Promoting Physical Activity

BR IGHT FUTURE S GU IDE L INE S FOR HEALTH SUPERV I S ION OF IN FANTS , CH I LDREN , AND ADOLE SCENT S

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In recent years, a number of governmentalagencies and national organizations havefocused on the need for Americans toincrease their physical activity levels. The USSurgeon General, the Centers for Disease

Control and Prevention, andthe Presidents Council onPhysical Fitness have recog-nized and championed theimportance of physical activ-ity to overall health.2-4

Healthy People 2010lists physical activity asa leading health indi-cator and includesgoals to improvelevels of physicalactivity and reduce

sedentary behavioramong adolescents.5

In addition, the USDepartment ofHealth and HumanServices and US

Department of Agricultures DietaryGuidelines for Americans recommend thatchildren and adolescents engage in at least60 minutes of moderate to vigorous physicalactivity on most days of the week, preferablydaily.1

The dramatic rise in pediatric obesity inrecent years has increased health careprofessionals and parents attention to theimportance of physical activity. Along with abalanced and nutritious diet, regular physicalactivity is essential to preventing pediatricoverweight conditions.1,3 Therefore, healthcare professionals are encouraged to reviewthis Bright Futures theme in concert with thePromoting Healthy Nutrition and PromotingHealthy Weight themes.

Physical Inactivity: A Growing Problem forChildren and AdolescentsChildren and adolescents live in an environ-ment today in which opportunities for physi-cal inactivity are increasingly common.Children ride to school rather than walk or

Promoting Physical Activity Theme6

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INTRODUCTIONPhysical activity is an essential component of a healthy lifestyle and mustbegin in infancy and extend throughout adulthood. Regular physical activ-ity increases lean body mass, muscle, and bone strength and promotesgood physical health. It fosters psychological well-being, can increase self-esteem and capacity for learning, and can help children and adolescentshandle stress. Vigorous-intensity physical activity (eg, jogging or other aer-obic exercise) generally provides more benefits than moderate-intensityphysical activity.1 Families should emphasize physical activity early in achilds life, because, as children mature, modern culture provides manytemptations to adopt a sedentary lifestyle.


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bike, many schools are reducing or eliminat-ing physical education classes and time forrecess, many parents are afraid to let theirchildren play outside, and labor-savingdevices abound. Screens (television, videos,computers, and video games) are all aroundus, and screen time is an important com-ponent of daily life.The primary sedentary behavior for

preschoolers is watching television. Children6 years and younger spend an average of 2hours per day in front of the TV, which isabout the same amount of time they spendplaying outside.6 For adolescents, time spentwatching television represents the singlegreatest source of physical inactivity, secondonly to sleep.7 Therefore, reducing theamount of time children and adolescentsspend in front of a screen can provide oppor-tunities for them to be physically active.8

Parental awareness and assessment of screentime should encourage a balance thatincludes adequate time for physical activity.The American Academy of Pediatrics recom-mends that children younger than 2 yearsshould not watch television, and children 2years and older should limit media time to nomore than 1 to 2 hours of quality program-ming daily.9 (For more information on thistopic, see the Promoting Healthy WeightTheme.)In an environment that supports inactivity,

being physically active must be a lifelong,conscious decision. Health care professionalscan support children, adolescents, and fami-lies in this daily commitment by explainingwhy physical activity is important to overallhealth, providing information about commu-nity physical activity resources, and beingphysically active themselves.

Children and Youth With Special HealthCare NeedsChildren and youth with special health careneeds should be encouraged to participate inphysical activity, based on their ability and

health status, as appropriate. Participating inphysical activity can make their tasks of dailyliving easier, improve their health status, and,ultimately, reduce morbidity from secondaryconditions during adulthood. Health care pro-fessionals can help parents and childrenselect appropriate activities and duration byconsidering the childs needs and concerns,cognitive abilities, and social skills, as well asadaptations that will enable the child to havea positive experience.Opportunities for physical activity should

be included in the childs IndividualizedEducation Program (IEP) at school, as wellas the care plan for home services. Manyorganizations (eg, American Physical TherapyAssociation, Disabled Sports USA, andNational Sports Center for the Disabled) pro-vide information on appropriate physicalactivities and potential adaptations for specif-ic conditions and disabilities. Programs suchas the Special Olympics also can encouragechildren with special heath care needs tobecome involved with physical activity.10

Promoting Physical Activity: InfancyBirth to 11 MonthsThe first year of life is marked by dramaticchanges in the amount and type of physical

For adolescents, timespent watching televi-sion represents thesingle greatest sourceof physical inactivity,second only to sleep.

