1. family and parenting
2. children

 Obesity Prevention through
Physical Activity in School-Age
Children and Adolescents
Universidad Camilo José Cela
September 2011
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
AUTHORS
Directors
Viuda-Serrano, Alejandro
González Millán, Cristina
Pérez-González, Benito
Coordinators
Aznar Laín, Susana
Luis-Pascual, Juan Carlos
Writers
Del Coso Garrigós, Juan
García Aparicio, Amaia
Laguna Nieto, María
Merino Merino, Elena
Rodríguez Cabrero, Marta
Collaborators
Burillo Naranjo, Pablo
Gallo Salazar, César
García Pastor, Teresa
García Tardón, Bruno
Herrero González, Mª Elena
López Cerrillo, Encarnación
Maestre Rodríguez, José Manuel
Mediavilla Saldaña, Lázaro
Pardo García, Rodrigo
Ruíz Vicente, Diana
Salinero Martín, Juan José
Soriano Segarra, María Lledó
Theirs Rodríguez, Cecilia Inés
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
INDEX
1. INTRODUCTION ......................................................................................................................... 1 2. BACKGROUND ......................................................................................................................... 15 2.1. Promotion of physical activity guidelines at an individual level ....................................... 15 2.2. Promotion of physical activity guidelines from family environment ............................... 25 2.3. Promotion of physical activity guidelines from school environment ............................... 32 2.4. Promotion of physical activity guidelines from local government ................................... 44 2.5. Promotion of physical activity guidelines from non-­‐governmental organizations .......... 58 2.6. Promotion of physical activity guidelines at a governmental level .................................. 67 3. METHODOLOGY ...................................................................................................................... 78 4. CONCLUSIONS (physical activity charter) ................................................................................ 81 5. REFERENCES ............................................................................................................................ 88 6. DOCUMENTS ......................................................................................................................... 104 Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
1. INTRODUCTION
Physical activity and child obesity
Regular physical activity is associated with a healthier, longer life (12). However, most adults and young people in Spain are not physically
active enough for health benefits. The worldwide situation is similar in both
developed and developing countries, with a large body of research evidence
indicating decreasing levels of physical activity and physical fitness within all
age brackets (3).
Physical inactivity is widely recognized as a major risk factor for
chronic diseases (4), and ranks between the second and sixth most
important risk factor in contributing to the population burden of disease in
western society (5-7). Its prevalence is higher than that of all other
modifiable risk factors (5). Physical inactivity during the early years of life is
currently indicated as a major contributor to the increasing levels of obesity,
and other serious medical conditions, seen in children and adolescents in
Europe and elsewhere (8-11).
The increased political, media and scientific interest in obesity since
the late 1990’s has placed physical activity high among current public
health issues, and the Olympic Committee itself recognizes that a reduction
of sedentary habits, such as computer games and social networks, would
bring social and health benefits (4). Factors determining physical activity at
an early age are personal, socio-cultural and environmental (12). A recent
OECD study shows that infant obesity has become a pandemic, since the
percentages of overweight youth has increased in developing and developed
countries alike (13).
INTRODUCTION
1
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
0 5 9 10 Slovak Republic (1999) 11-­‐17 Turkey (2001) 12-­‐17 Luxembourg Denmark (1997) 5-­‐16 Poland (2001) 7-­‐9 Japan (2000) 6-­‐14 Switzerland (2007) 6-­‐13 Netherlands (2003) 5-­‐16 Norway (2005) 3-­‐17 Finland France (2006) 11-­‐17 Hungary (2005) 7-­‐18 Austria (2003) 8-­‐12 Germany (2002) 5-­‐17 Czech Republic (2005) 6-­‐17 Belgium (2005) 4-­‐15 Greece (2003) 13-­‐17 Sweden (2001) 6-­‐13 Iceland (2003) 9 Korea (2005) 10-­‐19 Ireland (2007) 4-­‐13 Slovenia (2007) 6-­‐12 Chile (2000) 6 Israel (2007) 5-­‐7 Australia (2007) 9-­‐13 Canada (2004) 12-­‐17 UK England (2004) 5-­‐17 Mexico (2006) 5-­‐17 New Zealand (2002) 5-­‐14 Portugal (2003) 7-­‐9 Italy (2006) 8-­‐9 Spain (2000) 13-­‐14 UK Scotland (2008) 12-­‐15 United States 2004) 6-­‐17 Indonesia (2000) 10-­‐18 India (2002) 5-­‐17 Russia (2004) 10-­‐18 China (2004) 6-­‐11 South Africa (2004) 6-­‐13 Brazil (2002) 7-­‐10 10 4 15 12 10 11 20 14 14 15 15 16 16 16 16 25 30 18 19 19 20 20 21 22 22 22 23 24 25 25 26 26 27 29 29 35 31 31 32 33 33 40 35 35 22 Figure 1. Percentage of overweight children (including obese ones). OECD 2010 (13)
Despite of the importance of physical activity, the ignorance regarding its
prescription remains high (14) even if it appears to be vital for less than 6
year old children for trying to avoid adult overweight and obesity (15).
INTRODUCTION
2
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
The linkage between physical inactivity and childhood overweight
and obesity
The mechanism of obesity development is not fully understood. It is a
complex multi-factorial issue, which means that the rising prevalence of
obesity can therefore not be explained or addressed by a single factor (16).
However, it is clear that obesity occurs when energy intake exceeds energy
expenditure (see Figure 2). Genetic factors influence the susceptibility of a
given child to an “obesogenic” (obesity promoting) environment. In other
words, some children are more prone to obesity than others as a result of
hereditary factors. In the vast majority of cases environmental factors,
lifestyle preferences, sleep time (17) and cultural environment are the
significant factors that influence obesity. While changes in children´s diets
have undoubtedly contributed to increasing global levels of paediatric
overweight and obesity, most experts now believe that decreased physical
activity is the major contributor (16, 18-20).
Figure 2. Changes in body weight are determined by a balance of energy intake (food
calories) and energy expenditure (calories burned) (16).
INTRODUCTION
3
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
When the growing problem of overweight and obesity was first
recognized in the 1980’s and 1990’s, obesity was first viewed as a personal
disorder or abnormality that required treatment. While this may be partially
true, strategies to curb the obesity epidemic using this philosophy failed
(16). Now there is more of an “ecological” approach to the problem of
obesity where it is seen as a normal consequence of an increasingly
abnormal “obesogenic” environment (21, 22).
One important aspect of this abnormal environment is the changing
physical activity environment, which affords progressively less opportunities
for spontaneous physical activity, both in adults and young people. This is
even more evident in children who have less and less opportunities to
organize games or activities with others. Special difficulties arise from the
implementation of physical activity in obese or overweight children and
adolescents according to different publications (23-25).
The key to success in tackling the problem of obesity now lies in
understanding, measuring and altering this “obesogenic” environment. In
May 2004, a report by the International Obesity Taskforce (IOTF) to the
World Health Organization (WHO) highlighted examples of problematic
social trends that are believed to be contributing to the childhood obesity
epidemic (26). These included:
1. An increase in the use of motorized transport, (i.e. to school).
2. Reduced opportunities for recreational physical activity.
3. Increased sedentary recreation.
4. Multiple TV channels around the clock.
5. Greater quantities and variety of energy dense foods available.
6. Rising levels of promotion and marketing of energy-dense foods.
7. More frequent and widespread food purchasing opportunities.
8. More use of restaurants and fast food stores.
9. Larger portions of food offering better ‘value’ for money.
INTRODUCTION
4
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
10.Increased frequency of eating occasions.
11.Rising use of soft drinks to replace water, (i.e. to school).
Therefore, lack of sufficient physical activity (points 1-4) is strongly
indicated as a contributor to the rising problem of obesity. It is now widely
accepted that increasing physical activity participation and decreasing
sedentary behaviour should be the major focus of strategies aimed at
preventing and treating overweight and obesity in young people (27).
The IOTF report also concluded that the domination of obesitypromoting environmental factors meant that treatment would be unlikely to
succeed without strategies to deal with the prevailing environment through
a broad-based public health programme, and urged policy-makers to
develop strong policies to address the rising problem.
Health consequences of obesity in young people
The negative consequences of obesity during the early years of life
are both physiological (medical) and psychosocial. Probably the most
widespread consequences of childhood obesity are psychosocial. Obese
children become targets of early and systematic discrimination and tend to
develop a negative self-image that appears to persist into adulthood (28).
In addition, there are numerous health complications that become apparent
during youth including (28, 29):
1. Disturbances in blood lipids (i.e. elevated triglycerides, elevated lowdensity
lipoprotein
(LDL)
cholesterol
and
lowered
high-density
lipoprotein (HDL) cholesterol)
2. Glucose intolerance (i.e. insulin resistance) and type 2 diabetes
3. Atherosclerotic changes within arteries (coronary heart disease)
4. Hepatic problems such as cirrhosis
5. Hypertension
6. Sleep problems
INTRODUCTION
5
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
7. Orthopaedic
complications,
especially
of
the
hips
and
lower
extremities
Those studies that have investigated the long-term effects of
childhood or adolescent obesity on adult morbidity and mortality have
shown
greater
adult
all-cause
mortality,
coronary
heart
disease,
atherosclerotic vascular brain disease, hypertension, colorectal cancer,
diabetes, gout and arthritis, amongst other medical conditions (16, 30-32).
The rates of morbidity and mortality from these diseases increase with
higher degrees of obesity (30, 33).
In addition, a large body of research evidence has shown that once a
child has become obese, there is a high probability that this obesity will
continue into adulthood (34, 35). Therefore, there is general acceptance
that children should be considered the priority population for intervention
strategies aimed at treating or, ideally, preventing the onset of obesity.
Physical activity must be a major component of interventions designed to
prevent or treat childhood obesity. A study on the prevalence of infant
obesity among Spaniards, carried out by the Spanish Agency for Food
Safety and Nutrition, called ALADINO (Alimentación, Actividad Física,
Desarrollo Infantil y Obesidad) with the participation of 7,923 school
children aged 6 to 10 for the 2010-2011 school year, has indicated the
prevalence of a26.3% over-weight in boys and 25.9% in girls, and a 22%
obesity in boys and 16.2% in girls. Said percentages have not changed
since the previous survey, enKid (1998-2000) except for girls, who show a
weight increase (36).
Definitions
Physical activity is defined as body movement produced by a muscle action
which increases energy expenditure. It is an encompassing term that
includes physical “exercise” (16, 37).
INTRODUCTION
6
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
Physical exercise is a more specific term and implies planned, structured,
repetitive and purposeful physical activity, often with the goal of improving
or maintaining somebody’s physical fitness.
For example, gardening or
walking up stairs in one’s home may not be classed as structured
“exercise”, but it is certainly physical activity (16, 37).
Physical fitness is a physiological state of well-being that provides the
foundation for the tasks of daily living, a degree of protection against
chronic disease and a basis for participation in sport. In essence, physical
fitness describes a set of attributes relating to how well one performs
physical activity (16, 37).
Figure 3. The health and wellness continuum
Health is a reflection of somebody’s overall physical, mental and social wellbeing. It is much more than simply the absence of disease. Health, as it is
well known, is not static over time, and can go from near death situations
(ill health) to optimal physiological functioning (high level wellness) (see
Figure 2) (16, 38).
INTRODUCTION
7
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
Important descriptive aspects of physical activity and exercise
The “dose” of physical activity that a person receives is dependent
upon factors contained within the “F.I.T.T.” principle (16):
Frequency (how often). How often you practice physical activity (often
expressed as number of times per week).
Intensity (how hard). How strenuous the physical activity is (often
described as light, moderate or vigorous).
Time (how long). The duration of the physical activity.
Type. The specific kind of exercise practised (i.e.. running, swimming, etc.).
These factors can be manipulated to vary the “dose” of physical
activity. Often this is expressed in terms of energy expenditure (calories
burned). It can be seen that the more intense the physical activity is, the
greater the rate at which calories are used up which may reduce the needed
time to burn a set of calories (16).
Clarification of moderate-to-vigorous intensity physical activity
(MVPA)
Of all the factors contained within the FITT principle, intensity is
probably the most difficult one to measure. The physical activity guidelines
for both adults and young people (the latter is detailed further on) make
reference to the importance of exercise at least of moderate intensity (39).
A person who is doing moderate intensity activity will usually feel:
•
Increased breath-rate, being able to have a conversation.
INTRODUCTION
8
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
Increase of heart-rate at the point in which pulse should be easily
taken at wrist, neck or chest.
•
Increase of warmth feeling, possibly accompanied by sweating on
hot or humid days
A bout of moderate intensity activity can be continued for many
minutes and does not cause exhaustion or extreme fatigue in healthy
individuals when continued for an extended period (16).
It is important to understand that moderate intensity is relative to
each individual’s fitness level. For example, a fitter individual would need to
perform activity at a higher absolute intensity than an unfit individual in
order to feel the similar sensations of increased breathing, heart rate and
temperature that are characteristic of moderate intensity activity.
Different methods for assessing exercise intensity are discussed in
further detail in the following lines.
Further methods for gauging intensity of physical activity
There are some other ways of monitoring the intensity of physical
activity. The most widely used are:
1. The talk test (40)
The talk test method of measuring intensity is simple:
• Light intensity: Active people at a light intensity level should be able
to either sing or carry on a normal conversation while doing the
activity. Some example of light activity would be easy walking or
cleaning.
• Moderate intensity: Active people at a moderate intensity level
should be able to carry on a conversation with some difficulty while
INTRODUCTION
9
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
practicing the activity. A fair example would be brisk walking, biking
or dancing.
• Vigorous intensity: Getting exhausted as well as having an easy outbreathing conversation while exercising, means the activity can be
considered vigorous.
Examples of vigorous activity would include
jogging or running and strenuous sports such as basketball,
swimming, handball, etc.)
2. Heart rate:
Heart rate can be measured easily either at the wrist (the radial
pulse) or the neck (the carotid pulse) and should be converted into the
number of beats per minute (bpm).
Heart rate measuring can be taken
either in a full minute or in a shorter period of time (i.e. 15, 20 or 30
seconds) and multiply by the relevant factor (4, 3 or 2 respectively) to
convert to bpm.
Heart beat evaluating/testing at rest as well as maximal heart beating
knowledge are needed to be able to gauge exercise intensity effectively. It
is always better to test the heartbeat at rest when people are truly rested,
such as either recently woken up in the morning or after being seated
quietly for a few minutes. Maximal heart rate is often roughly estimated
using the simple equation “220 – age”. For example, if a child was 15 years
old, their estimated maximal heart rate would be 220 – 15 = 205 bpm.
The best method to determine target heart rate ranges for monitoring
intensity of physical activity is using the heart rate reserve (HRR) method
technique, also known as the Karvonen method (41). In this method,
resting heart rate (RHR) is firstly subtracted from the maximal heart rate
(MHR) to obtain HRR. For example, assuming that the 15 year old child
above had a resting heart rate of 80 bpm. The HRR of this person is MHR
(205) – RHR (80) = 125 bpm.
INTRODUCTION
10
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
For practical purposes on heart-rate-range calculating, Table 1 –
shown below- must be consulted to determine the relevant % values of
HRR:
Table 1. Physical activity intensity table by using % Heart Rate Reserve and Rating of
Perceived Exertion.
Relative intensity
Intensity descriptor
% Heart Rate Reserve
(%HRR)
Rating of Perceived
Exertion (RPE) †
Very light
Light
Moderate
Vigorous
Very vigorous
<20
20-39
40-59
60-84
>85
<10
10-11
12-13
14-16
17-19
Adapted from ACSM (42)
†See section 3 below for an explanation of rating of perceived exertion.
It can be appreciated that moderate intensity regards to 40-59% of
heart rate reserve = 50 (0.40 x 125) – 74 (0.59 x 125). We must now add
the resting heart rate back onto each number to determine the final target
heart rate range.
Therefore, the corresponding heart rate range for our
child for moderate intensity activity is 130 (50 + 80) to 154 (74 + 80) bpm.
For vigorous intensity exercise, the heart rate range for this child
would be 155 to 185 using exactly the same procedure as above.
3. Rating of perceived exertion using the Borg scale:
Perceived exertion is how hard you feel you are working based on the
physical sensations you experience during exercise. An example of a Borg
scale is shown below in Table 2.
INTRODUCTION
11
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
While exercising, you should look at the rating scale expressions,
appraise your exertion feelings as honestly as possible and provide the
proper number. This is your “rating of perceived exertion” or RPE.
As is shown in Table 1 (find attached previously), moderate physical
activity is represented by a 12-13 Borg Scale’s RPE degree (around
“somewhat hard”). Light and vigorous activities fall into the ranges of 10-11
and 14-16 respectively.
Table 2. The Borg Scale on Rating of Perceived Exertion
Score
Level of exertion
6
None
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Extremely light (7,5)
Very light
Light
Somewhat hard
Hard (heavy)
Very hard
Extremely hard
Maximum exertion
4. Metabolic equivalent (MET) level:
A metabolic equivalent (1 MET) is the amount of energy (oxygen)
your body uses as you sit quietly, for instance while reading a book.
Intensity may be described as a multiple of this value. The harder your
body works during a physical activity, the higher the MET level at which you
are working (16).
INTRODUCTION
12
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
Standard tables (see Table 3) can be consulted to ascertain roughly
the intensity of the activity concerned. They define physical activities and
their MET levels:
• Any activity that burns 3-6 METs is considered moderate intensity
• Any activity that burns >6 METs is considered vigorous intensity
Table 3. Intensities and energy expenditure of the most usual types of physical activity.
Source: based on data from Ainsworth et al. (43)
Activity
Intensity
Intensity
(METS)
Ironing
Cleaning & dusting
Walking – strolling, 3-4 km/h
Painting/decorating
Walking – 4-6 km/h
Hoovering
Golf – walking, pulling clubs
Badminton – social
Tennis – doubles
Walking – brisk, >6 km/h
Mowing lawn – walking, using
power mower
Cycling – 16-19 km/h
Aerobic dancing
Cycling – 19-22 km/h
Swimming – slow crawl, 45m per
minute
Tennis – singles
Running – 9-10 km/h
Running – 10-12 km/h
Running – 12-14 km/h
Light
Light
Light
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
2.3
2.5
2.5
3.0
3.3
3.5
4.3
4.5
5.0
5.0
35
37
37
45
50
53
65
68
75
75
Moderate
Moderate
Vigorous
Vigorous
Vigorous
5.5
6.0
6.5
8.0
8.0
83
90
93
120
120
Vigorous
Vigorous
Vigorous
Vigorous
8.0
10.0
11.5
13.5
120
150
173
203
INTRODUCTION
Energy
expenditure (kcal
equivalent, for a
person of 30kg
doing the activity
for 30min)
13
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
From an environmental view of the obesity problem, where the
individual is both cause and effect with the environment, considered
increasingly “obesogenic”. Environment, physical activity proposals must be
made from different environments simultaneously to achieve the best
results and they must be interconnected starting from individual level (see
Figure 4).
This document will address each level separately.
Figure 4. Intervention proposals organized in the different areas.
INTRODUCTION
14
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
2. BACKGROUND
2.1. Promotion of physical activity guidelines at
an individual level
Development of the recommendations at an individual level
The American College of Sports Medicine (ACSM) launched the first
consensus
of
physical
activity
recommendations
for
children
and
adolescents in 1988 (44), establishing at least 20-30 minutes of daily
vigorous physical activity for both age groups.
