Physical activity plays an important role in children’s cardiovascular health, musculoskeletal health, mental and behavioral health, and physical, social, and cognitive development. Despite the importance in children’s lives, pediatricians are unfamiliar with assessment and guidance regarding physical activity in children. With the release of the 2018 Physical Activity Guidelines by the US Department of Health and Human Services, pediatricians play a critical role in encouraging physical activity in children through assessing physical activity and physical literacy; providing guidance toward meeting recommendations by children and their families; advocating for opportunities for physical activity for all children in schools, communities, and hospitals; setting an example and remaining physically active personally; advocating for the use of assessment tools and insurance coverage of physical activity and physical literacy screening; and incorporating physical activity assessment and prescription in medical school curricula.

The 2017 Youth Risk Behavior Survey (YRBS) revealed that only 26.1% of American adolescents reported levels of activity consistent with current guidelines, and 15.4% of students reported not being physically active for at least 1 hour on a single day in the previous week.1  With the exception of increased sports participation among high school female students, overall youth physical activity levels have decreased.2  The lowest rates of physical activity occur among adolescent girls, children and youth with special health care needs (CYSHCN), and youth of minority status; rates of inactivity increased with age.1,3  Although only approximately one-fourth of children report meeting physical activity guidelines, objective measurement of activity by accelerometer reveals that less than half of children and 8% of adolescents were meeting the 2008 Physical Activity Guidelines from the US Department of Health and Human Services of 60 minutes daily of moderate-to-vigorous physical activity (MVPA) as recently as 2016.1,4,5  With rates of obesity rising over the last decades, annual relative increases of 4.8% in the incidence of type 2 diabetes mellitus,6  and declines in estimated life expectancy at time of birth since 1993, the role of physical activity on child, and later adult, health remains an important component of preventive care and disease treatment.7,8 

In 2006, the American Academy of Pediatrics (AAP) published the policy statement “Active Healthy Living: Prevention of Childhood Obesity through Increased Physical Activity.”9  That statement addressed not only the role of physical activity in obesity but also identification of individuals at risk for decreased physical activity, age-appropriate activity recommendations, and the role of schools in promoting activity.9  Since that time, the AAP and other organizations have published statements on the assessment, prevention, and treatment of pediatric obesity that include recommendations to promote improved nutrition and sleep, decreased sedentary time, and increased physical activity, although details regarding how to achieve physical activity recommendations are limited.1013  Unfortunately, 5 years after the 2008 Physical Activity Guidelines were released, only 23% of family physicians and 33% of pediatricians were able to correctly identify current physical activity guidelines for children 6 to 18 years of age.14,15  Physical activity is a “priority topic” in Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, Fourth Edition, for every health supervision visit starting at 18 months of age, with inclusion of recommending meeting the Physical Activity Guidelines beginning at 5 years of age.16  The 2018 Physical Activity Guidelines outline the recommended physical activity levels for children and adolescents, provide guidelines for children younger than 6 years, and support the role of physical activity on not just physical health but also in development, mental health, and school performance (Table 1).17  As such, this clinical report replaces the previous statement on active healthy living, augments existing statements, highlights the role of physical activity in all children’s health, and provides guidance for physicians to better assist families in increasing physical activity.

The relationships between physical activity, cardiovascular health, and body composition have been well established. Morris et al18  demonstrated decreased rates of adult coronary heart disease in active versus sedentary employees of the London Transport Executive in 1953. In the absence of longitudinal studies assessing the impact of childhood physical activity on adult mortality, studies have confirmed the benefit of physical activity on children’s cardiorespiratory fitness, lipid profiles, insulin sensitivity, and serum glucose concentrations in individuals with obesity as well as associations with more optimal cardiovascular profiles in the most physically active children.1924  Importantly, for the developing child, aerobic activity and strength training result in increased muscle mass and decreased fat mass.21,22,25  Physical activity also increases bone density and improves balance, protecting against falls and injury both in childhood and later in life.2630  Overall, strong evidence supports that MVPA improves cardiovascular and muscular fitness, bone health, weight status, and cardiometabolic risk factor status in children and adolescents, as outlined by the 2018 Physical Activity Guidelines Advisory Committee.31 

Less widely appreciated, physical activity benefits behavioral, cognitive, and social aspects of child health. Increased physical activity has also been shown to be associated with decreased rates of smoking and fewer symptoms of depression, and increased rates of inactivity and sedentary activity can predict future alcohol and drug use in adolescents.3234  Both randomized controlled trials and systematic reviews support the effect of physical activity on academic performance, possibly even in a dose-response relationship.3541  Children who are provided opportunities to be physically active during school focus and behave better, including children with attention-deficit/hyperactivity disorder.4244  Benefits may be even greater in children with autism spectrum disorder who show decreased perseverative behavior and easier redirection after a bout of physical activity.45,46  The 2018 Physical Activity Guidelines Advisory Committee concluded that in children ages 5 to 13 years, acute bouts of physical activity and regular MVPA improve cognition, including memory, processing speed, attention, and academic performance.31 

Even more concerning than the rates of inactivity among children overall is the low rate of physical activity among CYSHCN.3  CYSHCN represent a wide range of children with chronic physical, developmental, behavioral, or emotional conditions.47  The benefits of physical activity for CYSHCN are substantial. Physical activity plays a vital role in strength, endurance, and bone health for all children and especially for children with neuromotor disorders such as spina bifida, muscular dystrophy and other myopathies, Prader-Willi syndrome, and cerebral palsy.4854  Beyond musculoskeletal benefits, activity may play a role in speech and fine motor development, possibly through opportunities for social interaction, postural control and positioning, and use of orofacial muscles required for breathing during physical activity.5560  Despite its pronounced benefits, rates of physical activity in CYSHCN are much lower than in health-normative peers.3,61  Any successful effort to increase physical activity requires approaches tailored to an individual’s unique needs.62 

Physical activity may also create unexpected benefits in children with other chronic health conditions. Children with a history of cancer experience increased rates of cardiovascular events, and physical activity has been shown to improve cardiovascular risk factors in this population.6365  Physical activity also improves immune function, which may decrease pulmonary infection, and improves weight gain in children with cystic fibrosis.6669  Physical activity benefits cardiorespiratory function in, and may be engaged in safely by, children with congenital heart disease under properly advised and supervised programs.7072 

The 2018 Physical Activity Guidelines Advisory Committee reaffirmed the 2008 Physical Activity Guidelines, which recommend children and adolescents (6–17 years of age) engage in at least 60 minutes of physical activity every day, including vigorous-intensity as well as muscle- and bone-strengthening activities, at least 3 days per week (Table 1).31  The AAP has advised that physical activity should also include a muscle-strengthening program that targets all major muscle groups, starts with no load and incrementally may add load once exercise technique is mastered, involves 2 to 3 sets of 8 to 15 repetitions, and is performed 2 to 3 days per week for at least 8 weeks.73 

The 2018 Physical Activity Guidelines Advisory Committee concluded there is strong evidence that a greater volume of physical activity among children ages 3 to 5 years of age is associated with a decreased risk of excessive weight gain and improved bone health.31  The committee concluded these children should aim to achieve at least the median level of physical activity of children this age, which is 3 hours or more of physical activity per day.31  This is consistent with other guidelines that suggest that adults should provide opportunities for free play and unstructured physical activity for children 3 to 5 years of age,15,74  including at least 180 minutes of physical activity throughout the day (approximately 15 minutes every hour while awake) that helps to develop movement skills in a variety of activities and in a variety of environments. The higher volume of activity recommendation for children 3 to 5 years of age is based on the nature of their activity being intermittent and typically of lower intensity than older children.75  Infants should be physically active several times per day, mostly through interactive floor-based play.75  The AAP clinical report “The Power of Play: A Pediatric Role in Enhancing Development in Young Children” offers guidance on appropriate approaches for young children.76 Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs is another AAP publication providing guidance for child care settings.77 

For all children and adolescents, it is important that activities are appropriate to a child’s age, enjoyable, and varied.75  Examples of child and youth physical activities as well as recommendations based on the principles of frequency, intensity, time, and type of activity are included in Tables 2 and 3.

Attention to physical literacy, defined by the Aspen Institute as “the ability, confidence, and desire to be physically active for life” may provide an opportunity to increase and sustain physical activity across childhood and adolescence.85  Ability includes competence in fundamental movement skills including throwing, catching, jumping, striking, running, kicking, agility, balance, and coordination. Fundamental movement skills emerge starting with gross motor skill development in infancy and early childhood, progress throughout early and midchildhood, and are honed in preadolescence and adolescence (see Table 4).85  Competency in fundamental movement skills is a strong predictor of both current and future physical activity levels, cardiovascular fitness, BMI, and risk of overweight and obesity.8688  Confidence, or self-efficacy in one’s ability to play sports or enjoy physical activity, develops from early positive experiences with physical play and a variety of sports that are inclusive and welcoming of all children, regardless of their abilities.85  Desire encompasses the interest and enjoyment in physical activity and movement.85 

Teenagers report the strongest facilitators of physical activity include a favorable attitude toward physical activity; motivation; perception of competence and body image; fun; influence of friends, family, and physical education teachers; and environmental physical activity opportunities.91  Higher physical literacy is associated with higher physical activity levels and cardiorespiratory fitness in children and adolescents.92,93  On the other hand, children who do not develop fundamental movement skills are unlikely to develop the confidence and desire to be active and are at increased risk for sedentary lifestyle and its associated risks, as demonstrated by children with developmental coordination disorder who experience increased rates of obesity.94,95 

Children who do not engage in regular physical activity miss out on important benefits such as improved self-esteem, leadership and team building skills, decreased stress and anxiety, decreased depression, and fun, as well as improved physical and brain health.74  Because physical activity is essential to normal pediatric development and health, the term “exercise deficit disorder” has been proposed to identify children who, for a variety of reasons, do not engage in sufficient physical activity to promote overall health.96 

Many groups experience barriers to being physically active and developing fundamental movement skills, such as girls, children of minority status, children from low-income households (rural and urban), and CYSHCN.85  If these skills do not develop, the likelihood of being physically inactive later in life increases, creating an integral role for the pediatrician in screening for physical literacy, physical activity opportunities, and exercise deficit disorder97  and referring to a youth fitness specialist, physical education teacher, or physical and/or occupational therapist because structured programming improves fitness, strength, and functional movement skills.98,99  National standards outline physical literacy as the primary purpose of physical education classes in schools.100 

The role of early physical activity and literacy on later adult health may play a role in fracture risk beyond effects of impact activities on bone density and geometry.101  Multidirectional ball sports earlier in life appear to protect against stress fractures in adolescent runners.102  Physical function or, rather, dysfunction has been found to be a contributor to adult “fragility” fracture risk.103  Because osteopenia only explains part of fracture risk, the role of sarcopenia, the loss of muscle, especially with aging, has been proposed as an important risk factor to the extent that, similar to exercise deficit disorder, the term “dysmobility syndrome” has been coined for adults, both resulting from dynapenia, the loss of muscle.104,105 

The typical preschooler spends more than 6 hours per day in sedentary activity and just under 15 minutes per day in MVPA.106  More than 20% of children watch 3 or more hours of television per day on school days,1  and the average 8- to 18-year-old spends more than 7 hours per day in front of a screen.107 

