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ORIGINAL
ARTICLES

EVIDENCE BASED PHYSICAL ACTIVITY FOR SCHOOL-AGE YOUTH

WILLIAM B. STRONG, MD,* ROBERT M. MALINA, PHD,* CAMERON J. R. BLIMKIE, PHD, STEPHEN R. DANIELS, MD, PHD,
RODNEY K. DISHMAN, PHD, BERNARD GUTIN, PHD, ALBERT C. HERGENROEDER, MD, AVIVA MUST, PHD, PATRICIA A. NIXON, PHD,
JAMES M. PIVARNIK, PHD, THOMAS ROWLAND, MD, STEWART TROST, PHD, AND FRANCxOIS TRUDEAU, PHD

Objectives To review the effects of physical activity on health and behavior outcomes and develop evidence-based
recommendations for physical activity in youth.
Study design A systematic literature review identified 850 articles; additional papers were identified by the expert
panelists. Articles in the identified outcome areas were reviewed, evaluated and summarized by an expert panelist. The strength
of the evidence, conclusions, key issues, and gaps in the evidence were abstracted in a standardized format and presented and
discussed by panelists and organizational representatives.
Results Most intervention studies used supervised programs of moderate to vigorous physical activity of 30 to 45 minutes
duration 3 to 5 days per week. The panel believed that a greater amount of physical activity would be necessary to achieve similar
beneficial effects on health and behavioral outcomes in ordinary daily circumstances (typically intermittent and unsupervised
activity).
Conclusion School-age youth should participate daily in 60 minutes or more of moderate to vigorous physical activity that
is developmentally appropriate, enjoyable, and involves a variety of activities. (J Pediatr 2005;146:732-7)

ecommendations for appropriate amounts of physical activity for the US

R population, including school-age youth, have been developed by several

organizations and agencies.1 Although recent reviews have summarized the
benefits of regular physical activity on the health of youth and its potential for reducing the
See editorial, p 719.

incidence of chronic diseases that are manifested in adulthood,2-5 a more systematic From the Department of Pediatrics, Med-
ical College of Georgia, Augusta, Georgia;
approach is indicated. This report presents results of a systematic evaluation of evidence Tarleton State University, Stephenville,
dealing with the effects of regular physical activity on several health and behavioral Texas; Department of Kinesiology, McMas-
ter University, Hamilton, Ontario, Canada;
outcomes in US school-age youth, with the goal of developing a recommendation for the Department of Exercise Science, University
of Georgia, Athens, Georgia; Children’s
amount of physical activity deemed appropriate to yield beneficial health and behavioral Hospital Medical Center,Cincinnati, Ohio;
outcomes. Department of Pediatrics, Adolescent and
Sports Medicine, Baylor College of Medicine,
Houston, Texas; Department of Family
Medicine and Community Health, Tufts
METHOD University School of Medicine, Boston,
Massachusetts; Department of Health and
Under a contract with the Divisions of Nutrition and Physical Activity and Exercise Science, Wake Forest University,
Adolescent and School Health of the Centers for Disease Control and Prevention and the Winston-Salem, North Carolina; Depart-
ment of Kinesiology, Michigan State Univer-
Constella Group, an expert panel was convened to review and evaluate available evidence sity, East Lansing, Michigan; Pediatric
Cardiology, Baystate Medical Center,
on the influence of physical activity on several health and behavioral outcomes in youth Springfield, Massachusetts; Department of
aged 6 to 18 years. The co-chairs of the panel selected panelists on the basis of expertise in Kinesiology, Kansas State University, Man-
hattan, Kansas; Departement des Sciences
specific areas: adiposity, cardiovascular health (lipids and lipoproteins, blood pressure, the de l’Activite Physique, Université du Quebec
metabolic syndrome, type 2 diabetes mellitus, cardiovascular reactivity, heart rate à Trois-Rivières, Trois-Rivières, Quebec
City, Canada.
variability, inflammation, and cardiovascular fitness), asthma, several domains of mental *Contributed equally to this work.
health (self-concept, anxiety, depression), academic achievement, injury associated with Submitted for publication Sep 9, 2004; last
revision received Nov 29, 2004; accepted
physical activity, and musculoskeletal health (bone mineral, muscular strength, and Jan 26, 2005.
endurance). The epidemiology and tracking of physical activity and overweight in youth Reprint requests: William B. Strong, MD,
3209 Huxley Dr, Augusta, GA 30909.
E-mail: [email protected].
0022-3476/$ - see front matter
Copyright ª 2005 Elsevier Inc. All rights
HDL-C High-density lipoprotein cholesterol level MS Metabolic syndrome reserved.
LDL-C Low-density lipoprotein cholesterol level
10.1016/j.jpeds.2005.01.055

