Childhood obesity is a worldwide disease. The World Health Organization estimates that 22 million kids under age 5 are obese, and the vast majority of obese adolescents will become obese adults (1,2). A strong relationship exists between weight and physical activity level in children and adolescents (2). Weight increases as physical activity levels decline (2). A recently published article demonstrates a profound decrease in regular activity by adolescents compared with younger children. Nearly all of the 9-yr-old children (>99%) were meeting recommended weekday physical activity levels compared with 30% of 15-year-old adolescents (3).
The purpose of this article is to 1) review the literature regarding the relationship between physical activity (PA) and child obesity, including clinical and public health recommendations for child/adolescent PA; 2) discuss office-based physical activity promotion for the prevention of overweight and obesity in children and adolescents; and 3) provide strategies for quality improvement related to office-based PA promotion for children and adolescents.
From the age of 2 yr, girls are less active than boys. This gap between the sexes is greatest during adolescence. By the age of 13 to 15 yr, only 41% of girls reach the recommended minimum levels of PA compared with 68% of boys (4).
This accelerated decline in teenage years continues into adulthood and later life. While PA declines with age, time spent in sedentary activities steadily increases with age (5).
Child PA is highly influenced by parental PA levels. Parent inactivity is a strong predictor of child inactivity (6). Likewise, the frequency of parents watching television with their children has been found to be positively associated with children's television viewing (7), whereas children whose parents are active with them are reported to have higher levels of physical activity (8).
There is a strong evidence base linking physical inactivity and obesity in children and adolescents. In a recently published article, investigators found that for each weekday that adolescents participated in physical education, the odds of being an overweight adult decreased by 5% (2). Similarly, PA also is highly linked to screen time. As screen time increases, vigorous activity declines and body mass index (BMI) increases (9).
PHYSICAL ACTIVITY RECOMMENDATIONS
The American Heart Association (AHA) (10) and the American Academy of Pediatrics (AAP) (11) have published guidelines for PA in children and adolescents. These guidelines are meant to serve as a guide for practitioners as well as parents and their children regarding appropriate levels of PA to maintain health and prevent disease. The AHA recommends that all children aged 2 yr and older should participate in at least 30 minutes of enjoyable, moderate-intensity physical activity every day. Activities should be developmentally appropriate and varied. This activity can be performed continuously or broken up into shorter time periods, such as two 15-min periods or three 10-min periods.
The AAP, through their Active Healthy Living: Prevention of Childhood Obesity through Increased Physical Activity (11), encourages children and adolescents to be physically active for at least 60 minutes per day, which may be accumulated over the course of a day in smaller increments. Events should be of moderate intensity and include a wide variety of activities as part of sports, recreation, transportation, chores, work, planned exercise, and school-based physical education classes. These activities should be primarily unstructured and fun if they are to achieve best compliance.
Healthy People 2010 has specific goals related to child and adolescent PA (12). These include 1) to increase the proportion of adolescents who engage in moderate PA for at least 30 min on 5 or more of the previous 7 d from a baseline of 27% in 1999 to 35% by 2010; and 2) to increase the proportion of adolescents who engage in vigorous PA, which promotes cardiorespiratory fitness, at least 3 d each week for at least 20 min per occasion from a baseline of 65% in 1999 to 85% by 2010.
To meet the Healthy People 2010 goals, physicians caring for children, adolescents, and their families need to take a more proactive role in screening for physical inactivity and promoting PA on a regular basis to reinforce the public health message regarding the benefits of PA and the risks related to physical inactivity. The AAP states that "promoting physical activity should be a priority in every physician setting, a patient's level of physical activity should be assessed at every well-child visit, and it is important to determine the child's readiness to make a behavior change, as well as to identify potential barriers to change" (11).
Steven Blair, P.E.D., FACSM and Timothy Church M.D., Ph.D., in an article published in the Journal of the American Medical Association, "The Fitness, Obesity, and Health Equation Is Physical Activity the Common Denominator?" (13) came out with one of the strongest statements regarding the role of physicians in physical activity promotion, stating that "The medical community needs to lead in communicating the importance of physical activity for health and weight maintenance. Just as weight is addressed in some manner at nearly every physician visit, so should attention be given to recommending the accumulation of 30 minutes a day of moderate intensity physical activity at least 5 days of the week."
