UK Physical Activity Guideline 2011

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Start Active,Stay ActiveA report on physical activity or health

rom the our home countries

Chie Medical Ofcers


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DH INFORMATION READER BOX

Policy EstatesHR/Workorce CommissioningManagement IM&TPlanning FinanceClinical Social Care/Partnership Working

Document purpose For Inormation

Gateway reference 16306

Title Start Active, Stay Active: A report on physical activity rom the our homecountries Chie Medical Ofcers

Author Department o Health, Physical Activity, Health Improvement and Protection

Publication date 11 Jul 2011

Target audience PCT CEs, NHS Trust CEs, SHA CEs, Care Trust CEs, Foundation Trust CEs,Medical Directors, Directors o PH, Directors o Nursing, Local Authority CEs,Allied Health Proessionals, GPs, Communications Leads

Circulation list PCT CEs, NHS Trust CEs, SHA CEs, Care Trust CEs, Foundation Trust CEs,Medical Directors, Directors o PH, Directors o Nursing, Local Authority CEs,Directors o Adult SSs, PCT Chairs, NHS Trust Board Chairs, Allied HealthProessionals, GPs, Emergency Care Leads, Directors o Childrens SSs, VoluntaryOrganisations/NDPBs, Workplace Health Leads, Business OrganisationsVoluntary

Description A UK-wide document that presents guidelines on the volume, duration,requency and type o physical activity required across the liecourse to achievegeneral health benefts. It is aimed at the NHS, local authorities and a rangeo other organisations designing services to promote physical activity. Thedocument is intended or proessionals, practitioners and policymakers concernedwith ormulating and implementing policies and programmes that utilisethe promotion o physical activity, sport, exercise and active travel to achievehealth gains.

Cross-reference N/A

Superseded docs At least fve a week. Evidence on the impact o physical activity and itsrelationship to health: A report rom the Chie Medical Ofcer 2004 CancerReorm Strategy (December 2007)

Action required N/A

Timing By 11 Jul 2011

Contact details Physical Activity TeamRoom 703133155 Waterloo RoadLondonSE1 8UG

www.dh.gov.uk

For recipients use


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ContentsForeword by the Chie Medical Ofcers 3

Acknowledgements 5Executive summary 6CHAPTER ONE Introduction 9

What is physical activity? 9Physical activity and the prevention o chronic disease 10Promotion o mental health and well-being 13Sedentary behaviour 13Just how active are we? 13

The cost o inactivity 14Development o UK-wide CMO guidelines or physical activity 15

CHAPTER TWO Key principles 16Who do the guidelines apply to? 16Risks o physical activity 17Doseresponse relationship 17What type o activity counts? 17Other health benefts 19

CHAPTER THREE Early years (under 5s) 20Introduction 20Guidelines or early years 20Summary o supporting scientifc evidence 21Understanding the guidelines or early years 22


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CHAPTER FOUR Children and young people (518 years) 26Introduction 26Guidelines or children and young people 26Summary o supporting scientifc evidence 27Understanding the guidelines or children and young people 28

CHAPTER FIVE Adults (1964 years) 32Introduction 32Guidelines or adults 32Summary o supporting scientifc evidence 33Understanding the guidelines or adults 34

CHAPTER SIX Older adults (65+ years) 38Introduction 38Guidelines or older adults 39Summary o supporting scientifc evidence 39Understanding the guidelines or older adults 41

CHAPTER SEVEN Taking action 45Introduction 45What is new in this report? 45How can the guidelines be used? 46Examples o eective action 47New opportunities or action 48Challenges 48Conclusion 49

ANNEX A Process and methodology 50ANNEX B Glossary 53ANNEX C Expert working groups 55ANNEX D Reerences 57


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Foreword by the ChieMedical OfcersProessor Dame Sally Davies,CMO or England

Dr Tony Jewell, CMO or Wales

Harry Burns, CMO or Scotland

Dr Michael McBride,CMO or Northern Ireland

Whatever our age, there is good scientifc evidencethat being physically active can help us leadhealthier and even happier lives. We also know thatinactivity is a silent killer. Thereore, it is importantthat the public health community provides people

with the inormation on which to base healthyliestyle choices. Start Active, Stay Active is aimedat proessionals and policy makers and is thefrst link in a chain o communication to inormbehaviour change.

This report establishes a UK-wide consensuson the amount and type o physical activity weshould all aim to do at each stage o our lives.In reaching this consensus, we have drawn uponrecent international, large-scale reviews in theUnited States and Canada and have benefted

rom the contribution o international expertsengaged in the World Health Organization Global

Recommendations on Physical Activity or Health.We are grateul to all who have been involved in thiscollaborative eort.

Start Active, Stay Active updates the existing

guidelines or children, young people and adults,and includes new guidelines or early years andolder people or the frst time in the UK. The exibilityo the guidelines creates new ways to achieve thehealth benefts o an active liestyle, while retaininga strong link to previous recommendations. For allage groups, they highlight the risks o excessivesedentary behaviour, which exist independentlyo any overall volume o physical activity.

Our aim is that as many people as possible becomeaware o these guidelines and use them to achieve

the recommended activity levels. However, thisreport does not and indeed cannot set out the

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Start Active, Stay Active A report on physical activity or health rom the our home countries Chie Medical Ofcers

specifc messages we need to reach communitiesacross the UK with diverse needs, liestyles and

attitudes to activity. This is an important next stepor the individual home countries.

Similarly, helping people to achieve these guidelineswill require new and exciting partnerships to helpcreate a more active society. Across the physicalactivity sector, we need to build upon the diversityo opportunities to be active including sport, activetravel, dance, gardening and exercising in a naturalenvironment the list goes on.

We also need to recognise that people will draw

upon a range o dierent activities, varying theirparticipation according to where they are in theliecourse. However, parents, grandparents andsiblings can be important role models, and whenamilies are active together everyone standsto beneft.

The guidelines or each lie stage apply to all;however, barriers related to gender, ethnicity,

disability and access need to be addressed.The challenge then is to work across communities,bringing together all those organisations andproessions with a part to play local government,business, third sector organisations, planners, sportand local champions to make physical activitynot just an aspiration or the ew, but rather a realityor all.

July 2011

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AcknowledgementsWe would like to give special thanks or the support we have received rom the British Heart Foundation(BHF) National Centre or Physical Activity and Health and the leadership provided by Proessor Fiona Bull(School o Sport, Exercise and Health Sciences, Loughborough University).

We would like to thank the contributing authors and members o our Physical Activity Guidelines EditorialGroup (PAGEG) and the members o the expert working groups (listed in Annex C). Their ongoing adviceand support has been invaluable.

PAGEG members

Dr Len Almond BHF National Centre or Physical Activity and Health, Loughborough University

Proessor Stuart Biddle School o Sport, Exercise and Health Sciences, Loughborough University

Proessor Fiona Bull School o Sport, Exercise and Health Sciences, Loughborough University

Dr Nick Cavill Cavill Associates and BHF Health Promotion Research Group, University oOxord

Dr Richard Ferguson School o Sport, Exercise and Health Sciences, Loughborough University

Dr Charlie Foster BHF Health Promotion Research Group, University o Oxord

Proessor Ken Fox Centre or Exercise, Nutrition and Health Sciences, University o Bristol

Proessor Marie Murphy School o Sports Studies, University o Ulster

Proessor John Reilly Division o Developmental Medicine, University o Glasgow

Proessor Gareth Stratton School o Sport and Exercise Science, Liverpool John Moores University

Thanks also to Andy Atkin (BHF National Centre or Physical Activity and Health) and Alison Hardy(Department o Health), who both undertook editing o this report, as well as Proessor Mark Bellis (Centreor Public Health, Liverpool John Moores University) and the representatives o the our home countries ortheir contributions.

Finally, a special thanks to the Department o Health and, in particular, Kay Thomson and Deborah Moir whoproject managed this work on behal o the our home countries.

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Executive summaryThese guidelines are issued by the our ChieMedical Ofcers (CMOs) o England, Scotland,Wales and Northern Ireland. They draw on globalevidence or the health benefts people can achieveby taking regular physical activity throughout theirlives. Regular physical activity can reduce the risko many chronic conditions including coronary heartdisease, stroke, type 2 diabetes, cancer, obesity,mental health problems and musculoskeletalconditions. Even relatively small increases in physicalactivity are associated with some protection againstchronic diseases and an improved quality o lie.