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activity the infant displays. Motor skill devel-opment begins with involuntary reflexes thatensure the infants survival. These reflexesbecome integrated as the infant gains volun-tary control over his body. All infants usuallyacquire motor skills in the same order, but therate at which these skills are acquired variesfrom child to child.At each visit, the health care professional

should provide parents with appropriate guid-ance about the childs next developmentalsteps to help them plan safe, educational,and appropriate physical activities (Box 1).Infants need parents and other caregivers toprovide consistent, lively, and developmentallyappropriate physical activity. Without ade-quate physical stimulation, infants adoptmore sedentary behaviors and tend to rollover, crawl, and walk later than babies whoenjoy physical activity with a parent orcaregiver.Part of the infants day should be spent

with a caregiver or parent who provides bothsystematic and spontaneous opportunities foractive play and physical activity. Parents or

caregivers can help the child be activethrough floor play, supervised tummy time,and all daily routines, such as diapering,dressing and bathing, pulling to sit, rollingover, lifting arms over head, pulling to stand,and helping to lift a foot for a sock. Gamessuch as pat-a-cake, peek-a-boo, and howbig is the baby? all encourage active move-ment of the infant.Giving infants freedom of movement

encourages them to explore their environ-ment and learn about their surroundings.Playpens, swings, and infant seats may beappropriate at certain times, but parentsshould be encouraged to let the infant movearound freely with close supervision. Infantwalkers and jumpers and car safety seatsshould not be used as positioning devices inthe home. Consideration should be given tofamilies who live in environments where theydo not feel it is safe for their child to explore,such as in shelters or substandard housing.Discussions with parents who live in theseenvironments can help them identify appro-priate activities so that their child can meetthe daily physical activity recommendations.Health care professionals should caution

parents not to use the television or othermedia to entertain or educate fussy orbored infants during the first years of life. Atthis stage of a childs development, television,videos, and computers are not effective toolsfor these purposes. Quiet play, such as read-ing, talking, and singing, is preferablebecause it helps the child appreciate thesocial component of physical activity andinteractivity.Infants with special health care needs may

have delays in motor movement due togenetic or metabolic conditions, prematurebirth, developmental delays, or other causes.The health care professional should provideparents with information on Early Inter-vention Services for their child. These servicesprovide support on ways to promote theinfants development within the familys dailyroutines.

Without adequatephysical stimulation,infants adopt moresedentary behaviorsand tend to roll over,crawl, and walk laterthan babies whoenjoy physical activitywith a parent or care-giver.

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BOX 1Physical Activity Guidelines for Infants Infants should be placed in safe set-tings that facilitate physical activityand do not restrict movement forprolonged periods.

Infants should be placed in settingsand environments that meet orexceed recommended safety standardsfor performing large-muscle activi-ties.

Adapted from National Association for Sport andPhysical Education. Active start: a statement of physicalactivity guidelines for children birth to five years. 2002.Available at: http://www.aahperd.org/naspe/template.cfm?template=toddlers.html. Accessed March1, 2006.11


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Promoting Physical Activity: EarlyChildhood1 to 4 YearsA primary reason for promoting physicalactivity during early childhood is to assistyoung children in mastering basic motorskills.12 As a child progresses through infancyinto the toddler years, her strength and flexi-bility increase and she is better able to controlher head and neck. Most (but not all) chil-dren develop gross motor skills in a typicalsequencewalking, marching, galloping,hopping, running, traveling around obstacles,and skipping.12 Most children also master finemotor skills (manipulation) and spatial rela-tionships during the toddler and preschoolyears. Eye-hand and eye-foot coordination,balance, and depth perception develop dur-ing the preschool years as well. Physical activ-ity can promote the mastery of these skills, allof which are important milestones in thechilds development. In addition, physicalactivity can improve physical and mentalhealth and is fun for the child.Component activities that build upon each

other include gross motor activity (largemovement skills), stability activity, manipula-tive activity (small movement or fine motorskills), and rhythm activity.12 Some activities,such as dancing, combine several of thesecomponents. Movement concepts includelearning about where and how the bodymoves, the effort it takes to move the body(eg, time and force), and the relationship ofthe body to what is around it. Structured playcontributes to stability, flexibility, and stamina.Engaging young children in all forms of