WHEN SHOULD YOU START PA COUNSELING?
According to the Utah Prams Data Book, the proportion of women who were overweight or obese before becoming pregnant increased from 25.1% in 1991 to 35.2% in 2001, making obesity the most common chronic disease of pregnancy (14). The consequences of maternal obesity on the childhood obesity epidemic have been highlighted in several studies. As maternal BMI in the first trimester increases, the adjusted odds of child overweight increase proportionately (15). Similarly, after adjusting for a number of factors including maternal pre-pregnant BMI, excessive gestational weight gain is associated with a higher likelihood of the child becoming overweight (16). The best predictor of postpartum weight retention is excessive weight gain during pregnancy (17). Exercise during pregnancy has been found to reduce the likelihood of excessive weight gain, and women who exercise in the postpartum period are less likely to retain their pregnancy weight gain (18). As the vast majority of women (>90%) who exercise during pregnancy continue to exercise after birth (19), it is important that prenatal care providers encourage pregnant women to participate in physical activity during pregnancy.
AMERICAN ACADEMY OF PEDIATRICS PHYSICAL ACTIVITY RECOMMENDATIONS
Infants and Toddlers
Structured exercise programs or classes are not necessary for infants and toddlers. Parents should provide opportunities for safe, developmentally appropriate play activity. These activities may include walking in the neighborhood, walking through a park or zoo, unorganized free play outdoors such as running around a playground and exploring the backyard, or playing with age-appropriate equipment and toys. Structured play as exercise is not necessary for toddlers; they are constantly on the move (20). It's important to keep in mind that "graduating to training pants doesn't necessarily signal a readiness for structured sports programs with equipment and rules and expectations of victory or failure" (21).
Preschool Children (4-6 Yr)
To encourage a lifetime of PA, parents and guardians should provide activity opportunities that are fun, playful, and safe. Preschool-aged children should be encouraged to participate in activities that emphasize exploration and experimentation to engage their imagination and begin the motor learning process for certain activities such as running, kicking, catching, and throwing a ball. Preschoolers also can tolerate walking longer distances with their parents and siblings. To encourage a habit of active transportation, it isappropriate and encouraged that children walk to local grocery stores, libraries, etc., rather than driving in a car orriding in a stroller. Screen time should be limited to less than 2 h a day (20).
Elementary School-Aged Children (6-9 Yr)
Elementary school-aged children should work on improving motor skills, visual tracking, and balance. Free play should be encouraged and may involve more sophisticated movement patterns with emphasis on fundamental skill acquisition (20). Examples of this may include dancing, jump rope, and miniature golf. Organized sports may be initiated for this age group, with a focus on enjoyment rather than competition (20).
Middle School-Aged Children (10-12 Yr)
The motivation for participation in PA begins to shift for children in this early adolescent age group. Bringing attention to the social and physical benefits of regular participation may serve to promote regular participation. Physical activities for middle school-aged children can shift toward skill development, with an increasing focus on tactics and strategy. Supervised weight training, emphasizing proper technique with small weights and high repetitions, is appropriate for middle school-aged children. Certain weight training activities such as the use of heavier weights and maximum lifts (squat lifts, clean and jerk, dead lifts) should be avoided (20).
This is a critical age for the promotion of lifetime PA, especially since recent evidence has demonstrated that girls are most likely to drop out of PA at this time. Given the profound influence of peers, it is essential that adolescents find activities that are fun and involve their friends and peer group. Organized sports are often a venue that supports regular PA. Other age-appropriate activities for individuals in this age group include fitness activities such as aerobic dance, karate, yoga, strength training with free weights and machines, active transportation such as walking or biking to school, and household activities that promote energy expenditure like gardening and yard work (20).
OFFICE-BASED PHYSICAL ACTIVITY COUNSELING
Before embarking on counseling for inactive, insufficiently active families (younger children) or adolescents, it is wise to understand their current stage of change regarding PA, or your counseling efforts may be inappropriate. Table 1 outlines Prochaska's Stage of Change model related to PA behaviors (22).
