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EDUCATIONAL MODULE Vol. 11(6), June 2003
HYSICAL ACTIVITYFOR CHILDRENAND YOUTH
Canadians are gaining awareness of the healthbenefits of
physical activity. Behaviour change mustfollow awareness, however,
if patients are tocounter the health risks associated with
sedentaryliving.
Physicians are continually challenged to identifyeffective and
practical strategies to encourageongoing participation in
physically active pursuitsparticularly when sedentary choices for
recreationand leisure options are so popular.
To help family physicians facilitate positive changesin physical
activity levels, this module will explorethe factors that influence
physical activityparticipation, and will provide a set of practical
toolsfor interacting with children and parents.
CASES
Case 1: Jamie B., age 4, male
Jamie is a healthy youngster who is in for a checkupand
immunization update prior to starting school.[The following
questions also could apply at earlierwell-child visits anytime from
2 years on.] How could you incorporate physical activityinto the
anticipatory guidance provided at awell-care visit? How could you
counsel Jamies parents aboutenhancing their childs recommended
amountof physical activity?
Case 2: Farah W., age 8, female
Farahs mother has brought her in today, requestinga note that
her daughter be allowed to take the busto school for medical
reasons. Farah is a healthyyoungster who is doing well
academically.
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EDUCATIONAL MODULE Volume 11(6), June 2003
2
Her mother is concerned because she has to walk onekilometre to
school each way and is exhausted by thetime she gets home from
school. The school boardprovides a bus for children who live more
than onekilometre away, but will not provide it for Farah
becauseshe lives within that boundary. Farahs mother alsoexpresses
concern about her childs safety while walkingto and from school.
How could you determine if Farah is getting therecommended amount
of activity for her age?What strategies could help Farah become
morephysically active?How could you address the mothers
concernsabout Farahs walking to school?
Case 3: Rob S., age 13, male
Rob presents with a mild cold and complains aboutfeeling tired a
lot of the time. As part of the exam, younotice that he is at the
95th percentile in height and 15kg above the 95th percentile in
weight. On furtherenquiry, he appears to be sensitive about his
size. Hismain form of physical activity is "gym", which occurstwice
a week at school. Each gym period is 40 minuteslong and includes
time for changing clothes, takingattendance, and setting
out/striking equipment. Rob isalso having some problems in school
performance.
How could you use this opportunity to initiate adiscussion with
Rob about physical activity?How could you assist Rob in getting
therecommended amount of activity for his age?How could you counter
Robs reluctance tobecoming more active?
INFORMATION SECTION
Benefits of Physical Activity
1. In children and adolescents, daily physical activityhas many
benefits. A variety of studies (Level 4evidence) have shown that it
can: positively affect lean muscle mass and bone
density1,2
help decrease excess body fat3 and/or maintaina healthy body
weight4,5
improve self-esteem and decrease anxiety,depression, and
moodiness6,7
enhance academic performance8
2. Physical activity helps reduce resting blood pressurein
children and adolescents with hypertension (Level4 evidence) and
has been positively correlated with
a decrease in resting blood pressure in adults. 5,6,9
3. Because physical activity is correlated with lowerfasting
insulin and greater insulin sensitivity inchildhood (Level 4
evidence), increasing physicalactivity levels may also reduce the
risk of type 2diabetes in children.6,10
At this time, there are a limited number of large, high-quality
studies by which to more definitively evaluateother effects of
physical activity. 11
Role of Family Physicians
4. Family physicians are in a position to significantlyinfluence
the physical activity levels of their youngpatients, and they will
see more than 90% of youthsaged 5-17 years in their practice at
least once in atwo-year period.12,13
5. The optimal time for broaching the subject ofphysical
activity is during routine checkups or wellvisits. Secondary
opportunities occur duringfollow-up appointments for injuries or
illnesses,visits for chronic diseases (e.g. asthma), andphysical
examinations before participation in sportsor camp programs. 13
6. Younger children rely heavily on parental supportand
direction in becoming more physically active.Although physicians
may have concerns aboutactively promoting physical activity with
parents, aconsiderable majority of Canadian adults are
eitheralready active, taking steps to become active, or ina period
of relapse from activity.14 They are,therefore, likely to support
initiatives to increase thephysical activity of their children.
Current Recommendations
7. Adult guidelines for physical activity are notnecessarily
appropriate for children andadolescents.15 Adults frequently choose
physicalactivity that is structured, highly organized, andoften
continuous in nature. In contrast, childrensactivity is
characterized by short bursts of activity,alternating with frequent
short periods of rest.Given sufficient free time, children tend
toaccumulate a greater volume of physical movementthrough active,
unstructured play.15
8. Canadas Physical Activity Guides (Appendix 4)have tried to
de-emphasize absolute values intime spent in physical activity and
have taken theapproach of increasing accumulated time spent
inphysical activity and decreasing accumulated
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EDUCATIONAL MODULE Volume 11(6), June 2003
3
screen time (e.g., television , computer, video).16
It is recommended, however, that at least 30minutes of active
time each day be spent invigorous activities (such as running,
basketball, orsoccer).17 For optimal health benefits, other
studiessuggest as much as 2 to 2.5 hours per day of
activeincidental play (NOT continuous play) for pre-schoolor
elementary school children.6,18
Strategies for Promoting Physical Activity
For Physicians
9. Systematically Ask, Advise, Assist during routinevisits to
raise the awareness of patients and parentsabout physical activity
limits and/or lifestyle choices(a strategy devised originally for
smokers).19 Usethe Ask phase to uncover what the patientconsiders
an important benefit, and use thatinformation to drive the Advise
and Assistphases.
Ask every patient about physical activitylevels and the personal
benefits.
Advise on simple solutions to reducinginactivity.
Assist with specific recommendations forphysical activity when
asked.
10. Encourage young patients, where appropriate, to
be active during recess, at lunch, and immediatelyafter school
hours and on weekends. This strategyhas been shown to be valuable
in setting goodphysical activity patterns.20
11. Discuss with parents the time commitmentinvolved in
assisting children to be more active andin providing transportation
to appropriate sites forphysical activity such as a recreation
centre; localpark; dance, martial arts, or gymnastics studio;
orsports facility.21
12. Understand the influence of age, gender, andcultural
background to help identify at-riskpopulations and set the stage
for successfulinterventions that take into account
differentcohorts: 22 young girls who are characteristically less
active
than boys minority ethnic groups, where culturally-
appropriate opportunities may be an issue pre-adolescence, when
physical activity levels
begin to drastically decline.
