EDUCATIONAL MODULE

Vol. 11(6), June 2003

HYSICAL ACTIVITY
FOR CHILDREN
AND YOUTH

Canadians are gaining awareness of the health

benefits of physical activity. Behaviour change must
follow awareness, however, if patients are to
counter the health risks associated with sedentary
living.
Physicians are continually challenged to identify
effective and practical strategies to encourage
ongoing participation in physically active pursuits
particularly when sedentary choices for recreation
and leisure options are so popular.
To help family physicians facilitate positive changes
in physical activity levels, this module will explore
the factors that influence physical activity
participation, and will provide a set of practical tools
for interacting with children and parents.
CASES
Case 1: Jamie B., age 4, male
Jamie is a healthy youngster who is in for a checkup
and immunization update prior to starting school.
[The following questions also could apply at earlier
well-child visits anytime from 2 years on.]
How could you incorporate physical activity
into the anticipatory guidance provided at a
well-care visit?
How could you counsel Jamies parents about
enhancing their childs recommended amount
of physical activity?
Case 2: Farah W., age 8, female
Farahs mother has brought her in today, requesting
a note that her daughter be allowed to take the bus
to school for medical reasons. Farah is a healthy
youngster who is doing well academically.

EDUCATIONAL MODULE

Volume 11(6), June 2003

a decrease in resting blood pressure in adults. 5,6,9

Her mother is concerned because she has to walk one

kilometre to school each way and is exhausted by the
time she gets home from school. The school board
provides a bus for children who live more than one
kilometre away, but will not provide it for Farah because
she lives within that boundary. Farahs mother also
expresses concern about her childs safety while walking
to and from school.

3. Because physical activity is correlated with lower

fasting insulin and greater insulin sensitivity in
childhood (Level 4 evidence), increasing physical
activity levels may also reduce the risk of type 2
diabetes in children.6,10
At this time, there are a limited number of large, highquality studies by which to more definitively evaluate
other effects of physical activity. 11

How could you determine if Farah is getting the

recommended amount of activity for her age?
What strategies could help Farah become more
physically active?
How could you address the mothers concerns
about Farahs walking to school?

Role of Family Physicians

4. Family physicians are in a position to significantly
influence the physical activity levels of their young
patients, and they will see more than 90% of youths
aged 5-17 years in their practice at least once in a
two-year period.12,13

Case 3: Rob S., age 13, male

Rob presents with a mild cold and complains about
feeling tired a lot of the time. As part of the exam, you
notice that he is at the 95th percentile in height and 15
kg above the 95th percentile in weight. On further
enquiry, he appears to be sensitive about his size. His
main form of physical activity is "gym", which occurs
twice a week at school. Each gym period is 40 minutes
long and includes time for changing clothes, taking
attendance, and setting out/striking equipment. Rob is
also having some problems in school performance.

5. The optimal time for broaching the subject of

physical activity is during routine checkups or well
visits. Secondary opportunities occur during
follow-up appointments for injuries or illnesses,
visits for chronic diseases (e.g. asthma), and
physical examinations before participation in sports
or camp programs. 13
6. Younger children rely heavily on parental support
and direction in becoming more physically active.
Although physicians may have concerns about
actively promoting physical activity with parents, a
considerable majority of Canadian adults are either
already active, taking steps to become active, or in
a period of relapse from activity.14 They are,
therefore, likely to support initiatives to increase the
physical activity of their children.

How could you use this opportunity to initiate a

discussion with Rob about physical activity?
How could you assist Rob in getting the
recommended amount of activity for his age?
How could you counter Robs reluctance to
becoming more active?

Current Recommendations

INFORMATION SECTION

7. Adult guidelines for physical activity are not

necessarily appropriate for children and
adolescents.15 Adults frequently choose physical
activity that is structured, highly organized, and
often continuous in nature. In contrast, childrens
activity is characterized by short bursts of activity,
alternating with frequent short periods of rest.
Given sufficient free time, children tend to
accumulate a greater volume of physical movement
through active, unstructured play.15

Benefits of Physical Activity

1. In children and adolescents, daily physical activity
has many benefits. A variety of studies (Level 4
evidence) have shown that it can:
positively affect lean muscle mass and bone
density1,2
help decrease excess body fat3 and/or maintain
a healthy body weight4,5
improve self-esteem and decrease anxiety,
depression, and moodiness6,7
enhance academic performance8

8. Canadas Physical Activity Guides (Appendix 4)

have tried to de-emphasize absolute values in
time spent in physical activity and have taken the
approach of increasing accumulated time spent in
physical activity and decreasing accumulated

2. Physical activity helps reduce resting blood pressure

in children and adolescents with hypertension (Level
4 evidence) and has been positively correlated with
2

EDUCATIONAL MODULE

Volume 11(6), June 2003

screen time (e.g., television , computer, video).16

It is recommended, however, that at least 30
minutes of active time each day be spent in
vigorous activities (such as running, basketball, or
soccer).17 For optimal health benefits, other studies
suggest as much as 2 to 2.5 hours per day of active
incidental play (NOT continuous play) for pre-school
or elementary school children.6,18

13. Physicians and their staff can demonstrate support

of healthy living and physical activity through 13 23:
exhibiting posters which advertise community
events or recreation schedules
leaving a supply of take-away copies of the
various Health Canada Physical Activity
resources for Children and for Youth (see
Appendix 3) in the waiting room
leaving help yourself physical activity
prescription pads (Appendices 5 and 6) in the
waiting room
arranging with community recreation sources to
display their up-to-date brochures in the waiting
room
conspicuously posting a list of local day care
centres, recreation centres, or fitness facilities
that promote physical activity for children.6
displaying on office walls photographs of
physicians and staff engaged in physical activity
or local community fundraising initiatives

Strategies for Promoting Physical Activity

For Physicians
9. Systematically Ask, Advise, Assist during routine
visits to raise the awareness of patients and parents
about physical activity limits and/or lifestyle choices
(a strategy devised originally for smokers).19 Use
the Ask phase to uncover what the patient
considers an important benefit, and use that
information to drive the Advise and Assist
phases.

14. Consider wearing a pedometer as way to role

model the importance of physical activity. It
potentially provides a bond between patient and
physician, particularly if the physician can
commiserate with the patient on challenges in
meeting the recommended 10,000 steps per day.
(See Info point 26 and Patient Information Sheet
for more details on a pedometer). 24

Ask every patient about physical activity

levels and the personal benefits.
Advise on simple solutions to reducing
inactivity.
Assist with specific recommendations for
physical activity when asked.