732
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were also reviewed because of their public health implications, percentile is defined as ‘‘risk of overweight,’’ and a BMI $95th
but are not included in this report. percentile is defined as overweight. The labels ‘‘overweight’’
and ‘‘obesity,’’ respectively, are often used in the literature. A
Literature Search BMI >5th and #85th percentile is considered normal weight.
Criteria for overweight and obesity, however, varied
Databases (PubMed, ERIC, PsycINFO, 1980 to the
among studies considered (eg, weight >20% of that expected
present) were searched for publications in English that were
for height [relative weight], estimated percent fat >25% in
related to physical activity and specific outcomes in youth.
boys and >30% in girls, triceps skinfold >85th age- and sex-
Approximately 1220 abstracts were reviewed, and >850 articles
specific percentiles, and BMI >85th, >90th, or >95th age- and
were provided to the respective panelists. Articles not
sex-specific percentiles). Subjects who were normal weight
identified in the bibliographic searches were added by several
had weight, percent fat, skinfold thickness, or BMI below the
panelists.
cut-points. Designation of subjects as overweight/obese or
normal weight was accepted as described in the respective
Evaluation of Articles reports.
The panelists systematically evaluated and abstracted
relevant articles for each outcome. This information was Adiposity
abstracted for each report: complete citation, study design,
Cross-sectional and longitudinal observational studies
characteristics of the study population, measure of physical
suggest that youth of both sexes who participate in relatively
activity, statistical analyses, outcome measures, main findings,
high levels of physical activity have less adiposity than less
and evidence for dose-response effects. The co-chairs and
active youth.6-17 Experimental studies of overweight boys and
panelists developed conceptual definitions and inclusion and
girls involved in systematic physical activity interventions
exclusion criteria for each of the outcomes. On the basis of the
provide more specific information about the influence of
review of reports, each expert provided a summary of the
physical activity on adiposity. Programs of moderately intense
evidence for strength (strong [>60% of studies reviewed],
exercise 30 to 60 minutes in duration, 3 to 7 days per week
moderate [30%-59% of studies], weak [<30% of studies]) and
lead to a reduction in total body and visceral adiposity in
direction (positive, null, negative) of physical activity effects
overweight children and adolescents.18-20 However, such
on each health and behavioral outcome.
programs do not influence the percentage of body fat in
normal weight children and adolescents.20-24 Limited evi-
Meeting Format
dence indicates that more intensive and longer sessions (>80
A meeting of the panel and representatives of major minutes/day) are more successful in reducing percentage
organizations and agencies with interests in physical activity fatness in normal weight boys and girls.6,25 The results suggest
and health of youth was convened in January 2004. The 2-day that relatively greater amounts of vigorous physical activity
meeting was designed and convened for maximum input from may be needed to have a beneficial effect on adiposity in
the expert panelists and individuals representing the invited normal weight youth.
organizations and agencies (Appendix). Panel members gave
presentations summarizing the evidence for an assigned
Cardiovascular Health
outcome; each presentation was followed by an open discus-
sion. The process of developing physical activity recom- Many indicators of cardiovascular health cluster with
mendations was then discussed among all participants. overweight and adiposity, and this should be noted in
Subsequently, the co-chairs and panelists met to develop a evaluating potential effects of physical activity.
recommendation for physical activity for school-age youth in
the context of the strength of evidence available for each health METABOLIC SYNDROME. Many studies view the metabolic
and behavioral objective. syndrome (MS) as a clustering of risk factors. A proposed
definition of the MS for adolescents is based on abdominal
obesity (waist circumference >90th percentile), triglycerides
RESULTS
($110 mg/dL), blood pressure (>90th percentiles for age, sex,
Evidence pertaining to the influence of physical activity height), fasting glucose ($110 mg/dL), and reduced high-
on each health and behavior outcome in youth is summarized density lipoprotein cholesterol level (HDL-C; #40 mg/dL).26
in Table I; available online at http://www.us.elsevierhealth. Few studies have evaluated the impact of physical activity on
com/jpeds. the MS in youth.
Obese adolescent boys with the MS have lower exercise
Normal Weight, Overweight, and Obesity performance (exercise duration with a multistage treadmill
Much of the evidence dealing with adiposity and protocol) than obese boys without the MS.27 Adolescents with
cardiovascular outcomes is based on subjects classified as type 2 diabetes mellitus, in addition to being obese, report no
overweight or obese. Current criteria are based on age- and or very little habitual physical activity.28 In overweight
sex-specific cut-points of the body mass index (BMI, kg/m2). children, exercise successfully reduced triglyceride and insulin
In the context of national US surveys, a BMI >85th and <95th levels in a randomized trial,29 wheras a 40-minute program of

