Couch kids: the nation’s future... Four years on from our first report into childhood obesity and children still aren’t getting the diet or exercise they need.

beating heart disease together

Foreword Getting our kids off the couch - and why it matters

Currently, in the UK:

We all know that eating healthily and getting enough physical activity are vital in helping to prevent obesity, heart disease and other lifestyle-related ill health.

Almost two out of three adults and one in three children are overweight or obese(1). If this trend continues:

But this report shows us that despite concerted efforts to get kids more active in recent years, worrying gaps remain. A disturbingly high number of young people in all four nations of the UK aren’t reaching the target of 60 minutes of physical activity every day. Indeed, in England, for example, 15% of boys and 19% of girls aren’t even achieving 30 minutes a day.

Research has suggested that, without appropriate intervention, overweight or obesity could affect as many as nine out of ten adults and two out of three children by 2050(1).

If we are serious about reversing the tide of childhood obesity, we need to act now. The British Heart Foundation (BHF) continues to call for the toughest restrictions on the marketing of unhealthy food to children and for an environment that empowers parents, for example through better food labelling, to make healthy food choices for their children. This must be accompanied by action to ensure that opportunities for kids to get more physically active are accessible, appealing and part of everyday life. While we shouldn’t underestimate the progress that has been made in some parts of the UK, such as the increase in PE hours taught in English schools, we need to move decisively, and quickly, to ensure that the current generation of our children and young people have the best chance of long and healthy lives.

Peter Hollins Chief Executive British Heart Foundation

It’s an international problem. In 2003 the World Health Organisation suggested that overweight and obesity were starting to replace undernutrition and infectious diseases as the most significant contributors to ill health(2). And it’s especially important for our children. Obese children are more likely to become obese adults(3), making them more vulnerable to serious conditions which increase the risk of heart disease, strokes and some cancers. Conversely, active children are more likely to be active adults(4). There is clearly no single cause of the growing increase in obesity - sedentary lifestyles, dietary changes, a social environment conducive to obesity, and other factors all play a part. However, evidence now exists which shows that physical activity is one of the factors that can play a major role in improving the future health and wellbeing of our children. This report presents the results of current research on why physical activity is so important for our children, how much physical activity they do, how much they need and what provision is and should be made to help them be more active. It assesses the levels of obesity among our children and, crucially, puts forward recommendations for action. In order to do this, we have drawn on evidence from England, Scotland, Wales and Northern Ireland, although in some areas, more research is urgently needed to help us address these vital issues. The BHF will continue to campaign tirelessly on this issue. Because we believe that the tide of obesity can be turned, and that if all of us, from government to individual parents, work together, our children, and future generations, will live more active, healthier, and happier lives.

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Contents Why is physical activity important for our children and young people?

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How much activity should children and young people do?

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• Children and young people aged five and over 6 • Children from birth to five years 7 How active are children and young people in the UK?

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• Activity in schools 14 • Active transport 17 • Activity in leisure time outside school 19 How sedentary are our children and young people?

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Factors associated with physical activity in children and young people

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What motivates our children and young people to be active? And what barriers stop them?

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How good are our children’s and young people’s diets?

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Obesity in children and young people

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• Prevalence of overweight and obesity 30 • Differences in the prevalence of overweight and obesity according to gender, ethnicity and socio-economic group 30 • Trends over time 30 • Potential health problems associated with obesity 32 • Possible causes of obesity 33 • Tackling the issue 33 • Young people’s concerns about their weight 33 Conclusion and recommendations

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• The BHF and physical activity 38 Appendix 1. Key factors associated with physical activity for young people

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Why is physical activity important for our children and young people? ‘Evidence demonstrates that the physical fitness and health… of children and young people are substantially enhanced by frequent physical activity.’(5) In 2004, a Department of Health report highlighted the current and future health benefits of physical activity for children and young people(6), which has recently been supported by wide-ranging reviews of the existing evidence(7)(5). While it is difficult to identify clear outcomes of physical activity for children, there is sufficient evidence to indicate that physical activity is an important health behaviour that should be encouraged(8)(9)(7).

Direct health benefits Physical activity can help prevent overweight and obesity and Type II diabetes, improve skeletal health and can have psychological health benefits for children(7). Some of the findings of a recent, comprehensive review of the evidence(5) are: Table 1: Health benefits of physical activity for children and young people(5) There is strong evidence for: • better cardiovascular and metabolic health • improved cardiorespiratory endurance and muscular fitness • stronger bones • more favourable body fat composition. There is some evidence for: • reduced symptoms of anxiety and depression.

Potential improvement of health in adulthood There is limited evidence that childhood physical activity directly affects health in adulthood(7): •

Obesity tracks from childhood to adulthood (ie, obese children are more likely to be obese adults). Physical activity helps maintain optimal body weight in childhood, and consequently can help to reduce the risk of obesity in adulthood(7).

• Stronger bones developed in childhood may reduce the risk of later osteoporosis.

Increased likelihood of continuing to be active as an adult It is possible that an active lifestyle in childhood and adolescence may track through into adulthood. The potential tracking of physical activity from childhood to adulthood is important as there is comprehensive evidence that an active lifestyle in adulthood has direct health benefits(6). Although it’s difficult to determine the extent of tracking from childhood to adulthood, it seems physical activity does track. Research varies as to whether the correlation is small(7) or small to moderate(10), with stronger correlations between adolescence and adulthood(10). Tracking may be stronger among the more active(4) and when the quality of the physical activity experience in childhood is improved (11)(12)(13).

Other possible benefits Physical activity and fitness in childhood may: • improve cognitive function(7)

Cardiovascular disease (CVD) is the UK’s biggest killer, and substantial evidence shows that CVD has its origins in childhood(7). Although there is only a small association between CVD risk factors and physical activity in youth(6)(7), it seems that physically active children and young people have more favourable cardiovascular and metabolic risk profiles(5).

There is sufficient evidence to indicate that physical activity is an important health behaviour that should be encouraged.

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• improve academic achievement(14) • accelerate neurocognitive processing(15). Some researchers suggest that physical activity may be the best stimulus for the brain to be ready to learn and grow(16)(17) and that solving problems through play drives the development of neural pathways in the brain(18). Active children are also less likely to smoke, or to use alcohol / get drunk or take illegal drugs(19)(20). The UK ranked bottom out of 21 of the world’s richest countries in UNICEF’s report on children’s wellbeing(21).

A wide range of factors were considered in relation to children’s wellbeing including physical activity. Physical activity is associated with psychological health benefits including improved self-esteem(7) and may therefore have an important role in improving wellbeing. Children and young people see play as important to them, and potential benefits associated with play include: • building resilience(22) • contributing to development and learning(23) • providing an opportunity to explore, experiment and understand(23) • rehearsing specific skills that may be needed in adult later life(24).

Summary With 33% of 15 year old girls and 19% of 15 year old boys in Great Britain rating their health as fair or poor(28), identifying ways to improve adolescents’ perceptions of their health is important and physical activity may have an important role to play in this. Overall there is a strong rationale for promoting physical activity among children(7).

Identifying ways to improve adolescents’ perceptions of their health is important and physical activity may have an important role to play in this.

Benefits for individuals with a disability There is strong evidence that physical activity can improve the health of those with a physical or cognitive disability(5), (please see p.12) although this research was not specifically focused on children and young people. Benefits for preschoolers There is growing evidence that increased physical activity in preschool children is associated with improved physical health status (including, for example, adiposity, bone health and cardiovascular risk factors)(25)(26)(27). However, more research is needed in this area.

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How much activity should children and young people do? Evidence appears to suggest that a minimum target of 60 minutes of physical activity a day is appropriate for children and young people aged 5 to 18. There is a suggestion that more physical activity may be better(29) and that the inclusion of vigorous activity could have important additional benefits(5). It is clear that young people should participate in certain types of physical activity to improve their overall health. However, there’s not enough data to produce definitive guidelines on the minimal or optimal amounts of physical activity they need to gain particular health benefits(5).

Children and young people should achieve a total of at least 60 minutes of at least moderate intensity physical activity each day. Children and young people aged five and over UK guidelines The current physical activity guidelines across the UK are similar but not the same as indicated in Table 2: Table 2: Current physical activity guidelines in the UK Country England(6)

Northern Ireland

Scotland(30)

Wales(31)

Guideline A total of at least 60 minutes of at least moderate intensity physical activity each day This should include activities to improve bone health, muscle strength and flexibility at least twice a week A total of at least 60 minutes of at least moderate intensity physical activity each day At least 60 minutes of moderate activity on most days of the week 60 minutes of moderate intensity physical activity on at least five days of the week

The 60 minutes physical activity can be accumulated throughout the day. This suits the sporadic nature of

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childhood activity and may be as beneficial as longer exercise sessions(32). However, some researchers have suggested longer sessions may be necessary to help prevent childhood obesity(33). Table 3: Examples of activities to help children and young people meet the physical activity guidelines Moderate Brisk walking, swimming, intensity activities cycling, PE, dancing and most sports Activities to Climbing, skipping, and jumping enhance strength for younger children and body conditioning and resistance exercise for adolescents Activities to Gymnastics, dance, aerobics, enhance bone running, skipping and sports health such as basketball Although most of the UK guidelines are well established, awareness of them is poor, with only 10% of both boys and girls in England able to correctly recall the guideline(34). And, in Northern Ireland, only 8% of parents could recall the guideline(35). EU guidelines The European Union and its member states also recommend a minimum of 60 minutes daily moderate intensity physical activity for children and young people(36). However there are concerns that this level of activity may not be sufficient, particularly in terms of preventing increasing levels of obesity(6)(37)(38). In addition, physical activity at a vigorous, rather than moderate, intensity, is recommended for maximum cardiovascular protection(6)(5) and greater increases in bone health(29).

Only 10% of both boys and girls in England are able to correctly recall the physical activity guideline. Other countries’ guidelines The US, Australia and Ireland, like the UK, all recommend: •

at least 60 minutes of physical activity per day, however, guidelines in these countries include a combination of moderate and vigorous activity(39)(40)(5)(41).

Further, the US recommend that young people participate in vigorous intensity activity at least three days per week in order to cause more improvement in cardiorespiratory fitness(5). Canada’s guidelines also include moderate to vigorous intensity activity, and recommend that young people should aim to increase their physical activity by 90 minutes a day (over five months), 30 minutes of which should be vigorous(42)(43). A recent review of the Canadian guidelines(29) has suggested retaining the vigorous intensity but suggests a possible minimum target of 60 minutes physical activity a day. Like the UK, Canada, the US and Ireland all recommend that young people include muscle and bone strengthening activities as part of their 60 minutes activity, with the US and Ireland suggesting this should happen at least three days a week (as compared to the two days currently recommended in England).

Children from birth to five years Intuitively, physical activity during earIy childhood would seem natural and beneficial and evidence is emerging of the potential benefits of physical activity in this age group. A Canadian review(37) found that there is currently little research to support a specific guideline on the level of activity among preschool children (2 - 5 years) that will significantly improve their health. As little as an additional 60 minutes a week of physical activity may improve bone properties, aerobic fitness and motor skills in some children(37), but more research is needed as the scientific evidence is too weak to determine specific activity guidelines for this age group.