The health effects of a sedentary lifestyle are an area of intense research and emerging concern. For adults, physical inactivity is associated with increased all-cause mortality, cardiovascular disease incidence and mortality, cancer incidence and mortality, and diabetes incidence,108  among other harmful health consequences. The 2018 Physical Activity Guidelines Advisory Committee concluded that there is limited available scientific evidence linking sedentary behavior to health outcomes; however, given the high prevalence of physical inactivity in youth, especially CYSHCN, replacing some sedentary time with MVPA could improve health, given the strong association.31,109  More research is needed to better understand the effects of time spent sitting and in light-intensity physical activity among children and adolescents.110 

Although the advent of exergaming, or active video games, pose an attractive option to promote physical activity in children drawn to electronic media and video games and averse to traditional physical activity, exergaming primarily promotes only light physical activity, with few games demonstrating effectiveness in increasing activity to moderate or vigorous levels.111  Although MVPA occurs with specific games in structured settings, applicability to home settings and the ability to achieve sustained, or cumulative, durations necessary to meet physical activity guidelines has not been demonstrated.112,113 

The AAP advises that parents develop a family media use plan to help children limit screen time activities to ensure they do not replace adequate sleep, physical activity, and other behaviors essential to health.114  Likewise, Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, Fourth Edition, recommends physical activity and play as alternatives to screen time, as well as a way to promote family routine and social interaction, in addition to benefitting normal growth and development.16 

Among adults, substantial international evidence supports the use of multiprong physical activity counseling and referral strategies, particularly those linking health care and community-based resources, to improve physical activity levels.115,116  Meta-analyses and systematic reviews have shown that physician counseling (odds ratio, 1.42; 95% confidence interval, 1.17–1.73) and exercise referral systems (relative risk, 1.20; 95% confidence interval, 1.06–1.35) promote improvements in adult patients’ physical activity for up to 12 months,117120  with evidence supporting the notion that physical activity counseling can be successfully implemented in routine clinical practice121,122  and that protocols are acceptable among health care providers.123  Integration of physical activity counseling and referral strategies into adult primary care settings has also been found to be cost-effective,124128  provide early return on investment because of lower health care use and costs,129,130  and have been successfully scaled to national levels with adequate sustainability.128 

Although the experience from adult medicine shows that multicomponent intervention approaches can be effectively implemented within established primary care practices making use of existing resources and personnel, evidence on the effectiveness of physical activity promotion in pediatric settings is more limited.131  To date, most interventions have been centered on multiple health behaviors including sedentary time and healthy diet in the context of weight management. For example, the Patient-Centered Assessment and Counseling for Exercise Plus Nutrition (PACE+) intervention showed that computer-assisted, individually tailored counseling for physical activity in children 11 to 15 years of age can be effective in reducing sedentary time and improving compliance with physical activity guidelines at 12 months, particular among boys.132 

The Physical Activity Guidelines for Americans Midcourse Report assessed evidence-based recommendations to increase youth physical activity across multiple sectors.31  In this report, the authors found insufficient evidence to support specific strategies for physical activity promotion in the clinical setting.31  The 2018 Physical Activity Guidelines Advisory Committee remarked that this could be improved with more robust and standardized strategies incorporating additional team members and tools such as motivational interviewing and a specific exercise prescription.31  The committee also noted that individually focused interventions delivered in a variety of settings can successfully increase youth physical activity, especially when families and schools are incorporated into the interventions.31 

The Healthcare Effectiveness Data and Information Set measure on Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents assesses the percentage of patients 2 to 17 years of age who had an outpatient visit with a primary care provider and who had evidence of BMI percentile documentation, counseling for nutrition, and counseling for physical activity during the measurement year.133  Depending on insurance type, 60% or fewer pediatric visits contained documentation of counseling for physical activity or referral for physical activity on the basis of administrative data or medical record review that included a note indicating the date and at least one of the following activities: (1) discussion of current physical activity behaviors (eg, exercise routine, participation in sports activities, examination for sports participation); (2) checklist indicating physical activity was addressed; (3) counseling or referral for physical activity; (4) member received educational materials on physical activity; or (5) anticipatory guidance for physical activity. Examples of notations that do not count toward this requirement include “notation of ‘cleared for gym class’ alone without any documentation of a discussion” or “notation of ‘health education’ or ‘anticipatory guidance’ without any specific mention of physical activity.”133 

The US Preventive Services Task Force recommends that clinicians screen children 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral intervention that includes physical activity and nutritional counseling to promote improvement in weight status. Rated as a “B” recommendation, this strategy must be included in health plans under the Affordable Care Act’s Prevention and Health Promotion activities.134  Similarly, the AAP clinical report on obesity prevention also underscores the importance of physical activity promotion by pediatricians and other health care providers.10  Given the critical importance of play in childhood, of which physical play is one type, the AAP recommends that clinicians write a “prescription for play” at well-child visits in the first 2 years of life.76 Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, Fourth Edition, encourages play as a way to decrease screen time starting at 18 months of age, promoting behavioral management and social development starting at 2 years of age, and advancing to promotion of physical activity guidelines at 5 years of age for growth and development.16  As such, physical activity is a component of the Bright Futures health supervision priorities of social and emotional well-being, school readiness and performance, and risk-behavior reduction.16 

Early in life, opportunities for the development of physical literacy occur at home. Parents are integral, not only in role-modeling movement, but also in playing with their children to allow for acquisition of necessary skills.76  The role of parents is even more important in CYHSCN given the complexity of needs and barriers to participation that children with disabilities face.135  Free-play is the primary exposure of necessity.76  Playing catch, climbing structures and natural elements, such as boulders and trees, and tag address skills in travel, hand-eye coordination, and balance and strength through natural exploration and fun play. Organized sports are unnecessary at early ages but are beneficial for more specific skill development once a child is ready on the basis of physical, cognitive, and behavioral readiness.136  Children who engage in a variety of different activities and sports, especially those that help build fundamental movement skills such as gymnastics, swimming, and track will be more likely to develop physical literacy as well as enjoyment of physical activity and attain recommended levels of MVPA.85  Sport specialization, as outlined in the AAP statement “Sports Specialization and Intensive Training in Young Athletes,” is discouraged before puberty because there is no evidence that young children will benefit from early sport specialization in the majority of sports, and some data suggest that early specialization leads to higher rates of overuse injury and burnout from concentrated activity.83,137,138  Exposure to nature has also been shown to have its own benefits on health; thus, opportunities for play and movement outdoors, even in the smallest of green spaces, are important and create an increased appreciation of movement and nature.139,140 

In many areas, school provides the primary opportunity for physical activity and acquisition of physical literacy. In fact, the 2018 Physical Activity Guidelines Advisory Committee found strong evidence that interventions that affect multiple components of schools are effective for increasing youth physical activity, particularly among those at highest risk of physical inactivity, such as adolescent girls and children with limited access to safe and affordable activity opportunities outside of school.31  The American Heart Association calls for schools to become the central element in a community system that ensures that students participate in enough physical activity to develop healthy lifestyles.141  Developing physical education curricula that promotes enjoyment of movement and skill development is important, especially including CYSHCN, as is providing opportunities for movement before, during, and after school.142  National standards outline the role of physical education classes in physical literacy.100  It is important to recognize that in physical education classes at school, a number of factors have been shown to result in children spending less than 50% of class time engaged in MVPA.143,144  Opportunities for additional movement throughout the day through active classrooms benefit not only the child through increased physical activity but also the learning environment as a result of improved behavior.36,42,145  Opportunities for recess and physical education during school that maximize movement and minimize sedentary and/or standing time and encourage social interaction are critical.146,147  Schools also provide a safe place for physical activity before and after school that many children do not have at home, especially outside, increasing the time spent in MVPA.148150  SHAPE America, the Society of Health and Physical Educators, discourages the use and withholding of physical activity as punishment in schools.100 

In a nationally representative sample (N = 811) of US primary care physicians caring for children and adolescents (pediatrics and family medicine), most physicians reported assessing physical activity in youth using general questions about the amount of physical activity (98%).14  However, a lower proportion (66%) asked specific questions about duration, intensity, and type of physical activity, and only a minority reported using a standardized questionnaire (7%) or other written physical activity assessments (6%).14  In comparison, 98% of physicians reported regularly measuring weight objectively on a scale in the office setting.14  That the majority of pediatric primary care physicians report somehow assessing physical activity levels in their clinical practice is encouraging, but the study by Huang et al14  that revealed fewer than one-third of pediatricians could correctly identify guidelines calls into question the degree to which providers are correctly screening for insufficient physical activity or adequately counseling adolescents and their families on the recommended “dose” of physical activity for health.

Several methods have been used to assess physical activity in children and adolescents including questionnaires, activity logs, pedometers, and research-grade and consumer-oriented accelerometers. Practicality, validity, and reliability are important considerations when deciding appropriate methods to assess physical activity levels in clinical settings.120  Although physical activity is important, assessment of physical literacy (Table 4) is first necessary to quantify current activity, create appropriate goals for improvement, and allow for dose-response relationships to changes in other health parameters (and subsequent studies to demonstrate benefit or lack thereof) (Table 5). In the absence of opportunities to directly assess movement, quantification of physical activity may serve as a surrogate measure for younger children in representing opportunities for development of physical literacy. Simply asking children about their enjoyment of movement may provide insight into their physical literacy.105 

In the adult population, systematic assessment of physical activity levels in clinical settings has been established through the integration of a self-reported physical activity vital sign (PAVS) into electronic health records (EHRs).151  The PAVS has been promoted through the Exercise is Medicine initiative of the American College of Sports Medicine.115,152154  The PAVS consists of 2 questions (Fig 1), adapted from the Behavioral Risk Factor Surveillance System and validated to screen for inactivity in clinical settings.155157  Integration of the PAVS into the EHR of large health care systems resulted in greater physical activity–related counseling, weight change in adult patients with obesity, and hemoglobin A1c changes in those with diabetes.158,159  The Institute of Medicine (now National Academy of Medicine) has supported the inclusion of the PAVS and/or objective assessment of physical activity in EHRs.160 

Assessment of physical activity levels in youth via self-report is a more complex undertaking because youth are less likely to make accurate self-report assessments than adults because of developmental differences, especially in the ability to perform detailed recall and understand concepts regarding physical activity duration and intensity.161,162  In addition, youth have an activity pattern that is more variable and intermittent compared with adults.163  Furthermore, sports practices involve MVPA for only a fraction of the time, and the amount of time varies greatly by sport.164  A thorough review of physical activity assessment tools is included in the Supplemental Information.