Evidence Based Physical Activity For School-Age Youth 733

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moderate to vigorous physical activity 3 times/week improved endothelial function76-78 are inconclusive, but experimental
some aspects of the MS (triglyceride level, insulin level, studies indicate a beneficial effect of activity on cardiovascular
adiposity).30 Several studies show improvement in elements of autonomic tone.56,79
the MS in association with physical activity in obese and non-
obese youth,31-36 but the amount of activity necessary to CARDIOVASCULAR FITNESS (AEROBIC FITNESS). Correlational
prevent or treat the MS is not specified. studies indicate low-to-moderate positive relationships be-
tween physical activity and maximal and submaximal in-
LIPIDS AND LIPOPROTEINS. Relationships between physical dicators of aerobic fitness. Comparisons of habitually active
activity and total cholesterol, HDL-C, low-density lipopro- and less-active children and adolescents show better levels of
tein cholesterol (LDL-C), and triglyceride levels are generally aerobic fitness in the former.15,80-97 Experimental training
weak in observational studies. The results suggest a beneficial studies with youth 8 years and older indicate improvements
effect of physical activity on HDL-C and triglyceride levels, in aerobic fitness.21,24,34,58,61,64,98-109 Successful programs
but no consistent effect on total cholesterol or LDL-C ordinarily involve continuous vigorous activity (eg, 80%
levels.10,14,17,24,30,36-49 Two studies, however, indicate a null of maximal heart rate) for >30 minutes at least 3 days per
effect of physical activity on lipid and lipoprotein levels.50,51 week.110,111 Change with systematic training averages ap-
The latter more likely applies to youth who entered a study proximately 10% (3-4 mL/kg/min).
with relatively normal values. Results of studies relating lipid
and lipoprotein levels to cardiovascular (aerobic) fitness are Asthma
inconsistent and do not indicate a significant association.20,52-57
Comparisons of population-based and convenience
Intervention studies, including clinical or school-based trials
samples of youth with asthma give inconsistent results.
(randomized and non-randomized), show a weak beneficial
Physical activity levels are higher,112,113 lower,114 or not
effect on HDL-C and triglyceride levels, but not on total
cholesterol or LDL-C levels.25,58-60 School-based interven- different112,115-117 in asthmatic compared with non-asthmatic
youth. However, higher levels of activity are associated with
tions have not been effective in improving lipid and lipopro-
greater reporting of asthma115 or related symptoms (eg, whistling,
tein levels.34,61
wheezing116) in asthmatic youth. Some,117-119 but not all,120-122
Allowing for variation in the available data, it appears
studies indicate lower levels of aerobic and anaerobic fitness
that a minimum of 40 minutes of activity per day, 5 days per
in youth with asthma. Risk of developing asthma may be
week for 4 months is required to achieve improvement in lipid
associated with overweight in boys123 and girls.124 Controlled
and lipoprotein levels, primarily increased HDL-C and
aerobic programs (2-3 sessions/week for at least 6 weeks)125-128
decreased triglyceride levels. This implies the need for a
sustained amount of moderate to vigorous physical activity on result in improved aerobic and anaerobic fitness in youth with
asthma, but are not associated with systematic improvements
a regular basis to induce and maintain the beneficial effect.
in pulmonary function126,128,129 or exercise-induced broncho-
The role of weight loss in mediating the effect of activity on
constriction.126-128
lipid and lipoprotein levels has not been studied in youth.