These benefts can deliver cost savings or healthand social care services. However, the beneftso physical activity extend urther to improvedproductivity in the workplace, reduced congestionand pollution through active travel, and healthydevelopment o children and young people.

The our UK home countries all previously hadphysical activity guidelines. As our understanding othe relationship between physical activity and healthhas grown, we have evolved the guidelines to reectthe evidence base and address inconsistencies.

These new guidelines are broadly consistent withprevious ones, while also introducing new elements.

This report emphasises or the frst time theimportance o physical activity or people o all ages.We have thereore updated the existing guidelinesor children and young people and or adults andhave developed new guidelines or early years andor older adults.

In addition, the report highlights the risks osedentary behaviour or all age groups. Emergingevidence shows an association between sedentarybehaviour and overweight and obesity, with someresearch also suggesting that sedentary behaviouris independently associated with all-cause mortality,type 2 diabetes, some types o cancer andmetabolic dysunction.6 These relationships areindependent o the level o overall physical activity.For example, spending large amounts o time beingsedentary may increase the risk o some healthoutcomes, even among people who are active atthe recommended levels.6

These guidelines also allow greater exibility orachieving the recommended levels o physicalactivity. Bringing all o these aspects togethercreates a number o key eatures o this report,including:

a liecourse approach a stronger recognition o the role o vigorous

intensity activity

the exibility to combine moderate and vigorousintensity activity

an emphasis upon daily activity new guidelines on sedentary behaviour.

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Executive summary

Each o us should aim to participate in anappropriate level o physical activity or our age.Each o the liecourse chapters provides anintroduction, sets out the guidelines or that agegroup, summarises the evidence and discusses

what the guidelines mean or people. We hopethat this report will be read by policy makers,healthcare proessionals and others working inhealth improvement. The guidelines are designed tohelp proessionals to provide people with inormationon the type and amount o physical activity that theyshould undertake to beneft their health, in particularto prevent disease. The age groups covered in thisreport are:

early years (under 5s) children and young people (518 years) adults (1964 years) older adults (65+ years).

EARLY YEARS (under 5s)

1. Physical activity should be encouraged rombirth, particularly through oor-based play andwater-based activities in sae environments.

2. Children o pre-school age who are capableo walking unaided should be physically activedaily or at least 180 minutes (3 hours), spreadthroughout the day.

3.All under 5s should minimise the amount otime spent being sedentary (being restrainedor sitting) or extended periods (except timespent sleeping).

CHILDREN AND YOUNG PEOPLE(518 years)

1.All children and young people should engagein moderate to vigorous intensity physicalactivity or at least 60 minutes and up toseveral hours every day.

2.Vigorous intensity activities, including thosethat strengthen muscle and bone, should beincorporated at least three days a week.

3.All children and young people should minimisethe amount o time spent being sedentary(sitting) or extended periods.

ADULTS (1964 years)

1.Adults should aim to be active daily. Overa week, activity should add up to at least150 minutes (2 hours) o moderate intensity

activity in bouts o 10 minutes or more one wayto approach this is to do 30 minutes on at least5 days a week.

2.Alternatively, comparable benefts can beachieved through 75 minutes o vigorousintensity activity spread across the weekor a combination o moderate and vigorousintensity activity.

3.Adults should also undertake physical activityto improve muscle strength on at least two

days a week.

4.All adults should minimise the amount o timespent being sedentary (sitting) or extendedperiods.

OLDER ADULTS (65+ years)

1. Older adults who participate in any amounto physical activity gain some health benefts,including maintenance o good physical andcognitive unction. Some physical activity is

better than none, and more physical activityprovides greater health benefts.

2. Older adults should aim to be active daily.Over a week, activity should add up to at least150 minutes (2 hours) o moderate intensityactivity in bouts o 10 minutes or more oneway to approach this is to do 30 minutes onat least 5 days a week.

3. For those who are already regularly active atmoderate intensity, comparable benefts can

be achieved through 75 minutes o vigorousintensity activity spread across the week ora combination o moderate and vigorousactivity.

4. Older adults should also undertake physicalactivity to improve muscle strength on at leasttwo days a week.

5. Older adults at risk o alls should incorporatephysical activity to improve balance andco-ordination on at least two days a week.

6.All older adults should minimise the amounto time spent being sedentary (sitting) orextended periods.

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Despite the widely reported benefts o physicalactivity, the majority o adults and many childrenacross the UK are insufciently active to meet theprevious recommendations. There are clear andsignifcant health inequalities in relation to physical

inactivity according to income, gender, age, ethnicityand disability.710

These guidelines apply across the population,irrespective o gender, race or socio-economicstatus. However, barriers related to saety,culture and access, or example, can have adisproportionate eect upon the ability o individualsto respond to the guidelines; thereore, interventionsto promote physical activity must consider this. Thisis particularly signifcant where eorts are ocused inlocations comprising large numbers o traditionallysedentary groups and individuals.

This report sets out clearly what people need todo to beneft their health, and can help them tounderstand the options or action that ft theirown busy lives. There now needs to be careuland planned translation o these guidelines intoappropriate messages or the public, which relateto dierent situations. However, communicationalone is not enough: this has to be matched withconcerted action at all levels to create environmentsand conditions that make it easier or people to beactive. New aspects o the guidelines also provideresh opportunities or action.

A new approach that makes physical activityeveryones business is not without challenge orexample, transerring knowledge and understandingto proessionals in other sectors, and managing thecompeting pressures on urban environmentsto retain green space and promote active travel.

Finally, these new guidelines may require some

changes to the way we monitor and report onphysical activity.

In conclusion, we know enough now to acton physical activity. The evidence or action iscompelling, and we have reached a uniqueUK-wide consensus on the amount and type ophysical activity that is needed to beneft health.This new approach opens the door to new andexciting partnerships and will help to create a moreactive society.

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CHAPTER ONE

IntroductionPromoting active liestyles can help us addresssome o the important challenges acing the UKtoday. Increasing physical activity has the potentialto improve the physical and mental health o thenation, reduce all-cause mortality and improve lieexpectancy. It can also save money by signifcantlyeasing the burden o chronic disease on the healthand social care services. Increasing cycling andwalking will reduce transport costs, save money andhelp the environment. Fewer car journeys can reducetrafc, congestion and pollution, improving the healtho communities.1 Other potential benefts linked tophysical activity in children and young people includethe acquisition o social skills through active play(leadership, teamwork and co-operation), betterconcentration in school and displacement oanti-social and criminal behaviour.2

The importance o physical activity or health wasidentifed over 50 years ago. During the 1950s,comparisons o bus drivers with more physicallyactive bus conductors and ofce-based telephonistswith more physically active postmen demonstratedlower rates o coronary heart disease and smalleruniorm sizes in the more physically active

occupations.

3

This research led the way or urtherinvestigation, and evidence now clearly shows theimportance o physical activity in preventing ill health.

It is important or us to be active throughout ourlives. Physical activity is central to a babys normalgrowth and development. This continues throughschool, and into adulthood and older years. Beingphysically active can bring substantial benefts andthere is consistent evidence o a doseresponserelationship, i.e. the greater the volume o physicalactivity undertaken, the greater the health benefts

that are obtained.

This report emphasises the importance ophysical activity or individuals o all ages and,or the frst time, provides specifc guidelines orthose aged under 5 and older adults. Buildingupon the emerging evidence base, we are alsorecommending that individuals should minimisesedentary behaviour (e.g. sitting or long periods)which is now recognised as an independent riskactor or ill health.

What is physical activity?

Physical activity includes all orms o activity, suchas everyday walking or cycling to get rom A to B,

active play, work-related activity, active recreation(such as working out in a gym), dancing, gardeningor playing active games, as well as organised andcompetitive sport.

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Physical activity(expenditure of calor ies,raised heart rate)

Everyday activity: Active recreation: Sport:Active travel Recreational walking Sport walking

(cycling/walking) Recreational cycling Regular cycling

Heavy housework Active play ( 30 min/week)

Gardening Dance Swimming

DIY Exercise and

Occupational activity fitness training

(active/manual work) Structured competitive

activity

Individual pur suits

Informal spor t


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In addition to defning the appropriate levels ophysical activity, this report also looks at sedentarybehaviour. Sedentary behaviour is not simply alack o physical activity but is a cluster o individualbehaviours where sitting or lying is the dominant

mode o posture and energy expenditure is very low.

Sedentary behaviours are multi-aceted and mightinclude behaviours at work or school, at home,in transit and in leisure time. Typically, sedentarybehaviours include watching TV; using a computer;travelling by car, bus or train; and sitting to read,talk, do homework or listen to music.