While these guidelines seem reasonable, there is no clear relationship between physical activity and specific health outcomes in preschool children and the amount and type of physical activity required to optimise healthy growth and development during the preschool years is not yet known(37). However, some guidelines on how best to encourage preschoolers to be active are important. The Canadian review has suggested some more general recommendations for preschoolers: Table 4: Recommendations for physical activity in preschool children(37) •

Promoters of physical activity for preschool children should consider their natural activity patterns, which are typically spontaneous and intermittent.

•

Physical activity for preschool children should focus on gross motor play (eg, play activities involving large muscle groups and whole body movements) and locomotor activities (eg, walking, running, galloping) that children find fun.

•

Physical activity experiences for preschool children will be enhanced by adult facilitation (including modelling) that provides mastery experiences (ie, activities they can achieve successfully) and positive feedback about those experiences.

• Whenever possible, preschool children should be given access to play spaces and equipment outdoors.

There are currently no recognised activity recommendations for under-5s in the UK. However, US guidelines suggest that preschoolers aged 12-36 months should accumulate at least 30 minutes daily of structured physical activity and those aged 3 - 5 years at least 60 minutes(44). In addition, preschoolers should engage in at least 60 minutes and up to several hours of daily, unstructured physical activity and should not be sedentary for more than 60 minutes at a time except when sleeping.

As little as an additional 60 minutes a week of physical activity may improve bone properties, aerobic fitness and motor skills in some children. 7

How active are children and young people in the UK? National health surveys show that there are still significant proportions of young people, especially adolescent girls, who are not reaching the recommended levels of physical activity. Studies using objective measures indicate even higher numbers of children and young people are not achieving the 60 minutes a day target.

Overall activity levels based on national health surveys 2-15 year olds achieving 60 minutes a day, seven days a week outside school hours (See Figure 1) Boys

Girls

England (2007)

72%

63%(34)

Scotland (2003)

74%

63%(45)

Wales* (2007)

42%

30%(46)

* includes school time

However, 61% of boys and 49% of girls aged 4 -15 years in Wales do reach the recommended target on at least five days a week. Less data are available from Northern Ireland as they do not currently have a comparable health survey, but indications are that activity levels here are low - one survey of 8 -12 year-olds found only 24% took part in 60 minutes a day(47) and another revealed only 15% of young people taking part in 60 minutes a day of sport, exercise or active play that made them ‘out breath or hot and sweaty’(48). In comparing countries, it should be recognised that differing research methodologies may have some influence on the respective levels of activity recorded.

In England 15% of boys and 19% of girls don’t even achieve 30 minutes of activity each day. Although activity levels appear relatively high in England and Scotland, even in these countries a disturbingly high number of young people aren’t reaching the 60 minutes target. In England 15% of boys and 19% of girls aren’t even achieving 30 minutes of activity each day (see Figure 2). In Wales, the situation is equally worrying with 11% boys and 12% girls not participating in 60 minutes of activity on any day of the week(46). And in Northern Ireland, 22% of 11 to 16 year olds did not take part in even moderate intensity activity on any day of the week(49).

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The 2005/06 Health-Behaviour in School-aged Children (HBSC) survey(28), conducted by the World Health Organisation, which collects national data on the physical activity levels of young people aged 11, 13 and 15 years, from 41 countries and regions, is revealing. The survey showed that, in England, Scotland and Wales (Northern Ireland is not included in this survey), the percentages of young people participating in 60 minutes of moderate-to-vigorous activity daily was similar to the average for all the countries and regions (see Figure 3). However, it is worrying that these figures indicate high percentages of young people may be missing out on the benefits of physical activity, particularly as emerging evidence indicates that vigorous activity may be important(5). Average numbers of children achieving 60 minutes of moderate to vigorous activity a day in England, Scotland and Wales Boys

Girls

11 yrs

34%

21%

15 yrs

20%

9%(28)

It is also troubling that 3 -5 year olds, who are generally thought to be spontaneously active, may only be taking part in limited amounts of moderate to vigorous intensity activity(50)(51).

Objective measurements of physical activity Objective measures consistently report lower levels of activity than those reported by children themselves. The Health Surveys in England(34), Scotland(45) and Wales(46) report relatively high levels of participation in physical activity. However, because these surveys rely on questionnaires to collect data, they are unlikely to be as accurate as objective measurements, and may substantially overestimate the number of young people achieving the 60 minutes a day target(52)(53)(54). While objective measures of physical activity consistently record lower levels of physical activity, these discrepancies vary. Studies using accelerometers adopt different thresholds which affects the levels of activity measured. For example, one study using three METs* to represent ‘moderate’  intensity found that

60 70 50 60 40 50 30 40

Figure 1: Percentage of young people participating in a minimum of 60 minutes physical activity of at least moderate intensity on seven days a week

20 30 Figure 3: Percentage of young people aged 11 and 15 who report participating in at least 60 minutes of 10 20 moderate-to-vigorous activity daily (2005/06) 0 10

80

0

70

40

60

20 25

20 70

15 20

10 60

10 15

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5 10

40 Sources: 80 England: Health Survey for England 2007. See reference 34. 30 Scotland: Scottish Health Survey 2003. See reference 45. 70 Wales: Welsh Health Survey 2007. See reference 46. 20 Health Survey for England and Scottish Health Survey do Note: 60 not include physical activity within school. 10 50 Figure 2: Percentage of young people in England 0 achieving high, medium and low levels of physical 40 activity (2007)

25 Figure 3b: 15 year olds 25 20 20

20 70

15 10

10 60

10

High

Medium

Low

5 5

40 40

0

30 35

0 80

20 30

HBSC average = the average for all 41 countries and regions in the 70 80 Health Behaviour in School-aged Children Study.

10 25

High

Medium

Low

15 Source: Health Survey for England 2007. See reference 34. 40 High = 60mins, 7 days a week; Note: Medium = 30 -59 mins, 7 days a week; 10 35 = lower level or not at all. Low

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High

Figure 3a: 11 year olds

Source: Inequalities in Young People’s Health. Health Behaviour in 60 70 School-aged children international report from the 2005/06 Survey. See reference 28. 50 60

40 50 30 40 20 30 10 20 0 10

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42% of boys and 11% of girls met the 60 minutes a day guideline(55) while only 5.1% of boys and 0.4% of girls were found to achieve 60 minutes a day in another study that used four METs as the cut-off point(53). *A Metabolic Equivalent Task (MET) is a measure used to compare the energy expended doing an activity as compared to that expended at rest (one MET).

Although objective measurements provide more accurate data, tools such as accelerometers are costly and complex and therefore would be difficult to use to collect population-level data(34).

Trends in physical activity levels There have been no major changes in young peoples’ physical activity levels over the last 5 - 10 years. Figure 4 shows that there have been no major changes in the percentage of young people reaching recommended activity levels in England between 2002 and 2007 or in Scotland between 1998 and 2003. However, the Scottish data does show bigger changes in some age groups, particularly for girls, which is encouraging: Girls achieving the 60 minutes a day target in Scotland 5 - 7 yrs

8 - 10 yrs

13 - 15 yrs

1998

68%

64%

36%

2003

75%

75%

41%(45)

One positive trend in England seems to be a decline in the proportion of people in the lowest physical activity group, particularly among girls, which suggests that some of the least active are starting to do more, although they are still not reaching the recommended 60 minutes.

There have been no major changes in the percentage of young people reaching recommended activity levels in England between 2002 and 2007.

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Percentage of young people who did at least 30 minutes physical activity, seven days a week: Boys

Girls

1997

64%

51%

2002

73%

65%

2007

85%

81%(56)(34)

Differences by gender A consistent finding across all studies, both those using surveys and those using objective measurements, is that boys are more active than girls across the 2-15 years age range. The differences in activity levels between boys and girls are apparent even at an early age(50) but the gap between the sexes is greatest in adolescence(8)(57)(58). The Health Survey for Scotland shows that boys consistently record higher levels of physical activity than girls. The gender gap was particularly pronounced among older age groups: 68% of boys aged 13-15 years participated in 60 minutes activity a day compared to 41% of girls(45).

The differences in activity levels between boys and girls are apparent even at an early age. Similarly, 15 year old boys in Wales were found to be twice as likely as girls to take part in recommended levels of activity(59), and in England 66% of 15 year old boys participated in physical activity for 60 minutes a day as compared to 47% of girls(34). The HBSC survey(28) also shows consistently lower levels of physical activity among 11-15 year old girls than among boys. Studies using objective measurements have similarly found boys to be more physically active than girls(54)(53)(55), with differences observed both in the percentage of boys and girls meeting the 60 minute a day guideline and the time spent participating in physical activity. One study found that 42% of boys met the 60 minutes a day guideline as compared to only 11% of girls. Girls also spent 27% less time than boys participating in physical activity (45 minutes a day versus 57 minutes a day(55)).

15 25 10 20 5

Young people’s perceptions of their own levels of physical activity mirror these gender differences: 42% of boys and 29% of girls aged 11-15 years saw themselves as ‘very physically active’ compared to others and 10% of boys and 16% of girls said they were ‘not very’ or ‘not at all’ physically active(34).

Figure 4: Trends in percentage of young people 15 0 participating in at least 60 minutes of moderate physical activity daily

Differences by age

60

Physical activity levels of girls decrease with age, with a particular drop-off after the age of about 10 years. Scotland(45)

The Health Survey for shows that boys appear to maintain relatively high levels of physical activity between 2 and 15 years but girls’ activity levels decline, particularly after 10 years of age (see Figure 5). This also held true for England:

Physical activity levels of girls decrease with age, with a particular drop-off after the age of about 10 years. Girls meeting recommended levels of physical activity (Scotland) Age

Girls

8 - 10

75%

11 - 12

57%

13 - 15

41%*(45)

*By comparison, 68% of boys met the recommended levels.

Girls meeting recommended levels of physical activity (England)

10 80 70 5

0 50 40 80 30 70 20 60 10 50 0 40 Sources: 30 England: Health Survey for England 2002 and 2007. 80 references 56 and 34. See 20 Scotland: Scottish Health Survey 2003. See reference 45. 70 10

Figure 5: Differences in percentages of young people 60 in0 Scotland achieving at least 60 minutes of moderate intensity physical activity daily according to gender 50 and age (2003) 40 80 30 70 20 60 10 50

Age

Girls

0 40

8

73%

30

15

47%(34)

There was also an increasing proportion of girls in the ‘low’ physical activity category from the age of 12 onwards, with 17% of girls aged 10 and 11 and 34% of those aged 15 years in this category(34).

20 10 0 Source: Scottish Health Survey 2003. See reference 45.

