Review

Children and adolescents with Down syndrome, physical tness

and physical activity
Ken Pitetti
a,
*
, Tracy Baynard
b
, Stamatis Agiovlasitis
c
a
Department of Physical Therapy, College of Health Professions, Wichita State University, Wichita, KS 67260-0043, USA
b
Department of Kinesiology & Nutrition, University of Illinois at Chicago, Chicago, IL 60612, USA
c
Department of Kinesiology, Mississippi State University, Mississippi State, MS 39762, USA
Received 8 July 2012; revised 7 September 2012; accepted 26 September 2012
Abstract
Children (5e12 years) and adolescents (13e19 years) with Down syndrome (DS) possess a set of health, anatomical, physiological,
cognitive, and psycho-social attributes predisposing them to limitations on their physical tness and physical activity (PA) capacities. The
paucity of studies and their conicting ndings prevent a clear understanding and/or substantiation of these limitations. The purpose of this
article was to review the measurement, determinants and promotion of physical tness and PA for youth (i.e., children and adolescents) with DS.
The existing body of research indicates that youth with DS: 1) have low cardiovascular and muscular tness/exercise capacity; 2) demonstrate
a greater prevalence of overweight and obesity; 3) a large proportion do not meet the recommended amount of daily aerobic activity; and 4) their
PA likely declines through childhood and into adolescence. Future research should focus on: 1) strength testing and training protocols; 2)
methodologies to determine PA levels; and 3) practical interventions to increase PA.
Copyright 2012, Shanghai University of Sport. Production and hosting by Elsevier B.V. All rights reserved.
Keywords: Activity; Adolescents; Children; Down syndrome; Fitness
1. Introduction
1.1. Background and genetics
The condition of Down syndrome (DS) was rst described in
a clinical lecture report delivered in 1866 by the British physi-
cian, John Langdon Down, entitled Observation on the ethnic
classication of Mongoloid idiots.
1
Dr. Down used the
derogatory term Mongoloid because children with DS
displayed facial features (e.g., epicanthal fold) that shared
similarities with the prevailing erroneous ethnic theory estab-
lished by the German anatomist, Johann Friedrich Blu-
menbach.
2
Catalyzed by editorials in The Lancet, together with
political pressure by advocacy groups and parental organiza-
tions in the 1960s, the term mongolism was dropped from
medical references by the World Health Organization and
replaced by Down syndrome during the 1970s.
3
The cause of
DS remained unknown until the 1950s when it became possible
to identify chromosomal abnormalities with the discovery of
karyotype techniques. In 1959 the French geneticist, Dr. Jerome
Lejeune, reported that DS was caused by an extra 21st chro-
mosome, an aneuploidy condition known as trisomy 21.
4
The
vast majority of cases of DS are due to full trisomy 21, with
every somatic cell in the body having an extra 21st chromosome
(Table 1). A smaller percentage of persons with DS are due to
mosaic trisomy (2%e4%) and Robertsonian translocation
(3%e4%).
5
Reports have suggested that children with mosaic
* Corresponding author.
E-mail address: ken.pitetti@wichita.edu (K. Pitetti)
Peer review under responsibility of Shanghai University of Sport
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http://dx.doi.org/10.1016/j.jshs.2012.10.004
DS have similar health and developmental difculties as chil-
dren with full trisomy 21, but to a lesser degree
6
and those with
DS caused by Robertsonian translocation have increased
frequency of psychiatric disorders.
7
1.2. Demographics
In the United States the incidence of DS at birth from 1979
to 2003 increased from 9.0 to 11.8 per 10,000 births
(Table 1).
8
It is suggested that the probable cause for the
increase in DS is related to the trend toward later child
bearing, with women over 35 being ve times more likely than
younger women to have children with DS.
5
1.3. The intellectual and health proles of persons with
Down syndrome
Although about one-third of the causes of intellectual
disabilities (ID) remain unknown, the three major known
causes of ID are DS, Fetal Alcohol Spectrum Disorder, and
Fragile X syndrome.
6
As is the case for all persons with ID,
the degree of ID in persons with DS is determined by limi-
tations in both cognitive function and in adaptive behavior
(e.g., conceptual, social, and practical adaptive skills).
7-9
The
degree of cognitive impairment is variable, with the majority
classied as mild (IQ: 50e55e69) or moderate (30e35 to
50e55) while a smaller percentage (<10%) are severe
(IQ < 20e25 to 30e35).
10,11
Adaptive behavior encompasses
conceptual skills (language, reading and writing, self direc-
tions), social skills (self esteem, gullibility, naivete, avoids
victimization) and practical adaptive skills (dressing, toileting,
preparing meals, using transportation, occupational skills) that
allow individuals to be functional in their everyday life.
10,11
Adaptive behavior may improve with early intervention but
the level of function varies according to innate capacities and
social support systems (Table 1).
10,11
Although ID affects every day functioning, the health
proles of children and adolescents with ID without DS are
unremarkable. In contrast, the effects of DS involve a range of
medical conditions in addition to ID that may be identied at
birth or develop during the life span (Table 1). These condi-
tions include increased risk of congenital heart disease (50%),
hearing loss (75%), eye disease (60%), obstructive sleep apnea
(75%), gastrointestinal conditions (10%), thyroid (hypothy-
roidism) disease (15%), and atlanto-axial/atlanto-occipital
instability (10%e30%).
8,9
Excluding birth, nearly half of
children with DS are hospitalized before age 3, with the
principle causes for hospitalization being congenital heart
disease (e.g., septal and valvular anomalies) and respiratory
illnesses (pneumonia, acute, and chronic bronchitis).
10
These medical conditions increase demands on the health
care system that can be as much as 13 times higher than for
children (0e4 years) without DS.
11
Health care costs have
been reported to decline with age, and by adolescence the cost
of health care services have been reported to decrease to
1.1e1.7 times of those without disabilities.
12,13
However,
diagnosis of congenital heart disease and level of indepen-
dence inuence total health care cost, independent of age.
12
These health care estimates do not address overall cost to
families affected by DS, such as special education, individual
transport needs, housing modications, and related cost to
family members (e.g., employment opportunities).
Survival for persons with DS has improved over the past
few decades with life expectancy nearing 60 years paralleling
the improvement in social and medical support systems.
14e16
However, mortality rates of persons with DS remain higher
overall than those of the general population with the leading
causes of death being congenital anomalies (e.g., heart
defects), Alzheimers disease, pneumonia, leukemia, and all
circulatory diseases (e.g., ischemic heart disease, cerebrovas-
cular disease).
14,17,18
Death rates for persons with DS increase
signicantly after age 40.
19
The main cause for the upsurge in
mortality in middle-aged adults with DS is the deterioration in
functional abilities and rise in behavioral problems due to
Alzheimers disease.
20e23
Because of early onset of meno-
pause, women with DS are four times more likely to develop
Alzheimers disease than their male counterparts.
24
Other
disorders of aging in DS are pulmonary disorders (recurrent
pneumonia caused by recurrent aspiration), sensory impair-
ments (hearing and vision), and musculoskeletal disorders
(e.g., osteoporosis and orthopedic complications caused by
joint instability).
23
2. Physical tness: cardiovascular, muscle, and body
composition
2.1. Cardiovascular tness
2.1.1. Cross-sectional studies
Uniformly, peak aerobic capacity (VO
2peak
) in both youth
and adults with DS is reduced in comparison to their peers
without disabilities (WOD) and with ID but without DS.
25e27
This is accompanied by lower peak work rates as well as
Table 1
Description, demographics, and health proles of persons with Down
syndrome.
