Recommendations

IAP National Task Force for by 2025, and that the proportional rise will be
Childhood Prevention of Adult greatest in developing countries (48%),
especially China (68%) and India (59%). India
Diseases: The Effect of Childhood will have more people with diabetes (~ 57
Physical Activity on Prevention of million), than any other country, with the
Adult Diseases greatest numbers in the 45-64 years age group.
It is likely that type 2 diabetes will soon start to
emerge in children. The economic and health
Anura V. Kurpad* consequences of this epidemic can spell
Sumathi Swaminathan** disaster for the nation unless immediate
Swarnarekha Bhat*** remedial measures are instituted.
The pediatricians cannot now afford to
ignore the rapidly accumulating evidence that
Preamble these adult diseases are either programmed at
The adverse health consequences of the the delicate fetal stage or have their origins in
rapid nutrition transition in the Asian region infancy or childhood. Realizing the crucial
are now beginning to get noticed. These role of pediatricians in prevention of these
include insulin resistance, type 2 diabetes, adult diseases, the Indian Academy of
hypertension, coronary artery disease, Pediatrics constituted a “National Task Force
hyperlipidemia, metabolic syndrome for Childhood Prevention of Adult Diseases”.
(Syndrome X), stroke and certain cancers. An The initial and main envisaged objective of
epidemic related to this transition is already this Task Force is to frame evidence based
unfolding itself in India. Mortality from guidelines to help those caring for children to
cardiovascular disease is expected to rise by institute preventive measures for developing
about 60%, and overtake deaths from adult diseases. The broader long-term
infectious diseases by 2015-2020. The objective is to liaise with other stakeholders to
prevalence of type 2 diabetes has increased by catalyze the initiation of relevant public health
40% in Chennai between 1988 and 1994. It is action.
predicted that the prevalence of type 2 diabetes The following is a pertinent review of
will rise by 30% worldwide, from 4% to 5.4% evidence and the recommendations on one of
these proposed preventive measures, namely,
* Dean, Institute of Population Health and Clinical
Research, St John’s National Academy of Health "The Effect of Childhood Physical Activity on
Sciences, Bangalore 560034, India. Prevention of Adult Diseases". The document
** Research Associate, Division of Nutrition St John’s was drafted by the Writing Committee
National Academy of Health Sciences, Bangalore established for this purpose and circulated for
560034, India. comments to the entire “Task Force”
** Professor, Department of Pediatrics, St John’s (members listed in Annexure 1).
Medical College and Hospital, Bangalore 560034,
India.
1.0 Summary
Correspondence to Prof. Anura V. Kurpad. This document assesses the possibility of

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prevention of adult disease through physical than targeted or secondary prevention.

activity in childhood. Generally, it would Overall, a sustainable health promotion
appear that children and adolescents in intervention program which is directed at
developed countries have little physical physical activity should be able to achieve
activity. This may well be similar in India. positive social, behavioral, cognitive and
There are several ways in which physical physical or biological outcomes.
activity can influence the incidence of adult
Data from India is lacking, and there is a
chronic disease (Table I). Physical activity in
childhood could prevent childhood obesity need for research in this area to define whether
physical activity has a role in prevention of
which in turn could prevent the occurrence of
childhood morbidity. Childhood obesity or disease, to define whether there is a dose-
response of benefit, and to identify who would
morbidity could track into adult obesity and
morbidity, with the risk for developing chronic be benefited most by intervention. Further,
there is a need for operational research into the
disease at that stage in life, and there is some
evidence for these mechanisms at present. An efficacy and benefit of interventions.
interesting perspective on childhood physical 2. Definitions
activity is the possibility that this may either
track by itself into adulthood, or have an 2.1. Physical activity and inactivity in
exclusive role in preventing adult disease children
regardless of adult body weight and lifestyle. 2.1.1. Physical activity
While there is insufficient data on the latter,
the former situation is a possibility, although Physical activity is a global term referring to
the type of physical activity is an important “any bodily movement produced by skeletal
variable to consider. Conversely, it is muscle that results in a substantial increase
possible for physical inactivity to track into over the resting energy expenditure”(1).
adulthood.
2.1.2. Physical inactivity (sedentary behavior)
The role of interventions to improve Physical inactivity or sedentary behavior can
physical activity and prevent childhood be defined as “a state when body movement is
obesity is less clear. However, even if minimal and energy expenditure approximates
interventions are undertaken, they should be resting metabolic rate (RMR)”(2). It includes
holistic, incorporating changes in lifestyle, diet participation in physically passive behaviors
and physical activity. A combined approach such as television viewing, reading working at
should also be undertaken so that intervention the computer, talking with friends on the
strategies are implemented at the home and telephone, driving a car, meditating or eating.
family level, at school and within the
community. Curriculum time should be given 2.2. Classifications of activity
for physical activity, and schools should 2.2.1. Classification of physical activity
embrace policies that encourage participation according to intensity of effort in
in physical activity. Interventions should also children(3)
be designed to be inclusive of all children, and
adequately trained, motivated personnel Classifying the physical effort of activities
should be involved in these programs. It is according to children's heart rate (above 2
better to implement primary prevention, rather years of age)

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Sedentary < 96 activities undertaken in the individual's

Light 96 - 120 discretionary free time and is selected on the
basis of personal needs and interests. It
Moderate 121 -145
includes exercise and sport:
Heavy > 145
• Exercise: A planned and structured subset
2.2.2. Classification of activity according to of leisure time physical activity that is
nature or purpose of the activity(3) usually undertaken for the purpose of
Sleep: In bed at night; napping improving or maintaining physical fitness.
• Physical fitness: Includes cardio-
School: Classroom work; recess; other school
respiratory fitness, muscle strength, body
activities
composition, and flexibility, comprising a
Domestic chores: Child care; cleaning house; set of attributes that people have or achieve
washing dishes; laundry; food preparation and that relates to the ability to perform
cooking; miscellaneous house-hold crafts and physical activity(4).
tasks; fetching water; fuel collection. • Sport: Implies a form of physical activity
Production: Agricultural activities; household that involves competition. It may also
manufacturing and crafts for sale; textile work; embrace general exercise and a specific
hunting fishing and gathering; trading and occupation.
selling; wage work. 2.4. Units of physical activity
Non-work activities: Eating; personal care and
2.4.1. Physical activity levels(1)
hygiene; resting; walking and traveling; school
homework; play and leisure; social and Physical activity level (PAL) values
religious activities. express daily 24-hour energy expenditure as a
multiple ofbasal metabolic rate (BMR),
2.3. Leisure time physical activity
thereby allowing approximate adjustment for
The non-work physical activity includes individuals of different sizes. PALs are a
leisure time physical activity(1), which are universally accepted way of expressing energy

TABLE I–Summary of strength of evidence on childhood physical activity and risk of developing adult disease

Evidence Decreased risk No relationship Increased risk

Convincing Adult chronic disease and Television viewing and

adult physical activity childhood obesity
Low bone mineral density Childhood morbidity with
with physical activity (exercise) childhood obesity
Probable Direct effect of vigorous Sedentary behavior such as TV
childhood activity viewing and increased energy
intake
Possible Increased physical activity
in childhood tracking to adulthood
Insufficient Interventions to increase physical
activity in children