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Differences by socio-economic status There is no clear association between overall physical activity and socio-economic status, but there is evidence that socio-economic status may affect the type of physical activity young people participate in. Although socio-economic status appears to have little significant impact on physical activity levels,(58) (60)(34), the 2003 Scottish Health Survey(45) did find a slight tendency for girls’ activity to increase as income decreased. For example, 68% of girls in the lowest income quartile met the guidelines compared with 61% in the highest. However, the HBSC survey(28) found that boys and girls from less affluent families tend to report lower levels of activity. However, if the primary significance of socio-economic status (or social class) is that it determines life choices, it may affect the type of physical activity young people participate in(61). For example, the 2007 Health Survey for England(34) found that participation in sport and exercise tended to increase as comparable household income increased, while the reverse was true for walking, with higher levels of participation among those in the lowest socio-economic group. Socio-economic status can also influence the type of physical activity young people do through its impact on their participation in clubs. A survey in 2002(62) found that young people living in the 20% of most deprived areas in England were less likely to be members of a sports club than those living in other areas (35% versus 47%), and were less likely to take part in sport at youth clubs or other organisations (48% versus 58%). Participation among children and young people with a disability Children and young people with a disability take part in physical activity and sport less frequently and their experiences are less positive than their non-disabled peers(63) and the proportion of those with a disability or severe illness participating in sport and exercise tends to be lower than for young people generally(64). (Please also see p.5)

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Participation among children and young people from different ethnic groups Ethnicity has an influence on participation in physical activity. With the exception of Pakistani boys and Irish boys and girls, children in minority ethnic groups are less likely than the general population to achieve their 60 minutes a day(65). Additionally, in most groups, girls are less likely to have a high level of physical activity than boys, though the proportions of boys and girls achieving this level of physical activity are similar among Black Caribbean, Chinese and Irish children. Chinese boys (38%) were much less likely than boys in other groups to have achieved the recommended level of physical activity. Among girls, the proportions who had reached this level ranged from 36% of Pakistani girls to 60% of Irish girls. A recent study also observed that Asian pupils and black girls were considerably less active than white pupils(66). Other studies also showed that both adult and young South Asians consistently report lower levels of physical activity compared to the general population(67)(65).

Other participation patterns A variety of other factors also influence activity levels. Region Activity levels are likely to vary from region to region within each country. For example, in London only 63% of boys and 50% of girls achieved the guideline, while South West England recorded the highest levels (81% of boys and 75% girls)(34). Season The time of year appears to have an effect, with children being most active in the summer and least active in the winter(68)(53)(69). Also, during school term time, young people may be more active during the week than at weekends(70)(53) but there may be differences between boys and girls, with boys possibly engaging in higher activity levels at weekends(71). Some young people are less active during school holidays(48) and, given free choice, as in holidays and at weekends, children’s daily activity drops(72).

Parental activity Parents’ physical activity levels also appear to influence their childrens’. In households where both parents reported high levels of physical activity, children in all age and gender groups were also more likely to report higher levels than households with only one active parent(34). Parental physical activity levels may have a particular impact on girls: teenage girls with low activity levels have the highest proportions of parents with low activity levels.

Much of the data are based on the percentages of young people meeting the guideline of 60 minutes a day of moderate intensity activity. There are indications that this level of activity may not be sufficient to achieve all the potential health benefits(5). However, if the UK guidelines are revised in line with those adopted by some of the other countries, data from the 2005/06 HBSC survey(28) shows that even greater percentages of young people may not reach recommended levels of physical activity.

Summary At best, there are still significant numbers of young people not meeting the recommended levels of physical activity, especially adolescent girls, with about 30% of boys and 40% of girls in England and Scotland and significantly more than this in Wales and Northern Ireland reportedly not reaching the 60 minutes a day target(34)(45). However, studies using objective measurements suggest that the situation could be much worse, and further research is needed to fully understand the current activity patterns of young people in the UK. The lack of awareness of the 60 minutes a day physical activity guidelines among young people could be one contributing factor to low activity levels among some groups and this needs to be addressed.

There are significant numbers of young people not meeting recommended levels of physical activity… The evidence particularly highlights a need to target the low activity levels of adolescent girls who appear to be missing out on the many benefits associated with an active lifestyle. If girls are unsuccessful in changing their activity patterns as they move into adulthood, they could be more vulnerable to those health problems associated with inactivity(34). Interestingly, girls aged 11 -15 years (74%) were more likely than boys (61%) to want to do more physical activity regardless of age(34) so it appears there is the potential to improve this situation.

…however, some studies suggest that the situation could be much worse.

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Activity in schools Although the amount of curricular PE that schools offer varies across the UK, in all cases extra-curricular activities and breaktimes / lunchtimes provide valuable opportunities for pupils to participate in additional activity. Schools have a vital role to play in helping our children and young people get more active, by promoting physical activity(73) and providing opportunities for, and knowledge about, the activity our children need. Within the UK, there are targets for all nations regarding curriculum allocation for PE, which centre around achieving a minimum of 2 hours per week. However, the infra-structure and delivery mechanisms for school sport and activity vary considerably across the UK. In England, there is a long term Government ambition as part of the School Sport and Young People Strategy (PESSYP) which aims to offer all children at least five hours of sport every week, comprising: • at least two hours high quality PE in the curriculum (for 5 -16 year olds) •

the opportunity for at least a further three hours sport outside the school day, delivered by a range of school, community and club providers (for 5 -19 yr olds).

The results are encouraging. In English schools taking part in School Sports Partnerships, 90% of pupils took part in at least two hours of high quality PE and out of hours school sport in a typical week(74). This is a significant increase on previous years, with the greatest gains made in Years 1 (5 - 6 years) and 2 (6 - 7 years) (see Figure 6). The percentage of pupils taking part at this level increased from 56% in 2004/05 to 95% in 2007/08.

Curriculum PE For some young people, PE remains their only structured or organised, regular physical activity. It’s therefore crucial that all pupils receive at least two hours of the highest quality physical education a week. However, the National targets for PE and school sport are, on their own, not sufficient to help children and young people achieve the seven hours of physical activity a week to receive all of the health benefits from being active.

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There has been a significant increase in the number of young people participating in two hours or more of curricular PE in England. In 2007/08 78% of pupils participated in at least 120 minutes of curriculum PE - compared to just 34% in 2003/04(74) (see Figures 7 and 8). This improvement is promising, and has had a major impact on the success of the overall levels of participation in PE and school sport, but it also means that 22% of young people are still not receiving the recommended two hours each week. However, this represents the time teachers say pupils spend in PE, rather than the actual amount of activity they do. It’s likely that pupils are getting much less than two hours of actual activity in their PE lessons. One study showed that pupils were moderately or vigorously active for approximately 18% of the available lesson time - an average of only 6.6 minutes per lesson(75).

22% of young people are still not receiving the recommended two hours of PE each week. As with the percentage of pupils participating in at least 2 hours of school sport, rates are fairly similar for Years 1 - 9 but then drop by around 20 minutes at Years 10 (14 -15 years) and 11 (15 -16 years) to 99 minutes and 96 minutes respectively. This drop in provision is of concern, given the low levels of activity among adolescent girls(74). Provision in primary schools has significantly increased between 2003 and 2008 with the greatest increases for Years 1 & 2 - from 96 to 122 minutes per week(74). Across all year groups, just 8% of pupils participated in less than 90 minutes of curriculum PE in a typical week while 12% had more than 150 minutes. Schools in Scotland, Wales and Northern Ireland are falling short of achieving the two hours curricular PE. In Wales, primary schools offer, on average just 93 minutes per week across year groups and secondary schools 99 minutes (ranging from 116 minutes in Year 7 to just 77 minutes in Year 11)(76)(77). The HM Inspectorate of Education for Scotland (HMIE) have stated that, in 2008, of those primary schools inspected in Scotland only a third were providing two hours of PE at each stage and in secondary schools two thirds of schools met the target at S1/S2, the majority at S3/4 and only one in seven at S5 and S6(78). In Northern Ireland just 14% of primary schools pupils receive two

100

80

60

hours curriculum PE per week(79). In Northern Ireland 51% of pupils in secondary schools spent two or more hours a week doing PE or games at school, 45% spent up to two hours and 3% spent no time(49). Figure 6: Changes in the percentage of young people in different year groups participating in at least 2 hours of high quality PE and out of school hours school sport in a typical week

Figure 7: Total curriculum time that all pupils in each year group spend taking part in PE in a typical week. 40

150 20

120 0

90

Figure 6a: Primary 100

100

60 80

80 100

30 60

60 80

0 40

40 60 Source: School Sport Survey 2007 / 08. See reference 74. 20

20 40

0 20

1000

Figure 6b: Secondary 80 100

60 80

Figure 8: The amount of curricular PE per week in SSP 0 schools, England 2007/08 80 70 60 50 40

40 60

20 40

30 20 10

0 20

0

800 70 Source: School Sport Survey 2007/08. See reference 74. 80 60

70 50 60 40 50 30

Source: School Sport Survey 2007/08. See reference 74. 60

50 40

15 30

Daily physical activity Time constraints are the most often cited reason for pressures on curriculum time for PE(80). However, there is a move to improve out of school provision and introduce daily physical activity sessions to broaden and expand on what is offered in curriculum time. The most effective school-based activites are those which occur throughout the whole school day as part of the curriculum(81). More schools have introduced 10 minute daily physical activity sessions, which have a positive impact on; academic performance, students’ concentration and cognitive functioning(82), as well as helping pupils focus on their classroom tasks(83).

Extracurricular activities Extracurricular activities can be a fundamental link between curricular PE and young people’s participation in sport and physical activity in their leisure time(84). In England, there has been a substantial increase in the range of activities available to pupils out of school hours in schools involved in School Sport Partnerships as a result of the national drive to raise participation levels(85)(86). The latest School Sport Survey(74) showed that 12% of pupils achieve their two hours of PE and school sport through a ‘top up’ of out-of-hours school sport, including lunch or breaktime activities, rather than through curriculum PE. In Northern Ireland, 50% of boys and 37% of girls (aged 11-16) took part in sport or physical activity after school on at least one day a week(49). However, there is concern about the kinds of extracurricular activities on offer and the strongly competitive, performance and sporting orientation that appears to characterise extracurricular provision(87).

In Northern Ireland, 50% of boys and 37% of girls (aged 11-16) took part in physical activity after school at least one day a week.

16

This is particularly true in Scotland, where there has been a decrease in the number of pupils taking part in extracurricular activity, with evidence suggesting that school provision appeals to those who are already keen to participate, resulting in a small number of pupils taking part in large amounts of activity(88). Only up to half of young people may be taking part in extracurricular activities: Participation in out of school activities Wales

Scotland

58%

60%

Primary Secondary

42%(89)

29%(90)

In addition, data from Scotland indicate that the percentages taking part in after school clubs are increasing among pupils in primary schools but decreasing for secondary school pupils and boys in secondary schools (36%) are more likely than girls (22%) to go to a club. Club-based activity plays an important part. In England, schools had links to an average of 7.6 different clubs during 2007/08, up from just 5 in 2003/04: Pupils participating in school-linked club-based activity (England) Yrs 2 - 11 (av.)

