Abstract
Although physical activity (PA) provides children with various health benefits, many children do not engage in regular PA. Health care professionals can effectively encourage children and their families to participate in more PA through lifestyle changes. The strategies that clinicians can employ to promote PA are discussed in this article.
Specifically, HCPs [health care professionals] are encouraged to include the entire family, support lifestyle PA [physical activity], promote self-efficacy, and encourage self-monitoring.
The benefits of physical activity (PA) in youth have been extensively studied.1-3 As discussed in this issue by McMurray and Ondrak, 4 PA in childhood significantly decreases cardiometabolic risk factors. Despite these benefits, physical inactivity in children remains widespread.5,6 There are even greater concerns for adolescents as PA has been shown to drastically decline during this developmental period. 7 Furthermore, behaviors established during adolescence strongly track into adulthood. 5 Given the low levels of PA in children and adolescents and the benefits associated with increasing PA, it is important that effective ways of increasing these behaviors are identified.
Schools provide an excellent opportunity to reach children of all ethnicities in order to establish healthy lifestyles at a young age.8,9 Because of this, many policies have been implemented to increase PA at the school level. Middle school students have been shown to now spend 54% of physical education (PE) class engaged in moderate to vigorous PA. 10 This is encouraging as earlier studies reported that middle school children spent only 16% to 24% of PE class engaged in moderate to vigorous PA. 11 Although these school-based health initiatives seem to have affected the quality of PE received by students, little is known about the effectiveness of these policies to impact the growing rates of childhood obesity and comorbid conditions. A longitudinal analysis of elementary school children found that the prevalence of obesity either increased or a high level of obesity was maintained with these policies in place from 2004 to 2007. 12 Although schools have been identified as a national focal point for obesity prevention, 13 the need for additional PA outside the school system is clear.
Health care professionals (HCPs) can play an important role in promoting PA. 14 The importance of HCPs in providing encouragement to engage in PA has been identified by multiple health organizations,15,16 and clinicians should be trained to effectively counsel their patients in increasing PA. 14 Several recommendations have been made to promote PA in children. Specifically, HCPs are encouraged to include the entire family, support lifestyle PA, promote self-efficacy, and encourage self-monitoring.
Inclusion of Families
The efficacy of family-based interventions for lifestyle management has been demonstrated over the past 25 years.17-20 Traditional family-based approaches are typically parent led and framed as helping the entire family instead of a targeted child.21-25 However, in some interventions, parents have been viewed as the sole agent of change. 24 More recent interventions have taken a global family approach that addresses not only health-related behaviors but also general family functioning.26,27 Because of the profound effect that parents have on children’s values and attitudes, it is not surprising that parents serving as role models significantly enhance attempts to change child behavior. 28 However, obtaining family support to consistently increase PA may prove difficult given economic and time constraints. Although many obstacles and challenges exist for including families in the treatment of children, finding ways to encourage families to engage in lifestyle PA can help promote longer term changes.
Lifestyle Physical Activity
The type of PA recommended can greatly influence adherence in children. Lifestyle PA includes participation in intramural sports programs, use of community-centers and school facilities, completing household chores such as gardening, and walking or biking to school. Lifestyle PA may be lower in intensity than programmed aerobic exercise but promotes better adherence as it is incorporated into the routine activities of the child. 29 Additionally, lifestyle PA has been shown to help promote long-term maintenance of weight loss in children. 29 Calisthenics, which are often promoted in school settings, are less likely to foster long-term adherence. 29 For example, going to the gym may be a viable option for adults to engage in regular PA; however, children and adolescents are more likely to engage in PA when it is a form of structured play.
Increasing Self-Efficacy
Self-efficacy is the level of confidence that individuals have in their ability to engage in specific behaviors. 30 In terms of PA, self-efficacy may be best understood as children’s confidence in being able to perform similarly to their peers. High self-efficacy makes it more likely that individuals will be adherent to and maintain recommendations. 31 Many children, especially those who are overweight or obese, feel uncomfortable during PA because of factors such as decreased coordination, differences in speed, and poor self-esteem. 32 Additionally several activities compete for children’s time, especially sedentary behaviors. 14 Because of these and other factors, children who are not confident in PA are unlikely to engage in it. 33 Improving self-efficacy can directly address the feelings of inadequacy, which, in turn, increases the likelihood of children engaging in PA.
Having a helper or “proxy agent” may be important in the initial stages of developing a new behavior. 34 For children, parents may best fill this role. Specifically, parents should be encouraged to engage in PA that is comfortable for their children and allows them to set their own pace. As their confidence, they should be encouraged to develop independent activities with parents serving as a role model. Taking small steps is consistent with the behavioral principle of shaping. 35 In terms of PA, children (and adults) should start slowly and gradually increase their activity levels. For example, sedentary children who are asked to begin a running program are not likely to maintain this level of activity. Instead, they may benefit from recommendations of walking, which transitions to walking longer distances, which then leads to walking with interspersed jogging, and so on.
Children and parents have a tendency to engage in high levels of PA too quickly, which is often associated with pain and discourages the continuation of these activities. 36 Because parents can play a beneficial role in assisting their children, it may also be important to promote parental self-efficacy in PA as well.
Self-Monitoring
As with all lifestyle behaviors, self-monitoring may be one of the most important components for creating change. 37 It is common for children and parents to report different amounts of child PA, and HCPs are encouraged to refer to both reports and discuss the differences in order to identify possible areas of difficulty or misunderstanding.
Conclusion
Although the need for PA in children is clear, there are still many issues that need to be better understood. For example, the optimal level of PA required to effectively slow the rate of weight gain in children needs to be determined. 38 In addition, little evidence exists for ways to motivate individuals to engage in long-term PA. 39 These limitations notwithstanding, encouraging children and their families to engage in and increase PA remains a significant issue. To effectively promote PA in this age-group, HCPs are encouraged to include families, promote lifestyle PA instead of “exercise,” promote self-efficacy, and recommend self-monitoring.