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expenditure and are a composite index of 3.0. Assessment of physical activity in

physical activity patterns. children
In order to avoid obesity, populations should 3.1. Primary or criterion standards:
remain physically active throughout life, at a
Doubly labeled water
PAL value of 1.75 or more. Thus:
The doubly labeled water (DLW) method,
Lifestyle PAL
also thought to be the “gold standard” is a non-
Sedentary 1.4 invasive means of assessing energy expendi-
Limited activity 1.55 - 1.60 ture in free-living children. A dose of stable
isotope (2H218O) is administered orally to the
Physically active 1.75 subject to enrich the pools of 2H and 18O in the
body. Over the next 5 to 14 days, 2H is
2.4.2. Metabolic equivalents
eliminated as water, while 18O will be
This is essentially a multiple of BMR for eliminated as water and CO2. The difference
each type of activity. Total energy expenditure between the elimination rates is proportional to
for a particular activity is computed as the CO2 production, which can be related to the
product of BMR/min, the specific MET and oxygen consumption through the use of
the duration of activity in minutes (See MET respiratory or food quotient and finally to the
Table II at end of this document). The 24 hour energy expenditure(7,8).
energy expenditure is computed by adding up
Direct observation
all the MET values for the various activities in
a day. The PAL is calculated as the ratio of the This is a practical and appropriate criterion
24 hour energy expenditure to the BMR. measure of physical activity and patterns of
activity for infants and young children. The
2.5. Physical activity and energy technique is usually observation over a period
expenditure/balance of a few seconds to one minute time sampling
in free living conditions(7).
Energy balance is simply a balance
between energy intake and expenditure. If the Indirect calorimetry
energy intake is greater than the energy
Open circuit calorimetry estimates energy
expenditure, the person is said to be in
expenditure from O2 consumption and CO2
“positive energy balance”. The surplus energy
production. This technique requires a captive
is stored in the body, either as glycogen (these
subject and is hence used to validate and mea-
stores are small), or as energy dense fat, which
sure only short-term energy expenditure(7).
can grow in size. The components of energy
expenditure are the basal metabolic rate 3.2. Secondary measures
(BMR, about 60%), thermogenesis (about
Heart rate monitoring
10%) and physical activity (about 30%). The
BMR varies by a small amount on a basis(5), Minute-by-minute measurement of heart
and adaptations in thermogenesis are similarly rate is used in estimating energy expenditure
small(6). However, big differences can occur or physical activity, since heart rate and energy
in physical activity, since it is discretionary, expenditure are linearly related. However the
and it therefore forms a large and modifiable nature of the relationship varies between
component of energy expenditure. individuals, and hence has to be characterized

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TABLE II–General Physical Activities Defined by Level of Intensity

The following is modified from the CDC and ACSM guidelines for all ages.

Light Activity+ Moderate Activity+ Vigorous Activity+

Less than 3.0 METs* 3.0 to 6.0 METs* Greater than 6.0 METs*
(less than 3.5 kcal/min) (3.5 to 7 kcal/min) (more than 7 kcal/min)

Walking casually, less than Walking at a moderate or brisk Jogging or running

3 miles per hour (mph) pace of 3 to 4.5 mph on a level Walking and climbing briskly up a hill
Walking in the house or yard surface inside or outside, such as or stairs
Window shopping, strolling and • Walking to school, work, Backpacking
stopping frequently· or to shop; Mountain climbing, rock climbing
Casual walking, sauntering, • Walking for pleasure; and roller skating
strolling, purposeless wandering • Walking the dog; or
• Walking as a break from work.
Walking downstairs
Hiking
Roller skating at a leisurely pace
Bicycling less than 5 mph - using Bicycling 5 to 9 mph, level Bicycling more than 10 mph or bicycling
very light effort terrain, or with few hills on steep uphill terrain
Stretching exercises-slow Yoga Calisthenics-push-ups, pull-ups,
warm-up Gymnastics vigorous effort.Karate, judo,
General home exercises, light or taekwondo, jujitsu, jumping rope
moderate effort, getting up and
down from the floor
Table tennis for leisure Table tennis-competitive Tennis-singles
Tennis-doubles
Playing catch-football or cricket Basketball -shooting baskets Most competitive sports
Throwing a ball Football game
Basketball game
Throwing a Frisbee Playing Frisbee Handball-general or team
Most competitive sports Juggling
Bowling Cricket-batting and bowling
Darts, Billiards Badminton
Swimming-floating Swimming-recreational Swimming-steady paced laps
Treading water-slowly, moderate Treading water-fast, vigorous effort
effort
Diving-springboard or platform
Putting groceries away-generally Putting groceries away-walking Carrying several heavy bags of groceries
Stocking shelves with food and carrying especially large or at one time up a flight of stairs
heavy items
Sitting and playing a board game Playing on school playground Running
or video game equipment, moving about, Skipping
Sitting while reading, writing, swinging, or climbing Jumping rope
coloring, painting,
using a computer

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TABLE II (contd...)–General Physical Activities Defined by Level of Intensity

+
Light Activity Moderate Activity+ Vigorous Activity+
Less than 3.0 METs* 3.0 to 6.0 METs* Greater than 6.0 METs*
(less than 3.5 kcal/min) (3.5 to 7 kcal/min) (more than 7 kcal/min)
Gardening and Yard work: Gardening and yard work: Gardening and yard work: heavy
pruning, weeding while sitting or raking the lawn, bagging grass or or rapid shoveling (more than 5 kg
kneeling, or slowly walking and leaves, digging, hoeing, light per minute), digging ditches, or
seeding a lawn shoveling (less than 10 lbs carrying heavy loads
per minute), or weeding while
standing or bending
Planting trees, trimming shrubs and
trees, hauling branches, stacking
wood
Light housework: Moderate housework: scrubbing the Heavy housework: moving or
dusting, vacuuming, sweeping floor or bathtub while on hands and pushing heavy furniture, carrying
floors, straightening, making beds, knees, hanging laundry on clothesline, household items weighing 10kg or
cooking or serving food, washing sweeping an outdoor area, cleaning more up a flight or stairs, or
dishes, folding and putting away out the garage, washing windows, shoveling coal into a stove.
laundry, sewing, or carrying out moving light furniture, packing or Standing, walking, or walking down
light bags of trash unpacking boxes, walking and putting a flight of stairs while carrying
Most other household tasks done household items away, carrying out objects weighing 25 lbs or more
while sitting or standing heavy bags newspapers, and plastics,
or carrying water or firewood
General household tasks requiring
considerable effort

