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The role of primary care in promoting children’s physical activity
  1. J S Huang1,4,
  2. J Sallis2,
  3. K Patrick3
  1. 1
    Department of Pediatrics, University of California San Diego, La Jolla, California, USA
  2. 2
    Department of Psychology, San Diego State University, San Diego, California, USA
  3. 3
    Department of Family and Preventive Medicine, University of California San Diego, La Jolla, California, USA
  4. 4
    Division of Gastroenterology and Nutrition, Rady Children’s Hospital, San Diego, California, USA
  1. Dr K Patrick, Professor of Family and Preventive Medicine, University of California, San Diego, 9500 Gilman Drive, Dept 0811, La Jolla, CA 92093-0811, USA; kpatrick{at}ucsd.edu

Abstract

Regular physical activity enhances health during childhood and adolescence and is important in setting the stage for participation in physical activity across the lifespan. Physician–patient interactions during childhood and adolescence provide important opportunities for clinicians to influence physical activity behaviours. This article reviews current physical activity recommendations for youth and the wide range of health benefits provided to youth from engaging in regular physical activity. It also outlines a practical counselling model, the 5As approach, that can guide clinical counselling for physical activity, and reviews how an increasingly important model of practice organisation, the Care Model, can be used to promote physical activity in children and adolescents. Family, social and environmental influences on child and adolescent physical activity are also addressed.

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There is strong evidence of the health benefits of physical activity,1 including improvements in longevity, cardiovascular diseases, cardiovascular disease risk factors, diabetes, obesity, osteoporosis, immune functioning, certain types of cancer, and mental health among adults. There is also some evidence that regular physical activity can improve body composition, insulin sensitivity, hyperlipidaemia and blood pressure among obese children who engage in regular moderate to high intensity physical activity.2 Consensus emerged almost 15 years ago on recommendations for physical activity in adolescents,3 and the American Medical Association’s Guidelines for Adolescent Preventive Services recommends that all adolescents annually receive guidance about the benefits of exercise and be encouraged to engage in safe exercise on a regular basis.4 Guidelines from the United Kingdom Health Education Authority recommend 60 minutes of daily physical activity for youth.5 6 Guidelines recently released by the US Department of Health and Humans Services extend these recommendations to include muscle strengthening physical activity on at least 3 days/week and bone strengthening on at least 3 days/week.7 Objective measures suggest that less than 40% of teens are meeting the 60 minute guideline.8 Females, older adolescents, minorities and disadvantaged youth are even less likely to be meeting this recommendation.7 In addition, the latest report from the US Department of Health and Human Services demonstrates that adolescents are not achieving current moderate and vigorous physical activity goals, and evidence suggests that adolescents are reducing their participation in physical activity.7

Paediatricians, family physicians and others in primary care have many opportunities to promote physical activity among children and adolescents. In general, paediatricians are the main primary care providers for children 14 years and younger, but play a decreasing role in primary care for adolescents older than 14 years.9 Although children and adolescents visit physicians less often than do patients in other age groups, the amount of contact is extensive. The number of US physician office visits in 2001–02 for children under 15 years was 5.7 visits/year for those with private insurance and 3.3 visits/year for those covered under Medicare, Medicaid, no insurance or other.10 Overweight youth and youth with other chronic diseases modifiable by physical activity may be even more likely to visit a primary care physician compared to non-overweight children.11 In addition, adolescents have indicated a willingness and desire to discuss weight issues with their healthcare provider.12 13 Physical activity during childhood and adolescence is crucial because lifetime physical activity habits are established during this period. Among a cohort of 453 23–25-year-old men who had undergone standardised fitness tests as children, better fitness scores in childhood predicted ongoing physical activity as adults.14 Thus, primary care physicians, with adequate resources and support, can play a part in the development of healthy physical activity habits among youth.