32%

Primary

40%

Secondary

25%

Yr 11

19%(74)

Participation in club-based activities in Wales is higher, but this data does not specifically focus on clubs linked to schools: Pupils participating in club-based activity (Wales) Primary

78%

Secondary

73%

of which: Boys

59%

Girls

47%(89)

And, in Northern Ireland, 59% of pupils were members of a club or team (not connected with their school) that involved them in sport or physical activity(49).

Breaktimes Children in the UK can have up to 600 break periods at school per year(91), providing valuable opportunities to take part in daily physical activity. Primary school boys and girls aged 5-10 years may spend about 30% of breaktimes engaged in moderate to vigorous physical activity (MVPA) with boys tending to be more active than girls(92). In a survey of 11 to 16 year olds in Northern Ireland, 58% of boys said they were active during lunchtimes as compared to 15% of girls, while during breaktimes 38% of boys were active compared to only 7% of girls(49). Environmental changes, eg, providing playground markings(93), obstacle courses(94), and equipment(95) have been found to increase breaktime MVPA levels. Although children take part in self-directed active play, schools also often provide activity sessions / clubs at breaktime. For example, in Scotland 25% of extracurricular activities in secondary schools take place at lunchtime and 27% of primary school pupils and 29% of secondary attend lunch/breaktime clubs(90).

Active transport Active transport (such as walking and cycling), particularly to and from school, has decreased in the last three decades but there are initial signs that this downward trend may be starting to change. Since 1975, the change in school journeys from walking and cycling to car has been marked (see Figure 9, p.18). However, evidence suggests that in the last few years this trend may be slowing: Journeys to school On foot

By car

1975/76 (5-15 yrs)

61%

11%(96)

2005/06 (5-16 yrs)

46%

30%(97)

Fewer parents now allow their children to walk to school unaccompanied(99). Journeys to school alone (5-10 yr olds) 1985/86 2005

21% 6%(99)(100)

Even greater changes are evident if comparisons are made with earlier years. About 40% of people born in 1932/41 travelled to school alone at the age of 10-11 years compared to 9% of children of a similar age born in 1990/91(101).

Active transport particularly to and from school, has decreased in the last three decades. The decline in active transport to and from school may be starting to change(97). There have been slight increases in the proportion of young people walking to and from school: Journeys to school 5 - 10 yr olds

11 - 16 yr olds

2003

51%

40%

2006

52%

41%(97)

17

60 50 50 40 40 30 30 20

Although these figures are still less than those recorded in 1995/97, and a long way short of numbers walking to school in the 1970s, they are a promising move in the right direction. Between 2003 and 2006 levels of cycling remained static at 1% in the younger age group, but have risen in 11-16 year olds from 2% to 3%. There was a corresponding decrease, of three percentage points in 13-16 year olds being taken to school by car but there was no change for children aged 5 -10 years. Encouraging schools to introduce travel plans may be contributing to these possible positive changes. These plans reduce car journeys to and from school in 60 to 90% of schools and at the end of March 2007 more than 14,000 schools in England (56%) had an approved travel plan in place(102). Walking to school may make a significant contribution to young people’s activity levels and, particularly for boys, active transport may contribute to a more physically active profile across the day(70)(103)(104)(105)(106)(107). Findings have included the following: • The journey to and from school can contribute 8-14 minutes per day of moderate to vigorous intensity activity(103). • Children aged 12-13 may use more calories in a week walking to and from school than they do in two hours of PE(70). • Children and adolescents who walk or cycle to school are more likely to meet activity guidelines than those who travel by car or bus(106). • Children who walk to school are significantly more likely to play sport(104). Increasingly, research is showing the value of active travel and its potential contribution to activity levels(7). Patterns of travel to school can have a significant impact on overall activity levels among young people and are likely to contribute to the differences in participation in physical activity internationally(108). With recent data suggesting that some progress may have been made in reversing the decline in active travel, continuing efforts in this area are important.

18

Figure 9: Changes in mode of transport to and from 20 10 school, 1995/97, 2003 and 2006 10 0

Figure 9a: 5-10 year-olds. 0 60 60 50 50 40 40 30 30 20 20 10 10 0 0

Figure 9b: 11 – 16 year olds 50 50 40 40 30 30 20 20 10 10 0 0

Source: National Travel Survey 2006. See reference 97.

Activity in leisure time outside school Active play continues to be the most common type of activity children participate in outside of school. When asked what they like doing, 83% of children aged 4-16 years mentioned ‘playing sport’ and 58% ‘playing outside near home’(109). Further, 73% indicated they would like to play more sport and 62% that they would like to play outside more. But how do young people actually spend their leisure time beyond school?

Active play

Not surprisingly, there are seasonal differences in active play with one study showing that 89% of 3-5 year olds played outside in July as compared to only 21% in January(113). (See also p.12)

Participation in sports and exercise Participation levels in sports and exercise are lower than for active play: Sports and exercise participation in 2-15 year olds England

Outdoor and unstructured play may be one of the best forms of physical activity for children(110). Play is also creative and helps socialisation. The Chief Medical Officer for England’s report recommended that children should have 3 - 4 afternoon or evening play opportunities in a week, and that this would make an important contribution to their activity levels(6). Unstructured play can account for as much as 210 minutes of activity a week, often making a more significant contribution to overall activity levels than PE lessons(111). Active play continues to be the most common type of physical activity children take part in outside school: Active play days per week in England (2 - 15 years) At least 1 day

5 or more days

Boys

93%(34)

70%(112)

Girls

88%(34)

59%(112)

Active play hours per week in Scotland (2 - 15 years) 7 hrs or more

Av. hrs per week

Boys

52%

8.5%

Girls

44%

7.5%(45)

The amount of time spent on active play decreases with age for both boys and girls. This is particularly pronounced in girls - by the time they reach 15, only 16% of girls in Scotland spend seven hours or more in active play(45) and 29% of those in England(112) engage in this type of activity at least five days a week.

At least 1 day

5 or more days

None

Boys

69%(34)

22%(112)

33%(112)

Girls

64%(34)

14%(112)

40%(112)

Scotland 7 hrs or more

None

Boys

24%

27%

Girls

14%

32%(45)

In both England(34) and Scotland(45), boys’ participation in sports and exercise increases significantly at 5-6 years of age and then remains relatively stable, while for girls participation drops off significantly after the age of 10-11. Boys said they would like to do more ball sports (39%), bike riding and swimming (both 35%), girls preferred swimming (47%) and ball sports (38%)(34). There is a general decrease in interest in most activities with age, with the exception of jogging and walking which vary little with age.

Walking In England, 91% of both boys and girls had walked continuously for 5 minutes at least once a week out of school hours(34), with 65% of boys and 63% of girls having done so on at least five days a week(112). Similar levels were recorded in Scotland(45): 70% of Scottish girls and boys participated in walking on five or more days a week, spending an average of 4.2 and 4.1 hours respectively on this type of activity each week.

19

How sedentary are our children and young people? Young people are increasingly spending a significant amount of time being sedentary, which could have important implications for their health, irrespective of the amount of physical activity they do. Some researchers suggest that high levels of sedentary behaviour can have a negative impact on the health and wellbeing of children and young people whether or not they meet the physical activity guidelines(114)(115)(116). Also: • there may be a relationship between sedentary behaviour and overweight(117)(118) • the effects of sedentary behaviour may build up over the course of childhood(119) • sedentary behaviour may contribute to weight status independently of the level of physical activity(118)(120). We need to fully understand the potential independent effects of sedentary behaviour on health, and more research is needed in this area. However, it is clear that young people should avoid being too sedentary and, where possible, find physically active alternatives. This has prompted physical activity guidelines in a number of countries that include a recommendation to reduce sedentary behaviour(39)(40)(42)(43). The National Association for Sport and Physical Education (NASPE) in the US discourages periods of inactivity over two hours among children, especially during the daytime(121).

It is clear that young people should avoid being too sedentary and, where possible, find physically active alternatives. Sedentary behaviour doesn’t just refer to screen-based activities such as watching TV, playing computer games, or social networking, which tend to be the focus of attention. Listening to music, spending time with friends, homework and reading are all examples of sedentary activities which, although they are valuable, also take up a substantial percentage of young people’s free time(122). Young people appear to spend a lot of time being sedentary. This pattern may start at a very young age with median time* spent in sedentary behaviour recorded as 79% of monitored hours at three years of age, and 76% at five years in one study(51). *This refers to taking a middle figure in a study range rather than an overall average.

20

For 14 year old girls, one study revealed that the five most consuming sedentary activities occupied, on average, around 4.38 hours per weekday and 6.66 hours per weekend day as compared to active transport and sports and exercise which only occupied 44.2 minutes and 53 minutes on weekdays and weekend days respectively(123). A study of 5 -11 year-olds who were overweight found they were sedentary for 80.7% of their monitored time(124). Socio-economic factors may be relevant. There is some evidence that sedentary behaviour is greater in those from lower socio-economic groups(66).

Screen-based sedentary behaviour Watching TV occupies a significant amount of young peoples’ time but as children watch TV and engage in physical activity at different times of the day, the relationship between TV viewing and physical activity is small and it seems there is time for both. The fact that TV viewing, computer and video games, and social networking take up large amounts of young people’s time is hardly surprising: 80% of 5 -16 year olds have their own TV, 70% have their own DVD player,and nearly all have a computer at home, with more than half having their own computer(125). TV / video viewing takes up at least one and a half hours per day(126) and children and young people spend an average of five hours and 20 minutes a day in front of a TV or computer screen(127). The overall volume of media viewing (watching TV, playing video games and using computers) is estimated at 35-40 hours a week in 11-17 year olds(128). Watching television every day seems to be the norm even at 22 months of age. In Scotland, 64% of children of this age watch TV every day and 24% of children aged 1 - 3 years watch one to two hours a day on weekdays(113). The same survey found that 84% of 3 - 5 year olds in Scotland watched TV every day and 30% watched over two hours every day.

TV accounts for 40-50% of the time young people spend inactively on weekdays and 35-50% at weekends. Children watch significant amounts of TV on both weekdays and weekends(123) (see Figure 10). Although only a minority watch more than four hours a day, TV accounts for 40 - 50% of the time young

people spend inactively on weekdays and 35 - 50% at weekends(123)(129)(130). Recent data from adolescent girls show that 38% watch more than two hours TV a day on weekdays and 58% at weekends(129).

Figure 10: Percentage of young people aged 11 and 15 who report watching television for two or more hours on weekdays 2005/06

Using computers and playing computer games are other key sedentary activities. The proportion of young people using a computer for emails, internet and /or homework for two or more hours on weekdays is higher than the average for other countries in the 2005/06 HBSC survey (see Figure 11, p.23(28)). There are no big differences between boys and girls, but computer use increases with age.

