Effectiveness of interventions to promote physical activity in children and adolescents: systematic review of controlled trials
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39320.843947.BE (Published 04 October 2007) Cite this as: BMJ 2007;335:703
All rapid responses
The article by van Sluijs et al is highly topical, given recent media interest in the "obesity epidemic"1.
Encouraging children to take exercise, and to do so in a way that they can carry into their adult lives, is clearly very important.
Unfortunately, as I have commented in the past,2 not all schools are easily convinced of the need to remove unnecessary barriers to exercise. After writing – as parent and public health physician – to suggest that Glyn School in Surrey permit boys to wear outer clothing that would permit them to be seen more easily by traffic (with supporting evidence, and an offer to attend a governors to explain the issues) I had a letter from the chair of governors which read:3
‘Thank you for your recent letter. I always appreciate receiving them as they continue to confirm the paucity of real evidence.
‘However, I wonder if there is a misunderstanding between us and if so perhaps it is due to our different perceptions of “evidence”, since my training was in pure science and yours in applied.
‘Further, after over 40 years of business experience, I have learned to be sceptical about the “opinions” of so-called experts. I am sure I do not have to remind you of the consequences of relying on the advice of two of your medical colleagues — Roy Meadow and Andrew Wakefield.’
Not all schools will be quite so determined to uphold conservative dress codes at the expense of health and safety; and Surrey is clearly unusual (7/10 of the top 10 districts for “hazardous drinking” are in Surrey4) but getting more exercise for their pupils onto schools’ agendas might be an uphill struggle if the Surrey experience is replicated elsewhere.
Peter English.
1 BBC News. (2007, 14/10/07). "Obesity 'as bad as climate risk'." Retrieved 17/10/07, 2007, from http://news.bbc.co.uk/1/hi/health/7043639.stm.
2 BMJ 2006;333:200 (22 July), doi:10.1136/bmj.333.7560.200 (http://www.bmj.com/cgi/content/full/333/7560/200)
3 Ardern P. Personal communication (letter). 2004 (6 May)
4 BBC News. (2007, 16/10/07). "Wealthy areas head alcohol table." Retrieved 17/10/07, 2007, from http://news.bbc.co.uk/1/hi/health/7045830.stm.
Competing interests: Parent of secondary school children
Competing interests: No competing interests
We read with interest this week’s BMJ systematic review on physical activity promotion interventions of children and youths (1) but the review lack of deserves attention for several potentially important physical activity behaviors. (2) Encouraging active transport is one way to increase overall levels of physical activity. (2) Walking and cycling are two forms of physical activity that meet the metabolic criteria for achieving health benefits from exercise. (3)
Walking or cycling can be fitting more easily into everyday life and life’s tasks than the addition of recreational exercise with its extra time and cost commitments. Walking has the further benefit of being available to most people regardless of income, location or age. (4) Therefore walking is basic forms of transportation that are accessible to virtually all humans in the world.
However, children's independent mobility is greatly influenced by traffic and parents' real and perceived concerns about safety. (2) The epidemic of childhood obesity has been attributed largely to sedentary life styles. Therefore it is critical to identify the barriers and potential effective strategies for surmounting the problems that hinder walking and cycling. (5, 6) One recent study in US explored the question why children don’t walk to school more often. Parents reported multiple barriers that inhibit walking and biking to school as follows: long distances (55%), traffic danger (40%), weather (24%), crime (18%), and school policy (7%). Similarly, in UK a recent study shows that 85% of parents were worried about traffic danger on the journey to school. (5) Parents discouraging their children from walking and cycling to school because they are worried about the dangers from traffic (7)
Cost-benefit analysis of using safe bike/pedestrian trails in Lincoln, Nebraska, to reduce health care costs associated with inactivity was conducted. The cost-benefit ratio was 2.94, which means that every $1 investment in trails for physical activity led to $2.94 in direct medical benefit. Therefore, building trails is cost beneficial from a public health perspective. (8)
Contemporary health promotion places considerable emphasis on creating supportive environments (9). Consistent with this trend, there have been calls for greater consideration of the physical environment in physical activity research and practice (10).