In the early 90s the American Heart Association (AHA) updated this
recommendation, emphasizing that children and adolescents had to be
active in their daily living activities, as well as achieving at least 3-4
Moderate to Vigorous Physical Activity (MVPA) sessions of 30-60 minutes
per week (45).
However, those early children’s and adolescents’ physical activity
statements and guidelines were based primarily on the study of adults.
Finally, in 1992 an advisory committee, composed of leading
scientists and representatives of primary care medical societies and
appropriate government agencies, was assembled to direct the development
of a consensus on physical activity guidelines for adolescents. Sallis &
Patrick stated the first health-related physical activity targeted specifically
to children and adolescents (46). There were two recommendations:
1. All adolescents should be physically active daily, or nearly every
day, as part of play, games, sports, work, mobility, recreation,
physical education, or planned exercise, in the context of family,
school, and community activities.
BACKGROUND: Promotion of physical activity guidelines at an individual level
15
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
This recommendation is based on that established by the American
College of Sport Medicine (44).
2. Adolescents should engage in a minimum of three sessions per
week where, at least, 30 minutes of moderate to vigorous
physical activities are required. Moreover, young non-often-active
people should engage in, at least, moderate daily physical activity
for 20 minutes and gradually increase.
This recommendation is based on evidence that regular participation
in continuous moderate to vigorous physical activity during adolescence
provides numerous health benefits.
In the next four years the scientific literature (47) supported Sallis &
Patrick recommendations (46). Later on recommendations were revised and
the physical activity recommended time was increased till one hour a day
and specific activities including muscle strength, flexibility and bone health
were introduced (48).
The new recommendations included:
1. All young people should participate in a minimum of one daily
hour of moderate physical activity.
2. At least twice a week, some of these activities should help to
enhance and maintain muscle strength and flexibility, and bone
health.
This MVPA rating was based on observation of the majority of young
people that already met MVPA-30 minutes criteria and their physical activity
levels were prone to decrease with age. Biddle et al. (48) proposed
examples of moderate physical activity for all young people such as walking,
BACKGROUND: Promotion of physical activity guidelines at an individual level
16
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
cycling, swimming, dancing, etc. For younger children, activities can be
carried out as part of active play. Such activity may be performed in a
continuous fashion or intermittently accumulated throughout the day. Given
that young people have demonstrated patterns of intermittent activity,
emphasising the accumulation of PA over the day seems a more practical
approach. Teenagers are more likely to be active by performing structured
continuous bouts of MVPA through sports, active transportation, dance or
structured exercise.
Table 4. How can children and adolescents perform these recommended activity levels of
activity? (16)
Young children




Daily walk to and from school.
Daily school activity sessions (breaks and clubs).
3-4 afternoon or evening play opportunities.
Weekend: longer walks, visits to park or swimming pool,
bicycle rides, etc.
Adolescents



Daily walk (or cycle) to and from school.
3-4 organized of informal midweek sports or activities.
Weekend: walks, cycling, swimming, sports activities.
The second recommendation of Biddle et al. (48) talked about
practicing some of these activities at least twice a week in order to enhance
and maintain the muscular strength and flexibility, as well as bone health.
Participation
in
strength
and
weight-bearing
activities
is
positively
associated with bone mineral density.
The Biddle et al. recommendations (48) are taken into account
worldwide, as they are based on current scientific evidence and expert
opinion in the field of physical activity and health (39). They are the
minimum suggested levels in order for children and adolescents to obtain
health benefits.
BACKGROUND: Promotion of physical activity guidelines at an individual level
17
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
These recommendations have been endorsed by several international
organizations, such as the British Government, the French Ministry of
Health, Centres for Disease Control and Prevention (CDC: Centres for
network control and prevention of diseases) of the United States and the
Ministry of Health and Senior Citizens of Australia (14, 21, 26-29, 34, 3941, 44). The latter introduced a council in terms of downtime, limiting hours
of
ICT
(Information
and
Communication:
TV,
internet,
videogames,
telephone), especially during daylight hours (21, 29, 44). Scientific
literature has supported said recommendations (18, 49).
As of 2001, a minimum of steps performed per day was established
(50) as a parallel guideline; later youth resistance recommendations by
Biddle et al. (48) were developed. Both aspects will be described
immediately below.
Firstly, Tudor-Locke & Myers (50) suggested in a systematic review,
that children 8 to 10 years could be expected to take between 12.000 and
16.000 steps per day. One year later, Vincent and Pangrazi (51) found
evidence of the relationship between steps per day and health benefits and
suggested that a reasonable minimum of physical activity may be to 11.000
steps a day for girls and 13.000 steps a day for boys. Years later, in a
review
of
recommendations
(52),
Tudor-Locke
&
Myers
established
minimum of 12.000 steps for girls 6 to 12 and 15.000 steps for boys. Later
on, Adams et al. (53), in a subsequent research, set the recommendation of
60 minutes MVPA daily. Twelve year old children should accumulate
between 10.000 and 11.700 steps per day.
Secondly, youth resistance recommendations cited by Biddle et al.
(48) began to be progressively detailed. Faigenbaum et al., in 1996 (54)
had established 10-40 minutes per session (1 set of 6-15 repetitions), 2-3
times per week. Faigenbaum et al. (55) confirmed and supported the
concept that muscular strength and muscular endurance can be improved
BACKGROUND: Promotion of physical activity guidelines at an individual level
18
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
during the childhood years, supporting the prescription of higher repetition
moderate load resistance training programs during the initial adaptation
period (1 set of 13 to 15 repetitions per exercise). It is very important to
ensure qualified instruction and supervision, as well as an appropriate
progression of the volume and intensity of training. The main aim of these
programs is that children and adolescents cannot only learn advanced
strength training exercises but also feel good about their performances, and
have fun (56). Studies of the NSCA (National Strength and Conditioning
Association) reviewed by Hass (57), suggested that child-size machines
should be used whenever it is possible. A subsequent review (58)
complements the training protocols already established by earlier studies,
and suggests beginning the strength program including all low endurance
muscle groups and emphasises a proper technique achievement. Moreover,
it sets the training period at 20-30 minutes per session. Each training
session should begin with a 10-15 minutes warm-up period and would finish
with stretching during a cool-down period.
Finally, in 2009 these strength guidelines have been updated (59) for
children and adolescents, adding the following aspects (See Document A):
1.
Provide
qualified
instruction
and
supervision.
Although
all
training sessions should be supervised by a qualified adult,
additional supervision may be needed during the first few weeks
of the resistance training program.
2.
Ensure that exercise environment is safe and hazard-free.
3.
Start each training session with a 5-10 minute dynamic warmup period (i.e. hops, skips, jumps, and movement-based
exercises for the upper and lower body).
4.
Begin with relatively light loads and always focus on the correct
exercise technique.
5.
Perform 1–3 sets of 6–15 repetitions on a variety of upper-and
lower-body strength exercises.
BACKGROUND: Promotion of physical activity guidelines at an individual level
19
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
6.
Include specific exercises that strengthen the abdominal and
lower back region. Include comprehensive exercises, especially
in the beginning of the program, strengthen muscle groups in
each session, including specific exercises that strengthen the
abdominal and lower back region.
7.
Focus on symmetrical muscular development and appropriate
muscle balance around joints. Also, the choice of exercises
should promote muscle balance across joints and between
opposite muscle groups (i.e. quadriceps and hamstrings).
8.
Perform 1–3 sets of 3–6 repetitions on a variety of upper- and
lower-body power exercises.
9.
Sensibly progress the training program depending on needs,
goals, and abilities.
10.
Increase gradually the stamina (5–10%) as strength improves.
11.
Cool-down with less intense calisthenics and static stretching.
12.
Listen to individual needs and concerns throughout each session.
13.
Begin resistance training 2–3 times a week on non-consecutive
days will allow an adequate recovery between sessions (48-72
hours between sessions) and will be effective for enhancing
strength and power in children and adolescents.
14.
Use individualized workout logs to monitor progress.
15.
Keep the program fresh and challenge by systematically varying
the training program. It can include weight machines as well as
free weights, elastic bands, medicine balls, and body weight
exercises, etc.
16.
Optimize performance and recovery with healthy nutrition,
proper hydration, and adequate sleep. In addition, educational
sessions on lifestyle factors and behaviours that are conductive
to high performance.
17.
Support and encouragement from instructors and parents will
help maintain interest.
BACKGROUND: Promotion of physical activity guidelines at an individual level
20
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
Recommendations at an individual level
The Biddle et al. recommendations (48) are considered as a reference
at an international level. They are based on current scientific and expert
evidence and opinions in the field of physical activity and health (39) and
have been endorsed by several international organizations, such as the
British Health Department, Centres for Disease Control and Prevention
(CDC: centres for network control and prevention of diseases) of the United
States and the Ministry of Health and Senior Citizens of Australia.
There are however small changes made by certain institutions, to be
explained below.
Firstly, the Australian Government Department of Health and Ageing
distinguishes the achievement of physical activity guidelines between 2
groups of ages: children from 5 to 12 years old (60) and adolescents from
12 to 18 (61). They advised setting limits on the time allotted for engaging
in sedentary behaviour. Children should not spend more than two hours a
day using electronic media for entertainment (i.e. computer games, TV,
Internet), particularly during daylight hours.
Another initiative at the institutional level was launched by Health
Canada reporting that recommendations for children (aged 6-9) and for
adolescents (aged 10-14) were treated in two separate documents (62, 63).
The basic recommendations within these guidelines were that children and
youth, independent of their current physical activity level, should increase
the time they currently spend on physical activity by 30 minutes a day, and
progress, over approximately 5 months, to 90 minutes a day. The key
recommendations from Health Canada were:
1. Build up physical activity throughout the day in periods of at
least 5 to 10 minutes.
BACKGROUND: Promotion of physical activity guidelines at an individual level
21
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
2. Combine three types of physical activity: endurance, flexibility
and strength.
3. Reduce “non active” time spent on TV, video, computer games
and surfing the Internet, starting with 30 minutes less per day.
4. They eventually provide a variety of ideas to stimulate activity.
The most recent physical activity recommendations were issued by
the U.S. Department of Health and Human Services (64). These “2008
Physical
Activity
Guidelines
for
Americans”
are
based
on
extensive
systematic review and critical analysis of the current evidence in health of
children and adolescents (65). Accordingly, children and adolescents aged
6-17 should do at least one hour physical activity every day, which should
include MVPA. As part of their 60 or more minutes of daily physical activity,
children and adolescents should include muscle-strengthening physical
activity and bone-strengthening physical activity at least 3 days a week.
This recommendation of at least one hour of daily physical activity is
quite similar to several recent U.S. and an Australian Government (60, 61)
recommendation but less than the Canadian recommendation of 90 minutes
physical activity a day (62, 63).
Following the advice of the US Department of Health WHO published
World Recommendations for Physical Activity and Health (66). In said
document they establish three pieces of adv ice for boys and girls between
5 and 17 years of age:
1. Children between 5 and 17 should accumulate a minimum of 60
minutes of vigorous physical activity daily.
2. Physical activity for more than 6o minutes awards additional health
benefits.
3. Daily physical activity must be mainly aerobic. It is convenient to
do vigorous activities, especially to strengthen muscles and bones,
at least three times a week.
BACKGROUND: Promotion of physical activity guidelines at an individual level
22
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
At any rate, it is advisable to increase activities progressively in such
a way that children may find the activity pleasant (67).
A common feature of most of the recommendations has been the
emphasis on the variety of physical activities included. For example,
activities
that
involve
moderate
to
vigorous
intensity
have
cardio-
respiratory benefits and help to maintain caloric balance in children and
adolescents, whereas muscle strength activities have also good benefits on
caloric balance but include bone health benefits: i.e. sessions where
children and adolescents performed weight supporting physical activities
that imply high physical tension in bones and joints such as: jogging,
jumping, bending, ball games or physical training. Active games involving
transport activities such as climbing, gymnastics and fighting will help
develop and maintain muscular fitness and flexibility. This range of different
types and intensities of activity provides a complete set of healthy benefits
to all body systems.
Although all that stated above is valid for everyone, both male and
female children and adolescents should start by adopting a more adult type
of physical activity lifestyle, and therefore it is more successful to promote
different activities. These activities can include daily walk to and from
school, organized sports or activities, exercise classes and leisure activities
such as dancing.
Children should meet recommendations with daily walking to/from
school, daily school activity sessions (breaks and sport clubs), afternoon or
evening play opportunities during the week and at weekend, visiting park or
swimming
pool,
bicycle
rides,
etc.
Adolescents
should
meet
recommendations with daily walking (or cycling) to/from school, organized
or informal midweek sports or activities, dancing or organized sports
activities in weekend (16). Nevertheless, a study by Shakle et al. (68),
published in 2011, affirms that organized sports, such as football, only fulfil
BACKGROUND: Promotion of physical activity guidelines at an individual level
23
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
part (25%) of the recommended 60 minutes. It must also be noted that the
level of obesity in children must be taken into account when recommending
physical activities (14).
Finally, WHO (World Health Organization) is nowadays developing the
final stages of global physical activity recommendations (65). Before
concluding, three relevant physical activities recommendations for children
will be mentioned:
1. Practicing some activity is always better than no activity.
2. Many health benefits increase with the increase of the intensity,
frequency and/or duration of activity (although health benefits
are better documented in adults than in children).
3. The health benefits of physical activity greatly outweigh the
health risks and health benefits are largely independent of
gender, race and ethnicity.
BACKGROUND: Promotion of physical activity guidelines at an individual level
24
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
2.2. Promotion of physical activity guidelines from
family environment
Family environment
The family is the foremost development environment since we are
children. Studies show that the family has a great impact on children's
behaviour and therefore helps children to maintain an adequate weight (4,
69, 70-72), fomenting healthy and active lifestyles (15).
Lifestyle has changed with the advent of new technology. Most people
have cars, television, computers and digital entertainment devices. Thus,
the automobile is used for everything, homework is always done sitting at
the computer, etc. All of these have become habits acquired during
childhood. There is a preference for either watching TV over playing games
in a park with friends (16), and going to/from school by car rather than
walking. In this respect, the debate opened around the possible use of some
interactive videogames based on physical activity for health improvement is
interesting. Nevertheless, the educational advantages of said proposals are
uncertain (73).
Eating habits have been also modified. Formerly, meals were usually
cooked at home with fresh ingredients, although nowadays the consumption
of frozen meals, pastries and anything that allows us to spend the least
time possible has increased. As a consequence of this, we have not kept the
energy balance between our diets and daily energy expenditure, giving rise
to some bad eating habits, which have to be treated so as to globally
broach the problem of excess weight (74).
It must be remembered that obesity is not only a cosmetic problem
but is also detrimental to health and self esteem. In the short term, being
BACKGROUND: Promotion of physical activity guidelines from family environment
25
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
overweight may prevent a child from playing normally with his friends,
using the clothes that he likes, or having to endure the ridicule of other
children. In the long term, obesity is associated with increased risk of heart
disease, type 2 diabetes, increased blood pressure, high cholesterol, certain
cancers and other chronic diseases. A child with overweight or obesity is
likely to become an obese adult (16, 72), many of the habits that are
learned in childhood tend to consolidate during adolescence and may
become routine when adult (75). It is important to note that there is a
greater relationship established between physical activity in childhood and
adulthood activity when assessing the quality of childhood experience than
when attention is focused only to quantity (16). Studies such as those
carried out by Villagrán Pérez et al. in 2010 (76) al substantiate the fact
that family history and lifestyles can have an effect on the development and
maintenance of infantile obesity.
Nevertheless, treatment of overweight families or overweight parents
has still not been researched sufficiently. At the time of writing there is a
prevention program in progress called “Early Stop, (Stockholm Obesity
prevention Program), which has as an objective the evaluation of early
obesity prevention in overweight Swedish families. This program is
pioneering the fight against behavior which leads to obesity, such as diet
imbalance, absence of physical activity and sleep alterations, from the age
of one to six. All the above may require the intervention of health specialists
such as diet experts, physiotherapists and nurses, since the effects can be
seen during the first years of a child´s life (70).
For these reasons, the relevance of parents providing support to
children must be considered. They may prevent obesity and promote
healthy living. Children see their parents as role models, so if parents are
eating properly and do regular physical activity. They are creating those
same habits and attitudes in their children (69, 71, 72, 77-80). With simple
things like setting a time to exercise together, deciding to eat vegetables for
BACKGROUND: Promotion of physical activity guidelines from family environment
26
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
dinner, having available fruit available when hungry… and in general, being
able to gradually change bad habits.
Another habit that can be modified to improve our health is setting
out to make more journeys on foot. The bus can be taken one or two stops
away from home or got off earlier to finish the journey on foot. If bored at
home, people can go out to the playground instead of staring at television,
after dinner a short walk can be taken, shopping can be a family affair, and
healthy food can also be also bought (72). Children’s behaviour it is always
reinforced when parents show they like the ideas they are promoting (75).
The family can enhance life skills among its members. As mentioned
above, the first step is for parents to make regular physical activity an
example for their children. Parents' associations can promote extracurricular activities within the school, finding school a safe place where
children can do different sports. These activities may appear very attractive
to children because they are performed in a familiar place and with friends
(79, 81).
When setting out physical activity for children and adolescents, their
personality and preferences have to be taken into account. It is important
to create the routine of exercising at least one hour a day (71, 77). Some
people prefer a leisure environment while others prefer competitive sports.
In the latter case we must be cautious in situations of failure or stress that
may lead a child to want to stop the activity. Enhancing child motivation as
well as supporting them while practicing active habits will be very important
to keep them interested (79, 81). If they are not particularly interested in
physical activity, it must be gradually integrated within daily activities or
games (75).
If parents show interest in their physical education classes at school
or in some specific activity, they are encouraging children and adolescents
BACKGROUND: Promotion of physical activity guidelines from family environment
27
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
to perform physical activity by themselves. In addition to this, it is
important not to focus on his performance and this must be taught to
compare only to themselves (75).
Studies allow us to know why children do or don´t do physical activity
(75). Below is a list of motivating and de-motivating factors:
MOTIVATING
Having fun
Sharing experiences with their family
DEMOTIVATING
Giving more importance to winning than to
playing
Not progressing. Not having been helped on
skills-improvement.
Well-advising from an enthusiastic person in
Performing the same thing over and over
physical activity
again
Feeling that activity is a personal choice
Feeling pressure to play
Feeling competent and fit
Injuries
Playing with peers
Feeling ridiculed
Experiencing a variety of activities and
The external imposition of the activity taking
movements
place
Figure 5. Motivating and de-motivating activities.
Benefits acquired from the practice of physical should be included
within children´s and adolescents’ education. Thus, teaching them to have
an active life provides them with the following things (16, 72, 75):
• It keeps them healthy.
• It maintains weight.
BACKGROUND: Promotion of physical activity guidelines from family environment
28
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
• It strengthens their muscular-skeletal system (muscles and bones).
Increased bone mineralization.
• It develops their strength and endurance.
• It improves the motor nervous system maturation and increases
motor skills.
• It helps them to release stress.
• It helps them to sleep better.
• It promotes mental health.
• It helps them to feel better about themselves.
• It
helps
them
to
improve
their
academic
performance
and
sociability.
• It is a hobby to be practiced when bored.
• It's fun to share these activities with family and friends.
Nevertheless, we must not forget that knowledge of the benefits of
physical activities, and being aware of the inconveniences of obesity, do not
in themselves guarantee that children will have the expected healthy habits
(78).