Physical activity and the prevention ochronic disease

Physical inactivity is the ourth leading risk actoror global mortality (accounting or 6% o deathsglobally). This ollows high blood pressure (13%),tobacco use (9%) and high blood glucose (6%).Overweight and obesity are responsible or 5%o global mortality.4

The benefts o regular physical activity have beenclearly set out across the liecourse. In particular,or adults, doing 30 minutes o at least moderateintensity physical activity on at least 5 days a week

helps to prevent and manage over 20 chronicconditions, including coronary heart disease, stroke,type 2 diabetes, cancer, obesity, mental healthproblems and musculoskeletal conditions.4 Thestrength o the relationship between physical activityand health outcomes persists throughout peopleslives, highlighting the potential health gains thatcould be achieved i more people become moreactive throughout the liecourse.

There is a clear causal relationship between theamount o physical activity people do and all-cause

mortality.4

While increasing the activity levels o alladults who are not meeting the recommendationsis important, targeting those adults who aresignifcantly inactive (i.e. engaging in less than30 minutes o activity per week) will produce thegreatest reduction in chronic disease.

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Introduction

Table

1.

Therelationshipbetweenphysicalactivityandhealtho

utcomes

Healthoutcome

Natureofass

ociationwithphysicalactivity

Effectsize

S

trengthof

e

vidence

All-cause

mort

ality

Clearinverserelationshipbetweenphysicalactivity

andall-causemortality.

Thereisanapproximately30%r

iskreduction

acrossallstudies,wh

encomparingthemost

activewiththeleasta

ctive.

S

trong

Card

iorespiratory

health


andcardioresp

iratoryrisk.

Thereisa20%to35%lowerrisko

cardiovasculardiseas

e,coronaryheartdisease

andstroke.

S

trong

Meta

bolichealth


andriskotype2diabetesandmetabolicsyndrome.

Thereisa30%to40%lowerriskometabolic

syndromeandtype2

diabetesinatleast

moderatelyactivepeoplecomparedwiththose

whoaresedentary.

S

trong

Energybalance

Thereisaavo

urableandconsistenteectoa

erobic

physicalactivityonachievingweightmaintenance.

Aerobicphysicalactivityhasaconsistenteect

onachievingweightm

aintenance(lessthan3%

changeinweight).

Physicalactivityalone

hasnoeectonachieving

5%weightloss,exce

ptorexceptionally

largevolumesophysicalactivity,orwhenan

isocalorifcdietismaintainedthroughoutthe

physicalactivityinterv

ention.

Followingweightloss

,aerobicphysicalactivity

hasareasonablycon

sistenteectonweight

maintenance.

S

trong

S

trong

M

oderate

Musculoskeletal

health

Bone:

Thereisaninverseassociationophysicalactivitywith

relativeriskohipractureandvertebralracture.

Increasesinex

erciseandtrainingcanincrease

spine

andhipbonem

arrowdensity(andcanalsominimise

reductioninsp

ineandhipbonedensity).

Bone:

Riskreductionohip

ractureis36%

to68%a

tthehighestlevelophysicalactivity.

Themagnitudeothe

eectophysicalactivity

onbonemineraldensityis1%to2%.

M

oderate

(weakor

v

ertebral

racture)

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Introduction

Promotion o mental health and well-being

Physical activity has an important role to playin promoting mental health and well-being bypreventing mental health problems and improving

the quality o lie o those experiencing mental healthproblems and illnesses.

For example, evidence shows that physical activitycan reduce the risk o depression, dementia andAlzheimers. It also shows that physical activity canenhance psychological well-being, by improvingsel-perception and sel-esteem, mood and sleepquality, and by reducing levels o anxiety and atigue.

Sedentary behaviour

The evidence suggests a growing concern overthe risks o sedentary behaviour. Although mosto this research has ocused on the relationshipbetween sedentary behaviour and overweight andobesity, some research also suggests that sedentarybehaviour is independently associated with all-causemortality, type 2 diabetes, some types o cancer andmetabolic dysunction.6

Sedentary behaviours in adults are impacted by age,gender, socio-economic conditions, occupation,weight status and some characteristics o the

physical environment. These relationships areindependent o the level o overall physical activity.For example, spending large amounts of timebeing sedentary may increase the risk of somehealth outcomes, even among people who areactive at the recommended levels.6

Just how active are we?

Levels o physical activity in both adults and childrenare regularly measured throughout the UK, althoughthere are some dierences in the methods used

to collect the data. However, despite the multiplehealth gains associated with a physically activeliestyle, there are high levels o inactivity acrossthe UK.

Adults including older adults

Based on sel-reported data, the percentage oadults in each o the home countries shown to meetprevious physical activity recommendations is setout in Table 2.710

Table 2. The percentage of adults meetingprevious physical activity guidelines

Country Men Women

England 40% 28%

Northern Ireland 33% 28%

Wales 36% 23%

Scotland 43% 32%

Note:

England, Northern Ireland and Wales: based on the physical

activity guideline or adults o 30 minutes or more o moderate

intensity on at least 5 days a week.

Scotland: based on the physical activity guideline or adults

o 30 minutes or more o moderate intensity on most dayso the week.

These data show that more than hal o adultsdo not meet the previous recommended levelso physical activity. However, the true position islikely to be worse than this as individuals appearto over-estimate the amount o physical activitythey do in sel-reported surveys. Recent objectivemeasurements o physical activity suggest lowerlevels o participation; or example, accelerometrydata collected in England reported that only

6% o men and 4% o women met the previousguidelines.7

Across the UK, participation in physical activitydeclines signifcantly with age or both men andwomen and also varies between geographical areaso the UK and socio-economic position.

Children and young people

Based on sel-reported data, the percentage ochildren in each o the home countries shown tomeet previous physical activity recommendations

is set out in Table 3.7, 911

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Table 3. The percentage of children meetingprevious physical activity guidelines

Country Boys Girls

England (aged 215) 32% 24%

Northern Ireland(Years 812)

19% 10%

Wales (aged 415) 63% 45%

Scotland (aged 215) 76% 67%

Note:

England and Northern Ireland: based on the physical activity

guideline or children o 60 minutes or more o moderate

intensity each day.

Wales and Scotland: based on the physical activity guideline or

children o 60 minutes or more o moderate intensity on 5 days

a week.

Across the UK, boys are more likely than girls to beactive at almost every age. Physical activity declineswith age in both sexes, but more steeply in girls.

Early years

For those aged under 5, UK data are only availableor 3 and 4 year olds. These data show that themean total time spent being physically active is

120150 minutes per day with 1011 mean hoursspent being sedentary.12

What about sedentary behaviour?

According to sel-reported measures o sedentarybehaviour, approximately two-thirds o adults spendmore than two hours per day watching TV andusing the computer. Signifcant proportions o adultsreport spending between three and our hourssitting during their leisure time. These estimateshighlight the pervasiveness o sedentary behaviours.

The studies that have used objective measures toassess the time adults spend sitting or lying confrmthe sel-reported estimates, suggesting that themajority o adults and older adults spend substantialproportions o the day in sedentary pursuits.6

Health inequalities

There are clear and signifcant health inequalities inrelation to physical inactivity according to income,gender, age, ethnicity and disability.711

For example, across the UK:

Physical activity is higher in men at all ages. Physical activity declines signifcantly with

increasing age or both men and women.

Physical activity is lower in low-incomehouseholds.

Certain ethnic groups have lower levels ophysical activity. For example, in England,physical activity is lower or black or minorityethnic groups, with the exception o Arican-Caribbean and Irish populations.

Boys are more active than girls. Girls are more likely than boys to reduce their

activity levels as they move rom childhoodto adolescence.

The cost o inactivity

Inactivity not only has consequences or health,it also places a substantial cost burden on healthservices, through the treatment o long-termconditions and associated acute events such asheart attacks, strokes, alls and ractures, as wellas the costs o social care arising rom the loss ounctional capacity. As more o us live longer, therewill be huge potential to derive benefts to health

and social care services rom increasing activity.