Characteristic Description
Description and demographics 1. Caused by trisomy 21
2. 11.8 per 10,000 births (USA)
3. Mild/moderate intellectual disability
4. Limited adaptive skills
5. Life span near 60 years
Health proles
Childhood 1. Congenital heart disease (septal and
valvular defects)
2. Respiratory illnesses (pneumonia
and chronic bronchitis)
Adulthood 1. Deterioration of functional capacities
due to dementia of Alzheimers type
2. Recurrent pneumonia
3. Sensory impairments (hearing and
vision)
4. Musculoskeletal disorders (joint
instability and osteoporosis)
48 K. Pitetti et al.
a faster time to exhaustion (Table 2).
27
Such ndings were rst
reported by Eberhard et al.
28
in 1989, whereby they demon-
strated a 15% lower VO
2peak
using bicycle ergometry compared
to age-matched children WOD. In 1990, Fernhall et al.,
26
using
a validated treadmill protocol, reported lower VO
2peak
in
adolescents with DS when compared to adolescents WOD and
that lack of motivation or understanding protocol instructions in
participants with DS did not contribute to their ndings.
Following these initial contributions, the literature has
consistently demonstrated lower VO
2peak
values when indi-
viduals with DS are compared to individuals WOD and with
ID but without DS. In the largest sample to date (total n 635;
n 133 with DS, n 180 with ID, n 322 WOD), Baynard
et al.
25
reported that VO
2peak
(absolute and relative values) is
lower in children and adolescents with DS through young
adulthood and into middle age, regardless of the comparison
group. Furthermore, the authors also demonstrated VO
2peak
does not signicantly change after the age of w16 years.
25
Interestingly, the average VO
2peak
at this age in individuals
with DS is similar to normative values found in middle-aged to
older persons WOD, yet individuals with DS do not appear to
experience the age-related decline in VO
2peak
as is expected in
those WOD (Table 2).
25
Three physiologic factors that potentially contribute to low
VO
2peak
values in persons with DS are autonomic dysfunction,
reduced ventilatory capacity, and metabolic dysfunction.
When considering autonomic dysfunction, lower peak heart
rate (HR) responses have been consistently reported across all
age groups for persons with DS.
25
The cause of lower peak HR
in persons with DS is still not completely understood at this
time, but Fernhall et al.
29
demonstrated in a group of young
adults with DS (mean age 24 years) a blunted to non-existent
catecholamine response to peak exercise. This suggests that
some portion of the autonomic pathway is dysfunctional and
contributes to the lower HR response. Although diminished
sympathoexcitation in adults with DS has been reported,
30,31
to date no studies have included youth with DS (Table 2).
Further, with higher obesity levels generally observed in
persons with DS, the interaction between autonomic control
and obesity may be an important avenue to investigate in this
population.
It was also postulated that due to the relatively large
tongues (macroglossia) compared to the bony connes of the
oral cavity in persons with DS, ventilation would be restricted
at high work levels and thus limit peak performance. Indeed,
adolescents and young adults with DS have been reported to
have low peak ventilation.
26
However, Fernhall and Pitetti
27
concluded that peak ventilatory parameters (e.g., ventilatory
equivalents, and peak minute ventialation) were appropriate
for a given VO
2peak
. In addition, imaging work has established
that children with DS do not have true macroglossia, although
they have relatively large tongues compared to their oral
cavity volume.
32
Therefore, ventilation capacity does not
appear to restrict the peak performance of youth with DS.
However, gaps do exist in the literature with little to no data
available for additional ventilatory parameters, such as peak
minute ventilation/maximal ventilatory volume or peak tidal
volume/ventilatory capacity. This type of data would broaden
our understanding of potential limitations to exercise in
persons with DS.
Metabolic limitations have also been suggested to constrain
the physical capacity of youth and young adults with DS.
However, only two studies actually measured ventilatory
threshold in adolescents and young adults with DS.
33,34
Collectively, these two studies reported that ventilatory
threshold was difcult to detect (e.g., V-slope method);
however, in those participants where it was detectable, normal
ventilatory thresholds were observed when expressed as
a percentage of VO
2peak
. Given that the respiratory exchange
ratio is related to substrate utilization and exercise intensity,
collection of blood lactate would assist in determining the role
that metabolic function may have in limiting exercise perfor-
mance in youth with DS. However, submaximal and maximal
exercise blood lactate levels have not been reported in the
literature for youth with DS. In line with this, supramaximal
testing (e.g., Wingate testing) is not reliable enough to date to
help complete a metabolic prole in youth with DS.
35
It is important to note that several studies using eld tests
also report lower predicted VO
2peak
and/or exercise perfor-
mance in youth and young adults with DS compared to peers
WOD (Table 2).
36,37
The largest eld study to date to measure
run performance (20-m shuttle run) had 119 youth (11e18
years) with DS, 394 youth with ID but without DS, and 80
youth WOD.
38
Children and adolescents with ID but without
DS had better run performance than their peers with DS
independent of age, sex, and body mass index (BMI).
38
Furthermore, those WOD had better run performance than
their peers with ID, again independent of age, sex, and BMI.
38
Table 2
Physical tness in youth with Down syndrome (DS).
Characteristic Description
Cardiovascular tness 1. Low peak aerobic capacity/time to exhaustion
2. Low peak heart rate
3. Peak aerobic capacity does not change
signicantly with age after w16 years
4. Autonomic dysfunction a primary factor
related to low tness
5. Field tests largely support laboratory ndings
6. Responsive to aerobic endurance training,
particularly with improvements in work
capacity
Muscular strength 1. Lower strength compared to individuals
without disabilities
2. Resistance training appears safe and benecial
for improving strength
3. Improved leg strength does not appear
improve aerobic capacity
Body composition 1. Youth with DS in North America and Europe
are more obese/overweight vs. counterparts
without disabilities
2. Cause of high rate of overweight/obesity is
multifactorial (physiological, societal,
environmental, psychological, etc.)
3. Studies show no improvement in body
composition from exercise training alone,
likely due to lack of dietary control
Youth with DS: Fitness and activity 49
Thus, poor running performance of children and adolescents
with ID, with and without DS, is not a consequence of age,
sex, or BMI.
Furthermore, Fernhall et al.
39,40
produced a regression
equation from the results of the 20-m shuttle run to predict
VO
2peak
in children and adolescents with ID, with and without
DS. This equation was cross-validated in 2003 by Guerra
et al.,
41
however, this study consisted of a greater percentage
of children and adolescents with DS and they were not able to
validate Fernhalls
39,40
original equation designed for persons
with ID to a sample with DS alone. The prediction of VO
2peak
,
from a 20-m shuttle run test, was further examined by
Agiovlasitis et al.,
42
whereby they reported that while shuttle
performance was a predictor of VO
2peak
in youth with DS, the
equation had low predictability at the individual level.
Therefore, the use of the regression equation developed by
Fernhall et al.
39,40
to predict VO
2peak
in persons with ID does
not appear to be specic for youth with DS.
2.1.2. Training studies
There are relatively very few longitudinal training studies
in persons with DS, particularly in youth. For this reason,
training studies in young adults with DS will be utilized here
with the understanding that it would be likely that youth with
DS would experience similar ndings. A meta-analysis was
conducted by Dodd and Shields
43
that included four papers,
which met their inclusion criteria.
44e47
They reported that
aerobic training programs, which conformed to the American
College of Sports Medicine guidelines, were effective for
improving VO
2peak
, peak ventilation, time to exhaustion, and/
or maximum workrate.