Nor can we forget that growing tastes and preferences change, so the
time spent in physical activity may decrease. Parents can help them, finding
activities that are among their interests, reminding them of the importance
and benefits of active people, avoiding reducing everything to winning or
losing. If they consider they do not have enough time for sports, parents
could perhaps help them to organize their schedule. Moreover, if parents
held an active lifestyle, their friends would probably do so, providing them
with a proper active environment (16, 75).
BACKGROUND: Promotion of physical activity guidelines from family environment
29
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
Recommendations at a family level
It is proposed that the family should proceed as follows:
1. Being a role model and serving as an example (69, 71, 72, 77-80).
This influence includes:
• Practicing physical activity with the children
• Being physically active
2. Paying attention and giving support (70, 75, 78, 80). This type of
influence is the “non visual” one and includes:
• Being concerned about school physical education, showing interest
in their physical activity
• Guiding them into a based-on-self-interested physical activity
• Helping them to progress in different activities, not allowing them to
give up when they are not competent
• Trying to avoid their feeling ridiculous when they have difficulties in
physical activities
• Respecting their abilities and preferences
• Not forcing them to become elite sportspeople
• Teaching them to be their own role model
• Encouraging them to avoid dropping out
3. Providing opportunities and facilities (16, 71, 75, 77, 79, 81). This
type of influence is the “tangible support”, including:
• Giving them leisure and sports material to encourage play
• Helping them to organize their schedule, including time for
BACKGROUND: Promotion of physical activity guidelines from family environment
30
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
outstanding activities: meals, homework, reading and physical
activity
Try to get them to use the stairs instead of the elevator
• Going to the park or other safe places to actively play and/or
practice their sport
• Dressing them in comfortable clothes that allow them to play freely
without having to worry about getting soiled
• Finding out about the possibilities of practising recreational physical
activities and sports in the neighbourhood
• Facilitating their enrolment and regular attendance at physical
activity programs
BACKGROUND: Promotion of physical activity guidelines from family environment
31
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
2.3. Promotion of physical activity guidelines from
school environment
Physical activity in a healthy school environment
Although one aim of the school is tackling childhood obesity (82-84),
it has huge contradictions in relation to physical activity. Firstly, there is not
a balance between practice and competition. Secondly physical education
(PE) has become marginalized in the school context just when we need to
resolve the problem of childhood obesity (85) and regular physical activity
becomes a requirement (86). Changing PE curriculum by giving more PE
hours will let students increase the time allotted to moderate or vigorous
physical activity (MVPA) (82, 87).
The need to increase physical activity in school and being physically
active is an important aim to stop the spectacular increase in obesity (88).
These data were shown by the World Health Organization Regional Office for
Europe (WHO) (88, 89). It recommends for children and adolescents more
and better opportunities for physical activity, such as a minimum of 60
minutes of varied physical activity. Due to the fact that our society has
changed habits of movement (children and young people prefer spending
most of their leisure time watching computer and TV at home rather than
playing actively in the street), our environment provides fewer opportunities
for spontaneous physical activity for children and young people. Although
government has to keep on seeking new solutions it is also true that
everyone is equally responsible and forced to rediscover the potential of
sport education, active play and physical activity in order to counter
sedentary practices.
Physical Education will be among the objectives of the International
Council for Health, Physical Education, Recreation, Sport and Dance
(ICHPER) for school, and any standards as the Standard 3: Health-
BACKGROUND: Promotion of physical activity guidelines from school environment
32
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
Enhancing Fitness (Achieve and maintain a health-enhancing level of
fitness) and the Standard 4: Physically Active Lifestyle (Exhibit a physically
active lifestyle) (90).
Physical Education has never had priority in the curriculum. A piece of
evidence is that the PE hours have being reduced (91). Families were
usually not aware of the need for a minimum of physical activity daily, so
they did not complement the shortcomings of movement seen in the
schooling of their children with an additional practice schedule. Nowadays,
parents are becoming aware of their children’s motion deficit and lack of
healthy physical activity and are paying for sport and physical activity
outside school hours, but this depends on the economic status of each
family. Sport and physical activity must be part of the social life (86) but
always depending on cultural circumstances (49).
The UNESCO’s International Charter on Sport emphasizes that
Physical Education is a fundamental right for everyone (92). It means we
must assure universal practice through the enhancement of physical
education programs and adequate sports education. Physical Education and
sports should be recognized as an integral part of quality education and
should be a national priority (93). International guidelines are ignored and
Physical Education and sport continue being, in some occasions, a privilege
for children and young people (94) although they should be an essential
part of every educational project. Everyone talks about tackling both obesity
and inactivity in children and young people, extending the habits and sports
activities among the citizenry. However, if we do not want the Physical
Education curriculum to disappear, we need to ensure current credit hours
for PE.
School is the key to develop, implement and maintain policies that
promote a healthy lifestyle for everyone (82, 95-97). Due to the fact that
children and adolescents spend almost half of their wakeful hours in school
BACKGROUND: Promotion of physical activity guidelines from school environment
33
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
should serve as a vehicle to reinforce healthy habits over time (89, 98, 99).
We highly recommend the usage of individualized plans to promote such
attitudes (100). Therefore, the school must strengthen physical education
and physical activity (88).
Active and healthy programs have to involve the entire school
community in order to reduce the chances of chronic diseases, increase
students' knowledge about diet, nutrition and physical activity (16). It also
improves the care and attitude of pupils in classes (101) and cognitive
performance (102, 103) (i.e. increasing to 5 the number of weekly Physical
Education
sessions)
(104).
It
seems
that
girls
benefit
most
from
participation in sports. A recent study indicates that girls who practice
athletics improve their academic results, the effects being seen even in their
adult years (105, 106).
Sports authorities handling physical activity and health in the school
should be aware that children are more active during free time in schools
with sufficient playing areas, facilities and sports equipment, where
supervision is an important factor (107). Innovative playground markings in
schools can increase total energy expenditure, rate of energy expenditure
and duration of physical activity (108). Therefore many school playgrounds
should improve their sports facilities in order to avoid having games and
sports practices dropping off (88). An interesting proposal appears in a
2010 document for the Let´s move program, in which students practice
sports during their recess breaks, as well as during maths, language and
other courses (109).
Effective school physical education
School should offer a at least 20 to 30 minutes of moderate to
vigorous physical activity (MVPA) each day (16, 46, 110) which should
gradually increase until at least one physical practice time MVPA weekly
BACKGROUND: Promotion of physical activity guidelines from school environment
34
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
(16, 97, 111-114) where a couple of sessions weekly will be dedicated to
working muscle strength (59), flexibility (39, 88) and bone-mass (16, 39,
48, 64, 75, 115, 116). Some authors raise the minimum to 90 minutes
(117).
On a physical activity five-levelled-scale (118): inactive, slightly
active, moderately active, very active and extremely active, we would
ensure the daily hour of physical practice as recommended for all children
and youth. That means that, at least, it is necessary to have the moderately
active profile, because they are achieving a high level of protection from
chronic diseases resulting from physical inactivity, and the risk of injury is
the lowest. Thus, at school, the student appropriately uses the Physical
Education hours and supply of other complementary practices but also
performs some systematic curricular activities sports, recreational or of
moderate intensity.
The equivalent of this moderately active profile in the Physical
Activity Pyramid Corbin for children (118) and adolescent (119) would reach
the level-2 covering physical activities of daily living (i.e. taking the stairs
instead of the elevator) (120, 121) and also active games and aerobic
activities, sports or recreation (i.e. bicycle riding).
Nowadays, compulsory Physical Education classes should ensure 2
hours, and in the longer term, 3 hours a week in all educational levels of
direct practice (93). Allowing 150 minutes for elementary schools and 225
minutes for secondary schools (97, 122), but not mandatory in preschool
(3-6 years) where it is recommended to be active at least 3 hours a day
(123) and also the age group (16-18) (112) making this practice universal
(124). WHO (88) explains the need to include physical activity in school
legislation in the same line of UNESCO (125), which thinks that all Member
States should include the Physical Education and Sport (PES) curricula in
their education systems, and make compulsory the PE and sports in the
BACKGROUND: Promotion of physical activity guidelines from school environment
35
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
curriculum (126, 127) this will ensure a minimum daily amount of physical
activity as part of academic curriculum covering basic needs of motion (128,
129) because the active lifestyle and the practice of PES is a right for all
students (92). In this sense, a recent study of Fernandes and Sturm, 8.246
boys and girls from 970 US schools were reviewed, verifying that body
mass was reduced is those following the physical activity recommendations
(130).
The school Physical Education curriculum must uphold the minimum
competence to adopt and maintain an active lifestyle (16, 49, 89, 97, 111,
113, 114, 131, 132). In addition to improving motor competence of
students, Physical Education will get them to feel competent. Therefore, PE
must foment new skills, must master new abilities, and must increase
children and youth´s self-confidence (88). Girls will especially need to feel
competent and supported in PE and more variety of non-traditional sports
and activities should be included in their classes.
In general, Physical Education for an active lifestyle must be offered
to everyone (133) and programs must cover individual and social needs
(92). All in all, PE is where children and youth learn how to be active so that
they feel confident and motivated to undertake, on their own, physical
activity outside of PE class (133). Half of the PE program should be devoted
to MVPA and half to developing skills (16, 110, 134).
Physical Education focused on MVPA increases the fitness of children
and young people (135) and simultaneously tries to improve their autonomy
in the physical practice and their responsibility for an active and healthy
lifestyle. For example, 3-6 years: 10-15 minutes of daily moderate activity
(136); 7-12 years: several 10-15 minute activities with 5 or more minute
breaks throughout the day (136) with active game or new games as
throwball; 13-18 years: aerobic work are combined work strength into three
or more sessions a week, longer earlier stages (136) with dancing, yoga,
BACKGROUND: Promotion of physical activity guidelines from school environment
36
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
games, traditional sports, organized sports and another physical, recreation
or expressive activities.
We must ensure the carrying-out of PE programs (16, 97, 110)
without any interference of other more sedentary subjects (96). Focusing
on Physical Education programs we can collect some interventions to cope
with curriculum, policy and environmental strategies (62, 64, 71, 77)
because they are more effective than curriculum-only approaches (137).
This would allow PES programs to be qualitatively assessed and accredited
(125) and that PE teachers could be a skilled-qualified professionals (16,
92, 93, 110). We must not forget youth in correctional institutions, since
they have fewer opportunities for physical activities and are consequently
less active (138).
Extracurricular physical activity
Specific physical fitness programs as extracurricular activity can
decrease the risk of obesity (139). Extracurricular physical activity is very
important (16, 110, 127) as a supplement to the school because ofthe
shortage of Physical Education hours. This practice, before and after the
school, is one of the best predictors of fitness and fatness in children´s
physical activity pattern (84, 98, 134).
The school sport facilities must be opened as long as possible within a
safe environment (16, 91, 93, 96, 111, 114) and provide students with the
most varied range extracurricular physical activities, in collaboration with
parents' associations. These activities must take into account the needs and
interests and be attractive to the majority of students (16, 49, 91, 97, 111,
114). Championships should be organized among schools as well (112, 127)
paying close attention to girls (88, 100, 112), who should be offered less
competitive activities (15).
BACKGROUND: Promotion of physical activity guidelines from school environment
37
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
All these physical activities, active games and healthy sports should
respect the principles of fair play, sportsmanship and inclusion. Positive
experiences will be the result of the creation of healthy practice habits in
the medium term.
The school must ensure the methodology (112), sensitization (96),
and update training in fitness and health of the staff to assist in organizing
of these physical activities (16, 93, 111, 114, 131, 140) materials or in the
evaluation criteria (127). Coordination and training, as well as teachers, are
essential to national implementation (100), regardless of the dispensed
subject matter or area which is covered (97, 112).
On the other hand, families could be informed about the best physical
activities for their children or how to prevent and avoid injuries (30).
Injuries are a potential barrier which must be assumed. The real danger is
the maintenance of sedentary behaviour and habits from childhood (84,
134). Nevertheless, the ways in which we can reduce the possible risks of
physical activity, active play and healthy sport are:
•
Respecting the needs and interests of children and youths in the
choice of activity, considering as well it´s appropriateness for
them as well (141).
•
Reporting, from the school to families concerning how to reduce
risk behaviour and measures for the prevention of more basic
injuries.
•
Monitoring and assessing student participation in programs which
the school is involved in, especially those that either add some
new activity or have some kind of limitation or disability that be
recommended.
•
Advising the practice towards other activities with less impact or
more appropriate, especially when detecting chances of chronic
injuries.
BACKGROUND: Promotion of physical activity guidelines from school environment
38
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
Improving attitudes toward the practice of physical activity and
exercise for children and mainly young people.
•
Rejecting the use of physical activity as punishment.
•
Using places, spaces and facilities which are adequate and safe.
School will maintain an Evaluation Plan to monitor and carry out
appropriate control of the level of participation in the different intervention
programs that promote physical activity and sports in the center (16, 111,
114, 125).
The school will work with parents' associations (88), with networks or
with local sports agencies, recreational, social or health organizations (111,
142) and make their participation easier in physical activity programs
developed at school. Participation and attitude improvement of the families
toward the practice and exercise taking place at school is an essential
element in programs that seek to increase physical activity in children and
young students.
Additional school physical activity
School should promote the practice of physical activity by providing
space and time to students who want to actively participate in recreational,
institutional or traditional sports, dance or any healthy practice, individually
or collectively, to avoid a sedentary lifestyle (16, 111, 114, 142). In
addition to this, they must also encourage educative sports competitions to
enrol the participation of all students (131), promoting different levels,
incorporating offsets to maintain the interest of competition with the aim of
the maximum possible participation.
It is important to include children and adolescents especially for the
design, development and evaluation of physical activity programs. School,
within this culture of participation, may request the collaboration of
BACKGROUND: Promotion of physical activity guidelines from school environment
39
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
students as coordinators, referees, judges, and organizers of the activities
offered to younger children.
School should support, promote and spread a culture of wellness in
general, and voluntary physical practice, in particular, for all members of
the education community, in addition to the students, faculty, another staff
and families (16, 82, 97, 100, 111, 114). In this sense, it is important to
limit the use of candy and snack machines within the sports facilities (143).
Recess is a good time to offset the sedentary lifestyle that involves
the processes of teaching and learning of most subjects in the curriculum
(132). Recess will last approximately 30 minutes (16, 110) for every 3
continuous hours. In this period it is advisable to organize expressive
activities, recreational or sports activities that help to develop habits that
result in an adequate use of leisure and free time conducive to a healthy
lifestyle (49). All in all, this period of time should increase the physical
activity of the less active children during breaks at school (especially girls in
intermediate schools) (89).
School transportation
Attending school is a good opportunity for physical activity and only
half of the children often use active transport to and from school (i.e.
walking, bicycling, skateboarding or other more active ways) (144). Active
transport gives an opportunity for children's physical abilities to regulate the
amount of physical activity they perform. (i.e. coming and going to school
results in an increase of over 1000 in the number of steps taken each day
of the week) (145).
Reasons given by parents and caregivers to avoid having their children
go and come walking to school were: living too far away from school, traffic
BACKGROUND: Promotion of physical activity guidelines from school environment
40
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
hazard such as moving traffic or crossing a road, lack of time, weather...
(137, 144).
School should encourage active movement of the members of their
community, especially children and youth within a secure environment (16,
111, 113, 114) for cyclists and pedestrians (97) because many students are
going by bus or by car to school instead of walking or riding a bike (89, 97).
(i.e. car-free zones, by reducing the speed limit to 30 km/h or putting speed
humps) (88).
Another interesting initiative are the Walking-buses where children
walk to school in groups being watched by adults (88), establishing and
promoting multiple safe routes of these small groups of students to school
(16, 96, 110). This way it is possible increase physical activity, improve
pedestrian safety of children who walk or bike to school, adding more
minutes of physical activity throughout the day (146).
Adolescents whose parents live in a safe, accessibly and aesthetically
pleasing neighbourhood, are more likely to walk or cycle (147). Where
measures have been put in place to slow down or reduce traffic, more
children are allowed to walk or ride to school on their own (148). Results
across various studies show that children’s participation in physical activity
is positively associated with the transport infrastructure (i.e. sidewalks,
controlled intersections and access to public transport) (149).
BACKGROUND: Promotion of physical activity guidelines from school environment
41
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
Recommendations at school level
After reviewing the scientific literature and current reality of schools,
it is proposed that school administrators act as follows:
•
Claiming health education and daily physical activity for all
students (87).
•
Ensuring that physical education and extracurricular programs
offer a combination of recreational activities, fitness, competitive
and non competitive sports which can be practiced during all
one´s life (88, 89).
•
Providing time during the day (i.e. playtime, active school
transport) for unstructured physical activities (i.e. walking or
cycling to school, games during playtime, etc.) (16, 111, 114,
142).
•
Hiring qualified physical activity professionals (16, 92, 93, 110).
•
Providing internal training for teachers in the promotion of physical
activity (97, 112).
•
Providing programs to promote health for school staff (16).
•
Establishing a link with health professionals in order to track the
situation of children overweight/obesity (111, 142).
•
Establishing a link with physical activity programs offered in the
community for the information of these programs to come to
school and parents (16).
•
Involving families and community organizations in school physical
activity programs (16).
•
Promoting a school environment that encourages physical activity
by means of opening sports facilities during non-school or evening
hours, weekends and holidays (4, 108).
•
Working together with companies and other community groups for
children
and
adolescents
with
lower
incomes
to
have
transportation and appropriate equipment to participate in physical
activity programs (92, 133).
BACKGROUND: Promotion of physical activity guidelines from school environment
42
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
Ensuring that facilities for physical activity meet or even exceed
safety criteria (88).
•
Not using physical activity as punishment, neither by prohibition
(playtime, games) nor by obligation of doing it (push-ups, extra
exercises, etc.).
•
Increasing the students' knowledge on how to be physically active
(16).
•
Encouraging positive feelings about physical activity.
•
Working for school staff to make physical activity fun and
interesting (16, 49, 91, 97, 111, 114).
BACKGROUND: Promotion of physical activity guidelines from school environment
43
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
2.4. Promotion of physical activity guidelines from
local government
Introduction
Nowadays in the majority of communities, the opportunities for
children and adolescents to be physically active have been dramatically
curtailed,
where
they
are
not
active
enough
to
reach
health
recommendations and the trend is toward less activity (91).
Both the drop in physical activity and the rise of obesity need to be
urgently tackled, and cities are playing an important role in this. To
strengthen health policies governments also need to support further
research that quantifies the causal links between both physical activity and
health. Some changes are also needed in social environments, as well as
some evaluations of local policies and programmes to cover these issues
(91).
In the 21st century, promoting physical activity should be seen as a
requirement where sport and physical activity must more than ever become
part of social life (86, 150). On a large scale, action should be coherent and
consistent across different government levels and sectors, because physical
activity is not only a public health issue but also promotes the well-being of
communities and the protection of the environment and comprises an
investment in future generations (89). In this way, young people have a
fundamental role to play not only in the formulation of health and
environmental policies but also in the decision-making processes and a
healthier-and-more-sustainable- building world (91).
Local governments –along with jurisdiction over many aspects of land
use, food marketing, community planning, education, transportation, health
and nutrition programs, and other community issue- are strongly positioned
to promote behavior that will help children and adolescents reach and
BACKGROUND: Promotion of physical activity guidelines from local government
44
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
maintain healthy weights. Promoting children’s healthy eating and activity
will require the involvement of an array of government officials, including
mayors and commissioners or other leaders from counties, cities or
townships (91, 151, 152). Many departments, including those responsible
for public health, public works, transportation, parks and recreation, public
safety, planning, economic, development, and housing will also need to be
involved.