The estimated direct cost o physical inactivity to theNHS across the UK is 1.06 billion. This is basedupon fve conditions specifcally linked to inactivity,namely coronary heart disease, stroke, diabetes,colorectal cancer and breast cancer. This fgurerepresents a conservative estimate, since it excludesthe costs o other diseases and health problems,such as osteoporosis and alls, which aect manyolder people.13

Inactivity also creates costs or the wider economy,through sickness absence and through thepremature death o productive individuals. It alsoincreases costs or individuals and or their carers.In England, the costs o lost productivity have beenestimated at 5.5 billion per year rom sicknessabsence and 1 billion per year rom the prematuredeath o people o working age.14

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Introduction

Increasing physical activity can also support otherimportant agendas; or example, the Netherlandshas shown how increasing active travel can beneftthe wider economy.15 Journeys made on oot orby bike rather than car will reduce emissions and

can create a more pleasant local environment.Communities can beneft rom saer and morepleasant streets, improved air quality, lower carbonemissions and reduced congestion.

Development o UK-wide CMOguidelines or physical activity

Why do we publish guidelines?

UK governments have a duty to inorm their citizensabout the relationship between liestyle and health.

People need to be aware o the levels o physicalactivity that deliver health benefts and the healthimpacts o leading an inactive liestyle. Theseguidelines will not only assist with the work o policymakers, healthcare proessionals and others whosupport health improvement, but can alsohelp individuals to take responsibility or their ownliestyle choices.

Prior to this report, the our UK home countriesalready had physical activity guidelines. However, anemerging evidence base, the publication o updated

international guidelines and dierences between theexisting UK guidelines gave rise to the need or acollaborative approach to updating the guidelines.

We have updated the guidelines rom theperspective o disease prevention and have notincluded the role o physical activity as a treatmentor people with pre-existing conditions. Furthermore,there were no guidelines or early years or orsedentary behaviour across the UK, so our task hasbeen to assess the available evidence and developnew guidelines in these areas.

The development o new UK guidelines wasalso acilitated by the publication o revisedguidelines in the US and Canada and by the WorldHealth Organization, since these provided anopportunity to capitalise on a scientifc review o theevidence base. In particular, the US Governmentreported on a comprehensive two-year reviewo the health benefts o physical activity and theCanadian Government undertook similar andcomplementary work.

What evidence have we considered?

Given these recent large-scale scientifc reviews,it was unnecessary to undertake another ull reviewo the primary literature. Instead, a set o key

documents were identifed as the primary sourceso evidence and used to underpin the UK work.The key sources were:

Physical Activity Guidelines Advisory CommitteeReport (2008) rom the Physical ActivityGuidelines Advisory Committee ormed by theUS Department o Health and Human Services

scientifc reviews undertaken as part o theCanadian Physical Activity Guidelines reviewprocess

review papers undertaken as part o the BritishAssociation o Sport and Exercise Sciences(BASES) consensus process

where needed, individual high quality reviewpapers or individual study papers reporting onrelevant issues not covered in the US, Canadianor BASES review process.

We have based this report on the evidence romthese sources. Statements that are based onevidence rom alternative sources have beenreerenced (see Annex D).

The process or reviewing the evidence anddeveloping the guidelines is explained in Annex A.However, in brie, expert advisory working groupswere set up and tasked with reviewing the keysources o evidence and developing dratrecommendations or new physical activity andsedentary behaviour guidelines. Ater nationalconsultation phases involving a large scientifcmeeting and web-based consultation, a PhysicalActivity Guidelines Editorial Group (PAGEG) wasestablished. The PAGEG was responsible or

translating the recommendations into this report.

This report is organised by our age groups, witha dedicated chapter or each age group detailingthe guidelines, supporting scientifc evidence andinterpretation o what the guidelines entail. Somereaders will only be interested in specifc age groups,so where statements apply to more than one agegroup, we have replicated them in each chapter,to enable easy use o the report.

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CHAPTER TWO

Key principlesWho do the guidelines apply to?

The age groups covered in this report are:

early years (under 5s)

children and young people (518 years)

adults (1964 years)

older adults (65+ years).

The guidelines dier across the age groupsbecause people have dierent needs at dierentages and stages o development. For example, assoon as they can walk, pre-school children need

unstructured, active and energetic play to allowthem to develop their undamental movement skillsand master their physical environment. They need tobe active or several hours a day in order to achievethis. By the time children start school, however,they are developmentally ready to beneft rom moreintensive activity, over shorter periods, so a dailyminimum o 60 minutes o moderate intensity activityis recommended.

We recognise that dierences exist within age groupsand that individuals will have dierent developmental

needs. The age groups used are only a guide,reecting the best available evidence and harmonisingwith those used by other countries and organisations.There is also much to be gained rom amilies beingactive together. Active parents and the opportunity todo things with other amily members inuence youngpeoples participation in physical activity.16

The benefts o dierent types o physical activityare dierent at key lie stages. While it is notuntil adulthood and older age that the increasein morbidity and premature mortality is seen,the exposure to risk through inactivity begins inchildhood. Furthermore, peoples liestyles, andthe role o physical activity within their liestyles,vary throughout their lives.17

Figure 1. Key stages of disease developmentthroughout the life course

Prematuremortality

Diseaseanddisorders

Riskfactors RISKGrowthand

development

Childhood Adolescence Young Middl e OldAdulthood

Source: Department o Health (2004)At least ve a week:

Evidence on the impact o physical activity and its relationship to

health. A report rom the Chie Medical Ofcer

Figure 1 shows a hypothetical model o the keystages o disease development throughout theliecourse. The upper line on the graph representstheoretical rates o progression through growthand development, development o risk actors, onseto disease and disorders, and premature mortality or inactive individuals. The lower line representsactive individuals. In this model, physical inactivityhas negative eects at all stages o lie in termso impaired growth and development, or high riskactors, with the fnal expression as disease or earlydeath being seen primarily rom mid-adulthood.

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Key principles

Disability

Many people have physical, emotional, mentaland/or intellectual impairments or challenges.We did not specifcally review the available evidence

in this area and the array o dierent impairmentsand disabilities makes generalisation very difcult.Nevertheless, most disabled people would beneftrom physical activity according to their capacity.The expert advisory working groups agreed that theguidelines in this report would be broadly applicable.Specifc activities may however require adaptationto individual needs and abilities and saety concernsmust be addressed. Environmental barriers, socialoppression and psychological challenges also needto be considered.

Risks o physical activityThe risks associated with taking part in physicalactivity are low and continuing with an inactive orsedentary liestyle presents greater health risksthan gradually increasing physical activity levels.Previously inactive people who increase their activitygradually are unlikely to encounter signifcant risks.17

Risks occur predominantly among those exercisingat vigorous levels and those taking part incontact sports. However, most o these risks are

preventable. Extremely rarely, inactive and unftindividuals who start vigorous physical activity mayace increased cardiovascular risks.17

Doseresponse relationship

As outlined in Chapter 1, becoming more physicallyactive can bring substantial benefts. There is aclear doseresponse relationship between physicalactivity and diseases such as coronary heart diseaseand type 2 diabetes, in that greater benefts occurwith greater participation (see Figure 2). From a

public health perspective, helping people to moverom inactivity to low or moderate activity willproduce the greatest beneft.

This curvilinear doseresponse curve generally holdsor coronary heart disease and type 2 diabetes; thehigher the level o physical activity or ftness, thelower the risk o disease. Curves or other diseaseswill become more apparent as the volume oevidence increases.17

Figure 2. Doseresponse curve

RISKHigh

LowInactive or PHYSICAL ACTIVITYvery unfit OR FITNESS LEVEL Very activeor fit

Source: Department o Health (2004)At least ve a week:

Evidence on the impact o physical activity and its relationship to

health. A report rom the Chie Medical Ofcer

The prevention o dierent conditions may requiredierent amounts (doses) o activity. For example,it may be that more activity is required to reduce therisk o colon cancer than is needed to reduce therisk o coronary heart disease. However, there is notenough evidence to recommend specifc amountso activity or dierent conditions. These guidelinesoutline the recommended amount needed orgeneral health beneft.

What type o activity counts?For most people, the easiest and most acceptableorms o physical activity are those that can beincorporated into everyday lie. Examples includewalking or cycling instead o travelling by car, bus ortrain. However, a larger quantity o activity at higherintensity (such as playing sport) can bring urtherbenefts, and this might be the aspiration ormany people.

Table 4 gives some examples o activities that wouldbe light, moderate and vigorous intensity. It also

shows the intensity o dierent activities measuredin METs (metabolic equivalents a measure o howar energy expenditure is raised above the energyrequired at rest) and the total energy expenditure (inkilocalories (kcal), or a person o 60kg exercising or30 minutes).