15. Physicians can use their influence in communities

to speak out strongly in favour of quality daily
physical education (QDPE)6, especially if parents
feel that school is the one safe place for children
and youth to get some of the recommended daily
physical activity.

10. Encourage young patients, where appropriate, to

be active during recess, at lunch, and immediately
after school hours and on weekends. This strategy
has been shown to be valuable in setting good
physical activity patterns.20
11. Discuss with parents the time commitment
involved in assisting children to be more active and
in providing transportation to appropriate sites for
physical activity such as a recreation centre; local
park; dance, martial arts, or gymnastics studio; or
sports facility.21

For Parents

12. Understand the influence of age, gender, and

cultural background to help identify at-risk
populations and set the stage for successful
interventions that take into account different
cohorts: 22
young girls who are characteristically less active
than boys
minority ethnic groups, where culturallyappropriate opportunities may be an issue
pre-adolescence, when physical activity levels
begin to drastically decline.

17. Parents should consider being physically active

with their children and families a top priority. 26

16. Parents are powerful physical activity role models

for their children 20, with studies showing a 30% to
40% positive association with a childs being
active25, particularly during the first decade of life.16

EDUCATIONAL MODULE

Volume 11(6), June 2003

Sample activities for parents to consider:

Take your older child to the fitness centre with
you
Get involved in a program for Moms/Dads
and Tots
Help coach a sport team where your child is
involved
Go swimming or hiking as a family on the
weekend
Walk to school with the children

playgrounds16, and the building of new

playgrounds (per 20,000 people there are twice
as many golf courses as playgrounds) 29
arrange for a trained professional to supervise
or monitor their childs exercise time either
singly (if this is financially feasible) or as part
of a group in a recreation centre.20

Table 1. Factors to consider in counseling about

physical activity
FACTORS ASSOCIATED WITH PHYSICAL ACTIVITY IN

18. A simple and effective way for parents to increase

physical activity among their children is to ensure
that they have time to play outdoors either during
the day (for pre-school children) or after school.5,21

CHILDREN AND YOUTH22

Children

Youth (Variables can be

divided into two
categories)

19. As many as 75% of children engage in inactive

pursuits after school: doing homework, reading,
watching television, or playing computer or video
games. These pursuits often add up to the
equivalent of a full-time desk job (i.e., 40 hours per
week)! It has been shown that children and youth
who are not active after school, or are not involved
in community sports programs, are generally
sedentary.21

time spent outdoors

an inclination to be
physically active
a healthy diet
previous experience
with physical
activity
access to both
facilities and
equipment
intention to be
physically active

Psychological and
behavioural:
level of self-esteem
and perceived
competence
sensation seeking
previous experience
with physical activity
participation in
community sports
Social/cultural and
physical environment
parental support
support from
significant others
siblings who are
physically active
opportunities to be
physically active

20. While intrinsic motivation (e.g., having fun) is

crucial to ongoing participation, parents can use
extrinsic motivators (such as calendars, daily logs,
journals, or rewards) to nurture increased physical
activity or a more active lifestyle. 20 Nearly half of
parents agree that being physically active for fun is
preferable to competition and winning for their
children.20
21. Therefore, activities that are selected to foster
confidence, competence, and, most of all,
enjoyment are critical in enticing children to be
more active.

The following are associated with a negative effect

on physical activity levels
perceived barriers
to physical activity

22. Parents can take the following actions to improve

physical activity levels:
create walking school buses 27, cooperatives
to supervise physical activity, and/or car pools
to share responsibility for transporting children
to or from activity programs.21
lobby with the school board for a greater
emphasis on daily quality physical education
(QDPE) 28 and a greater access to facilities for
unstructured play during and after school
hours.20 28 16
approach
city
hall
about sidewalk
maintenance, the creation of safe cycling
routes 21, the installation of lighting in

depression
inactive pursuits after
school and on
weekends

Children
23. Children should naturally be more active than
adults.18 One of the ways for children to maintain
a healthy balance of caloric intake and output is to
be physically active for at least 60 minutes per
day.15
24. Children age 4 years to 12 years respond positively
to activities that are FUN. They are more willing
4

EDUCATIONAL MODULE

Volume 11(6), June 2003

to be involved in activities they enjoy and/or

personally select, than in activities that their
parents may favour or think beneficial.21
Making activity seem fun for children,
therefore, is a key to promoting participation.

THE BOTTOM LINE

Seize available opportunities to promote
physical activity (at well-care visits, during
visits for follow-up or for minor problems).
Take advantage of the waiting room to actively
promote physical activity.
Encourage kids to be active outdoors after
school and on weekends.
Involve parents both as role models and
facilitators of physical activity for their children.

25. Regular positive feedback from parents as well as

physicians help children stick with their physical
activity prescription or program.15
26. Pedometers are simple to use, inexpensive, and
self-motivating devices to get older children
involved in their own activity levels. 30
a. The following range of steps has been
suggested in the literature based on a 5-day
pedometer program.30:
12,000 to 16,000 steps as a goal for
children 8-10 years;3
11,000 to 12,000 steps for
adolescents 14 to 16 years old.30
b. The disadvantage is that they do not provide
intensity levels of exercise. 30

CASE COMMENTARIES
Case 1: Jamie B., age 4, male
How could you incorporate physical activity into
the anticipatory guidance provided at a well-care
visit?
Anticipatory guidance has been a traditional part of wellbaby and well-child care. Until recently, evidence was
not necessary for physicians to encourage parents to
ensure play time for children as it was taken for granted
that children would play and be active. Sadly, this is no
longer the case.

27. Other self-monitoring tools that children could

create and/or use, include:
a personal log sheet for recording activity
levels, designed by children themselves using
their computer skills
the poster-sized Health Canada
Physical Activity Chart with colourful
stickers available at no charge through
the Health Canada website
(http://www.healthcanada.ca/paguide) or
by calling 1-888-334-9769.

Making a personal notation about physical activity under

the heading of Education and Advice on the Rourke
Baby Record, Guide III, (available at
http://www.ctfphc.org) of young patients, can serve as a
reminder to inquire about physical activity at well-care
visits.