43
One of the rst training studies in adolescents with DS was
conducted by Millar et al.,
45
with 14 individuals participating
in a 10-week walking/jogging program, 3 days/week at 65%e
75% peak HR, which resulted in no change in VO
2peak
, but did
improve treadmill test time by 9%.
45
Training studies that
have measured VO
2peak
since the report by Millar et al.
45
have
supported those initial ndings, in that improvements have
been seen in exercise/work capacity without signicant
improvements in VO
2peak
with training interventions lasting
12e16 weeks (Table 2).
9,48
Further evidence of positive
training effects stems from an often overlooked study,
whereby HR recovery following a 3-min step test and resting
HR were decreased in a group of 10 individuals with DS
(8e18 years) after a 13-week training program.
49
Lastly, an
interesting case study reported that a young 10.5-year-old
female with DS following 6 weeks of training did not alter her
estimated VO
2peak
, but her submaximal HR was lower during
the treadmill test, as was her respiratory rate, indicating
improved work capacity and capacity for change.
50
While aerobic training studies are limited in persons with
DS, let alone youth, previous work suggests exercise training
is benecial in youth with DS even if VO
2peak
itself is not
necessarily an expected outcome. It is especially important to
consider training studies in youth with DS in that early
intervention to improve their work/exercise capacity could
impact the health anomalies specic to the condition of DS.
2.2. Muscular strength
Few studies exist that have employed strength testing and/
or training in youth with DS. Strength decrements were rst
characterized in youth with DS in 1994 by Cioni et al.,
51
in
which children and adolescents with DS (n 25) exhibited
weak knee extensor strength compared to a WOD control
group. Furthermore, these authors concluded that adolescents
with DS generally do not show improvements in strength
beyond the age of 14 years.
51
These ndings can be extended
to the hip abductors as well.
52
Interestingly, Pitetti and Fern-
hall
53
explored the relationship between VO
2peak
and strength
in youths aged 10e17 years with ID (n 29), including eight
children with DS, and found a signicant relationship between
knee exion/extension strength and aerobic capacity
(r 0.56e0.62). Their data suggest that leg strength may be
a limiting factor in both work and aerobic capacity in persons
with DS, which is also supported by similar work in adults
(Table 2).
54
There is a small body of literature in young adults with DS
(mean age w24e25 years) that further extends the limited
ndings in youth. Several studies have demonstrated lower
muscle strength in young adults with DS for both knee, and/or
elbow extensors/exors compared to participants WOD.
55e58
In those studies that distinguished between individuals with
ID with or without DS, no general differences in strength were
observed between these two groups, whereas the control group
WOD was always stronger (65%e225% stronger). However, it
should be noted that while not different, Croce et al.
57
have
reported lower hamstring to quadriceps ratios in adults with
DS (20%) vs. those WOD and 10% lower compared to adults
with ID without DS. This may suggest reduced muscular
performance and knee joint stability.
The number of strength training intervention studies that
included individuals with DS is even smaller, with two studies
known to have specically trained youth with DS.
59,60
Weber
and French
59
found that resistance training improved overall
muscular strength in adolescents with DS (e.g., 10 muscular
tests performed), yet this study lacked a control group.
Recently, Shields and Taylor
60
demonstrated that a 10-week
community-based progressive resistance training intervention
was successful in increasing lower limb strength (as well as
muscle endurance) in 23 adolescents with DS, with no changes
in upper limb strength. Unfortunately, no measure of work
and/or aerobic capacity was performed in these studies.
59,60
Lastly, a case study demonstrated that a young girl with DS
improved general muscle strength (e.g., trunk, hip, knee, and
shoulder) following a 10-week combined aerobic and resis-
tance program.
50
These data collectively suggest that strength
training in youth is benecial. Little to no data exist on the
relationship between strength training and improving work
capacity in youth with DS (Table 2). A recent study by Cowley
et al.
61
reported a small, but signicant increase in relative
VO
2peak
following a 10-week strength training program in
young adults with DS, yet no difference in absolute VO
2
was
observed, suggesting this improvement was mediated by
weight loss (w5 kg).
50 K. Pitetti et al.
A group of progressive resistance exercise training studies
clearly demonstrate that strength training is a safe and
important component of exercise prescription in young adults
with DS (24e29 years).
61e64
These studies lasted 10e12
weeks and all employed a 2e3 days/week training of large
muscle groups, with improvements found in both upper- and/
or lower-body strength. Interestingly, Cowley et al.
61
concomitantly measured aerobic capacity and reported no
change in absolute VO
2peak
and a small but signicant
decrease in relative VO
2peak
(Table 2).
2.3. Body composition
Equivocal evidence exists regarding body composition in
persons with DS. The lack of consistency may involve meth-
odological issues for measuring body composition (e.g.,
skinfolds vs. dual energy X-ray absorptiometry) or perhaps
comparing weight status using different vehicles, such as
a laboratory measures versus BMI. Another possible contrib-
utor may be ethnic and/or environmental issues as well.
Caution is urged when interpreting global statements on body
composition in DS for these reasons.
Numerous investigations have reported that the prevalence
of overweight and obesity are substantially higher in individ-
uals with DS compared to their age-matched peers WOD and
with ID but without DS.
65,66
Prasher
67
reported that w48% of
adults with DS were obese, with w27% being overweight
(both sexes averaged) and that being overweight and/or obese
was associated with living at home compared to group-home
situations. This is consistent with Rubin et als
65
report of
w48% for men and w56% of women being overweight/
obese. Interestingly, BMI was found to decrease throughout
the lifespan in males and females with DS, whereas BMI
increases through the lifespan in the general population.
67
This
is in contrast to Baynard et al.,
25
whereby they reported BMI
increases not only in the control group, but also in groups of
ID, with and without DS, up through middle-age. Prasher
67
was unable to adequately explain why BMI would decrease
from young adulthood (16e19 years) through the 20 s into the
60 s. Perhaps the Alzheimers issues that individuals with DS
often experience could provide a possible explanation.
Early work by Sharav and Bowman
68
demonstrated that
young children with DS (w4e5 years) were not different from
their siblings WODin BMI. Additionally, Luke et al.
69
reported
non-signicant but higher BMI and lower fat-free mass in
children with DS (9 years old) versus a control group WOD,
whereas other investigators have observed higher BMIs and/or
percentage of body fat in youth with DS compared to peers
WOD.
52,70
However, these studies also included adults in their
samples.
52,70
In contrast to Luke et al.,
69
others have observed lower total
muscle mass in persons with DS versus individuals WOD.
70
This has been further substantiated recently in Spanish youth
with DS that did exhibit higher body fat content and lower lean
mass than peers WOD.
71
In Greece, researchers observed that
22% of adolescents in their sample were obese and that percent
body fat, BMI, fat mass and fat-free mass were also greater in
adolescents with DS (10e18 years) than in children with DS
(2e9 years).
72
It is important to note that several studies do
suggest that children and adults with developmental disabilities
in the United States and Australia have greater prevalence rates
of overweight and obesity compared to non-disabled age-
matched controls. Yet these studies only have a small portion of
individuals with DS included.
65,66
However, the prevalence of
overweight/obesity has recently been questioned and it may not
be as high as previously thought.
73
It is also possible interna-
tional differences exist that need further examination. More
work will need to be conducted not only at the physiological
level, but work at the environmental, community, societal and
psychological levels to fully delineate the numerous factors
involved in obesity (Table 2).