13. Physicians and their staff can demonstrate supportof healthy
living and physical activity through 13 23: exhibiting posters
which advertise community
events or recreation schedules leaving a supply of take-away
copies of the
various Health Canada Physical Activityresources for Children
and for Youth (seeAppendix 3) in the waiting room
leaving help yourself physical activityprescription pads
(Appendices 5 and 6) in thewaiting room
arranging with community recreation sources todisplay their
up-to-date brochures in the waitingroom
conspicuously posting a list of local day carecentres,
recreation centres, or fitness facilitiesthat promote physical
activity for children.6
displaying on office walls photographs ofphysicians and staff
engaged in physical activityor local community fundraising
initiatives
14. Consider wearing a pedometer as way to rolemodel the
importance of physical activity. Itpotentially provides a bond
between patient andphysician, particularly if the physician
cancommiserate with the patient on challenges inmeeting the
recommended 10,000 steps per day.(See Info point 26 and Patient
Information Sheetfor more details on a pedometer). 24
15. Physicians can use their influence in communitiesto speak
out strongly in favour of quality dailyphysical education (QDPE)6,
especially if parentsfeel that school is the one safe place for
childrenand youth to get some of the recommended dailyphysical
activity.
For Parents
16. Parents are powerful physical activity role modelsfor their
children 20, with studies showing a 30% to40% positive association
with a childs beingactive25, particularly during the first decade
of life.16
17. Parents should consider being physically activewith their
children and families a top priority. 26
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4
18. A simple and effective way for parents to increasephysical
activity among their children is to ensurethat they have time to
play outdoors either duringthe day (for pre-school children) or
after school.5,21
19. As many as 75% of children engage in inactivepursuits after
school: doing homework, reading,watching television, or playing
computer or videogames. These pursuits often add up to
theequivalent of a full-time desk job (i.e., 40 hours perweek)! It
has been shown that children and youthwho are not active after
school, or are not involvedin community sports programs, are
generallysedentary.21
20. While intrinsic motivation (e.g., having fun) iscrucial to
ongoing participation, parents can useextrinsic motivators (such as
calendars, daily logs,journals, or rewards) to nurture increased
physicalactivity or a more active lifestyle. 20 Nearly half
ofparents agree that being physically active for fun ispreferable
to competition and winning for theirchildren.20
21. Therefore, activities that are selected to fosterconfidence,
competence, and, most of all,enjoyment are critical in enticing
children to bemore active.
22. Parents can take the following actions to improvephysical
activity levels: create walking school buses 27, cooperatives
to supervise physical activity, and/or car poolsto share
responsibility for transporting childrento or from activity
programs.21
lobby with the school board for a greateremphasis on daily
quality physical education(QDPE) 28 and a greater access to
facilities forunstructured play during and after schoolhours.20 28
16
approach city hall about sidewalkmaintenance, the creation of
safe cyclingroutes 21, the installation of lighting in
playgrounds16, and the building of newplaygrounds (per 20,000
people there are twiceas many golf courses as playgrounds) 29
arrange for a trained professional to superviseor monitor their
childs exercise time eithersingly (if this is financially feasible)
or as partof a group in a recreation centre.20
Table 1. Factors to consider in counseling aboutphysical
activity
FACTORS ASSOCIATED WITH PHYSICAL ACTIVITY INCHILDREN AND
YOUTH22
Children Youth (Variables can bedivided into twocategories)
time spent outdoors an inclination to be
physically active a healthy diet previous experience
with physicalactivity
access to bothfacilities andequipment
intention to bephysically active
Psychological andbehavioural: level of self-esteem
and perceivedcompetence
sensation seeking previous experience
with physical activity participation in
community sportsSocial/cultural andphysical environment parental
support support from
significant others siblings who are
physically active opportunities to be
physically active
The following are associated with a negative effecton physical
activity levels
perceived barriersto physical activity
depression inactive pursuits after
school and onweekends
Children
23. Children should naturally be more active thanadults.18 One
of the ways for children to maintaina healthy balance of caloric
intake and output is tobe physically active for at least 60 minutes
perday.15
24. Children age 4 years to 12 years respond positivelyto
activities that are FUN. They are more willing
Sample activities for parents to consider: Take your older child
to the fitness centre with
you Get involved in a program for Moms/Dads
and Tots Help coach a sport team where your child is
involved Go swimming or hiking as a family on the
weekend Walk to school with the children
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EDUCATIONAL MODULE Volume 11(6), June 2003
5
to be involved in activities they enjoy and/orpersonally select,
than in activities that theirparents may favour or think
beneficial.21
Making activity seem fun for children,therefore, is a key to
promoting participation.
25. Regular positive feedback from parents as well asphysicians
help children stick with their physicalactivity prescription or
program.15
26. Pedometers are simple to use, inexpensive,
andself-motivating devices to get older childreninvolved in their
own activity levels. 30 a. The following range of steps has
been
suggested in the literature based on a 5-daypedometer
program.30: 12,000 to 16,000 steps as a goal for
children 8-10 years;3 11,000 to 12,000 steps for
adolescents 14 to 16 years old.30
b. The disadvantage is that they do not provideintensity levels
of exercise. 30
27. Other self-monitoring tools that children couldcreate and/or
use, include: a personal log sheet for recording activity
levels, designed by children themselves usingtheir computer
skills
the poster-sized Health CanadaPhysical Activity Chart with
colourfulstickers available at no charge throughthe Health Canada
website(http://www.healthcanada.ca/paguide) orby calling
1-888-334-9769.
Youth/adolescents
28. Adolescents might be enticed into being moreactive by
experimenting with less traditional kindsof activities (e.g. rock
climbing, skateboarding,street or hip hop dancing, or kayaking)
available inthe community, through school or municipalrecreation
departments.31
29. Youth involved in organized sports, in contrast withyouth
not so involved, expend more energy inmoderate to vigorous
activities and spend less timewatching television than their less
active peers.32
30. Physicians may be able to engage adolescents insetting goals
and objectives for the Lets GetActive prescription by acknowledging
their growingdesire for independent decision making.31
THE BOTTOM LINE Seize available opportunities to promote
physical activity (at well-care visits, duringvisits for
follow-up or for minor problems).
Take advantage of the waiting room to activelypromote physical
activity.
Encourage kids to be active outdoors afterschool and on
weekends.
Involve parents both as role models andfacilitators of physical
activity for their children.
CASE COMMENTARIES
Case 1: Jamie B., age 4, male
How could you incorporate physical activity intothe anticipatory
guidance provided at a well-carevisit?