Physicians face many barriers to implementing physical activity assessment, counseling, and referral in the clinical setting.151  Clinical visit times are short, and the list of preventive guidance to incorporate into well-child checks is long.151  Solutions will likely require interprofessional approaches and engagement with community organizations in development of tools to provide interventions and track physical activity, integration of measurements of activity into the EHR, and identification of associations with health outcomes.151  Regardless, physical activity assessment, counseling, and promotion follows the same approach as used in other areas of lifestyle change for chronic disease, yet it is applicable to all patients (Table 5).165 

Pediatricians will need efficient workflows to incorporate physical activity assessment, counseling, and referral into the clinical visit. This could be accomplished through a PAVS in the medical record, previsit questionnaires, or screening performed by support staff.151  EHR companies and health care institutions are encouraged to include tools to measure, document, report, and investigate physical activity measures and association with other health outcomes, including assessing for physical literacy. For example, the Intermountain Healthcare system developed and integrated into their EHR system a pediatric PAVS for use at preventive care visits for children ages 6 to 18 years.151  This tool combines the PACE+ validated item with the addition of questions to assess activity participation on specific settings and domains (physical education, recreation, sports, transportation, home, after school, sedentary or screen time) in an effort to facilitate compliance assessment and guide goal-setting and domain-specific counseling.151  Since 2011, the Kaiser Permanente Health System integrated into its EHR system and clinical workflows the pediatric exercise vital sign, modeled after the YRBS questions, for youth 5 to 18 years (Fig 1).166  Although not yet formally validated in children, implementing the PAVS as a part of the health visit and within the EHR represents a starting point in initiating the conversation around physical activity in primary care and assessing the potential to predict future disease risk158  as well as determining the validity of the PAVS in pediatric practice.167  Brief tools for assessing physical activity are included in Table 6 (see the Supplemental Information for a full discussion regarding the tools and methodology used to identify advantages and disadvantages of each).

Similar to adult-based approaches, once the current physical activity level of the child is understood, providers can offer more specific, developmentally tailored physical activity advice or set an appropriate incremental goal for increase in activity and can include further guidance and referral resources in the after-visit summary.120  For children identified as needing further intervention, a brief follow-up visit could be scheduled, or the patient could be referred to a community resource (such as a teacher or community center).120  In addition, support staff could receive appropriate training to elaborate on a provider’s physical activity prescription and connect patients with community and technology resources to fill the prescription.120  Special emphasis on addressing barriers for CYSHCN may be needed to assist patients and families with underlying mobility issues.168,169  Further guidance for CYSHCN may be found in the AAP clinical report “Promoting the Participation of Children With Disabilities in Sports, Recreation, and Physical Activities.”128 

Institutional support of pediatric physical therapists, occupational therapists, athletic trainers, exercise specialists, social workers, and other professionals is necessary to assist in addressing the needs of the children most at risk for inactivity, such as CYSHCN; children of minority, rural, and urban status who experience insufficient access or resources to physical activity; and adolescent girls.116,170  Ideal partnerships result in access to programs that are safe, close to home, financially feasible, fun, and culturally appropriate and offer adaptive experiences and intellectually appropriate programming (eg, Special Olympics) so that children facing barriers receive the same opportunities as their peers (Table 6).168 

Insurance companies can play a role by providing coverage for necessary services and reducing reasons for payment denials because improved physical literacy and physical activity, even for nonambulatory individuals, result in later health benefit and savings in health care expenditures.171 

Many patients, families, and community organizations look to pediatricians to provide physical activity recommendations for sports participation, modifications for children with special needs or an acute or chronic injury, and increasingly for management of many physical and behavioral conditions such as prediabetes and attention-deficit/hyperactivity disorder.172  Yet many pediatricians may feel they do not have the experience or training needed to guide their patients toward meeting physical activity recommendations. In medical school, they likely received little to no training in exercise prescription.173  Most did not fare any better in residency, with only 26% of pediatric residency programs reported having a curriculum in physical activity counseling, with the greatest barrier being the lack of faculty with training in physical activity counseling, limiting provider knowledge and self-efficacy.174176  Encouragingly, training pediatric residents in physical activity counseling has been shown to improve the physical activity of patients.177  Implementing curricula and providing education is an effective first step (Table 7), which could be expanded to continuing medical education for practicing clinicians.

Clinicians have a responsibility to model physical activity for their patients and families through their own physical activity and community engagement. Several studies have shown that physicians’ personal physical activity behaviors are an important correlate of their attitudes and clinical practice regarding physical activity.178,179  Interestingly, the greatest predictor of asking about physical activity by pediatricians is being personally “fit and healthy” themselves.180  In addition, physical activity is integral to personal well-being for the health care professional, improving quality of life and work-life balance and decreasing burnout.181184  The AAP has published a clinical report on the subject.185 

Pediatricians are encouraged to promote physical literacy and activity in children and progress toward recommended physical activity guidelines in one or more of the following ways.

  1. Assess and document gross motor skills and physical activity as appropriate at health care visits (Table 5, Fig 1).

    • Assess gross motor skill development, physical literacy, and physical activity levels at all health supervision visits, with early referral to assess and treat identified delays or deficits (Table 4). A PAVS may be a useful screening tool to guide specific counseling (Fig 1).

    • For CYSHCN, discuss physical activity prescription and any physical activity limitations with subspecialists who are sharing in a patient’s care. Clearly document a patient’s individual physical activity prescription so that other providers, therapists, caretakers, and parents can help a child implement the prescription.

    • For children who are insufficiently active, identify barriers to activity and use behavioral strategies such as motivational interviewing to help patients and families identify doable strategies to increase activity.

  2. Discuss the role and benefits of physical activity on physical and social growth and development and management of other health conditions as well as in mental health, school performance, behavioral management, and risk-behavior reduction specifically related to the patient.

  3. Encourage parents to not only “do as I say” but also “do as I do” because children who grow up in families with active parents are much more likely to be active themselves.

  4. Provide specific tools and resources to help families build skills. Assist families in overcoming barriers to physical activity by referring families to community advocates and community-based activity programs and other places to be active, such as sports clubs, recreation centers, parks, walking and biking trails, skate parks, and playgrounds.

  5. Advocate with health care organizations, insurance providers, schools, and community organizations to increase opportunities for physical activity for all children.

    • Encourage healthy child care centers and preschools to provide ample opportunities for children to move in ways that they were designed to move, that is, in frequent, short bursts.

    • Support education policies that engineer physical education and literacy back into the school day and shared use policies that allow for safe, accessible, affordable access to recreational space.

    • Support the development of programs that provide resources for physical activity of children who are hospitalized (and their siblings) and for children needing additional resources to be physically active, such as CYSHCN and those who experience socioeconomic barriers.

  6. Identify opportunities for physical activity assessment and prescription for children facing barriers to activity. Those most at risk for inactivity include children of minority, urban, and rural status, adolescent girls, and CYSHCN. In many cases, school-based physical activity interventions are the most promising approach to increase physical activity.186 

  7. Advocate for the inclusion of physical activity assessments within EHRs and use the assessments to provide patient-specific physical activity recommendations for pediatric patients.

    • Advocate for payment from public and private payers for administration of validated physical activity assessment instruments.

    • Investigate the type and effects of physical activity on health outcomes of pediatric patients.

  8. Work with medical schools, residency programs, and health care institutions to develop curricula in exercise prescription and methods for physical activity assessment and prescription that include the recommended frequency, intensity, duration, and type of activity, taking into consideration the child’s current health, fitness, and preferences (Table 7).

Felipe Lobelo, MD, PhD

Natalie D. Muth, MD, MPH, FAAP, FACSM

Sara Hanson, PhD

Blaise A. Nemeth, MD, MS, FAAP

Cynthia R. LaBella, MD, FAAP, Chairperson

M. Alison Brooks, MD, FAAP

Greg Canty, MD, FAAP

Alex B. Diamond, DO, MPH, FAAP

William Hennrikus, MD, FAAP

Kelsey Logan, MD, MPH, FAAP

Kody Moffatt, MD, FAAP

Blaise A. Nemeth, MD, MS, FAAP

K. Brooke Pengel, MD, FAAP

Andrew R. Peterson, MD, MSPH, FAAP

Paul R. Stricker, MD, FAAP

Donald W. Bagnall – National Athletic Trainers’ Association

Anjie Emanuel, MPH

Christopher F. Bolling, MD, FAAP, Chairperson

Sarah Armstrong, MD, FAAP

Matthew Allen Haemer, MD, MPH, FAAP

Natalie D. Muth, MD, MPH, FAAP

John Rausch, MD, MPH, FAAP

Victoria Rogers, MD, FAAP

Stephanie Moore Walsh, MD, FAAP

Alyson B. Goodman, MD, MPH – Centers for Disease Control and Prevention

Mala Thapar, MPH

Drs Lobelo, Muth, Hanson, and Nemeth served as coauthors of the manuscript, providing substantial input into content and revision; and all authors approved the final manuscript as submitted.

Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

FUNDING: No external funding.