3. Physical activity (PA) in youth with DS
Apart from physical tness, PA has the potential to improve
health in youth with DS. Although the relationship of PA and
health outcomes has not been directly examined in youth with
DS, it is reasonable to assume that the ndings in the general
population of youth also apply to those with DS. PA may
improve the cardiovascular, metabolic, musculo-skeletal, and
psychosocial health proles of all youth.
74e76
For this reason, the 2008 Physical Activity Guidelines for
Americans devoted a section to children and adolescents.
76
Specically, it is recommended that youth older than 6 years
perform 60 min of PA daily. Most of aerobic activity should be
of either moderate or vigorous intensity, dened as 3.0e5.9
and >5.9 metabolic equivalent units (METs), respectively;
however, vigorous-intensity activity should be performed at
least 3 days/week. Muscle- and bone-strengthening activities
are important components of the recommended 60 min of
daily activity and each should be performed at least 3 days/
week. Importantly, the Guidelines call for the promotion of
physical activities that are age-appropriate, enjoyable, and
offer variety. Recent evidence, however, suggests that most
American youthdespecially adolescentsddo not meet the
required amount of daily PA and that their activity levels
decline as they grow.
77
The issues of interest therefore are: (a)
whether the PA levels of youth with DS differ from those of
youth WOD, and (b) whether youth with DS meet the current
recommendations for PA.
Answering these questions is difcult because research on
PA in youth with DS is limited. In a review of research pub-
lished prior to 2008,
78
the authors could not conclude whether
the PA levels of youth with ID, including those of youth with
DS, are different from those of children WOD. As the authors
explained, this was due to methodological problems of
previous research such as insufcient description of samples
and questionable applicability of objective or subjective
measurements of PA to youth with ID.
3.1. Measurement of PA in youth with DS
Subjective PA assessments using questionnaires are not as
accurate as objective ones.
77
This difculty is magnied in
Youth with DS: Fitness and activity 51
youth with DS by the need to use parental or caregiver/teacher
proxy reports.
78
One study demonstrated questionable accu-
racy of PA measurement by proxy reports for adults with ID.
79
It is possible that subjective assessment of PA in youth with
DS may benet if questionnaires are obtained from both
parents and teachers or caregivers; such practice may offer
a more accurate representation of the activities youths with DS
engage in throughout the day. Nevertheless, to our knowledge,
the psychometric properties of subjective measures have not
been examined in youth with DS. Finally, in-depth inter-
viewsdtypically with parentsddo not allow for a quantica-
tion of the amount of PA performed by youth with DS.
Objective PA measurements with accelerometers or
pedometers are preferable, but they should be used carefully in
youth with DS. Pedometers appear valid and reliable during
locomotion in youth with intellectual or developmental
disabilities,
80,81
but their accuracy may be compromised
during games and sport activities conducted in physical
education.
82
Additionally, spring-levered pedometers are less
accurate than piezoelectric in people with DS.
83
Furthermore,
using step-rate cut-points to estimate moderate- and vigorous-
intensity activity in youth with DS may be problematic. Adults
with DS have lower step-rate cut-points for activity intensity
even when accounting for their shorter height compared to
adults without DS
84
dthis may potentially apply to youth with
DS. Similarly, accelerometry-determined cut-points for
moderate- and vigorous-intensity activity developed for youth
WOD may not be applicable to youth with DS. This has been
demonstrated for adults with DS
85
and it has been suggested to
be partially due to an altered gait pattern that increases the
energy expenditure.
86
It is possible that this also applies to
youth with DS who also exhibit altered gait patterns,
87,88
potentially duedat least in partdto decits of the cere-
bellum.
89
Additionally, cut-offs developed in youth WOD may
be inappropriate for those with DS because the latter have very
low cardiovascular tness. Finally, there have been some
reports of compliance issues with accelerometers secured at
the hip in youth with DS.
90,91
Although these difculties are
not extensive, they highlight the need for adequate familiar-
ization and parental supervision. Alternately, researchers could
consider other placement sites, such as the wrist, where the
accelerometer could be secured with an irremovable strap.
These measurement issues should be collectively considered
when evaluating previous reports of PA in youth with DS.
3.2. What are the PA levels of youth with DS?
In infants with DS, movementdespecially of the
legsdmay be important for motor development. Children with
DS appear to reach stages in motor development with some
delay.
92
A notable example is the onset of independent
walking which occurs about a year later (wage 2) in children
with DS than children with typical development.
93,94
It is
possible that low levels of motor activity during early infancy
may contribute to this phenomenon. One study found that,
during the rst 6 months of life, infants with DS show lower
levels of general movements as measured by observation than
infants with typical development.
95
In contrast, analyzing
video recordings, others reported no differences between
infants with and without DS in the total amount of leg
movements
93
which are presumably more relevant for the
development of walking. Subsequently, infants with DS were
found to show more low-intensity and less high-intensity leg
motor activity than infants with typical development.
96,97
Furthermore, greater amount of high-intensity activity at
about 1 year of age was associated with earlier walking onset
in infants with DS.
96,97
Finally, a randomized controlled study
showed that infants with DS, who underwent home-based
stepping training while supported over customized treadmills,
achieved independent walking by an average of 101 days
earlier than infants with DS not undertaking this intervention;
the intervention was initiated once infants with DS could sit
independently and it was conducted 5 days/week, 8 min/day,
until the onset of independent walking.
94
Taken together, these
data suggest that alterations in PA patterns in infants with DS
are associated with their motor development, thus supporting
the need for early interventions.
96
The objective data on PA levels of children and adolescents
with DS are limited and provide somewhat conicting results.
Non-resting total energy expenditure measured with doubly-
labeled water did not differ between 5- and 11-year-old chil-
dren with DS from the U.S. and peers WOD of similar age and
BMI.
98
In another U.S. study, the amounts of total, low-
intensity, and moderateeintensity activity, as well as time
spent sedentary measured with hip-accelerometry over 7 days
did not differ between children with DS aged 3e10 years and
similarly-aged siblings WOD;
90
however, the children with DS
participated in less and shorter bouts of vigorous-intensity
activity than their siblings. Notably, children both with and
without DS in that study exceeded the recommendations for
total and vigorous-intensity aerobic activity. Similarly,
Australian children and adolescents with DS met on average
the recommended amounts of moderate- and vigorous-inten-
sity activity as measured by hip-accelerometry
91
and also
appeared more active than U.S. youth.
77
But there was large
between-person variability in activity levels and 58% of the
children with DS did not meet the recommended amount. In
the same study, youths with DS aged 13e17 years showed
lower total, moderate-, and vigorous-intensity activity than
those aged 7e12 years, indicating a possible age-associated
decline in PA. Recent acceleromety-derived data from the U.S.
demonstrated that, on average, children and adolescents with
DS did not engage in moderate-to-vigorous PA for 60 min/
day.
99
Furthermore, PAwas lower and sedentary behavior was
higher in older youths with DS compared to younger ones.
Another U.S. study using accelerometry
100
showed that, prior
to an intervention, youth with DS aged 8e15 years were active
at moderate-to-vigorous levels for an average of about 43 min,
although there was signicant between-people variation in this
value. Finally, cross-sectional accelerometry-determined data
from England demonstrated lower amount and faster age-
associated decline of moderate-to-vigorous activity in people
with DS than people with ID but without DS across the life-
span (Table 3).
101
52 K. Pitetti et al.
Some subjective datadobtained with parental reports or in-
depth interviewsdsupplement the literature on PA of youth
with DS. Canadian children with DS aged 2e14 years were
rated by their parents as less active and as spending more time
indoors compared to siblings without DS,
68
although all youth
in this study with DS participated in organized sports at least
once per week.