Figure 10a: 11 year-olds

The percentages of young people playing computer games or on games consoles for two or more hours on weekdays are similar in other countries (see Figure 12, p.23), but there is some variability between England, Scotland and Wales. (No data are currently available for Northern Ireland). Boys are far more likely to play computer games in both age groups. Significant differences between boys and girls in levels of playing computer games have also been noted in other studies(129)(123).

40 60

80% of 5-16 year olds have their own TV.

Figure 10b 15 year-olds 70 0

Watching TV and other electronic media are often blamed for increasing inactivity and obesity among young people. However, the relationship between watching TV and physical activity is small(131) and it seems there is time for both(131)(132). On weekdays, out-of-school TV viewing peaks later in the day, during middle to late evening, and physical activity earlier, so the two behaviours do not necessarily compete(132). The relationship between sedentary behaviour and levels of overweight and obesity may be more about the associated eating habits of young people rather than its impact on physical activity. TV viewing has been associated with higher consumption of energydense foods(133), sweets and soft drinks and lower consumption of fruit and vegetables(134). It is important to look at the whole range of sedentary behaviours. Currently, little is known about the factors underlying habitual inactivity in young people(8) and there is a need to consider specific behaviours such as watching TV in the wider context of changes in lifestyle and the structure of society(128).

80 70 60 80 50 70

30 50 20 40 10 30 0 20 80 10

60 80 50 70 40 60 30 50 20 40 10 30 0 20 10 40 0 35 HBSC average = the average for all 41 countries and regions in the 30 40 Health Behaviour in school-aged Children Study. Source: Inequalities in Young People’s Health. Health Behaviour in 25 35 School-aged children international report from the 2005/06 Survey. See reference 28. 20 30

15 25 10 20 5 15 0 10

21

There may be a need for different behavioural targets in interventions to reduce sedentary behaviour(126) and it may be useful to attempt to reduce sedentary behaviour when it is most likely to compete with physical activity. The hours immediately after school are critical to adolescents’ participation in physical activity(107). Promoting active transport and restricting the use of technology may help increase physical

activity at this time. Research indicates this doesn’t appear to displace time spent doing homework(107). Sedentary behaviour should be studied separately from physical activity(128)(8)(135). And developing a better understanding of sedentary behaviour in relation to physical activity and overweight may be critical for preventing and reducing overweight in youth(136).

Factors associated with physical activity in children and young people A range of related factors (known as correlates) of physical activity have been identified which, other than age and gender, are likely to have only small or small-to-moderate effects in isolation and may work best in interaction with other influences(7). Appendix 1 (please see p.40) identifies factors that have consistently been associated with physical activity in children and young people. It provides a summary of the findings identified in a review of these factors which was carried out by the NICE Public Health Collaborating – Physical Activity(137). Conclusions were based on findings from five systematic reviews(57)(138)(139)(140)(58). Correlates of physical activity were grouped under five main headings: demographic and biological, psychological, behavioural, social/cultural and environmental. Appendix 1 summarises key correlates identified under each of these headings(137). The review(137) also considered the evidence relating to socio-economics and Body Mass Index (BMI) as correlates of physical activity but findings were inconsistent. The relationship between socio-economic status and physical activity is unclear with respect to children and adolescents (measurement variability is a potential issue here) and higher BMI seems only to correlate with lower activity levels in recent data on adolescent girls.

22

Correlates of preschool children and physical activity have also been considered(141) and three variables, in particular, appear to have an effect: • Boys are more active than girls. • The children of parents who participate in physical activity with them are more active. • Children who spend more time in outdoor play spaces are more active.

70 80 60 70 50 60 40 50 30

Figure 11: Percentage of young people aged 11 and 15 40 20 report using a computer for emails, internet and / who or 30 homework for two or more hours on weekdays 10 (2005/06) 20 0

50 60 40 50 30 40 20 Figure12: Percentage of young people aged 11 and 30 15 who report playing computer games or games console for two or more hours on weekdays 10 20 (2005/06) 0

Figure 11a: 11 year-olds

10 Figure 12a: 11 year-olds

40 0

60 0

10

35 40 30 35 25 30 20 25 15 20 10 15 5 10 0 5 60 0 Figure 11b: 15 year-olds

50 60 40 50 30 40 20 30 10 20 0 10 50 0

Figure 12b: 15 year-olds

50 60

40 50

40 50

30 40

30 40 20

20 30

30 10

10 20

20 0 10 60 0

0 10

0

50 60 average = the average for all 41 countries and regions in the HBSC Health Behaviour in school-aged Children Study. 40

Source: Inequalities in Young People’s Health. Health Behaviour in 50 School-aged children international report from the 2005/06 Survey. See 30 reference 28.

HBSC average = the average for all 41 countries and regions in the Health Behaviour in school-aged Children Study. Source: Inequalities in Young People’s Health. Health Behaviour in School-aged children international report from the 2005/06 Survey. See reference 28.

40 20 30 10 20 0 10

23

What motivates our young people to be active? And what barriers stop them? A recent review suggests that for children of all ages, enjoyment, friendship groups, social interaction, parental, familial and peer supports influence young people’s participation in physical activity(142).

The following are all influential:

One survey found that 61% of boys and 74% of girls would like to do more physical activity, which is very encouraging(34). It’s particularly promising that 76% of 15 year old girls indicated they would like to be more active, which is important given the low levels of activity in this group. So what’s stopping them from putting this desire into action?

• the opportunity to do things with other family members(143).

What motivates young people to be active?* Aspects of physical activity that children value

Local opportunities are important in encouraging young people to be more active. In particular, there is a need for:

These include:

• better provision of youth clubs

• having a choice of sporting and exercise opportunities

• cleaning up of parks and open spaces

• activity as a means of having fun and spending time with friends

• more extra-curricular opportunities in schools, and

• a sense of belonging (for those in a team) • enjoying competition and • feelings of achievement. Children also mention keeping ‘fit and healthy’, being in good shape and controlling weight, particularly girls(143). Enjoyment and a chance to show off their skills(144) and opportunities for independent outdoor play(142) have also been highlighted as important, and older children identify physical activity as a way of relaxing, forgetting their troubles(143) and relieving stress(144). *The sub-headings under which facilitators and barriers have been grouped are those used in a systematic review of this area, which included factors identified by children themselves and by their parents(143).

Family life and parental support Parents have an important role to play in: • creating opportunities for physical activity and giving financial support(144) • encouraging their children, providing transport and paying for activities(145) Parental physical activity(112)(139), parental education(139) and family income(139) are also important factors.

24

• a supportive, encouraging, inspiring family • parents who provide practical support, and

Most children develop their attitudes and behaviours through socialisation, and the family (together with peers and teachers) have a key influence(146). Greater access to opportunities for physical activity

• better cycle paths • making school facilities more accessible outside school lesson times(143). Owning a car (and therefore being able to access opportunities further away from home) and having a garden will also encourage more physical activity(143) as will greater access to more activity opportunities.

In England 61% of boys and 74% of girls would like to do more physical activity. More variation in the types of activity on offer can increase interest among children(147)(144). In particular developing the social side of physical activity through more opportunities for activities that are fun, with space and time for both single-sex and mixed activities(144). Light and moderate intensity activities and those categorised as individual can also achieve higher levels of sustained participation than vigorous intensity or team activities(148).

What barriers stop young people being active?

And:

Brunton et al (2004) identified key but interrelated barriers to children’s participation in physical activity which fall into the following four main areas(143).

• parental constraints related to fear of strangers(23)

Preferences and priorities

• poor quality of places to play(142).

Lack of spare time and preference for doing other things are barriers to physical activity. (This doesn’t necessarily mean that children don’t like sport and physical activity - they often just find other things more interesting)(143)(23)(144).

Due to concerns over safety, parents (and children) impose restrictions on their activity and children are unable to go very far away from home and /or unable to use local play areas, even if they’re close to home. Children’s opportunity to range independently has dropped considerably(149)(150)(151)(152)(153). A recent survey found that 42% of children aged 7-12 years are not allowed to play in their local park without an adult present(154) and over recent decades parents have increasingly tried to avoid risks to their children from outside the home by restricting their children’s independent mobility(155). Indeed, cultural shifts are such that letting children roam or play outside unaccompanied is now sometimes judged as an indication of irresponsible parenthood(156).

Family life and parental support Although family life and parental support can help increase levels of activity in young people, they can also act as barriers. For example, if parents don’t participate in sport and exercise or are not enthusiastic about them, it could have a negative impact on their children(143). The transfer of attitudes, beliefs and behaviours from parents and peers play a key role in explaining social inequalities in health, and the underlying factors and behaviours associated with poorer health, including a lack of physical activity(34). Restrictions on opportunities for physical activity

• safety and cultural factors(144) • risk of personal accidents(142) and

Intolerant adults complaining about noise and nuisance can also be a barrier, forcing children indoors(157). Lack of enjoyment

• cost

Enjoyment is crucial to young people to taking part in physical activity, and a lack of enjoyment is clearly a barrier.

• distance, particularly for those in rural areas

Factors include:

For structured sport, this includes:

• lack of a means of safe travel, and • lack of facilities(143). Also, children from lower incomes families are more likely to identify cost and lack of local access to facilities as barriers(143). (See also p.12) Young people also mention a lack of choice of physical activity as a barrier, together with not being asked about what types of activity they would like to do and a lack of practical and material resources needed to keep them involved(144). For unstructured physical activity, barriers include: • busy traffic

• believing their physique or coordination skills are not well suited to a particular sport • shame and embarrassment • frustration with complex or unclear rules • boredom • playing sport in bad weather(143). (See p.12) For many, the fact that friends are not taking part stops them being active. Other negative factors include: • self-consciousness about bodies(144)

• threat of crime

• dislike of highly structured activities or those organised by adults(144)

• threat of intimidation by older children, and

• inadequate or unwelcoming facilities(63)

• neglect of local play areas(143).

• an overtly competitive and stressful atmosphere(158)(159).

25

Further, being hit or kicked, falling over, getting cold and wet, getting hot and sweaty(62) and sport and exercise being ‘too difficult/tiring’(160) also put young people off sport.

When 11-16 year olds were asked about what could be done to help them get involved in physical activity(144), the majority of their suggestions related to increasing practical and material resources such as:

An additional barrier may be that those who most need to be more active don’t realise it - a high proportion of both boys and girls whose activity levels were low saw themselves as being fairly active compared to others (68% and 67% respectively). Younger girls had the least accurate perception of their own levels of activity(34).

• creating more cycle lanes

Specific motivators and barriers are particularly relevant for different target groups and types of activity. It’s not possible to consider these here but a series of reviews by the NICE Public Health Collaborating Centre - Physical Activity identify facilitators and barriers for girls, active travel, active play and children under eight years(142)(23).

Parental support can help increase young people’s activity levels… Summary The factors above have important implications for anyone responsible for encouraging and supporting more young people to be active. Action to help increase physical activity could include empowerment of children, emphasis on fun and enjoyment, and enhancing positive attitudes of parents to all forms of activity regardless of gender and age(142). There isn’t space to consider effective interventions in detail in this report, but please refer to NICE Reviews 4-8(161)(162) (163)(164)(23) for information on interventions for different target groups / types of activity.

