EXERCISE IS MEDICINE

Exercise Deficit Disorder in Youth: Play Now or

Pay Later
Avery D. Faigenbaum, EdD, FACSM1 and Gregory D. Myer, PhD, FACSM2,3,4

children at risk for physical inactivity

Abstract
and promote positive lifestyle choices.
Although the benefits of regular physical activity are widely acknowl-
Childhood is a sensitive period of
edged, recent epidemiological findings indicate that a growing number
life, which is characterized by dynamic
of youth are not as active as they should be. The impact of a sedentary
changes in physiological and psycho-
lifestyle during childhood and adolescence on lifelong pathological pro-
logical development as well as the es-
cesses and associated health care costs has created a need for im-
tablishment of healthy or unhealthy
mediate action to manage, if not prevent, unhealthy behaviors during
behaviors. Physical activity, like ciga-
this vulnerable period of life. The concept of identifying children with
rette smoking, is a learned behavior that
exercise deficit disorder early in life and prescribing effective exercise
is influenced by one’s family, friends,
interventions to prevent the cascade of adverse health outcomes later
and environment (32). Thus, children
in life is needed to raise public awareness, focus on primary preven-
who are not exposed to an environ-
tion, and impact the collective behaviors of health care providers, gov-
ment with opportunities to enhance
ernment officials, school administrators, public health agencies, and
motor skill proficiency (e.g., catching,
insurance companies.
kicking, and hopping) tend to be less
active during adolescence, which may
manifest into sedentary lifestyle habits
Introduction during adulthood (3,4,44). That is, children who do not
Global health recommendations state that children and develop the prerequisite motor skills early in life may not be
adolescents should accumulate 60 min or more of moder- able to break through a hypothetical ‘‘proficiency barrier’’
ate to vigorous physical activity (MVPA) each day (49,50). later in life that would allow them to participate in a variety
In addition to enhancing cardiorespiratory and musculo- of sports and activities with confidence and vigor (42). The
skeletal fitness, regular physical activity has the potential eventual decline and disinterest in physical activity, which
to enhance a child’s emotional, social, and cognitive well- seems to be a contemporary corollary of low motor skill
being (9,35). Yet recent epidemiological reports indicate proficiency, starts even earlier in overweight children who
that contemporary youth are not as active as they used to may perceive physical activity to be boring or discomforting
be, and this decline in physical activity seems to emerge by (6,26). Recent findings indicate that infants (3 to 18 months)
age 6 (36,47). Since physical fitness in youth is recognized with high subcutaneous fat were 2.3 times more likely to
as a powerful marker of health (35), evidenced-based inter- demonstrate delayed motor development compared with
ventions and public health policies are needed to identify infants with less subcutaneous fat (43). These data indicate
that increased body fat and motor development delay are
1
linked even during infancy.
Department of Health and Exercise Science, The College of New Jersey,
Children who do not participate regularly in a variety of
Ewing, NJ; 2Sports Medicine Biodynamics Center and Human
Performance Laboratory, Cincinnati Children’s Hospital Medical Center, physical activities early in life may not develop the motor
Cincinnati, OH; 3Department of Pediatrics, College of Medicine, University skill repertoire and perceived confidence to meet or exceed
of Cincinnati, Cincinnati, OH; and 4The Ohio State University Sports national recommendations for physical activity (24,45). In
Medicine Center, Departments of Family Medicine, Biomedical support of these observations, accelerometry-measured MVPA
Engineering, Cell Biology and Physiology, The Ohio State University,
Columbus, OH.
at age 5 was a predictor of adjusted fat mass at ages 8
and 11 in boys and girls (22). In the aforementioned report
Address for correspondence: Avery D. Faigenbaum, EdD, FACSM, (22), boys and girls in the highest quartile of MVPA at
Department of Health and Exercise Science, The College of New Jersey, age 5 had a lower fat mass at ages 8 and 11 than 5-year-
2000 Pennington Rd., Ewing, NJ 08628; E-mail: [email protected] old children in the lowest MVPA quartile. These findings
1537-890X/1104/196Y200
highlight the importance of encouraging regular MVPA in
Current Sports Medicine Reports young children as one strategy to limit fat gains during
Copyright * 2012 by the American College of Sports Medicine preadolescence.