Source: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and
prevention, National Centre for Chronic Disease Prevention and Health Promotion, Division of Nutrition and
Physical Activity. Promoting physical activity: a guide for community action. Champaign, IL: Human Kinetics,
1999. (Table adapted from Ainsworth BE, Haskell WL, Leon AS, et al. Compendium of physical activities:
classification of energy costs of human physical activities. Medicine and Science in Sports and Exercise 1993; 25(1):
71-80.
*The ratio of exercise metabolic rate. One MET is defined as the energy expenditure for sitting quietly, which, for the
average adult, approximates 3.5 ml of oxygen uptake per kilogram of body weight per minute (1.2 kcal/min for a 70-
kg individual). For example, a 2-MET activity requires two times the metabolic energy expenditure of sitting quietly.
+
For an average person, defined here as 70 kilograms or 154 pounds. The activity intensity levels portrayed in this
chart are most applicable to men aged 30 to 50 years and women aged 20 to 40 years. For older individuals, the
classification of activity intensity might be higher. For example, what is moderate intensity to a 40-year-old man
might be vigorous for a man in his 70s. Intensity is a subjective classification.
Data for this chart were available only for adults. Threfore, when children’s games are listed, the estimated
intensity level is for adults participating in children’s activities.
To compute the amount of time needed to accumulate 150 kcal, do the following calculation: 150 kcal divided by the
MET level of the activity equals the minutes needed to expend 150 kcal. For example: 150/3 METS = 50 minutes of
participation. Generally, activities in the moderate-intensity range require 25-50 minutes to expend a moderate
amount of activity, and activities in the vigorous-intensity range would require less than 25 minutes to achieve a
moderate amount of activity. Each activity listed is categorized as light, moderate, or vigorous on the basis of current
knowledge of the overall level of intensity required for the average person to engage in it, taking into account brief
period when the level of intensity required for the activity might increase or decrease considerably.

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for each individual studied. This has been able to complete this diary, although its
validated to assess physical activity in children accuracy should be viewed with caution.
aged between 7 to 15 years(7).
3.4. Problems associated with measurement
Motion sensors - Pedometers, accelerometers of physical activity in children
Pedometers are simple electronic devices Physical activity in epidemiological terms
used to estimate mileage walked or the number is usually measured by a questionnaire. It is
of steps taken over a period of time. The important to understand that this may be
technique has been validated in children fraught with problems, in terms of reporting
between the ages of 4-11 years of age. accuracy. There can be problems of under-
However, it does not assess intensity or pattern reporting or large amounts of random error,
of activity. increasing the dispersion or variability of the
Accelerometers are electronic devices data, and reducing confidence in making
measuring accelerations produced by body associations. It is also important that
movements. It has been validated in children questionnaires cover all domains of activity.
between 2 to 16 years of age. However this too, Finally, the problem remains of measuring
does not detect daily or hourly patterns of physical activity over relatively short periods
activity(7, 9). of time, but extrapolating these findings to
3.3. Subjective measures later life events.

Self-report questionnaires 4.0. Linkages between physical activity and

adult disease
This technique is useful in large-scale
studies for previous day's recall of physical In recent years there is an escalation in the
activity. Recall errors, deliberate misrepre- prevalence of overweight and obesity in
sentations, social desirability are some of the different countries, both in adults and in
drawbacks of this method, especially in children. In a study in India on 13 to 18 year
children. old children, age adjusted prevalence of over
Interviewer-administered questionnaires nutrition was 17.8 % for boys and 15.8 % for
girls. The prevalence increased with age and
This technique is used in large-scale was higher in lower tertiles of physical activity
studies. A trained administrator could improve and in the higher socio-economic group(11).
a child's cognition and accuracy. Examples of This seems clearly to be due to changes in the
such questionnaires can be found in Jacobs lifestyle of children. Links between television
et al.(10), where a comparison of many viewing and obesity have been shown during
questionnaires has been made. However, it is the period of childhood and adolescence, with
most important that questionnaires be each hourly increment of TV viewing by
designed and tested with reference to the adolescents being associated with a 2%
scientific question being asked as well as the increase in prevalence of obesity(12).
cultural, ethnic and linguistic context.
The key issue of this paper is to demonstrate
Activity diaries
the benefits of physical activity in childhood in
While this may be the most accurate terms of the prevention of adult disease. There
subjective technique in adults, its use is limited is conflicting evidence in this regard, and
in pediatric populations. Adolescents may be Figure 1 demonstrates a framework in which

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Low physical activity in childhood

5 4 1 3

Childhood Childhood
obesity risk/morbidity other
than obesity

Low adult Adult obesity Adult risk other

physical activity than obesity

Adult morbidity or disease

Fig. 1. Potential linkages between childhood physical activity and adult disease. Numbers 1, 2, 3, 4 and 5 refer to text.

this possibility may be analyzed, and the day, but do not specifically define the
following below is evidence whether each of energy or time spent in physical activity. From
the pathways between a lowered physical the viewpoint of simple energetics, since obese
activity in childhood is linked to adult disease. children have a heavier weight, it seems likely
that the cost of carrying this weight in weight-
In the discussion below, each numbered bearing tasks is likely to be high. Thus, total
point refers to evidence for or against each energy expenditure measured in obese
linkage between childhood physical activity children has been reported to be higher than
and adult disease (Fig. 1). that of normal weight children(13-15). This
4.1. Linkage between physical activity and seemingly paradoxical fact is explained above,
obesity in children (No. 1 in figure) and importantly, is a clear indicator that the
problem in childhood obesity is not simply a
Energy expenditure measurements are matter of low physical activity. Earlier studies
often used as a surrogate for physical activity, on food intake of obese children suggested that
and this is usually measured by the DLW they had a lower daily energy intake than
technique, or by calorimetry. These techniques normal weight children; this in turn suggested
give a total value for energy expended during that their total energy expenditure was lower,

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and besides constitutional decreases in energy odds ratio for being overweight was
expenditure components such as the BMR, significantly increased by 12% for every hour
their physical activity was singled out as a of television viewing and significantly reduced
major determinant of childhood obesity. The by 10% for every hour of physical activity
higher TEE seen in obese children therefore after controlling for several variables
suggests that there may be under-reporting of including age and gender(21). To directly test
energy intake in these children. the causal relationship between television
viewing behaviors and body fatness (that is,
However, does this mean that physical
the intervention only addressed TV viewing
activity is not a determinant of the prevention of
time, without specifically substituting more
childhood obesity? Actual measurements of
active behaviors), one study did show that
physical activity show that obese children
television viewing is indeed a cause of
spend less time in this domain of energy
increased body fatness(22).
expenditure(16). It is possible that physical
inactivity may be the important determinant of Studies on obese and non-obese children
energy expenditure, and may indirectly have also shown that decreased physical
determine the amount (or reduction) in time activity could either be a cause or a
spent in physical activity. In Pima Indian consequence of obesity. A study by Yu
children, in whom there were significantly et al.( 23) on obese and non-obese children in
greater amounts of time spent in sedentary Hong Kong, showed a significant difference
activities such as television viewing, less time between the two groups in the amount of time
was spent in sports activities(17). The spent on sedentary activities, with the obese
relationship between television viewing and group spending 51 % more time than non-
obesity in children has been reviewed(18), and obese children.The ratio of active-to-sedentary
the mixed results found of either weak waking time was 0.6 for obese children and 1.9
associations, or no associations at all, between for non-obese children. If this trend of
the amount of television watched and obesity. continued physical inactivity were to continue
Statistically significant associations have been over a period of time, it could track towards
observed between hours of TV watching per adulthood, thereby being a major risk factor
day and obesity(12). Another study has shown leading to non-communicable diseases like
that there was a dose-response relationship type 2 diabetes, cardiovascular disease and
between hours of television viewing and the cancer.
incidence and prevalence of overweight over a
Obesity in children is therefore related to
4 year period; as much as 60% of the
physical activity; this may be more so in some
prevalence in overweight could be attributed to
groups. Importantly, obesity or weight gain is
excess television viewing(19). In another
a matter of a positive energy balance, which is
study, an increase in physical activity was
the difference between energy intake and
associated with decreasing BMI in girls and in
expenditure. It seems reasonable to suggest
overweight boys, while conversely, an increase
that in obese children who stay obese despite
in inactivity was associated with increasing
having a relatively higher TEE than their lean
BMI in girls(20). These effects were generally
counterparts, it is likely that the energy intake
stronger among overweight children.
is even greater than the high energy
A similar finding has been observed in a expenditure. It becomes important to titrate
less developed country like Mexico, where the energy expenditure against intake, in order to