AAP

American Academy of Pediatrics

CYSHCN

children and youth with special health care needs

EHR

electronic health record

MVPA

moderate-to-vigorous physical activity

PACE+

Patient-centered Assessment and Counseling for Exercise plus Nutrition

PAVS

physical activity vital sign

YRBS

Youth Risk Behavior Survey

1
Kann
L
,
McManus
T
,
Harris
WA
, et al
.
Youth risk behavior surveillance - United States, 2015
.
MMWR Surveill Summ
.
2018
;
67
(
8
):
1
479
2
Bassett
DR
,
John
D
,
Conger
SA
,
Fitzhugh
EC
,
Coe
DP
.
Trends in physical activity and sedentary behaviors of United States youth
.
J Phys Act Health
.
2015
;
12
(
8
):
1102
1111
3
Woodmansee
C
,
Hahne
A
,
Imms
C
,
Shields
N
.
Comparing participation in physical recreation activities between children with disability and children with typical development: a secondary analysis of matched data
.
Res Dev Disabil
.
2016
;
49–50
:
268
276
4
Troiano
RP
,
Berrigan
D
,
Dodd
KW
,
Mâsse
LC
,
Tilert
T
,
McDowell
M
.
Physical activity in the United States measured by accelerometer
.
Med Sci Sports Exerc
.
2008
;
40
(
1
):
181
188
5
Li
K
,
Haynie
D
,
Lipsky
L
,
Iannotti
RJ
,
Pratt
C
,
Simons-Morton
B
.
Changes in moderate-to-vigorous physical activity among older adolescents
.
Pediatrics
.
2016
;
138
(
4
):
e20161372
6
Mayer-Davis
EJ
,
Lawrence
JM
,
Dabelea
D
, et al;
SEARCH for Diabetes in Youth Study
.
Incidence trends of type 1 and type 2 diabetes among youths, 2002-2012
.
N Engl J Med
.
2017
;
376
(
15
):
1419
1429
7
Arias
E
,
Heron
M
,
Xu
J
. United States Life Tables, 2012. In:
Natl Vital Stat Rep
, vol.
65
.
2016
:
1
65
8
Xu
J
,
Murphy
SL
,
Kochanek
KD
,
Arias
E
. Mortality in the United States, 2015. In:
NCHS Data Brief
.
2016
:
1
8
9
Council on Sports Medicine and Fitness
;
Council on School Health
.
Active healthy living: prevention of childhood obesity through increased physical activity
.
Pediatrics
.
2006
;
117
(
5
):
1834
1842
10
Daniels
SR
,
Hassink
SG
;
Committee on Nutrition
.
The role of the pediatrician in primary prevention of obesity
.
Pediatrics
.
2015
;
136
(
1
).
11
Barlow
SE
;
Expert Committee
.
Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report
.
Pediatrics
.
2007
;
120
(
suppl 4
):
S164
S192
12
Styne
DM
,
Arslanian
SA
,
Connor
EL
, et al
.
Pediatric obesity-assessment, treatment, and prevention: an Endocrine Society clinical practice guideline
.
J Clin Endocrinol Metab
.
2017
;
102
(
3
):
709
757
13
Spear
BA
,
Barlow
SE
,
Ervin
C
, et al
.
Recommendations for treatment of child and adolescent overweight and obesity
.
Pediatrics
.
2007
;
120
(
suppl 4
):
S254
S288
14
Huang
TT
,
Borowski
LA
,
Liu
B
, et al
.
Pediatricians’ and family physicians’ weight-related care of children in the U.S
.
Am J Prev Med
.
2011
;
41
(
1
):
24
32
15
US Department of Health and Human Services
.
Physical activity guidelines
.
2008
.
Available at: www.health.gov/PAGuidelines. Accessed January 7, 2013
16
Hagan
JF
Jr,
Shaw
JS
,
Duncan
PM
, eds.
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents
. 4th ed.
Elk Grove, IL
:
American Academy of Pediatrics
;
2017
17
US Department of Health and Human Services
.
Physical Activity Guidelines for Americans
. 2nd ed.
Washington, DC
:
US Department of Health and Human Services
;
2018
.
18
Morris
JN
,
Heady
JA
,
Raffle
PA
,
Roberts
CG
,
Parks
JW
.
Coronary heart-disease and physical activity of work
.
Lancet
.
1953
;
262
(
6796
):
1111
1120; concl
19
Herrmann
SD
,
Angadi
SS
.
Children’s physical activity and sedentary time and cardiometabolic risk factors
.
Clinical J Sport Med
.
2013
;
23
(
5
):
408
409
20
Belcher
BR
,
Berrigan
D
,
Papachristopoulou
A
, et al
.
Effects of interrupting children’s sedentary behaviors with activity on metabolic function: a randomized trial
.
J Clin Endocrinol Metab
.
2015
;
100
(
10
):
3735
3743
21
van der Baan-Slootweg
O
,
Benninga
MA
,
Beelen
A
, et al
.
Inpatient treatment of children and adolescents with severe obesity in the Netherlands: a randomized clinical trial
.
JAMA Pediatr
.
2014
;
168
(
9
):
807
814
22
Davis
CL
,
Pollock
NK
,
Waller
JL
, et al
.
Exercise dose and diabetes risk in overweight and obese children: a randomized controlled trial
.
JAMA
.
2012
;
308
(
11
):
1103
1112
23
Moore
JB
,
Beets
MW
,
Brazendale
K
, et al
.
Associations of vigorous-intensity physical activity with biomarkers in youth
.
Med Sci Sports Exerc
.
2017
;
49
(
7
):
1366
1374
24
Tarp
J
,
Child
A
,
White
T
, et al;
International Children’s Accelerometry Database (ICAD) Collaborators
.
Physical activity intensity, bout-duration, and cardiometabolic risk markers in children and adolescents [published correction appears in Int J Obes (Lond). 2019;43(11):2346]
.
Int J Obes (Lond)
.
2018
;
42
(
9
):
1639
1650
25
Sigal
RJ
,
Alberga
AS
,
Goldfield
GS
, et al
.
Effects of aerobic training, resistance training, or both on percentage body fat and cardiometabolic risk markers in obese adolescents: the healthy eating aerobic and resistance training in youth randomized clinical trial
.
JAMA Pediatr
.
2014
;
168
(
11
):
1006
1014
26
Hind
K
,
Burrows
M
.
Weight-bearing exercise and bone mineral accrual in children and adolescents: a review of controlled trials
.
Bone
.
2007
;
40
(
1
):
14
27
27
Wu
F
,
Callisaya
M
,
Wills
K
,
Laslett
LL
,
Jones
G
,
Winzenberg
T
.
Both baseline and change in lower limb muscle strength in younger women are independent predictors of balance in middle age: a 12-year population-based prospective study
.
J Bone Miner Res
.
2017
;
32
(
6
):
1201
1208
28
Collard
DC
,
Verhagen
EA
,
Chinapaw
MJ
,
Knol
DL
,
van Mechelen
W
.
Effectiveness of a school-based physical activity injury prevention program: a cluster randomized controlled trial
.
Arch Pediatr Adolesc Med
.
2010
;
164
(
2
):
145
150
29
MacKelvie
KJ
,
Khan
KM
,
Petit
MA
,
Janssen
PA
,
McKay
HA
.
A school-based exercise intervention elicits substantial bone health benefits: a 2-year randomized controlled trial in girls
.
Pediatrics
.
2003
;
112
(
6 pt 1
).
30
Detter
F
,
Rosengren
BE
,
Dencker
M
,
Lorentzon
M
,
Nilsson
J
,
Karlsson
MK
.
A 6-year exercise program improves skeletal traits without affecting fracture risk: a prospective controlled study in 2621 children
.
J Bone Miner Res
.
2014
;
29
(
6
):
1325
1336
31
Physical Activity Guidelines Scientific Advisory Committee
.
Physical Activity Guidelines Advisory Committee Report
.
Washington, DC
:
US Department of Health and Human Services
;
2018
32
Ali
MM
,
Amialchuk
A
,
Heller
LR
.
The influence of physical activity on cigarette smoking among adolescents: evidence from Add Health
.
Nicotine Tob Res
.
2015
;
17
(
5
):
539
545
33
Korhonen
T
,
Kujala
UM
,
Rose
RJ
,
Kaprio
J
.
Physical activity in adolescence as a predictor of alcohol and illicit drug use in early adulthood: a longitudinal population-based twin study
.
Twin Res Hum Genet
.
2009
;
12
(
3
):
261
268
34
Korczak
DJ
,
Madigan
S
,
Colasanto
M
.
Children’s physical activity and depression: a meta-analysis
.
Pediatrics
.
2017
;
139
(
4
):
e20162266
35
Van Dusen
DP
,
Kelder
SH
,
Kohl
HW
 III
,
Ranjit
N
,
Perry
CL
.
Associations of physical fitness and academic performance among schoolchildren
.
J Sch Health
.
2011
;
81
(
12
):
733
740
36
Mullender-Wijnsma
MJ
,
Hartman
E
,
de Greeff
JW
,
Doolaard
S
,
Bosker
RJ
,
Visscher
C
.
Physically active math and language lessons improve academic achievement: a cluster randomized controlled trial
.
Pediatrics
.
2016
;
137
(
3
):
e20152743
37
Ardoy
DN
,
Fernández-Rodríguez
JM
,
Jiménez-Pavón
D
,
Castillo
R
,
Ruiz
JR
,
Ortega
FB
.
A physical education trial improves adolescents’ cognitive performance and academic achievement: the EDUFIT study
.
Scand J Med Sci Sports
.
2014
;
24
(
1
):
e52
e61
38
Martin
A
,
Saunders
DH
,
Shenkin
SD
,
Sproule
J
.
Lifestyle intervention for improving school achievement in overweight or obese children and adolescents
.
Cochrane Database Syst Rev
.
2014
;(
3
):
CD009728
39
Bass
RW
,
Brown
DD
,
Laurson
KR
,
Coleman
MM
.
Physical fitness and academic performance in middle school students
.
Acta Paediatr
.
2013
;
102
(
8
):
832
837
40
Rauner
RR
,
Walters
RW
,
Avery
M
,
Wanser
TJ
.
Evidence that aerobic fitness is more salient than weight status in predicting standardized math and reading outcomes in fourth- through eighth-grade students
.
J Pediatr
.
2013
;
163
(
2
):
344
348
41
Lamming
L
,
Pears
S
,
Mason
D
, et al;
VBI Programme Team
.
What do we know about brief interventions for physical activity that could be delivered in primary care consultations? A systematic review of reviews
.
Prev Med
.
2017
;
99
:
152
163
42
Mahar
MT
.
Impact of short bouts of physical activity on attention-to-task in elementary school children
.
Prev Med
.
2011
;
52
(
suppl 1
):
S60
S64
43
Carlson
JA
,
Engelberg
JK
,
Cain
KL
, et al
.
Implementing classroom physical activity breaks: associations with student physical activity and classroom behavior
.
Prev Med
.
2015
;
81
:
67
72
44
Silva
AP
,
Prado
SO
,
Scardovelli
TA
,
Boschi
SR
,
Campos
LC
,
Frère
AF
.
Measurement of the effect of physical exercise on the concentration of individuals with ADHD
.
PLoS One
.
2015
;
10
(
3
):
e0122119
45
Neely
L
,
Rispoli
M
,
Gerow
S
,
Ninci
J
.
Effects of antecedent exercise on academic engagement and stereotypy during instruction
.
Behav Modif
.
2015
;
39
(
1
):
98
116
46
Oriel
KN
,
George
CL
,
Peckus
R
,
Semon
A
.
The effects of aerobic exercise on academic engagement in young children with autism spectrum disorder
.
Pediatr Phys Ther
.
2011
;
23
(
2
):
187
193
47
McPherson
M
,
Arango
P
,
Fox
H
, et al
.
A new definition of children with special health care needs
.
Pediatrics
.
1998
;
102
(
1 pt 1
):
137
140
48
Schoenmakers
MA
,
de Groot
JF
,
Gorter
JW
,
Hillaert
JL
,
Helders
PJ
,
Takken
T
.
Muscle strength, aerobic capacity and physical activity in independent ambulating children with lumbosacral spina bifida
.