Anticipatory guidance has been a traditional part of well-baby
and well-child care. Until recently, evidence wasnot necessary for
physicians to encourage parents toensure play time for children as
it was taken for grantedthat children would play and be active.
Sadly, this is nolonger the case.
Making a personal notation about physical activity underthe
heading of Education and Advice on the RourkeBaby Record, Guide I I
I , (avai lable athttp://www.ctfphc.org) of young patients, can
serve as areminder to inquire about physical activity at
well-carevisits.
In provinces where funding does not cover well-carevisits up to
the age 5 years, physicians will need to takeadvantage of visits
for other reasons in order tointroduce the topic of physical
activity (Info point 5).The following Talking Tips, modeled after
Ask,Advise, Assist, could be helpful in a discussion with thechild
and parents (Info point 9). (See Appendix 1 forother interview
question samples)
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EDUCATIONAL MODULE Volume 11(6), June 2003
6
Talking Tips Is your child involved in active play on most,
if
not all, days of the week? Would you say that the total length
of time
accumulated in active play adds up to at least2 hours per
day?
In the past 6 months, has your child beeninvolved in community
physical activityprograms (such as swimming or childrensgymnastics
or Tee ball)?
How much television do you allow your childto watch each
day?
What active things do you do together as afamily?
Do you believe your child is active enough tobe healthy?
Adapted from Patrick, 2001 6
Depending upon the maturity level of the child, thephysician
might choose to directly ask the young patienta couple of questions
about physical activity levels. How could you counsel the parents
aboutenhancing Jamies physical activity level?
Try to determine the level of importance that the parentsplace
on physical activity and their willingness to workwith their
children at increasing physical activity. Thisinformation will
influence the guidance that you provide.
Advise Jamies parents that, for children this age, it
isreasonable to expect as much as 2 to 2.5 hours per dayof active
play for optimal growth and development. Thisplay, however, usually
is incidental and intermittentrather than planned or structured
(Info point 7) by justallowing Jamie to play outdoors for at least
part of theday (Table 1. Factors to consider in counseling
aboutphysical activity, page 4) and encouraging doingactivities he
enjoys and finds fun (Info point 24).
If neighbourhood safety is an issue, Jamies parentscan form a
block cooperative whereby parents rotateresponsibility for a group
of children in the home yard.Alternatively, this same cooperative
can take turnsgetting a group of children to preschool or
localactivities, either by walking the children to and from
thecentre or facility, or by providing transportation (Infopoint
22). Provide Jamies parents with brochures ofcommunity activities,
programs, and services(preferably available in your waiting room)
(Info point13) and suggest that they contact one of
theparticipating organizations about suitable programming.If the
cost of programs is a concern, suggest that
Jamies parents investigate municipal programs orofferings of
not-for-profit organizations like YMCAs orYWCAs, where subsidized
programs and services areavailable.
Case 2: Farah W., age 8, female
How could you determine if Farah is getting therecommended
amount of activity for her age?
The patient requesting support for something that is
notnecessarily medical always represents a difficultsituation.
Frequently, it will require some exploration ofthe issues to
understand both the child and the parentspoints of view as well as
some tact and provision ofinformation.
If Farahs mother seems concerned about a medicalcondition
causing the exhaustion, it may be necessary,at some time, to
perform a physical examination and/orother testing to provide
reassurance. Address otherbarriers to physical activity that might
be causingconcern for both Farah and her mother.
When illness has been ruled out, then Farah could beasked for
more information about her daily activityhabits.
Talking Tips What kinds of activities do you and friends
do? How much time each day do you spend in
physical education at school? Do you belong to any sports teams
either at
school or in the community? What do you do after school? What
kinds of activities do you do with your
family (brothers and sisters)? How much time do you spend
watching
television, surfing the net, or playing videogames?
(See Appendix 1 for more suggestions)
If it appears that Farah participates on school teams, isactive
at recess, and has numerous lessons (violin,ballet, gymnastics,
piano, swimming) throughout theweek, counsel Farahs mother about
the benefit ofunstructured time and creative play.
If you have determined that Farahs current level ofactivity is
insufficient to achieve the necessary healthbenefits, provide
Farahs mother with information on the
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EDUCATIONAL MODULE Volume 11(6), June 2003
7
amount of physical activity that is normal and healthy foran
8-year-old.(Appendix 4)
Note that if Farah takes 12 to 15 minutes to walk toschool (a
reasonable, moderate pace), her totalaccumulated walking time would
be 25 to 30 minutes.The daily walk to school, then, is less than
the optimalrecommendation of moderate accumulated activity perday
including 15-minute individual bouts of exerciseand Farah should
consider increasing her daily physicalactivity by 30 minutes
(Appendices 4 and 5 and Infopoint 8).
What strategies could help Farah become morephysically
active?
Ask Farah and her mother to consider purchasing apedometer to
determine if Farah is getting an adequateamount of physical
activity. Provide Farah and hermother with a Pedometer Exercise
Prescription(Appendix 7) and information about how to obtain a
freebooklet on pedometers (available from the AlbertaCentre for
Active Living, Appendix 3, # 9). Theprescription and booklet will
explain the purpose ofpedometers as well as how to undertake and
record thistype of exercise. Encourage Farahs mother to walk
andplay with her daughter and oversee her chart-keepingactivities
as a means for providing vital support andmotivating feedback (Info
point 25). As is appropriatefor an 8-year-old, the pedometer
results will provideinformation on the volume of Farahs daily
activity butnot the intensity (Info point 26). The idea behind
thestrategy is simply to get Farah more active by engagingher in a
self-monitoring, quantifiable measure to charther progress. As an
alternative strategy, help Farah choose one or twoactivities that
she really enjoys doing and that can bedone after school or on
weekends. Provide her with aCall to Action prescription (Appendix
5), and check offthe activity preferences and the recommended
increaselevels, that you have determined in prior discussion.Also
refer Farah and her mother to recreation activitiesbrochures
(preferably available in the waiting room) andsuggest they
investigate some of the communityrecreation programs that might
interest Farah, such asswimming, dancing, after-school clubs,
martial arts, ormartial arts alternatives (Info point 24). These
activitiescan be used to fulfill the goal activity requirements in
theprescription. Farah and her mother can considerparticipating in
these activities together (Info point 17).Often organizations like
the YWCA will have combinedclasses for parents and children.
How could you address the mothers concernsabout Farahs walking
to school?