physical activity (active play and interactiveguided play) promotes the joy of movement,the sense of control, and the ability to navi-gate the body through space. The mostprevalent form of physical activity in earlychildhood is active play. Simply playing out-side (eg, walking, running, climbing, andexploring the outdoor environment) is animportant opportunity for physical activity.Interactive guided play, which includes

developmentally appropriate structured formsof physical activity, such as dancing or simplegames, allows a caregiver to help the childmaster specific motor skills in a safe andsupervised manner.Physical activity in young childhood also

has other benefits. An Iowa study of youngchildren showed that physical activity con-tributes to optimal bone development.13

Other research has shown that adolescentswho had the highest levels of activity in theirpreschool years also had lower accretion ofbody fat.14 Active play and interactive guidedplay in the young can prevent pediatricoverweight and obesity,15 and also appear toincrease self-esteem and reduce symptomsof depression and anxiety during earlychildhood.10

Young children with special health careneeds can and should enjoy physical activityas much as any other child. Depending onthe childs diagnosis and health status, suchactivities may need to be modified by par-ents, preschool teachers, child care workers,or therapists. Young children who have sig-nificant physical or cognitive impairmentsusually are enrolled in Early Intervention pro-grams where physical activity takes place aspart of the routine day. Alternatively, they arein preschool or child care settings wherephysical movement activities are adapted totheir particular disability, if necessary. Healthcare professionals can encourage families toask teachers and therapists for help in inte-grating those activities into daily routines athome. In addition, many young children withspecial health care needs (depending on thetype of disability) can be included in physicalactivities that are enjoyed by all children inthe community, from playground swings andslides to preschool gymnastic and danceclasses.

Young children withspecial health careneeds can and shouldenjoy physical activityas much as any otherchild. Depending onthe childs diagnosisand health status,such activities mayneed to be modifiedby parents, preschoolteachers, child careworkers, or therapists.

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Promoting Physical Activity: MiddleChildhood5 to 10 YearsAs children grow and develop, their motorskills increase, giving them an opportunity toparticipate in a variety of physical activities.Children may try different physical activitiesand establish one or more interests that serveas the foundation for lifelong participation inphysical activity. When children have multipleoptions for physical activity available in thecommunity, they can be encouraged toexpress their preferences, develop competen-cies, and find activities that fit their skills andinterests.During the middle childhood years, parents

are a major influence on a childs level of

physical activity. Parents should encouragetheir children to be physically active. Parentswho also participate in physical activity withtheir children (eg, walking, dancing, biking,hiking, playing outside, or participating insports such as basketball or baseball) demon-strate the importance of regular physicalactivity and show their children that physicalactivity can be fun. Children also can be influ-enced to participate in physical activity byother family members, peers, teachers, andpeople depicted in the media.Children are motivated to participate in

physical activity by having fun, by feelingcompetent, and through variety. Age-appropriate activities, coaching styles, and PR

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BOX 2Age-Appropriate Physical ActivitiesAge Motor Skills Being Developed Appropriate Physical Activities

5-6 years Fundamental (eg, running, Activities that focus on having fun andgalloping, jumping, hopping, developing motor skills rather thanskipping, throwing, catching, on competitionstriking, or kicking) Simple activities that require little

instruction Repetitive activities that do not requirecomplex motor and cognitive skills(eg, running, swimming, tumbling, orthrowing and catching a ball)

7-9 years Fundamental Transitional Activities that focus on having fun and(eg, throwing for developing motor skills rather thandistance or throwing on competitionfor accuracy) Activities with flexible rules

Activities that require little instruction Activities that do not require complexmotor and cognitive skills (eg, entry-level baseball or soccer)

10-11 years Transitional Complex Activities that continue to focus on(eg, playing basketball) having fun and developing motor skills

rather than on competition Activities that require entry-levelcomplex motor and cognitive skills

Activities that continue to emphasizemotor skill development but that beginto incorporate instruction on strategyand teamwork


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lar disease). This awareness may make themreceptive to actions that may reduce risks ofthese diseases. Health care professionals canconsider linking exercise and physical activi-ties with reduced risk of diseases that nega-tively affect their families and perhaps manypeople within their communities.Adolescents have numerous options for

regular physical activity, and the longer anadolescent participates in vigorous physicalactivity, the greater the health benefits.16

Competitive sports appeal to some; othersenjoy noncompetitive activities that providevariety and opportunities for socialization.Even those adolescents who are heavilyscheduled with school, extracurricular activi-ties, and part-time jobs can be physicallyactive through short periods (eg, 10-minuteduration) of moderate-intensity activity.