Youth/adolescents

In provinces where funding does not cover well-care

visits up to the age 5 years, physicians will need to take
advantage of visits for other reasons in order to
introduce the topic of physical activity (Info point 5).
The following Talking Tips, modeled after Ask,
Advise, Assist, could be helpful in a discussion with the
child and parents (Info point 9). (See Appendix 1 for
other interview question samples)

28. Adolescents might be enticed into being more

active by experimenting with less traditional kinds
of activities (e.g. rock climbing, skateboarding,
street or hip hop dancing, or kayaking) available in
the community, through school or municipal
recreation departments.31
29. Youth involved in organized sports, in contrast with
youth not so involved, expend more energy in
moderate to vigorous activities and spend less time
watching television than their less active peers.32
30. Physicians may be able to engage adolescents in
setting goals and objectives for the Lets Get
Active prescription by acknowledging their growing
desire for independent decision making.31

EDUCATIONAL MODULE

Volume 11(6), June 2003

Jamies parents investigate municipal programs or
offerings of not-for-profit organizations like YMCAs or
YWCAs, where subsidized programs and services are
available.

Talking Tips
Is your child involved in active play on most, if
not all, days of the week?
Would you say that the total length of time
accumulated in active play adds up to at least
2 hours per day?
In the past 6 months, has your child been
involved in community physical activity
programs (such as swimming or childrens
gymnastics or Tee ball)?
How much television do you allow your child
to watch each day?
What active things do you do together as a
family?
Do you believe your child is active enough to
be healthy?
Adapted from Patrick, 2001 6

Case 2: Farah W., age 8, female

How could you determine if Farah is getting the
recommended amount of activity for her age?
The patient requesting support for something that is not
necessarily medical always represents a difficult
situation. Frequently, it will require some exploration of
the issues to understand both the child and the parents
points of view as well as some tact and provision of
information.
If Farahs mother seems concerned about a medical
condition causing the exhaustion, it may be necessary,
at some time, to perform a physical examination and/or
other testing to provide reassurance. Address other
barriers to physical activity that might be causing
concern for both Farah and her mother.

Depending upon the maturity level of the child, the

physician might choose to directly ask the young patient
a couple of questions about physical activity levels.
How could you counsel the parents about
enhancing Jamies physical activity level?

When illness has been ruled out, then Farah could be

asked for more information about her daily activity
habits.

Try to determine the level of importance that the parents

place on physical activity and their willingness to work
with their children at increasing physical activity. This
information will influence the guidance that you provide.

Talking Tips
What kinds of activities do you and friends
do?
How much time each day do you spend in
physical education at school?
Do you belong to any sports teams either at
school or in the community?
What do you do after school?
What kinds of activities do you do with your
family (brothers and sisters)?
How much time do you spend watching
television, surfing the net, or playing video
games?

Advise Jamies parents that, for children this age, it is

reasonable to expect as much as 2 to 2.5 hours per day
of active play for optimal growth and development. This
play, however, usually is incidental and intermittent
rather than planned or structured (Info point 7) by just
allowing Jamie to play outdoors for at least part of the
day (Table 1. Factors to consider in counseling about
physical activity, page 4) and encouraging doing
activities he enjoys and finds fun (Info point 24).
If neighbourhood safety is an issue, Jamies parents
can form a block cooperative whereby parents rotate
responsibility for a group of children in the home yard.
Alternatively, this same cooperative can take turns
getting a group of children to preschool or local
activities, either by walking the children to and from the
centre or facility, or by providing transportation (Info
point 22). Provide Jamies parents with brochures of
community activities, programs, and services
(preferably available in your waiting room) (Info point
13) and suggest that they contact one of the
participating organizations about suitable programming.
If the cost of programs is a concern, suggest that

(See Appendix 1 for more suggestions)

If it appears that Farah participates on school teams, is
active at recess, and has numerous lessons (violin,
ballet, gymnastics, piano, swimming) throughout the
week, counsel Farahs mother about the benefit of
unstructured time and creative play.
If you have determined that Farahs current level of
activity is insufficient to achieve the necessary health
benefits, provide Farahs mother with information on the
6

EDUCATIONAL MODULE

Volume 11(6), June 2003

If Farahs mother is concerned about her child walking
alone to school, she could organize a neighbourhood
parent cooperative (as in Case 1) and create a walking
school bus (Appendix 3) where a group of youngsters
walk together to and from school, perhaps accompanied
by a parent who works from home (a great way to
increase the physical activity level of the parent at the
same time). Perhaps Farah could walk to school with
other children who live in her neighbourhood. If there is
a concern that is not related to physical capability (for
example, bullies on the way to school, taunting),
another child may be having a similar problem. Ask
Farahs mother if she would consider telephoning
another mother to explore this possibility.

amount of physical activity that is normal and healthy for

an 8-year-old.(Appendix 4)
Note that if Farah takes 12 to 15 minutes to walk to
school (a reasonable, moderate pace), her total
accumulated walking time would be 25 to 30 minutes.
The daily walk to school, then, is less than the optimal
recommendation of moderate accumulated activity per
day including 15-minute individual bouts of exercise
and Farah should consider increasing her daily physical
activity by 30 minutes (Appendices 4 and 5 and Info
point 8).
What strategies could help Farah become more
physically active?

Case 3: Rob S., age 13, male

Ask Farah and her mother to consider purchasing a

pedometer to determine if Farah is getting an adequate
amount of physical activity. Provide Farah and her
mother with a Pedometer Exercise Prescription
(Appendix 7) and information about how to obtain a free
booklet on pedometers (available from the Alberta
Centre for Active Living, Appendix 3, # 9). The
prescription and booklet will explain the purpose of
pedometers as well as how to undertake and record this
type of exercise. Encourage Farahs mother to walk and
play with her daughter and oversee her chart-keeping
activities as a means for providing vital support and
motivating feedback (Info point 25). As is appropriate
for an 8-year-old, the pedometer results will provide
information on the volume of Farahs daily activity but
not the intensity (Info point 26). The idea behind the
strategy is simply to get Farah more active by engaging
her in a self-monitoring, quantifiable measure to chart
her progress.
As an alternative strategy, help Farah choose one or two
activities that she really enjoys doing and that can be
done after school or on weekends. Provide her with a
Call to Action prescription (Appendix 5), and check off
the activity preferences and the recommended increase
levels, that you have determined in prior discussion.
Also refer Farah and her mother to recreation activities
brochures (preferably available in the waiting room) and
suggest they investigate some of the community
recreation programs that might interest Farah, such as
swimming, dancing, after-school clubs, martial arts, or
martial arts alternatives (Info point 24). These activities
can be used to fulfill the goal activity requirements in the
prescription. Farah and her mother can consider
participating in these activities together (Info point 17).
Often organizations like the YWCA will have combined
classes for parents and children.