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prevent weight gain; this means that even physical activity was available in terms of the
though obese children have higher TEE, they pulse rate, but this showed a significant trend
still may have low levels of habitual physical of declining as BMI increased, indicating that
activity; clearly, it is important to increase their the high BMI students were relatively less
physical activity(24). active(29). This has also been observed in
other studies relating pre-pubertal weight for
4.2. Linkage between childhood obesity and
males and females with adult mortality(30), as
adult obesity (No. 2 in figure).
well as in the pre World War Boyd-Orr
Childhood BMI is related to the adult BMI cohort, where those with childhood BMI
and the pattern of BMI changes from 2 to 25 y above the 75th centile had an increased risk of
has stronger effects on subsequent adult all-cause and cardiovascular mortality(31).
overweight than birth weight and adult Similarly, in a locality with high adult
lifestyle variables(25). The predictability of mortality rates, adolescents were found to have
adult overweight from childhood BMI is best a higher level of coronary risk factors such as
from the BMI at age 18 years and not good overweight, smoking, physical inactivity and
below 13 years(26). A recent study has hypercholesterolemia, compared with children
indicated links between rapid infant weight who came from a locality with average
gain and the obesity both in childhood and coronary heart disease related mortality(32).
young adulthood. In a cohort of 300 African This is not necessarily dependent on adult
Americans was followed from birth till the age weight, as adolescent obesity has been shown
of 20 years, a trend toward rapid weight gain in to be a risk factor for many adverse health
early infancy was associated with young adult effects(33). This implies that prevention of
obesity(27). A follow-up study for a period of obesity from the period of childhood should be
22 years in Japan(28) showed that a major public health measure.
approximately 32% of obese boys and 41% of
4.3. Linkage between childhood physical
obese girls grew into obese adults. The
activity and morbidity (other than
problem of childhood obesity tracking into
obesity) (No. 3 in figure)
adult obesity is not the only problem; direct
linkages can be traced to adult morbidity and In recent years, there is an increase in
mortality, sometimes independent of adult evidence that physical activity increases bone
weight. A recent study in Glasgow on 8335 density and thereby prevents osteoporosis in
men and 2340 women, who as students came later life. During childhood years, especially in
from relatively affluent backgrounds, showed the pre-pubertal phase, the maximum increase
a positive association between BMI in in bone density occurs. Under conditions of
adolescence and mortality in later life(29). disuse and inactivity, both skeletal and muscle
Each increment of BMI by 5 kg/m2 in this tissues atrophy, in children, who are in their
cohort was associated with increased hazard growth periods(34). A cross-sectional study on
for all cause mortality (adjusted for height, bone mineral density (BMD) and physical
number of siblings, pulse rate, birth order and activity on children showed that physical
smoking and for age in menarche in females) activity was strongly associated with bone
of approximately 18% in men (p = 0.015) and mass in pre-pubertal children, with males
30% in women (p = 0.096). Indeed, there were showing greater associations. Those parti-
trends of increased cancer related mortality as cipating in sports showed a 4.2% higher BMD
well in this cohort. Only a crude indicator of at the femoral neck and a 4.3% higher BMD at

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the spine(35). This latter point is important, hand in hand; this is true as one study has
since only high intensity activity has beneficial shown that there were significant correlations
effects on bone health(36). between physical activity and health related
physical fitness in Taiwanese adolescents(45).
It is important to look at cardiovascular risk
Physical activity also has an effect on the
factors as well, since there are important
psychological variables of adolescents and
correlations of clinical risk factors in early life
may influence behaviors that increase the risk
with anatomic changes in the aorta and
of obesity. For example, physical inactivity,
coronary vessels with atherosclerosis along
through television viewing will increase
with cardiac and renal changes related to
behaviors that are pre-morbid in themselves:
hypertension(37,38). Obese Indian children
first is the possibility that increased dietary
have been found to have a higher prevalence of
intake and the intake of high calorie foods will
essential hypertension(39). Physical activity
increase with television viewing(18), and more
levels (PAL) in a normal range have been
worrying is the relationship between television
found to correlate with flow mediated
viewing and the initiation of smoking among
dilatation of the brachial artery in children(40).
youth(46). Several papers reviewed by
Physical fitness (but not physical activity) in
Friedenreich(47) indicate that physical activity
adolescence is related to the presence of
has a role in cancer prevention as there is
cardiovascular disease risk factors in young
convincing evidence linking physical activity
adulthood(41). These findings are repeated
to colon and breast cancer. However, no
in the Amsterdam Growth and Health
longitudinal study has been conducted from
Longitudinal Study(42), in which body fatness
the period of childhood.
in adulthood as well, was similarly related to
physical fitness in adolescence. More active 4.4 Linkage between physical activity in
children had lower insulin secretion and childhood and physical activity in
greater insulin sensitivity that were adulthood (No. 4 in figure)
independent of body fat or fat distribution(43).
Chronic disease in adults is strongly linked
Further, in a Finnish study of 743 20-year old
to the daily amount of physical activity.
males both a childhood aptitude for endurance
Therefore, in assessing the protective effect of
athletic events and a continuity of vigorous
physical activity in childhood, it seems logical
physical activity were found to be associated
to look for the effect this has on physical
with protection against coronary heart
activity in adulthood. Further, the question
disease(44). The probable link between
should also be whether physical inactivity also
physical activity and coronary heart disease is
has similar effects on physical inactivity in
possibly mediated through the process of
adulthood. Adult physical activity has a low to
obesity tracking through childhood with
moderate relation with activity measured after
cumulative lifetime effects leading to the
13 years of age(48). The longitudinal
development of adverse levels of total
development of the physical activity profile,
cholesterol, LDL-cholesterol, triglycerides
in turn, had an influence on a better
and decreased HDL-cholesterol level.
cardiovascular disease risk profile. An analysis
These findings draw more attention to the from the Harvard Alumni study also showed
maintenance of physical fitness, rather than that correlations between physical activity
physical activity level, in adolescence. It may during college were not well correlated with
be argued that physical activity and fitness go physical activity during later life(49). This