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Table 4. Intensities and energy expenditure for common types of physical activity

Activity Intensity Intensity(METS)

Energyexpenditure(Kcal equivalent,

for a person of 60kg

doing the activity for30 minutes)

Ironing

CleaninganddustingWalkingstrolling,2mph

Light

Light

Light2.3

2.5

2.569

75

75Painting/decorating

W 3mphalking

Hoovering

ModerateModerate

Moderate

3.03.3

3.5

9099

105

clubswalking, pullingGolf

socialBadminton

TennisdoublesModerate

Moderate

Moderate4.3

4.5

5.0129

135

150Walkingbrisk,4mph

walking, using power-mowerMowing lawn

1012mphCycling

ModerateModerateModerate

5.05.56.0

150165180

Aerobic dancing

1214mphCycling

Swimmingslowcrawl,50yardsper minuteVigorous

Vigorous

Vigorous

6.5

8.0

8.0

195

240

240

Tennissingles Vigorous 8.0 240minutes/mile)6mph (10Running Vigorous 10.0 300minutes/mile)7mph (8.5Running Vigorous 11.5 345

minutes/mile)8mph (7.5Running Vigorous 13.5 405

MET = Metabolic equivalent 1 MET = A persons metabolic rate (rate of energy expenditure) when at rest2 METS = A doubling of the resting metabolic rate For a full definition of METS, see Annex B.

Source: Department o Health (2004)At least ve a week: Evidence on the impact o physical activity and its relationship to health.

A report rom the Chie Medical Ofcer

Moderate intensity activity stimulates the bodyscardiorespiratory, musculoskeletal and metabolicsystems and, over time, causes them to adaptand become more efcient. People can tell whentheir activity is moderate intensity because they willbreathe aster, experience an increase in heart rateand eel warmer. They may even sweat on hot orhumid days. The amount o activity needed to reachthis varies rom one person to another. An unftor overweight person may only have to walk up aslope, whereas a very ft athlete may be able to runquite ast beore he or she notices these signs. Overtime, a persons ftness level will improve so thatin walking, or example, ocusing on the perceivedeort to reach moderate intensity may mean thattheir speed increases. Vigorous intensity activitycan bring health benefts over and above moderateintensity. A person who is doing vigorous intensity

activity will usually be breathing very hard, be shorto breath, have a rapid heartbeat and not be able tocarry on a conversation comortably.

Muscle strengthening activity

Training with weights (or body weight), where thebodys muscles work or hold against an appliedorce or weight, can also bring about health beneftsand should be promoted across the age ranges.Muscle strengthening activity should work all the

large muscle groups o the body. Higher amountso activity can improve muscle unction to a greaterdegree. There is good evidence or the healthbenefts o muscle strengthening activities, includingthe maintenance o unctional ability, the stimulationo bone ormation and a reduction in bone loss.The evidence also supports the benefcial eecto this type o activity on glucose metabolism andblood pressure.

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Key principles

Shorter sessions o activity

The evidence shows that the benefts o physicalactivity can be achieved through sessions o10 minutes or more o moderate to vigorous

intensity activity. This duration is sufcient to improvecardiovascular ftness and lessen some risk actorsor heart disease and type 2 diabetes. Althoughmore research is required, there is also someevidence that sessions o vigorous intensity activityless than 10 minutes may be benefcial to health.

Shorter sessions o physical activity oer an easierstarting point or people who have been inactiveor some time, and or those who have busy livesand fnd it hard to prioritise activity. For people whohave been inactive, it is important to allow the body

time to adapt. Gradually progressing rom shorter tomore sustained sessions will increase an individualsftness while reducing any potential risks. Moreover,shorter bouts o activity such as just one to twominutes will break up sedentary time and shouldbe encouraged.

Other health benefts

Activity also provides benefts or well-being, orexample improved mood, a sense o achievement,relaxation or release rom daily stress. These

outcomes can play an important role in improvingpeoples adherence to activity programmesand ensuring that physical health beneftsare maintained.

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CHAPTER THREE

Early years (under 5s)

Introduction

This set o guidelines applies to children rom birthuntil they are 5. This age group has not previouslybeen included in UK public health guidelines orphysical activity.

During the early years, young children undergorapid and wide-ranging physical and psychologicaldevelopments that lay the oundation or theiruture health and well-being. It is thereore a keypublic health responsibility to provide the bestpossible conditions or under 5s to develop. Theseguidelines reect a growing awareness that early lie

experiences impact upon uture health outcomes,and draw on notable recent advances in the scienceo physical activity and health.

The evidence base or early years is relatively new.It comprises dierent types o studies includingobservational and, to a lesser extent, experimentalresearch. Overall, it supports the conclusion thatregular physical activity during the early yearsprovides immediate and long-term benefts orphysical and psychological well-being. Physicalactivity has very low risks or most under 5s.

However, the risk that childhood inactivity willlead to poor health in later lie is very high.

These guidelines are relevant to all children under5 years o age, irrespective o gender, race orsocio-economic status, but should be interpretedwith consideration or individual physical andmental capabilities. All young children should beencouraged to be active to a level appropriateor their ability. In the absence o evidence or thebenefts o physical activity or young disabledchildren, advice should be sought rom healthcareproessionals to identiy the types and amounts ophysical activity that are appropriate.

These guidelines describe the minimum amounto activity or many health benefts. However,regular participation in physical activity at a levelgreater than outlined in these guidelines will provideadditional health gains. For very inactive under 5s,increasing activity levels, even i these are below therecommendation, will provide some health benefts.For these children, a gradual increase in the durationo activity is recommended.

All children under 5 who are overweight or obesecan gain health benefts rom meeting the guidelines,even in the absence o any changes to their weightstatus. To achieve and maintain a healthy weight,additional physical activity and a reduction in calorieintake may be required.

The new guidelines or early years are aimed at theollowing groups:

inants who cannot yet walk unaided (Guideline 1) pre-school children who can walk unaided

(Guideline 2)

all those aged under 5 (Guideline 3).Guidelines or early years1. Physical activity should be encouraged rom

birth, particularly through oor-based play andwater-based activities in sae environments.

2. Children o pre-school age* who are capableo walking unaided should be physically activedaily or at least 180 minutes (3 hours), spreadthroughout the day.

3.All under 5s should minimise the amount otime spent being sedentary (being restrained

* See glossary (Annex B) or defnition.

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or sitting) or extended periods (except timespent sleeping).

Summary o supporting scientifc

evidenceIn recent years, there has been considerable growthin research exploring the benefts o physical activityor children under 5. However, the depth andbreadth o the evidence or this age group remainsrelatively small compared with that or older childrenand adults. These guidelines reect evidenceobtained rom predominantly observational research,including reviews inorming the development o theAustralian early years guidelines and the combinedinput o experts in this feld o study.

Physical activity is central to optimal growth anddevelopment in the under 5s. Evidence romobservational research and a small number oexperimental studies indicates that regular physicalactivity is valuable in developing motor skills,promoting healthy weight, enhancing bone andmuscular development, and or the learning osocial skills.1721 Thereore, these guidelines highlightthe essential role o physical activity in promotingphysical and psychological development duringthese years and contributing towards establishing

patterns o behaviour that may persist into laterchildhood and adulthood.

The guidelines or early years reer to activity oany intensity, i.e. light, moderate or vigorous (moreenergetic activity).

Physical activity should be encouraged rom birth,particularly through foor-based play and water-based activities in sae environments.

This recommendation is consistent with recentevidence and expert opinion, and with evidence o

associations between physical activity and healthbenefts, in particular preventing overweight andobesity.1722

There is considerable expert opinion rom manyinternational sources that letting children crawl, playand roll around on the oor in the home or childcaresetting is essential during the early years, particularlyor children who cannot yet walk. These activitiesare sae, accessible to all and enable unrestrictedmovement. They also provide valuable opportunitiesto build social and emotional bonds with parents,

siblings and other children. Appropriate water-based activities, such as parent and baby swim


sessions, provide similar opportunities and are alsorecommended.

Children o pre-school age who are capable owalking unaided should be physically active daily or

at least 180 minutes (3 hours), spread throughoutthe day.

This recommendation is consistent with internationalexpert opinion and recently developed, evidence-based public health guidelines or early years romother countries.19, 2224 It is supported by researchexploring associations between activity and varioushealth outcomes in this age group, data on thepatterns o activity during the early years andchanges in activity patterns as children age.20

There is some evidence o associations betweenphysical activity and health benefts, in particularpreventing overweight and obesity. Aligned with this,there is evidence indicating that or older childrenactivity typically declines with age, or examplebetween childhood and adolescence.25 Data romtracking studies show support or an associationbetween higher levels o activity in childhood leadingto more sustained participation in physical activityin later years. Thus it is important to establish ahigh level o activity at the earliest age in order toencourage activity patterns later in childhood that

are sufcient to beneft health.