If Farahs mother is concerned about her child walkingalone to
school, she could organize a neighbourhoodparent cooperative (as in
Case 1) and create a walkingschool bus (Appendix 3) where a group
of youngsterswalk together to and from school, perhaps
accompaniedby a parent who works from home (a great way toincrease
the physical activity level of the parent at thesame time). Perhaps
Farah could walk to school withother children who live in her
neighbourhood. If there isa concern that is not related to physical
capability (forexample, bullies on the way to school,
taunting),another child may be having a similar problem. AskFarahs
mother if she would consider telephoninganother mother to explore
this possibility.
Case 3: Rob S., age 13, male
How could you use this opportunity to initiate adiscussion with
Rob about physical activity?
Here is another opportunity to Ask, Assist, and Advise.During
Robs examination, brief discussion on hiscurrent physical activity
level might open withSometimes fatigue and lack of energy can
actually bethe result of not enough physical activity. Describe
forme your activity during a typical day. What activities doyou
prefer?. The written prescription could recommendthat, until the
cold abates, Rob bundle up and do two10-minute sessions of light
activity each day in thefresh air (like walking or bike riding)
until his return visitin 2 weeks. Remind him about his
personalresponsibility for getting better (Info point 30).
An intervention during an unrelated visit is typicallybrief,
simply an awareness-raising or planting-of-the-seed for a follow-up
visit in a couple of weeks (Infopoint 5). To ensure that Rob
returns to see you,schedule a follow-up appointment to discuss the
resultsof a throat swab or blood work, and Robs progress onthe
written prescription. This is an opportune time inRobs life to
intervene because physical activity levelsdrop drastically between
grades 7 and 11, and it iseasier to keep adolescents participating
in physicalactivity than it is to overcome the inertia of
inactivity.
How could you assist Rob in getting therecommended amount of
activity for his age?
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EDUCATIONAL MODULE Volume 11(6), June 2003
8
Talking Tips Including your physical education classes,
how much time did you spend in physicalactivity in the last 2
days (the last week?)
What do you and your friends usually doduring your free
time?
What do you generally do when you gethome from school?
How much time do you spend watchingtelevision, surfing the net,
or playcomputer/video games each day?
What kinds of activities do you do as afamily?
A couple of quick questions will provide a roughpicture of Robs
current physical activity levels.
Rob needs to add 30 minutes daily to his activity levelsand
decrease his screen time by 30 minutes (Info point8 and Appendix
4). Health Canada stronglyrecommends vigorous activity for at least
30 minutes ofthis daily total. As an ultimate goal for fitness
after 5months, Rob might aim at 3 or more weekly sessions
ofcontinuous moderate or vigorous activity lasting at least20
minutes each session (Appendix 4).
To engage Rob in taking responsibility for his physicalactivity,
suggest that he explore sports (such asbasketball or football)
where his size is an advantage.He also could experiment with less
traditional andcurrently cool physical activity options such as
rockclimbing, skateboarding, or kayaking (Info point 28).
Robs present size also perfectly suits a supervisedresistance
training program, where extra mass isadvantageous. Supervised
resistance training programsare available through the YMCA or YWCA,
MunicipalRecreation Centres, Public Health Department, or
localcommercial fitness centres. Rob can select from theprograms
and services offered in the brochures in thewaiting room (Info
point 13). As suggested in the Dareto Be Active prescription
(Appendix 6), Rob can trackhis activity on a computer chart or
journal that hedesigns for himself, in a daily logbook, or on a
schoolday planner. Request that Rob bring his personal trackrecord
with him to the next visit so that you mightdiscuss the results of
his prescription and his reactionto it (Info point 30). The success
that he will experiencewill positively affect his self-esteem and
improve bothhis perception of, and his actual, body image (Info
point1). These activities might also appeal to Robs friends,so that
they could participate as a group, an importantconcept (support
from significant others) in promotingphysical activity at this age
(Table 1. Factors to considerin counseling about physical activity,
page 4).
Mention information resources available to Rob throughthe
Physical Activity Guide and provide Rob with a copyof the Lets Get
Active Magazine for Youth (Appendix3). The baseline recommendations
for his Dare to beActive! prescription (Appendix 6) will be
determinedfrom the answers Rob gives to your questions about
hisphysical activity habits and preferences. If timepermits, a
couple of quick anthropometricmeasurements (e.g. waist, chest, and
upper arm) wouldprovide a measurable benchmark for comparison
atRobs follow-up appointment in a month, the typicallength of time
that it takes to adopt or discard a potentialhabit.
How could you counter Robs reluctance tobecoming more
active?
Anticipate resistance from Rob. He might say he getsplenty of
physical activity during school physicaleducation classes. Discuss
with him that the activityprovided at school is meant only as a
supplement to thephysical activity he gets at home and through
otheractivities.
Rob might better understand the relationship betweenphysical
activity and his current size if he actually seesthe chart showing
the percentile comparison of heightand weight. With an explanation
of the percentileresults, he might begin to understand the need
tobalance out his weight and his height so that they bettermatch
and that increasing physical activity in thepresence of his already
healthy diet should help createthis balance (Info point 23). This
is a good opportunityto explore Robs poor self-image.
Rob may mention that transportation to and fromactivities is an
issue. The waiting room literature willprovide low-cost activity
opportunities available atcommunity centres or municipal
facilities. Suggest thatRob pick up a copy of interesting brochures
andrecommend that he discuss his transportation issue withhis
parents. You could offer to call his parents toreinforce your
prescription recommendation, raise theissue of transportation and
suggest his parents considerlinking with other parents to create a
car pool orhelping Rob choose activities in a facility that is
withinwalking distance for Rob (Table 1. Factors to considerin
counseling about physical activity, page 4).
The Foundation for Medical Practice Education,volume 11(6):1-8,
June 2003
Production of this document has been madepossible by a financial
contribution from the
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EDUCATIONAL MODULE Volume 11(6), June 2003
9
Population Health Fund, Health Canada. The viewsexpressed herein
do not necessarily represent theofficial policies of Health
Canada.
The Foundations module team would like toacknowledge, with
thanks, the PBSG group facilitated byDr. Garth Verbonac, Surrey,
British Columbia, who pilot-tested this educational module.
We encourage you to direct your questions andcomments to the
clinical discussion bulletin boardon our website: www.fmpe.org
While every care has been taken in compiling the
informationcontained in this module, the Program cannot guarantee
itsapplicability in specific clinical situations or with individual
patients.Physicians and others should exercise their own
independentjudgement concerning patient care and treatment, based
on thespecial circumstances of each case.Anyone using the
information does so at their own risk and releasesand agrees to
indemnify The Foundation for Medical PracticeEducation and the
Practice Based Small Group Learning Programfrom any and all injury
or damage arising from such use.