REFERENCES:
(1) Van Sluijs E.M.F., McMinn A.M., Griffin S.J. Effectiveness of interventions to promote physical activity in children and adolescents: systematic review of controlled trials. BMJ 2007 doi: 10.1136/bmj.39320.843947.BE
(2). Giles-Corti, B., Salmon, J. Encouraging children and adolescents to be more active. BMJ 2007; 335: 677-678
(3) Desapriya E, Pike I, Babul S., Health benefits of physical activity. CMAJ. 2006; 26; 175(7):776
(4) Mason, C. Transport and health: en route to a healthier Australia. Medical Journal of Australia 2000; 172:230-232
(5) Rowland D., DiGuiseppi C., Gross M., Afolabi E., Roberts I. Randomized controlled trial of site specific advice on school travel patterns. Arch Dis Child 2003; 88: 8-11
(6). Desapriya E.B., Pike I., Basic A., Subzwari S. Deterrent to healthy lifestyles in our communities. Pediatrics. 2007;119(5):1040-2
(7) British Medical Association Board of Science and Education. Injury prevention. London: BMA, 2001.
(8). Wang G, Macera CA, Scudder-Soucie B, Schmid T, Pratt M, Buchner D. A cost-benefit analysis of physical activity using bike/pedestrian trails. Health Promot Pract. 2005; 6(2):174-9.
(9). World Health Organization (WHO).The Ottawa Charter for health promotion. Health Promotion International, 1986;1, 3–5.
(10). Sallis, J.F., Owen, N., 1990. Ecological models. In: Glanz, K., Lewis, F.M. and Rimer, B.K. Editors, 1990. Health behavior and health education: Theory, research, and practice (2nd ed.)Jossey-Bass, San Francisco, pp. 403–424.
Competing interests: None declared
Competing interests: No competing interests
EDITOR---Physical fitness and exercise are important aspects of health and well-being of persons of all ages. Earlier there has been a focus on intensive and vigorous exercise, but regular walking and other moderate physical activities have also been beneficial (1). A recent systematic review (2) from the Institute of Metabolic Science in Cambridge looked at 57 studies to determine the effectiveness of interventions to promote physical activity in children and adolescents. They found that multi-component interventions, which included both school, family or community had the greatest potential for being effective.
PHYSICAL ACTIVITY OVER TIME
Tracking physical fitness and activity over time will make our understanding better concerning when children settle into their long-term exercise and fitness patterns. It will also provide information as to when to initiate programs focusing on preventing sedentary adults behaviors. One study (3) tracked physical fitness and physical activity over a five year period with children and adolescents in Muscatine, Iowa, USA. They examined 126 pre- or early-pubescent children (mean age boys 10.8 yr and girls 10.3 yr). Physical fitness was measured using direct determination of oxygen uptake and maximal voluntary isometric contraction, while physical activity was assessed via questionnaire. Boys classified as sedentary based on initial measurements of TV viewing and video game playing were 2.2 times more likely than their peers to also be classified as sedentary at follow-up. Tracking of most physical fitness and physical activity variables was moderate to high, indicating some predictability of early measurements for later values. Sedentary behavior tracked better in boys, whereas vigorous activity tended to track better in girls. These observations suggested that preventive efforts focused on maintaining physical fitness and physical activity through puberty will have favorable health benefits in later years.
A longitudinal study from Belgium of Flemish males from 18 to 40 years of age followed 130 males from age 13 to age 18 years with remeasure at the ages of 30, 35, and 40 years (4). Physical fitness showed the highest stability in flexibility (r = 0.91 between 18 and 30 years, r = 0.96 for both the 30-35 and 35-40 ages intervals), while physical activity showed the highest stability during work (r between 0.70 and 0.98 for the 5-year intervals). Results indicated that for some fitness characteristics the high-active subjects were more fit than their low-active peers. Although possible confounding factors were present (e.g., heredity), a higher level of physical activity during work and leisure time on a regular basis benefited physical fitness considerably.
Another study from Michigan (5) examined whether organized sports participation during childhood and adolescence was related to participation in sports and physical fitness activities in young adulthood. The analyses included more than 600 respondents from three waves of data (age 12, age 17, and age 25). Childhood and adolescent sports participation was found to be a significant predictor of young adult participation in sports and physical fitness activities.