The 180 minutes can be activity o any intensity.This aligns with the types o physical activity mostnaturally occurring during the early years, includingintermittent and sporadic patterns.

All under 5s should minimise the amount o timespent being sedentary (being restrained or sitting)or extended periods (except time spent sleeping).

Sedentary behaviour reers to a group o behaviours

that typically occur while seated or lying down andwhich require very low levels o energy expenditure.In the early years, typical sedentary behavioursmight include watching TV; travelling by car, busor train; or being strapped into a buggy. Thereis evidence that under 5s spend a large proportiono time being sedentary and that this is a barrier tophysical activity.7

Although there is a lack o research exploring thehealth consequences o sedentary behaviour inchildren under 5 specifcally, there is emerging

evidence that sedentary behaviour in the early yearsis associated with overweight and obesity as well aslower cognitive development. Importantly, patterns

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o sedentary behaviour, particularly TV viewing,are relatively stable over time. Thus there is a needto establish healthy patterns o behaviour duringthe early years in order to protect against possiblehealth detriments in the uture.6, 20

Evidence that sedentary behaviour is independentlyassociated with adverse health outcomes isaccumulating rapidly. This evidence suggests thatprolonged periods o sedentary behaviour are anindependent risk actor or poor health.26, 27 However,the available data are not sufcient to suggest a timelimit or this age group. Based on current evidence,reducing total sedentary time and breaking upextended periods o sitting is strongly advised orchildren during the early years.

Understanding the guidelines orearly years

Why do we need guidelines or early years?

Children under 5 have not previously been includedin UK public health guidelines or physical activity.However, there is concern over levels o habitualphysical inactivity and sedentary behaviour amongyoung children. The guidelines or those aged518 years are not suitable or early years, as theyspeciy a level o intensity that is not developmentally

appropriate or most children under 5. Childreno pre-school age who can stand and walk needopportunities to play that allow them to developtheir undamental movement skills and master theirphysical environment. One hour a day is not enoughto achieve this.

The evidence suggests that physical activity,especially in the orm o play, is a basic and essentialbehaviour that must be ostered and encouragedduring the frst fve years o lie. Conversely,opportunities or young children to be sedentary

should be limited and replaced with more physicallyactive options.28

Further research is needed to identiy and describethe health benefts o physical activity in the earlyyears, along with the dose o physical activityrequired to achieve these benefts. This will helpto refne uture public health guidelines or thisage group.

How do the guidelines refect dierences in theunder 5 population?

Under 5s encompasses a very diverse populationrom the newborn through to children about

to start school, and the stage o developmentcan vary markedly in children o the same age.As childrens motor skills develop at dierent rates,the key distinction we have used is between thosenot yet able to walk and those who are able towalk unaided.

Most children in the UK start school beore their fthbirthday. By this time, children are developmentallyready to beneft rom more intensive activity overshorter periods a minimum o 60 minutes omoderate intensity every day is recommended

(see Chapter 4 or more inormation). It is unlikelyto be practical or schools to ollow dierentguidelines or children within the school year(some o whom will have reached age 5 andsome o whom will have not).

How can activity or early years be supported?

Ideally, children under 5 should build up the requiredquantity o physical activity across the course otheir day. This is typically characterised by sporadicsessions o activity interspersed with periods orest. This pattern o activity also protects againstchildren engaging in prolonged periods o sedentarybehaviour by prompting regular breaks rom sittingor lying down.

The social and physical environments in whichactivity is most likely to occur, such as the home,childcare and leisure acilities, should be stimulating,un and sae.

Young children also need the reedom to createtheir own opportunities or active play lead their

own activities, direct their own play and engage inimaginative play. This will encourage independenceand appropriate exploration in a sae and supervisedenvironment. Parents and carers o young childrenneed to take appropriate measures to ensure thatplay and other physical activity is sae.

Similarly, young children can participate in a widerange o activities planned by adult carers andparents (such as in daycare settings or to ft amilycircumstances). Adults might contribute somestructure or ormality or acilitate play by providing

enabling environments within which young childrenplay more constructively and generate their ownphysically active games and play or example,

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a designated play area with a range o equipmentand challenges. Adult-led play (acilitating,prompting, stimulating or ocusing) as well as morestructured activities such as dancing and gymnastic-type movement or water-based activities such as

learning to swim can make a signifcant contributionto the overall volume o daily physical activity.

Parents and carers can encourage activity byinteracting with young children in a physically activeway as oten as possible. Adults are important rolemodels and their involvement in physical activity andplay will encourage a young child to be more activeand enjoy their interactions, which will stimulateurther participation.

Many young children are naturally active but someare shy, reserved or reluctant to join in with othersand need to be guided and shown how to enjoyusing dierent equipment and play spaces.

Olivia (not yet walking)

Olivia is 8 months old and is John andLauras rst child. John works full time. Laurais on maternity leave and cares full time forOlivia. Laura has always been active and shewants to bring Olivia up to enjoy being active

as well. As Olivia is not yet walking, Lauraoften spends time with her on a play mat intheir living room or outside when the weatheris good. Laura uses toys and other objects toencourage Olivia to move and crawl to reachthem and to explore the different shapesand textures. Once a week, Laura attendsa parent and baby swim held at the localleisure centre. These sessions are led by aqualied swim instructor and give Olivia theopportunity to explore other movements.Laura is also careful about the amount of

time Olivia spends in her carrier or highchair,although it is often an easier option whenshes in public places such as catching upwith friends at the local caf. As Laurasfriends also have young children, they meettwice a week at someones house or at thelocal park where they can let the childrenmove around and play freely.


What types o activities are relevant or inants whoare not yet walking?

For inants, being physically active means beingallowed to move their arms and legs while lying on

their stomach or back in a variety o ree spaces andwithout being restrained by clothing. This includesreaching or and grasping objects, turning the headtowards stimuli, pulling, pushing and playing withother people. Play spaces need to encourage youngchildren to learn new movements and use their largemuscle groups or kicking, crawling, pulling up to astanding position, creeping and eventually walking.Objects placed out o reach will encourage inantsto move towards them.

What types o activities are relevant or pre-school

children who are walking?

Once pre-school children can walk by themselves,they tend to be active in requent and sporadicsessions but at low intensity. These sessions couldadd up to 180 minutes o physical activity per day;however, most UK pre-school children currentlyspend 120150 minutes a day in physical activity,and so achieving this guideline would mean addinganother 3060 minutes per day.

For pre-school children, physical activity mainlycomprises unstructured, active play and learninglocomotor, stability and object-control skills. It isimportant that they have the opportunity to practisethese skills in a variety o enabling environments andthat they receive encouragement, regular eedbackand support rom adults. Active play will normallyinclude activity that involves moving the trunk andmore exertion than the minimal movement requiredto carry out simple everyday tasks such as washing,bathing and dressing, or activities such as playingboard games or passive play (or example, cratactivities, drawing, dressing up or playing at a

sand table).

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Active play opportunities should encourage youngchildren to:

use their large muscle groups practise a wide range o dierent movements experience a variety o play spaces and

equipment

set up their own play areas make up their own active play have un and eel good about themselves

and what they can do.

Under 5s also beneft rom physical activity otherthan active play, such as walking to the shops.

Table 5. Typical activities providing health anddevelopmental benets

Active play: activities Climbing rame orthat involve movements riding a bikeo all the major musclegroups, i.e. the legs,buttocks, shouldersand arms, andtranslocation o the

More energeticsessions o activity,e.g. running andchasing games

trunk (movement o the Water-basedtrunk rom one place to activitiesanother)

Development o Running, jumping,locomotor, stability and hopping, gallopingobject-control skills and skipping

Balancing, ridingand climbing

Kicking, catching,throwing, strikingand rolling

Dance, gymnasticsor water-basedactivities

Everyday activities Walking/skippingto shops, a riendshome, a park or toand rom a nursery

Tariq (capable o walking)

Tariq is 3 years old. He has an older brotherwho has just started school. They enjoy

playing games together and are lucky tohave a park near their house. His father,Yusuf, is a keen footballer and so he oftentakes both boys to the park at the weekendand in the evenings when its light enough torun around with a football. During the day,Tariq goes to nursery, as both his father andmother work. At the nursery, he takes part ina variety of games and activities includinglots of supervised physically active playsuch as using climbing equipment and moreenergetic organised running games. He also

plays with a range of equipment and toyswhich the nursery provides. Tariqs motherSadia picks him up and they usually take thebus part of the way home and walk the rest.