Local level initiatives have the greatest potential to encourage
physical
activity.
Consequently,
mobilizing
and
supporting
local
governments and local communities to develop this potential will be a key
to
success
(88).
However,
It
must
be
politically,
technically
and
economically supported by regional and national authorities. If necessary,
new technical and economic support mechanisms should be established and
adapted to local needs (88). For these policies to be successful, they must
be implemented at a national level (143).
The health sector has a major role to play in promoting and
coordinating action to support physical activity in each level, and this should
invite and motivate different sectors and stakeholders to collaborate in
promoting physical activity. In this way, local communities should cooperate
with health services to facilitate, and provide individual information to
people who have been recommended by health professionals to practise
physical activity as preventive treatment (88).
It is quite clear that no single organization can be expected to deal
with all of the aspects of physical activity and sport. The overall objectives
identified herein may be global, but the strategies must necessarily be
regional, supported by national commitment, and the implementation of
specific programmes must be normally local (86, 88). A close cooperation
should be established between regional/provincial and local governments in
order to implement and follow up on work (88, 96).
BACKGROUND: Promotion of physical activity guidelines from local government
45
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
Community involvement and evaluation are vital to tackle childhood
obesity. It is critical for local government officials and staff to involve
constituents
in
local
needs
and
identifying
top
priorities.
Engaging
community members in the process will help to identify local assets, focus
resources, and improve implementation plans. As obesity prevention actions
are being implemented, they will need to be evaluated in order to provide
important information on what does and does not work (151).
The vision is towards shaping societies where healthy lifestyles
related to diet and physical activity are the norm, where healthy goals are
aligned with those related to the economy, society and culture and where
healthy choices are made more accessible and easy for individuals (153).
Barriers
The social reasons for the non-practice of physical activity are (88, 89,
91, 96, 127, 144, 154-156):
•
The quality of the neighbourhood affects the residents´ own free
will to have physically active use of common spaces.
•
Parents are quite reluctant to let children play outside or letting
them go playground on their own due to traffic road fears and/or
crime.
•
Children and adolescents are given a lift in home-school journeys
because of the distance and/or road safety concerns.
•
Even if there are safety routes such as back alleys and cycle lanes,
tracks and paths, children may choose not to use them, especially
if they are in isolated areas. Children may prefer to be in places
where they can be seen and where they can see other people.
•
Competitive sports programmes may be one reason that young
people are particularly likely to drop out of sports.
BACKGROUND: Promotion of physical activity guidelines from local government
46
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
Suburbs with wide streets, long blocks, few sidewalks and a lack of
mixed land use leave children and young people with “nowhere to
go” and may have contributed to the increase in passive indoor
recreational activities such as computer gaming and watching
television.
•
Different socioeconomic groups also show inequalities. Poorer
people have less free time and worse access to leisure facilities, or
live in non-physical-activity-supported environments.
•
Scant financial resources.
Evidence suggests that environment –where people live, work, learn
and play– influences both the simple and complex factors involved in
physical activity (91, 157, 158).
In adopting policies and practices tailored to raising healthy children,
local communities have an opportunity to achieve equity. The equal
distribution of health resources among all population groups, regardless of
their social standing, poverty, poor housing, racial segregation, lack of
access to quality education, and limited access to health care contribute to
the uneven well-being of some groups of people, especially those who live
in poor communities (151).
Recommendations at a local level
Actions to improve our community and increase physical activity in
children and adolescents:
1. Urban Environment:
•
Provide a framework through regional health authorities to
create healthy communities (88, 122, 159).
BACKGROUND: Promotion of physical activity guidelines from local government
47
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
Identify
opportunities
and
challenges
to
improve
the
community surroundings (160).
•
Communities can be designed to encourage activities, such as
walking, biking, or sports games (88, 96, 153, 160, 161).
•
Adequate space and sports facilities (88, 89, 150, 155, 162).
•
To make access easier to outdoor recreational facilities (88, 89,
96, 97, 126, 127, 133, 150, 153, 155, 163, 164).
•
To make access easier for the practice of physical activity in
children and adolescents with disabilities and chronic illnesses
(91).
•
Build or enhance infrastructures to support more walking and
cycling (97, 153, 163, 165, 166).
•
Adopt pedestrian and cycling, learning to develop a long-term
vision for walking and cycling in the community, and guide its
implementation (151, 161, 162).
•
Plan, build, and maintain a network of sidewalks and street
crossing that create a safe and sound walking environment and
schools, parks, and other destinations (91, 151, 158, 161, 162,
165, 166).
•
Enhance safety traffic in areas where people are or could be
physically active (97, 158, 162, 163).
•
Plan,
build,
and
retrofit
streets
to
reduce
speed
limit,
accommodate cyclists, and improve the walking environment
(91, 151).
•
Plan, build, and maintain a well-connected network of off-street
trails and paths for pedestrians and cyclists (91, 126, 133, 151,
164).
BACKGROUND: Promotion of physical activity guidelines from local government
48
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
Provide on and off-leash walking areas for dog owners within
walking distance of areas where older people, families and
people with disabilities live (91).
•
Increase destinations within walking and cycling distance (151,
153).
•
Create safety areas to park bicycles in recreational areas
(162).
•
Collaborate with school districts and developers to build new
schools in central locations close to residential areas and away
from moving traffic roads (97, 151, 163).
2. Programs for walking and cycling:
•
Foment active transportation (50, 88, 91, 114, 122, 127, 144,
145, 150, 153, 162, 167, 168).
•
Adopt community policing strategies that improve safety and
security of streets, especially in higher crime neighborhoods
(151, 169).
•
Collaborate with schools to develop and implement safe routes
to school in order to increase the number of children safely
walking and cycling to schools (91, 110, 126, 127, 151, 153,
158).
•
Affordable bicycles, helmets, and equipment for lower-income
families (122, 151).
•
Reduce fares for children, families and students in order to
promote use and improvement of school services, parks,
recreation centers, and other family destinations (88, 151).
BACKGROUND: Promotion of physical activity guidelines from local government
49
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
Implement a traffic enforcement program to improve safety for
pedestrian and cyclists (131, 151).
3. Recreational physical activity:
•
Build and maintain safe and attractive parks and playgrounds
nearby residential areas and schools (91, 96, 104, 126, 133,
151, 158, 160, 170).
•
Adopt community policing strategies that improve safety and
security for park use, especially in high crime neighborhoods
(151, 169).
•
Improve access to public and private recreational facilities in
communities with a shortage of recreational options through
cost cuts, increased cooperating hours, and development of
appropriate cultural activities (122, 151, 162).
•
Increase the frequency and intensity of physical activity in
order to engage children and adolescents during-and-afterschool (152).
•
Create after-school programs and other publicly or privately
supported active recreation (151).
•
Encourage the use of stairs versus elevator (165, 166).
•
Collaborate with school districts and other organizations to
establish facilities agreements allowing fields, playgrounds, and
recreation centers to be used by community residents when
schools are closed; adopting if necessary, regulatory and
legislative policies to handle liability issues that might block
implementation (4, 49, 96, 133, 151).
BACKGROUND: Promotion of physical activity guidelines from local government
50
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
Create and promote youth athletic leagues and increased
access to fields, with special emphasis on income and gender
equity (126, 151).
•
Build and provide incentives to build recreation centers in
neighborhoods (151).
4. Routine physical activity:
•
Institute
regulatory
policies
about
play
space,
physical
equipment, and duration of play in preschool, after-school, and
child-care programs (151).
•
Create incentives for remote parking and drop-off zones and/or
dis-incentivate nearby parking and drop-off zones at schools,
public facilities, shopping malls and other destinations (151).
•
Improve stairway access, especially in places frequented by
children (151).
5. Schools:
•
Adopt
strategies
to
facilitate
regional
and
international
cooperation among specialists of physical education sciences,
institutions and countries (125).
•
Develop structures for team research on physical education
sciences thematic (125).
•
Establishing a Technical Working Group to monitor standards
for quality PES and to ensure sustainability of regional
initiatives (125).
•
Work with schools in order to promote daily and high quality
physical education at all levels (91).
•
Create
healthy
school
policy
that
includes
management
practices, decision-making processes, rules, procedures and
BACKGROUND: Promotion of physical activity guidelines from local government
51
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
policies at all levels that promote health and well-being, and
shape a respectful, welcoming and caring school environment
(91, 171).
•
Maximize the opportunities for action in the fields of physical
activity
and
sport,
including
the
creation
of appropriate
legislative frameworks, adequate public and private funding,
education and research (86, 172).
•
Support the employment relationship within schools (staff and
students) and among schools (171).
•
Encourage and provide schools with safe and appropriate
spaces and facilities in order students to spend their time
actively (91, 127).
•
Create safety areas to either store or park bicycles in schools
(162).
•
Increase opportunities to do physical activity during school
focusing on frequency and intensity (152).
•
Offer physical activity programs and sports for children and
youth out of school competition calendar (173).
•
Talk with schools about increasing physical activity through
classroom lessons that have movement activities (160).
•
Promote financial resources for the promotion of physical
activity extracurricular (131).
•
Provide a range of extracurricular programs in schools to meet
the needs and interests of specific children and adolescent
populations, such as racial and ethnic minority groups, people
with disabilities, and low-income groups (174, 175).
BACKGROUND: Promotion of physical activity guidelines from local government
52
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
Provide access to school buildings that enable safe participation
in physical activity (174).
•
Working with schools, educational system, parents, police and
local officials to provide active and safe routes to go to schools
and teach children to ride safely through these pathways (91).
•
Encourage schools' administrations to promote and support the
implementation of activities related to health promotion for
school staff (127).
•
Provide funds for in-service training and some incentives for
teachers to participate in additional training (114, 127).
•
Maintain an active school health council and designate a school
health coordinator to promote physical activity and healthy
eating (176, 177).
•
Strengthen the school's nutrition and physical activity polices
(176).
•
Develop, implement, and evaluate innovative pilot programs
for both staffing and teaching about wellness, healthful eating,
and physical activity (114, 152, 167).
6. Healthcare:
•
Primary care interventions are needed to promote physical
activity, including advice about reducing television time (89).
•
Establish a relationship between the surgery and school (111).
•
Work in collaboration with the Primary Care Trusts and general
practitioners to establish programs and formation of the
association and members of the schools (178).
BACKGROUND: Promotion of physical activity guidelines from local government
53
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
Work with pediatric services for children, leisure services and
partnerships for physical activity and sport (91, 178).
7. Transport:
•
Proper transport settings can provide excellent opportunities to
achieve the recommended daily amount of moderate physical
activity for general health benefits (88).
•
Promote active transport as “the walking school bus” (50, 88,
91, 114, 122, 127, 144, 145, 162, 167, 168, 179).
•
More research should be done not only to evaluate the
effectiveness of interventions that promote physically active
transport but also to determine the best combination of
measures that can support a cultural paradigm shift towards
physically active transport (88).
•
Improve access to public transportation (91, 97, 161, 163).
•
More cycling and walking will reduce air pollution, noise and
traffic congestion, and they will create safer neighborhoods.
Investing in physically active transport reduces the need for
expensive road construction and maintenance, and is highly
cost-effective when health benefits are taken into account (88).
8. Media and social marketing:
•
Provide a mechanism for sharing data on active living, for
example on the health costs of inactivity and pedestrian travel
and safety patterns, across government departments and with
the non-governmental private sector (91).
•
Provide clear and consistent media messages on physical
education and sport practices and their positive influences (88,
92, 152).
BACKGROUND: Promotion of physical activity guidelines from local government
54
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
Implement a communication strategy that show the benefits of
physical activity and active transport, how to overcome barriers
to being active and how to get involved in active living in one’s
neighborhood, city and the surrounding areas (91).
•
Develop advertising campaigns, (mass media, radio, internet,
television,
other
promotional
materials)
using
consistent
messages to promote physical activity (88, 151).
•
Create advertising campaigns to show the general public about
the walking and cycling benefits (127).
•
Provide a knowledge of physical activity for families through
sport events (162).
•
Design an advertising campaign that establishes physical
activity as a health equity issue and reframes obesity as a
consequence of environmental inequities and not just the result
of poor personal choices (151).
•
Develop advertising campaigns to prevent sedentary activities,
tobacco and alcohol (84, 151).
•
Adjust the physical activity level to the characteristics and
needs of the population (165, 166).
9. Organizations:
•
Enrol in partnerships with community agencies, voluntary
organizations,
religious
organizations
and
sport
clubs
to
promote and enable active living for children and youth, and
disable people (91).
•
Build or grow a community group to prevent childhood
overweight and obesity (160).
BACKGROUND: Promotion of physical activity guidelines from local government
55
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
Provide a range of programs in community recreation centers
to find the needs and interests of specific adolescent and young
adult populations, such as racial and ethnic minority groups,
disable people, and low-income groups (174, 175, 178).
•
Provide access to community facilities that enable safety
participation in physical activity (174).
•
Provide opportunities for healthy food and physical activity in
community programs, particularly for high-risk population (48,
128, 152).
•
Participate in community coalitions or partnerships to tackle
obesity (97, 163).
•
Support the employment relationship between schools and
other community organizations as well as representing groups
(171).
10.
•
Screen time:
Implement school-based interventions to reduce children’s
screen time (152).
•
Adopt regulatory policies cutting screen time in preschool and
after-school programs (151).
Although a number of organizations, companies, institutions, and
agencies must be involved in designing and implementing changes, efforts
cannot succeed unless they also engage the families, schools, and
communities that create the environment in which children live and are
brought up (88, 152).
BACKGROUND: Promotion of physical activity guidelines from local government
56
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
International non-governmental agencies, national and local sports
bodies can contribute to the process of motivation of young people to enrol
them in recreational sport.
BACKGROUND: Promotion of physical activity guidelines from local government
57
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
2.5. Promotion of physical activity guidelines from
non-governmental organizations
Introduction
Childhood and adolescent obesity is not only a responsibility for
country administrations and public health agencies. Non-governmental
organizations (i.e., sports clubs, community youth associations, etc.) play
an important role in proposing and/or developing policies to prevent and to
treat obesity and their related disorders (165, 166). These associations can
support advocacy efforts to improve the quantity but also the quality of the
physical
activity
that
every
child
performs
daily.
Non-governmental
organizations complement school curricula, and help to create the culture of
physical activity by partnering with schools and supporting families (126).
In addition, these partners can assist in creating awareness, publicity and
visibility for healthy behaviors and contribute by collaborating and cosponsoring programs for young people (127). These kinds of programs have
been developed with satisfactory results for children and adolescents (180).
For these reasons, government policies should be implemented to provide
economical support, spaces and encouragement to non-governmental
organizations to get broader physical activities and to reach new groups of
children (91, 181, 182).
The role of sports organizations: Olympic Committees, Sports
Federations and other international organizations (TAFISA)
Sports Federations play a central role in the practice and promotion
of sport. In addition, they should pay special attention in sports to
education of young athletes, their psychological balance and health,
especially supporting amateur athletes by facilitating their access and
training, and protecting their health. As indicated by the EU legislation
BACKGROUND: Promotion of physical activity guidelines from non-governmental organizations
58
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
"sports Federations should promote different levels of practice, from
recreational to high-level sport" (183).
With regard to National Olympic Committees (NOC), the Olympic
Charter, article 28, says their task within each country is to "promote the
spirit of Olympism, ensure compliance with the Olympic Charter, promote
ethics and development of sport" (184).
There are numerous examples of programs sponsored by these
organizations to promote youth sports. These programs have increased
recently due to the great concern over the current issues surrounding
youth: lack of values, drugs and obesity, among others. It is in this point
where the IOC Commission of Sport for All is situated. It was created by the
IOC in 1983 and its most important goal is to promote, support and spread
out health and social improvements obtained from a regular practice of
physical
activity,
by
means
of
cooperation
of
International
Sports
Federations (ISF), National Olympic Committees (NOCs) and national sports
organizations (185).
The IOC focused the theme of the 12th World Sport for All Congress
in the study and promotion of a healthy and active life. The motto of this
Congress, held in Malaysia in 2008, was “Sport for All - Sport for Life”. Its
aim was to find solutions to avoid the increasing trend of physical inactivity.
One of the key findings of the Congress was that sport and physical activity
should be a key element in health policies and particularly in relation to
obesity (186).
In the same way, the Spanish Olympic Committee has recently
welcomed (in March 2010) the meeting of the Spanish NOC Commission for
Nutrition and Healthy Habits in Sports, chaired by the Minister of Health and
Social Policy, Trinidad Jimenez, accompanied by the president of the
Spanish NOC, Alejandro Blanco, and the president of the Commission,
BACKGROUND: Promotion of physical activity guidelines from non-governmental organizations
59
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
Carmelo Paniagua. An the event were the director of the National Agency
for Anti-doping, the Deputy Minister of Sports in Madrid, members of the
National Sports Council, presidents of the Spanish Federations, directors of
sports institutes, representatives of universities, professionals and media.
This represents a very good example of coordination and teamwork of the
different
governmental,
non-governmental,
local,
public
and
private
agencies (187).
Regarding the International Federations, an interesting example can
be found in the International Football Federation (FIFA) and its new
initiative “Football for Health”. It has been elaborated under the Medical
Assessment and Research Centre of the FIFA (F-MARC) in close cooperation
with African doctors and organizations such as AMREF (African Medical &
Research Foundation). It aims, under the "Win in Africa with Africa"
program, to provide to all players and fans of the continent the most
important victory of all: health (188).
Another example in this area is the British Athletics Federation (UK
Athletics), which is working with the insurance company Aviva and the UK
Health Department to implement the project “Change4Life” that promotes
healthy lifestyle habits, especially among youth. Aviva is the main sponsor
of the Federation and has a number of programs for grass roots activities in
UK Athletics, and around all of them the company implements collaboration
with the project “Change4Life” (189).
In addition to sports Federations and Olympic Committees, other
international organizations also promote, through hard work, the practice of
physical activity, sport for all and traditional games for health. Among all,
Trim & Fitness International Sport for All Association (TAFISA) stands out as
the leading one. Its main objective is to promote “Sport for All” around the
world, address to different groups and bring them upon practice of physical
activity and sport. TAFISA programs include events with a longstanding
BACKGROUND: Promotion of physical activity guidelines from non-governmental organizations
60
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
tradition and record such as the “World Challenge Day”, the “World Walking
Day” and the “World Festival of Traditional Sports”. At the same time,
TAFISA is currently developing new activities such as Certified Leadership
Courses in Sport for All and the “Active Cities” program. The last one will be
launched in the near future (190).
Although there are examples of the efforts these organizations are
already making and also of recent projects, it is important to increase and
accelerate these projects and implement other ones in order to promote
physical activity and sport as the best tool for a healthy life.
Family as collaborator of NGO
The influence of the family setting on the children´s physical activity
behavior has been discussed previously. However, the participation of
parents and other members of the family in sports organizations or
community associations may be essential for child physical activity after
school
hours
(191).
These
associations
are
non-profit
organizations
composed primarily by members of the community. Hence, the initiative of
family to begin or to take part in these organizations allows the existence
and well running of programs aimed to increase extracurricular physical
activity. The family may have a great influence on their child’s participation
by simply being involved with the team or organization in some capacity
(133). Other possible action of the parents is within the neighborhood since
it may be a site for the implementation of policies to target overweight and
obesity in children. Parents could work ensuring that neighborhoods are
safe and have an infrastructure for physical activity (169).