Disabil Rehabil
.
2009
;
31
(
4
):
259
266
49
Jansen
M
,
van Alfen
N
,
Geurts
AC
,
de Groot
IJ
.
Assisted bicycle training delays functional deterioration in boys with Duchenne muscular dystrophy: the randomized controlled trial “no use is disuse”
.
Neurorehabil Neural Repair
.
2013
;
27
(
9
):
816
827
50
Voet
NB
,
van der Kooi
EL
,
Riphagen
II
,
Lindeman
E
,
van Engelen
BG
,
Geurts
AC
.
Strength training and aerobic exercise training for muscle disease
.
Cochrane Database Syst Rev
.
2010
;(
1
):
CD003907
51
Reus
L
,
Pillen
S
,
Pelzer
BJ
, et al
.
Growth hormone therapy, muscle thickness, and motor development in Prader-Willi syndrome: an RCT
.
Pediatrics
.
2014
;
134
(
6
).
52
Chad
KE
,
Bailey
DA
,
McKay
HA
,
Zello
GA
,
Snyder
RE
.
The effect of a weight-bearing physical activity program on bone mineral content and estimated volumetric density in children with spastic cerebral palsy
.
J Pediatr
.
1999
;
135
(
1
):
115
117
53
Henderson
RC
,
Lark
RK
,
Gurka
MJ
, et al
.
Bone density and metabolism in children and adolescents with moderate to severe cerebral palsy
.
Pediatrics
.
2002
;
110
(
1 pt 1
).
54
Szalay
EA
,
Cheema
A
.
Children with spina bifida are at risk for low bone density
.
Clin Orthop Relat Res
.
2011
;
469
(
5
):
1253
1257
55
Coleman
A
,
Weir
KA
,
Ware
RS
,
Boyd
RN
.
Relationship between communication skills and gross motor function in preschool-aged children with cerebral palsy
.
Arch Phys Med Rehabil
.
2013
;
94
(
11
):
2210
2217
56
Visscher
C
,
Houwen
S
,
Scherder
EJ
,
Moolenaar
B
,
Hartman
E
.
Motor profile of children with developmental speech and language disorders
.
Pediatrics
.
2007
;
120
(
1
).
57
Oudgenoeg-Paz
O
,
Volman
MC
,
Leseman
PP
.
Attainment of sitting and walking predicts development of productive vocabulary between ages 16 and 28 months
.
Infant Behav Dev
.
2012
;
35
(
4
):
733
736
58
Oudgenoeg-Paz
O
,
Volman
MC
,
Leseman
PP
.
First steps into language? Examining the specific longitudinal relations between walking, exploration and linguistic skills
.
Front Psychol
.
2016
;
7
:
1458
59
Apkon
SD
,
Grady
R
,
Hart
S
, et al
.
Advances in the care of children with spina bifida
.
Adv Pediatr
.
2014
;
61
(
1
):
33
74
60
Casey
AF
,
Emes
C
.
The effects of swim training on respiratory aspects of speech production in adolescents with down syndrome
.
Adapt Phys Activ Q
.
2011
;
28
(
4
):
326
341
61
Pan
CY
,
Tsai
CL
,
Chu
CH
,
Sung
MC
,
Ma
WY
,
Huang
CY
.
Objectively measured physical activity and health-related physical fitness in secondary school-aged male students with autism spectrum disorders
.
Phys Ther
.
2016
;
96
(
4
):
511
520
62
Murphy
NA
,
Carbone
PS
;
American Academy of Pediatrics Council on Children With Disabilities
.
Promoting the participation of children with disabilities in sports, recreation, and physical activities
.
Pediatrics
.
2008
;
121
(
5
):
1057
1061
63
Mulrooney
DA
,
Yeazel
MW
,
Kawashima
T
, et al
.
Cardiac outcomes in a cohort of adult survivors of childhood and adolescent cancer: retrospective analysis of the Childhood Cancer Survivor Study cohort
.
BMJ
.
2009
;
339
:
b4606
64
Järvelä
LS
,
Kemppainen
J
,
Niinikoski
H
, et al
.
Effects of a home-based exercise program on metabolic risk factors and fitness in long-term survivors of childhood acute lymphoblastic leukemia
.
Pediatr Blood Cancer
.
2012
;
59
(
1
):
155
160
65
Järvelä
LS
,
Niinikoski
H
,
Heinonen
OJ
,
Lähteenmäki
PM
,
Arola
M
,
Kemppainen
J
.
Endothelial function in long-term survivors of childhood acute lymphoblastic leukemia: effects of a home-based exercise program
.
Pediatr Blood Cancer
.
2013
;
60
(
9
):
1546
1551
66
Boas
SR
,
Danduran
MJ
,
McBride
AL
,
McColley
SA
,
O’Gorman
MR
.
Postexercise immune correlates in children with and without cystic fibrosis
.
Med Sci Sports Exerc
.
2000
;
32
(
12
):
1997
2004
67
van de Weert-van Leeuwen
PB
,
Slieker
MG
,
Hulzebos
HJ
,
Kruitwagen
CL
,
van der Ent
CK
,
Arets
HG
.
Chronic infection and inflammation affect exercise capacity in cystic fibrosis
.
Eur Respir J
.
2012
;
39
(
4
):
893
898
68
van de Weert-van Leeuwen
PB
,
Hulzebos
HJ
,
Werkman
MS
, et al
.
Chronic inflammation and infection associate with a lower exercise training response in cystic fibrosis adolescents
.
Respir Med
.
2014
;
108
(
3
):
445
452
69
Selvadurai
HC
,
Blimkie
CJ
,
Meyers
N
,
Mellis
CM
,
Cooper
PJ
,
Van Asperen
PP
.
Randomized controlled study of in-hospital exercise training programs in children with cystic fibrosis
.
Pediatr Pulmonol
.
2002
;
33
(
3
):
194
200
70
Duppen
N
,
Etnel
JR
,
Spaans
L
, et al
.
Does exercise training improve cardiopulmonary fitness and daily physical activity in children and young adults with corrected tetralogy of Fallot or Fontan circulation? A randomized controlled trial
.
Am Heart J
.
2015
;
170
(
3
):
606
614
71
Takken
T
,
Giardini
A
,
Reybrouck
T
, et al
.
Recommendations for physical activity, recreation sport, and exercise training in paediatric patients with congenital heart disease: a report from the Exercise, Basic & Translational Research Section of the European Association of Cardiovascular Prevention and Rehabilitation, the European Congenital Heart and Lung Exercise Group, and the Association for European Paediatric Cardiology
.
Eur J Prev Cardiol
.
2012
;
19
(
5
):
1034
1065
72
Lantin-Hermoso
MR
,
Berger
S
,
Bhatt
AB
, et al;
Section on Cardiology
;
Cardiac Surgery
.
The care of children with congenital heart disease in their primary medical home
.
Pediatrics
.
2017
;
140
(
5
):
e20172607
73
McCambridge
TM
,
Stricker
PR
;
American Academy of Pediatrics Council on Sports Medicine and Fitness
.
Strength training by children and adolescents
.
Pediatrics
.
2008
;
121
(
4
):
835
840
74
US Department of Health and Human Services
.
Physical Activity Guidelines for Americans Midcourse Report: strategies to increase physical activity among youth
.
2012
.
75
Lipnowski
S
,
Leblanc
CM
;
Canadian Paediatric Society, Healthy Active Living and Sports Medicine Committee
.
Healthy active living: physical activity guidelines for children and adolescents
.
Paediatr Child Health
.
2012
;
17
(
4
):
209
212
76
Yogman
M
,
Garner
A
,
Hutchinson
J
,
Hirsh-Pasek
K
,
Golinkoff
RM
;
Committee on Psychosocial Aspects of Child and Family Health
;
Council on Communications and Media
.
The power of play: a pediatric role in enhancing development in young children
.
Pediatrics
.
2018
;
142
(
3
):
e20182058
77
American Academy of Pediatrics
;
American Public Health Association
;
National Resource Center for Health and Safety in Child Care and Early Education
.
Preventing Childhood Obesity in Early Care and Education: Selected Standards From Caring for Our Children: National Health and Safety Performance Standards
, 4th ed.
Itasca, IL
:
American Academy of Pediatrics
;
2019
78
Garber
CE
,
Blissmer
B
,
Deschenes
MR
, et al;
American College of Sports Medicine
.
American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise
.
Med Sci Sports Exerc
.
2011
;
43
(
7
):
1334
1359
79
Jetté
M
,
Sidney
K
,
Blümchen
G
.
Metabolic equivalents (METS) in exercise testing, exercise prescription, and evaluation of functional capacity
.
Clin Cardiol
.
1990
;
13
(
8
):
555
565
80
Conger
SA
,
Bassett
DR
.
A compendium of energy costs of physical activities for individuals who use manual wheelchairs
.
Adapt Phys Activ Q
.
2011
;
28
(
4
):
310
325
81
Clanchy
KM
,
Tweedy
SM
,
Boyd
RN
,
Trost
SG
.
Validity of accelerometry in ambulatory children and adolescents with cerebral palsy
.
Eur J Appl Physiol
.
2011
;
111
(
12
):
2951
2959
82
Butte
NF
,
Watson
KB
,
Ridley
K
, et al
.
A youth compendium of physical activities: activity codes and metabolic intensities
.
Med Sci Sports Exerc
.
2018
;
50
(
2
):
246
256
83
Brenner
JS
;
Council on Sports Medicine and Fitness
.
Sports specialization and intensive training in young athletes
.
Pediatrics
.
2016
;
138
(
3
):
e20162148
84
Denny
SA
,
Quan
L
,
Gilchrist
J
, et al;
Council on Injury, Violence, and Poison Prevention
.
Prevention of drowning
.
Pediatrics
.
2019
;
143
(
5
):
e20190850
85
The Aspen Institute
.
Physical literacy in the United States: A model, strategic plan, and call to action.
Available at: https://assets.aspeninstitute.org/content/uploads/files/content/docs/pubs/PhysicalLiteracy_AspenInstitute.pdf. Accessed January 18, 2020
86
Lubans
DR
,
Morgan
PJ
,
Cliff
DP
,
Barnett
LM
,
Okely
AD
.
Fundamental movement skills in children and adolescents: review of associated health benefits
.
Sports Med
.
2010
;
40
(
12
):
1019
1035
87
O’ Brien
W
,
Belton
S
,
Issartel
J
.
The relationship between adolescents’ physical activity, fundamental movement skills and weight status
.
J Sports Sci
.
2016
;
34
(
12
):
1159
1167
88
Jaakkola
T
,
Yli-Piipari
S
,
Huotari
P
,
Watt
A
,
Liukkonen
J
.
Fundamental movement skills and physical fitness as predictors of physical activity: a 6-year follow-up study
.
Scand J Med Sci Sports
.
2016
;
26
(
1
):
74
81
89
Centers for Disease Control and Prevention
.
CDC’s developmental milestones
.
90
US Olympic and Paralympic Committee
.
American Development Model
.
91
Martins
J
,
Marques
A
,
Sarmento
H
,
Carreiro da Costa
F
.
Adolescents’ perspectives on the barriers and facilitators of physical activity: a systematic review of qualitative studies
.
Health Educ Res
.
2015
;
30
(
5
):
742
755
92
Belanger
K
,
Barnes
JD
,
Longmuir
PE
, et al
.
The relationship between physical literacy scores and adherence to Canadian physical activity and sedentary behaviour guidelines
.
BMC Public Health
.
2018
;
18
(
suppl 2
):
1042
93
Lang
JJ
,
Chaput
JP
,
Longmuir
PE
, et al
.
Cardiorespiratory fitness is associated with physical literacy in a large sample of Canadian children aged 8 to 12 years
.
BMC Public Health
.
2018
;
18
(
suppl 2
):
1041
94
Hendrix
CG
,
Prins
MR
,
Dekkers
H
.
Developmental coordination disorder and overweight and obesity in children: a systematic review