BLOOD PRESSURE. Little evidence supports the efficacy of Mental Health

or need for exercise training to reduce blood pressure in Indicators of mental health in youth were delimited to
normotensive youth. A meta-analysis62 and comprehensive anxiety, depression, and self-concept. There are too few studies
review63 indicate no clear association between physical activity of physical activity and other important aspects of mental
and reduction of blood pressure in normotensive youth. health, such as perceived stress,130-132 emotional distress,133-134
Limited studies of youth with systemic hypertension show a and perceived vigor or exhaustion.133,135 Moreover, the dearth
beneficial effect of aerobic activity programs of 12 to 32 weeks of prospective population cohort studies136,137 and randomized
duration on blood pressure64-66 Strength training after an controlled trials138 limits conclusions about causality in results
aerobic intervention prevents the return of blood pressure that are derived mainly from cross-sectional and quasi-
to pre-intervention levels in hypertensive adolescents.67 experimental studies.
However, an 8-week strength training program by itself has
no influence on blood pressure in hypertensive youth.68 ANXIETY AND DEPRESSION. Cross-sectional studies suggest
Overall, data suggest that a physical activity intervention with weak positive associations between physical activity and lower
a duration (at least 30 minutes), frequency (3 times/week), and scores on scales of anxiety132,139-141 and depression symp-
intensity sufficient to improve aerobic fitness (approximately toms,130,132,141-147 whereas quasi-experimental studies show
80% of maximal heart rate) can be in reducing blood pressure strong positive influences of physical activity and improve-
in youth with mild essential hypertension. Continued physical ment on measures of anxiety132,135 and depression symp-
activity is necessary to maintain the beneficial effect. toms.132,135,148-150 The influence of physical activity on anxiety
and depression symptoms varies with mode of activity.
OTHER CARDIOVASCULAR VARIABLES. Studies of physical acti-
vity in relation to hemostasis (fibrinogen),30,69-73 inflamma- SELF-CONCEPT. Self-concept refers to the perception of
tion (high sensitivity C-reactive protein),72,74,75 and self, whereas self-esteem refers to the value placed on one’s