26

• making activities more affordable • increasing access to clubs for dancing and •

providing single sex physical activities in youth clubs alongside or followed by mixed sex (non-physical) activities (combining sports and leisure facilities).

They also suggested emphasising the fun and social aspects of physical activity. Motivators may differ according to whether young people are active: • social benefits • competitiveness • a sense of achievement, and • feelings of confidence. or inactive: • enjoyment • wellbeing • avoiding boredom and • help with losing weight (for females)(165).

…but if parents don’t participate or aren’t enthusiastic, it could have a negative impact. Similarly, barriers may vary according to age and in relation to significant turning points in children’s lives. For example, physical activity tends to drop off with the transition from primary to secondary school. This is associated with individual factors such as internal developmental changes as well as structural factors such as a different physical activity culture and ethos(166). Support from family and significant others at key transitional phases is essential to keep children active(167). (See also p.24 and p.25)

How good are our children’s and young people’s diets? Young people’s diets are too high in saturated fat, salt and sugar and most still don’t eat enough fruit and vegetables. More work is needed to help children and young people to put knowledge into action when it comes to healthy eating. However, education alone is unlikely to be sufficient to achieve this. Healthy eating during childhood and adolescence is vital as a means to ensure healthy growth and development and to set up a pattern of positive eating habits to carry through into adult life. Eating healthily, combined with being more physically active can help to prevent key risk factors for heart disease in adulthood, including raised cholesterol levels and blood pressure. Eating at least five portions of fruit and vegetables a day is also important for a balanced and healthy diet.

What are our children and young people eating? The National Diet and Nutrition Survey (NDNS) of young people aged 4-18 years(168) provides comprehensive information on the dietary habits and nutritional status of the population in Great Britain. Using this survey as a basis, we can identify areas of concern in relation to the eating habits of this age group.

Diets high in saturated fat are linked to raised cholesterol levels and excess salt is linked to raised blood pressure. Overall, diets were found to exceed the Committee On Medical Aspects of Food Policy (COMA)(169) recommendations for saturated fat, non-milk extrinsic sugars (NMES) and salt, all of which have implications for future health problems. Diets high in saturated fat are linked to raised cholesterol levels and excess salt is linked to raised blood pressure, both of which are risk factors for heart disease. Some regional and national differences were also observed, with intakes of vitamins and minerals being lower in Scotland and Northern England than in other areas.

Fruit and vegetable consumption Populations with higher consumption levels of fruit and vegetables have been shown to have lower levels of a range of chronic diseases including heart disease,

diabetes and certain cancers. As a result the UK has developed a recommendation for people to consume at least five portions of fruit and vegetables per day. In the UK, figures show that on average, adults are not meeting this recommendation, and that average consumption of fruit and vegetables is even lower for children(34) (45). In order to increase children’s intake, there has been considerable emphasis on education as well as the practical provision of fruit and vegetables in schools through changes to school meals and dedicated fruit and vegetable schemes. To some extent, these messages appear to be getting through to children. Figures show that a high proportion (63% of boys and 73% of girls in England) knew that they need to eat five portions of fruit or vegetables a day(34). Intake also appears to be increasing: However, while this is encouraging, average consumption figures remain below the minimum of five portions a day (see Figure 13, p.29). Figures for both England and Scotland show that the majority of children are still eating less than the minimum recommendation: Percentage of 5-15 year olds eating five portions of fruit and vegetables a day England Boys

Girls

2001

11%

11%

2007

21%

21%(34)

Boys

Girls

12%

12%(45)

Scotland

2003

Intake however, appears to decline with age. Teenagers are eating less fruit and vegetables than younger children and, and further analysis of data reveals additional differences between groups. Consumption of fruit and vegetables increases as household income increases(34)(45) with children in the highest income group in Scotland, for example, being twice as likely to eat their five portions a day as compared to those in other income groups.

27

This finding was confirmed by the recent Low Income National Diet and Nutrition Survey (170), which highlighted that intake of fruit and vegetables was even lower among low income families than the general population. Girls were consuming, on average, two portions of fruit and vegetables a day and boys only 1.6 portions.

Consumption of high fat, salt and sugar (HFSS) foods Foods that are high in fat, salt and/or sugar are contributing to the increased levels of saturated fat, salt and sugar seen in the NDNS(168). Savoury snacks, chips, biscuits and chocolate confectionary were among the foods most commonly consumed during the survey and eaten by 80% of the group during the survey period. Three quarters of those participating in the survey also drank carbonated soft drinks. Although 45% drank low calorie versions, the full sugar versions were the primary source of NMES intake, followed by chocolate confectionary. In 2000/01, almost half of 13 year olds boys and girls in Scotland, a third of those in England, and a quarter in Wales, reported eating sweets or chocolate bars every day(108) (see Figure 14).

A third of 13 year olds in England reported eating sweets or chocolate bars every day. The Health Survey for Scotland shows that in 2003 young people were still eating large quantities of such foods. Among children aged 2 - 15: • 60% consumed sweets and chocolates at least once a day • 50% ate crisps daily and • around half usually ate biscuits at least once a day(45).

28

In Wales: • 29% of children aged 4-15 years ate sweets every day and • 22% ate crisps daily(46). A proportion of children develop a pattern of consuming less healthy foods and drinks at a very early age. A recent study in Scotland identified that 90% of children aged 22 months ate sweets or chocolate once a week or more often, including 43% who ate sweets or chocolate once a day or more(113). Almost half of children this age had crisps or savoury snacks once a day or more and over one in ten had a soft drink at least once a day.

90% of Scottish children aged 22 months ate sweets or chocolate once a week or more. Fatty and sugary foods and drinks are heavily marketed and promoted(102), and the food industry spends an estimated 75% of its £450 million advertising budget targeting children(171), with a large proportion of this being spent on HFSS products. Given the amount of children consuming these products seen in the NDNS, the potential impact of such advertising cannot be exaggerated. Please also see the BHF’s campaign report on children’s food marketing How parents are being misled(172).

The food industry spends an estimated 75% of its £450 million advertising budget targeting children.

25 20 20 15 15 10

Figure 13: Percentage of young people in England consuming five or more portions of fruit and vegetables per day (2001/06)

Figure 14: Percentage of young people aged 11 and 10 in England, Scotland and Wales who report eating 15 5 sweets or chocolate bars every day (2001/02)

25

0 Figure 14a: 11 year-olds

20

15

10

5

0 50 Source: Health Survey for England 2006. See reference 112. 40

5

50 0 50 40 40 30 30 20 20 10 10 0 0 50 Figure 14b: 15 year-olds

30

50 40

20

40 30

10

30 20

0

20 10

50

10 0

40

30

0

Source: Health Behaviour in School-aged Children Study. See reference 108.

20

10

0

29

Obesity in children and young people Obesity during childhood, especially in adolescence, is linked to obesity in adulthood. This in turn is an independent risk factor for heart disease and will also impact on other risk factors. Levels of obesity in adults and children have increased rapidly over the last 30 years. The causes of this rise in obesity are likely to be multifactoral but at the core is an energy imbalance resulting from excess energy consumption and insufficient energy expenditure.

Ethnicity In England, Chinese boys were less likely than boys in the general population to be overweight or obese. Black Caribbean and Black African boys and girls and Pakistani boys were more likely than boys and girls in the general population to be obese, but a lower percentage of Pakistani girls were obese than in the general population(65). (Please also see p.12) Percentage of obese boys and girls aged 2-15 years

Prevalence of overweight and obesity National health surveys suggest that approximately a third of young people aged 2-15 years in England, Scotland and Wales are overweight or obese, with Welsh figures (at 36%) slightly higher than those in the other two countries(34)(173)(46) (see Figures 15 and 16). Obesity figures from Northern Ireland suggest similar levels to the other countries(174): Obesity in England, Scotland, Wales and Northern Ireland

Boys

Girls

Black African

31%

27%

Black Caribbean

28%

27%

Pakistani

25%

15%

Chinese

14%

12%

General population

19%

18%(65)

Socio-economic status

Boys

Girls

England

17%

16%(34)

Scotland

17%

13%(173)

Wales

20%

19%(46)

Northern Ireland

20%

15%(174)

There is no clear association between overweight and obesity and socio-economic classification among boys but there are some differences among girls(45)(34). The highest prevalence is seen in the lowest income groups. Overweight/obesity: Lowest vs highest income group, girls 2-15 years England

Differences in the prevalence of overweight and obesity according to gender, ethnicity and socio-economic group. In the UK there appear to be no consistent differences between the levels of obesity among boys and girls. There is some evidence of an association between socio-economic status and obesity in girls, but not in boys, and obesity varies according to ethnicity.

30

Overweight

Obese

Highest

24%

9%

Lowest

35%

22%(34)

No significant differences were found among boys of any age.

Gender

Trends over time

The most recent data indicate that in England and Wales, levels of overweight and obesity are similar in boys and girls(34)(46), but in Scotland, overall, a greater proportion of boys (36%) than girls (27%) were either overweight or obese(173).

There have been significant increases in the prevalence of obesity over the last 30 years. While it is impossible to predict the trajectory of childhood obesity with absolute certainty, predictions suggest that this issue will continue to remain important for personal and public health in the future.

Significant increases in the prevalence of overweight and obesity in England(56)(175)(176) and Scotland(175) have been observed over the last 30 years. Obesity in England and Scotland (2 -15 year olds) (See Figure 17, p. 32)

If trends continue upwards, however, the Foresight report (2008)(177) has suggested that by 2025 obesity among 11-15 year olds could have increased by 6 percentage points for boys and 11 percentage points for girls from 2004 levels(177). Figure 15: Prevalence of obesity and overweight among 2-15 year olds in England (2007)

England Boys

Girls

1995

11%

12%

2007

17%

16%(34)

35 30 25

Scotland Boys

Girls

1998

14%

14%

2003

18%

14%(173)

20 35 15 30 10 25 5 20

Although there was an overall upward trend in the prevalence of obesity between 1995 and 2007 in England, there are indications that the trend may be flattening out(34). Despite a significant increase between 2000 and 2007 in the percentage of boys aged 2 -15 years classed as overweight or obese (four percentage points) and among girls aged 2 -10 years (five percentage points), there has been statistically no significant change in the prevalence of obesity year-on-year between 2005 and 2007. Data from the next few years will confirm whether this apparent halt in the year-on-year rise in obesity is sustained or whether, longer term, the trend will continue upwards(34). In Scotland, for example, the upward trend among boys, but not girls, seems to have continued unabated: Overweight or obesity among 2-15 year olds in Scotland (1998/08) Boys

Girls

1998

28%

28%

2003

32%

29%

2008

37%

27%(173)

0 15 10 Figures are based on UK BMI reference data. Note: 50 Source: Health Survey for England 2007. See reference 34. 5 40 Figure 16: Prevalence of obesity and overweight among 0

2-15 year olds in Scotland (2008) 30 50 20 40 10 30 0 20

35 10 30 0 25

Note: Figures are based on UK BMI reference data. 20 Source: Scottish Health Survey 2008. See reference 173. 35 15 30 10 25 5 20 0 15 10 35

31

30

20

10

Figure 17: Trends in overweight and obesity prevalence 0 among children aged 2-15 in England (1995/07) 35 30

Potential health problems associated with obesity

25

Obesity in childhood often persists into adulthood, when it can have a significant impact on health.