Authors: Francine Lemire, CCFP, FCFPFamily PhysicianMississauga,
Ontario
J.W. Mackie, FACSM,DipSports Med, CCFPFamily PhysicianVancouver,
British Columbia
Storm Russell, PhDPsychologistWakefield, Quebec
Reviewers: Oded Bar-Or, MD, FACSMProfessor of
PediatricsHamilton, Ontario
Maureen F. Kennedy, MD,CCFP, MSc Exercise Medicine,Dip. Sport
Med.Director, Fitness MDCalgary, Alberta
Medical Editor: Richard Russek, MD, CCFPFamily
PhysicianCambridge, Ontario
Associate Editor: Lynda Cranston, Hons BAHamilton, Ontario
Medical Writer/ Dawnelle Hawes, BA, BKin, MEdResearcher:
Hamilton, Ontario
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EDUCATIONAL MODULE Volume 11(6), June 2003
10
LEVELS OF EVIDENCE
Level ofEvidence
Therapy/Prevention Prognosis Diagnosis
1a Systematic review or meta-analysis of well-designed
randomized trials using explicitcriteria for inclusion and
includingadequately large total numbers
Systematic review (with homogeneity) ofinception cohort studies
or a CDR(clinical decision rule or guide) validatedin different
populations
Systematic review (with homogeneity) ofLevel 1 diagnostic
studies; or a clinicaldecision rule validated in different
clinicalcentres
1b Large randomized trials with clear-cutresults (and low risk
of error)
Individual inception cohort study with$80% follow-up
Study with independent blind comparisonof an appropriate
spectrum of consecutivepatients
1c All or none case-series All or none case-series Absolute
positive specificity (rules indiagnosis) or negative sensitivity
(rulesout)
2a Systematic review or meta-analysis of well-designed
randomized trials using explicitcriteria for inclusion but still
with moderaterisk of error (e.g., often with
subgroupanalysis).Systematic review of cohort studies
withhomogeneity
Systematic review (with homogeneity) ofretrospective cohort
studies or untreatedcontrol groups in RCTs
Systematic review (with homogeneity) ofdiagnostic studies at 2b
level
2b Small RCT with moderate to high risk oferror [low power]:a.
Trial with high false-positive ()errorinteresting positive trend
that is not statistically significant.b. Trial with high
false-negative () erroranegative trial that could not exclude
thereal possibility of a clinically importantbenefit or difference
because of smallnumbers.Individual well-designed cohort study
Retrospective cohort study or follow-up ofuntreated control
patients in an RCT orCPG not validated in a test set
Any of: Independent blind or objectivecomparison; Study
performed in a set of non-consecutive patients, or confined to
anarrow spectrum of study individuals (orboth), all of whom have
undergone boththe diagnostic test and the referencestandard; A
diagnostic CDR not validated in a testset
2c Audit or Outcomes Research Audit or Outcomes Research
3a Systematic review of case-control studieswith homogeneity
Prospective or retrospective cohort studyof adequate size, but
with somelimitations in methodology
Systematic review with homogeneity of 3bstudies
3b Individual well-designed case-control study Study with
independent blind comparisonof an appropriate spectrum, but
thereference standard was not applied to allstudy patients;
Non-consecutive study
4 Case-series; Cohort and case-control studies that lackdefined
comparison groups and/or did notmeasure interventions &
outcomes insimilar and appropriate ways
Poor quality prognostic cohort studies inwhich sampling was
biased ormeasurement of outcomes achieved in
-
EDUCATIONAL MODULE Volume 11(6), June 2003
11
REFERENCES
1. Janz KF, Burns TL, Torner JC, Levy SM, Paulos R, Willing MC
et al. Physical activity and bone measures in young children:the
Iowa bone development study. Pediatrics 2001; 107(6):1387-1393.
Accessed at: http://home.mdconsult.com
2. Lloyd T, Chinchilli VM, Johnson-Rollings N, Kieselhorst K,
Eggli DF, Marcus R. Adult female hip bone density reflectsteenage
sports-exercise patterns but not teenage calcium intake. Pediatrics
2000; 106(1 Pt 1):40-44. PMID:10878147
3. Rowlands AV, Eston RG, Ingledew DK. Relationship between
activity levels, aerobic fitness, and body fat in 8- to
10-yr-oldchildren. J Appl Physiol 1999; 86(4):1428-1435. Accessed
on: Jan. 8, 2003 at http://www.jap.org
4. Patrick K, Sallis JF, Prochaska JJ, Lydston DD, Calfas KJ,
Zabinski MF et al. A multicomponent program for nutrition
andphysical activity change in primary care: PACE+ for adolescents.
Arch Pediatr Adolesc Med 2001; 155(8):940-946. PMID:11483123
5. Canadian Fitness and Lifestyle Research Institute (CFLRI).
Understanding Youth Physical Activity. The Research File
2000;Reference No. 00-05.
6. Bright Futures in Practice: Physical Activity. Arlington, VA:
National Center for Education in Maternal Child Health, 2001.
7. Kirkcaldy BD, Shephard RJ, Siefen RG. The relationship
between physical activity and self-image and problem behaviouramong
adolescents. Soc Psychiatry Psychiatr Epidemiol 2002;
37(11):544-550.
8. California Department of Education. New Study Supports
Physically Fit Kids Perform Better Academically.
NationalAssociation for Sport and Physical Education 2002. Accessed
on Jan. 3, 2003 at http://www.aahperd.org/naspe
9. Boreham C, Twisk J, Neville C, Savage M, Murray L, Gallagher
A. Associations between physical fitness and activitypatterns
during adolescence and cardiovascular risk factors in young
adulthood: the Northern Ireland Young Hearts Project.Int J Sports
Med 2002; 23 Suppl 1:S22-S26. PMID: 12012258
10. Schmitz KH, Jacobs DR, Jr., Hong CP, Steinberger J, Moran A,
Sinaiko AR. Association of physical activity with
insulinsensitivity in children. Int J Obes Relat Metab Disord 2002;
26(10):1310-1316. PMID: 12355326
11. Evidence for Policy and Practice (EPPI-Centre). Young people
and physical activity: a systematic review of research onbarriers
and facilitators. Information and Co-ordinating Centre, editor.