How could you use this opportunity to initiate a

discussion with Rob about physical activity?
Here is another opportunity to Ask, Assist, and Advise.
During Robs examination, brief discussion on his
current physical activity level might open with
Sometimes fatigue and lack of energy can actually be
the result of not enough physical activity. Describe for
me your activity during a typical day. What activities do
you prefer?. The written prescription could recommend
that, until the cold abates, Rob bundle up and do two
10-minute sessions of light activity each day in the
fresh air (like walking or bike riding) until his return visit
in 2 weeks. Remind him about his personal
responsibility for getting better (Info point 30).
An intervention during an unrelated visit is typically
brief, simply an awareness-raising or planting-of-theseed for a follow-up visit in a couple of weeks (Info
point 5). To ensure that Rob returns to see you,
schedule a follow-up appointment to discuss the results
of a throat swab or blood work, and Robs progress on
the written prescription. This is an opportune time in
Robs life to intervene because physical activity levels
drop drastically between grades 7 and 11, and it is
easier to keep adolescents participating in physical
activity than it is to overcome the inertia of inactivity.
How could you assist Rob in getting the
recommended amount of activity for his age?

How could you address the mothers concerns

about Farahs walking to school?

EDUCATIONAL MODULE

Volume 11(6), June 2003

Mention information resources available to Rob through
the Physical Activity Guide and provide Rob with a copy
of the Lets Get Active Magazine for Youth (Appendix
3). The baseline recommendations for his Dare to be
Active! prescription (Appendix 6) will be determined
from the answers Rob gives to your questions about his
physical activity habits and preferences.
If time
permits, a couple of quick anthropometric
measurements (e.g. waist, chest, and upper arm) would
provide a measurable benchmark for comparison at
Robs follow-up appointment in a month, the typical
length of time that it takes to adopt or discard a potential
habit.

Talking Tips
Including your physical education classes,
how much time did you spend in physical
activity in the last 2 days (the last week?)
What do you and your friends usually do
during your free time?
What do you generally do when you get
home from school?
How much time do you spend watching
television, surfing the net, or play
computer/video games each day?
What kinds of activities do you do as a
family?
A couple of quick questions will provide a rough
picture of Robs current physical activity levels.

How could you counter Robs reluctance to

becoming more active?
Anticipate resistance from Rob. He might say he gets
plenty of physical activity during school physical
education classes. Discuss with him that the activity
provided at school is meant only as a supplement to the
physical activity he gets at home and through other
activities.

Rob needs to add 30 minutes daily to his activity levels

and decrease his screen time by 30 minutes (Info point
8 and Appendix 4). Health Canada strongly
recommends vigorous activity for at least 30 minutes of
this daily total. As an ultimate goal for fitness after 5
months, Rob might aim at 3 or more weekly sessions of
continuous moderate or vigorous activity lasting at least
20 minutes each session (Appendix 4).

Rob might better understand the relationship between

physical activity and his current size if he actually sees
the chart showing the percentile comparison of height
and weight. With an explanation of the percentile
results, he might begin to understand the need to
balance out his weight and his height so that they better
match and that increasing physical activity in the
presence of his already healthy diet should help create
this balance (Info point 23). This is a good opportunity
to explore Robs poor self-image.

To engage Rob in taking responsibility for his physical

activity, suggest that he explore sports (such as
basketball or football) where his size is an advantage.
He also could experiment with less traditional and
currently cool physical activity options such as rock
climbing, skateboarding, or kayaking (Info point 28).
Robs present size also perfectly suits a supervised
resistance training program, where extra mass is
advantageous. Supervised resistance training programs
are available through the YMCA or YWCA, Municipal
Recreation Centres, Public Health Department, or local
commercial fitness centres. Rob can select from the
programs and services offered in the brochures in the
waiting room (Info point 13). As suggested in the Dare
to Be Active prescription (Appendix 6), Rob can track
his activity on a computer chart or journal that he
designs for himself, in a daily logbook, or on a school
day planner. Request that Rob bring his personal track
record with him to the next visit so that you might
discuss the results of his prescription and his reaction
to it (Info point 30). The success that he will experience
will positively affect his self-esteem and improve both
his perception of, and his actual, body image (Info point
1). These activities might also appeal to Robs friends,
so that they could participate as a group, an important
concept (support from significant others) in promoting
physical activity at this age (Table 1. Factors to consider
in counseling about physical activity, page 4).

Rob may mention that transportation to and from

activities is an issue. The waiting room literature will
provide low-cost activity opportunities available at
community centres or municipal facilities. Suggest that
Rob pick up a copy of interesting brochures and
recommend that he discuss his transportation issue with
his parents. You could offer to call his parents to
reinforce your prescription recommendation, raise the
issue of transportation and suggest his parents consider
linking with other parents to create a car pool or
helping Rob choose activities in a facility that is within
walking distance for Rob (Table 1. Factors to consider
in counseling about physical activity, page 4).

The Foundation for Medical Practice Education,

volume 11(6):1-8, June 2003

Production of this document has been made

possible by a financial contribution from the
8

EDUCATIONAL MODULE

Volume 11(6), June 2003

Population Health Fund, Health Canada. The views

expressed herein do not necessarily represent the
official policies of Health Canada.

Authors:

The Foundations module team would like to

acknowledge, with thanks, the PBSG group facilitated by
Dr. Garth Verbonac, Surrey, British Columbia, who pilottested this educational module.

Francine Lemire, CCFP, FCFP

Family Physician
Mississauga, Ontario
J.W. Mackie, FACSM,
DipSports Med, CCFP
Family Physician
Vancouver, British Columbia

We encourage you to direct your questions and

comments to the clinical discussion bulletin board
on our website: www.fmpe.org

Storm Russell, PhD

Psychologist
Wakefield, Quebec

While every care has been taken in compiling the information

contained in this module, the Program cannot guarantee its
applicability in specific clinical situations or with individual patients.
Physicians and others should exercise their own independent
judgement concerning patient care and treatment, based on the
special circumstances of each case.
Anyone using the information does so at their own risk and releases
and agrees to indemnify The Foundation for Medical Practice
Education and the Practice Based Small Group Learning Program
from any and all injury or damage arising from such use.

