Physical activity, weight status and diet in adolescents: are children meeting the guidelines

doi:10.4236/health.2010.210167

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Vol.2, No.10, 1142-1149 (2010) Health

doi:10.4236/health.2010.210167

Physical activity, weight status and diet in adolescents:

are children meeting the guidelines?

Spencer E. Boyle, Georgina L. Jones, Stephen J. Walters*

Medical Statistics Group, School of Health and Related Research, University of Sheffield, Sheffield, UK; *Corresponding Author:

s.j.walters@sheffield.ac.uk

Received 20 May 2010; revised 1 June 2010; accepted 10 June 2010.

ABSTRACT

Childhood obesity is on the increase and main-

taining regular physical activity and consuming

a healthy diet have become essential tools to

combat the condition. The United Kingdom go-

vernment has recommended guidelines for op-

timal levels of diet and activity in children. The

aim of this paper is to describe and compare

self-reported physical activity levels, diet, and

Body Mass Indices (BMI) amongst adolescent

children, aged 11-15, in the South West (SW)

and North West (NW) regions of England and to

see if these children were meeting the current

targets for optimal levels of: physical activity;

fruit/vegetable consumption; fat consumption

and BMI. We report the results of a cross-sec-

tional survey of four secondary schools and

1,869 children using the self-reported Western

Australian Child and Adolescent Physical Activ-

ity and Nutrition Survey (CAPANS) physical ac-

tivity instrument and a food intake screener qu-

estionnaire, in summer and winter. We found

that 25% (469/1869) 95% CI: 23% to 27%, of chil-

dren engaged in 60 minutes of moderate to vi-

gorous physical activity per day; 53% (995/1866)

95% CI: 51% to 56%, took 5 portions of fruit and

vegetables per day; while 22% (407/1861) 95% CI:

20% to 24% consumed recommended amount of

fats, and 23.7% (276/1164) 95% CI: 21% to 26%,

of pupils were obese or overweight as classified

by their BMI. Self reported physical activity in

young people regardless of area is lower than

previously reported and the lack of students

engaging in 60 minutes moderate to vigorous

activity could have serious public health con-

sequences. If sustained, this could lead to more

overweight adults, and more ill health.

Keywords: Physical Activity; Diet; Exercise;

Adolescents; Guidelines

1. INTRODUCTION

There is considerable evidence that adult health varies ac-

cording to the region in England in which they live [1-5].

Life expectancy throughout England differs markedly

between regions [6]. The health consequences of being

overweight or obese in adulthood are now well establish-

ed [7]. A systematic review of the short and long-term of

consequences of childhood obesity reported short term

clinical effects of obesity on children such as increased

incidence of asthma and diabetes but also long term con-

sequences of increased risk of cardiovascular disease

into adulthood [8]. Childhood obesity is now becoming

more prevalent: the latest figures for England, in 2006,

show 23.7% of 11-15 year old males and 26.2% females

are now classed as obese [9]. Taking regular exercise and

maintaining a healthy weight through diet are thought to

be essential factors in combating this trend [10].

The United Kingdom (UK) government has recognis-

ed the public health consequences for the rising trend in

obesity in the population and has set targets for healthy

Body Mass Index (BMI), physical activity and diet in

children [11]. The current guidelines recommend 60

minutes of moderate to vigorous activity per day [11].

However, the number of secondary school children ach-

ieving this level of activity of varies from 41% (ages 11

to 15) [12] to 80% (age 11) [13]. Dietary guidelines also

recommend the consumption of at least five portions of a

variety of fruit and vegetables per day and that less than

35% of daily dietary calorific intake should be made up

of fats [14]. Fat intake in a national diet survey [15], in

young people age 4-18 years, was 36.9%, around the re-

commend level but fruit and vegetable consumption was

mixed. However, another later health survey [13] show-

ed that only 13% of children aged 5-15 years had eaten

the recommended five or more portions of fruit and ve-

getables in the previous day.

