GG soccer, football GG shoveling snow, raking leavesGG gymnastics, aerobicsGG tobogganing, ice skating

Every day Increase your vigorous activity by:

9910 minutes (Phase/Mth 1)9915 minutes (Phase/Mth 2)9920 minutes (Phase/Mth 3)9925 minutes (Phase/Mth 4)9930 minutes (Phase/Mth 5)

DECREASETIME

SittingActivities

GG sitting in front of the TVGG sitting doing computer gamesGG sitting playing video gamesGG surfing on the internetGG ________________

Every day Decrease your sitting-in-front-of-a-screen time:9920 minutes (Phase/Mth 1)9930 minutes (Phase/Mth 2)9940 minutes (Phase/Mth 3)9950 minutes (Phase/Mth 4)9960 minutes (Phase/Mth 5)

Adapted from: Green Prescription, Hillary Commission, Ministry of Health, Wellington, NZ,, Canadas Physical Activity Guide for Youth, 2002, withAdapted from: Green Prescription, Hillary Commission, Ministry of Health, Wellington, NZ,, Canadas Physical Activity Guide for Youth, 2002, withinformation from the Canadian Fitness and Lifestyle Research Institute 2001 Physical Activity Monitorinformation from the Canadian Fitness and Lifestyle Research Institute 2001 Physical Activity Monitor

On a computer program log of your own design, on a calendar, or in your school planner, record the totaltime that you participate in each of the above categories and describe how you feel during each activitysession.

Bring in your completed scheduler to your doctor on : ___________________ (Appt date)

Signed: _______________________________ Date: __________Doctors Signature: _______________________



Name:__________________________________________

D.O.B.: _____ /_________/____________

Phone No.: (_____) - ____________________________

LL PEDOMETER EXERCISE PRESCRIPTION LL

I want you and your family to work with me to make sure you are getting enoughphysical activity to keep you healthy, happy, and doing well in school. This tool is afun way to discover how much activity you are getting and to measure increases inyour activity level toward an even healthier YOU! This is how it works.

1. For this experiment, you will need a pedometer, available at local fitness equipment stores, sportinggoods stores, the Running Room retail stores, or through an AVON representative (inquire about a ABally Kids pedometer $14.99).

2. Clip the pedometer to your waist and wear it from the time you get up until the time you go to bed.3. The pedometer will measure every step that you take all day long: going to school, playing at recess, at

lunch, after school, and after supper.4. At the end of each day, record the number that is displayed on the pedometer on your Health Canada

Physical Activity Chart (available free with stickers from Health Canada 1-888-334-9769).5. To set your starting point (Level), measure and record the number of steps you take each day for 3 days.

If that number is below 10,000 steps, start at Level 1. For any number of steps higher than 10,000, startat the closest level (e.g. if your total is 12, 342 steps for any one day, start at level 8)

6. When you the steps you take in a day matches the goal for your level, put a sticker on your calendar andshare this information with your parents.

7. Dont forget to reset the pedometer to 0 (zero) each night before going to bed, so it will be ready to puton the following morning.

8. Challenge your family to try to keep up with you!

Pedometer Prescription Recommendations

Level Beginning of week End of week

1 10,000 10,500

2 10,500 11,000

3 11,000 11,500

4 11,500 12,000

5 12,000 12,500

6 12,500 13,000

7 13,000 13,500

8 13,500 14,000

9 14,000 15,000

10 15,000 16,000 Congratulations !!!

Bring in your completed poster with all the information on the following date: ______________________,200_____

Signature of doctor: _________________________________Date of prescription: ______________________, 200_____


Documents

Physical Activity for Children