What intensity o activity is appropriate or theunder 5s?

The recommended 180 minutes (3 hours) orpre-school children who can walk can include lightintensity activity, active play and more energeticactivities, such as running, swimming and skipping.

More energetic play will make children hu and puand this will encourage the development o theircardiorespiratory system.

The 180 minutes o physical activity should bespread throughout the day rather than in one longsession. For this age group, the amount o physicalactivity is more important than the intensity.

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Table 6. Examples of sedentary behaviour and activities at different intensities

Denition Example activities

Sedentary Naps, TV viewing, fdgeting, drawing, reading

Light Pottering, slow movement o the trunk rom one place to another, e.g. movingabout, standing up, walking at a slow pace

Moderate to vigorous(more energetic)

Rapid movement o the trunk rom one place to another, e.g. climbing,swinging/hanging, playing games in a park with riends, riding a bike, dancing tomusic, running, swimming, skipping

Decreasing sedentary behaviour

There is evidence rom studies o inants andpre-school children that extended periods o sitting

may be detrimental to their health. Sedentarybehaviour also goes against the childs naturaltendencies to be active. Physical restraint, suchas long periods in pushchairs or highchairs, is acommon barrier to physical activity that is uniqueto this age group.

For both inants and pre-school children, beingsedentary or long periods during the day displacestheir opportunities or physical activity. Attending todaily tasks while young children are roaming reemay prove a challenge to busy parents. However,

parents, carers and proessionals should be awareo the need to reduce sedentary time in order toincrease physical activity and to help establishmore active behaviours.

Examples o reducing sedentary behaviour include:

reducing time spent in inant carriers, car seatsor highchairs

reducing time spent in walking aids or babybouncers (as these limit ree movement)

reducing time spent in ront o the TV or otherscreens.

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CHAPTER FOUR

Children and youngpeople (518 years) Introduction

This set o guidelines applies to children and youngpeople aged between 5 and 18. During this period,children and young people establish behaviourpatterns that have important implications or theirimmediate and long-term health and well-being.Among the myriad social, emotional and institutionaltransitions that take place are reductions in habituallevels o physical activity and increased participationin certain sedentary behaviours; these changes haveimportant public health implications. I we can helpchildren and young people to establish and maintainhigh volumes o physical activity into adulthood,

we will reduce the risk o morbidity and mortalityrom chronic non-communicable diseases later intheir lives.

A strong and expanding body o evidence,drawing upon both observational and experimentalmethodologies, indicates that regular physicalactivity is associated with numerous health beneftsor this age group. This includes reduced body atand the promotion o healthy weight, enhancedbone and cardio-metabolic health, and enhancedpsychological well-being. The evidence urther

supports recommendations on limiting sedentarybehaviour, which may be associated with healthrisks that are independent o participation in physicalactivity. Physical activity has very low risks or mostchildren and young people; however, the risk o poorhealth rom inactivity is very high.

These guidelines are relevant to all children andyoung people aged between 5 and 18, irrespectiveo gender, race or socio-economic status, butshould be interpreted with consideration oindividual physical and mental capabilities. Thereis substantially less research on the health beneftso physical activity or disabled people. Based

on the evidence, the guidelines can be appliedto disabled children and young people,emphasising that they need to be adjusted foreach individual based on that persons exercisecapacity and any special health issues or risks.

The guidelines describe the amount o activityrequired to achieve substantial health benefts.However, regular participation in physical activityat higher levels will provide additional health gains.For children and young people who are currentlyinactive, doing some physical activity, even i it isless than the guidelines, will provide some healthbenefts. For such children and young people,a gradual increase in the requency, duration andintensity o activity to achieve the guidelines isrecommended. Children and young people who areoverweight or obese can gain health benefts rommeeting the recommended levels o physical activity,even in the absence o any changes to their weightstatus. To achieve and maintain a healthy weight,additional physical activity and a reduction in calorieintake may be required.

Guidelines or children and young people

1.All children and young people should engage inmoderate to vigorous intensity physical activityor at least 60 minutes and up to several hoursevery day.

2.Vigorous intensity activities, including thosethat strengthen muscle and bone, should beincorporated at least three days a week.

3.All children and young people should minimisethe amount o time spent being sedentary(sitting) or extended periods.

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Children and young people (518 years)

Summary o supporting scientifcevidence

A strong body o evidence, comprising bothobservational and experimental research, indicates

that regular participation in physical activity amongchildren and young people provides immediate andlong-term benefts or physical and psychologicalwell-being. The evidence base is growing rapidly;recent large-scale epidemiological studies,utilising valid measures o physical activity, havedemonstrated stronger associations than havebeen observed previously and helped to clariydoseresponse relationships between activity andspecifc health outcomes.6, 17, 25, 2933

All children and young people should engage inmoderate to vigorous intensity physical activity or atleast 60 minutes and up to several hours every day.

Physical activity provides important health beneftsor children and young people. This conclusion isbased upon evidence rom observational studies inwhich higher levels o activity were associated withmore avourable health outcomes and experimentalstudies, in which exercise treatments resulted inimprovements in health-related measures.34, 35

Reviews o the literature conclude that physicalactivity should be moderate to vigorous intensity

to gain signifcant health benefts. The potentialhealth benefts o light intensity physical activityhave been little studied in this age group. Thus,while it is clear that moderate and vigorous intensityactivities are associated with many health benefts,the same may not be true or low intensity activity.34

Further research is needed to explore the impacto low intensity activity on health in children andyoung people.

The available evidence shows signifcant andmeaningul health benefts associated with

participation in 60 minutes o physical activity daily,over and above activities o daily living.34, 35

A doseresponse association between activityand health outcomes is urther supported bythe evidence, such that regular participation inactivity at a higher level than this (greater duration,increased intensity) is associated with even greaterbenefts. In recommending up to several hourso activity daily, these guidelines acknowledgethe doseresponse relationship, supportingengagement in higher levels o activity in orderto obtain maximal benefts.

In much o the research conducted to date, it hasbeen the volume o physical activity that has typicallybeen o primary interest rather than the distributiono activity throughout the week. Accordingly, theweekly distribution o activity associated with optimal

health beneft is currently unknown.29 However,at least some o the health benefts associatedwith physical activity result rom acute responsesthat occur or up to 2448 hours ollowingactivity. In order to reect this evidence, as well asencourage regular activity habits across the week,it is recommended that children and young peopleengage in daily physical activity.

Vigorous intensity activities, including thosethat strengthen muscle and bone, should beincorporated at least three days a week.

Reviews o the literature indicate that, or somehealth outcomes (such as cardiorespiratory ftness,muscular and bone strength), it is necessary toincorporate vigorous intensity physical activity.29, 35

The beneft o vigorous intensity activity was impliedin previous guidelines. However, the evidenceaccumulated in recent years has urthered ourunderstanding o its role in promoting health andsupports the inclusion o a specifc guideline or thistype o activity.17, 34, 35 There is now a signifcant bodyo evidence to support the act that vigorous activity

is required to increase ftness in young people.In children, higher levels o ftness are positivelyrelated to better metabolic health. Further intenseactivity is also important in optimising bone health,particularly prior to the adolescent growth spurt.Muscular development is also positively relatedto sel-esteem and resistance exercise has beeneective at increasing strength.

There is, however, a lack o evidence regarding thehealth benefts associated with specifc durationso vigorous activity. Thereore, an evidence-based

recommendation or the length o individual sessionso vigorous intensity activity or children and youngpeople cannot be provided at present.

Many o the health outcomes examined, includingweight status and cardio-metabolic health, aremainly responsive to aerobic-type activities.However, bone health appears to be mostavourably aected by resistance training and otherhigh impact activities, such as jumping. Previouspublic health guidelines or the UK recommendedactivities that produced high physical stresses

on the bones at least twice a week.17 Evidenceaccumulated in recent years has shown that

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the optimal dose o activity required to beneftbone health may be greater than previouslyrecommended.34, 35 To reect these advances in ourunderstanding, the new guidelines recommend thatactivities that strengthen muscle and bone should

be incorporated on at least three days per week.