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self-concept. Self-concept comprises several domains— known denominator, relatively accurate exposure data, imme-
academic and non-academic, social and emotional, and phys- diate access to treatment by an athletic trainer, and a well-
ical (sport competence, strength or endurance, appearance). designed data collection system.
The structure of self-concept changes with age and becomes Although limited, information on injuries related to
more clearly differentiated in the transition into puberty physical education classes suggests that the injury rate is nearly
and during adolescence. Cross-sectional studies suggest a 0 during 20-minute sessions held 3 times/week,214-217 whereas
moderately positive association between physical activity the prevalence of injury in a supervised after school program is
and physical self-concept, but weak positive associations low, 0.0016 per student hour.218
between physical activity and global, social, and academic
self-concept.133,139,140,143,145,151-162 Quasi-experimental stud- Musculoskeletal Health and Fitness
ies135,149,150,163-188 indicate strong positive effects of physical
MUSCULAR STRENGTH AND ENDURANCE. Although muscular
activity on physical (sport competence) and global self-concept
strength and endurance were not among the primary health
and weaker positive effects on social and academic self-
outcomes initially examined, panel members recommended
concept. The influence of physical activity on self-concept may
inclusion because they are important components of physical
be mediated by mode of activity, with beneficial effects
fitness. Correlational studies and cross-sectional comparisons
associated with aerobics, aerobics combined with strength/
give equivocal results relating physical activity to indicators of
flexibility activities, dance, perceptual-motor, and cognitive
muscular strength and endurance,81,94,219-225 but longitudinal
behavioral modifications to augment physical activity.
studies of adolescents indicate a positive influence of habitual
Although sport activities are positively associated with global
physical activity on upper body muscular endurance.81,220,223
self-concept, they have the potential for negative influence.
Experimental studies of resistance training 2 or 3 times per
Coaching and teaching styles are particularly relevant to the
week (with a day of rest between training sessions) show
self-concept in organized sport189 and physical education.190
improvements in muscular strength and endurance during
childhood and adolescence.226-241 Most studies focus on pre-
Academic Performance adolescent children, and strength gains are not associated with
Indicators of academic performance include grade point muscular hypertrophy.230,232,237,241 Muscular hypertrophy in
average, scores on standardized tests, and grades in specific association with gains in strength with resistance training
courses; measures of concentration, memory, and classroom occurs in adolescent boys,242 but data for adolescents of both
behaviors are indirect estimates. The addition of physical sexes are limited.
education to the curriculum results in small positive gains in
academic performance.191-193 The quasi-experimental data BONE MINERAL. The tensile and compressive forces associ-
also suggest that allocating more curricular time to programs of ated with muscular contractions during weight-bearing activ-
physical activity does not negatively affect academic achieve- ities and specialized exercises such as strength/resistance
ment, even when time allocated to other subjects is reduced.194 training have a favorable influence on skeletal tissue. Case
Some results also suggest a relative increase in academic studies,243,244 correlational studies,245-252 retrospective studies
performance per unit of time.194,195 Cross-sectional observa- of activity in childhood in relation to bone mass in
tions show a positive association between academic perfor- adulthood,253-259 comparisons of habitually active and inactive
mance and physical activity142,196-199 and physical fitness.200 children and adolescents,260-266 and comparisons of elite
Physical activity has a positive influence on concentration and young athletes with less active youth267-281 indicate a bene-
memory201-209 and on classroom behavior.194 Mechanistic ficial effect of physical activity on skeletal health. The
studies of cognitive function also suggest a positive effect of osteogenic influence of physical activity is generally site-
physical activity on intellectual performance.210 specific and related to local mechanical strains. The benefits
are reflected in bone mineral content, bone mineral density,
Injuries and bone mineral apparent density. Prospective studies of
children with varying levels of current or past physical
Children and adolescents incur injury in physical
activity,282-287 and experimental studies give similar results
activities associated with recreation, free play, organized and
in pre-pubertal boys and in girls who were either prepuber-
unorganized sport, and physical education. Most data are case
tal215,257,288-292 or in the early stages of puberty.216,293-295 The
series based on convenience samples from emergency depart-
experimental studies generally involve programs of 10 to 60
ments or sports medicine clinics. Other data are from accident
minutes duration of moderate to high-strain activity (impact,
reports, insurance records, interviews, and retrospective
weight bearing) for 2 to 3 or more days per week. The benefits
questionnaires. Variation in definition of injury, inadequate
are not as clearly established for adolescents214,295,296 in later
exposure data, and lack of description of the population at risk
stages of puberty (primarily girls).
limits the value of much of the published research in drawing
valid conclusions about the risks of injury to children and
adolescents associated with a given physical activity.211 DISCUSSION
Descriptive longitudinal studies of injury in several high Discussions of the benefits of physical activity for youth
school sports are an exception.212,213 These studies have a are often framed in the context of the future health status of