A study from New Jersey (6) looked at the outcomes of an exercise program directed towards Black and Hispanic college-age women. Forty-four women (36 Black, seven Hispanic and one Black/Hispanic) attended exercise classes three times per week for 16 weeks. Compared to low attendees, the high attendees had significantly higher exercise self-efficacy (p <.001), perceived benefits and barriers (p =.004), aerobic fitness, flexibility, muscle strength and percentage of body fat (all p <.001). Daily activity levels improved significantly in the high attendance group following the program (p <.001) and at eight weeks post-program completion (p =.01).
ADOLESCENT PHYSICAL FITNESS IN ISRAEL
In a study of 13 year olds during 1984-1985 from five Jerusalem public schools physical ability was defined in the biological dimension by the running time for 1000 meters and in the psychological dimension by sport motivation (7). The intervention program involved a periodic and progressive increase of physical effort of children in 16 gym lessons during the regular curriculum. The test group improved their running time and had better sport motivation than the control group with differences between boys and girls and an influence of sexual maturation on running time in girls.
As a participant in the World Health Organization (WHO) cross national study on health behaviors in school aged children (HBAC) initiated in 1982 data has also been available for Israel on exercise (8,9). The last results from 1997/98 (9) showed that 76% of 15 year olds males in Israel (in the US: 74%) and 48% of females (US: 54%) exercised twice a week or more.
CONCLUSIONS
Body composition, cardiovascular fitness, strength and fexibility will all benefit from physical exercise and fitness. Intervention and prevention programs should ensure that fitness in adolescence be continued in adult and later life to maximize well-being and health (10).
AFFILIATIONS
Joav Merrick, MD, MMedSci, DMSc, is professor of pediatrics, child health and human development affiliated with Kentucky Children’s Hospital, University of Kentucky, Lexington, United States and the Zusman Child Development Center, Division of Pediatrics, Soroka University Medical Center, Ben Gurion University, Beer-Sheva, Israel, the medical director of the Division for Mental Retardation, Ministry of Social Affairs, Jerusalem, the founder and director of the National Institute of Child Health and Human Development. Numerous publications in the field of pediatrics, child health and human development, rehabilitation, intellectual disability, disability, health, welfare, abuse, advocacy, quality of life and prevention. Received the Peter Sabroe Child Award for outstanding work on behalf of Danish Children in 1985 and the International LEGO-Prize (“The Children’s Nobel Prize”) for an extraordinary contribution towards improvement in child welfare and well- being in 1987. E-Mail: jmerrick@internet-zahav.net. Website: www.nichd- israel.com
Isack Kandel, MA, PhD, is senior lecturer/assistant professor at the Faculty of Social Sciences, Department of Behavioral Sciences, Ariel University Center at Samaria, Ariel. During the period 1985-93 he served as the director of the Division for Mental Retardation, Ministry of Social Affairs, Jerusalem, Israel. Several books and numerous other publications in the areas of rehabilitation, disability, health and intellectual disability. E-mail: kandelii@zahav.net.il
Meir Lotan, BPT, MScPT, is a physiotherapist working as lecturer at the School of Health Sciences, Department of Physical Therapy, Ariel University Center of Samaria, Ariel, affilated with the Israeli National Rett Syndrome evaluation team and director of the Therapeutic Department, Zvi Quittman Residential Center, Millie Shime Campus, Elwyn, Jerusalem. He has a special interest in physiotherapy and persons with intellectual disability, Snoezelen and physical activity for children and adults with intellectual disability with an emphasis on individuals with Rett syndrome. Awarded in 2000 by the IRSA (Int Rett Syndr Ass) for his service to individuals with Rett syndrome. Numerous publications in international peer-reviewed journals in his areas of interest. E-mail: ml_pt_rs@netvision.net.il
Hatim A Omar, MD, Professor of Pediatrics and Obstetrics and Gynecology and Director of the Section of Adolescent Medicine, Department of Pediatrics, University of Kentucky, Lexington. Dr. Omar has completed residency training in obstetrics and gynecology as well as Pediatrics. He has also completed fellowships in vascular physiology and adolescent medicine. He is the recipient of the Commonwealth of Kentucky Governor’s Award for Community Service and Volunteerism and is well known internationally with numerous publications in child health, pediatrics, adolescent medicine, pediatric and adolescent gynecology. Email: haomar2@uky.edu Website: http://www.ukhealthcare.uky.edu/kch/physicians/omar.htm
REFERENCES
1. US Department of Health and Human services. Physical activity and health: A report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention (CDC), Nat Center Chr Disease Prev Hlth Prev, 1996.