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RECOMMENDATIONS

may also be due to a methodological issue: activity can be successfully introduced, or

physical activity assessed over a short time increased in the lifestyle of a child, it is
period in an individual may not be a valid necessary to understand prevailing patterns
proxy for activity over the long term, although, and determinants of physical activity in
in the same study, the BMI measured at college children. The potential for positive physical
did correlate better with BMI in later life. activity behaviors learned during childhood to
However, these findings do not allow a carry through to adulthood and positively
confident linkage to be made between activity affect health is definitely an incentive to
levels in childhood and adulthood. promote physical activity from the period of
childhood. Rapid psychosocial and biological
4.5. Linkage between physical activity in development occurs during the period of
childhood to adult morbidity or
infancy, childhood and adolescence which
mortality (No. 5 in figure) would also be reflected in their physical fitness
Data that show clear trends in relating and physical activity patterns. The importance
childhood activity to later life events and of promoting physical activity in children
mortality are scanty; however, the Harvard becomes even greater, especially when it is
Alumni Study does provide some insight into evident that in the past leisure activities for
the effect of physical activity during late children often meant active play, but leisure
adolescence (or college) with the risk of death today may mean a quiet sedentary activity
later in life. In this study, after adjustment for such as viewing television or playing a
potential confounders, the relative risks of computer game(52).
dying associated with increasing quintiles of Fox and Riddoch(53) summarized the
total energy expenditure in college, showed a pattern of activity of children and adolescents
significant and decreasing trend(50). The as being mainly incurred through:
relationship was more clear for vigorous than
non-vigorous activity. However, the effect of • Transport, as in cycling or walking to
childhood activity on later life mortality is school or shops
clearly influenced by adjustments to lifestyle
• Informal play, such as playground, street
in later years. Changes in lifestyle, such as
or park games during free time
increasing physical activity, or quitting
smoking, are important in preventing adult • Formal play, as in physical education
morbidity or mortality(51). classes, organized sport or exercise
sessions at school or elsewhere
Overall, it appears that the evidence
linking physical activity in childhood to adult • Work, such as in delivery rounds, jobs in
disease, through a variety of pathways, is sales or shelf stacking, or household tasks.
present, although not strong. The linkage of
childhood events and lifestyle to adult disease 5.1. Infancy
is multi-factorial, and it is difficult to pinpoint In the case of infants, physical activity
physical activity as being the critical factor in becomes difficult to define as energy cost of
this process. physical activity is not easy to assess,
5.0. Patterns of physical activity in children especially with growth costs to be accounted
for. However, Wells and Davies(54)
In order to understand how physical longitudinally estimated the physical activity

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of 124 free living infants between 1.5 to 12 by 83% from year 1 to year 10. By 16 or 17
months of age. Total energy expenditure and years 56% of black and 31% white girls
body composition were estimated using reported no habitual leisure time activity.
doubly labeled water. Activity energy Racial differences in physical activity were
expenditure increased markedly over the first more notable at older ages. Aaron et al.(58)
year of life, from 5% of energy intake at 6 longitudinally studied a total of 782
weeks to 34% at 12 months. PAL was adolescents, aged 12-15 years, for their
calculated using the ratio of activity energy physical activity using a questionnaire, for a
expenditure (AEE) to the predicted sleeping period of 4 years. Physical activity declined by
metabolic rate (SMR), and it was found that 26%, and this decrease seemed to be a function
this level increased from 0.1 to 0.58 from of the decrease in number of activities. They
6 weeks to 9 months and then got decreased to suggest that it could be critical to have pre-
0.53 at 12 months of age. This was attributed to adolescent children maximize their exposure to
environmental rather than to developmental various activities at a young age to enhance the
factors. likelihood that they will maintain participation
in some of these activities in later years.
5.2. School-going children and adolescents
Tracking physical activity behaviors from In school going children, physical activity is
childhood have given insights into the change related to the school curriculum, especially
in patterns in physical activity as children grow during the ages of between 8 to 15 years.
biologically and emotionally, and these could However in late adolescence, it becomes more a
serve to identify periods during which matter of choice(56, 59). In the study by
intervention for promoting positive physical Gordon-Larsen et al.(59), consisting of 17,766
activity behaviors. US adolescents (11-21 years), enrolled in the
National Longitudinal Study of Adolescent
Decline in physical activity in children as Health studying in the middle and high
they increase in age and differences with schools, important associations between
ethnicity has been recorded by many investiga- modifiable environmental factors, such as
tors(55,56). Strauss et al.(55) reported that participation in school physical education and
there was a significant decline in physical community recreation programs occurred with
activity levels (measured using the motion the activity patterns of adolescents.
detector) between ages 10 and 16 years, in a Participation in daily school physical education
cross-sectional study of 92 children. Moderate program classes and use of community
and vigorous activity levels decreased recreation center were associated with an
significantly between ages 10 and 16 years for increased likelihood of engaging in high level
both sexes(55,56). In a follow up study which moderate to vigorous physical activity.
prospectively followed up black and white girls However, despite marked and significant
enrolled in the National Heart, Lung and Blood impact of physical activity in school programs,
Institute Growth and Health Study for 10 few adolescents participated in school physical
years(57), it was observed that physical activity education programs and this decreased with
levels declined with racial differences being age. Gavarry et al.(60) showed that school
evident. Physical activity assessed by a days increased the habitual physical activity
Habitual Activity Questionnaire to measure of children (assessed through heart rate
leisure time physical activity showed a decline monitoring over a seven day period and daily

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RECOMMENDATIONS

activity dairy) compared to school-free days in 7.8 hours per week. Differences in gender
their study of 182 children between the ages of were also found to be related to age. Strauss et
6-20 years. Further, compulsory activity at al (55) reported that before the age of 13 years,
school made a difference to for all children similar levels of physical activity were present
compared to the school day without PE in girls and boys, while after the age of 13
lessons(61). In contrast to the observations on years, boys were significantly more active than
school-going children and adolescents, in girls.
primary school children (aged 7.0 to 10.5 years)
By contrast, in 4-11 year-old children(64),
the total amount of physical activity did not
no gender difference was observed in activity
depend on the duration of physical education
energy expenditure and total energy
timetabled at school, as these children
expenditure, and in PAL (although mean PAL
compensated by being active out of school(62).
of 1.4 ± 0.3 in boys and 1.2 ± 0.4 girls were
This implies that although school physical
observed). Similar trends were observed in a
education does make a difference to activity of
cross-sectional study in Oxford on physical
children, age also contributes significantly to
activity levels of 10-13 year old children (n=38
activity.
children ,12 boys and 26 girls) on school days
In children aged 10 - 16 years (n=92), it has with and without physical education using
been observed that those who spent the least activity diaries, the mean PAL value for all
time participating in sedentary behaviors were children was 1.52 ± 0.08, with 1.50 or boys
significantly more likely to have high levels of and 1.53 for girls. For boys the lowest mean
moderate activity compared with those who PAL value of 1.46 was observed during the
spent the most time in sedentary behaviors. weekend, while for girls the lowest mean value
Time spent on television and computer were of 1.48 was on the school day without PE(61).
inversely correlated with moderate activity
6.0. Determinants of physical activity in
(p=0.01) (55). However, there are no Indian
children
data available on this issue.
The determinants of physical activity in
5.3. Gender based differences in physical
children are also important to know in order to
activity
understand how to create sustainable
Conflicting reports on differences in interventions that are successful in increasing
patterns of activity among male and female their activity.
children occur in several studies, with some
6.1. Socio-demographic determinants
showing definite differences, while others
showing none. In 3 to 4 year-olds (n = 104), Adolescents are more likely to be
total activity was found to be significantly physically active if they had a circle of friends
different with total activity being higher in who are active. Peer influence also appears to
boys than in girls (63). Total physical activity be important with respect to participation in
declined by 69 % in male subjects, and by 36 organized sports. Children whose parents are
% in female subjects during school days from physically active have been reported to be
childhood to adolescence (60). Dovey et al nearly 6 times as likely to be active than
(56) reported that in girls, there was a decrease children whose parents are both inactive(65).
from 7.5 hours to 4.3 hours a week, while in
Advanced maternal education and higher
boys it decreased from 11.7 hours per week to
income were associated with lower levels of