Evidence Based Physical Activity For School-Age Youth 735

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protocols varied somewhat among studies, but most used

programs of continuous moderate to vigorous activities for
30 to 45 minutes duration for 3 to 5 days per week. It is
reasonable, however, to expect that the amount of physical
activity necessary to achieve similar or greater beneficial effects
in the context of ordinary daily activities, which are typically
intermittent, would be substantially more than indicated in
controlled experimental conditions. This is generally consis-
tent with rationale for prior recommendations.4 Moreover,
allowing for inter- and intra-individual differences in physical
activity and in response to physical activity among free-living
children and adolescents, 60 minutes or more of moderate to
vigorous physical activity on a daily basis is consistent with
desired health and behavioral outcomes.
Physical activities of children and adolescents vary with
Figure. Changing emphasis of physical activity during childhood age, type of exercise, and setting. Physical activity begins in
and adolescence. The figure is modified after R. M. Malina. Fitness infancy with pushing up, turning, crawling, and eventually
and performance: adult health and the culture of youth, new walking, and it progresses to more complex activities as
paradigms? In: R. J. Park and M. H. Eckert, editors. New neuromuscular control develops. Basic movement patterns
possibilities, new paradigms? (American Academy of Physical develop during preschool ages and are the foundation for a
Education Papers No. 24). Champaign, IL: Human Kinetics
Publishers; 1991. p. 30-8. wide range of physical activities at later ages. With growth,
maturation, and experience, basic movements are integrated
and coordinated into more specialized and complex movement
the individual. It is also important to consider physical activity skills that characterize the free play, games, sports, and other
as it relates to the multiple demands of childhood and activities of school-age youth. Guided instruction and super-
adolescence associated with physical growth, biological ma- vised practice, specifically by qualified teachers, coaches, and
turation, and behavioral development. These processes vary others who work with children, are important in learning
considerably among individuals, occur simultaneously and movement skills. Types and contexts of activities are variable
interact, and provide the backdrop against which youth and change with age during childhood and adolescence.
evaluate their own status among peers, especially during Activities of children aged 6 to 9 years are largely anaerobic (as
adolescence. This backdrop has implications for many in non-sustained activities or games such as ‘‘tag’’), and they
decisions youth make, including those about physical activity. help the child learn basic and more specialized motor skills. As
Evidence-based data are strong for beneficial effects of youth move into the pubertal transition (about age 10-14
physical activity on musculoskeletal health, several compo- years, earlier in girls than in boys), these skills are incorporated
nents of cardiovascular health, adiposity in overweight youth, into a variety of individual and group activities and many
and blood pressure in mildly hypertensive adolescents. organized sports. Mature structure and function are ap-
Evidence is adequate to make informed judgments about the proached or attained in late adolescence (age 15-18 years), so
beneficial effects of physical activity on lipid and lipoprotein that physical activity programs can be more structured.
levels and adiposity in normal weight children and adolescents, Recommended priorities for physical activities during
blood pressure in normotensive youth, other cardiovascular childhood and adolescence relative to the development of
variables, self-concept, anxiety, and depression symptoms, and skills and to behavioral, health, and fitness benefits are
academic performance. A definition of the MS for youth is not schematically illustrated in the Figure. During the preschool
yet firmly established. However, the association between the and early school ages, general movement activities develop
MS and adiposity, lipid and lipoprotein levels, and blood movement patterns and skills (dashed line in Figure). As these
pressure suggests that regulation of overweight through basic movements become established and skills improve,
physical activity may have a beneficial effect on components health, fitness, and behavioral components of physical activ-
of the syndrome. ities increase in importance (solid line in Figure). Health-
related activities include those that emphasize cardiovascular
and muscular endurance and muscular strength and those that
Recommendations involve weight bearing. The setting of physical activity is
School-age youth should participate every day in 60 especially important in achieving positive behavioral out-
minutes or more of moderate to vigorous physical activity that comes. Although there is less emphasis on the development of
is enjoyable and developmentally appropriate. Interventional motor skills during adolescence, refinement of those skills is
studies indicate specific amounts of physical activity necessary important and new movement skills can be learned and can
for beneficial changes in the skeletal health, aerobic fitness, contribute to a physically active lifestyle.
and muscular strength and endurance of youth, and in Activities are generally classified as low, moderate,
adiposity in youth who are overweight (Table). Activity and vigorous intensity on the basis of METs (metabolic