Extracurricular exercise to reach physical activity recommendations
As suggested previously, schools play a key role in setting kids and
adolescents on the path to moving more, primarily by increasing the time of
BACKGROUND: Promotion of physical activity guidelines from non-governmental organizations
61
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
Physical Education in the curricula (192). However, it is complex for children
and adolescents to meet the recommended levels of physical activity with
only the time spent in the Physical Education classes. Nowadays, even in
the countries with best Physical Education programs, it does not provide
adequate amounts of physical activity for children (193). Apart from
schools, sports clubs and community-based organizations provide the most
typical scenarios for sport and physical activity during after-school hours (4,
194). These non-governmental associations with a heterogeneous nature
(parents
associations,
sports
clubs,
youth
associations,
etc.)
aid
to
complement the quantity of physical activity obtained in formal Physical
Education classes, to achieve the 60-90 min. of daily exercise recommended
(48, 127, 128). Additional benefits of extracurricular activities include the
participation of students in a wider variety of activities and increased
opportunities for cooperation between schools, students, parents and the
community (160).
Environmental models for physical activity
There is a strong correlation between children´s physical activity and
the
amount
of time
they
spend
outdoors
(195).
Non-governmental
interventions to promote physical activity in childhood and adolescence
should be a goal to provide supportive environments for children and
adolescents of all ages, based on the ecological models of health behavior
(48). These models assert that health and physical activity behaviors are
strongly influenced by intrapersonal, social and physical environment
variables. Thus, effective interventions for the prevention and treatment of
obesity should be those involving multiple levels of influence (196). Under
this background, parks, sport fields, playgrounds and cycling and jogging
paths are necessary to create a “behavior” that enhances structured and
informal physical activity, in opposition to other buildings (i.e. stores, shops
or theaters) that promote sedentariness (48). It is essential that national,
regional and local governments finance and create attractive environments
BACKGROUND: Promotion of physical activity guidelines from non-governmental organizations
62
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
and facilities for the development of exercise and physical activity (126).
Additionally, it is necessary to promote and support the use of natural
environments (beaches, hills, etc.) and facilities (i.e. public parks) for sports
classes or youth associations meetings (97, 127). This ecological model will
allow taking up programs under sport clubs’ or non-governmental bodies’
organization.
Schools open after hours
Following an ecological conception of physical activity, not only the
existence of spaces and facilities but also its availability is essential to
promote physical activity during childhood. For example, most schools have
indoor and outdoor facilities especially designed for physical activity and
equipped for the performance of a variety of sports. However, schools in
most countries usually have policies that forbid or limit the use of these
facilities during evenings or weekends. These rules lead to the actual
situation, in which schools have one of the most prepared facilities for
physical activity but they are also the least available for extracurricular
activities (89).
A special recommendation of the present report is to encourage
schools and education agencies to change their policies (4) and to establish
partnerships with sports clubs and associations (127). This will provide
spaces and material for extracurricular exercise programs during afterschool hours and weekends, and it will also be supported by others (97,
163). Local governments may reach an agreement with schools, in order to
set up partnerships with community-based organizations and to allow the
use of school facilities for physical activity programs (97, 127, 167).
Standards and plans should be developed to ensure easy access to
attractive recreational areas with supportive infrastructure and affordable
facilities (88, 89).
BACKGROUND: Promotion of physical activity guidelines from non-governmental organizations
63
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
How to promote children´s participation
Childhood obesity is due to a positive energy imbalance in which daily
energy intake exceeds energy expenditure (197). However, extracurricular
activities scheduled in sports clubs and community associations should not
be considered as a “math formula” focusing only on increasing energy
expenditure. Exercise and sports activities must be fun, having flexibility of
scheduling and combining numerous activities and games in order to both
promote participation (198) and reach the psychosocial benefits which come
from exercise. Moreover, activities performed in their own free will enlarge
the benefits from exercise which lead to body weight reduction, in
comparison to strictly programmed activities (199). Thus, to promote the
highest children’s and adolescents’ participation in clubs and sports
organizations, a variety of competitive and non-competitive activities, and
both individual and team activities should be offered (126, 127, 133).
This wide offer of exercise activities will reach the maximum number
of students' needs, interests and abilities and it will help students to have
access to adequate physical activity (127, 131). On the other hand, exercise
programs with a low impact on the childhood physical activity behavior are
characterized by restriction to athletes or fit children, offered for a part of
the year, infrequent meetings for development of activities and/or include
low physical training (48).
Activities for fun
It is important that associations report to children and youth people
about the several benefits of being physically active beyond just a healthy
body weight and a good shape (133). However, although physical activity
results in many health benefits, these advantages do not motivate children
and young people to be physically active. On the other hand, they are prone
to participate in physical activities for fun, enjoyment, and for social reasons
(200). Sport organizations (leagues, clubs, teams, etc.) should offer a
BACKGROUND: Promotion of physical activity guidelines from non-governmental organizations
64
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
variety of sport opportunities, such as multi-sport programs that meet the
needs of children and youth with varying abilities, interests and skill sets.
Offering special events for playing, or organized new activities will
encourage greater participation in sport and physical activity. Associations
should work with schools and families to offer after-school physical activity
programming with the maximal scope (113). Finally, not only nongovernmental organizations but also schools should help in promoting the
organization of inter-schools sport competitions (127), in addition to the
physical activity scheduled during Physical Education lessons.
Peer influence and team sports
Another aspect to be taken into account when planning physical
activity programs during adolescence is peer influence in youth boys and
girls. Physical activity during adolescence is very much a social activity and
peer group may influence youths when they want to take up a new activity.
Moreover,
adolescents
influence
each
other,
meaning
that
active
adolescents have also active friends (201). For these reasons, communitybased programs should emphasize activities that allow interaction among
participants, in order to promote interrelationship and friendship. It is
relevant to mention the role that team sports may have in recreation among
the physical activities developed by clubs and organizations, especially for
the
treatment
of
adolescent
obesity.
Team
sports
activities
allow
adolescents to enhance their physical skills, to develop healthy behaviour
within defined roles, to learn a range of social skills and to build up a social
identity (48). These benefits are summarized in adolescents when playing
with partners versus individual sports. All these benefits are added to those
obtained intrinsically by the performance of the sport activity (133).
To summarize, sport clubs and community-based organizations should
be taken into account as ways of tackling childhood and youth obesity. They
should be the promoting-exercise tools for after schools-hours, in order to
BACKGROUND: Promotion of physical activity guidelines from non-governmental organizations
65
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
meet the physical activity criteria for children and adolescents. However, it
will work out if there are government funds, the existence and availability of
facilities and outdoor spaces, and collaboration with schools.
Recommendations at a non-governmental level
After reviewing the scientific literature and the current reality at a
non-governmental level we propose:
•
All sports Federations should promote sport for all, regardless of
participants level. They must implement educational programs,
with special emphasis on health care (183).
•
Olympic Committees, as warranters of health promotion through
the practice of physical activity and sport, should take the
initiative to encourage and promote projects, especially targeting
youth, so that said projects could be implemented later by sports
institutions (185).
•
Encouraging family participation, especially of girls (15), in sports
activities
promoted
by
NGOs
in
order
to
ensure
greater
consistency shown by children in the practice of such activities
(133, 169, 191).
•
Sports clubs and NGOs should provide physical activity programs
after school (127).
•
Sports clubs and NGOs should be provided with the use of school
facilities in out-of-school hours (89, 97, 163).
BACKGROUND: Promotion of physical activity guidelines from non-governmental organizations
66
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
2.6. Promotion of physical activity guidelines at a
governmental level
Introduction
Physical activity is not just a public issue; it is a fundamental means
of improving people's physical and mental health (202). Additionally, it is
essential to the healthy growth and development of children and youth, and
it also provides social and behavioral benefits (91). Therefore it must be a
priority of social and health agendas (86). Regular physical activity goes far
beyond losing weight. Physical activity, when coupled with a healthy
balanced diet, or preventing weight gain, can also prevent demonstrated
health problems (i.e. physical and emotional) (202) associated with obesity
(152).
To our concern, promoting physical activity is not a luxury, it is a
necessity. Countries need to change their tendency towards inactivity, and
the good news is that said trend can be reversed. A call to action includes
different levels of government and different sectors (86, 88, 202) and must
be based on a number of key principles defined by the WHO/Europe and the
HEPA (202):
•
Taking a healthy approach to population
•
Using a broad definition of physical activity
•
Engaging multiple sectors
•
Improving the environment for physical activity
•
Working at multiple levels
•
Basing programs on the stated needs of the population
•
Applying multifaceted, comprehensive and effective approaches
BACKGROUND: Promotion of physical activity guidelines at governmental level
67
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
Improving equity
•
Using the best available and sustainable evidence.
National action is needed to introduce strategies and coordinated
approaches that can lead to gradual increases in physical activity to
counteract obesity (88, 153). Public authorities are responsible and are in
charge of facing the challenge of making physical activity attractive by the
implementation of several means (86, 92, 131) and by linking partnerships
among all stakeholders (153, 203).
It is also important to set as a priority in the fight against obesity
during the first stages of life when habits and behaviors are formed, often
enduring after several years (152). Therefore, a special target is childhood
obesity, which is considered the onset of adult obesity, since obese children
are more likely to become obese adults (15, 161) or at least most of them
will probably deal with weight-related issues for the rest of their lives (200).
In the fight against obesity, different sectors and interventions must
be coordinated and taken into consideration since the root of the problem
lies in many modifiable factors (i.e. family, school, urban design, etc.) and
non modifiable factors (i.e. genetic factors). Efforts cannot succeed unless
they engage all the actors (86, 153).
Creating a special agency could promote and coordinate actions to
develop, support and enhance efforts to tackle obesity. This agency could
lead five major areas:
•
Making physical activity part of primary prevention
•
Documenting effective interventions and disseminating research
•
Showing the economic benefit of investing in physical activity
•
Connecting relevant policies and actions between ministries and
sectors
BACKGROUND: Promotion of physical activity guidelines at governmental level
68
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
Advocating and exchanging information
[Adapted from HEPA (202)]
National and international clinical organisms are welcome to submit
proposals to improve health care providers’ and professionals’ training and
education on health promotion, physical activity and exercise prescription as
well as on overweight and obesity management. These courses should be
included in their academic curricula. In addition to this, universities can play
an important role in prescribing and assessing exercise, and specific
arrangements could be made (131, 167).
To achieve marked progress in public health with regards to physical
activity, national policies should reduce the prevalence of physical inactivity
(88). In fact, sedentary behavior is an important health factor that is
distinct from physical activity (204) and the goal now is not to remove it,
keeping sedentary activities at a reasonable level (200).
An example of national policy is what the National Sports Council has
recently launched in Spain in 2010. In order to promote universal access to
high-quality sport for the whole population, the National Sports Council, in
close cooperation with Autonomous Regions, local authorities, universities
and other government bodies, together with the private sector, has
launched a series of actions that give form to the “National Physical Activity
and Sport Plan” to be developed during the next 10 years (112).
In the same way, we can find:
•
The USA Healthy People National Plan (Healthy People 2010)
where obesity, overweight and physical activity were included as
work areas (205).
•
The Mexican National Health Program 2007-2012, “for a healthy
Mexico: building alliances for better health” (206).
•
The French National Nutrition and Health Program (PNNS) (207).
BACKGROUND: Promotion of physical activity guidelines at governmental level
69
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
•
The Spanish NAOS Strategy (Strategy for Nutrition, Physical
Activity and Obesity Prevention) from 2005 (208).
•
The Chilean EGO Plan (Global Strategy to fight against Obesity)
launched in 2006 (209).
•
In Taiwan, the program to promote health in schools, coordinated
by the Ministries of Education and Health (DHO) (210).
•
The program “Guadagnare Salute” of the Italian Health Ministry
started
up
in
2007,
given
support
by
the
Italian
Olympic
Committee in 2011 (211).
And many others following WHO guidelines to fight against obesity
through physical activity.
International cooperation to deal with obesity is needed, as many key
measures are cross-border and many countries have already developed
their own national physical activity policies and action plans (153, 167). We
must learn from these experiences and coordinate actions.
It would be desirable to create an international research network to
study, at short-term, factors related to childhood obesity, and at long-term,
to lead interventional policies (128). These research groups could work on
nutrition and physical activity as an effective tool to collect data and
implement both physical and biological actions, and to monitor the
effectiveness of interventions (152, 161).
Public information is defined as “the provision of information and
other communications strategies to encourage people and groups to adopt
positive health practices throughout the life cycle, not only to develop the
skills they need to be healthy but also support others in healthy lifestyle
decisions” (122). Media play a critical role and must be aware of their
responsibility to provide information and foster public awareness, and
support public health policies (153, 212).
BACKGROUND: Promotion of physical activity guidelines at governmental level
70
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
Public information on sedentary lifestyles and obesity and their
consequences, as well as special campaigns to improve knowledge and
encourage children and adolescents to move towards healthier lifestyles,
should
be
highly
recommended
(128,
167).
Working
groups
where
members of food companies, consumers, media and health agencies are
represented could try to promote and stimulate healthy lifestyles (213,
214). In this respect, developing or improving national food guidelines and
guidelines for physical activity, and advertise them could be helpful to
promote healthy lifestyles among the population (92, 152, 153, 160).
The majority of children and youth do not value the long-term health
benefits of physical activity, and many of these health benefits may not be
evident for years. Messages for children and youth must be informative
(focusing on the immediate and short-term benefits of physical activity),
relative (stressing things that are important for this age group), and
persuasive (215). It is not these benefits which motivate them to be
physically active, since they are prone to participate and engage in physical
activity for fun, enjoyment and to socialize (91, 200).
Developing a mechanism to limit the impact or the advertising
pressure for energy-dense food and beverages, and regulate foods and
beverage products that can be sold in schools and vicinities (127, 160, 163)
could be helpful for creating responsible marketing and advertising
practices. Special attention needs to be paid to children and adolescents,
whose inexperience or credulity should not be exploited by commercial
activities and interests (153). Although different interests may exist
between private sector and government’s public health interests, it is
important to recognize possible meeting points (127).
BACKGROUND: Promotion of physical activity guidelines at governmental level
71
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
Education: school curriculum
If governments shared the responsibility for children’s physical
activity between health and education departments, optimal outcomes in
both health and learning could be more likely achieved (216).
There are no standards in physical education curricula, therefore
governments could be encouraged to develop, implement or strengthen a
national school curriculum that includes relevant information on healthy
diets and physical activity and information on media and marketing literacy
(113, 127, 160, 167) that provides students with the knowledge to take
physical activity and diet based-on informed decisions (healthy lifestyles)
but this information does not only concern physical education, because
health is a transversal issue.
Governments should also consider the development of a national
curriculum framework for physical education lessons (93, 114, 125) where
the physical and/or sports education subject would be included as
mandatory in schools during the school year (93, 125, 127) being therefore
part of the core of the curriculum (125, 126) and ensuring a certain amount
of physical activity (114, 161). A physical education curriculum for preschool
and
even
pre-kindergarten
should
be
considered
(93,
217).
Increasing the number of these lessons is one of the most direct ways to
increase students’ physical activity (127, 165) but also hiring physical
education specialists (92, 93, 111, 125, 171) in order for them to lead
physical education lessons and curricula, which has been shown to increase
students’ levels of vigorous physical activity in class (171). Programs must
be qualitatively assessed and accredited (125). Lessons should be well
planned, offer a variety of creative, enjoyable learning opportunities
throughout the year (126) and include more variety of nontraditional sports
and activities as well as adapted instruction in order to reach different
students’ preferences and needs (114, 133, 160).
BACKGROUND: Promotion of physical activity guidelines at governmental level
72
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
On the one hand, these classes should focus on a general skills
development in a variety of activities and exercise to increase the amount
of time students engage in physical activity during class, instead of focusing
only on the development of specific skills (171). The goal is learning how to
be active, making students feel confident, to help them in knowledgedeveloping, attitudes and motivate them to undertake physical activity on
their own outside the school (16, 86, 114, 133, 160).
On the other hand, it is important to be aware of school’s real power.
Schools play a critical role because they reach every child (regardless of
age, ability, gender, culture or socio-economic background) (200) but it
cannot provide all the physical activity that they need (192). In fact physical
education lessons often do not meet the recommended levels for children
and adolescents (193). It is important to add physical activity obtained from
formal classes.
Physical education teachers’ training should also be an important
topic (93, 110, 112). Providing funds for training and incentives for teachers
to participate in additional training programs may be desirable as well as
encouraging schools’ administrations to implement facilitate and support
activities related to health promotion. It is important for them to be aware
and responsible for the messages they give (112-114, 127). Creating
strategies and a network for cooperation and knowledge - sharing for the
specialists of physical education and the professionals at university level
researching on the physical education scope should be desirable (93, 125).
The Health System
Physical activity and health are unquestionably related. Taking that
into account governments should ensure promotion of physical activity as a
priority in their health policies, being also an efficient component of
prevention and primary care (218). Likewise, Governments should facilitate
BACKGROUND: Promotion of physical activity guidelines at governmental level
73
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
coordination between health and other related sectors to ensure public
policies to improve physical activity opportunities (219).
Examples of these practices can be found in Sweden. The Swedish
Institute of Health Sciences (Vardalinstitutet) includes on its website (220)
a section named Elderly health, how can we promote it?, which provides
information on the promotion and preventive care for the elderly, including
physical activity, diet, culture, environment, etc.
In Denmark, it is recommended that family doctors prescribe physical
activity as a prevention of lifestyle-related diseases, whether they have
already been diagnosed or to prevent their occurrence. They are expected
to talk once a year to their patients about lifestyle and health (219).
An interesting challenge, already underway in some countries, is to
create
physical
activity
programs
in
primary
care
by
means
of
interdisciplinary action. Such programs should be specific to each person
and designed by professionals of Physical Activity and Sport Sciences, in
cooperation with medical staff. So far, there has been some uncertainty
about who is the agent responsible for guiding physical activity prescribed
by health system. However, it seems obvious that the design of such
programs should be carried out by both fields (221).
We can find examples of multidisciplinary work among different
sectors, for instance in Spain. The Program for Developing Community
Health and Education (222) is included within the framework of the
Community Activities in Primary Care Program (PACAP) and the program of
the Society of Primary Care Nursing in Madrid (SEMAP) (223). All of them
are training programs for healthcare professionals to be qualified to
encourage the practice of healthy physical exercise programs from primary
care.
BACKGROUND: Promotion of physical activity guidelines at governmental level
74
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
Policies / economy / tax
Government and national parliaments should ensure consistency and
sustainability through regulatory action, including legislation of all the
actions. Other important tools include policy reformulation, fiscal and public
investment policies, capacity-building and partnership, research, planning
and monitoring (214). Establishing public/private partnerships with public
health objectives should be encouraged (153).
Actions would include measures to promote and ensure access to and
availability of healthier food (manufactures are called to reduce the fat, free
sugars and salt content and include adequate nutritional labeling), including
fruit and vegetables; economic measures that facilitate healthier food
choices even to the lower population groups who find and face more
difficulties for making healthy options (153, 163, 212). Affordable prices for
fruits and vegetables through cooperation between the department of
health and the agriculture sector, even having pieces of fruit for free in
schools and holiday centers and facilities (167) or creating “health –foods
outlets” (212, 224). Incentives could be provided to produce, distribute and
procure products from local farms (164).