196 Volume 11 & Number 4 & July/August 2012 Exercise Deficit Disorder

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 The impact of a sedentary lifestyle during childhood and contemporary youth are not as active as they should be, and
adolescence on lifelong pathological processes (e.g., dia- we need to pay greater attention to lifestyle modification
betes and cardiovascular disease) and associated health care during childhood to prevent the progression of risk factors
costs has created a need for immediate action to manage, if and pathological processes.
not prevent, unhealthy behaviors such as physical inactivity Although signs, symptoms, and test results are often used
during this vulnerable period of life (23,39,46). As illus- to identify diseases or disorders, the construct of EDD is
trated in Figure 1, children who do not develop funda- unique because there are not any clinical markers or labo-
mental motor skills and gain competence and confidence in ratory tests that can be used to diagnose this condition.
their ability to perform various movements are less likely to Rather, a specific exercise history or ‘‘play history’’ can be
engage in regular exercise and more likely to have disease used to aid in the identification and treatment of physically
risk factors and eventually experience negative health out- inactive individuals before they become resistant to lifestyle
comes. Because many chronic diseases that become clin- interventions. Recently, Sallis (41) suggested that health care
ically manifest during the adult years are influenced by providers should obtain an ‘‘exercise vital sign’’ on every
lifestyle habits established during the growing years, par- adult patient they see. In the same light, pediatric health
ticipation in meaningful physical activities early in life may care providers should screen all youth with a ‘‘play history’’
prevent the development of risk factors and pathological to identify young patients who do not meet the current
processes later in life. This view is supported by the current recommendations for 60 min or more of MVPA each day
prevalence of overweight and obesity in sedentary youth (i.e., 420 minIwkj1). Youth with EDD should be treated
and the troubling diagnosis of type 2 ‘‘adult-onset’’ diabetes with the same energy and resolve as a pediatric patient who
in adolescents who, for the most part, are obese (30,33,39). has hypertension or dyslipidemia. Although most youth are
resistant to shots and medications, the treatment for EDD is
regular physical activity that is age-appropriate and enjoy-
Exercise Deficit Disorder able. Of note, there are no medications to treat deficiencies
Exercise deficit disorder or EDD is a term used to in movement skill or physical inactivity.
describe a condition characterized by reduced levels of Since primary prevention is designed to prevent disease
regular physical activity (G60 min of daily MVPA) that are rather than treat it, the first step is to identify children
below recommendations consistent with positive health who are not participating in 60 min or more of MVPA each
outcomes (12,14). The use of this term conveys a fresh view day. While the optimal amount and type of exercise may
of this conventional health care concern that can be used vary with age, gender, and exercise history, participating
to raise public awareness about the importance of regular daily in a variety of developmentally appropriate activities
exercise for the developing body. Despite noteworthy efforts for at least 60 min is consistent with established guidelines
from professional organizations and public health agencies, (49,50). Identification of asymptomatic children who do
not participate in the recommended amount of MVPA can
facilitate the development of a management plan, which
should include treatment as well as plans for long-term
follow-up and family education about healthy lifestyle choices.
Since most parents of inactive children wrongly consider their
children to meet or exceed current physical activity recom-
mendations (8), identifying youth with EDD and providing
parents with specific recommendations for achieving phys-
ical activity goals can help to encourage positive behavior
change that is supportive within the family structure.
While the term physical activity generally refers to any
bodily movement produced by skeletal muscle that results
in energy expenditure, the term exercise connotes a type of
physical activity that is planned and regular. The use of the
term exercise in EDD does not suggest that free play during
childhood is inconsequential but rather emphasizes the pre-
mise that habitual physical activity should be ‘‘prescribed’’
by health care providers, pediatric fitness professionals, and
physical education teachers. Viewed from this perspective,
participation in outdoor play, recreational activities, fitness
programs, physical education classes, and sports practice can
all contribute to the physical and psychosocial development
of a child provided these activities are consistent with the
needs, abilities, and interests of the participants. As Rowland
(38) has emphasized, regular exercise early in life is a ‘‘strat-
agem of preventive medicine’’ that will reduce adult disease
Figure 1: The cascade of adverse events that may result from risks later in life.
a lack of fundamental movement skill (FMS) development during If current trends continue, the health-related consequences
childhood. of physical inactivity and childhood obesity will likely pose