For patients/families in the precontemplation phase, providing information regarding the benefits of PA and risks of physical inactivity is an appropriate course of action. Those who have reached even the contemplative phase are ready for more action-oriented counseling. The 5As model that has successfully been utilized in tobacco cessation has been modified for PA counseling. Table 2 includes a list ofpotential questions for patients for each of the 5As.
Regardless of their stage of change, parents should be asked to recall the number of times per week their child plays outside for at least 30 min, as well as the number of hours per day their child spends in front of a television, video game, or computer screen. Adolescents should be asked about the number of days they achieve 30 min of vigorous activity and/or 60 min of moderate intensity activity.
What to tell parents:
- Be a role model for your children. If children see you being physically active and having fun, they are more likely to be active and stay active throughout their lives.
- Involve the whole family in PA like hiking, biking, basketball, tennis, skiing, or other activities.
- Focus on fun. Capitalize on the PA accumulated during activities like walking in the mall, to local stores, libraries, cafes, during activities like snow sledding, walking in the park, or playing golf. Older and younger children can help with household tasks such as car washing, lawn mowing, and gardening. Offering active options like joining a local recreation center or after-school program, or taking lessons in a sport or activity they enjoy, such as swimming, tumbling, cheerleading, dance, or karate lessons.
- Encourage your child to be physically active every day.
Changing the PA behaviors of an individual or family can be difficult. Physicians do not counsel their patients on PA for a multitude of reasons: a belief that it is futile, inadequate knowledge, inadequate time, and poor reimbursement, to name a few. To succeed, not only must the patient's barriers be overcome, but also those of the physician. Using the 5As as a framework, we have developed some tools, strategies, and systems to help clinicians overcome some of the barriers to office-based PA promotion.
PA assessment tools can help with the "ask." Because parental PA level is the most important predictor of child PA (8), it is important that clinicians ask not only children about their PA level, but also ask about the PA level of parents or guardians. The Physical Activity Vital Sign (PAVS) (Fig. 1) is one such tool. The PAVS is a two-question tool designed to be administered by a nurse or medical assistant at the start of a patient care visit that assesses moderate intensity PA. Its simplicity and brevity make it a reasonable tool to include as part of well-child visits or visits related to physical activity (e.g., weight management, consequences of overweight or obesity - diabetes mellitus, hyperlipidemia, hypertension, and musculoskeletal concerns). Recommended PA levels for adults are 30 min of moderate intensity PA 5 d each week, or 20 min of vigorous PA three times per week. Parents or guardians who are meeting this standard should be educated regarding appropriate levels of PA to promote health and prevent disease, and a "family-centered" approach to PA promotion should be undertaken.
The PAVS also is a reasonable tool to use with adolescents ages 13 yr and older, as they are capable of understanding the questions, but the recommended levels of PA for adolescents are higher than that for adults - upwards of 60 min of moderate to vigorous PA on at least 5 d of theweek.
PA assessment in children can be more difficult. Asking a 6-yr-old child the PAVS questions would yield little in the way of useful information. To be useful, a tool must provide clinically relevant information, possess reasonable validity and reliability, and be simple and short enough to be part ofa 15- to 20-min ambulatory visit. While there are no validated office-based clinical PA assessment tools for children, the following questions could provide valuable information regarding current physical activity levels:
- How many days of physical education do you participate in at school in a week?
- How many days in a week do you run, bike, swim, or play sports for 1 h?
- On average, how many hours each day do you spend in front of a screen, either television or computer, outside of school?
Answers to these questions fit in nicely with the 5-2-0-1 framework and can lead to discussions regarding currently recommended levels of PA as well as screen time. It also gives an opportunity to educate parents on their role as advocates for school-based PA. As concerns for academic rigor within schools increase and because of consequences of the No Child Left Behind legislation, schools have cut back on the amount of time children have physical education classes. It is not uncommon for adolescents to have no structured physical education classes as part of their high school curriculum (23). Parents can be empowered to ask school officials about the amount of PA their child/children are getting at school and request that physical education be a required part of the school curriculum.