On the side of physical activity, governments must invest to offer
affordable
recreational/exercise,
both
building
and
natural
facilities
(including adaptations for socially disadvantaged groups) (225) to create
opportunities and stimulate daily physical activity, providing the benefits
from increased physical activity (86, 92, 113, 153, 162, 163, 165). Physical
activity – related outlets could be developed to encourage physical activity
even for those with lower incomes (for membership and non-membership,
health clubs, spas, fitness facilities, dance studios, etc.) (212). When
designing urban spaces and transport policies, governments are encouraged
to promote cycling and walking (113, 153, 163, 165) especially for routes to
and from school (127) and are encouraged to locate schools within walking
distance of residential areas (113, 163, 165). Parents’ action to encourage
BACKGROUND: Promotion of physical activity guidelines at governmental level
75
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
active lifestyles walking or cycling to school is essential (226). Governments
are also asked to improve access to public transport (163). It is also
important to set strategies to evaluate and monitor the impact of these
campaigns (133, 153).
Taxes and subsidies could be used to modify the relative prices of
less healthy food and beverages, which would probably reduce their
consumption (212). However, people seem to oppose tax-based regulations
(227, 228). Perhaps other types of tax regulations could be proposed, such
as the Canadian Federal Children’s Fitness. It allows promoting physical
fitness to claim a tax credit per child of up to 500$ per year and child
(under 16 years old), for parents who register their children in programs
(122).
Recommendations at a governmental level
After reviewing the scientific literature and the current reality at a
governmental level we propose the following:
•
Promoting public information campaigns on sedentary lifestyles,
obesity and its consequences, as well as special campaigns aimed
at
raising
awareness
of
children
and
young
people
and
encouraging them to adopt healthier lifestyles (153, 212).
•
Promoting working groups which include representatives of the
food
industry,
consumers,
media
and
health
agencies,
to
encourage healthier lifestyles (92, 152, 153, 160, 213).
•
Governments should develop national educational curricula that
include relevant information on healthy diet and physical activity
(113, 127, 160, 167).
•
Governments
should
also
develop
a
planned
curriculum
framework for physical education classes, in which the subject is
BACKGROUND: Promotion of physical activity guidelines at governmental level
76
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
compulsory, and increase the number of physical education
hours. They should also propose a physical education curriculum
for kindergarten (93, 114, 125).
•
Governments should promote the creation of multidisciplinary
groups to encourage physical activity within the health system
(219, 220).
•
Governments should promote tax policies that reward healthy
lifestyles (122, 214).
BACKGROUND: Promotion of physical activity guidelines at governmental level
77
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
3. METHODOLOGY
A synthesis research has been performed for this current study. The
main worldwide organizations linked -directly or not- with obesity and
physical activity, as well as scientific works related to the main aim of this
study, have been included as documentary sources.
Regarding organizations, both national and international official
documents from different organizations have been reviewed. The most
important ones among them appear on the following table.
Table 5. National and International reviewed organizations
UNESCO (UNITED NATIONS EDUCATIONAL, SCIENTIFIC AND CULTURAL ORGANIZATION) WHO (WORLD HEALTH ORGANIZATION) HEPA EUROPE (HEALTH-­‐ENHANCING PHYSICAL ACTIVITY) IOC (INTERNATIONAL OLYMPIC COMMITTEE) EU (EUROPEAN UNION) GOVERNMENTS: •
AUSTRALIA •
SPAIN •
USA •
FRANCE •
NEW ZEALAND FRENCH NATIONAL PROGRAM HEALTH CANADA GoFPEP (GLOBAL FORUM FOR PHYSICAL EDUCATION PEDAGOGY) GAISF (GENERAL ASSOCIATION OF INTERNATIONAL SPORTS FEDERATIONS) TAFISA (TRIM & FITNESS INTERNATIONAL SPORT FOR ALL ASSOCIATION) SPORT FOR ALL CONGRESSES (IOC) METHODOLOGY
78
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
ISF (INTERNATIONAL SCHOOL SPORT FEDERATION) ICSSPE (INTERNATIONAL COUNCIL OF SPORT SCIENCE AND PHYSICAL EDUCATION) HHS (US DEPARTMENT OF HEALTH AND HUMAN SERVICES) PAHO (PAN AMERICAN HEALT ORGANIZATION) Documentation has been obtained after making a strip-search of the
web pages from all mentioned organizations. From all the documents found,
only those relating to both young children and adolescents have been used.
After making a first qualitative selection phase, a content analysis has been
carried out through an expert committee, arriving at the final verified
conclusions.
This synthesis has been supported by the conclusions taken from
scientific reviews.
Concerning these latter documents, research has been carried out by
hand and with computers, including the following criteria: physical activity,
physical education, obesity, children, and prevention.
Different aspects have been considered as inclusion/exclusion criteria
for the selected studies: size sample, publishing journal impact, publishing
date, author relevance, etc.
Different groups of collaborators have been established in order not
only to perform the systematic literature review but also the selection and
creation each section of the document -along with their own references-.
Finally, an expert committee has been created to establish the final
conclusions within the different targeting areas of the study (such as
individual, family, school, local, governmental and non-governmental
METHODOLOGY
79
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
environments).
This
mentioned
committee
has
reviewed
the
final
conclusions and the drafting of the current study “Obesity Prevention
through
METHODOLOGY
Physical
Activity
in
School-Age
Children
and
Adolescents”.
80
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
4. CONCLUSIONS (physical activity charter)
PHYSICAL ACTIVITY GUIDELINES AND
GOOD PRACTICES TO PREVENT
CHILDHOOD OBESTY
The findings from the research conducted by Camilo José Cela
University are listed below. Sixteen basic points constitute a declaration of
intent, addressing the world, from the family to national and international
policies, going for actions in other areas such as school, community or local
and regional corporations.
Last minute scientific contributions, worldwide recommendations on
obesity prevention through physical activity in children and young people in
grade school, have been included and taken into account in this updated
compendium
of
seventeenth
essential
conclusions
to
fight
obesity
worldwide.
Individual level
1. Physical activity for children and adolescents recommended for
health maintenance and improvement. Regarding Biddle et al. (48),
we support that:
•
Young people should be practicing at least 60 minutes (30 minutes
for sedentary people) of moderate-to-vigorous intensity physical
activity per day.
•
Being practiced at least twice a week, these guidelines should help to
improve bone health, muscle strength and flexibility.
CONCLUSIONS
81
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
It is important to understand that these physical activity guidelines
are the minimum recommended levels for young people to be healthy.
Physical activity increases relative to those recommendations will result in
further health gains for the vast majority of children and adolescents, as
there appears to be a graded linear relation between physical activity and
health status.
Age and gender should be taken into account in order to help children
to achieve these aims, considering a wide range of activity suggestions to
suit children´s and adolescent´s needs and preferences.
Young children:
 Walking to and from school daily.
 Daily school activity sessions (breaks and clubs).
 3-4 afternoon or evening play opportunities.
 Weekend: longer walks, visits to park or swimming pool,
bike rides, etc.
Teenager:
 Walk or cycle to school and back daily.
 3-4 organized or informal midweek sports or activities.
 Weekend: walks, biking, swimming, sports activities
2. A special emphasis will be made in proposing physical activities
based on muscular strength, to avoid and treat obesity as well as
improving bone health. It is important to ensure a good instruction
and a qualified supervision to implement these programs. We suggest
following Faigenbaum et al. (59) recommendations.
CONCLUSIONS
82
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
At a Family level
3. Parents can exert a good role modelling influence on physical
activity
(practising
physical
activities
on
their
own),
social
influence(showing interest in child’s physical activities) and supportive
influence (providing transportation from/to the sport facility, giving
presents related to physical activity, encouragement, positive feedback,
etc.). Parents should be provided with training to be aware of these
types of influences.
4.
The Family must pass on healthy habits to their children. Parents
are the first to raise their children, so it must be they who can work
shaping children´s attitudes and behaviour regarding diet, sleep,
entertainment, television, exercise, etc. We propose:
•
Creating healthy eating habits in children, deciding on home food
eating.
•
Encouraging children to do at least one daily hour of physical
activity, being aware that it is advisable
•
Sharing activities with their children. It constitutes a role model as
well as a learning context to follow guidelines
•
Encouraging and facilitating the practice of physical activity as
recreation, both in childhood and adolescence.
•
Encouraging walking, trying to reduce car use for short journeys.
•
Controlling the time that children spend in sedentary activities
such as watching television or playing with the computer.
Reducing it is as important as increasing the practice of physical
activity. According to the Canadian Paediatric Society and the
American Academy of Paediatrics, children should not exceed two
daily hours in sedentary activities.
CONCLUSIONS
83
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
5. Avoiding the use of physical activity as a punishment as well as
not pressuring young people into certain sports or activities, is
essential. It is recommended to increase the exposure to pleasant and
positive physical activity experiences, putting quality before quantity.
School level
6. School setting must ensure a minimum of compulsory physical
practice a week (120-150 minutes in primary school and 150-225
minutes in high school).
7. The importance of Physical Education must be recognized as
compulsory within the school curriculum. It must be educational,
health oriented, individualized, fair (individual goal setting), enjoyable
and realistic, to promote a greater autonomy focused on the process of
having students more responsible for their own health, fitness and wellbeing. Modern Physical Education must be different from the traditional
sports-and-performance-based style, of which most adults have negative
recollections. Classes should be designed and led by professionals
in order to satisfy students’ preferences and needs, offering a wide
range of attractive and varied physical activities, so that young people
may discover those which they enjoy the most and which ones they are
competent in (students should also get involved in designing and
developing physical activity programs in the school setting); they should
be focused on learning how to be active, making students feel confident,
helping them develop the knowledge and attitudes, and motivating them
to undertake active lifestyles outside school environment.
CONCLUSIONS
84
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
At a Local level
8. Local governments should promote cooperation and relations
among communities, schools, health centers and families. Efforts
to promote physical activity in schools should ideally be part of a
comprehensive overall school health program. Such a program
could include health education, physical education, health services,
school
counselling
and
social
services,
nutrition
services,
the
psychosocial and physical environment and staff for health promotion,
parents, coaches, monitors... Everyone can play a role in encouraging
lifelong physical activity in young people. The school should monitor the
effectiveness of such programs and make the appropriate changes to
improve them. Health promotion activities and continuing additional
training for teachers should be implemented and encouraged.
9. Local governments should promote and encourage the use of
sports resources (already built sports facilities, clubs and schools) for
the practice of recreational physical activities by citizens outside
regular hours of use. Sports clubs and community-based organizations
should be taken into account as key factors on developing strategies to
reduce childhood and youth obesity. They should be the executants of
exercise during after schools-hours to meet the physical activity criteria
for children and adolescents.
10. It is essential to create policies to promote easy ways and safe
environments to practice physical activity and healthy lifestyles,
where citizens can actively move (walking or riding) in both urban and
natural environments. Thus encouraging active transportation within
communities.
CONCLUSIONS
85
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
At a Non-Governmental level
11. Sports
organizations,
sports
Federations
and
Olympic
Committees should propose programs of physical activity and
sport
for
all,
regardless
of
age,
ability
or
other
personal
characteristics. For example, physical activity and adapted sport
classes, sports for grandparents and grandchildren, family days for
physical activity and sport, etc.
12. Improving adults’ physical activity attitudes (school teachers,
parents/guardians, general practitioners –GPs–, etc.) towards exercise
and physical activity through education (guides of physical activity,
educational seminars…) and increasing NGOs participation with
sport for all programs (physical activity classes for teachers or
professionals)
are
important
aspects
of
the
drive
towards
more
physically active young people in society.
13. Young people from low socioeconomic levels or ethnic minorities may be
especially prone to physical inactivity and obesity. Special efforts must
be made to ensure that physical activity is promoted in these
groups with sensitivity towards cultural values and beliefs.
At a Governmental level
14. Sedentary life should become a “conscious” term. Once this
concept is acquired, it will be possible to reduce its impact. The
increasing influence of the Mass Media, marketing, television and
Internet on children means the increase of this mentioned sedentary life.
Health promotion strategies must adapt to these changes and
not resist them. This position encourages providing information,
fostering public awareness and supporting public health policies
CONCLUSIONS
86
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
through Mass Media. They are called to be specially cautious and
responsible in their marketing and advertising campaigns when targeting
children and youth. What we could call “fair–marketing and advertising”.
Likewise, children and adolescents must set their sedentary time (new
technology programmes) during daylight hours, and propose alternative
leisure activities.
15. Creating
multidisciplinary
working
groups
(medical
staff,
physical education and sport professionals, physical therapists,
nurses, nutritionists) where Physical Activity and Sport graduates will
have an important role in the creation of specific physical activity
programs and also in training health professionals.
16. Tax regulation and subsidies could be used to reward both a
healthy diet and healthy physical habits.
17. Creating National Obesity Prevention Agencies is a desirable
initiative to coordinate local, regional and national physical activity
promotion campaigns for the prevention and treatment of obesity.
Communication between agencies from all over the world would be a
good way to create worldwide policies to fight against child obesity
through physical activity.
CONCLUSIONS
87
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
5. REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Lee IM, Paffenbarger RS, Hennekens CH. Physical activity, physical
fitness and longevity. Aging-Clinical and Experimental Research.
1997;9(1-2):2-11.
Paffenbarger RS, Hyde RT, Wing AL, Hsieh CC. Physical activity, allcause mortality, and longevity of college alumni. New England Journal
of Medicine. 1986 Mar 6;314(10):605-13.
Boreham C, Riddoch C. The physical activity, fitness and health of
children. Journal of Sports Sciences. 2001;19(12):915-29.
International Olympic Committee. Final Declaration, 13th World Sport
for All Congress. Jyväskylä, Finland 2010.
Powell KE, Blair SN. The public health burdens of sedentary living
habits: theoretical but realistic estimates. Medicine & Science in Sports
& Exercise. 1994 Jul;26(7):851-6.
Warburton DER, Nicol CW, Bredin SSD. Health benefits of physical
activity: the evidence. Canadian Medical Association Journal.
2006;174(6):801-9.
World Health Organization. The world health report 2002 - Reducing
Risks, Promoting Healthy Life. Geneva: 2002.
Livingstone MB. Childhood obesity in Europe: a growing concern. Public
Health Nutrition. 2001 Feb;4(1A):109-16.
Speiser PW, Rudolf MCJ, Anhalt H, Camacho-Hubner C, Chiarelli F,
Eliakim A, et al. Consensus statement: Childhood obesity. Journal of
Clinical Endocrinology & Metabolism. 2005;90(3):1871-87.
Jorge Neves PM, Torcato AC, Urquieta AS, Rozin Kleiner AF.
IMPORTÂNCIA DO TRATAMENTO E PREVENÇÃO DA OBESIDADE
INFANTIL. Educação Física em Revista. 2010;4(2):50-61.
Cattaneo A, Monasta L, Stamatakis E, Lioret K, Castetbon K.
Overweight and obesity in infants and pre-school children in the
European Union: A review of existing data. Obesity reviews.
2010;11(1):389-98.
Sallis J, Saelens B. Assessment of physical activity by self-report:
Status, limitations and future directions. Research Quarterly for
Exercise and Sport. 2000(71):1-14.
Organization for Economic Co-operation and Development. Obesity and
the Economics of Prevention: Fit not Fat. Paris: OCDE; 2010.
Thibault H, Duché P, Meyer M, Pérès G. Activité physique et obésité de
l'enfant: Bases pour une prescription adaptée: Ministére de la Santé,
de la Jeunesse, des Sports et de la Vie Associative 2010.
Pahkala K, Heinonen O, Lagström H, Hakala P, Sillanmäki L, Kaitosaari
T, et al. Parental and Childhood Overweight in Sedentary and Active
Adolescents. Scandinavian Journal of Medicine and Science in Sports.
2010(20):74-82.
Aznar S, Webster T. Actividad física y salud en la infancia y la
adolescencia. Guía para todas las personas que participan en su
REFERENCES
88
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
educación. Ministerio de Sanidad y Consumo, Ministerio de Educación y
Ciencia. Madrid: Grafo S. A.; 2006 [12/03/2010]; Available from:
http://www.msc.es/ciudadanos/proteccionSalud/adultos/actiFisica/doc
s/ActividadFisicaSaludEspanol.pdf.
Pik Shan Kong A, Chung Chow C. Medical Consequences of Childhood
Obesity: A Hong Kong Perspective. Research in Sports Medicine.
2010(18):16-25.
Strong W, Malina R, Blimkie C, Daniels S, Dishman R, Gutin B, et al.
Evidence Based Physical Activity for School-age Youth. The Journal of
Pediatrics. 2005(146):732-7.
Goran M, Treuth M. Energy expenditure, physical activity and obesity
in children. Pediatric Clinics of North America. 2001;48(4):931-53.
Aznar S, Naylor P, Silva P, Pérez M, Angulo T, Laguna M, et al.
Patterns of physical activity in Spanish children: a descriptive pilot
study. Child: Care Health Development. 2011;37(3):322-8.
Egger G, Swinburn B. An ''ecological'' approach to the obesity
pandemic. British Medical Journal. 1997;315(7106):477-80.
World Health Organization. Socio-environmentally determined health
inequities among children and adolescents: Oficina Regional para
Europa 2010.
Must A, Tybor D. Physical Activity and Sedentary Behavior: a Review of
Longitudinal Studies of Weight and Adiposity in Youth. International
Journal of Obesity. 2005(29, suppl. 2):84-96.
Viner P, Cole T. Who Changes Body Mass between Adolescence and
Adulthood? Factors Predicting Change in BMI between 16 Years and 30
Years in the 1970 British Birth Cohort. International Journal of Obesity.
2006;30(9):1368-74.
Booth S, Sallis J, Ritenbaugh C, Hill J, Birch L, Frank L. Environmental
and Societal Factoros Affect Food Choice and Physical Activity:
Rationale, Influences and Leverage Points. Nutrition Reviews.
2001;59(3):21-36.
Lobstein T, Baur L, Uauy R. Obesity in children and young people: a
crisis in public health. Obesity Reviews. 2004 May;5 Suppl 1:4-104.
Janssen I, Katzmarzyk PT, Boyce WF, Vereecken C, Mulvihill C, Roberts
C, et al. Comparison of overweight and obesity prevalence in schoolaged youth from 34 countries and their relationships with physical
activity and dietary patterns. Obesity Reviews. 2005;6(2):123-32.
Dietz WH. Health consequences of obesity in youth: Childhood
predictors of adult disease. Pediatrics. 1998;101(3):518-25.
Rosenbaum M, Leibel RL. Pathophysiology of childhood obesity.
Advances in Pediatrics. 1988(35):73-137.
Daniels SR, Jacobson MS, McCrindle BW, Eckel RH, Sanner BM.
American Heart Association Childhood Obesity Research Summit
Report. Circulation. 2009 April 21, 2009;119(15):2114-23.
Aznar Laín S, Cortés Rico O, Ferreira Montero I, Gandarillas Grande A,
Grima Serrano A, Janer Llobera J, et al., editors. Prevención de la
REFERENCES
89
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
obesidad infantil y juvenil. 1ª conferencia de prevención y promoción
de la salud en la práctica clínica en España; 2007; Madrid.
Lee Y. Consequences of childhood obesity. Annals Academy of Medicine
Singapore. 2009 January;38(1):75-7.
Daniels S. The consequences of childhood overweight and obesity.
Future Child. 2006;16(1):47-67.
Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T.
Do obese children become obese adults - A review of the literature.
Preventive Medicine. 1993;22(2):167-77.