All children and young people should minimise theamount o time spent being sedentary (sitting) orextended periods.

Sedentary behaviours require very low energyexpenditure. Such behaviours including travellingby car, bus or train, watching TV and playingcomputer or video games are very commonamong children and young people. There isemerging evidence which indicates that sedentary

behaviours, such as TV viewing or accumulatedtotal sedentary time, are associated with overweightand obesity and metabolic dysunction in youngpeople.6, 26 This evidence suggests that prolongedperiods o sedentary behaviour are an independentrisk actor or poor health.

The available evidence supports a recommendationon limiting sedentary behaviour to manageoverweight and obesity and metabolic markerso health in children and young people. However,there is currently insufcient evidence to quantiy

this precisely in terms o a time limit or sedentarybehaviour. Thereore, based on available evidence,reducing total sedentary time and breaking upextended periods o sitting is strongly advised.

Understanding the guidelines or childrenand young people

Why do we need new guidelines or children andyoung people?

We have had guidelines or children and young

people in the UK since 1998, with the most recentpublished in 2004.17 These new guidelines arebased on the latest evidence; they update andstrengthen previous versions and are, or the frsttime, ully consistent across the UK.

There are two key dierences between thesenew guidelines and previous versions: the newguidelines state more clearly the health beneftso vigorous intensity activity and they include anew recommendation on sedentary behaviour.A minimum o 60 minutes o moderate to vigorous

activity per day has been carried orward rom

previously published guidelines or childrenand young people and remains the headlinerecommendation.

Are there particular challenges or children and

young people?

There is a great deal o variation in physical activitybehaviour between the ages o 5 and 18, with thepattern o physical activity changing rom shortbursts o high intensity activity in childhood to moreadult patterns o physical activity and sedentarybehaviour in late adolescence. Between the ageso 5 and 7, these guidelines build on those or earlyyears, while the behaviour o older teenagers is likelyto be more similar to that o adults.

These revised guidelines need to be interpretedwith consideration or children and young peoplesgrowth and development. Children and youngpeople are a heterogeneous population. Theliecourse o a young person includes the transitionrom childhood to adulthood, with the complexitieso adolescence occurring in between. Thetransition rom primary to secondary school is otenassociated with signifcant decreases in physicalactivity, especially in girls, while the transitionrom compulsory education into employment oryoung people who leave school coincides with

a general decrease in physical activity in bothgirls and boys. Also, the majority o young peoplelive with their parents or carers who act as rolemodels and provide varying levels o social andlogistical support.

Children and young people should be given theopportunity to be active whenever possible.However, parents who perceive the environmentto be unsae should consider what this level o riskentails and how to manage this without limiting achilds opportunity to be physically active. I children

have positive experiences o physical activity, theywill be more likely to remain active and urtherdevelop their skills. It is also important that childrenlearn to manage physical risks themselves, as thiswill enhance their development o physical andsocial skills.

In some areas, the environment may not beconducive to being physically active. However,there is also a population trend towards spendingmore time inside, where technology and in-houseentertainment systems can increase screen

watching and sedentary behaviours. Subsequently,less time is spent in active pursuits.

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Children and young people (518 years)

Finally, encouraging childhood physical activity isespecially important or children rom disadvantagedor vulnerable groups or where amily or peer supportor being active is limited.

What do the guidelines mean or children and youngpeople?

Given the opportunity, most children enjoy takingpart in physical activity. To help children meetthese guidelines, opportunities to be physicallyactive need to be available on a daily basis, withinthe constraints o other pressures such as schoollearning time. Activities also need to be varied andshould provide physical challenges appropriate oreach age and stage o development. For youngpeople and those approaching adulthood, physical

activity becomes more structured, including regularphysical education, sport, dance and active travel,whereas play is a key activity in younger children.

It is important to emphasise that the intensityof physical activity should be above andbeyond that experienced during daily living.This means that light activity such as moving aroundthe house and walking slowly between schoollessons or while shopping does not contributetowards the 60 minutes o physical activity.

However, the reduction in sedentary time shouldresult in an increase in light physical activity andthereore total energy expenditure. For example,children and young people may engage in lightactivity and reduce sitting and lying time by playingactive computer games or engaging in activities thatinvolve moving in and around the home, classroomor community. It is also important to realise thatsedentary behaviour and vigorous physical activitycan co-exist, as children and young people mayengage requently in activities o vigorous intensity,but may also spend extended time sitting, or

example in ront o a screen.

While we do not have sufcient scientifc evidenceto recommend a maximum amount o sedentarytime or children and young people and whiletime spent sleeping, studying and reading doesnecessitate sitting or lying, we recognise that manyyoung people spend too much time in sedentarybehaviours, and opportunities to reduce this shouldbe sought.

Lisa (14 years old)

Lisa lives in a rural village. She used to goto the small local primary school but now

travels eight miles by bus to a secondaryschool, where she has many friends. Sheused to do a lot of sport at her primaryschool but stopped taking part becauseit was difcult to get home from matchesand training. Lisas father is a single parentwho cares for Lisa and her younger brother,Tom, but needs Lisa to help out. During herspare time, Lisa is constantly in touch withher school friends through social media butshe also meets up after school regularlywith friends in the same village to cycle or

run together. Lisas father, a physiotherapist,knows about the recommendations forchildren and young peoples physical activity.He engages the children in family activities toreduce the amount of time they spend sittingdown at home. They enjoy video game sportand tness competitions at home but try togo out together once a week and during theweekend as a family to take part in a sportingactivity such as tennis. The village youth clubholds a monthly dance night, where Lisa andher friends dance for up to three hours.

What type o activities should children and youngpeople participate in?

Children and young people should participate inphysical activities that are appropriate or their ageand stage o development. Patterns o activity inchildren commonly involve a mixture o running,jumping, climbing, hopping and skipping activities,interspersed with short periods o rest. These brieperiods o activity can also involve the developmento object-control (catching, throwing, striking, kicking)

and stability (balancing) movement skills, as well ascounting towards the bone and muscle strengtheningrecommendations. These patterns are characterisedby high intensity activity interspersed with shortperiods o moderate and light activity or standing.These activities o varying intensity can cumulativelycontribute towards the recommended 60 minutesa day i they are at least 10 minutes in duration.

Physical activity or children and young peoplenaturally occurs throughout most days and innumerous settings. This ranges rom active travel

to school, outdoor play in the park, indoor play indedicated play centres, physical education, school

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playtime, participation in sports and dance clubs,swimming or cycling, outdoor and adventurousactivities (or example, girl guides or scout groups)or martial arts clubs.

Younger children begin their active lives throughplay. This is important or their physical, cognitiveand social development and is largely dictated bythe opportunities that parents and carers give them.Young people become independent o their parentsthrough the teenage years and are more inuencedby riends and external role models.

Table 7. Types of activity

Type ofactivity

Examples

Unstructured(children)

Indoor or outdoor play, activetravel

Unstructured(young people)

Social dancing, active travel,household chores, temporarywork

Structured Organised, small-sided games(children and with equipment that maximisesyoung people) success (large racquets, low

nets, big balls etc.)

Educational instruction (throughteaching and coaching) thatpromotes skill learning anddevelopment

Sport and dance

Musclestrengtheningand bone health(children)

Activities that require childrento lit their body weight or towork against a resistance.Jumping and climbingactivities, combined with theuse o large apparatus and

toys, would be categorised asstrength promoting exercise

Musclestrengtheningand bone health(young people)

Resistance-type exerciseduring high intensity sport,dance, water-based activitiesor weight (resistance) training inadult-type gyms

Activity can be structured or unstructured.Unstructured activity can be described as inormalor ree play and activities with little input or direction

rom parents or carers. Structured activity mightinclude elements o ormality or acilitation by adults.Examples o activities are given in Table 7.

The degree o structure and organisation o activitychanges gradually with a shit away romunstructured, active play predominant at youngerages towards structured and organised physicalactivity in youth. A balance o unstructured and

structured activity will enable young people to beactive both independently and dependent on adults.

Peter (7 years old)

Peter is the youngest child in a sportyfamily. They live in a bustling town withgood local amenities. His father and motherare active members of the local footballclub, where his brother, James, excels atunder-14 level. His 11-year-old sister, Jane,

is also an active member of the local danceschool and represents her school at netballand athletics. On weekdays, he does atleast 60 minutes of moderate to vigorousphysical activity. He walks to school withhis older sister. On arrival, he often joins inwith playground games such as tag, as well

UK Physical Activity Guideline 2011

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