736 Strong et al The Journal of Pediatrics  June 2005

 Under embargo until June 13, 2005, 12:00 AM ET

equivalents for specific activities on the basis of the ratio of important contributors to encouraging healthy behaviors.
activity to resting energy expenditure). Tables of MET values Children live at home and receive their health care in a variety
for a variety of activities based largely on measurements in of settings, including a pediatrician or family practitioner’s
adults are available.297 Because exercise energy expenditure per office, clinics, and public health facilities. The child’s health
unit of body mass is higher in children and adolescents than in care providers should routinely screen for overweight and
adults,298 these MET values have limitations. Nevertheless, inactivity and counsel parents and other care givers about the
moderate-to-vigorous activities require about 5 to 8 METs,4 health risks of overweight and the health benefits of physical
and such intensity is needed to derive most health benefits. activity, not only for the child, but also for the parents. At
Brisk walking, bicycling, and active outdoor playing ordinarily home, in day care, and in preschool, children should be
reach this criterion. regularly encouraged to be active and to explore. The amount
The recommended 60 minutes or more of physical of time that they are restrained from being active should be
activity can be achieved in a cumulative manner in school minimized. Two recent sets of guidelines for the promotion of
during physical education, recess, intramural sports, and physical activity among youth are excellent sources of infor-
before and after school programs. In this regard, the Centers mation on this topic.309,310 Physicians are important in this
for Disease Control recommends daily quality physical process and should be strong advocates of a physically active
education from kindergarten through grade 12. Both physical lifestyle for youth at home and in schools and communities.
education and recess afford opportunities to achieve the daily
physical activity goal without any evidence of compromising CONCLUSIONS
academic performance. Opportunities to influence youth
participation in physical activities are readily available at Increasing the level of habitual moderate- to vigorous-
home and school, as well as in community and health care intensity physical activity in youth is a health promotion and a
settings. disease-prevention strategy. Sedentary youngsters should
Physical inactivity is a strong contributor to overweight. progress toward the recommended level of physical activity
Sedentary activities such as excessive television viewing, gradually. The recommendations are consistent with presently
computer use, video games, and telephone conversations available scientific evidence and are also in general accord with
should be discouraged. Reducing sedentary behaviors to <2 recommendations promoted by governmental agencies4,311,312
hours per day is important to increasing physical activity and to and professional organizations.3,313,314
health.
The decline in physical activity during adolescence is of APPENDIX
special concern.299-301 Data from several European countries
American Cancer Society; American Academy of
highlight the importance of involvement in community-based
Kinesiology and Physical Education; American Diabetes
sport clubs during adolescence as an important predictor of
Association; American Heart Association; American College
physical activity in adolescence.302-306 Restoration of intra-
of Sports Medicine; American Academy of Pediatrics; Centers
mural sport programs and expansion of the school day for such
for Disease Control and Prevention, National Association for
programs in middle and high schools may provide opportu-
Sport and Physical Education; National Cancer Institute;
nities for all students to be physically active.
National Heart, Lung and Blood Institute; National Institute
For youth who have been physically inactive, an
of Arthritis and Musculoskeletal and Skin Diseases; National
incremental approach to the 60-minute goal is recommended.
Institute of Child Health and Human Development; National
Increasing activity by 10% per week, an approach used in
Institute of Diabetes and Digestive and Kidney Diseases;
athletic training, appears to be acceptable and achievable.
National Center for Health Statistics; Robert Wood Johnson
Attempting to achieve too much too rapidly is often coun-
Foundation; US Department of Agriculture; US Department
terproductive and may lead to injury.
of Health and Human Services, Office of Public Health
Risk of overweight307 and sedentary behavior308 are
Science; and the US Department of Health and Human
increasingly evident in children aged 2 to 5 years, which has
Services, Office of Disease Prevention and Health Promotion,
implications for subsequent ages. It is important to promote
President’s Council on Physical Fitness and Sports.
physical activity and limit the amount of physical inactivity
beginning with the preschool child. The family unit, the References available online at http://www.us.
pediatric community, day care centers, and preschools are elsevierhealth.com/jpeds.

Evidence Based Physical Activity For School-Age Youth 737