1-186. 2001. London, UK, Social Science ResearchUnit; University of
London. Accessed on Jan. 10, 2003 at : http://eppi.ioe.ac.uk
12. Craig CL, Russell SJ, Cameron C. Physical activity and the
media. What messages are Canadians receiving? 1998 mediastudy: an
inmedia analysis 1998. Canadian Fitness and Lifestyle Research
Institute1998 Capacity Study
13. Sallis JF, Prochaska JJ, Taylor WC. A review of correlates
of physical activity of children and adolescents. Med Sci
SportsExerc 2000; 32(5):963-975. PMID:10795788
14. Canadian Fitness and Lifestyle Research Institute. 2001
Physical Activity Monitor. The data for the North: Interim
report.2001 Physical Activity Monitor 2002. Accessed at:
http://www.cflri.ca
15. Corbin CB, Pangrazi RP. Guidelines for Appropriate Physical
Activity for Elementary School Children. 2003 Update.National
Association for Sport and Physical Education 2002; Position
Statement. Council for Physical Education for Children(COPEC).
Accessed on Jan.7 at http://www.aahperd.org/naspe
16. Bar-Or O. Physical Activity in Children and Youth - Practice
Based Small Group Learning Program. 23-4-2003.
PersonalCommunication
17. Health Canada. Teacher's Guide to physical activity for
youth 10-14 years of age. Canada's Physical Activity Guide
toHealthy Active Living 2002. Accessed online at
http://www.healthcanada.ca/paguide or 1-888-334-9769
18. Epstein LH, Paluch RA, Kalakanis LE, Goldfield GS, Cerny FJ,
Roemmich JN. How much activity do youth get? Aquantitative review
of heart-rate measured activity. Pediatrics 2001; 108(3):E44.
PMID:11533362
19. Pipe A. Get active about physical activity. Ask, advise,
assist: get your patients moving. Can Fam Physician 2002;
48:13-13.
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EDUCATIONAL MODULE Volume 11(6), June 2003
12
PMID:11852603
20. Canadian Fitness and Lifestyle Research Institute (CFLRI).
Helping Children to Be Active. The Research File 1999;Reference No.
99-02.
21. Sallis JF, Pate RR. Determinants of youth physical
acitivity: FITNESSGRAM Reference Guide. The FITNESSGRAMReference
Guide 2001. Accessed at: http://www.cooperinst.org
22. Canadian Fitness and Lifestyle Research Institute (CFLRI).
Influences on Children's Activity. The Research File 2001;Reference
No. 01-01.
23. Royal Australian College of General Practitioners TR.
Putting prevention into practice. A guide for the implementation in
thegeneral practice setting (Green Book), 1st edition ed.
Melbourne, Australia: RACPG, 1998. Accessed on Feb. 13, 2003 at
http://www.racgp.org.au
24. Stapleton S. Fat chance: How physicians can help patients
lighten their load. The directions are clear: Eat your vegetables.
Drink water. Exercise regularly. Still the numbers on the scale go
up. How can doctors get patients to comply?amednews.com The
Newspaper for America's Physician. 18-11-2002. Accessed on Nov. 11,
2002 at http://www.ama-assn.org
25. Sallis JF, Prochaska JJ, Taylor WC, Hill JO, Geraci JC.
Correlates of physical activity in a national sample of girls and
boysin grades 4 through 12. Health Psychol 1999; 18(4):410-415.
PMID:10431943
26. Kennedy M. Physical Activity in Youth and Children.
11-4-2003. Personal e-mail Communication.
27. Canadian Fitness and Lifestyle Research Institute (CFLRI).
Active & Safe Travel to School. The Research File
2001;Reference No. 01-09.
28. Sallis JF, Conway TL, Prochaska JJ, McKenzie TL, Marshall
SJ, Brown M. The association of school environments withyouth
physical activity. Am J Public Health 2001; 91(4):618-620.
PMID:11291375
29. Crotty MT. Parents advised to find balance between TV
viewing, Video Games, Computers, Homework and Physical Activityfor
Children. National Heart Alliance press release . 2001. Accessed on
Apr, 2003 athttp://www.irishheart.ie/news/NHApressrelease.htm
30. Tudor-Locke C. Taking steps toward increased physical
activity: Using pedometers to measure and motivate. ThePresident's
Council on Physical Fitness and Sports Research Digest 2002; Series
3(No. 17). Accessed on: Jan, 2003
athttp://www.indiana.edu/~preschal
31. Rowland TW. Adolescence: A 'Risk Factor' for Physical
Inactivity. Research Digest (President's Council on Physical
Fitnessand Sports) 1999; Series 3(No. 6). Accessed on Dec. 20, 2002
at http://fitness.gov/activity
32. Katzmarzyk P.T., Malina RM. Contribution of organized sports
participation to estimated daily energy expenditure in
youth.Pediatric Exercise Science 1998; 10(378):386.
33. Health Canada. Canada's Physical Activity Guide for
Children. Canada's Physical Activity Guide to Healthy Active
Living2002. Accessed online at http://www.healthcanada.ca/paguide
or 1-888-334-9769
34. Health Canada. Canada's Physical Activity Guide for Youth.
Canada's Physical Activity Guide to Healthy Active Living
2002.Accessed online at: http://www.healthcanada.ca/paguide or
1-888-334-9769
-
Appendix 1. SAMPLE INTERVIEW QUESTIONS, INFANT TO ADOLESCENT
Sample interview questions that might be asked during a routine
health exam of an infant (5 yrs) or anadolescent (>11 yrs)
(adapted from Patrick, 2002) 6
For the childDo you think physical activity is important? Why?
(or whynot?) Do you think you are in good shape?Do you do something
physically active most days of theweek? What time of day are you
most active? (e.g. after school,after supper, on the weekends?)What
physical activities do you really enjoy doing? Whichones do you
really dislike doing?Do you participate in physical activities as a
family? (forexample, walking, biking, hiking, skating, swimming,
orrunning?)How much time each day do you spend watching
televisionor DVDs or playing computer games?
For the parentDoes your child regularly participate in
physicalactivity (for example on most, if not all, days of
theweek?)How does your child spend his/her after school hours?What
are your childs favourite physical activities?What physical
activities does your child dislikeparticipating in?How much time
each day do you allow your child towatch television, play video
games, or watch movies?Are you physically active as a family?How
might you help your child become more active?
Appendix 2
Characteristics of Childrens Physical Activity15
Children are naturally more active than adolescents or
adults.Activities need to be of short duration to maintain a young
childs attention.Children seek concrete reasons for consistently
being active not abstract reasons such as health.Children learn
skills by being physically active and in mastering these skills,
increase in self-confidence.Self-efficacy has a strong association
with later in life adherence to a physically active
lifestyle.Skills learned in childhood will sustain leisure
activities during adulthood.High intensity activities may be
discouraging for some children.Although inactive children tend to
become inactive adults, the opposite is not necessarily true.