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physical inactivity(57,59). Pregnancy was have reported a preference for television

associated with decline in physical activity viewing and other small screen activities (like
only for black girls but not in white girls, electronic games and computers).
while cigarette smoking was associated with
(c) Low energy level: Feeling tired lazy and
decline in physical activity only in white
sluggish, along with the realization that ‘junk
girls(57).
food’ slowed one down.
6.2. Environmental determinants (d) Motivation: Low level of self-motivation
Seasonal and geographic influences were and low levels of motivation from others
found to play a large role in physical activity (parents or teachers) have been perceived as
behaviors, with the activity highest in summer barriers to physical activity.
and lowest in winter(66). Lack of safe outdoor (e) Time constraints: Lack of time due to
play areas in many portions of large cities homework or other plans and commitments
limits children's ability to engage in active have been perceived as barriers. In the Indian
physical play or recreational sports(23,67). context, with increasing emphasis being given
Torun et al.(3) have reviewed several on tuitions and homework, there is a
papers and indicated that compared with consequent forced decrease in physical
children (aged 5 to 19 years) in industrialized activity of children.
societies (PAL = 1.58-1.65), children in ( f ) Social factors: Peer pressure with friends
developing rural areas (mean PAL = 1.74 to also involved in sedentary activities. Parental
2.06) sleep less at night, participate longer in preferences and support, as well as motivation
moderate and/or heavy physical activities, and also have a role here. Teasing and bullying
have a greater energy expenditure in relation to (between genders) was also reported.
their basal metabolic rate. Few studies have
been conducted in children from cities in (g) Lack of access to facilities: The extent to
developing countries and their physical which the environment is conducive to physical
activity falls between those in industrialized activity (safe streets and playgrounds) is
countries and those in rural areas of likely to have a strong impact on activity
developing countries (PAL = 1.56-1.62). levels(69).
The perceived benefits of physical activity
7.0. Perceived benefits and barriers to
have been positively associated with physical
physical activity
activity in children and adolescents(70). These
Children should view physical activity as perceived benefits of activity have also been
being interesting and fun to do. However, there explored using semi-structured focus groups
can be important and significant barriers to and specific prompts in a qualitative study(68)
engaging in physical activity. The barriers to and are:
engaging in physical activity are(55, 68):
(a) Social benefits: Physical activity was
(a) Self-efficacy: This refers to the confidence fun. It allowed socializing with friends, and
in ability to be physically active. Increased the possibility of understanding and enjoying
level of physical activity has been shown to be teamwork. It also resulted in parent
associated with increased self-efficacy. approval.
(b) Preference for indoor activities: Children (b) Psychological enhancement: Physical

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activity resulted in a sense of achievement, 8.0. Do interventional measures work?

pride, self-esteem and confidence. It enhanced
As a first principle, it seems reasonable that
the mood, and inculcated a sense of discipline.
physical activity interventions should be
A reduction in sense of guilt and a sense of
tailored to the physical and social capacity of
balance in life was achieved.
the group of children, particularly for obese
(c) Feeling good physically: Children felt children in the group(72). In addition, it would
refreshed after physical activity, and there also appear that schools would provide an
was a sense of ‘creation of energy’ along excellent forum for prevention efforts, because
with reduction of fatigue. Sleep was also of their potential to reach large numbers of
enhanced. children and to deliver structured risk-
reduction programs. This is reinforced by the
(d) Sports performance: There was an
discussion (above) that physical activity tends
improved sports performance, along with skill
to decline in adolescence. However, a note of
development. Physical activity was also
caution should be sounded in school programs:
perceived to improve coordination, agility,
they should not target obese children alone,
flexibility and reflexes, along with fitness and
since this can create stigma. It also loses focus
strength.
on the target of primary prevention. It also
(e) Cognitive benefits: Students reported that seems reasonable to presume that intervention
physical activity cleared the mind and programs would be very effective if both
thinking. It enhanced concentration and brain school and family were involved, and the
function. Pathways family intervention in American
( f ) Coping strategy: Physical activity was Indian children has shown that school based
perceived to provide stress relief, relaxation, family involvement programs could be
and was a distraction from worries. It provided successfully initiated(73). Finally, since low
an outlet for aggression, frustration and anger. physical activity and unhealthy eating tend to
track together, it is also feasible to include
7.1. Probable risks nutrition education and behavioral manage-
Intensive training is not an essential feature ment interventions along with physical activity
of physical activity. Graded increase in fitness interventions, so that a more holistic approach
training is important while training physically. is undertaken.
Musculoskeletal injuries, renal abnormalities, Intervention studies in schools in
gastrointestinal disturbances, immune system developed countries have shown some good
suppression and menstrual irregularities may effects in increasing physical activity. In one
accompany high training loads. Although these such intervention at the school level
conditions are mostly reversible with reduced (performed in multiple schools in the US, in a
training, they are undoubtedly troublesome and multiracial population trial called the Child
may partly offset any health benefits accruing and Adolescent Trial for Cardiovascular
from greater activity. They may also have an Health, CATCH), two primary end points that
adverse effect on exercise adherence, were undertaken were changes in the fat
reinforcing the likelihood of an optimal level of content of food service lunch offerings and the
activity for health purposes(71). However amount of moderate-to-vigorous (but not
physical fitness and experience may play a role vigorous) physical activity in Physical
in reducing the risk of injury. Education programs, over a 3 year period of 6

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RECOMMENDATIONS

semesters. The intervention resulted in declined from 16.6 to 14.6%), through a

significantly higher amounts of self-reported program of nutrition education and targeting
physical activity during school in the of overweight children(78). This was a
intervention group compared to controls, as government sponsored program, and given
well as in decline in fat intake(74). However, this success, and the less successful nature of
no significant difference between control and the more universal program described
intervention groups was seen in the change in above(75), it seems likely that the most cost-
BMI or triceps skinfold at the end of 3 years. In effective way forward is to target higher risk
another study performed in the UK (multiple children and devote resources to more
schools, Activity Program Promoting intensive treatment programs(79), as well as to
Lifestyles in Schools, APPLES), a one year have government involvement. However, this
program designed to influence eating and must be done with caution: it may well
physical activity in schools was instituted.This promote stigmatization and the emergence of
targeted the whole community, including eating disorders. It is also clear that different
parents, teachers and students, and could not countries will have different success rates with
find any change in physical activity levels in such programs.
the intervention schools after one year(75).
Indeed, there was a decline in the levels of Targeted interventions, based on parents
physical activity in overweight children. and care-givers have also proven effective in
However, the same authors noted that the smaller groups. In the Girls health Enrichment
implementation of the program was very Multi-site Studies (GEMS), culturally relevant
successful(76). Here is a paradox: a successful family based intervention measures to prevent
program implementation, with an unsuccess- excess weight gain in African American girls
ful outcome. aged 8-10 years, with a BMI above or equal to
the 25th percentile of the CDC growth charts
This seems to be the problem in many
was implemented. The interventions were
intervention studies as reviewed recently,
targeted to both the children and their parents
where it was found that there is little data
or care-givers. Girls in both child targeted and
available on the effectiveness of obesity
parent targeted interventions increased their
prevention programs in children and that at
level of moderate-to-vigorous activity by
present it is difficult to draw firm conclusions
12%(80). In a small group of children,
on this issue(77). It may be that many of these
behavioral interventions along with
programs utilize techniques for endpoints, that
counseling were useful in reducing television
are questionnaire based, which would increase
or small screen activities, as well as in
the variability of responses; as stated above,
increasing physical activity, suggesting that
physical activity is notoriously difficult to
behavioral interventions may be useful(81),
quantify accurately, and with a high variability
however, this still needs to be evaluated in
and small degrees of expected change, it is
terms of endpoints such as the prevention of
quite likely that many of these studies would
obesity, as well as in large numbers over the
lack the statistical power to detect change.
long term. Interestingly, in one longitudinal
Nevertheless, it has been reported that in study, multiple counseling sessions on
Singapore, there has been a successful physical activity from adolescence to
campaign to reduce obesity in school children adulthood did not result in a decrease in the
(over an 8 year period, prevalence of obesity rate of weight gain(48).