Moss B, Yeaton W. Young Children's Weight Trajectories and
Associated Risk Factors: Results from the Early Childhood Longitudinal
Study-Birth Cohort. American Journal of Health Promotion. 2011
January/February;25(3):190-8.
Agencia Española de Seguridad Alimentaria y Nutrición. Estudio de
prevalencia de obesidad infantil "ALADINO": Ministerio de Sanidad,
Política Social e Igualdad 2011.
Caspersen C, Powell K, Christenson G. Physical activity, exercise and
physical fitness: definitions and distinctions for health-related
research. Public Health Reports. 1985 Mar-Apr;100(2):126-31.
Bouchard C, Shephard R, Stephens T. Physical Activity, Fitness and
Health: International Proceedings and Consensus Statement.
Champaign, IL: Human Kinetics; 1994.
Cavill N, Biddle S, Sallis J. Health enhancing physical activity for young
people: statement of the UK expert consensus conference. Pediatric
Exercise Science. 2001(13):12-25.
Webster AL, Aznar-Lain S. Intensity of physical activity and the "Talk
Test" - A brief review and practical application. ACSMs Health & Fitness
Journal. 2008;12(3):13-7.
Karvonen MJ, Kentala E, Mustala O. The effects of training on heart
rate - A longitudinal study. Annales Medicinae Experimentalis Et
Biologiae Fenniae. 1957;35(3):307-15.
American College of Sports Medicine Position Stand. The recommended
quantity and quality of exercise for developing and maintaining
cardiorespiratory and muscular fitness, and flexibility in healthy adults.
Medicine & Science in Sports & Exercise. 1998 Jun;30(6):975-91.
Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ,
et al. Compendium of physical activities: an update of activity codes
and MET intensities. Medicine & Science in Sports & Exercise. 2000
Sep;32(9 Suppl):498-504.
American College of Sports Medicine. Opinion statement of physical
fitness in children and youth. Medicine & Science in Sports & Exercise.
1988;20:422-3.
Fletcher GF, Blair SN, Blumenthal J, Caspersen C, Chaitman B, Epstein
S, et al. Statement on exercise: Benefits and recommendations for
physical activity programs for all americans. A statement for health
professionals by the committee on exercise and cardiac rehabilitation
REFERENCES
90
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
of the council on clinical cardiology, American Heart Association.
Circulation. 1992;86(1):340-4.
Sallis JF, Patrick K. Physical Activity Guidelines for Adolescents:
Consensus Statement. Pediatric Exercise Science. 1994;6(4):302-14.
U. S. Department of Health and Human Services. Physical activity and
cardiovascular health. NIH Consensus Development Panel on Physical
Activity and Cardiovascular Health. The Journal of the American
Medical Association. 1996 Jul 17;276(3):241-6.
Biddle S, Sallis JF, Cavill N. Policy framework for young people and
health-enhancing physical activity. Young and Active? Young People
and Health-Enhancing Physical Activity: Evidence and Implications.
London, England: Health Education Authority; 1998.
U. S. Department
of Health and Human Services. The Surgeon
General's Call to Action To Prevent and Decrease Overweight and
Obesity 2001. Washington, D. C.: U. S. Department of Health and
Human
Services;
2001
[5/3/2010];
Available
from:
www.surgeongeneral.gov/topics/obesity/calltoaction/CalltoAction.pdf.
Tudor-Locke CE, Myers AM. Methodological considerations for
researchers and practitioners using pedometers to measure physical
(ambulatory) activity. Research Quarterly for Exercise & Sport. 2001
Mar;72(1):1-12.
Vincent SD, Pangrazi RP. An examination of the activity patterns of
elementary
school
children.
Pediatric
Exercise
Science.
2002;14(4):432-41.
Tudor-Locke CE, Hatano Y, Pangrazi RP, Kang M. Revisiting "how many
steps are enough?". Medicine & Science in Sports & Exercise. 2008
Jul;40(7 Suppl):537-43.
Adams MA, Caparosa S, Thompson S, Norman GJ. Translating physical
activity recommendations for overweight adolescents to steps per day.
American Journal of Preventive Medicine. 2009 Aug;37(2):137-40.
Faigenbaum AD, Kraemer WJ, Cahill B, Chandler J, Dziados J, Elfrink
LD, et al. Youth resistance training: Position Statement paper and
literature review. Strength & Conditioning. 1996;18(6):62-75.
Faigenbaum AD, Westcott WL, Loud RL, Long C. The effects of different
resistance training protocols on muscular strength and endurance
development in children. Pediatrics. 1999;104(1):5.
Faigenbaum AD. Strength training for children and adolescents. Clinics
in Sports Medicine. 2000 Oct;19(4):593-619.
Hass CJ, Feigenbaum MS, Franklin BA. Prescription of resistance
training for healthy populations. Sports Medicine. 2001;31(14):95364.
McCambridge TM, Stricker PR. Strength training by children and
adolescents. Pediatrics. 2008 Apr;121(4):835-40.
Faigenbaum AD, Kraemer WJ, Blimkie CJ, Jeffreys I, Micheli LJ, Nitka
M, et al. Youth resistance training: updated position statement paper
from the national strength and conditioning association. The Journal of
Strength and Conditioning Research. 2009 Aug;23(5 Suppl):60-79.
REFERENCES
91
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
60. Australian Government Department of Health and Ageing. Australia's
Physical Activity Recommendations for 5-12 Year Olds - Brochure
2004.
61. Australian Government Department of Health and Ageing. Australia's
Physical Activity Recommendations for 12-18 Year Olds - Brochure
2004.
62. Health Canada and the Canadian Society for Exercise Physiology.
Canada’s physical activity guide for youth. Canada, Ottawa, Ont:
Minister of Public Works and Government Services 2002.
63. Health Canada and the Canadian Society for Exercise Physiology.
Canada’s physical activity guide for children. Canada, Ottawa, Ont.:
Minister of Public Works and Government Services 2002.
64. U. S. Department of Health and Human Services. 2008 Physical
Activity Guidelines for Americans. 2008 [10/2/2010]; Available from:
http://www.health.gov/paguidelines/guidelines/default.aspx.
65. Oja P, Bull F, Fogelholm M, Martin B. Physical activity
recommendations for health: what should Europe do? BMC Public
Health. 2010;10(1 ):10.
66. World Health Organization. Recomendaciones mundiales sobre
actividad física para la salud 2010.
67. Atlantis E, Bernes E, Singh M. Efficacy of Exercise for Treating
Overweight in Children and Adolescents: A Systematic Review.
International Journal of Obesity. 2006;30(7):1027-40.
68. Shackle J, Nelson T, Ficker L, Kafka T, Kuder J, Economos C. Physical
activity during soccer and its contribution to physical activity
recommendations in normal weight and overweight children. Pediatric
Excercise Science. 2011 May;23(2):281-92.
69. Ward DS, Vaughn AE, Bangdiwala KI, Campbell M, Jone DJ, Panter AT,
et al. Integrating a family-focused approach into child obesity
prevention: Rationale and design for the My Parenting SOS study
randomized control trial. BMC Public Health. 2011;11:431-342.
70. Sobko T, Svensson V, Ek A, Ekstedt M, Karlsson H, Johansson E, et al.
A randomised controlled trial for overweight and obese parents to
prevent childhood obesity - Early STOPP (STockholm Obesity
Prevention Program). BMC Public Health. 2011;11:336-43.
71. U. S. Department of Health and Human Services. 2010
[10/03/2010]; Available from: www.healthfinder.gov/prevention/
ViewTopic.aspx?topicID=22&areaID=1&TopicContentID=265.
72. U. S. Department of Health and Human Services. Families Finding the
Balance: A Parent Handbook. We Can! Ways to Enhance Children's
Activity & Nutrition. National Heart, Lung, and Blood Institute (NHLBI).
2005 [22/04/2010]; Avalilable from: http://www.nhlbi.nih.gov.
73. Vander Schee CJ, Boyles D. 'Exergaming,' corporate interests and the
crisis discourse of childhood obesity. Sport, Education & Society.
2010;15(2):169-85.
74. Bryn Austin S. The Blind Spot in the Drive for Childhood Obesity
Prevention: Bringing Eating Disorders Prevention into Focus as a Public
REFERENCES
92
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
Health
Priority.
American
Journal
of
Public
Health.
2011
June;101(6):1-4.
Aznar S, Castro JM, Merino B, Veiga O. Actividad Física y Salud. Guía
para padres y madres. Madrid, España: Ministerio de Sanidad y
Consumo y Ministerio de Educación y Ciencia; 1999.
Villagrán Pérez S, Rodríguez-Martín A, Novalbos Ruiz J, Martínez Nieto
J, Lechuga Campoy J. Hábitos y estilos de vida modificables en niños
con sobrepeso y obesidad. Nutrición Hospitalaria. 2010;25(5).
U. S. Centers for Disease Control and Prevention (CDC). Atlanta, 2010
[6/02/2010]; Available from: www.cdc.gov/physicalactivity/everyone/
guidelines/children.html.
Dwyer J, Needham L, Simpson JR, Heeney ES. Parents report
intrapersonal, interpersonal, and environmental barriers to supporting
healthy eating and physical activity among their preschoolers. Applied
Physiology, Nutrition & Metabolism. 2008;33(2):338-46.
Power TG, Bindler RC, Goetz S, Daratha KB. Obesity Prevention in
Early Adolescence: Student, Parent, and Teacher Views. Journal of
School Health. 2010;80(1):13-9.
Roblin L. Childhood obesity: food, nutrient, and eating-habit trends
and influences. Applied Physiology, Nutrition & Metabolism.
2007;32(4):635-45.
Davison K, Jago R. Change in Parent and Peer Support across Ages 9 to
15 Years and Adolescent Girls' Physical Activity. Medicine & Science in
Sports & Exercise. 2009;41(9):1816-25.
Bucher Della Torre S, Akré C, Suris J-C. Obesity prevention opinions of
school stakeholders: a qualitative study. Journal of School Health.
2010;80(5):233-9.
Lee A, Mandy H, Vera K. Healthy School as an Ecological Model for
Prevention of Childhood Obesity. Research in Sports Medicine.
2010;18(1):49-61.
Li J, Hooker NH. Childhood Obesity and Schools: Evidence From the
National Survey of Children's Health. Journal of School Health.
2010;80(2):96-103.
Tremblay MS, et al. Conquering childhood obesity: Is the answer in the
past? Medicine & Science in Sports & Exercise. 2005(37):1187-94.
UNESCO. Declaration and Recommendations of the Word Forum on
Physical Activity and Sport. Quebec 1995. [3/01/2010]; Available
from: http://unesdoc.unesco.org/images/0010/001045/104555e.pdf.
Trudeau F, Shephard R. Contribution of school programmes to physical
activity levels and attitudes in children and adults. American Journal of
Sports Medicine. 2005;35(2):89–105.
WHO Regional Office for Europe. Steps to Health. A European
Framework to promote Physical Activity for Health. Copenhagen 2007
[09/03/2010]; Available from: http://www.euro.who.int/Document/
E90191.pdf.
REFERENCES
93
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
89. WHO Regional Office for Europe. Physical activity and health in Europe.
2006 [25/03/2010]; Available from: https://www.euro.who.int/
document/e89490.pdf.
90. International Council for Health, Physical Education, Sport and Dance
(ICHPERSD). International Standards for Physical Education and Sport
for
School
Children.
2010
[4/04/2010];
Available
from:
http://www.ichpersd.org/index.php/standards/international-standards.
91. WHO Regional Office for Europe, Edwards P, Tsouros A. Promoting
physical activity and active living in urban environments. The role of
local governments. The solid facts. Copenhagen 2006 [07/03/2010];
Available from: http://www.euro.who.int/document/e89498.pdf.
92. UNESCO. International Charter of Physical Education and Sport. Paris
1978 [2/03/2010] Available from: http://portal.unesco.org/en/ev.phpURL_ID=13150&URL_DO=DO_PRINTPAGE&URL_SECTION=201.html.
93. UNESCO. Innovative Practices in Physical Education and Sports in Asia.
Bangkok 2008 [12/02/2010]; Available from: http://unesdoc.unesco.
org/images/0015/001585/158509e.pdf.
94. Luis-Pascual JC, Díaz García A. Traditional Sport in Network.
International Journal of Eastern Sports & Physical Education
2009;7(1):34-45.
95. Mendelson R. Think tank on school-aged children: nutrition and
physical activity to prevent the rise in obesity. Applied Physiology,
Nutrition and Metabolism. 2007;32:495-9.
96. Toussaint JF. Retrouver Sa liberté de Mouvement. Plan national de
prévention par l'activité physique ou sportive. Francia: Ministère de la
Santé, de la Jeuneuse, des Sports et de la vie Associative; 2008.
97. U. S. Department of Health and Human Services, Office of the Surgeon
General. The Surgeon General's Vision for a Healthy and Fit Nation
2010. [11/2/2010]; Available from: http://www.surgeongeneral.gov/
library/obesityvision/obesityvision2010.pdf.
98. National Heart Foundation of Australia. Blueprint for an active
Australia. Key government and community actions required to increase
population levels of physical activity in Australia —2010 to 2013.
2009 [28/02/2010]; Available from: http://www.heartfoundation.org.
au/SiteCollectionDocuments/Blueprint%20for%20an%20active%20Aus
tralia%20FINAL.pdf.
99. Fox KR, Cooper A, McKenna J. The School and Promotion of Children’s
Health-Enhancing Physical Activity: Perspectives from the United
Kingdom. Journal of School Health. 2004(23):338-58.
100. Gibbsons B, Naylor P. Whole School Obesity Prevention Models:
Considerations for Secondary Schools. Physical and Health Education
2007:8-13.
101. Evenson K et al. Implementation of a school-based state policy to
increase physical activity. Journal of School Health 2009;79(5):231-6.
102. Sibbley B, Etnier C. The physical activity, fitness and health of children.
Journal of Sports Sciences. 2001(19):915-29.
REFERENCES
94
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
103. Sibbley B, Etnier J. The relationship between physical activity and
cognition in children: a meta-analysis. Pediatric Exercise Science.
2003(15):243-56.
104. Zhaner L, Puder JJ, Roth R, Schmid M, Guldimann R, Püshe U, et al. A
school-based physical activity to improve health and fitness in children
in 6-13 years (“Kinder-Sportstudie KISS”): study design of a
randomized controlled trial. BMC Public Health. 2006;6(147).
105. Kaestner R, Xu X. Girls’ Sports Participation and Adult Female Physical
Activity and Weight. Evaluation Review. 2010(54):152-78.
106. Stevenson B. Beyond the classroom: Using Title IX to measure the
return to high school sports: The National Bureau of Economic
Research 2010. Contract No.: 15728.
107. Sallis J, Conway T, Prochaska J, et al. The association of school
environments with youth physical activity. American Journal of Public
Health. 2001;91(4):618-20.
108. Stratton G, Leonard J. The effects of playground markings on the
energy expenditure of 5–7-year-old school children. Pediatric Exercise
Science. 2002(14):170-80.
109. White House Task Force on Childhood Obesity Report to the President.
Solving the Problem of Childhood Obesity within a Generation. May
2010.
110. Pate RR, Davis MG, Robinson TN, Stone EJ, McKenzie TL, Young JC.
Promoting physical activity in children and youth - A leadership role for
schools - A scientific statement from the American Heart Association
Council on Nutrition, Physical Activity, and Metabolism (Physical
Activity Committee) in collaboration with the Councils on
Cardiovascular Disease in the Young and Cardiovascular Nursing.
Circulation. 2006;114(11):1214-24.
111. Anderson SJ, Griesemer BA, Johnson MD, Martin TJ, McLain LG,
Rowland TW, et al. Physical fitness and activity in schools. Pediatrics.
2000;105(5):1156-7.
112. Consejo Superior de Deportes (CSD). Plan Integral para la Actividad
Física y el Deporte. Actividad Física, Deporte y Salud. Madrid 2009
[22/04/2010]; Available from: http://www.csd.gob.es/csd/estaticos/
plan-integral/salud.pdf.
113. Deforche B, De Bourdeaudhuij I, Hills AP. Interventions for the
prevention and management of childhood obesity. In: Hills AP, King
NA, Byrne NM, editors. Children, Obesity and Exercise: a practical
approach to prevention, treatment, and management of children and
adolescent obesity. Perth, UK: Routledge; 2007. p. 142-63.
114. U. S. Department of Health and Human Services. Guidelines for school
and community programs to promote lifelong physical activity among
young people. Journal of School Health. 1997;67(6):202-19.
115. Bass SL. The prepuberal years: a uniquely opportune stage of growth
when the skeleton is most responsive to exercise? Sports Medicine.
2000(30):73-8.
REFERENCES
95
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
116. Bergeron M. Improving Health through Youth Sports: Is Participation
Enough? New Directions for Youth Development. 2007(115):27-41.
117. Saris WH, Blair SN, van Baak MA, Eaton SB, Davies PS, Di Pietro L, et
al. How much physical activity is enough to prevent unhealthy weight
gain? Outcome of the IASO 1st Stock Conference and consensus
statement. Obesity Reviews. 2003 May;4(2):101-14.
118. Corbin CB. Fitness for life physical activity pyramid for children
[poster]. Champaign: Human Kinetics; 2003.
119. Corbin CB. Fitness for life physical activity pyramid for teens [poster].
Champaign: Human Kinetics; 2003.
120. Kahn E, Ramsey L, Brownson RC, Heath GW, Howze EH, Powell KE, et
al. The effectiveness of interventions to increase physical activity. A
systematic review. American Journal of Preventive Medicine.
2002(22):73-107.
121. Kerr NA, Yore M, Ham SA, Dietz WH,. Increasing stair use in a worksite
through environmental changes. American Journal of Health
Promotion. 2004(18):312-5.
122. Public Health Agency of Canada. The 2007 Report on the Integrated
Pan - Canadian Healthy Living Survey. 2007 [9/03/2010]; Available
from: http://www.phac-aspc.gc.ca/hl-vs-strat/pancan/index-eng.php.
123. Departament of Health and Ageing. Get up & Grow: Healthy eating and
Physical Activity for early childhood: Commonwealth of Australia;
2009.
124. Luis-Pascual JC. Physical Education as a privilege. Revista Pedagógica
Adal 2007;9(15):6.
125. UNESCO. Unesco Seminar on Quality of Physical Education and Sport.
Final Report. Porto-Novo: 2005 [27/03/2010]; Available from:
http://unesdoc.unesco.org/images/0014/001408/140825e.pdf.
126. ParticACTION. Take Action. A guide for those working towards getting
children and youth more physically active (Plan for action). Toronto
2009 [1/2/2010]; Available from: http://www.participaction.com/
ecms.ashx/Inspire/PlanforActionFinalEnglishFile.pdf.
127. World Health Organization. School policy framework: implementation
of the WHO global strategy on diet, physical activity and health.
Geneva: World Health Organization; 2008.
128. Brettschneider W, Naul R. Study on young peple's lifestyles and
sedentariness and the rolo of sport in the context of education as a
means of restoring the balance: European Union; 2004.
129. British Medical Association. Preventing Childhood Obesity. 2005.
130. Fernandes MM, Sturm R. The Role of School Physical Activity Programs
in Child Body Mass Trajectory. Journal of Physical Activity & Health.
2011;8(2):174-81.
131. E. U. Working Group "Sport & Health". EU Physical Activity Guidelines.
Recommended Policy Actions in Support of Health-Enhancing Physical
Activity. Brussels. European Communities; 2008.