BENEFITS OF PHYSICAL ACTIVITY IN CHILDREN

Childhood and adolescence encompass a series of physical, emotional and cognitive developmental stages. Physical activity provides benefits across all of these domains; it benefits cardiovascular fitness and physical strength, improves blood lipid profile, provides greater insulin sensitivity, decreases body adiposity, increases peak bone mass, improves cognitive and brain function, and enhances psychosocial well-being.1520 The benefits of physical activity are universal for all children, including those with chronic disease and disabilities. Children with type 1 diabetes who regularly engage in physical activity show improved glycaemic control.21 Regular exercise improves quality of life, cardiovascular fitness and exercise capacity in children with asthma.22 23 The participation of children with disabilities in sports and recreational activities promotes social acceptance and community involvement, optimises physical functioning, and enhances emotional and psychological well-being.24

SPECIFIC PHYSICAL ACTIVITY RECOMMENDATIONS BY AGE

Recommended physical activity guidelines differ according to age group.25 26 For infants (birth to 12 months), safe opportunities for physical activity and sensorimotor play are necessary for mastery of motor skills. Encouraging physical activity among infants in the prone position is important for motor development and performance.27 For toddlers (1–3 years), at least 30 minutes daily of structured physical activity and 60 minutes daily of unstructured physical activity should occur for development of motor skills necessary for more complex movements. Safety remains paramount during this period, and parent modelling is similarly important in influencing how children interact with the physical world. For preschoolers (3–5 years), the physical activity requirement is for 60 minutes daily of structured physical activity and 60 minutes to several hours of daily, unstructured physical activity. For children ⩾5 years (school-aged youth), children should accumulate 60 minutes to several hours of age-appropriate moderate to vigorous physical activity on five or more days of the week.28 29 Extended (>2 hours) periods of physical inactivity should be discouraged during waking hours.28 29 Performance of a wide variety of physical activities is important for refining already learned motor skills; similarly, parent modelling is crucial for instituting physical activity as a part of the daily routine. In the case of children with cardiopulmonary restrictions and disabilities, children should be closely monitored by a medical professional and the exact nature and duration of physical activity should be modified and adapted in accordance with expert recommendations.30 31

INDIVIDUAL COUNSELLING DOES MAKE A DIFFERENCE: THE 5A APPROACH

Physician counselling on physical activity has been associated with increased duration, frequency and intensity of leisure time exercise and/or sports among adolescents.32 One approach to physical activity counselling, the 5As model, is adapted from its use in counselling for tobacco use. The 5As model recommends that physicians assess a patient’s current physical activity level; advise the patient regarding the national recommendations and patient-oriented benefits; mutually agree with the patient about a physical activity goal that is congruent with the patient’s stage of change; assist the patient with written prescriptions, printed support materials, and self-monitoring tools; and arrange for follow-up and necessary subspecialty referrals with reminders to promote behavioural change.33 However, there are no reports of studies evaluating the use of this approach to counsel children and adolescents about physical activity.

Use of formalised screening and intake tools to assess health behaviours such as physical activity can facilitate initial behaviour assessment and behaviour monitoring over time. These can reduce the time spent assessing the patient’s current physical activity status, allowing more time for individualised, tailored counseling.34 Mutually determined goals should be specific, clear and measurable, with a usual timeframe of a week for accomplishment so that participants can easily determine success and/or failure. Given the specificity of goals, goals should be realistic and small in scope to encourage the likelihood of success and thus reinforcement.35 In the case of children, structured counselling messages must be age-appropriate and be customised according to non-modifiable determinants of physical activity, such as physical (orthopaedic, neurological and cardiopulmonary) limitations, age and genetic factors.