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In a developing country situation, albeit of the effectiveness of interventions, modifying

with much younger children, one long-term physical activity in children is an attractive and
study(82) evaluated just the effect of a physical non-restrictive approach towards preventing
activity intervention (15 minutes of walking obesity and the possibility of later life
plus 20 minutes of aerobic exercise) to Thai morbidity. There are several important
kindergarten children for 30 weeks. A reduction questions to be answered when determining
of the prevalence of obesity was found at the end activity recommendations. Does activity have a
of 4.5 months, in the intervention pre-school beneficial effect? Is there a dose- response? Is
children (P = 0.057). Data at 6 months post- there an inflection in the dose response that
intervention showed that the overall prevalence clearly defines a beneficial effect? Who is most
of obesity rose again in both intervention and benefited?
control groups, however this increase was less
in the intervention group(77). It is not known Answering these questions with regard to
(information not available) if the changes at physical activity is difficult given the
29.6 weeks plus 6 months are statistically confusion in the data. In addition, it is difficult
significant, but such small differences between to define dose responses, as well as inflections
groups are unlikely to be clinically significant. in the curve of the dose response, when weak
associations are present. Finally, with regard to
Overall, the data are conflicting, but the India, there is dearth of evidence on the
increase in physical activity of a child (in amount of, and benefit of, physical activity of
contrast to intensive physical training) is not children; regional, cultural, socio-economic
associated with negative effects. It must be and demographic differences could also lead
borne in mind that all these results are from to differences in physical activity patterns.
short-term studies and hence positive outcomes However, with evidence pointing towards the
may not be evident. Therefore, it is worthwhile increase in overweight and non-communi-
implementing programs that target physical cable diseases, probably tracking through to
activity in addition to a healthy diet and adulthood all over the world, promotion of
lifestyle. Lessons from the previous studies physical activity during the childhood years
should be heeded while implementing such should be a public health priority.
programs. It is clear that the prevention of
obesity in childhood, along with possible The WHO(83) recommendation for children
benefits on adult health, will require the reads as follows:
cooperation of many agencies, including the
school, community and government. It will 1. At least 30 minutes of cumulative
require the development of novel interventions, moderate physical activity everyday
with innovative educational and behavioral (walking/ brisk walking as well as other
approaches, in order to work successfully in a appropriate, healthy and enjoyable
sustainable manner. Finally, it should be physical activities and sport for all
sensitive to the needs of the children and the actions), with children of all ages requiring
program: an insensitive approach may well an additional 20 minutes of vigorous
cause more problems. physical activity three times a week.
(Listings of activities contributing to light,
9.0. Recommendations for promotion of moderate and vigorous activities are given
physical activity in Table II). Moderate intensity exercise of
On balance, it would appear that regardless a non-structured nature facilitates most of

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RECOMMENDATIONS

the disease prevention goals and health » Indoor games: Encourage and promote
promoting benefits. dancing, games with action, for
example hop-scotch, blind man's buff.
2. Restrict TV viewing, video games and use
of computers to a total of <2 hours per day 2. At the school-student level
Further recommendations to promote • Physical education must be compulsorily
physical activity in children are: integrated into the school and college
curriculum. Emphasis on competition
1. At the parent-child level
should not be the sole objective. Emphasis
• Encourage parents and physicians to should be placed on play and activities
promote physical activity from the period rather than "exercise". In sporting events,
of infancy, by stimulating and encouraging participation should be stressed and
the child to walk and play once he/she competition de-emphasized.
learns to do so. Discourage the use of
• Lack of space in the school for play
prams once the child learns to walk.
activities should be compensated for by
• Encourage parents to support their obtaining permission to use public
children's participation in appropriate, playgrounds for the children so that all
enjoyable physical activities. students in the school avail of the physical
education classes.
• Encourage familial participation in
games and sports activities (for example, • Educate teachers and parents about the
walking, swimming and other recreational benefits of physical activity. Show how
activities). this can be achieved.
• Encourage the participation of children in • More emphasis should be on making
household chores. physical activity seem an enjoyable
experience so that all children could
• Teach families to consciously reduce
participate. Suitable games should be
television viewing, through education and
conceived for children with mild and major
behavioral techniques. Restrict viewing of
disabilities and this should be incorporated
TV to less than 2 hours per day.
in the physical education program.
• Encourage physical activity as a lifestyle:
• Elementary school students should develop
» Walk and talk: Instead of sitting at basic motor skills that allow participation in
the table while doing home-work, a variety of physical activities, and older
take a walk and practice spellings, students should become competent in a
multiplication tables and general select number of lifetime physical activities
knowledge. they enjoy and succeed in.
» Household jobs: Encourage participa- • Discourage the use or withholding of
tion with responsibility in household physical activity as punishment.
chores, for example, walk the dog,
3. At a government-community level
dusting, cleaning cup-boards, vacuum-
ing, watering plants and gardening, • Increase playground facilities and safe play
washing their playthings and bicycles areas for children. Each area, especially in
and cars. big cities, should be developed with

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adequate infrastructure for public play- • Advise parents on the importance of being
grounds and parks for children to play and role models for active lifestyles and
provided with safe play equipment. providing children with opportunities for
increased physical activity. Familial
• Encourage the use of community programs
attitudes toward exercise and sport
for promoting physical activity (for
participation should be explored
example, playing team games and cycling
on safe roads with children in the • Advise parents to include planned
neighborhood). Provide safe and level activities instead of food as part of the
pedestrian paths for the public to family's reward system for positive
walk. accomplishments.
• Promote physical activity within a cultural • The child's access to regular convenient
context that is appropriate for each child. places of exercise and the ability of the
• Use media as an agent to promote physical family to encourage regular activity must
activity. In children messages promoted be assessed.
through TV and newspapers and magazines
are captured instantly and could prove to
• Emphasize the benefits of regular physical
activity: an improved cardiovascular risk
be a very effective way to disseminate
factor profile, increased energy expendi-
knowledge on physical activity.
ture, improved weight control, a general
4. At a targeted (secondary prevention) level sense of physical well-being, improved
• Targeted prevention should be a secondary interpersonal skills, and an outlet for
option psychological tension.