.
Obes Rev
.
2014
;
15
(
5
):
408
423
95
Cairney
J
,
Hay
JA
,
Faught
BE
,
Hawes
R
.
Developmental coordination disorder and overweight and obesity in children aged 9-14 y
.
Int J Obes (Lond)
.
2005
;
29
(
4
):
369
372
96
Myer
GD
,
Faigenbaum
AD
,
Stracciolini
A
,
Hewett
TE
,
Micheli
LJ
,
Best
TM
.
Exercise deficit disorder in youth: a paradigm shift toward disease prevention and comprehensive care
.
Curr Sports Med Rep
.
2013
;
12
(
4
):
248
255
97
Kantomaa
MT
,
Purtsi
J
,
Taanila
AM
, et al
.
Suspected motor problems and low preference for active play in childhood are associated with physical inactivity and low fitness in adolescence
.
PLoS One
.
2011
;
6
(
1
):
e14554
98
Farhat
F
,
Masmoudi
K
,
Hsairi
I
, et al
.
The effects of 8 weeks of motor skill training on cardiorespiratory fitness and endurance performance in children with developmental coordination disorder
.
Appl Physiol Nutr Metab
.
2015
;
40
(
12
):
1269
1278
99
Faigenbaum
AD
,
Rial Rebullido
T
,
MacDonald
JP
.
The unsolved problem of paediatric physical inactivity: it’s time for a new perspective
.
Acta Paediatr
.
2018
;
107
(
11
):
1857
1859
100
Society of Health and Physical Educators
;
American Heart Association
.
2016 Shape of the Nation report: status of physical education in the USA
.
2016
.
Available at: https://www.shapeamerica.org/advocacy/son/. Accessed May 4, 2019
101
Scerpella
TA
,
Bernardoni
B
,
Wang
S
,
Rathouz
PJ
,
Li
Q
,
Dowthwaite
JN
.
Site-specific, adult bone benefits attributed to loading during youth: a preliminary longitudinal analysis
.
Bone
.
2016
;
85
:
148
159
102
Tenforde
AS
,
Sainani
KL
,
Carter Sayres
L
,
Milgrom
C
,
Fredericson
M
.
Participation in ball sports may represent a prehabilitation strategy to prevent future stress fractures and promote bone health in young athletes
.
PM R
.
2015
;
7
(
2
):
222
225
103
Cawthon
PM
,
Fullman
RL
,
Marshall
L
, et al;
Osteoporotic Fractures in Men (MrOS) Research Group
.
Physical performance and risk of hip fractures in older men
.
J Bone Miner Res
.
2008
;
23
(
7
):
1037
1044
104
Binkley
N
,
Krueger
D
,
Buehring
B
.
What’s in a name revisited: should osteoporosis and sarcopenia be considered components of “dysmobility syndrome?”
.
Osteoporos Int
.
2013
;
24
(
12
):
2955
2959
105
Faigenbaum
AD
,
Rebullido
TR
,
MacDonald
JP
.
Pediatric inactivity triad: a risky PIT
.
Curr Sports Med Rep
.
2018
;
17
(
2
):
45
47
106
Dolinsky
DH
,
Brouwer
RJ
,
Evenson
KR
,
Siega-Riz
AM
,
Østbye
T
.
Correlates of sedentary time and physical activity among preschool-aged children
.
Prev Chronic Dis
.
2011
;
8
(
6
):
A131
107
Kaiser Family Foundation
.
Generation M2: media in the lives of 8- to 18-year-olds
.
2010
.
Available at: http://kff.org/other/event/generation-m2-media-in-the-lives-of/. Accessed September 29, 2016
108
Biswas
A
,
Oh
PI
,
Faulkner
GE
, et al
.
Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis [published correction appears in Ann Intern Med. 2015;163(5):400]
.
Ann Intern Med
.
2015
;
162
(
2
):
123
132
109
Lobenius-Palmér
K
,
Sjöqvist
B
,
Hurtig-Wennlöf
A
,
Lundqvist
LO
.
Accelerometer-assessed physical activity and sedentary time in youth with disabilities
.
Adapt Phys Activ Q
.
2018
;
35
(
1
):
1
19
110
Cliff
DP
,
Hesketh
KD
,
Vella
SA
, et al
.
Objectively measured sedentary behaviour and health and development in children and adolescents: systematic review and meta-analysis
.
Obes Rev
.
2016
;
17
(
4
):
330
344
111
Biddiss
E
,
Irwin
J
.
Active video games to promote physical activity in children and youth: a systematic review
.
Arch Pediatr Adolesc Med
.
2010
;
164
(
7
):
664
672
112
Barnett
A
,
Cerin
E
,
Baranowski
T
.
Active video games for youth: a systematic review
.
J Phys Act Health
.
2011
;
8
(
5
):
724
737
113
Lamboglia
CM
,
da Silva
VT
,
de Vasconcelos Filho
JE
, et al
.
Exergaming as a strategic tool in the fight against childhood obesity: a systematic review
.
J Obes
.
2013
;
2013
:
438364
114
Council on Communications and Media
.
Media use in school-aged children and adolescents
.
Pediatrics
.
2016
;
138
(
5
):
e20162592
115
Lobelo
F
,
Stoutenberg
M
,
Hutber
A
.
The exercise is medicine global health initiative: a 2014 update
.
Br J Sports Med
.
2014
;
48
(
22
):
1627
1633
116
Vuori
IM
,
Lavie
CJ
,
Blair
SN
.
Physical activity promotion in the health care system
.
Mayo Clinic Proc
.
2013
;
88
(
12
):
1446
1461
117
Orrow
G
,
Kinmonth
AL
,
Sanderson
S
,
Sutton
S
.
Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials
.
BMJ
.
2012
;
344
:
e1389
118
Williams
NH
,
Hendry
M
,
France
B
,
Lewis
R
,
Wilkinson
C
.
Effectiveness of exercise-referral schemes to promote physical activity in adults: systematic review
.
Br J Gen Pract
.
2007
;
57
(
545
):
979
986
119
Sanchez
A
,
Bully
P
,
Martinez
C
,
Grandes
G
.
Effectiveness of physical activity promotion interventions in primary care: a review of reviews
.
Prev Med
.
2015
;
76
(
suppl
):
S56
S67
120
Lobelo
F
,
Rohm Young
D
,
Sallis
R
, et al;
American Heart Association Physical Activity Committee of the Council on Lifestyle and Cardiometabolic Health
;
Council on Epidemiology and Prevention
;
Council on Clinical Cardiology
;
Council on Genomic and Precision Medicine
;
Council on Cardiovascular Surgery and Anesthesia
;
and Stroke Council
.
Routine assessment and promotion of physical activity in healthcare settings: a scientific statement from the American Heart Association
.
Circulation
.
2018
;
137
(
18
):
e495
e522
121
Eakin
EG
,
Brown
WJ
,
Marshall
AL
,
Mummery
K
,
Larsen
E
.
Physical activity promotion in primary care: bridging the gap between research and practice
.
Am J Prev Med
.
2004
;
27
(
4
):
297
303
122
Grandes
G
,
Sanchez
A
,
Sanchez-Pinilla
RO
, et al;
PEPAF Group
.
Effectiveness of physical activity advice and prescription by physicians in routine primary care: a cluster randomized trial
.
Arch Intern Med
.
2009
;
169
(
7
):
694
701
123
Aittasalo
M
,
Miilunpalo
S
,
Kukkonen-Harjula
K
,
Pasanen
M
.
A randomized intervention of physical activity promotion and patient self-monitoring in primary health care
.
Prev Med
.
2006
;
42
(
1
):
40
46
124
Garrett
S
,
Elley
CR
,
Rose
SB
,
O’Dea
D
,
Lawton
BA
,
Dowell
AC
.
Are physical activity interventions in primary care and the community cost-effective? A systematic review of the evidence
.
Br J Gen Pract
.
2011
;
61
(
584
):
e125
e133
125
Murphy
SM
,
Edwards
RT
,
Williams
N
, et al
.
An evaluation of the effectiveness and cost effectiveness of the National Exercise Referral Scheme in Wales, UK: a randomised controlled trial of a public health policy initiative
.
J Epidemiol Community Health
.
2012
;
66
(
8
):
745
753
126
Hogg
WE
,
Zhao
X
,
Angus
D
, et al
.
The cost of integrating a physical activity counselor in the primary health care team
.
J Am Board Fam Med
.
2012
;
25
(
2
):
250
252
127
Anokye
NK
,
Lord
J
,
Fox-Rushby
J
.
Is brief advice in primary care a cost-effective way to promote physical activity?
Br J Sports Med
.
2014
;
48
(
3
):
202
206
128
Edwards
RT
,
Linck
P
,
Hounsome
N
, et al
.
Cost-effectiveness of a national exercise referral programme for primary care patients in Wales: results of a randomised controlled trial
.
BMC Public Health
.
2013
;
13
:
1021
129
Nguyen
HQ
,
Ackermann
RT
,
Maciejewski
M
, et al
.
Managed-Medicare health club benefit and reduced health care costs among older adults
.
Prev Chronic Dis
.
2008
;
5
(
1
):
A14
130
Ackermann
RT
,
Williams
B
,
Nguyen
HQ
,
Berke
EM
,
Maciejewski
ML
,
LoGerfo
JP
.
Healthcare cost differences with participation in a community-based group physical activity benefit for Medicare managed care health plan members
.
J Am Geriatr Soc
.
2008
;
56
(
8
):
1459
1465
131
Meriwether
RA
,
Lobelo
F
,
Pate
RR
.
Themed review: clinical interventions to promote physical activity in youth
.
Am J Lifestyle Med
.
2008
;
2
(
1
):
7
25
132
Patrick
K
,
Calfas
KJ
,
Norman
GJ
, et al
.
Randomized controlled trial of a primary care and home-based intervention for physical activity and nutrition behaviors: PACE+ for adolescents
.
Arch Pediatr Adolesc Med
.
2006
;
160
(
2
):
128
136
133
National Committee for Quality Assurance
.
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
.
Washington, DC
:
National Committee for Quality Assurance
134
Grossman
DC
,
Bibbins-Domingo
K
,
Curry
SJ
, et al;
US Preventive Services Task Force
.
Screening for Obesity in Children and Adolescents: US Preventive Services Task Force Recommendation Statement
.
JAMA
.
2017
;
317
(
23
):
2417
2426
135
Yazdani
S
,
Yee
CT
,
Chung
PJ
.
Factors predicting physical activity among children with special needs
.
Prev Chronic Dis
.
2013
;
10
:
E119
136
Logan
K
,
Cuff
S
;
Council on Sports Medicine and Fitness
.
Organized sports for children, preadolescents, and adolescents
.
Pediatrics
.
2019
;
143
(
6
):
e20190997
137
LaPrade
RF
,
Agel
J
,
Baker
J
, et al
.
AOSSM early sport specialization consensus statement
.
Orthop J Sports Med
.
2016
;
4
(
4
):
2325967116644241
138
Jayanthi
NA
,
LaBella
CR
,
Fischer
D
,
Pasulka
J
,
Dugas
LR
.
Sports-specialized intensive training and the risk of injury in young athletes: a clinical case-control study
.
Am J Sports Med
.
2015
;
43
(
4
):
794
801
139
Tremblay
MS
,
Gray
C
,
Babcock
S
, et al
.
Position statement on active outdoor play
.
Int J Environ Res Public Health
.
2015
;
12
(
6
):
6475
6505
140
Aggio
D
,
Gardner
B
,
Roberts
J
, et al
.
Correlates of children’s independent outdoor play: cross-sectional analyses from the Millennium Cohort Study
.
Prev Med Rep
.
2017
;
8
:
10
14
141
Pate
RR
,
Davis
MG
,
Robinson
TN
,
Stone
EJ
,
McKenzie
TL
,
Young
JC
;
American Heart Association Council on Nutrition, Physical Activity, and Metabolism (Physical Activity Committee)
;
Council on Cardiovascular Disease in the Young
;
Council on Cardiovascular Nursing
.