Reviewers:

Oded Bar-Or, MD, FACSM

Professor of Pediatrics
Hamilton, Ontario
Maureen F. Kennedy, MD,
CCFP, MSc Exercise Medicine,
Dip. Sport Med.
Director, Fitness MD
Calgary, Alberta

Medical Editor:

Richard Russek, MD, CCFP

Family Physician
Cambridge, Ontario

Associate Editor: Lynda Cranston, Hons BA

Hamilton, Ontario
Medical Writer/
Researcher:

Dawnelle Hawes, BA, BKin, MEd

Hamilton, Ontario

EDUCATIONAL MODULE

Volume 11(6), June 2003

LEVELS OF EVIDENCE
Level of
Evidence

Therapy/Prevention

Prognosis

Diagnosis

1a

Systematic review or meta-analysis of welldesigned randomized trials using explicit

criteria for inclusion and including
adequately large total numbers

Systematic review (with homogeneity) of

inception cohort studies or a CDR
(clinical decision rule or guide) validated
in different populations

Systematic review (with homogeneity) of

Level 1 diagnostic studies; or a clinical
decision rule validated in different clinical
centres

1b

Large randomized trials with clear-cut

results (and low risk of error)

Individual inception cohort study with

$80% follow-up

Study with independent blind comparison

of an appropriate spectrum of consecutive
patients

1c

All or none case-series

All or none case-series

Absolute positive specificity (rules in

diagnosis) or negative sensitivity (rules
out)

2a

Systematic review or meta-analysis of welldesigned randomized trials using explicit

criteria for inclusion but still with moderate
risk of error (e.g., often with subgroup
analysis).
Systematic review of cohort studies with
homogeneity

Systematic review (with homogeneity) of

retrospective cohort studies or untreated
control groups in RCTs

Systematic review (with homogeneity) of

diagnostic studies at 2b level

2b

Small RCT with moderate to high risk of

error [low power]:
a. Trial with high false-positive ()
errorinteresting positive trend that is not
statistically significant.
b. Trial with high false-negative () errora
negative trial that could not exclude the
real possibility of a clinically important
benefit or difference because of small
numbers.
Individual well-designed cohort study

Retrospective cohort study or follow-up of

untreated control patients in an RCT or
CPG not validated in a test set

Any of:
Independent blind or objective
comparison;
Study performed in a set of nonconsecutive patients, or confined to a
narrow spectrum of study individuals (or
both), all of whom have undergone both
the diagnostic test and the reference
standard;
A diagnostic CDR not validated in a test
set

2c

Audit or Outcomes Research

Audit or Outcomes Research

3a

Systematic review of case-control studies

with homogeneity

Prospective or retrospective cohort study

of adequate size, but with some
limitations in methodology

3b

Individual well-designed case-control study

Case-series;
Cohort and case-control studies that lack
defined comparison groups and/or did not
measure interventions & outcomes in
similar and appropriate ways

Poor quality prognostic cohort studies in

which sampling was biased or
measurement of outcomes achieved in
<80% of study patients

Case-control study in which:

Reference standard was unobjective,
unblinded or not independent;
Positive and negative tests were not
verified using separate reference
standards; or
Study was performed in an
inappropriate spectrum of patients

Expert opinion (individual or committee)

without explicit critical appraisal

Expert opinion without explicit critical

appraisal, or based on physiology, bench
research or first principles

Expert opinion without explicit critical

appraisal, or based on physiology, bench
research or first principles

Systematic review with homogeneity of 3b

studies
Study with independent blind comparison
of an appropriate spectrum, but the
reference standard was not applied to all
study patients; Non-consecutive study

adapted from Sackett DL. Rules of evidence and clinical recommendations. Can J Cardiol 1993;9:487-489
and NHS Research and Development Centre for Evidence-Based Medicine 2001.

10

EDUCATIONAL MODULE

Volume 11(6), June 2003

REFERENCES

1.

Janz KF, Burns TL, Torner JC, Levy SM, Paulos R, Willing MC et al. Physical activity and bone measures in young children:
the Iowa bone development study. Pediatrics 2001; 107(6):1387-1393. Accessed at: http://home.mdconsult.com

2.

Lloyd T, Chinchilli VM, Johnson-Rollings N, Kieselhorst K, Eggli DF, Marcus R. Adult female hip bone density reflects
teenage sports-exercise patterns but not teenage calcium intake. Pediatrics 2000; 106(1 Pt 1):40-44.
PMID:10878147

3.

Rowlands AV, Eston RG, Ingledew DK. Relationship between activity levels, aerobic fitness, and body fat in 8- to 10-yr-old
children. J Appl Physiol 1999; 86(4):1428-1435. Accessed on: Jan. 8, 2003 at http://www.jap.org

4.

Patrick K, Sallis JF, Prochaska JJ, Lydston DD, Calfas KJ, Zabinski MF et al. A multicomponent program for nutrition and
physical activity change in primary care: PACE+ for adolescents. Arch Pediatr Adolesc Med 2001; 155(8):940-946.
PMID:11483123

5.

Canadian Fitness and Lifestyle Research Institute (CFLRI). Understanding Youth Physical Activity. The Research File 2000;
Reference No. 00-05.

6.

Bright Futures in Practice: Physical Activity. Arlington, VA: National Center for Education in Maternal Child Health, 2001.

7.

Kirkcaldy BD, Shephard RJ, Siefen RG. The relationship between physical activity and self-image and problem behaviour
among adolescents. Soc Psychiatry Psychiatr Epidemiol 2002; 37(11):544-550.

8.

California Department of Education. New Study Supports Physically Fit Kids Perform Better Academically. National
Association for Sport and Physical Education 2002. Accessed on Jan. 3, 2003 at http://www.aahperd.org/naspe

9.