69
Among 38 Australian youth with DS aged
11e18 years, only two engaged in PA more than 3 days/
weekda nding suggestive of low PA levels.
102
In a second
Australian study, less than one third of 208 youth with DS
aged 5e18 years were found to be active at moderate-to-
vigorous intensity for 60 min/day, although most participated
in sports.
103
Finally, during in-depth interviews, parents of
U.S. preschoolers with DS perceived their children as natu-
rally active. In contrast, parents of elementary-school students
perceived a gradual decrease in their childrens interest for PA,
supporting the possibility for an age-associated decline among
youth with DS.
104
The existing objective and subjective data do not allow us
to conclude with condence whether youth with DS have
lower PA levels than youth WOD, but this appears likely.
Additionally, it is not known if youth with DS meet the
required amounts of muscle- and bone-strengthening activi-
ties. Although there are no longitudinal data on the develop-
mental course of PA in youth with DS, it is likely that PA
declines with age in this population. Furthermore, a large
proportion of children and adolescents with DS may not meet
the recommended amount of daily aerobic activity.
3.3. Determinants of PA
The study of the determinants of PA in youth with DS is
still in its infancy. Following the approach of the International
Classication of Functioning, Disability and Health,
105
PA
may be inuenced by a childs health status, functional prole,
participation in life activities, and contextual factorsdeither
within the person or in the environment. DS is associated with
many health conditions, but there is great variability in the
number and extent of conditions that youth with DS exhibit. In
one study, medical issues were not associated with function
among youth with DS.
106
It is reasonable, however, to assume
that acute health problems might present barriers to PA for
youth with DS and that, when medical issues are efciently
overcome, PA may be facilitated.
The functional proles of youth with DS may also be
related to their PA levels. Quantitative and qualitative data
suggest that lower cognitive, behavioral, and motor skills may
present barriers to PA of youth with DS.
103,104,107,108
Some
theorists also argue that people with DS may have a tendency
for slower, safer, and more accurate movement patterns due to
interactions between neurological, environmental, and task-
associated constraints.
109
Additionally, the very low aerobic
and muscular tness of youth with DS may potentially affect
their involvement in physical activities, especially of higher
intensities, but this has not been directly examined (Table 3).
Contextual factors within the person may also be at play. In
support of this argument, the aforementioned lower partici-
pation in vigorous-intensity activities of children with DS
compared to their siblings
90
was collectively explained by age,
sex, race, ethnicity, income, maternal education, and BMI. It is
difcult, however, to determine the individual contributions of
these factors to PA of the children in that study. As previously
discussed, PA in youth with DS may decline with age,
91,101,104
although one study did not nd differences in sport partici-
pation between children and adolescents with DS.
103
Furthermore, whether PA differs between sexes in youth
with DS, as in youth WOD,
74,77
is not known. Data from
Taiwan, China showed no difference in recreational and sport
participation between boys and girls with DS.
108
In contrast,
another study conducted in Taiwan, China demonstrated that,
among youth with ID including DS, boys and those who had
positive attitudes towards exercise were more likely to be
regularly active after school.
110
It is also very likely that the social and physical environ-
ment contributes to the PA levels of children and adolescents
with DS (Table 3). This is supported by a wide variation in
types of leisure participation among youth with DS around the
world.
68,102,103,108,110,111
Furthermore, it has been argued that
inactivity among youth with DS may be a learned behavior
partially resulting from exclusionary practices.
112
Importantly,
lack of accessible, inclusive, and appropriately-designed
programs, as well as negative attitudes, transportation prob-
lems, competing family responsibilities, parental education
Table 3
Physical activity in youth with Down syndrome (DS).
Characteristic Description
Physical activity 1. Likely declines during the growing years
2. A large proportion of youth with DS does
not meet the recommendation for daily
aerobic activity
3. Youth with DS participate in a wide variety
of culturally-relevant leisure activities
Barriers to physical activity
Within the person 1. Health problems
2. Low tness levels
3. Low motor skills
Environmental 1. Lack of accessible, inclusive, and properly
designed programs
2. Transportation difculties
3. Negative attitudes towards people with
disabilities
4. Competing family responsibilities
5. Parental education and income
6. Lack of friends
Facilitators of physical activity
Within the person 1. Knowledge on physical activity and health
2. Positive attitude towards exercise
3. Determination to succeed
Environmental 1. Positive social and familial attitudes
2. Knowledgeable professionals
3. Structured programs that .
1) Are adapted to the needs of youth with DS
2) Provide knowledge on physical activity
and health
3) Are inclusive
4) Promote social interaction and enjoyment
Youth with DS: Fitness and activity 53
and income, and lack of friends, all reportedly present barriers
to PA for youth with DS.
90,104,107
3.4. PA promotion
Youth with DS reportedly participate in a wide range of
recreational activities. Examples include walking, swimming,
bowling, dancing, and team sports.
68,102,103,108,110,111
The
types of leisure participation among youth with DS likely vary
around the world; for example, swimming appears common in
Australia,
102,103
ice-skating in Canada,
68
and bicycling in
Taiwan, China.
108
Notably, walking is one of the most
commonly performed activities among youth with
DS,
108,110,111
suggesting that their altered gait pattern
87,88
may
not present a barrier to PA. Supporting this proposition, chil-
dren and adolescents with DS exhibit functional independence
in locomotion tasks.
106
Therefore, youth with DS have the
potential to participate in all types of culturally-relevant
physical activities.
Unfortunately, very little data exist on interventions to
promote PA in youth with DS. A randomized-controlled study
found that youth with DS who learned to ride a bicycle
increased their PA levels about 1 year after the intervention,
100
suggesting that motor skill development may improve long-
term PA. Furthermore, well-designed school programs allow
students with ID including those with DS to meet the PA
recommendations.
113
It should also be considered that 12
weeks of exercise training, combined with health education,
improves the attitudes towards exercise and psycho-social well
being of adults with DS,
114
but, to our knowledge, similar
studies in youth with DS have not been conducted (Table 3).
It has been recommended that PA promotion in all youth
aimed at ameliorating the age-associated decline in PA, sup-
pressing the development of pathological processes, and
creating life-long PA habits.
74
To achieve these goals in youth
with DS, PA promotion should be multi-factorial. Well-
designed programs should take into account the physical,
cognitive, and psycho-social health proles of children with
DS as well as their need for enjoyment and participation. But
at the same time, the environmental contexts in which PA,
exercise, and recreation occur must be appropriately designed.
Parents tell us that the PA of their children with DS may be
facilitated by positive familial and social attitudes, and struc-
tured programsdones that are adapted to the abilities of their
children, offer youth with DS knowledge on PA and health,
utilize their determination to succeed, and promote social
interactions and enjoyment.
104,107,111
4. Summary and future directions
4.1. Physical tness
Youth with DS have low peak aerobic capacity coupled
with low peak HR, suggesting autonomic dysfunction may be
a primary reason explaining low work performance in this
population. Furthermore, persons with DS also have low
muscular strength compared to individuals WOD. Exercise
training utilizing endurance and/or resistance exercise appears
benecial for youth with DS. The role of overweight/obesity
in youth with DS does not currently explain lower aerobic
capacities in persons with DS, yet more work needs to be
conducted to completely understand its role with regards to
aerobic capacity and PA in this population. Studies involving
multi-factorial issues (e.g., physiological, environmental, etc.)
common to youth with DS are necessary to understand how to
optimize quality of life in this population.