Promoting physical activity in children and youth: a leadership role for schools: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism (Physical Activity Committee) in collaboration with the Councils on Cardiovascular Disease in the Young and Cardiovascular Nursing
.
Circulation
.
2006
;
114
(
11
):
1214
1224
142
Jin
J
,
Yun
J
,
Agiovlasitis
S
.
Impact of enjoyment on physical activity and health among children with disabilities in schools
.
Disabil Health J
.
2018
;
11
(
1
):
14
19
143
Sutherland
R
,
Campbell
E
,
Lubans
DR
, et al
.
Physical education in secondary schools located in low-income communities: physical activity levels, lesson context and teacher interaction
.
J Sci Med Sport
.
2016
;
19
(
2
):
135
141
144
Hollis
JL
,
Williams
AJ
,
Sutherland
R
, et al
.
A systematic review and meta-analysis of moderate-to-vigorous physical activity levels in elementary school physical education lessons
.
Prev Med
.
2016
;
86
:
34
54
145
Beets
MW
,
Banda
JA
,
Erwin
HE
,
Beighle
A
.
A pictorial view of the physical activity socialization of young adolescents outside of school
.
Res Q Exerc Sport
.
2011
;
82
(
4
):
769
778
146
Dobbins
M
,
Husson
H
,
DeCorby
K
,
LaRocca
RL
.
School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18
.
Cochrane Database Syst Rev
.
2013
;(
2
):
CD007651
147
Murray
R
,
Ramstetter
C
;
Council on School Health
;
American Academy of Pediatrics
.
The crucial role of recess in school
.
Pediatrics
.
2013
;
131
(
1
):
183
188
148
Cradock
AL
,
Barrett
JL
,
Giles
CM
, et al
.
Promoting physical activity with the Out of School Nutrition and Physical Activity (OSNAP) Initiative: a cluster-randomized controlled trial
.
JAMA Pediatr
.
2016
;
170
(
2
):
155
162
149
Madsen
K
,
Thompson
H
,
Adkins
A
,
Crawford
Y
.
School-community partnerships: a cluster-randomized trial of an after-school soccer program
.
JAMA Pediatr
.
2013
;
167
(
4
):
321
326
150
Harmon
BE
.
Rethinking physical activity for children: implications for the working poor
.
Transl Behav Med
.
2017
;
7
(
1
):
69
71
151
Joy
EA
,
Lobelo
F
.
Promoting the athlete in every child: physical activity assessment and promotion in healthcare
.
Br J Sports Med
.
2017
;
51
(
3
):
143
145
152
Sallis
RE
,
Baggish
AL
,
Franklin
BA
,
Whitehead
JR
.
The call for a physical activity vital sign in clinical practice
.
Am J Med
.
2016
;
129
(
9
):
903
905
153
Sallis
R
.
Exercise is medicine: a call to action for physicians to assess and prescribe exercise
.
Phys Sportsmed
.
2015
;
43
(
1
):
22
26
154
Sallis
RE
,
Matuszak
JM
,
Baggish
AL
, et al
.
Call to action on making physical activity assessment and prescription a medical standard of care
.
Curr Sports Med Rep
.
2016
;
15
(
3
):
207
214
155
Coleman
KJ
,
Ngor
E
,
Reynolds
K
, et al
.
Initial validation of an exercise “vital sign” in electronic medical records
.
Med Sci Sports Exerc
.
2012
;
44
(
11
):
2071
2076
156
Ball
TJ
,
Joy
EA
,
Gren
LH
,
Shaw
JM
.
Concurrent validity of a self-reported physical activity “vital sign” questionnaire with adult primary care patients
.
Prev Chronic Dis
.
2016
;
13
:
E16
157
Ball
TJ
,
Joy
EA
,
Goh
TL
,
Hannon
JC
,
Gren
LH
,
Shaw
JM
.
Validity of two brief primary care physical activity questionnaires with accelerometry in clinic staff
.
Prim Health Care Res Dev
.
2015
;
16
(
1
):
100
108
158
Grant
RW
,
Schmittdiel
JA
,
Neugebauer
RS
,
Uratsu
CS
,
Sternfeld
B
.
Exercise as a vital sign: a quasi-experimental analysis of a health system intervention to collect patient-reported exercise levels
.
J Gen Intern Med
.
2014
;
29
(
2
):
341
348
159
Mann
DM
,
Palmisano
J
,
Lin
JJ
.
A pilot randomized trial of technology-assisted goal setting to improve physical activity among primary care patients with prediabetes
.
Prev Med Rep
.
2016
;
4
:
107
112
160
Institute of Medicine
.
Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 1
.
Washington, DC
:
National Academies Press
;
2014
161
Rangul
V
,
Holmen
TL
,
Kurtze
N
,
Cuypers
K
,
Midthjell
K
.
Reliability and validity of two frequently used self-administered physical activity questionnaires in adolescents
.
BMC Med Res Methodol
.
2008
;
8
:
47
162
Ekelund
U
,
Tomkinson
G
,
Armstrong
N
.
What proportion of youth are physically active? Measurement issues, levels and recent time trends
.
Br J Sports Med
.
2011
;
45
(
11
):
859
865
163
Sallis
JF
.
Self-report measures of children’s physical activity
.
J Sch Health
.
1991
;
61
(
5
):
215
219
164
Leek
D
,
Carlson
JA
,
Cain
KL
, et al
.
Physical activity during youth sports practices
.
Arch Pediatr Adolesc Med
.
2011
;
165
(
4
):
294
299
165
AuYoung
M
,
Linke
SE
,
Pagoto
S
, et al
.
Integrating physical activity in primary care practice
.
Am J Med
.
2016
;
129
(
10
):
1022
1029
166
McGlynn
EA
,
Lieu
TA
,
Durham
ML
, et al
.
Developing a data infrastructure for a learning health system: the PORTAL network
.
J Am Med Inform Assoc
.
2014
;
21
(
4
):
596
601
167
Adirim
T
,
Meade
K
,
Mistry
K
;
Council on Quality Improvement and Patient Safety
;
Committee on Practice and Ambulatory Management
.
A new era in quality measurement: the development and application of quality measures
.
Pediatrics
.
2017
;
139
(
1
):
e20163442
168
Buffart
LM
,
Westendorp
T
,
van den Berg-Emons
RJ
,
Stam
HJ
,
Roebroeck
ME
.
Perceived barriers to and facilitators of physical activity in young adults with childhood-onset physical disabilities
.
J Rehabil Med
.
2009
;
41
(
11
):
881
885
169
Shields
N
,
Synnot
A
.
Perceived barriers and facilitators to participation in physical activity for children with disability: a qualitative study
.
BMC Pediatr
.
2016
;
16
:
9
170
Bloemen
MA
,
Verschuren
O
,
van Mechelen
C
, et al
.
Personal and environmental factors to consider when aiming to improve participation in physical activity in children with spina bifida: a qualitative study
.
BMC Neurol
.
2015
;
15
:
11
171
Cradock
AL
,
Barrett
JL
,
Kenney
EL
, et al
.
Using cost-effectiveness analysis to prioritize policy and programmatic approaches to physical activity promotion and obesity prevention in childhood
.
Prev Med
.
2017
;
95
(
suppl
):
S17
S27
172
Leijon
ME
,
Stark-Ekman
D
,
Nilsen
P
, et al
.
Is there a demand for physical activity interventions provided by the health care sector? Findings from a population survey
.
BMC Public Health
.
2010
;
10
:
34
173
Connaughton
AV
,
Weiler
RM
,
Connaughton
DP
.
Graduating medical students’ exercise prescription competence as perceived by deans and directors of medical education in the United States: implications for Healthy People 2010
.
Public Health Rep
.
2001
;
116
(
3
):
226
234
174
Cardinal
BJ
,
Park
EA
,
Kim
M
,
Cardinal
MK
.
If exercise is medicine, where is exercise in medicine? Review of U.S. medical education curricula for physical activity-related content
.
J Phys Act Health
.
2015
;
12
(
9
):
1336
1343
175
Stoutenberg
M
,
Stasi
S
,
Stamatakis
E
, et al
.
Physical activity training in US medical schools: preparing future physicians to engage in primary prevention
.
Phys Sportsmed
.
2015
;
43
(
4
):
388
394
176
Goff
SL
,
Holboe
ES
,
Concato
J
.
Pediatricians and physical activity counseling: how does residency prepare them for this task?
Teach Learn Med
.
2010
;
22
(
2
):
107
111
177
Stahl
CE
,
Necheles
JW
,
Mayefsky
JH
,
Wright
LK
,
Rankin
KM
.
5-4-3-2-1 go! Coordinating pediatric resident education and community health promotion to address the obesity epidemic in children and youth
.
Clin Pediatr (Phila)
.
2011
;
50
(
3
):
215
224
178
Lobelo
F
,
Duperly
J
,
Frank
E
.
Physical activity habits of doctors and medical students influence their counselling practices
.
Br J Sports Med
.
2009
;
43
(
2
):
89
92
179
Lobelo
F
,
de Quevedo
IG
.
The evidence in support of physicians and health care providers as physical activity role models
.
Am J Lifestyle Med
.
2016
;
10
(
1
):
36
52
180
Binns
HJ
,
Mueller
MM
,
Ariza
AJ
.
Healthy and fit for prevention: the influence of clinician health and fitness on promotion of healthy lifestyles during health supervision visits
.
Clin Pediatr (Phila)
.
2007
;
46
(
9
):
780
786
181
Dyrbye
LN
,
Satele
D
,
Shanafelt
TD
.
Healthy exercise habits are associated with lower risk of burnout and higher quality of life among U.S. medical students
.
Acad Med
.
2017
;
92
(
7
):
1006
1011
182
Olson
SM
,
Odo
NU
,
Duran
AM
,
Pereira
AG
,
Mandel
JH
.
Burnout and physical activity in Minnesota internal medicine resident physicians
.
J Grad Med Educ
.
2014
;
6
(
4
):
669
674
183
Weight
CJ
,
Sellon
JL
,
Lessard-Anderson
CR
,
Shanafelt
TD
,
Olsen
KD
,
Laskowski
ER
.
Physical activity, quality of life, and burnout among physician trainees: the effect of a team-based, incentivized exercise program
.
Mayo Clin Proc
.
2013
;
88
(
12
):
1435
1442
184
Jonsdottir
IH
,
Rödjer
L
,
Hadzibajramovic
E
,
Börjesson
M
,
Ahlborg
G
 Jr.
.
A prospective study of leisure-time physical activity and mental health in Swedish health care workers and social insurance officers
.
Prev Med
.
2010
;
51
(
5
):
373
377
185
McClafferty
H
,
Brown
OW
;
Section on Integrative Medicine
;
Committee on Practice and Ambulatory Medicine
;
Section on Integrative Medicine
.
Physician health and wellness
.
Pediatrics
.
2014
;
134
(
4
):
830
835
186
Owen
MB
,
Curry
WB
,
Kerner
C
,
Newson
L
,
Fairclough
SJ
.
The effectiveness of school-based physical activity interventions for adolescent girls: a systematic review and meta-analysis
.
Prev Med
.
2017
;
105
:
237
249
187
Chinapaw
MJ
,
Mokkink
LB
,
van Poppel
MN
,
van Mechelen
W
,
Terwee
CB
.
Physical activity questionnaires for youth: a systematic review of measurement properties
.
Sports Med
.
2010
;
40
(
7
):
539
563
188
Adamo
KB
,
Prince
SA
,
Tricco
AC
,
Connor-Gorber
S
,
Tremblay
M
.
A comparison of indirect versus direct measures for assessing physical activity in the pediatric population: a systematic review
.
Int J Pediatr Obes
.
2009
;
4
(
1
):
2
27
189
Helmerhorst
HJ
,
Brage
S
,
Warren
J
,
Besson
H
,
Ekelund
U
.