Physical activity alsocan reduce symptomsof depression andanxiety and improveoverall mood.

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BOX 3Fluid Intake During Physical ActivitySports drinks usually contain 6% to 8%sugar as well as replenishing electrolytes.They are generally beneficial for physicalactivities that last longer than 60 min-utes. For brief periods of physical activi-ty, the caloric burden of these drinksoutweighs the benefits of fluid and elec-trolyte replacement.During extremely hot weather, out-

door physical activity should be sched-uled during the coolest times of the day(ie, before 10:00 am and after 6:00 pm).10

To avoid dehydration, children andadolescents should:

Drink before feeling thirsty, becausemild dehydration occurs before thirstsets in.

Drink cool water (40F to 50F)before, during, and after physicalactivity. Drink 4 to 8 ounces of water 1 to 2hours before physical activity.

Drink 4 to 8 ounces of water every 15to 20 minutes during physical activitythat lasts longer than 1 hour.

techniques are important (Box 2).10 Feelingsof failure, embarrassment, competition, andboredom, and rigid structure, discourageparticipation.Parents should be cautioned about relying

exclusively on schools to provide physicalactivity for their child, particularly if the childis not involved in organized sports. Given theemphasis on academics, outdoor recess andphysical education have been curtailed inmany school systems.Adequate fluid intake during physical activ-

ity is important to prevent dehydration (Box3). The risk of dehydration becomes greaterwith increased heat, humidity, intensity, orduration of physical activity, body surfacearea, and sweating.

Promoting Physical Activity:Adolescence11 to 21 YearsParticipating in regular physical activity helpsadolescents develop skills and pastimes theycan enjoy throughout their lives. Like theyounger child, the adolescent who partici-pates in physical activity increases his muscleand bone strength and lean muscle mass. Inaddition, physical activity may help himreduce body fat and maintain a healthy bodyweight. Physical activity also can reducesymptoms of depression and anxiety andimprove overall mood.16 Weight-bearingphysical activity contributes to buildinggreater bone density in adolescence andhelps maintain peak bone density in adult-hood.16

Some adolescents are aware of diseasesthat affect their family or community (eg,

obesity, diabetes, or cardiovascu-


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Current recommendations note that physicalactivity can be accumulated through 3 to 6ten-minute activities over the course of a day.The accumulated total of 60 minutes daily isthe important variable for overall health andcalorie burning. The longer an adolescentparticipates in vigorous physical activity, thegreater the health benefits.16

Social and peer influences can positively ornegatively affect participation in physicalactivities. The best physical activities are thosethat adolescents enjoy. In some communities,the lack of safe places for recreation requirescreative alternatives for physical activity, suchas using the steps at school or in apartmentcomplexes.During early adolescence, girls and boys

can participate in competitive sports together.However, with the onset of puberty, weightand strength differences rapidly become greatenough to pose a safety concern. Coed activi-ties should be limited to non-collision sports.To promote participation and enjoyment forall adolescents, including adolescents withspecial health care needs, physical educationteachers and coaches should establish teamsbased on each persons skill level, size, andstrength, rather than on gender.In the pursuit of enhanced performance,

adolescents who engage in competitivesports and physical activity can be vulnerableto misinformation and unsafe practices.Pressure to achieve a competitive edge canencourage adolescents to experiment withergogenic aids or performance-enhancingsubstances (eg, anabolic steroids, creatine,and stimulants). Many performance-enhancing substances offer no benefit, andsome can adversely affect performance andendurance, jeopardize health, and underminethe benefits of training. Use of anabolicsteroids is dangerous. Although they can helpbuild muscle mass, anabolic steroids causeearly closure of the epiphyseal plates, result-ing in stunted growth. Adolescents who usesteroids also risk sterility.