Counselling messages should also engage parents given the important role parents play in modelling physical activities for their children and in promoting family and social environments that will foster adoption of active and healthy lifestyles.36 Parents should be asked to aid in the goal-setting and achievement process via creating home environments that encourage physical activity (ie, via modelling and/or providing positive cues and rewards for desired behaviours) and providing opportunities for physical activity (ie, going to recreational sites such as parks and walking trails). Among children, evidence to date suggests that family involvement is essential to establishing healthy lifestyles and weight management success, particularly among younger children.37

A SYSTEMS APPROACH TO IMPLEMENTING PHYSICAL ACTIVITY: THE CARE MODEL

The Care Model38 is becoming increasingly recognised as an organising framework for clinical settings dedicated to promoting healthy living. The Care Model improves overall quality health management within primary care. This model highlights self-management support, practice teams delivering clinical and behavioural management, and a well designed clinical information system. Self-management support involves training patients in problem solving and goal setting so that they are empowered to manage their own health. Disease decision support consists of making evidence-based knowledge available to all clinic staff. Finally, clinical information systems involve reminders to providers to comply with care guidelines along with physician feedback about chronic disease management performance. This healthcare network also functions within a community whose resources are mobilised to meet the needs of the patient. In this framework, patients are encouraged to participate in effective community programmes and partner with community organisations to support and fill gaps in needed services.38 Relevant resources that would be utilised by consumer patients for physical activity goals would include community activity centres and local parks. Planned visits with patients and reminder systems for clinicians improve doctors’ performance and patient outcomes.39 Care Model interventions can also reduce healthcare costs and/or lower use of healthcare services.39 Several elements of the Care Model were evaluated in a one-year primary care-based approach to improve physical activity, and sedentary and diet behaviours in adolescents.40 This programme, PACE+, was successful in increasing active days/week in boys, and reducing sedentary behaviours by almost an hour in both girls and boys.

THE ROLE OF FAMILY, SOCIAL AND PHYSICAL ENVIRONMENT

Several environmental determinants affect physical activity levels among children. Physical environment determinants include the types of play and sedentary environments, while social environment variables consist of structured or unstructured physical activity opportunities, sedentary activity opportunities, physical activity policies, and social support (including physical activity training and education) regarding physical activity behaviours.41 Parents and family have a strong influence on children’s level of physical activity, through both modelling and reinforcement of exercise behaviours, and through active determination of opportunities for activity.36 42 There is evidence that providing opportunities for exercise at home may be particularly important for girls in neighbourhoods perceived to be unsafe by parents.43

Similarly, peer engagement in physical activity is associated with performance of physical activity performance among adolescents.42 Clinical environments should also reflect a consistent health message promoting physical activity and physical fitness. Posters and reading materials which provide helpful tips on how to foster home environments that support physical activity and engage children in moderate to vigorous activities should be prominently displayed or made readily available. Televisions and other media that promote sedentary activity should be removed from waiting rooms. Lastly, staff should be educated regarding the health benefits of physical activity, made aware of promotional materials and local recreational and physical activity resources, and encouraged to promote physical activity in their daily patient interactions.

CLINICAL IMPLICATIONS

Clinicians treating patients of all ages must promote the substantial health benefits of physical activity throughout the human lifespan. Given that physical activity behaviours established during youth influence life-long participation in physical activity, the cumulative impact of physical activity counselling in childhood can be substantial. Youth should be encouraged to engage in 60 minutes of physical activity daily, to include muscle strengthening physical activity on at least 3 days/week and bone strengthening on at least 3 days/week. Use of counselling models such as the 5As outlined above, or formalised screening and intake tools by physicians can facilitate initial assessment physical activity and promotion of improved levels of physical activity over time. The Care Model provides a useful organisational framework for instituting physical activity. It must be remembered that family, physical and social environmental determinants affect physical activity levels among children.

REFERENCES

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Footnotes

  • Competing interests: JS and KP are co-owners of, and receive income from, Santech, Inc., which is developing products related to the PACE+ programme described in this paper. The terms of this arrangement have been reviewed and approved by the University of California San Diego and San Diego State University in accordance with their respective conflict of interest policies.