4.2. PA
Cross-sectional data suggest that PA likely declines with
growth in youth with DS and that a large proportion of these
youths do not meet the recommended amount of daily aerobic
activity. Effective PA promotion should be multi-factorialdit
should be adapted to the physiological, cognitive, and psycho-
social proles of youth with DS, but should also consider
environmental modications. There is a need to improve the
assessment of PA with objective and subjective approaches.
Furthermore, longitudinal research is needed to examine how
PA levels change and what factors contribute to them during
growth in youth with DS. Finally, it is also important to
examine the effectiveness of specic interventions aimed at
increasing PA.
References
1. Down JLH. Observations on an ethnic classication of idiots. London
hospital reports 1866;3:259e62.
2. Bhopal R. The beautiful skull and blumenbachs errors: the birth of the
scientic concept of race. BMJ 2007;335:1308e9.
3. Classication and nomenclature of morphological defects. Lancet
1975;305:513.
4. Lejeune J, Gautier M, Turpin R. Study of somatic chromosomes from 9
mongoloid children. C R Hebd Seances Acad Sci 1959;248:1721e2.
5. Shin M, Besser LM, Kucik JE, Lu C, Siffel C, Correa A, et al. Prevalence
of Down syndrome among children and adolescents in 10 regions of the
United States. Pediatrics 2009;124:1565e71.
6. Schalock RL, Borthwick-Duffy SA, Buntinx WHE, Coulter DL,
Craig EM. Intellectual disability: denition, classication, and systems
of supports. 11th ed. Washington, DC: American Association on Intel-
lectual & Develomental Disabilities; 2010.
7. Edwards WLR. Mental retardation: denition, classication, and
systems of support. Washington, DC: American Association on Mental
Retardation; 2002.
8. American Academy of Pediatrics. Health supervision for children with
Down syndrome. Pediatrics 2001;107:442e9.
9. Cohen W. Health care guidelines for individuals with Down syndrome.
Down Syndrome Q 1996;1:1e10.
10. So SA, Urbano RC, Hodapp RM. Hospitalizations of infants and young
children with Down syndrome: evidence from inpatient person-records
from a statewide administrative database. J Intellect Disabil Res
2007;51:1030e8.
11. Boulet SL, Molinari NA, Grosse SD, Honein MA, Correa-
Villasenor A. Health care expenditures for infants and young children
with Down syndrome in a privately insured population. J Pediatr
2008;153:241e6.
12. Geelhoed EA, Bebbington A, Bower C, Deshpande A, Leonard H. Direct
health care costs of children and adolescents with Down syndrome.
J Pediatr 2011;159:541e5.
54 K. Pitetti et al.
13. Goldstein H. One year of health and social services for adolescents with
downs syndrome. A calculation of costs in a representative area of
Denmark. Soc Psychiatry Psychiatr Epidemiol 1989;24:30e4.
14. Day SM, Strauss DJ, Shavelle RM, Reynolds RJ. Mortality and causes of
death in persons with Down syndrome in California. Dev Med Child
Neurol 2005;47:171e6.
15. Glasson EJ, Sullivan SG, Hussain R, Petterson BA, Montgomery PD,
Bittles AH. The changing survival prole of people with downs
syndrome: implications for genetic counselling. Clin Genet
2002;62:390e3.
16. Yang Q, Rasmussen SA, Friedman JM. Mortality associated with Downs
syndrome in the USA from 1983 to 1997: a population-based study.
Lancet 2002;359:1019e25.
17. Hermon C, Alberman E, Beral V, Swerdlow AJ. Mortality and cancer
incidence in persons with Downs syndrome, their parents and siblings.
Ann Hum Genet 2001;65:167e76.
18. Hill DA, Gridley G, Cnattingius S, Mellemkjaer L, Linet M, Adami HO,
et al. Mortality and cancer incidence among individuals with Down
syndrome. Arch Intern Med 2003;163:705e11.
19. Strauss D, Eyman RK. Mortality of people with mental retardation in
california with and without Down syndrome, 1986-1991. Am J Ment
Retard 1996;100:643e53.
20. Day S. Estimators of long-term transition probabilities in multistate
stochastic processes. Riverside CA: University of California; 2001
[dissertation].
21. Esbensen AJ, Seltzer MM, Greenberg JS. Factors predicting mortality in
midlife adults with and without Down syndrome living with family. J
Intellect Disabil Res 2007;51:1039e50.
22. Strauss D, Zigman WB. Behavioral capabilities and mortality risk in
adults with and without Down syndrome. Am J Ment Retard
1996;101:269e81.
23. Torr J, Strydom A, Patti P, Jokenen N. Aging in Down syndrome:
morbidity and mortality. J Policy Prac Intell Disabil 2010;2:70e81.
24. Schupf N, Winsten S, Patel B, Pang D, Ferin M, Zigman WB, et al.
Bioavailable estradiol and age at onset of alzheimers disease in post-
menopausal women with Down syndrome. Neurosci Lett
2006;406:298e302.
25. Baynard T, Pitetti KH, Guerra M, Unnithan VB, Fernhall B. Age-related
changes in aerobic capacity in individuals with mental retardation: a 20-
year review. Med Sci Sports Exerc 2008;40:1984e9.
26. Fernhall B, Millar AL, Tymeson GT, Burkett LN. Maximal exercise
testing of mentally retarded adolescents and adults: reliability study.
Arch Phys Med Rehabil 1990;71:1065e8.
27. Fernhall B, Pitetti KH. Limitations to work capacity in individuals with
intellectual disabilities. Clin Exerc Physiol 2001;3:176e85.
28. Eberhard Y, Eterradossi J, Rapacchi B. Physical aptitudes to exertion in
children with downs syndrome. J Ment Dec Res 1989;33(Pt
2):167e74.
29. Fernhall B, Baynard T, Collier SR, Figueroa A, Goulopoulou S,
Kamimori GH, et al. Catecholamine response to maximal exercise in
persons with Down syndrome. Am J Cardiol 2009;103:724e6.
30. Baynard T, Pitetti KH, Guerra M, Fernhall B. Heart rate variability at rest
and during exercise in persons with Down syndrome. Arch Phys Med
Rehabil 2004;85:1285e90.
31. Fernhall B, Otterstetter M. Attenuated responses to sympathoexcitation
in individuals with Down syndrome. J Appl Physiol 2003;94:2158e65.
32. Guimaraes CV, Donnelly LF, Shott SR, Amin RS, Kalra M. Relative
rather than absolute macroglossia in patients with Down syndrome:
implications for treatment of obstructive sleep apnea. Pediatr Radiol
2008;38:1062e7.
33. Baynard T, Unnithan V, Pitetti K, Fernhall B. Determination of venti-
latory threshold in adolescents with mental retardation with and without
Down syndrome. Pediatr Exerc Sci 2004;16:126e37.
34. Mendonca GV, Pereira FD, Fernhall B. Oxygen uptake kinetics during
exercise in adults with Down syndrome. Eur J Appl Physiol
2010;110:575e83.
35. Guerra M, Gene-Barriga, Fernhall B. Reliability of wingate testing in
adolescents with Down syndrome. Pediatr Exerc Sci 2009;21:47e54.
36. Fernhall B, Pitetti K, Stubbs Jr NLS. Validity and reliability of the 1/2
mile run-walk as an indicator of aerobic tness in children with mental
retardation. Pediatr Exerc Sci 1996;8:130e42.
37. Varela AMPK. Heart rate responses to two eld exercise tests by
adolescents and young adults with Down syndrome. Adapted Phys
Activity Q 1995;12:43e51.