REFERENCES
96
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
132. Salmon J, Timperio A. Prevalence, trends and environmental influences
on child and youth physical activity. In: Karger, editor. Pediatric fitness
Secular trends and geographic variability. Basel, 2007. p. 183–99.
133. Active Healthy Kids Canada. The active Healthy Kids Canada Report
Card on Physical Activity for Children and Youth. 2009 [7/2/2010];
Available from: www.activehealthykids.ca/ecms.ashx/ReportCard2009/
AHKC-Longform_WEB_FINAL.pdf.
134. Dupuy M, Godeau E, Vignes C, Ahluwalia N. Socio-demographic and
lifestyle factors associated with overweight in a representative sample
of 11-15 year olds in France: Results from the WHO-Collaborative
Health Behaviour in School-aged Children (HBSC) cross-sectional
study. BMC Public Health. 2011;11:442.
135. Fairclough S, Stratton G. Physical education makes you fit and healthy:
Physical education’s contribution to young people’s physical activity
levels. Health Education Research. 2005;20(1):14-23.
136. Tomson L, Cuddihy T, Davidson M. Physical activity behaviour in
children and the measurement of physical activity. In: Routledge,
editor. Children, Obesity and Exercise: a practical approach to
prevention, treatment, and management of children and adolescent
obesity. Perth 2007. p. 113-29.
137. Timperio A, Crawford D, Telford A, et al. Perceptions about the local
neighborhood and walking and cycling among children. Preventive
Medicine. 2004(38):39-47.
138. Livsey S, Hockenberry S, Knoll C, Sladky A, Sickmund M. Required and
Voluntary Exercise: A Special Analysis of Juvenile Residential Facility
Census 2008 Data. Pittsburgh: National Center for Juvenile Justice
2010.
139. Dobbins M, De Corby K, Robeson P, Husson H., y Tirilis D. Schoolbased physical activity programs for promoting physical activity and
fitness in children and adolescents aged 6-18. Cochrane Database
Systematic Reviews 2009;21(1).
140. Abouzeid M, Lee J, Mohamed G. Comparative Study of Body Physique,
Physical Fitness between Korean and Egyptians Education Students.
Pan-Asian Journal of Sports & Physical Education 2009;1(1):102-11.
141. Washington R, Bernhardt D, Gomez J, Jonson MD, Martín TJ, Rowland
TW, et al. Organized sports for children and preadolescents. Pediatrics
2001(107):1459-62.
142. National Public Health Partnership. Be Active Australia: A framework
for health sector action for physical activity 2005–2010. 2009
[14/04/2010]; Available from: http://www.nphp.gov.au/publications/
documents/nphp_baa_aug_05_no_cover.pdf.
143. Craig R, Felix H, Walker J, Phillips M. Public Health Professionals as
Policy Entrepreneurs: Arkansas' Childhood Obesity Policy Experience.
American Journal of Public Health. 2010 November;100(11):2047-52.
144. Gerritsen S, Stefanogiannis N, Galloway Y. A Portrait of Health. Key
results of the 2006/07 New Zealand Health Survey. New Zealand:
Ministry of Health; 2008.
REFERENCES
97
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
145. Duncan JS. Body-size and steps in children: Key results of the 2004
BASIC Study. Auckland: Auckland University of Technology; 2005.
146. Vaughn AE, et al. Promotion of Walking for Transportation: A Report
From the Walk to School Day Registry. Journal of Physical Activity and
Health 2009(6):281-8.
147. Carver A, Salmon J, Campbell K, et al. How do perceptions of local
neighbourhood relate to adolescents’ walking and cycling? American
Journal of Health Promotion 2005;20(2):139-47.
148. Hillman M. The impact of transport policy on children’s development.
Canterbury Safe Routes to Schools Project Seminar. Canterbury (UK):
Christ Church University College; 1999.
149. Davison K, Lawson C. Do attributes in the physical environment
influence physical activity? A review of the literature. The International
Journal of Behavioural Nutrition and Physical Activity 2006(3):19.
150. World Health Organization. Estrategia Mundial sobre Régimen
Alimentario, Actividad física y salud. Marco para el seguimiento y
evaluación de la aplicación. Ginebra 2006.
151. Institute of Medicine (IOM). Local Government Actions to Prevent
Childhood Obesity. Washington, D.C.: National Academies Press; 2009.
152. Institute of Medicine (IOM). Preventing childhood obesity: health in the
balance.
Washington
2004
[09/03/2010];
Available
from:
http://www.iom.edu/~/media/Files/Report
Files/2004/PreventingChildhood-Obesity-Health-in-the-Balance/ChildhoodObesity4pagerfixfor
webpdf.ashx.
153. World Health Organization. European Charter on countering obesity.
Istanbul; 2006 [4/3/2010]; Available from: www.euro.who.int/
Document/E89567.pdf.
154. Genet G. Constraints to Active Leisure: A guide for local authorities.
New Zealand: Prepared for the Hillary Commision; 2000.
155. Ministry of Health. Healthy Eating - Healthy Action. Oranga Kay Oranga Pumau. A background 2003. Wellington: Ministry of Health;
2003.
156. Fulton J, Shisler J, Yore M, Caspersen C. Active Transportation to
School: Findings from a National Survey. Research Quarterly for
Exercise & Sport. 2005;76(3):352-7.
157. Wakefield J. Fighting obesity through the built environment.
Environmental Health Perspectives. 2004;112:616-18.
158. World Health Organization. Tackling Obesity by Creating Healthy
Residential Environments. Copenhagen 2007.
159. Saskatchewan Health's. Healthier Places to Live, Work and Play. A
Population Health Promotion Strategy for Saskatchewan. [5/3/2010];
Available from: www.health.gov.sk.ca/population-health-strategy.
160. U. S. Department of Health and Human Services, U.S. Office of the
Surgeon General. Childhood overweight and obesity prevention
initiative. 2009 [17/2/2010]; Available from: www.surgeongeneral.
gov/obesityprevention/index.html.
REFERENCES
98
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
161. Committee on the Environment, Pubic Health and Food Safety. White
Paper on Nutrition, Overweight and Obesity-related Health Issues.
European Parliament. 2008 [10/04/2010]; Available from: http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:C:2010:008E:0097:0
105:EN:PDF
162. Yeung J, Hills AP. Childhood obesity -an introduction. In: Hills AP, King
NA, Byrne NM, editors. Children, Obesity and Exercise: prevention,
treatment and management of childhood and adolescent obesity.
Perth, U.K: Routledge; 2007. p. 1-10.
163. Khan L, Sobush K, Keener D, Goodman K, Lowry A, Kakietek J, et al.
Recommended community strategies and measurements to prevent
obesity in the United States. Morbidity and Mortality Weekly Report.
2009;58(RR07):1-26.
164. Cavill N, Kahlmeier S, Racioppi F. Physical activity and health in
Europe. Evidence for action. Copenhagen: World Health Organization;
2006.
165. Task Force on Community Preventive Services. Increasing physical
activity: a report on recommendations of the Task Force on
Community Preventive Services. Morbidity and Mortality Weekly
Report. 2001;55(RR18):1-14.
166. National Health Committee. Active for Life: A call for action. The health
benefits of physical activity. Wellington: National Health Committee;
1998.
167. Commission of the European Communities. White Paper on a strategy
for Europe on nutrition, overweight and obesity-related health issues.
Brussels 2007.
168. Rosenberg D, Sallis J, Conway T, Cain K, McKenzie T. Active
transportation to school over 2 years in relation to weight status and
physical activity. Obesity (Silver Spring). 2006;14(10):1771-6.
169. Oliver NL, Hayes MV. Neighborhood Socio-Economic Status and the
Prevalence of Overweight Canadian Children and Youth. Canadian
Journal of Public Health. 2005;96(6):415-20.
170. Sallis J, Prochaska J, Taylor W. A review of correlates of physical
activity of children and adolescents. Medicine and Science in Sports
and Exercise. 2000;32:963-75.
171. Joint Consortium for School Health. Physical activity within a
comprehensive school health model. School policy maker's toolkit.
2009 [6/2/2010]; Available from: www.jcsh-cces.ca.
172. International Association for the Study of Obesity. Obesity:
Understanding and challenging the global epidemic. 2009-2010 report
2009.
173. Consejo Superior de Deportes. Plan integral para la actividad física y el
deporte. Actividad física, Deporte y Salud. Madrid: Consejo Superior de
Deportes; 2009.
174. Centers for Disease Control and Prevention. Physical Activity and
Health Adolescents and Young Adults. 1999 [22/2/2010]; Available
from: http://www.cdc.gov/nccdphp/sgr/pdf/adoles.pdf.
REFERENCES
99
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
175. Babey SH, Hastert TA, Wolstein J, Diamant AL. Income Disparities in
Obesity Trends Among California Adolescents. American Journal of
Public Health. 2010;100(11):2149-55.
176. U. S. Department of Health and Human Services, Centers for Disease
Control and Prevention. Make a Difference at Your School. 2008
[9/2/2010]; Available from: www.cdc.gov/HealthyYouth/keystrategies/
pdf/make-a-difference.pdf.
177. Shirer K, Miller P. Promoting Healthy Youth, Schools, and
Communities: A Guide to Community-School Health Councils. 2003
[3/3/2010]; Available from: www.cancer.org/downloads/PED/Guide_
to_Community_School_Health_Councils.pdf.
178. Houlihan B, Armour K, Harvey J, Nevill M, Padley M, Waring A. School
Sport Partnerships. Final annual monitoring and evaluation report: The
Partnership Development Manager Survey. Loughboroug: Institute of
Youth, School of Sport and Exercise Sciences, Loughborough
University; 2008.
179. Active and Safe routes to School (National Program). How to organize
a walking/cycling school bus. 1st ed. Ottawa: Go For Green; 1999.
180. Mind, Exercise, Nutrition... Do it! (MEND). 2010 [20/03/2010];
Available from: www.mendprogramme.com.
181. Brunton G. Children and physical activity: a systematic review of
barriers and facilitators. EPPI-Centre. 2003.
182. Story M, Kaphingst K, French S. The role of schools in obesity
prevention. The Future of Children [serial on the Internet]. 16(1):
Available
from:
http://www.futureofchildren.org/information2826/
information_show.htm?doc_id=355663.
183. Unión Europea. 2006 [3/05/2010]; Available from: http://europa.
eu/legislation_summaries/education_training_youth/youth/sport/l3500
7_es.htm.
184. Comisión de Nutrición y Hábitos Saludables en el Deporte del Comité
Olímpico Español. Comité Olímpico Español. 2007 [3/05/2010];
Available from: http://www.coe.es/web/COEHOME.nsf/VClasificacion
TercerMenu/48781E452FD3070CC1256E23005A4454?opendocument&
Query=ORGANIZACIÓN*3*-Normas+reguladoras?Carta+Olímpica.
185. The Sport for All Commission of the International Olympic Committee.
2009 [3/05/2010]; Available from:
http://www.olympic.org/en/
content/The-IOC/Commissions/Sport-for-All/?Tab=0.
186. International Olympic Committee. Living a healthy and active life;
2009 [3/05/2010]; Available from: http://www.olympic.org/en/
content/Olympism-in-Action/At-grassroot-level/Living-a-healthy-andactive-life/.
187. Desayunos del Comité Olímpico Español. 2010 [3/05/2010]; Available
from: http://www.coe.es/WEB/Noticias.nsf/VNoticias/46B7C4E2A8982
760C12576F5004E52CD?opendocument&Query=NOTICIAS*1*-1(3.
188. Medical Initiative. FIFA; 2010 [3/05/2010]; Available from: http://es.
fifa.com/aboutfifa/worldwideprograms/wininafrica/medicalinitiative.ht
ml.
REFERENCES
100
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
189. UK Health Department. Change4Life - Eat Well, Move More, Live
Longer. 2009 [8/05/2010]; Available from: http://www.dh.gov.uk/en/
MediaCentre/Currentcampaigns/ Change4Life/DH_092080.
190. TAFISA. 2006 [8/05/2010]; Available from: http://www.tafisa.de/
index.php?option=com_content&task=view&id=39&Itemid=69.
191. Pagnini D, King L, Booth S, Wilkenfeld R, Booth M. The weight of
opinion on childhood obesity: recognizing complexity and supporting
collaborative action. International Journal of Pediatric Obesity.
2009;4(4):233-41.
192. ParticipACTION, Canadian Fitness and Lifestyle Research Institute.
Lifestyle Tips. Schoolbased Physical Activity Interventions. 2009
[1/2/2010];
Available
from:
http://www.cflri.ca/eng/lifestyle/
documents/LifestyleTips_English_September.pdf.
193. World Health Organization. Promoting physical activity in schools: an
important element of a health-promoting school. Information Series
on School Health: WHO; 2006.
194. Simons-Morton BG, O'Hara NM, Parcel GS, Huang IW, Baranowski T,
Wilson B. Children's frequency of participation in moderate to vigorous
physical activities. Research Quarterly for Exercise % Sport.
1990;61(4):307-14.
195. Baranowski T, Thompson WO, DuRant RH, Baranowski J, J. P.
Observations on physical activity in physical locations: age, gender,
ethnicity, and month effects. Research Quarterly for Exercise % Sport.
1993;64(2):127-33.
196. Sallis JF, Owen N. Ecological models of health behavior. In: Glanz K,
Rimer BK, Lewis FM, editors. Health Behavior and Health Education:
Theory, Research, and Practice. San Francisco: Jossey-Bass; 2002. p.
462-84.
197. Epstein LH, Coleman KJ, Myers MD. Exercise in treating obesity in
children and adolescents. Medicine & Science in Sports & Exercise.
1996;28(4):428-35.
198. Epstein LH, Wing RR, Koeske R, Ossip D, Beck S. A comparison of
lifestyle change and programmed aerobic exercise on weight and
fitness changes in obese children. Behavior Therapy. 1982;13:651-65.
199. Epstein LH, Wing RR, Koeske R, Valoski A. A comparison of lifestyle
exercise, aerobic exercise and calisthenics on weight loss in obese
children. Behavior Therapy. 1985;16:345-56.
200. Public Health Agency of Canada, Health Behaviour in School-aged
Children. Healthy settings for young people in Canada. PHAC; 2008
[2/2/2010]; Available from: http://www.phac-aspc.gc.ca/dca-dea/yjc/
index-eng.php.
201. Hendry LB, Shucksmith J, Love JG, Glendinning A. Young people's
leisure and lifestyles. London: Routledge; 1993.
202. WHO Regional Office for Europe, European Network for the Promotion
of Health -Enhancing Physical Activity (HEPA Europe). Physical activity:
a basic requirement for health. Copenhagen, Rome 2006
REFERENCES
101
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
203.
204.
205.
206.
207.
208.
209.
210.
211.
212.
213.
214.
215.
216.
217.
218.
[07/03/2010]; Available from: http://euro.who.int/mediacentre/PR/
2006/20061117_1.
World Health Organization. European network for the promotion of
Health-Enhacing Physical Activity; Work programme 2010/2011.
2010.
Spanier PA, Marshall SJ, Faulkner GE. Tackling the obesity pandemic. A
call for sedentary behavior research. Canadian Journal of Public Health
2006;97(3):255-7.
U.S. Department of Health and Human Services. Resources for Action;
2010 [8/05/2010]; Available from: http://www.healthypeople.gov/lhi/
englishfactsheet.htm.
Programa Nacional de Salud. Mexico; [8/05/2010]; Available from:
http://alianza.salud.gob.mx/descargas/pdf/pns_version_completa.pdf.
Ministère de la Santé et des Sports (France). The French National
Nutrition and Health Program (PNNS). 2010 [8/05/2010]; Available
from: http://www.sante-sports.gouv.fr/programme-national-nutritionsante-pnns-presentation-d-un-bilan-et-de-nouvelles-mesures.html.
Ministerio de Sanidad y Política Social (España). Estrategia NAOS;
2007 [8/05/2010]; Available from: http://www.naos.aesan.msps.es/
naos/estrategia/que_es/.
Gobierno de Chile. Estrategia Global contra la Obesidad (EGO); 2010
[8/05/2010]; Available from: http://www.ego-chile.cl/paginas/ego.
htm.
Nain-Feng C. Strategies for Prevention and Treatment of Obesity
Among Children in Taiwan. Research in Sports Medicine.
2010;18(1):37-48.
Ministero della Salute. Guadagnare salute. Rendere facili le scelte
salutari 2007.
Chaloupka FJ, Powell LM. Price, availability, and youth obesity:
evidence from bridging the gap. Preventing Chronic Disease Public
Health Research, Practice and Policy 2009:6(3) [13/04/2010] Available
from: http://www.cdc.gov/pcd/issues/2009/jul/08_0261.htm.
European Childhood Obesity Group. 2010 [25/04/2010]; Available
from: www.ecog-obesity.eu.
Lobstein T, Baur LA. Policies to prevent childhood obesity in the
European Union. European Journal of Public Health. 2005;15(6):576-9.
Janssen I. Physical activity guidelines for children and youth. Applied
Physiology, Nutrition and Metabolism. 2007;32(suppl 2E):109-21.
Gladwin CP, Church J, Plotnikoff RC. Public policy processes and
getting physical activity into Alberta's urban schools. Canadian Journal
of Public Health. 2008;99(4):332-8.
Timmons BW, Naylor PJ, Pfeiffer KA. Physical activity for preschool
children — how much and how? Applied Physiology, Nutrition and
Metabolism. 2007;32(suppl 2E):122-34.
International Obesity TaskForce, European Association for the Study of
Obesity. Joint response to the Commission of the European
Communities Green Paper; 2006.
REFERENCES
102
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
219. Health & sport group (UE). Directrices de Actividad Física de la Unión
Europea; 2008 [8/05/2010]; Available from: http://www.csd.gob.es/
csd/estaticos/dep-salud/Directrices_Actividad_ Fisica_UE_Espanol.pdf.
220. Vardalinstitutet, Sweden Institute of Health Sciences. [8/05/2010];
Available from: www.vardalinstitutet.net.
221. Fédération Internationale d'Education Physique. Manifiesto Mundial de
Educación
Física;
2000
[8/05/2010];
Available
from:
http://www.fiep.net/index.asp?l=es&i=46.
222. Programa de Salud Comunitaria y Educación para el Desarrollo.
[8/05/2010]; Available from: www.sacyed.es.
223. Villalvilla D, Alonso C. Programa de la Sociedad de Enfermería
Madrileña
de
Atención
Primaria
(SEMAP).
Available
from:
http://www.semap.org/boletinSEMAP/7/PROGRAMA_DIEGO.pdf.
224. Swinburn B, Kumanyika S. Brazil as a world leader in policy actions to
prevent obesity. International Obesity TaskForce; 2010.
225. World Health Organization. Networking for physical activity 2011.
226. Edwards P, Tsourus AD. A healthy city is an active city: a physical
activity planning guide. Copenhagen: World Health Organization;
2008.
227. Evans WD, Finkelstein EA, Kamerow DB, Renaud JM. Public perceptions
to chilhood obesity. American Journal of Preventive Medicine.
2005;28(1):26-32.
228. Potestio ML, McLaren L, Robinson Vollman A, Doyle-Baker PK.
Childhood obesity. Perceptions Held by the Public in Calgary, Canada.
Canadian Journal of Public Health. 2008;99(2):86-90.
REFERENCES
103
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
6. DOCUMENTS
DOCUMENTS
104
Obesity Prevention through Physical Activity in
School-Age Children and Adolescents
DOCUMENTS
105