www.acsm-csmr.org Current Sports Medicine Reports 197

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
an unprecedented burden on youth, their families, and our children. Perhaps the most visible difference between chil-
health care system (21). Nowadays, computers and video dren and adults is that children tend to be ‘‘metabolic non-
games have decreased youngsters’ desire to move, and in specialists’’ regarding exercise performance (2). Unlike adults
some communities, crime and perceptions of unsafe con- who tend to specialize in sports such as weightlifting or long-
ditions understandably limit physical activity at parks and distance running, the strongest child in physical education
playgrounds. Some observers suggest that unless effective class is likely to be a leader in an endurance run as well.
interventions are developed and opportunities are created New insights into the design of youth exercise programs
for youth to participate regularly in physical activity, youth may prove to be valuable for pediatric health care providers
of today may, on average, live shorter lives than their parents and other professionals who develop and prescribe exer-
do (34). The enormity of this issue requires a change in the cise programs for younger populations. While supervised
current paradigm. and well-designed strength and conditioning programs have
Health care providers who treat children (e.g., physicians, proven to be safe and effective for children (16), integra-
nurses, physical therapists, certified athletic trainers, and tive neuromuscular training (INT), which includes general
pediatric exercise physiologists) should assess current exer- and specific exercises that are designed to enhance both
cise habits and, when appropriate, provide age-appropriate health-related (e.g., muscular strength and cardiorespira-
recommendations that are safe, convenient, worthwhile, tory endurance) and skill-related (e.g., agility, balance and
and fun. Moreover, physical education teachers need to coordination) components of physical fitness, is a novel
identify physically inactive youth and, with the support of approach for school-age youth (11,28). INT provides an
the school district, provide meaningful opportunities for opportunity for children to master fundamental movement
these children to participate in a variety of skill-enhancing skills (e.g., locomotor, object-control, and stability skills),
games and physical activities in a supportive environment. increase muscle strength, improve movement mechanics,
A convincing body of evidence has found that school-based and gain confidence in their physical abilities. Fundamental
interventions and after-school programs are effective in movement skill proficiency during the growing years has a
improving physical activity levels and reducing the preva- strong influence on developing and maintaining adequate
lence of childhood obesity (5,17). Parents also play a key physical fitness (3,25,44). Consequently, a child’s motor
role and should be cognizant of the long-term consequences skill competence and perceived confidence, which can be
of physical inactivity and should reduce television viewing, enhanced with INT, can drive participation in MVPA
promote daily physical activity, and serve as active role (including fitness and sport activities), which, in turn, may
models for their children. increase the likelihood that this positive lifestyle choice will
Current evidence and clinical observations support the be carried over into adulthood (Fig. 2).
need to identify and treat youth who do not accumulate INT programs that target the development of motor skills
60 min or more of MVPA each day. We presently under- and muscle strength in a socially supportive environment
invest in preventive care in the United States with less than
3% of our health care budget targeted for preventive ser-
vices (20). Furthermore, despite the potential salutary effects
of daily physical education, the mean physical education
budget for schools in the United States is only $764 per
annum (31). By comparison, it is estimated that medical-
related expenses for obesity will reach $348 billion by 2018
(48). Health care concerns related to physical inactivity
during childhood are emerging, and the identification of
EDD in youth by qualified professionals will help to em-
phasize the message that a lack of regular exercise during
childhood and adolescence is not consistent with long-term
health and well-being. The general public is now aware
of obesity-related health threats facing children, and there
seems to be strong public support for interventions aimed
at improving the health and well-being of children and
adolescents (10).

Exercise Prescription for Youth

If exercise is medicine, specific details of the ‘‘therapy’’
(including safety concerns) need to be properly prescribed
and monitored by qualified professionals who are knowl-
edgeable of the physical and psychosocial uniqueness of
younger populations. Clearly, if the pleiotropic benefits of
regular exercise early in life are to be realized during adult-
hood, exercise programs for children must be development-
ally appropriate, meaningful, and enjoyable. Children are not
miniature adults, and as such, exercise programs and training Figure 2: Potential influence of INT on MVPA, fitness and sports
paradigms designed for older populations are suboptimal for participation, and lifetime wellness.

