As noted throughout this book, the hard part of regular exercise is the “regular” and not the exercise. This is even truer for the pediatric population than it is for the adult population. Children are dependent on the family unit; therefore, the best chance of incorporating regular exercise into their daily lives is by making exercise a family affair. The goal of this chapter is to provide guidance to clinicians on how to counsel their pediatric patients and their families on making exercise a family affair.

This chapter discusses the importance of exercise in the pediatric population and the benefits of exercise to the entire family. The 5 As, as discussed in Chapter 2 (pp. 20-21; see also below), can be very helpful in organizing your intervention for this population. Let us recall them here: The “Five A’s Framework:” Assess, Advise, Agree, Assist, Arrange follow-up. They provide guidance on how you can effectively communicate the content of the American College of Sports Medicine’s (ACSM) children and adolescent guidelines for physical activity at various stages of a child’s development. The importance of the “new vital signs” (BMI measurements and exercise history) is stressed in this chapter and the barriers to regular family exercise are addressed. The ACSM Guidelines for the Exercise Prescription for Children and Adolescents are presented below (see pp. 232-233). They are designed to aid you in offering an exercise program that families can easily incorporate into their daily lives without the need for purchasing expensive equipment and freeing up a large amount of time. In order to ensure that regular exercise becomes a part of every family’s daily routine, as we have said throughout this book, it will be very helpful for you to use each patient encounter to reinforce the message that “Exercise IS Medicine.”

The first step in counseling families to incorporate regular exercise into their daily routine is to inform each family about the health benefits of regular exercise, as well as about the risks associated with lack of exercise. As stated in the
ACSM’s Guidelines for Exercise Testing and Prescription (1), most children (defined as <13 yr) participate in adequate amounts of physical activity. Recent trends, however, show physical activity levels decreasing through adolescence (defined as 13-18 yr or Tanner Stage 5), such that the majority of adolescents are not participating in sufficient amounts of physical activity to meet recommended guidelines (2, 3). Physical activity, however, has been shown to reduce death rates from heart disease, colon cancer, hypertension and diabetes (4).

As noted for children as well as for adults, the prevalence of physical activity has declined, while the prevalence of obesity has increased. Data from two NHANES surveys (1976-1980 and 2003-2004) show that the prevalence of obesity has almost tripled in all age groups: for children aged 2-5 years, prevalence increased from 5.0% to 13.9%; for those aged 6-11 years, prevalence increased from 6.5% to 18.8%; and for those aged 12-19 years, prevalence increased from 5.0% to 17.4% (5). Risk factors for cardiovascular disease (i.e., elevated total cholesterol, triglycerides, insulin level, and blood pressure) and Type 2 Diabetes are more common in obese children than in those of normal weight. The obesity epidemic may potentially reverse the improved life expectancy trend that has resulted from the decrease in infectious diseases during the twentieth century; today’s children may in fact have a shorter life expectancy than their parents (4). As is well-known, overweight children and adolescents are more likely to become obese adults, underscoring the magnitude of this public health problem. According to the Centers for Disease Control and Prevention (CDC), 80% of children who are overweight at 10-15 years of age are obese at age 25 (5).

It is clear that obesity has both genetic and environmental components. The environmental component is the well-known “more energy going in than being expended” factor. Clinicians may not be able to alter the genetic contribution to obesity, but they can influence the environmental contribution through nutritional and exercise counseling. (Nutrition counseling is beyond the scope of this chapter, but refer to Growing Up Healthy [7] for advice on nutrition counseling.)

Just as for adults, in addition to decreasing the risk for developing obesity and the co-morbidities associated with obesity (hypertension, heart disease, type II diabetes, arthritis, cardiomyopathy, fatty liver, and elevated triglycerides,) regular exercise in children has many other health benefits: improves bone density, especially in pre-pubertal children, helps to reduce future risk of osteoporosis, improves premenstrual syndrome, helps to reduce LDL cholesterol, and increases the heart-beneficial HDL cholesterol. Regular exercise also helps to improve muscle tone, strength, balance, and coordination.

Regular exercise has psychosocial benefits for children as well. Self-esteem improves in children who are physically active; school performance is enhanced; energy level is increased; and the risk of depression decreases through exercise’s affects on hormonal levels (8, 9). In fact, because of the amelioration of some
mood disorders with regular exercise, the exercise prescription is used by many pediatric psychiatrists to help alleviate symptoms in their patients (10). Children who are not physically active have a greater tendency to have depression and spend more time on computers, watching television, or playing video games than those who are physically active. These solitary and sedentary activities are obviously not conducive to developing a positive family environment (10). If children are engaging in regular exercise, overall harmony of the family can and will improve.

Each pediatric patient encounter provides an opportunity for you to recommend regular exercise for both your patient(s) and the whole family unit. Whether the office visit is a sick or well visit, it presents an opportunity for you to ask about exercise and nutrition habits. The well visit will beneficially incorporate the measurement of “the new vital signs,” calculation of BMI and plotting of BMI percentile, as well as asking about the family’s level of physical activity. Using the “5 As” (Assess, Advise, Agree, Assist, Arrange [see Chap. 2, pp. 20-21]) can help in organizing your counseling of the family on regular exercise. Since children are “not just small adults,” it is important for you to take into consideration the developmental stage of the child or adolescent and alter the exercise prescription accordingly. Children and adolescents require special consideration when exercising as a result of growth and the immaturity of their physiologic regulatory systems at rest and during exercise. Physiologic responses to acute exercise are also different in children as compared to adults (see Table 14.1).