BASIC RECOMMENDATIONS FOR PROMOTING ACTIVITY
Several sets of recommendations or guidelines have been developed to establish parameters for promoting physical activity among youth. These guidelines define the quantity and quality of activity needed to optimize physical fitness and to identify the health-related benefits of physical activity. All of these guidelines have incorporated the input of experts and the current scientific literature, yet acknowledge the gaps in research.

Both sets of recommendations emphasize daily physical activity. It is believed that participating in regular physical activity is probably more important for obtaining health-related benefits than is the intensity of the activity. Although obtaining physical fitness is a desirable goal, youth are inherently fit. Therefore, the recommendations focus on maintaining activity levels that will help to maintain fitness levels and to avoid a decline in activity levels through the adolescent years. Recommendations for youth should focus on promoting a variety of activities that are fun and can be easily incorporated into their lifestyle. These activities can include team sports, individual sports, and recreational or lifetime activities, such as walking, bicycling, and swimming. Any form of physical activity that is regular, enjoyable, and sustainable is the desired endpoint. However, parents and youth coaches should avoid the use of exercise as punishment for bad behavior. This implies that exercise is not fun, just the opposite of what should be promoted. [Partnering with Parents]

THE CHALLENGES OF PROVIDING ACTIVITY COUNSELING
Because of its many short- and long-term benefits, promoting physical activity should be a priority in every physician setting. Unfortunately, fitting this type of counseling into the list of tasks that need to be addressed during a well-child visit is often difficult, especially when limited reimbursement and time are allocated for health-promotion counseling.

INTERVENTIONS
Most physicians are familiar with and quite skilled at problem identification. Providing useful solutions or effective health promotion interventions within the confines of a busy clinical setting is more difficult. Some restraints, such as time and reimbursement, will not be changed until practice styles and reimbursement patterns are redefined. Therefore, efforts need to be focused on brief, yet effective interventions that easily can be incorporated into current practice patterns.

Promoting physical activity starts with providing magazines or other educational materials that promote healthy lifestyles and physical activity in the waiting room. Posters or pictures showing different types of activities, both vigorous and moderate, being done by a variety of children and adolescents with and without adults send a healthy message to patients and their families.

READINESS AND BEHAVIOR MODIFICATION
Successful models in adult physical activity counseling have incorporated concepts from stages of change theory, social cognitive theory, and behavior modification techniques. These include identifying the patient's readiness to make a behavioral change, goal setting, creating contracts, addressing barriers, and enlisting social support. These concepts can easily be incorporated into brief clinical counseling interventions and can be adapted to a variety of health behaviors.

The key point is that a physical activity prescription is needed only for those patients who are ready to make a change. Youngsters who meet the recommended levels of activity should receive brief reinforcement about their healthy lifestyle and encouragement about continuing their activity. This approach is more satisfying for patients and physicians, is a much better use of valuable counseling minutes, and allows physicians to spend the most time with patients who are ready to make positive changes.

For inactive children or adolescents who are not ready to change, identifying potential benefits and current barriers to activity can be an important first step. Often physical activity can be recommended for a medical reason, such as an increase in weight disproportionate to an increase in height, borderline blood pressure for age, or a strong family history of cardiovascular disease and/or diabetes. Because young people are much more focused on the present than on potential long-term benefits of physical activity, emphasizing current benefits can be a more effective motivation than the prevention of distant chronic diseases. Common patient barriers to physical activity include lack of time, lack of access to facilities, unsafe neighborhoods, and dislike of exercise. For this group, identifying salient benefits and addressing the barriers can be the first step toward getting the individual or family to think about becoming more physically active.

PHYSICAL ACTIVITY PRESCRIPTION
Presenting recommendations as a "physical activity prescription" is a useful concept. Writing a patient a prescription uses a medical model with which both physicians and patients are familiar. It also takes advantage of the "white coat effect" and reinforces to patients that physical activity is as important to their health as any medication that might be prescribed. Allowing the patient, and parent when appropriate, to participate in setting the physical activity goal will enhance compliance with the prescription. For many children, parents play an important role in any behavioral change; therefore, counseling needs to target both the child and the parent. Adapting simple behavioral change concepts into counseling will help make the limited time available for counseling more effective.