38. Pitetti K, Fernhall B. Comparing run performance of adolescents with
metnal retardationewith and without Down syndrome. Adapted Phys
Activity Q 2004;21:219e28.
39. Fernhall B, Pitetti KH, Millar AL, Hensen T, Vukovich MD. Cross
validation of the 20 m shuttle run in children with mental retardation.
Adapted Phys Activity Q 2000;17:402e12.
40. Fernhall B, Pitetti KH, Vukovich MD, Stubbs N, Hensen T, Winnick JP,
et al. Validation of cardiovascular tness eld tests in children with
mental retardation. Am J Ment Retard 1998;102:602e12.
41. Guerra M, Pitetti K, Fernhall B. Cross validation of the 20-m shuttle run
test for adolescents with Down syndrome. Adapt Phys Activ Q
2003;20:70e9.
42. Agiovlasitis S, Pitetti KH, Guerra M, Fernhall B. Prediction of VO
2peak
from the 20-m shuttle-run test in youth with Down syndrome. Adapt
Phys Activ Q 2011;28:146e56.
43. Dodd KJ, Shields N. A systematic review of the outcomes of cardio-
vascular exercise programs for people with Down syndrome. Arch Phys
Med Rehabil 2005;86:2051e8.
44. Varela A, Sardinha L, Pitetti K. Effects of an aerobic rowing training
regimen in young adults with Down syndrome. Am J Ment Retard
2001;106:135e44.
45. Millar AL, Fernhall B, Burkett LN. Effects of aerobic training in
adolescents with Down syndrome. Med Sci Sports Exerc
1993;25:270e4.
46. Tsimaras V, Giagazoglou P, Fotiadou E, Christoulas K, Angelopoulou N.
Jog-walk training in cardiorespiratory tness of adults with Down
syndrome. Percept Mot Skills 2003;96:1239e51.
47. Rimmer JH, Heller T, Wang E, Valerio I. Improvements in physical
tness in adults with Down syndrome. Am J Ment Retard
2004;109:165e74.
48. Ordonez FJ, Rosety M, Rosety-Rodriguez M. Inuence of 12-week
exercise training on fat mass percentage in adolescents with Down
syndrome. Med Sci Monit 2006;12:CR416e9.
49. Dyer S. Physiological effects of a 13-week physical tness program on
Down syndrome subjects. Pediatr Exerc Sci 1994;6:88e100.
50. Lewis CL, Fragala-Pinkham MA. Effects of aerobic conditioning and
strength training on a child with Down syndrome: a case study. Pediatr
Phys Ther 2005;17:30e6.
51. Cioni M, Cocilovo A, Di Pasquale F, Araujo MB, Siqueira CR,
Bianco M. Strength decit of knee extensor muscles of individuals with
Down syndrome from childhood to adolescence. Am J Ment Retard
1994;99:166e74.
52. Mercer VS, Lewis CL. Hip abductor and knee extensor muscle strength
of children with and without Down syndrome. Pediatr Phys Ther
2001;13:18e26.
53. Pitetti K, Fernhall B. Aerobic capacity as related to leg strength in youths
with mental retardation. Pediatr Exerc Sci 1997;9:223e36.
54. Pitetti KH, Boneh S. Cardiovascular tness as related to leg strength in
adults with mental retardation. Med Sci Sports Exerc 1995;27:423e8.
55. Angelopoulou N, Matziari C, Tsimaras V, Sakadamis A, Souftas V,
Mandroukas K. Bone mineral density and muscle strength in young men
with mental retardation (with and without Down syndrome). Calcif
Tissue Int 2000;66:176e80.
56. Pitetti KH, Climstein M, Mays MJ, Barrett PJ. Isokinetic arm and leg
strength of adults with Down syndrome: a comparative study. Arch Phys
Med Rehabil 1992;73:847e50.
57. Croce RV, Pitetti KH, Horvat M, Miller J. Peak torque, average power,
and hamstrings/quadriceps ratios in nondisabled adults and adults with
mental retardation. Arch Phys Med Rehabil 1996;77:369e72.
58. Horvat M, Pitetti KH, Croce R. Isokinetic torque, average power, and
exion/extension ratios in nondisabled adults and adults with mental
retardation. J Orthop Sports Phys Ther 1997;25:395e9.
Youth with DS: Fitness and activity 55
59. Weber R, French R. Downs syndrome adolescents and strength training.
Clin Kinesiol 1988;42:13e21.
60. Shields N, Taylor NF. A student-led progressive resistance training
program increases lower limb muscle strength in adolescents with
Down syndrome: a randomised controlled trial. J Physiother
2010;56:187e93.
61. Cowley PM, Ploutz-Snyder LL, Baynard T, Heffernan KS, Jae SY,
Hsu S, et al. The effect of progressive resistance training on leg strength,
aerobic capacity and functional tasks of daily living in persons with
Down syndrome. Disabil Rehabil 2011;33:2229e36.
62. Shields N, Taylor NF, Dodd KJ. Effects of a community-based
progressive resistance training program on muscle performance and
physical function in adults with Down syndrome: a randomized
controlled trial. Arch Phys Med Rehabil 2008;89:1215e20.
63. Tsimaras VK, Fotiadou EG. Effect of training on the muscle strength and
dynamic balance ability of adults with Down syndrome. J Strength Cond
Res 2004;18:343e7.
64. Mendonca GV, Pereira FD, Fernhall B. Effects of combined aerobic and
resistance exercise training in adults with and without Down syndrome.
Arch Phys Med Rehabil 2011;92:37e45.
65. Rubin SS, Rimmer JH, Chicoine B, Braddock D, McGuire DE. Over-
weight prevalence in persons with Down syndrome. Ment Retard
1998;36:175e81.
66. De S, Small J, Baur LA. Overweight and obesity among children with
developmental disabilities. J Intellect Dev Disabil 2008;33:43e7.
67. Prasher V. Overweight and obesity amongst downs syndrome adults. J
Intellect Disabil Res 1995;39:437e41.
68. Sharav T, Bowman T. Dietary practices, physical activity, and body-mass
index in a selected population of Down syndrome children and their
siblings. Clin Pediatr (Phila) 1992;31:341e4.
69. Luke A, Sutton M, Schoeller DA, Roizen NJ. Nutrient intake and obesity
in prepubescent children with Down syndrome. J Am Diet Assoc
1996;96:1262e7.
70. Baptista F, Varela A, Sardinha LB. Bone mineral mass in males and
females with and without Down syndrome. Osteoporos Int
2005;16:380e8.
71. Gonzalez-Aguero A, Ara I, Moreno LA, Vicente-Rodriguez G,
Casajus JA. Fat and lean masses in youths with Down syndrome: gender
differences. Res Dev Disabil 2011;32:1685e93.
72. Grammatikopoulou MG, Manai A, Tsigga M, Tsiligiroglou-
Fachantidou A, Galli-Tsinopoulou A, Zakas A. Nutrient intake and
anthropometry in children and adolescents with Down syndromeea
preliminary study. Dev Neurorehabil 2008;11:260e7.
73. Stancliffe RJ, Lakin KC, Larson S, Engler J, Bershadsky J, Taub S, et al.
Overweight and obesity among adults with intellectual disabilities who
use intellectual disability/developmental disability services in 20 U.S.
States. Am J Intellect Dev Disabil 2011;116:401e18.
74. Rowland T. Physical activity, tness, and children. In: Bouchard C,
Blair SN, Haskell WL, editors. Physical activity and health. Champaign,
IL: Human Kinetics; 2007. p. 259e70.