• Secondary prevention should be done by • Advise not to include or exclude children

experts, and with caution. from activities because of physical or
mental limitations. Suggestions for exer-
5. At the doctor/pediatrician-patient level cise should suit the child's physical
• Assess the degree of physical activity of ability.
the child. Assessment of activity should
begin as early as 2 years and through
• Encourage participation in noncompetitive
activities, and organized sports. Emphasize
adolescence.
on sports that can be enjoyed throughout
• Determine the time spent on sedentary life, participation in summer camps, and
activities, especially to TV viewing, video school physical education programs. The
games and computer usage and advise activities should be culturally suited. In
parents to establish time limits for the same Indian conditions, children could play
(< 2 hours/day). games like hide-and-seek, kabaddi, hop-
• Encourage the participation of the child in scotch, fly kites.
unstructured and structured play based on To aid in the process of rapidly assessing
the age of the child. the physical activity of a child, the following
• Advise physical activity as a lifestyle (as key questions (and suitable recommendations
mentioned in recommendations at parent- in the case of low physical activity) could be
child level). asked (and advised):

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have physical disabilities to be exempt from

Box 1: Screening children for their physical
activity
the physical education course; however they
should be required to provide modified
» If a toddler: While the parent/care-taker walks,
is the child carried, taken by pram, or does he/
physical education and health education for
she walk? these students. By modifying physical
Intervention: Child should be encouraged to education, health education, extracurricular
walk till tired. physical activities, and community sports and
» How many hours a day does the child spend on recreation programs, schools and communities
television/computer /video games? can help these young people acquire the
Intervention: More than 2 hours per day physical, mental, and social benefits of
should be actively discouraged. physical activity(85).
» How far is the school from home? How does
the child commute?Intervention: If the Box 2: Key messages to be conveyed
distance is less than ½ km, walking should be
encouraged. » Physical activity is beneficial for daily healthy
living. However, it need not be strenuous to be
» Totally how many hours are spent in active beneficial.
play both at home and school?Intervention: A
minimum of 30 minutes of moderate activity » WHO (2003) recommends at least 30 minutes
(walking briskly, general play etc.), with a of cumulative moderate physical activity
minimum of 20 minutes of vigorous activity everyday (walking/ brisk walking as well as
thrice a week. other appropriate, healthy and enjoyable
physical activities and sport for all actions).
» Children of all ages require an additional 20
minutes of vigorous physical activity three
9.1 Recommendations for children with
times a week. (Listings of activities
disabilities contributing to light, moderate and vigorous
It is mandatory that all individuals should activities are given in Table II).
be physical active to the extent of their » Moderate intensity exercise of a non-
structured nature facilitates most of the disease
capabilities. The WHO (84) has recommended
prevention goals and health promoting
that “persons with disability should be benefits.
provided with enough opportunities and
» Promote activities that the child enjoys at
support to perform sport and physical home, school and community. Children who
activities adapted to their physical conditions”. are forced to exercise are much less likely to be
regularly active in adulthood.
Children and adolescents who are obese or
» Time spent in sedentary activities and games,
who have physical or cognitive disabilities,
particularly TV viewing, video/computer
chronic health conditions (e.g., diabetes, heart games should be limited to ≤ 2 hours per day.
disease, or asthma), or low levels of fitness
» Discourage the use or withholding of physical
need instruction and programs in which they activity as punishment
can develop motor skills, improve fitness, and
experience enjoyment and success. Young
9.2. Making sports/play enjoyable
people who have these disabilities or health
concerns are often overtly or unintentionally In order make play or sports enjoyable
discouraged from engaging in regular physical CDC(85) has recommended that persons
activity even though they may be in particular concerned with training of children in sports
need of it. Schools may allow students who should ensure that:

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RECOMMENDATIONS

• Exposure to the sun is minimized by use of experience, so that active living is sustained
protective hats, clothing, and sunscreen; throughout the life span.
avoidance of midday sun exposure; and
use of shaded spaces or indoor facilities. 10.0. Future research needs
Effective research in this area is difficult to
• Heat-related illnesses should be prevented
do. It has been suggested that in order to
by ensuring that children and adolescents
effectively answer questions linked to the
frequently drink cool water, have adequate
influence of physical activity on childhood
rest and shade, play during cool times of
obesity, the ideal study would be a prospective
the day, and are supervised by people
randomized controlled trial, in which children
trained to recognize the early signs of heat
would be assigned to an active and sedentary
exhaustion and heat stroke. Cold-related
lifestyle; this is a study that will never
injuries can be avoided by ensuring that
take place(36). Nevertheless, epidemiological
young people wear multilayered clothing
studies are still useful, given that the data on
for outside play and exercise, increasing
physical activity in childhood as prevention
the intensity of outdoor activities, using
for adult disease is still sparse in India.
indoor facilities during extremely cold
weather, ensuring proper water tempera- It is important to get estimates of the
ture for aquatic activities, and provid- burden of childhood overweight in India.
ing supervision by persons trained to Further, research is required into the
recognize the early signs of frostbite and determinants of childhood obesity in India,
hypothermia. with emphasis on dietary and lifestyle patterns.
Structured physical activity questionnaires,
• Measures should be taken to avoid health which are validated, are also required to assess
problems associated with poor air quality physical activity patterns in different domains
(e.g., reduce the intensity of physical of activity. It must be remembered that
activity or hold physical education classes epidemiological associations that have been
or programs indoors). Children and found are weak, and a lot of studies are cross-
adolescents should be provided with, and sectional. This is however an important
required to use, protective clothing and research area, and requires studies of adequate
equipment appropriate to the type of power. The aim of such research should also
physical activity and the environment. be to answer specific questions, such as the
Protective clothing and equipment putative protective effect of physical activity,
includes footwear appropriate for the the possibility of defining a dose response and
specific activity; helmets for bicycling; so on. These questions are useful in translating
helmet, face masks, mouth guards, and epidemiological research into specific
protective pads for football. Protective recommendations.
gear and athletic equipment should be
frequently inspected, and they should be Physiological research looking at the effect
replaced if worn, damaged, or outdated. of physical activity in determining body
composition is also required. Further, the
Due importance should be given to these relationship between specific types of exercise
factors as most schools and sports trainers tend and body weight and composition, and bone
to ignore these important aspects in India. On mass can also be explored, particularly in
the whole, sports must be made an enjoyable India. While epidemiological approaches can

INDIAN PEDIATRICS 58 VOLUME 41__JANUARY 17, 2004

RECOMMENDATIONS

define relationships, the etiological framework 9. Durnin JVGA. Total energy expenditure of free-
for these must necessarily be physiological. living infants and children obtained by the doubly-
labeled water method. In: Activity, energy
Finally, research is required into the expenditure and energy requirements of infants and
effectiveness of school and home based inter- children. Ed by Schurch B, Schrimshaw NS: 1989;
ventions, on a longitudinal basis, on reducing 45-55.
the burden of childhood obesity. 10. Jacobs Jr, DR, Ainsworth BE, Hartman TJ, Leon
AS. A simultaneous evaluation of 10 commonly
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