For inactive or intermittently active youngsters who are interested in increasing their activity level, counseling should include an actual activity plan or physical activity prescription. Because these patients are ready to change, any counseling or direction provided is much more likely to translate into a behavior change. Focus should be placed on increasing moderate physical activity to between 30 and 60 minutes per day. This can be accomplished by accumulating several bouts of 10 to 15 minutes of activity. It is important to have the child be as clear as possible regarding the plan, including type of activity and intensity, location, when he or she is going to be active, and for how long. In order to make the plan detailed, the child will need to anticipate barriers and create solutions. The more detailed the plan, the more likely the child is to meet his or her goal.

CREATING A SOCIAL CLIMATE FOR PHYSICAL ACTIVITY
Physical activity needs to be fun and accessible for the individual if it is to be continued. It is important to help children choose an activity routine that is fun, developmentally appropriate, and realistic given his or her individual, family, and community resources. One method that has been used frequently in exercise prescription for adults incorporates the mnemonic FITT, which stands for frequency, intensity, time (duration), and type of activity. This can be useful for creating a physical activity prescription, and it can be used as a simple way to record recommendations in the medical record.

Suggestions for increasing physical activity can include walking or bicycling for transportation and planning physically active rather than sedentary activities with friends. Many adolescents, especially girls, may not be active because they think organized sports is the only type of exercise that "counts." Therefore, it is important to help adolescents identify the physical activity they may already be getting (eg, walking), as well as to reinforce the benefits of other lifetime activities such as bicycling, dancing, skating, and swimming.

Identifying ways to incorporate increased physical activity into the activities of daily living can also be useful. Examples include taking the stairs whenever possible, getting off the bus a stop earlier, taking walks with friends rather than talking on the telephone, and walking at least one lap of the mall before shopping.

Identifying a social support or physical activity buddy has been identified as an important component in making a successful behavior change. Parents of younger children should plan active times or vacations with their children. This increases their children's activity and provides an excellent role model for their children.

SAFETY CONCERNS
When neighborhood safety is a barrier, activities that can be done indoors, such as exercise to videos and dancing to popular music, should be recommended. Decreasing the amount of time spent in sedentary behaviors, such as watching television, talking on the telephone, playing computer or video games, especially in the late afternoon and early evening, will translate into more accumulated daily activity. Stretching while watching television or using some type of exercise equipment such as a stationary bicycle can increase activity during an otherwise sedentary time. Although the link between physical activity and television watching is not clear, increased watching has been linked to obesity. It makes intuitive sense that one way to increase activity is to decrease the amount of sedentary behavior.

REINFORCEMENT
The behavior of the child or adolescent who is appropriately active should be reinforced. Often it is helpful to identify the health benefits of regular activity, such as maintenance of appropriate weight, increased energy, improved sense of well-being, and self-esteem. It can also be useful to assess how confident a patient is that he or she will remain active and to provide solutions for any identified potential barriers to maintaining that activity.

Physicians and other health care providers need to be good role models for their patients and their families. This includes a personal plan for incorporating physical activity within their own busy schedules. Studies with internists show that physicians who are regular exercisers are more likely to provide more frequent and more aggressive physical activity counseling for their patients.

COMMUNITY AND SCHOOLS
Physicians can play an important role in promoting physical activity by being good role models for an active lifestyle and being advocates for physical activity in other arenas. Children and adolescents spend most of their time attending school. Physicians need to advocate for more health education and physical education that includes aerobic lifestyle activities (ie, walking, jogging, dancing), as well as teaching sport-specific skills. In addition, physicians can become more involved with teachers and coaching staffs. This communication improves the care of the young athlete and increases the effectiveness of the physicians, teachers, and coaching staffs. Changes in school policy potentially reach larger numbers of children than the promotion of physical activity with individuals in the office. Guidelines exist for the establishment of appropriate health education and physical education curricula. Physicians can be valuable advocates for promoting these guidelines.

Physicians are also important advocates for the availability of safe and accessible places for physical activity to occur within the community. This advocacy ranges from promoting the availability of open spaces, parks, recreation centers, and community centers to promoting the availability of schools and school playgrounds after hours. The CDC has published a set of guidelines for promoting physical activity within the community.

The American Academy of Pediatrics has developed a list of recommendations for assessing physical activity and fitness in the office setting. The following checklist incorporates many of those recommendations, but focuses on ways physicians can promote the behavior of regular physical activity (Table 5.2).

	Reprinted with permission. From American Academy of Orthopaedic Surgeons, American Academy of Pediatrics. Care of the Young Athlete. Elk Grove Village, IL: American Academy of Pediatrics; 2000;36-41.
INFORMATION FROM THE CENTERS FOR DISEASES CONTROL (CDC) Physical Activity and Good Nutrition: Essential Elements to Prevent Chronic Diseases and Obesity