Boreham C, Twisk J, Neville C, Savage M, Murray L, Gallagher A. Associations between physical fitness and activity
patterns during adolescence and cardiovascular risk factors in young adulthood: the Northern Ireland Young Hearts Project.
Int J Sports Med 2002; 23 Suppl 1:S22-S26. PMID: 12012258

10. Schmitz KH, Jacobs DR, Jr., Hong CP, Steinberger J, Moran A, Sinaiko AR. Association of physical activity with insulin
sensitivity in children. Int J Obes Relat Metab Disord 2002; 26(10):1310-1316. PMID: 12355326
11. Evidence for Policy and Practice (EPPI-Centre). Young people and physical activity: a systematic review of research on
barriers and facilitators. Information and Co-ordinating Centre, editor. 1-186. 2001. London, UK, Social Science Research
Unit; University of London. Accessed on Jan. 10, 2003 at : http://eppi.ioe.ac.uk
12. Craig CL, Russell SJ, Cameron C. Physical activity and the media. What messages are Canadians receiving? 1998 media
study: an inmedia analysis 1998. Canadian Fitness and Lifestyle Research Institute1998 Capacity Study
13. Sallis JF, Prochaska JJ, Taylor WC. A review of correlates of physical activity of children and adolescents. Med Sci Sports
Exerc 2000; 32(5):963-975. PMID:10795788
14. Canadian Fitness and Lifestyle Research Institute. 2001 Physical Activity Monitor. The data for the North: Interim report.
2001 Physical Activity Monitor 2002. Accessed at: http://www.cflri.ca
15. Corbin CB, Pangrazi RP. Guidelines for Appropriate Physical Activity for Elementary School Children. 2003 Update.
National Association for Sport and Physical Education 2002; Position Statement. Council for Physical Education for Children
(COPEC). Accessed on Jan.7 at http://www.aahperd.org/naspe
16. Bar-Or O. Physical Activity in Children and Youth - Practice Based Small Group Learning Program. 23-4-2003. Personal
Communication
17. Health Canada. Teacher's Guide to physical activity for youth 10-14 years of age. Canada's Physical Activity Guide to
Healthy Active Living 2002. Accessed online at http://www.healthcanada.ca/paguide or 1-888-334-9769
18. Epstein LH, Paluch RA, Kalakanis LE, Goldfield GS, Cerny FJ, Roemmich JN. How much activity do youth get? A
quantitative review of heart-rate measured activity. Pediatrics 2001; 108(3):E44. PMID:11533362
19. Pipe A. Get active about physical activity. Ask, advise, assist: get your patients moving. Can Fam Physician 2002; 48:13-13.

11

EDUCATIONAL MODULE

Volume 11(6), June 2003

PMID:11852603
20. Canadian Fitness and Lifestyle Research Institute (CFLRI). Helping Children to Be Active. The Research File 1999;
Reference No. 99-02.
21. Sallis JF, Pate RR. Determinants of youth physical acitivity: FITNESSGRAM Reference Guide. The FITNESSGRAM
Reference Guide 2001. Accessed at: http://www.cooperinst.org
22. Canadian Fitness and Lifestyle Research Institute (CFLRI). Influences on Children's Activity. The Research File 2001;
Reference No. 01-01.
23. Royal Australian College of General Practitioners TR. Putting prevention into practice. A guide for the implementation in the
general practice setting (Green Book), 1st edition ed. Melbourne, Australia: RACPG, 1998.
Accessed on Feb. 13, 2003 at http://www.racgp.org.au
24. Stapleton S. Fat chance: How physicians can help patients lighten their load. The directions are clear: Eat your vegetables.
Drink water. Exercise regularly. Still the numbers on the scale go up. How can doctors get patients to comply?
amednews.com The Newspaper for America's Physician. 18-11-2002. Accessed on Nov. 11, 2002 at http://www.amaassn.org
25. Sallis JF, Prochaska JJ, Taylor WC, Hill JO, Geraci JC. Correlates of physical activity in a national sample of girls and boys
in grades 4 through 12. Health Psychol 1999; 18(4):410-415. PMID:10431943
26. Kennedy M. Physical Activity in Youth and Children. 11-4-2003. Personal e-mail Communication.
27. Canadian Fitness and Lifestyle Research Institute (CFLRI). Active & Safe Travel to School. The Research File 2001;
Reference No. 01-09.
28. Sallis JF, Conway TL, Prochaska JJ, McKenzie TL, Marshall SJ, Brown M. The association of school environments with
youth physical activity. Am J Public Health 2001; 91(4):618-620. PMID:11291375
29. Crotty MT. Parents advised to find balance between TV viewing, Video Games, Computers, Homework and Physical Activity
for Children. National Heart Alliance press release . 2001. Accessed on Apr, 2003 at
http://www.irishheart.ie/news/NHApressrelease.htm
30. Tudor-Locke C. Taking steps toward increased physical activity: Using pedometers to measure and motivate. The
President's Council on Physical Fitness and Sports Research Digest 2002; Series 3(No. 17). Accessed on: Jan, 2003 at
http://www.indiana.edu/~preschal
31. Rowland TW. Adolescence: A 'Risk Factor' for Physical Inactivity. Research Digest (President's Council on Physical Fitness
and Sports) 1999; Series 3(No. 6). Accessed on Dec. 20, 2002 at http://fitness.gov/activity
32. Katzmarzyk P.T., Malina RM. Contribution of organized sports participation to estimated daily energy expenditure in youth.
Pediatric Exercise Science 1998; 10(378):386.
33. Health Canada. Canada's Physical Activity Guide for Children. Canada's Physical Activity Guide to Healthy Active Living
2002. Accessed online at http://www.healthcanada.ca/paguide or 1-888-334-9769
34. Health Canada. Canada's Physical Activity Guide for Youth. Canada's Physical Activity Guide to Healthy Active Living 2002.
Accessed online at: http://www.healthcanada.ca/paguide or 1-888-334-9769

12

Appendix 1. SAMPLE INTERVIEW QUESTIONS, INFANT TO ADOLESCENT

Sample interview questions that might be asked during a routine health exam of an infant (<1 year) (adapted from
Patrick, 2002) 6
How often do you play with your child?
Do both you and your spouse play with your child?
What are some physical activities you do with him?
How often during the day is your child in an open environment, such as on the living room floor?

Sample interview questions that might be asked during a routine health exam of a 1- to 4-year-old (adapted from
Patrick, 2002)6
How often do you play with your child?
What are some physical activities that you do with your child?
How often does your child get a chance to run?
How much television do you allow your child to watch each day?
Is your neighbourhood a safe place for your child to play?
Do you participate in physical activity? If so, which ones? Did you participate in physical activity when you were a
child?

Sample interview questions that might be asked during a routine health exam of a young child (>5 yrs) or an
adolescent (>11 yrs) (adapted from Patrick, 2002) 6
For the child
Do you think physical activity is important? Why? (or why
not?)
Do you think you are in good shape?
Do you do something physically active most days of the
week?
What time of day are you most active? (e.g. after school,
after supper, on the weekends?)
What physical activities do you really enjoy doing? Which
ones do you really dislike doing?
Do you participate in physical activities as a family? (for
example, walking, biking, hiking, skating, swimming, or
running?)
How much time each day do you spend watching television
or DVDs or playing computer games?