-
Appendix 3. RESOURCES
Free resources for children and youth
1. Health Canada. These resources are colourful and
age-appropriate. Available to everyone(1-888-334-9769) or at
http://www.healthcanada.ca/paguide
For school-age children (ages 6-9) For Youth (ages 10-14)
Gotta Move! Interactive magazine for childrenPhysical Activity
Guide for Children (single page)Physical Activity Chart &
Activity Stickers
Lets Get Active! Interactive Magazine for Youth Physical
Activity Guide for Youth (single page)
Helpful free resources for Parents2. Health Canada
(1-888-334-9769) or at http://www.healthcanada.ca/paguideFamily
Guide to Physical Activity for ChildrenFamily Guide to Physical
Activity for YouthHelping your children become more physically
active: Tips for parents and caregivers (fact sheet)
athttp://www.hc-sc.gc.ca
3. Caring for Kids. http://www.caringforkids.cps.ca or telephone
1-613-526-9397Child health information from Canadian Paediatric
Experts. Excellent resource on a wide variety of child-
andteen-rearing topics, such as:Promoting good television
habitsKeeping kids safe.Health active living.
4. Go for Green. http://www.goforgreen.caActive and Safe Routes
to School: brochure: activities one can start in the communityDid
you know? A childs ability to assess potential traffic dangers:
Fact Sheet (the Canadian Institute of ChildHealth-
CICH)Walking/Cycling School Bus: brochure: practical tips and
advice for starting.
5. Safe Kids Canada http://www.safekidscanada.ca Provides
information on safety aspects for children under 5 years and a
variety of other safety issues includingwinter, water, and
playground safety.
6. Caring for Kids Canadian Paediatric Society
http://www.caringforkids.cps.ca
7. Keep Kids Healthy Free pediatricians guide for all kinds of
parenting issues http://www.keepkindshealthy.com
Parenting Tips for newborn through adolescence including Fitness
and Exercise Guide
8. Kids Health American Academy of Family Physicians
http://www.kidshealth.org also http://www.familydoctor.org helpful
tips on a variety of topics from exercise to preventing abductions,
frombicycle safety to weight management.The Parent Package
http://www.ama-assn.org/ama/upload/mm/39/parentinfo.pdfA series of
online booklets providing parents with information about their
adolescents on 15 different topicsincluding: PHYSICAL ACTIVITY,
injuries, violence prevention, cigarettes, alcohol, illicit drugs,
depression, sex,HIV/AIDS, nutrition, making responsible choices,
growth and development, and vaccinations
9. PedometersFor information: Watch Your Step: Pedometers and
Physical Activity. WellSpring, 2003, Vol. 14(2) published bythe
Alberta Centre for Active Living. (8 pgs.) Available free of charge
at (780) 4276949 (toll-free in Alberta only: 1-800-661-4551) or
online at
http://www.centre4activeliving.ca/Publications/WellSpring/index.htm
-
How to effectively use your pedometer! Step by step guide and Q
& A. http://www.pedometer.com (Mar., 2003)
-Available at local sporting goods stores, the Running Room or
fitness equipment stores
-Bally Kids Go the Distance Pedometer, $14.99, currently
available through Avon catalogues, also online auctionsat
http://cgi.ebay.com (Mar., 2003)
Pokemon, Pikachu 2,website information
http://www.amazon.co.uk
-A variety of pedometers (including Pokemon, Pikachu 2)
available online through http://half.ebay.com/
orhttp://pages.ebay.ca/index.html (type in pedometer). Lots of
choices, including a wristwatch option.
Helpful resources, tools, fact sheets for physicians
10. Evidence-base Resource Sheets. Canadian Task Force on
Preventive Health Care (CTFPHC)http://www.ctfphc.orgRourke Baby
Records
11. Put Prevention into Practice (PPIP) Agency for Healthcare
Research and Quality (AHRQ)http://www.ahcpr.gov contains physician
preventive care fact sheets, charts, and reminder postcards
12. Putting Prevention into Practice The Royal Australian
College of General Practitioners (RACPG)a monograph on the
implementation of preventive care in practice with helpful and
practical appendiceshttp://www.racgp.org.au
-
Appendix 4
Comparison of activity guidelines: Physical activity for
children and youth
Guidelines for Appropriate Physical Activity for Elementary
School Children. Corbin & Pangrazi, 2003 15
Children (elementary school age)15 Adolescents (ages 11-21
years)15
It is recommended that children get at least 60 minutesand up to
several hours daily of accumulated activityappropriate for age and
skill level on all, or most, daysof the week.
For optimal ongoing health benefits, 50% of childrensactivities
should occur in 15- minute bouts (or more),alternating with brief
periods of rest.
Children who spend excessive time watching television,playing
computer games, or surfing the net, areunlikely to meet the minimum
physical activityguidelines above
A minimum of 30 to 60 minutes of accumulatedphysical
activity
3 or more sessions per week of activities that arecontinuous in
nature, lasting 20 minutes or more at amoderate to vigorous
intensity
Physical Activity Guidelines from Health Canada for Children and
Youth (aged 6-14 years)33,34 (See PatientInformation Sheet for
prescription)
An increase of 30- 90 minutes daily of physical activity
accumulated in 5- to 10-minute bouts of activity A minimum of 30
minutes daily (as part of the total above activity, not in addition
to it) should be spent in vigorous
activity such as running, basketball, or soccer A subsequent
decrease of 30 to 90 minutes daily of sedentary activities
-
Patient Information Sheet (Appendix 5)
LL Call to ACTION!Activity prescription for 6 to 10
year-olds
Name: _________________________ Phase (circle mth of
intervention)1 2 3 4 5
What is itCalled?
What Can I Do? How Often ? How Much MORE should I do?
ENDURANCE:
Activities thatuse ENERGY!
GG riding your bikeGG swimmingGG playground (swings, slides)GG
walking (quickly)GG tobogganing, winter playGG skating (relaxed)GG
ballet or dance class (relaxed)
Every day Increase your playtime by:9920 minutes (Phase/Mth
1)9930 minutes (Phase/Mth 2)9940 minutes (Phase/Mth 3)9950 minutes
(Phase/Mth 4)9960 minutes (Phase/Mth 5)
ENDURANCE:
HIGH ENERGYactivities!