Healthy People 2010 lists physical activityas a leading health indicator and includesgoals to improve levels of physical activityand reduce sedentary behavior amongadolescents.5 By encouraging increased physi-cal activity, health care professionals, programadministrators, and policy makers can helptheir communities achieve these goals anduse community resources efficiently.17

Preventing injury to adolescents duringphysical activity is a responsibility shared byparents, physical education teachers, coaches,recreation program staff, and adolescentsthemselves. (For more information on thistopic, see the Promoting Safety and InjuryPrevention Theme.) The practices listed in Box4 have been demonstrated to prevent sportsand exercise injury.

The longer an adoles-cent participates invigorous physicalactivity, the greaterthe health benefits.

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BOX 4Preventing Sports and Exercise Injury Stretch before participating in sports. Use appropriate safety equipment,such as batting helmets in baseballand softball, athletic supporter andcup for boys in contact sports, bicyclehelmets in biking, shin guards in soc-cer and field hockey, wrist guards andelbow and knee pads in in-line skat-ing, and goggles in handball and rac-quetball.

Limit duration of specific, repetitivephysical activities that require the useof the same muscles (eg, pitching orrunning).

Set an appropriate pace when begin-ning an activity and be aware of earlysymptoms of injury (eg, increase inmuscle soreness, bone or joint pain,excessive fatigue, or decrease in per-formance). Adolescents who experi-ence any of these symptoms shoulddecrease participation in physicalactivity until symptoms diminish, or,if the injury is severe, should ceaseparticipation temporarily.


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References

1. US Department of Agriculture. Dietary Guidelines for Americans, 2005. 6th ed. Washington, DC: US Department ofAgriculture, US Department of Health and Human Services; 2005

2. President's Council on Physical Fitness and Sports Web site. Available at: http://www.fitness.gov/. Accessed July 4, 20063. Centers for Disease Control and Prevention, Division of Nutrition and Physical Activity, National Center for Chronic Disease

Prevention and Health Promotion. Physical Activity for Everyone: Are There Special Recommendations for Young People?Available at: http://www.cdc.gov/nccdphp/dnpa/physical/recommendations/young.htm. Accessed March 1, 2006

4. Office of the Surgeon General. The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity.Rockville, MD: Office of the Surgeon General, US Public Health Service, US Department of Health and Human Services; 2001

5. US Department of Health and Human Services. Physical activity and fitness. In: Healthy People 2010: Objectives forImproving Health. Vol 2. 2nd ed. Washington, DC: US Government Printing Office; 2000:22-3-22-39

6. Rideout VJ, Vandewater EA, Wartella EA. Zero to Six: Electronic Media in the Lives of Infants, Toddlers and Preschoolers.Menlo Park, CA: Kaiser Family Foundation; 2003. Publication No. 3378. Available at: http://www.kff.org/entmedia/3378-CFM. Accessed April 10, 2007

7. Dietz WH, Strasburger VC. Children, adolescents, and television. Curr Probl Pediatr. 1991;21:8-328. Dietz WH. The obesity epidemic in young children. Reduce television viewing and promote playing. BMJ. 2001;322:313-3149. American Academy of Pediatrics, Committee on Public Education. Children, adolescents, and television. Pediatrics.

2001;107:423-42610. Patrick K, Spear B, Holt K, Sofka D, eds. Bright Futures in Practice: Physical Activity. Arlington, VA: National Center for

Education in Maternal and Child Health; 200111. National Association for Sport and Physical Education. Active Start: A Statement of Physical Activity Guidelines for Children

Birth to Five Years. Reston, VA: National Association for Sport and Physical Education; 200212. Sanders SW. Active for Life: Developmentally Appropriate Movement Programs for Young Children. Washington, DC:

National Association for the Education of Young Children; 200213. Janz KF, Burns TL, Torner JC, et al. Physical activity and bone measures in young children: the Iowa bone development study.

Pediatrics. 2001;107:1387-139314. Moore LL, Gao D, Bradlee ML, et al. Does early physical activity predict body fat change throughout childhood? Prev Med.

2003;37:10-1715. Krebs NF, Jacobson MS. Prevention of pediatric overweight and obesity. Pediatrics. 2003;112:424-43016. US Department of Health and Human Services. Physical Activity and Health. A Report of the Surgeon General. Atlanta, GA:

The Presidents Council on Physical Fitness and Sports, US Department of Health and Human Services; 199617. Centers for Disease Control and Prevention. Increasing physical activity: a report on recommendations of the Task Force on

Community Preventive Services. MMWR Recomm Rep. 2001;50(RR-18):1-14

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Promoting Physical Activity