For the parent

Does your child regularly participate in physical
activity (for example on most, if not all, days of the
week?)
How does your child spend his/her after school hours?
What are your childs favourite physical activities?
What physical activities does your child dislike
participating in?
How much time each day do you allow your child to
watch television, play video games, or watch movies?
Are you physically active as a family?
How might you help your child become more active?

Appendix 2
Characteristics of Childrens Physical Activity15
Children are naturally more active than adolescents or adults.
Activities need to be of short duration to maintain a young childs attention.
Children seek concrete reasons for consistently being active not abstract reasons such as health.
Children learn skills by being physically active and in mastering these skills, increase in self-confidence.
Self-efficacy has a strong association with later in life adherence to a physically active lifestyle.
Skills learned in childhood will sustain leisure activities during adulthood.
High intensity activities may be discouraging for some children.
Although inactive children tend to become inactive adults, the opposite is not necessarily true.

Appendix 3. RESOURCES

Free resources for children and youth

1. Health Canada. These resources are colourful and age-appropriate. Available to everyone
(1-888-334-9769) or at http://www.healthcanada.ca/paguide
For school-age children (ages 6-9)

For Youth (ages 10-14)

Gotta Move! Interactive magazine for children

Physical Activity Guide for Children (single page)
Physical Activity Chart & Activity Stickers

Lets Get Active! Interactive Magazine for Youth

Physical Activity Guide for Youth (single page)

Helpful free resources for Parents

2.

Health Canada
(1-888-334-9769) or at http://www.healthcanada.ca/paguide
Family Guide to Physical Activity for Children
Family Guide to Physical Activity for Youth
Helping your children become more physically active: Tips for parents and caregivers (fact sheet) at
http://www.hc-sc.gc.ca

3.

Caring for Kids. http://www.caringforkids.cps.ca or telephone 1-613-526-9397

Child health information from Canadian Paediatric Experts. Excellent resource on a wide variety of child- and
teen-rearing topics, such as:
Promoting good television habits
Keeping kids safe.
Health active living.

4.

Go for Green. http://www.goforgreen.ca

Active and Safe Routes to School: brochure: activities one can start in the community
Did you know? A childs ability to assess potential traffic dangers: Fact Sheet (the Canadian Institute of Child
Health- CICH)
Walking/Cycling School Bus: brochure: practical tips and advice for starting.

5.

Safe Kids Canada http://www.safekidscanada.ca

Provides information on safety aspects for children under 5 years and a variety of other safety issues including
winter, water, and playground safety.

6.

Caring for Kids Canadian Paediatric Society http://www.caringforkids.cps.ca

7.

Keep Kids Healthy Free pediatricians guide for all kinds of parenting issues
http://www.keepkindshealthy.com
Parenting Tips for newborn through adolescence including Fitness and Exercise Guide

8.

Kids Health American Academy of Family Physicians http://www.kidshealth.org

also http://www.familydoctor.org helpful tips on a variety of topics from exercise to preventing abductions, from
bicycle safety to weight management.
The Parent Package http://www.ama-assn.org/ama/upload/mm/39/parentinfo.pdf
A series of online booklets providing parents with information about their adolescents on 15 different topics
including: PHYSICAL ACTIVITY, injuries, violence prevention, cigarettes, alcohol, illicit drugs, depression, sex,
HIV/AIDS, nutrition, making responsible choices, growth and development, and vaccinations

9.

Pedometers
For information: Watch Your Step: Pedometers and Physical Activity. WellSpring, 2003, Vol. 14(2) published by
the Alberta Centre for Active Living. (8 pgs.) Available free of charge at (780) 4276949 (toll-free in Alberta only: 1800-661-4551) or online at http://www.centre4activeliving.ca/Publications/WellSpring/index.htm

How to effectively use your pedometer! Step by step guide and Q & A. http://www.pedometer.com (Mar., 2003)
-Available at local sporting goods stores, the Running Room or fitness equipment stores
-Bally Kids Go the Distance Pedometer, $14.99, currently available through Avon catalogues, also online auctions
at http://cgi.ebay.com (Mar., 2003)
Pokemon, Pikachu 2,website information http://www.amazon.co.uk
-A variety of pedometers (including Pokemon, Pikachu 2) available online through http://half.ebay.com/ or
http://pages.ebay.ca/index.html (type in pedometer). Lots of choices, including a wristwatch option.

Helpful resources, tools, fact sheets for physicians

10. Evidence-base Resource Sheets. Canadian Task Force on Preventive Health Care (CTFPHC)
http://www.ctfphc.org
Rourke Baby Records
11. Put Prevention into Practice (PPIP) Agency for Healthcare Research and Quality (AHRQ)
http://www.ahcpr.gov contains physician preventive care fact sheets, charts, and reminder postcards
12. Putting Prevention into Practice The Royal Australian College of General Practitioners (RACPG)
a monograph on the implementation of preventive care in practice with helpful and practical appendices
http://www.racgp.org.au

Appendix 4
Comparison of activity guidelines: Physical activity for children and youth
Guidelines for Appropriate Physical Activity for Elementary School Children. Corbin & Pangrazi, 2003 15
Children (elementary school age)15

Adolescents (ages 11-21 years)15

It is recommended that children get at least 60 minutes

and up to several hours daily of accumulated activity
appropriate for age and skill level on all, or most, days
of the week.
For optimal ongoing health benefits, 50% of childrens
activities should occur in 15- minute bouts (or more),
alternating with brief periods of rest.
Children who spend excessive time watching television,
playing computer games, or surfing the net, are
unlikely to meet the minimum physical activity
guidelines above

A minimum of 30 to 60 minutes of accumulated

physical activity
3 or more sessions per week of activities that are
continuous in nature, lasting 20 minutes or more at a
moderate to vigorous intensity

Physical Activity Guidelines from Health Canada for Children and Youth (aged 6-14 years)33,34 (See Patient
Information Sheet for prescription)
An increase of 30- 90 minutes daily of physical activity accumulated in 5- to 10-minute bouts of activity
A minimum of 30 minutes daily (as part of the total above activity, not in addition to it) should be spent in vigorous
activity such as running, basketball, or soccer
A subsequent decrease of 30 to 90 minutes daily of sedentary activities

Patient Information Sheet (Appendix 5)

Call to ACTION!

Activity prescription for 6 to 10 year-olds

Name: _________________________
What is it
Called?

What Can I Do?

ENDURANCE:

G
G
G
G
G
G
G

Activities that
use ENERGY!