Advise is the next step in the 5As model. Advice should be personalized, clear, and strong. To a parent whose child is depressed, you might consider advising, "Obesity is associated with an increased risk of depression in kids. Regular physical activity will result in better control of your/your child's weight, and less depression risk. Increasing your physical activity will not only improve how you feel, but also reduce your risk of depression. My advice to you is to increase your physical activity to 60 min a day. Would you like to discuss how you might do that?" Answers to these questions set the stage for education regarding adequate amounts of PA to promote health and prevent disease.
The 5-2-0-1 message advocated by the American Academy of Pediatrics should be a part of Advise during all well-child visits. This refers to 5 servings per day of fruits and vegetables, 2 h or less of screen time, 0 servings of sugar-sweetened beverages, and 1 h a day of PA.
Assessment comes next and largely is focused upon understanding barriers to change, previous efforts that may have failed, as well as a patient's or family's readiness to change. Discuss past experience with changing the patient or family's PA. It is important to identify barriers, high-risk situations for failure, as well as what worked and didn't work during past efforts to increase PA. Specific questions such as "Have you tried to increase your child's/family's physical activity in the past? What changes did you make? What worked and what did not? What barriers do you think will prevent you from achieving your goal? Are there particular times you know this will be difficult?" may be helpful in determining areas to focus upon.
Providing patients and families with a plan for change is the fourth A: Assist. PA can be promoted in several ways, including a printed exercise prescription generated during the course of the office visit, a "contract" for behavior change related to PA and sedentary activities, and distribution of educational materials including Web sites that offer age-appropriate and family-centered advice on PA. The Public Health Agency of Canada has published a series of booklets on PA for children, adolescents, and families, Physical Activity Guide for Children and Youth (http://www.phac-aspc.gc.ca/pau-uap/fitness/downloads.html) (24). These easy-to-read booklets offer practical advice for parents, children aged 6 to 9 yr, adolescents aged 10 to 14 yr, and schoolteachers regarding strategies for achieving a physically active lifestyle.
Finally, it is important that providers arrange for follow-up to support and reinforce their patients' behavior change related to PA. This often overlooked step is key in that it underscores the importance of PA to the health and welfare of patients. It provides an opportunity to measure improvement, to overcome barriers, and advance the exercise prescription.
CONTINUOUS QUALITY IMPROVEMENT AS A MOTIVATOR FOR CHANGE
Now that primary care providers in both pediatrics and family medicine are required to participate in ongoing quality improvement efforts to maintain their specialty Board certification (25), changing office systems to improve the delivery of healthcare in this critical area canserve two purposes - helping patients and their familiesandimproving the practice. The scope of this article prohibits a lengthy discussion of the quality improvement process, but using the framework of the 5As, or in this case the 4As, a practice can identify areas of health care delivery that they want to address, design an intervention to achieve that aim, and implement a measurement strategy to assess success. Table 3 outlines aseries of aims, interventions, and measurements that couldbe carried out in the ambulatory setting to improve office-based PA promotion.
Appendix A at the end of this article includes a Patient Exit Survey that can be used to measure change in clinic systems and provider behavior related to PA counseling. Although untested, it also may serve as a tool that further reinforces the importance of PA counseling by providers as well as reinforces this counseling in patients. It is important to measure baseline characteristics of the practice and/or practitioner before implementing a change. In this way, thePatient Exit Survey can be used at both stages, before andafter an intervention, to measure change. Typically, thepatient (or his or her parent, depending on the age ofthe patient) would be asked by a medical assistant or nurse to complete the Patient Exit Survey at the conclusion of the visit.
Children and adolescents in the United States are becoming increasingly overweight and underfit (26). Despite U.S. Preventive Services Task Force recommendations to the contrary (27), there is a strong need for physicians to participate in PA promotion (28). To succeed in this effort where many others have failed requires that physicians and other primary healthcare providers are knowledgeable regarding physical activity guidelines, have both the knowledge and skills related to office-based counseling for PA, and have in place systems that support these efforts. Continuous quality improvement efforts can serve as a motivator to change practice systems and provider behavior to assist patients with their physical activity goals.
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APPENDIX A: PATIENT EXIT SURVEY