20 15 10 5 0

Notes: Figures are based on UK BMI reference data. Data for 2004 and 2007 have been weighted for non-response. 35 Source: Health Survey for England 2007. See reference 34. 30

Table 7 shows further predicted changes in the future. Foresight also estimate that, by 2050, 70% of girls 25 could be overweight or obese, with only 30% in the healthy BMI range. A different picture emerges for 20 boys, with 55% predicted to be overweight or obese 15 2050 and around 45% in the healthy range. by 10

Table 7: Percentage predicted to be obese (international definition), by sex and age 5 0

Boys 50

Girls

40

Age

2004

2025

2050

6 - 10

10%

21%

>35%

11 - 15

5%

11%

23%

6 - 10

10%

14%

20%

11 - 15

11%

22%

35%

*Very wide confidence interval. 30 Source: McPherson et al, 2007. See reference 178. 20 recent National Heart Forum report(179) however, A analysed HSE data published since the Foresight report using a similar methodology. This suggests that while 10 rates of childhood obesity are likely to remain high, the rate with which this is set to increase may be slowing. 0 While this is encouraging, more data is required to understand if this is to be an ongoing trend.

By 2050, 70% of girls could be overweight or obese. 32

Regardless of the rate of increase, however, both reports suggest that childhood obesity levels will remain unacceptably high and it is vital that action to address this issue continues.

While obesity is established as a risk factor for CHD and linked to other risk factors including diabetes and raised blood pressure in adults, the impact for children is not as clear. Reports have suggested that a younger onset of conditions such as raised cholesterol and blood pressure and diabetes have been seen, but large trials have shown no impact on long term health if overweight children become healthy weight adults. In practise, however, obese children are likely to remain overweight as they move into adulthood. Data show that 26 - 41% of children who are obese at pre-school age and 42-63% of obese school-age children become obese adults(6). One US study found that 79% of obese 10 -14 year olds remained obese into adulthood(3). This means that these children will start adulthood with an increased risk of coronary heart disease, along with other health problems. The younger they are when they become obese, the longer they are likely to be living with this risk factor, meaning that they are at greater risk of developing health problems at a younger age(180). It is estimated that severely obese individuals (those with a BMI over 45) are likely to die on average 11 years earlier than those with a healthy weight(181), comparable to, and in some cases worse than, the reduction in life expectancy from smoking(102). Obese adults who were overweight as adolescents have higher levels of weight-related ill health and a higher risk of early death than adults who only become obese in adulthood(6).

26 - 41% of obese preschool children and 42 - 63% of obese school-age children become obese adults. However, in addition to the future risk of health problems, young people who are obese are likely to have lower levels of fitness, suffer from social discrimination and have low self-esteem and lower quality of life(6).

Possible causes of obesity At its root, obesity is a consequence of an energy imbalance – either too much consumed or insufficient expenditure. But the factors which have led to a situation where it is becoming the norm to be overweight or obese are numerous, and are the result of the attitudes and behaviours of individuals and society at large and the changing environment we are all exposed to. Although diet and physical activity are at the root of this issue, the recent Foresight Report(177) acknowledges the radical changes in society over the past five decades that have resulted in today’s increased levels of obesity. These changes, coupled with an underlying propensity in many people to both put on weight and retain it, have resulted in the prevalence in obesity today. The primary focus of this report is on the potential impact of physical activity and sedentary behaviours on levels of obesity. The majority of recent evidence appears to support a role for physical activity in preventing overweight and obesity in young people. However, more research is vital to accurately record our children’s routine levels of physical activity and total energy expenditure. Sedentary behaviour is a specific risk factor for obesity, especially watching TV(182). Reducing sedentary behaviour has resulted in some success in weight control(183) and may also be a marker for certain eating behaviours or food choices. The content of viewing may also have an impact on children’s food choices in relation to the advertising of HFSS foods during programmes children watch regularly. However, watching TV per se may not be significant as it does not necessarily replace physical activity(131)(58) (see p.21) and the amount watched by young people has not increased(184)(185) alongside increases in obesity.

Tackling the issue Parents may be unaware of their tendency to underestimate how much they and their children eat and overestimate the amount of physical activity they do(186). In addition, research has shown that parents often don’t recognise when their children have a weight problem(187). Coupled with this is the failure to make the connection between their children being obese and how this may contribute to

long-term health problems, including heart disease and Type 2 diabetes. Increasing physical activity and decreasing sedentary behaviour may be effective in reducing overweight and obesity in children and adolescents alongside appropriate nutritional intake(188). However, due to the variability in the causes of obesity, we need a range of different solutions to reduce its prevalence (177). Physical activity is therefore a key part of this, with some researchers suggesting that, unless physical activity increases to boost energy demands, dietary habits will need to be changed to meet the nutritional needs of a largely sedentary population(189). Targets have been set for obesity in Scotland to reduce the rate of increase in the proportion of children whose BMI is outside a healthy range by 2018. In England, the aim is to both reverse the trend in rising obesity and overweight among children and reduce it back to 2000 levels by 2020. This would mean reducing obesity in children aged 2-10 to 12% and overweight to 13%(112). If solutions to address the high levels of obesity are to be effective, Foresight recommends that we need to: • involve partners outside traditional health sectors • adopt multidisciplinary approaches to stimulate effective behaviour change • establish new social norms • create a supportive environment and, critically in the case of children, • engage parents(177). Due to the numerous factors contributing to obesity, solving the problem is a complex challenge. Campaigning by organisations like the BHF and positive action by government are vital to stemming the tide. There is also a key role for the food industry – manufacturers, retailers and caterers – in addressing pricing, reformulation, nutritional labelling and acceptable marketing of foods. However, it is also crucial that parents are made aware of the importance of their role in safeguarding the health of their children.

Young people’s concerns about their weight There are indications that many young people, especially girls, are unhappy with their weight and use weight control practices.

33

25 30 20 25 15 20 10 15 5

46% of 15 year old girls believe they are too fat.

Figure 18: Percentage of young people aged 11 and 15 10 who think they are too fat (2005/06)

Although addressing the problem of growing childhood obesity is crucial, it’s important not to cause children and adolescents unnecessary anxiety about their weight. The stigmatisation of overweight and obesity appears to be increasing(190) and body image has an important role in self-evaluation, mental health and psychological wellbeing(191) (192) (193).

Figure 18a: 11 year-olds

Many young people, particularly girls, are unhappy about their weight (see Figure 18) and attempt to control their weight which, in turn, can have negative physical and psychological effects. Girls are more likely than boys to judge themselves as too fat and this negative body image becomes more prevalent with age among girls. Percentage of UK children who believe they are too fat Age

Boys

Girls

11

24%

29%

15

25%

46%(28)

Furthermore, many young people are engaged in dieting and weight control behaviour. More girls than boys attempt to lose weight and this increases with age:

0 5

0 35 30 35 25 30 20 25 15 20 10 15 5 10 0 5 50 0

Figure 18b: 15 year olds 40 50

30 40

20 30

Percentage of UK children who attempt to lose weight Age

Boys

Girls

11

14%

17%

15

9%

27%(28)

10 20

0 10

0

This is a cause for concern, since extensive and/or long-term dieting to lose weight could have potentially serious consequences for young people’s development and health(28). The World Health Organisation points out that a balance is needed to ensure that young people both maintain a healthy body weight and are protected from the pressures of negative body image and weight control practices(28).

34

Source: Inequalities in Young People’s Health. Health Behaviour in School-aged children international report from the 2005/06 Survey. See reference 28.

Conclusion and recommendations Childhood obesity has never been higher up the list of public concerns, and levels are predicted to remain high if we do not address this issue now. Despite this, there have been no major changes in children and young people’s physical activity levels over the last decade. This report has demonstrated that there is still a significant proportion of children and young people who are not reaching the recommended daily levels of physical activity. Some of the shortfall is concentrated in particular groups, such as adolescent girls, young people from ethnic minority backgrounds and young people with a disability, and dedicated solutions are needed. The emphasis on increasing physical activity in schools has had a positive effect, particularly in England. However, this success is not replicated across the rest of the UK. There is still a lot more that can be done to integrate physical activity into and around the school day. This includes maximising the range of opportunities available to pupils during lunch and breaktimes and making journeys to and from school more active. Outside of school, children and young people are spending a significant amount of time in sedentary behaviour which could have a detrimental impact on their health, irrespective of the amount of physical activity they do. Children and young people need a range of easily accessible physical activities in their local community, especially the chance to take part in unstructured play. It’s clear that action is urgently needed to ensure that children are able to make healthy choices – including opportunities to achieve the recommended 60 minutes of physical activity each day. This action must encompass: • raising awareness of the importance of physical activity • provision of a range of opportunities to be active • consideration of the barriers to getting active, and • concerted efforts to reduce health inequalities. Since the last edition of Couch Kidsin 2004, we have seen childhood obesity move up the political agenda in all four UK nations. This has been matched by greater investment and support for a range of measures to get children and young people to be more active.

In England, physical activity has been given greater prominence through the Fair Playand Be Active Be Healthy strategies and a continuing focus on tackling childhood obesity. And, in 2009, the Department of Health launched Change4Life, a comprehensive social marketing programme to raise awareness of diet and exercise among parents and children, and to provide the support to help them make changes. At the time of publication, it is too early to evaluate the effectiveness of this initiative. The Westminster Government remains committed to increasing the number of play spaces for children and young people, including through Sure Startcentres, and has set targets for the number of active school travel plans. In Scotland, the Active Schoolsprogramme has helped to encourage healthy lifestyles at school and into adulthood. While there has been good progress on integrating physical education into the school day and local sports strategies, provision is not universal or necessarily prioritised. The Scottish Parliament’s Health Committee has recently expressed concerns about physical activity levels(78). In Wales, there has been good progress in introducing primary school children to a range of activities through the Dragon Sportinitiative and support for secondary school sport. Welsh planning statements seek to ensure that the built environment promotes physical activity. In May 2009, the Welsh Assembly launched an action plan, Creating an Active Wales(31), to build on the investment in improving people's health so far. It aims to develop a physical environment that makes it easier for people to choose to be more physically active, to support children and young people to live active lives and become more active adults, to encourage more adults to be more active more often throughout life and to increase participation. In Northern Ireland, investment in physical activity is allocated through the Extended Schools programme and the Sports Council for Northern Ireland. The Department of Education has invested over £3.7m in a physical literacy sports programme for primary school children. This programme involves coaches from the Gaelic Athletic Association and the Irish Football Association working with some 600 primary schools (Foundation Stage and Key Stage 1 pupils) to develop the physical literacy skills among young people. Additionally, the DHSSPS’s Get a life, get active initiative brings together key messages and resources on physical activity and the Fit Futures taskforce has identified physical activity as a key element of its work.