198 Volume 11 & Number 4 & July/August 2012 Exercise Deficit Disorder

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
can be an effective approach for improving the physical youth and a philosophy about physical activity and fitness
fitness of school-age youth. Children are at an optimal age training that is consistent with the needs, goals, and abilities of
in terms of motor skill learning when they are in primary younger populations. Ideally, pediatric fitness professionals
school (27,29), and unlike adolescents, they have not yet should be linked to the health care industry and available to
developed bad habits and are not as self-conscious about offer community-based interventions that are safe, enjoyable,
making a mistake in front of their peers. Because neuromotor and effective. A nationally recognized certification in pediatric
performance (e.g., muscle strength, speed of movement, and fitness may be needed to ensure safe participation in youth
coordination) of children has significantly declined over the programs while enhancing training outcomes for children and
past two decades (7,40), the integration of INT into physical adolescents.
education, sports practice, and after-school recreation pro-
grams may be an important ‘‘first step’’ in enhancing basic
fundamental movement skills and in promoting physical fit- Conclusions
ness in younger populations. In our view, getting a sedentary In adult populations, only a modest fraction of the total
8-year-old boy away from a high-tech computer game and cardiovascular risk burden is now being eliminated, and
actively involved in a low-tech INT program with his friends nonadherence to therapeutic interventions is considered a
is a success. risk factor in and of itself (23). Clearly, a population-wide
INT may be even more beneficial for children with a approach for prevention is required, and novel strategies
decreased genetic potential for motor development because for identifying inactive children, prescribing effective exer-
cognitive and motor capabilities are highly ‘‘plastic’’ and cise programs, and raising public awareness are desperately
amenable early in life (18,19,37). There may be an optimal needed. The importance of promoting regular physical ac-
window of opportunity during preadolescence in which tivity as part of a healthy lifestyle is so compelling that the
physically inactive youth can be targeted with INT when American College of Sports Medicine recently launched the
their neuromuscular system is most responsive to this type Exercise is MedicineA program to promote physical ac-
of training (29). Considering the potential for motor skill tivity for all people (1). This public health initiative calls on
learning, INT that is designed to enhance the development health care providers to assess and review every patient’s
of fundamental movement skills during this critical period physical activity habits and for fitness professionals to edu-
may provide the most lasting benefits during childhood and cate clients about the medicinal benefits of exercise.
adolescence (24,27). Without such public health initiatives and interventions
Although there is not one program of INT that provides that focus on disease prevention and health promotion early
the safest or most effective means for enhancing motor skills in life, youth may not develop the competence and confidence
and muscle strength in all youth, body weight exercises may to be physically active later in life and new health care con-
be particularly beneficial for the development of health- and cerns will continue to emerge. The concept of identifying
skill-related fitness measures. Medicine balls, dumbbells, asymptomatic children who are deficient in exercise could
and elastic bands also may provide a unique and challenging effectively impact the collective behaviors of health care
stimulus for school-age youth provided the program is age- providers, government officials, school administrators, pub-
appropriate and supervised by qualified teachers and fitness lic health agencies, and insurance companies to question
professionals (15). By integrating different training modal- the current symptom-reactive paradigm in an attempt to
ities and gradually progressing the program, training adap- obviate the need for extensive and expensive medical proce-
tations will be optimized and the likelihood of plateaus in dures later in life. Comprehensive, innovative, and aggressive
performance will be reduced (29). In the long term, INT strategies are desperately needed to identify youth with EDD
programs that are sensibly progressed will allow participants and promote regular participation in age-appropriate phys-
to make even greater gains because they will be challenged ical activities.
to adapt to even greater demands over time (13,28).
When working with children who are physically inactive, The authors declare no conflict of interest and do not have
it is important to remember that the goal of the program any financial disclosures.
should not be limited to increasing time spent in MVPA.
Developing fundamental movement skills, enhancing phys-
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200 Volume 11 & Number 4 & July/August 2012 Exercise Deficit Disorder

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