A systematic review of reliability and objective criterion-related validity of physical activity questionnaires
.
Int J Behav Nutr Phys Act
.
2012
;
9
:
103
190
Cancela
JM
,
Ayán
C
,
Castro
A
.
An evaluation of questionnaires assessing physical activity levels in youth populations
.
J Child Health Care
.
2013
;
17
(
3
):
274
293
191
Biddle
SJ
,
Gorely
T
,
Pearson
N
,
Bull
FC
.
An assessment of self-reported physical activity instruments in young people for population surveillance: Project ALPHA
.
Int J Behav Nutr Phys Act
.
2011
;
8
:
1
192
Strath
SJ
,
Kaminsky
LA
,
Ainsworth
BE
, et al;
American Heart Association Physical Activity Committee of the Council on Lifestyle and Cardiometabolic Health and Cardiovascular, Exercise, Cardiac Rehabilitation and Prevention Committee of the Council on Clinical Cardiology, and Council
.
Guide to the assessment of physical activity: clinical and research applications: a scientific statement from the American Heart Association
.
Circulation
.
2013
;
128
(
20
):
2259
2279
193
Booth
ML
,
Okely
AD
,
Chey
T
,
Bauman
A
.
The reliability and validity of the physical activity questions in the WHO Health Behaviour in Schoolchildren (HBSC) survey: a population study
.
Br J Sports Med
.
2001
;
35
(
4
):
263
267
194
Crocker
PR
,
Bailey
DA
,
Faulkner
RA
,
Kowalski
KC
,
McGrath
R
.
Measuring general levels of physical activity: preliminary evidence for the Physical Activity Questionnaire for Older Children
.
Med Sci Sports Exerc
.
1997
;
29
(
10
):
1344
1349
195
Bacardi-Gascón
M
,
Reveles-Rojas
C
,
Woodward-Lopez
G
,
Crawford
P
,
Jiménez-Cruz
A
.
Assessing the validity of a physical activity questionnaire developed for parents of preschool children in Mexico
.
J Health Popul Nutr
.
2012
;
30
(
4
):
439
446
196
Brener
ND
,
Kann
L
,
McManus
T
,
Kinchen
SA
,
Sundberg
EC
,
Ross
JG
.
Reliability of the 1999 Youth Risk Behavior Survey questionnaire
.
J Adolesc Health
.
2002
;
31
(
4
):
336
342
197
Brener
ND
,
Collins
JL
,
Kann
L
,
Warren
CW
,
Williams
BI
.
Reliability of the Youth Risk Behavior Survey questionnaire
.
Am J Epidemiol
.
1995
;
141
(
6
):
575
580
198
Troped
PJ
,
Wiecha
JL
,
Fragala
MS
, et al
.
Reliability and validity of YRBS physical activity items among middle school students
.
Med Sci Sports Exerc
.
2007
;
39
(
3
):
416
425
199
Prochaska
JJ
,
Sallis
JF
,
Long
B
.
A physical activity screening measure for use with adolescents in primary care
.
Arch Pediatr Adolesc Med
.
2001
;
155
(
5
):
554
559
200
Martínez-Gómez
D
,
Martínez-De-Haro
V
,
Del-Campo
J
, et al
.
[Validity of four questionnaires to assess physical activity in Spanish adolescents] [in Spanish]
.
Gac Sanit
.
2009
;
23
(
6
):
512
517
201
Ridgers
ND
,
Timperio
A
,
Crawford
D
,
Salmon
J
.
Validity of a brief self-report instrument for assessing compliance with physical activity guidelines amongst adolescents
.
J Sci Med Sport
.
2012
;
15
(
2
):
136
141
202
Liu
Y
,
Wang
M
,
Tynjälä
J
, et al
.
Test-retest reliability of selected items of Health Behaviour in School-aged Children (HBSC) survey questionnaire in Beijing, China
.
BMC Med Res Methodol
.
2010
;
10
:
73
203
Hardie Murphy
M
,
Rowe
DA
,
Belton
S
,
Woods
CB
.
Validity of a two-item physical activity questionnaire for assessing attainment of physical activity guidelines in youth
.
BMC Public Health
.
2015
;
15
:
1080
204
Patrick
K
,
Sallis
JF
,
Prochaska
JJ
, et al
.
A multicomponent program for nutrition and physical activity change in primary care: PACE+ for adolescents
.
Arch Pediatr Adolesc Med
.
2001
;
155
(
8
):
940
946
205
World Health Organization
.
Global School-Based Student Health Survey (GSHS)
.
Geneva, Switzerland
:
World Health Organization
;
2013
206
Haug
E
,
Rasmussen
M
,
Samdal
O
, et al;
HBSC Obesity Writing Group
.
Overweight in school-aged children and its relationship with demographic and lifestyle factors: results from the WHO-Collaborative Health Behaviour in School-aged Children (HBSC) study
.
Int J Public Health
.
2009
;
54
(
suppl 2
):
167
179
207
Pate
RR
,
McIver
KL
,
Dowda
M
,
Schenkelberg
MA
,
Beets
MV
,
Distefano
C
.
EASY-an instrument for surveillance of physical activity in youth
.
Med Sci Sports Exerc
.
2018
;
50
(
6
):
1216
1223
208
Trost
SG
,
O’Neil
M
.
Clinical use of objective measures of physical activity
.
Br J Sports Med
.
2014
;
48
(
3
):
178
181
209
Guthrie
N
,
Bradlyn
A
,
Thompson
SK
, et al
.
Development of an accelerometer-linked online intervention system to promote physical activity in adolescents
.
PLoS One
.
2015
;
10
(
5
):
e0128639
210
Lobelo
F
,
Kelli
HM
,
Tejedor
SC
, et al
.
The wild wild West: a framework to integrate mHealth software applications and wearables to support physical activity assessment, counseling and interventions for cardiovascular disease risk reduction
.
Prog Cardiovasc Dis
.
2016
;
58
(
6
):
584
594
211
Paridon
SM
,
Alpert
BS
,
Boas
SR
, et al;
American Heart Association Council on Cardiovascular Disease in the Young, Committee on Atherosclerosis, Hypertension, and Obesity in Youth
.
Clinical stress testing in the pediatric age group: a statement from the American Heart Association Council on Cardiovascular Disease in the Young, Committee on Atherosclerosis, Hypertension, and Obesity in Youth
.
Circulation
.
2006
;
113
(
15
):
1905
1920
212
Welk
GJ
,
Going
SB
,
Morrow
JR
 Jr.
,
Meredith
MD
.
Development of new criterion-referenced fitness standards in the FITNESSGRAM® program: rationale and conceptual overview
.
Am J Prev Med
.
2011
;
41
(
4
suppl 2
):
S63
S67
213
Lobelo
F
,
Pate
RR
,
Dowda
M
,
Liese
AD
,
Ruiz
JR
.
Validity of cardiorespiratory fitness criterion-referenced standards for adolescents
.
Med Sci Sports Exerc
.
2009
;
41
(
6
):
1222
1229
214
Ortega
FB
,
Ruiz
JR
,
Castillo
MJ
,
Sjöström
M
.
Physical fitness in childhood and adolescence: a powerful marker of health
.
Int J Obes (Lond)
.
2008
;
32
(
1
):
1
11
215
Bai
Y
,
Saint-Maurice
PF
,
Welk
GJ
,
Allums-Featherston
K
,
Candelaria
N
,
Anderson
K
.
Prevalence of youth fitness in the United States: baseline results from the NFL PLAY 60 FITNESSGRAM Partnership Project
.
J Pediatr
.
2015
;
167
(
3
):
662
668
216
Janz
KF
,
Broffitt
B
,
Levy
SM
.
Validation evidence for the Netherlands physical activity questionnaire for young children: the Iowa Bone Development Study
.
Res Q Exerc Sport
.
2005
;
76
(
3
):
363
369
217
Chen
X
,
Sekine
M
,
Hamanishi
S
, et al
.
Validation of a self-reported physical activity questionnaire for schoolchildren
.
J Epidemiol
.
2003
;
13
(
5
):
278
287
218
Godin
G
,
Shephard
RJ
.
A simple method to assess exercise behavior in the community
.
Can J Appl Sport Sci
.
1985
;
10
(
3
):
141
146
219
Sallis
JF
,
Buono
MJ
,
Roby
JJ
,
Micale
FG
,
Nelson
JA
.
Seven-day recall and other physical activity self-reports in children and adolescents
.
Med Sci Sports Exerc
.
1993
;
25
(
1
):
99
108
220
Fulkerson
JA
,
Sherwood
NE
,
Perry
CL
,
Neumark-Sztainer
D
,
Story
M
.
Depressive symptoms and adolescent eating and health behaviors: a multifaceted view in a population-based sample
.
Prev Med
.
2004
;
38
(
6
):
865
875
221
Gao
S
,
Harnack
L
,
Schmitz
K
, et al
.
Reliability and validity of a brief tool to measure children’s physical activity
.
J Phys Act Health
.
2006
;
3
(
4
):
415
422
222
Scerpella
TA
,
Tuladhar
P
,
Kanaley
JA
.
Validation of the Godin-Shephard Questionnaire in prepubertal girls
.
Med Sci Sports Exerc
.
2002
;
34
(
5
):
845
850
223
Koo
MM
,
Rohan
TE
.
Comparison of four habitual physical activity questionnaires in girls aged 7-15 yr
.
Med Sci Sports Exerc
.
1999
;
31
(
3
):
421
427
224
Janz
KF
,
Witt
J
,
Mahoney
LT
.
The stability of children’s physical activity as measured by accelerometry and self-report
.
Med Sci Sports Exerc
.
1995
;
27
(
9
):
1326
1332
225
Treuth
MS
,
Hou
N
,
Young
DR
,
Maynard
LM
.
Validity and reliability of the Fels Physical Activity Questionnaire for children
.
Med Sci Sports Exerc
.
2005
;
37
(
3
):
488
495
226
Burdette
HL
,
Whitaker
RC
,
Daniels
SR
.
Parental report of outdoor playtime as a measure of physical activity in preschool-aged children
.
Arch Pediatr Adolesc Med
.
2004
;
158
(
4
):
353
357
227
Schmidt
GJ
,
Walkuski
JJ
,
Stensel
DJ
.
The Singapore Youth Coronary Risk and Physical Activity study
.
Med Sci Sports Exerc
.
1998
;
30
(
1
):
105
113
228
Ihmels
MA
,
Welk
GJ
,
Eisenmann
JC
,
Nusser
SM
.
Development and preliminary validation of a Family Nutrition and Physical Activity (FNPA) Screening Tool
.
Int J Behav Nutr Phys Act
.
2009
;
6
:
14
229
Christison
AL
,
Daley
BM
,
Asche
CV
, et al
.
Pairing motivational interviewing with a nutrition and physical activity assessment and counseling tool in pediatric clinical practice: a pilot study
.
Child Obes
.
2014
;
10
(
5
):
432
441
230
Janz
KF
,
Lutuchy
EM
,
Wenthe
P
,
Levy
SM
.
Measuring activity in children and adolescents using self-report: PAQ-C and PAQ-A
.
Med Sci Sports Exerc
.
2008
;
40
(
4
):
767
772
231
Park
JM
,
Han
AK
,
Cho
YH
.
Construct equivalence and latent means analysis of health behaviors between male and female middle school students
.
Asian Nurs Res (Korean Soc Nurs Sci)
.
2011
;
5
(
4
):
216
221
232
Fernald
DH
,
Froshaug
DB
,
Dickinson
LM
, et al
.
Common Measures, Better Outcomes (COMBO): a field test of brief health behavior measures in primary care
.
Am J Prev Med
.
2008
;
35
(
5
suppl
):
S414
S422

Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Muth receives royalties from the American Academy of Pediatrics and F.A. Davis and previously had a consulting relationship with the American Council on Exercise; Drs Hanson, Lobelo, and Nemeth have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: Dr Muth receives royalties from the American Academy of Pediatrics and F.A. Davis and previously had a consulting relationship with the American Council on Exercise; Drs Hanson, Lobelo, and Nemeth have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data