2. van Sluijs EMF, McMinn AM, Griffin SJ. Effectiveness of interventions to promote physical activity in children and adolescents: Systematic review of controlled trials. BMJ 2007335:703-15.
3. Janz KF, Dawson JD, Mahoney LT. Tracking physical fitness and physical activity from childhood to adolescence: the muscatine study. Med Sci Sports Exerc 2000;32(7):1250-7.
4. Lefevre J, Philippaerts RM, Delvaux K, Thomis M, Vanreusel B, Eynde BV, Claessens AL, Lysens R, Renson R, Beunen G. Daily physical activity and physical fitness from adolescence to adulthood: A longitudinal study. Am J Hum Biol 2000;12(4):487-97.
5. Perkins DF, Jacobs JE, Barber BL, Eccles JS. Childhood and adolescent sports participation as predictors of participation in sports and physical fitness activities during young adulthood. Youth Society 2004;35(4):495-520.
6. D'Alonzo KT, Stevenson JS, Davis SE. Outcomes of a program to enhance exercise self-efficacy and improve fitness in Black and Hispanic college-age women. Res Nurs Health 2004;27(5):357-69.
7. Halfon ST, Bronner S. The influence of a physical ability intervention program on improved running time and increased sport motivation among Jerusalem schoolchildren. Adolescence 1988;23(90):405-16.
8. Harel Y, Kani D, Rahav G. Health behaviors in school-aged children (HBSC): A World Health Organization cross national study. Jerusalem: JDC- Brookdale Institute, 1997.
9. Currie C, Hurrelmann K, Settertobulte W, Smith R, Todd J, eds. Health and health behaviour among young people. WHO Policy Series: Health policy for children and adolescents Issue 1, WHO Regional Office for Europe, Copenhagen, 2000.
10. Lotan M, Merrick J, Carmeli E. Physical activity in adolescence. A review with clinical suggestions. Int J Adolesc Med Health 2005;17(1):13 -21.
Competing interests: None declared
Competing interests: No competing interests
Other useful sources to complete the picture
Sir
We enjoyed the review by van Sluijs et al. .
Some of the findings, such as the effectiveness of parental involvement, echo findings in our EPPI Centre systematic reviews on children and physical activity, young people and physical activity and a synthesis of research on walking and cycling. The report on children and physical activity can be picked up with a ‘physical activity AND children’ search in the Cochrane Library, and is indexed on PubMed.
Since one of the purposes of systematic reviews is to assist readers who would otherwise be faced with a mountain of primary studies, we would like to add to the resources provided in this article by drawing readers’ attention to the above and other sources including the Database of Abstracts of Reviews of Effects (DARE) (which includes NICE and HTA reports) and the Database of promoting health effectiveness reviews (DoPHER).
In addition, those undertaking systematic reviews have a ready source of public health trials in the Trials of Promoting Health Interventions (TRoPHI).
Jenny Woodman, Research Officer; Philip James Rose, Publications and Administrative Officer; Angela Harden Senior Research Scientist in Evidence Synthesis; Ann Oakley, Professor of Sociology and Social Policy, Helen Roberts, Professor of Child Health
1.van Sluijs EMF, McMinn AM, Griffin SJ. Effectiveness of interventions to promote physical activity in children and adolescents: Systematic review of controlled trials. BMJ 2007335:703-15.
2 Brunton G, Harden A, Rees R, Kavanagh J, Oliver S, Oakley A (2003) Children and physical activity: a systematic review of barriers and facilitators. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London http://eppi.ioe.ac.uk/cms/Default.aspx?tabid=245
3 Rees R, Harden A, Shepherd J, Brunton G, Oliver S, Oakley A (2001) Young people and physical activity: a systematic review of research on barriers and facilitators. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London. http://eppi.ioe.ac.uk/cms/Default.aspx?tabid=261
4 Brunton G, Oliver S, Oliver K, Lorenc T (2006) A Synthesis of Research Addressing Children's, Young People’s and Parents’ Views of Walking and Cycling for Transport. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London. http://eppi.ioe.ac.uk/cms/Default.aspx?tabid=943
5 http://eppi.ioe.ac.uk/webdatabases/Intro.aspx?ID=5
Competing interests: None declared
Competing interests: No competing interests