75. Strong WB, Malina RM, Blimkie CJ, Daniels SR, Dishman RK, Gutin B,
et al. Evidence based physical activity for school-age youth. J Pediatr
2005;146:732e7.
76. Physical Activity Guidelines Advisory Committee. 2008 physical
activity guidelines for Americans. Washington, DC: U.S. Department of
Health and Human Services; 2008.
77. Troiano RP, Berrigan D, Dodd KW, Masse LC, Tilert T, McDowell M.
Physical activity in the united states measured by accelerometer. Med Sci
Sports Exerc 2008;40:181e8.
78. Frey GC, Stanish HI, Temple VA. Physical activity of youth with
intellectual disability: review and research agenda. Adapt Phys Activ Q
2008;25:95e117.
79. Matthews L, Hankey C, Penpraze V, Boyle S, Macmillan S, Miller S,
et al. Agreement of accelerometer and a physical activity questionnaire
in adults with intellectual disabilities. Prev Med 2011;52:361e4.
80. Beets MW, Combs C, Pitetti KH, Morgan M, Bryan RR, Foley JT.
Accuracy of pedometer steps and time for youth with disabilities. Adapt
Phys Activ Q 2007;24:228e44.
81. Beets MW, Pitetti KH. Using pedometers to measure moderate-to-
vigorous physical activity for youth with an intellectual disability. Dis-
abil Health J 2011;4:46e51.
82. Pitetti KH, Beets MW, Flaming J. Accuracy of pedometer steps and time
for youth with intellectual disabilities during dynamic movements. Adapt
Phys Activ Q 2009;26:336e51.
83. Pitchford EA, Yun J. The accuracy of pedometers for adults with Down
syndrome. Adapt Phys Activ Q 2010;27:321e36.
84. Agiovlasitis S, Beets MW, Motl RW, Fernhall B. Step-rate thresholds for
moderate and vigorous-intensity activity in persons with Down
syndrome. J Sci Med Sport 2012;15:425e30.
85. Agiovlasitis S, Motl RW, Fahs CA, Ranadive SM, Yan H, Echols GH,
et al. Metabolic rate and accelerometer output during walking in people
with Down syndrome. Med Sci Sports Exerc 2011;43:1322e7.
86. Agiovlasitis S, McCubbin JA, Yun J, Mpitsos G, Pavol MJ. Effects of
Down syndrome on three-dimensional motion during walking at
different speeds. Gait Posture 2009;30:345e50.
87. Kubo M, Ulrich B. Coordination of pelvis-hat (head, arms and trunk) in
anterior-posterior and medio-lateral directions during treadmill gait in
preadolescents with/without Down syndrome. Gait Posture
2006;23:512e8.
88. Ulrich BD, Haehl V, Buzzi UH, Kubo M, Holt KG. Modeling dynamic
resource utilization in populations with unique constraints: preadoles-
cents with and without Down syndrome. Hum Mov Sci 2004;23:133e56.
89. Pinter JD, Eliez S, Schmitt JE, Capone GT, Reiss AL. Neuroanatomy of
downs syndrome: a high-resolution mri study. Am J Psychiatry
2001;158:1659e65.
90. Whitt-Glover MC, ONeill KL, Stettler N. Physical activity patterns in
children with and without Down syndrome. Pediatr Rehabil
2006;9:158e64.
91. Shields N, Dodd KJ, Abblitt C. Do children with Down syndrome
perform sufcient physical activity to maintain good health? A pilot
study. Adapt Phys Activ Q 2009;26:307e20.
92. Block ME. Motor development in children with Down syndrome:
a review of the literature. Adapt Phys Activ Q 1991;8:179e209.
93. Ulrich BD, Ulrich DA. Spontaneous leg movements of infants with
Down syndrome and nondisabled infants. Child Dev 1995;66:1844e55.
94. Ulrich DA, Ulrich BD, Angulo-Kinzler RM, Yun J. Treadmill training of
infants with Down syndrome: evidence-based developmental outcomes.
Pediatrics 2001;108:E84.
95. Mazzone L, Mugno D, Mazzone D. The general movements in children
with Down syndrome. Early Hum Dev 2004;79:119e30.
96. Lloyd M, Burghardt A, Ulrich DA, Angulo-Barroso R. Physical activity
and walking onset in infants with Down syndrome. Adapt Phys Activ Q
2010;27:1e16.
97. McKay SM, Angulo-Barroso RM. Longitudinal assessment of leg motor
activity and sleep patterns in infants with and without Down syndrome.
Infant Behav Dev 2006;29:153e68.
98. Luke A, Roizen NJ, Sutton M, Schoeller DA. Energy expenditure in
children with Down syndrome: correcting metabolic rate for movement.
J Pediatr 1994;125:829e38.
99. Esposito PE, Macdonald M, Hornyak JE, Ulrich DA. Physical activity
patterns of youth with Down syndrome. Intellect Dev Disabil
2012;50:109e19.
100. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical
activity benets of learning to ride a two-wheel bicycle for children with
Down syndrome: a randomized trial. Phys Ther 2011;91:1463e77.
101. Phillips AC, Holland AJ. Assessment of objectively measured physical
activity levels in individuals with intellectual disabilities with and
without Downs syndrome. PLoS One 2011;6:e28618.
102. Jobling A, Cuskelly M. Young people with Down syndrome: a prelimi-
nary investigation of health knowledge and associated behaviours. J
Intellect Dev Disabil 2006;31:210e8.
103. Oates A, Bebbington A, Bourke J, Girdler S, Leonard H. Leisure
participation for school-aged children with Down syndrome. Disabil
Rehabil 2011;33:1880e9.
104. Menear KS. Parents perceptions of health and physical activity needs of
children with down syndrom. Downs Syndr Res Pract 2007;12:60e8.
56 K. Pitetti et al.
105. World Health Organization. International classication of functioning,
disability and health (ICF). Geneva: World Health Organization; 2001.
106. Leonard S, Msall M, Bower C, Tremont M, Leonard H. Functional status
of school-aged children with Down syndrome. J Paediatr Child Health
2002;38:160e5.
107. Barr M, Shields N. Identifying the barriers and facilitators to participa-
tion in physical activity for children with Down syndrome. J Intellect
Disabil Res 2011;55:1020e33.
108. Wuang Y, Su CY. Patterns of participation and enjoyment in adolescents
with Down syndrome. Res Dev Disabil 2012;33:841e8.
109. Latash ML. Motor coordination in Down syndrome: the role of adaptive
changes. In: Weeks DJ, Chua R, Elliot D, editors. Perceptual-motor
behavior in Down syndrome. Champaign, IL: Human Kinetics; 2000.
p. 199e223.
110. Lin JD, Lin PY, Lin LP, Chang YY, Wu SR, Wu JL. Physical activity and
its determinants among adolescents with intellectual disabilities. Res Dev
Disabil 2010;31:263e9.
111. Buttimer J, Tierney E. Patterns of leisure participation among adoles-
cents with a mild intellectual disability. J Intellect Disabil
2005;9:25e42.
112. Jobling A. Life be in it: lifestyle choices for active leisure. Downs Syndr
Res Pract 2001;6:117e22.
113. Pitetti KH, Beets MW, Combs C. Physical activity levels of children with
intellectual disabilities during school. Med Sci Sports Exerc
2009;41:1580e6.
114. Heller T, Hsieh K, Rimmer JH. Attitudinal and psychosocial outcomes of
a tness and health education program on adults with Down syndrome.
Am J Ment Retard 2004;109:175e85.
Youth with DS: Fitness and activity 57