ENDURANCE:
HIGH ENERGY
activities!

DECREASE

TIME AT

Sitting Activities

riding your bike

swimming
playground (swings, slides)
walking (quickly)
tobogganing, winter play
skating (relaxed)
ballet or dance class (relaxed)

G riding your bike (for a long

time)
G skating, inline skating
G soccer
G running, jogging
G basketball, volleyball
G energetic dancing
G hockey
G high energy ballet or dance
class
G _______________
G
G
G
G
G

sitting in front of the TV

sitting doing computer games
sitting playing video games
surfing on the internet
________________

Phase (circle mth of intervention)

1 2 3 4 5
How Often ?

How Much MORE should I do?

Every day

Increase
920
930
940
950
960

Every day

your playtime by:

(Phase/Mth 1)
(Phase/Mth 2)
(Phase/Mth 3)
(Phase/Mth 4)
(Phase/Mth 5)

Increase
910
915
920
925
930

Every day

minutes
minutes
minutes
minutes
minutes

your very active play by:

minutes (Phase/Mth 1)
minutes (Phase/Mth 2)
minutes (Phase/Mth 3)
minutes (Phase/Mth 4)
minutes (Phase/Mth 5)

Decrease

of-a-screen
920 minutes
930 minutes
940 minutes
950 minutes
960 minutes

your sitting-in-fronttime:
(Phase/Mth 1)
(Phase/Mth 2)
(Phase/Mth 3)
(Phase/Mth 4)
(Phase/Mth 5)

Adapted from: Green Prescription, Hillary Commission, Ministry of Health, Wellington, NZ,, Canadas Physical Activity Guide for
Children, 2002, with information from the Canadian Fitness and Lifestyle Research Institute 2001 Physical Activity Monitor

Put a sticker on your poster or fridge calendar every time you follow all the doctors suggestions from
the chart above.
Bring your finished calendar or poster to your doctor by the following date:_________, 2003
Doctors Signature: _______________________

Feel Free to Copy this Sheet

Date: __________

Patient Information Sheet (Appendix 6)

Dare to be ACTIVE!

Physician-Patient Physical Activity Contract for Youth

Name of participant: _____________________________

ENDURANCE:
Moderate
Activities
that use
energy

ENDURANCE:
Vigorous
High energy
activities

DECREASE
TIME

Sitting
Activities

Phase (mth of intervention)

1 2 3 4 5

What Can I Do?

How Often?

How Long Do I Do It?

G brisk walking (to the mall, to your

friends, to school)
G bike riding
G swimming
G exercising at home
G skateboarding (stop & start)
G supervised weight training
G bowling
G baseball, softball
G Alpine skiing

Every day

Increase your moderate physical

activity by:
920
930
940
950
960

Every day

G
G
G
G

running, jogging
bicycling (brisk & continuous)
basketball, volleyball
dancing (fast)
inline skating, boarding (snow or
skate) (continuous)
soccer, football
shoveling snow, raking leaves
gymnastics, aerobics
tobogganing, ice skating

G
G
G
G
G

sitting in front of the TV

sitting doing computer games
sitting playing video games
surfing on the internet
________________

Every day

G
G
G
G
G

minutes
minutes
minutes
minutes
minutes

(Phase/Mth
(Phase/Mth
(Phase/Mth
(Phase/Mth
(Phase/Mth

1)
2)
3)
4)
5)

Increase your vigorous activity by:

910
915
920
925
930

minutes
minutes
minutes
minutes
minutes

(Phase/Mth
(Phase/Mth
(Phase/Mth
(Phase/Mth
(Phase/Mth

1)
2)
3)
4)
5)

Decrease your sitting-in-front-of-ascreen time:

920 minutes (Phase/Mth 1)
930 minutes (Phase/Mth 2)
940 minutes (Phase/Mth 3)
950 minutes (Phase/Mth 4)
960 minutes (Phase/Mth 5)

Adapted from: Green Prescription, Hillary Commission, Ministry of Health, Wellington, NZ,, Canadas Physical Activity Guide for Youth, 2002, with
information from the Canadian Fitness and Lifestyle Research Institute 2001 Physical Activity Monitor

On a computer program log of your own design, on a calendar, or in your school planner, record the total
time that you participate in each of the above categories and describe how you feel during each activity
session.
Bring in your completed scheduler to your doctor on :

___________________ (Appt date)

Signed: _______________________________
Doctors Signature: _______________________

Feel Free to Copy this Sheet

Date: __________

Patient Information Sheet (Appendix 7)

Name:__________________________________________
D.O.B.: _____ /_________/____________
Phone No.: (_____) - ____________________________

L PEDOMETER EXERCISE PRESCRIPTION L

I want you and your family to work with me to make sure you are getting enough
physical activity to keep you healthy, happy, and doing well in school. This tool is a
fun way to discover how much activity you are getting and to measure increases in
your activity level toward an even healthier YOU! This is how it works.

1. For this experiment, you will need a pedometer, available at local fitness equipment stores, sporting
goods stores, the Running Room retail stores, or through an AVON representative (inquire about a A
Bally Kids pedometer $14.99).
2. Clip the pedometer to your waist and wear it from the time you get up until the time you go to bed.
3. The pedometer will measure every step that you take all day long: going to school, playing at recess, at
lunch, after school, and after supper.
4. At the end of each day, record the number that is displayed on the pedometer on your Health Canada
Physical Activity Chart (available free with stickers from Health Canada 1-888-334-9769).
5. To set your starting point (Level), measure and record the number of steps you take each day for 3 days.
If that number is below 10,000 steps, start at Level 1. For any number of steps higher than 10,000, start
at the closest level (e.g. if your total is 12, 342 steps for any one day, start at level 8)
6. When you the steps you take in a day matches the goal for your level, put a sticker on your calendar and
share this information with your parents.
7. Dont forget to reset the pedometer to 0 (zero) each night before going to bed, so it will be ready to put
on the following morning.
8. Challenge your family to try to keep up with you!

Pedometer Prescription Recommendations

Level

Beginning of week

End of week

10,000

10,500

10,500

11,000

11,000

11,500

11,500

12,000

12,000

12,500

12,500

13,000

13,000

13,500

13,500

14,000

14,000

15,000

10

15,000

16,000

Congratulations !!!

Bring in your completed poster with all the information on the following date: ______________________,
200_____
Signature of doctor: _________________________________
Date of prescription: ______________________, 200_____

Feel Free to Copy this Sheet