GG riding your bike (for a longtime)
GG skating, inline skatingGG soccerGG running, joggingGG
basketball, volleyballGG energetic dancing GG hockeyGG high energy
ballet or dance
class GG _______________
Every day Increase your very active play by:9910 minutes
(Phase/Mth 1)9915 minutes (Phase/Mth 2)9920 minutes (Phase/Mth
3)9925 minutes (Phase/Mth 4)9930 minutes (Phase/Mth 5)
DECREASE TIME AT
Sitting Activities
GG sitting in front of the TVGG sitting doing computer gamesGG
sitting playing video gamesGG surfing on the internetGG
________________
Every day Decrease your sitting-in-front-of-a-screen time:9920
minutes (Phase/Mth 1)9930 minutes (Phase/Mth 2)9940 minutes
(Phase/Mth 3)9950 minutes (Phase/Mth 4)9960 minutes (Phase/Mth
5)
Adapted from: Green Prescription, Hillary Commission, Ministry
of Health, Wellington, NZ,, Canadas Physical Activity Guide
forAdapted from: Green Prescription, Hillary Commission, Ministry
of Health, Wellington, NZ,, Canadas Physical Activity Guide
forChildren, 2002, with information from the Canadian Fitness and
Lifestyle Research Institute 2001 Physical Activity
MonitorChildren, 2002, with information from the Canadian Fitness
and Lifestyle Research Institute 2001 Physical Activity Monitor
Put a sticker on your poster or fridge calendar every time you
follow all the doctors suggestions fromthe chart above.
Bring your finished calendar or poster to your doctor by the
following date:_________, 2003
Doctors Signature: _______________________ Date: __________
Feel Free to Copy this Sheet
-
Patient Information Sheet (Appendix 6)
LL Dare to be ACTIVE!Dare to be ACTIVE!Physician-Patient
Physical Activity Contract for YouthPhysician-Patient Physical
Activity Contract for Youth
Name of participant: _____________________________ Phase (mth of
intervention)1 2 3 4 5
What Can I Do? How Often? How Long Do I Do It?
ENDURANCE:
ModerateActivitiesthat useenergy
GG brisk walking (to the mall, to yourfriends, to school)
GG bike ridingGG swimmingGG exercising at homeGG skateboarding
(stop & start)GG supervised weight trainingGG bowlingGG
baseball, softballGG Alpine skiing
Every day Increase your moderate physicalactivity by:
9920 minutes (Phase/Mth 1)9930 minutes (Phase/Mth 2)9940 minutes
(Phase/Mth 3)9950 minutes (Phase/Mth 4)9960 minutes (Phase/Mth
5)
ENDURANCE:
VigorousHigh energyactivities
GG running, joggingGG bicycling (brisk & continuous)GG
basketball, volleyball GG dancing (fast)GG inline skating, boarding
(snow or
skate) (continuous)GG soccer, football GG shoveling snow, raking
leavesGG gymnastics, aerobicsGG tobogganing, ice skating
Every day Increase your vigorous activity by:
9910 minutes (Phase/Mth 1)9915 minutes (Phase/Mth 2)9920 minutes
(Phase/Mth 3)9925 minutes (Phase/Mth 4)9930 minutes (Phase/Mth
5)
DECREASETIME
SittingActivities
GG sitting in front of the TVGG sitting doing computer gamesGG
sitting playing video gamesGG surfing on the internetGG
________________
Every day Decrease your sitting-in-front-of-a-screen time:9920
minutes (Phase/Mth 1)9930 minutes (Phase/Mth 2)9940 minutes
(Phase/Mth 3)9950 minutes (Phase/Mth 4)9960 minutes (Phase/Mth
5)
Adapted from: Green Prescription, Hillary Commission, Ministry
of Health, Wellington, NZ,, Canadas Physical Activity Guide for
Youth, 2002, withAdapted from: Green Prescription, Hillary
Commission, Ministry of Health, Wellington, NZ,, Canadas Physical
Activity Guide for Youth, 2002, withinformation from the Canadian
Fitness and Lifestyle Research Institute 2001 Physical Activity
Monitorinformation from the Canadian Fitness and Lifestyle Research
Institute 2001 Physical Activity Monitor
On a computer program log of your own design, on a calendar, or
in your school planner, record the totaltime that you participate
in each of the above categories and describe how you feel during
each activitysession.
Bring in your completed scheduler to your doctor on :
___________________ (Appt date)
Signed: _______________________________ Date: __________Doctors
Signature: _______________________
Feel Free to Copy this Sheet
-
Patient Information Sheet (Appendix 7)
Name:__________________________________________
D.O.B.: _____ /_________/____________
Phone No.: (_____) - ____________________________
LL PEDOMETER EXERCISE PRESCRIPTION LL
I want you and your family to work with me to make sure you are
getting enoughphysical activity to keep you healthy, happy, and
doing well in school. This tool is afun way to discover how much
activity you are getting and to measure increases inyour activity
level toward an even healthier YOU! This is how it works.
1. For this experiment, you will need a pedometer, available at
local fitness equipment stores, sportinggoods stores, the Running
Room retail stores, or through an AVON representative (inquire
about a ABally Kids pedometer $14.99).
2. Clip the pedometer to your waist and wear it from the time
you get up until the time you go to bed.3. The pedometer will
measure every step that you take all day long: going to school,
playing at recess, at
lunch, after school, and after supper.4. At the end of each day,
record the number that is displayed on the pedometer on your Health
Canada
Physical Activity Chart (available free with stickers from
Health Canada 1-888-334-9769).5. To set your starting point
(Level), measure and record the number of steps you take each day
for 3 days.
If that number is below 10,000 steps, start at Level 1. For any
number of steps higher than 10,000, startat the closest level (e.g.
if your total is 12, 342 steps for any one day, start at level
8)
6. When you the steps you take in a day matches the goal for
your level, put a sticker on your calendar andshare this
information with your parents.
7. Dont forget to reset the pedometer to 0 (zero) each night
before going to bed, so it will be ready to puton the following
morning.
8. Challenge your family to try to keep up with you!
Pedometer Prescription Recommendations
Level Beginning of week End of week
1 10,000 10,500
2 10,500 11,000
3 11,000 11,500
4 11,500 12,000
5 12,000 12,500
6 12,500 13,000
7 13,000 13,500
8 13,500 14,000
9 14,000 15,000
10 15,000 16,000 Congratulations !!!
Bring in your completed poster with all the information on the
following date: ______________________,200_____
Signature of doctor: _________________________________Date of
prescription: ______________________, 200_____
Feel Free to Copy this Sheet