35

Recommendations

Schools

It is challenging to recommend blanket action as both the diverse needs of children and young people, and the range of barriers that may prevent them getting more active, need to be addressed. Nevertheless, the BHF has identified a number of measures that would help ensure physical activity is more accessible.

Schools across the UK should maximise the opportunities for children to take part in physical activity during and around the school day. This should encompass motivating and prompting children to be physically active at breaktimes, and to encourage opportunities outside school hours through the concept of Extended Schools. Including minimum hours for PE in the English curriculum has helped to drive improvements and this should now be taken up in other parts of the UK. We support the recent recommendation from the Scottish Parliament’s Health Committee that the two hours PE per week target should be included in all Single Outcome Agreements.

At national levels Tackling childhood obesity has been identified as a cross-government priority. However, further action is needed to make this a genuine priority beyond health ministries. In particular, public health must feature more strongly in the motivation for transport, local authority planning and education policies. We support the recent recommendations(194) from the House of Commons Health Select Committee for national governments to publish a Planning Policy Statement on Health and to ensure that health trusts are made statutory consultees for local planning procedures. This must include recognition of the importance of active travel to public health, including safe walking and cycling access for children to interesting places to play and to schools. As previously highlighted by the BHF, the quality of food available in leisure facilities has been overlooked(195). More cross-government action is needed to link physical activity and healthy eating, for example by requiring healthy food options to be available in venues participating in Change4Life initiatives. National Government guidelines UK governments should develop consistent guidelines, supported by a communications programme to ensure public awareness, on recommended levels of physical activity for all age groups. Recommendations for under-5s should be a priority and dedicated resources will be needed to ensure that these are communicated to early years professionals. The low levels of awareness about the importance of 60 minutes of physical activity a day for children are a concern. Sustained communication at population and individual level is needed to improve understanding. Existing vehicles such as the Change4Life campaign in England and the Get a life, get active initiative in Northern Ireland should be used to drive up levels of awareness.

36

School provision should explicitly recognise the diversity of provision and approaches needed to ensure that physical activity reaches as many children and young people as possible. In particular, schools must demonstrate how they are meeting the needs of adolescent girls and the least active groups. There has been good progress on developing school travel plans in England. Governments in Scotland, Wales and Northern Ireland should now seek to replicate this success and set ambitious targets for schools to develop these plans. Securing the Olympic legacy The run-up to the London 2012 Olympic and Paralympic Games and the Glasgow 2014 Commonwealth Games gives us an unprecedented opportunity to raise awareness of the importance of physical activity across the UK. A legacy that engenders physical activity for all must be the key test for the success of the Olympics and the Commonwealth Games, including an increase in the number of people taking part in physical activity. This is an opportunity to galvanise young people that must not be missed.

Collection of data We have found that Couch Kids has been valued by policymakers and practitioners as it provides a snapshot of physical activity levels among children and young people across the UK. However, the collection of information on physical activity levels and associated barriers is inconsistent across the four nations. This makes direct comparisons and the tracking of trends over time, including health inequalities between countries, difficult. This should be addressed through consistent collection of data by local authorities, regional bodies and national governments. This should cover the full range of physical activity including active travel and everyday activities.

activity should be allocated through Local Strategic Partnerships, Single Outcome Agreements and other local priority-setting mechanisms. Professional support If we are to achieve a step change in physical activity levels across the UK, professionals leading and delivering opportunities to get active need to be confident and well resourced. Governments across the UK should ensure that dedicated resources are made available to support professional development, particularly focusing on those individuals for whom delivering physical activity is only a part of their role.

NICE guidelines The National Institute for Health and Clinical Excellence (NICE) has published comprehensive guidance in this area, which includes recommendations for local authorities to develop physical activity plans in consultation with young people and for evaluation of physical activity interventions. The Scottish Government has also published a perspective echoing these recommendations. The challenge remains ensuring that this guidance is implemented in full. UK governments should undertake a costing exercise to establish the resources needed to implement NICE guidance on physical activity. Research The BHF National Centre for Physical Activity and Health is committed to strengthening the evidence base for effective physical activity interventions. This role must also be championed by the National Institute for Health and Clinical Excellence, NHS Scotland and others. While increasing emphasis and resources have been placed on physical activity, this must be coupled with initiatives to tackle sedentary behaviour. This needs to be examined through dedicated research. We have strategies to increase physical activity levels either in place or in development in all four nations of the UK, but indications are that these remain at the policy level – the real test is getting these strategies implemented at regional and local level. Infrastructure support must be put in place for county sports partnerships and appropriate resources for physical

37

The BHF and physical activity The BHF is committed to improving the heart health of the population and our engagement in public health is wide-ranging. Playing our part in supporting higher levels of physical activity across the UK is a key element of this work. For the last five years we have run our wide-ranging Food4Thoughtcampaign which aims to help tackle childhood obesity by making it easier for children and parents to make healthier choices about food and activity. Food4Thoughtis a multi-dimensional social marketing programme which targets 11-13 year olds, teachers, policymakers and parents. Messages are promoted via student and teaching packs, online resources, PR and advertising. In 2009, children will be able to learn about the benefits of physical activity via the ‘Yoobot ’, which allows them to create a mini version of themselves and test out what happens to health over decades in the future when the Yoobot makes healthy or unhealthy diet and activity choices. A poster campaign spreading the 60 minutes a day message throughout the UK is also available to primary and secondary schools. Since April 2000, we have funded the BHF National Centre for Physical Activity and Health based in the School of Sport, Exercise and Health Sciences at Loughborough University. The centre provides information, translates evidence into practice and raises the profile of physical activity in the health agenda, particularly in relation to the prevention of heart disease. We’ve also developed fundraising initiatives for children to get involved in physical activity with Jump Rope for Heart, a sponsored skipping challenge which raises money for both the BHF and local schools or children’s groups. The programme has been a great success since it was launched in 1987, and in 2008/09 alone around 100,000 children got more active by getting involved. A key part of the programme’s success has been the way that it allows children to get active either on their own or in groups. In 2007 we introduced Artie’s Olympics, a programme of competitive and non-competitive activities for under 8s and in 2009 we launched Ultimate Dodgeball, a team event for 7-16 year olds which helps children to organise a tournament and raise funds for the BHF and their school.

38

We produce many resources for use in and out of school for children and young people, teachers, playworkers and parents. In schools we have a range of resources from posters to teaching packs, one of which helps primary schools prepare a whole school development plan on physical activity. Out of school, we train tutors throughout the UK to offer Active Club Workshops, where they teach play leaders and child minders, who are often inexperienced at supervising physical activity, to use the BHF’s comprehensive free Active Clubpack. Resources for children to increase their activity over several weeks, and for parents to be active role models, are all aimed at making increased activity achievable from whatever starting point. Working in partnership with others to help tackle inequalities in cardiovascular disease is one of the BHF’s strategic objectives. In 2009, we launched the Hearty Livesprogramme, which invests £9m in local areas with a disproportionately high incidence of cardiovascular disease. We are working with local health trusts and local authorities to develop innovative projects to support their communities. For example, we will be working in partnership with NHS Hastings and Rother and Hastings Borough Council to increase the amount of time children and their families spend being active. We believe that our initiatives help to ensure that children and young people can be more active, reducing their risk of future health problems. But we must work together. If we are to be successful in reversing the trend in childhood obesity, concerted action from governments across the UK is vital.

39

Appendix 1. Key factors associated with physical activity for young people Summary of key correlates of physical activity for young people (137) Correlate

Direction of association

Estimated strength of association

Comments

Demographic and biological correlates(57)(139)(140)(58) Male gender +

Moderate to large

-

At least small -to - moderate in adolescence

Age

Gender differences are highly reproducible, but they could vary depending on type of physical activity studied. Highly reproducible but little effect in pre-adolescence.

Psychological correlates(57)(58) Positive motivation +

Effects are less likely in younger children. Perceived competence seems to be an important correlate of physical activity for Small in adolescent girls adolescents. Enjoyment of activity seems more important for girls than boys.

+

Small - to - moderate in adolescent girls

-

Small - to - moderate

Perceived barriers may reflect real barriers or be justifications of personal preferences

+

Moderate

Consistent with evidence for moderate tracking during childhood and adolescence.

+

At least moderate

Smoking

-

Moderate

Sedentary behaviour at weekends and after school

-

Small

(eg, enjoyment, perceived competence, self-efficacy) Body image Barriers

Behavioural correlates(57)(139)(140)(58) Previous physical activity Sport participation

Some evidence for larger effect in adolescent girls. Overall sedentary time was unrelated to physical activity.

Social/cultural correlates(57)(139)(140)(58) Parental and social support

40

+

Large

Parental support comes in many different forms including social, material or emotional. It is unclear what the most positive type of parental support is.*

Correlate

Direction of association

Estimated strength of association

Comments

Environmental correlates(57)(138)(139)(58) Access to facilities

Distance from home to school Time spent outside Local crime

+

Small to moderate

-

Moderate

+

Moderate to large

-

Small

Variables clustered around concepts of access, opportunities and availability to be active are associated with higher levels of physical activity. This will interact with local conditions. This is likely to interact with factors such as local amenities, safety, road traffic density etc.

Source: See reference 137. Note: All evidence is derived from systematic reviews of observational studies. *A distinction needs to be made between parental support and parental behaviour. There is ‘much uncertainty’ about the relationship between parental and child activity levels(140).

41

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McPherson, K et al, (2007); Tackling Obesities: Future Choices – Project Report. Government Office for Science.

2.

World Health Organisation (2003); Diet, Nutrition and the Prevention of Chronic Diseases. Report of a Joint WHO/FAO Consultation. Geneva: World Health Organisation.

3.

Whitaker, R.C. Wright, J.A. Pepe, M.S. et al (1997); Predicting obesity in young adulthood from childhood and parental obesity. The New England Journal of Medicine. 337: 869-73.

4.

Telama, R. Yang, X. Hirvensalo, M. Raitakari, O. (2006); Participation in organized youth sport as a predictor of adult physical activity: A 21year longitudinal study. Pediatric Exercise Science 18 (1): 76-88.

5.

US Department of Health and Human Services (2008); 2008 Physical Activity Guidelines for Americans. Washington, DC: U.S. Department of Health and Human Services.

6.

Department of Health (2004); At least five a week: Evidence on the impact of physical activity and its relationship to health. A report from the Chief Medical Officer. London: Author.

7.

National Institute for Health and Clinical Excellence (NICE) Public Health Collaborating Centre – Physical activity; Promoting physical activity for children Review One: Descriptive epidemiology. National Institute for Health and Clinical Excellence. London, 2007

8.

Biddle, S. J. H. Gorely, T. & Stensel, D. J. (2004); Health-enhancing physical activity and sedentary behaviour in children and adolescents. Journal of Sports Sciences, 22, 679-701.

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