S. E. Boyle et al. / Health 2 (2010) 1142-1149

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1143

This cross sectional self report survey aimed to des-

cribe and compare self-reported physical activity levels,

diet, weight and height amongst adolescent children,

aged 11-15, in the South West (SW) and North West

(NW) regions of England and to see if these children

were meeting the current targets for optimal levels of:

physical activity; fruit/vegetable consumption; fat con-

sumption and BMI.

2. METHODS

2.1. Design and Setting

Four comprehensive secondary schools were matched

according to characteristics described in Office for Stan-

dards in Education (Ofsted) reports; two were in the

northwest of England, two in the southwest. The schools

were selected on the basis of a close match in: examina-

tion results, percentage of children on free school meals

(FSM), and percentage of children with special educa-

tional needs (SEN). Questionnaires were completed in

class in the presence of a teacher and the same question-

nnaires were completed twice, once in the summer term

and once in the winter term.

University of Sheffield research ethics committee ap-

proval was obtained for this study and the Local Educa-

tion Authority was consulted in order to gain initial con-

tact with the secondary schools involved. Consultation

with the heads of the secondary schools followed this. In-

itially the study details were circulated in a school new-

spaper, which every parent receives, at each school. Af-

ter this process the whole school populations were given

an information letter to take home with a consent slip to

be returned by a parent or guardian. As children were of

secondary school age it was thought they could sign

consent to fill out a survey on the day of the study, if a

parental slip had not been returned [16].

2.2. Participants

Two thousand eight hundred and fifty-eight pupils aged

11-15 in four secondary schools in England (2 in the

NW) and 2 in the SW) region) were sent a letter with

consent slip attached explaining the survey study and in-

vited to participate in an anonymous survey on two oc-

casions (summer and winter). Thirty percent (869/2858)

of children responded to the winter survey and had valid

self-reported physical activity data, and 35% (1000/2858)

responded to the summer survey, an overall response

rate of 33% (1869/5716) (see Table 1). As this was an

anonymous survey no information was collected on the

characteristics of the non-respondents to the question-

naire, therefore a comparison of respondents to non-re-

spondents cannot be made. We also have no information

on how many children completed the survey in both wi-

nter and summer.

2.3. Measures

Self-reported demographic information was collected

from the pupils such as age, sex, ethnicity, entitlement to

free school meals, height and weight.

Table 1. Survey response rates and school characteristics.

School

1 2 3 4 Totals

Number of children role 1198 923 922 671 3714

GSCE Examination Results (2004)

% five or more passes with grades A to C 43% 52% 42% 51% National Average = 54.5%

Key stage 3 assessment results (2004)

(average point score) 32.8 32.5 31.9 33.9 England Average Point Score = 34.1

Percentage of SEN pupils on statement (2005)

Percentage, with SEN but not on statement

1.8%

25.1%

2.1%

27.1%

7.1%

5.9%

3.4%

16.7%

National Average SEN with Statement = 2.9%

without statement = 14.9%

1st wave: winter 2006

No. of children sent letters 965 744 567 582 2858

Questionnaires returned 438 343 213 64 1058

Incomplete questionnaires 81 83 25 0 189

Responders 357 260 188 64

869

1st wave overall response rate 357/965

(37%)

260/744

(35%)

188/567

(33%)

64/582

(11%) 869/2858 (30%)

2nd wave: summer 2007

No. of children sent letters 965 744 567 582 2858

Questionnaires returned 543 261 225 279 1308

Incomplete questionnaires 118 84 53 53 308

Responders 425 177 172 226

1000

2nd wave overall response rate 425/965

(44%)

177/744

(24%)

172/567

(30%)

226/582

(39%) 1000/2858 (35%)

SEN (Special Educational Need); GCSE (General Certificate of Secondary Education Examination)

S. E. Boyle et al. / Health 2 (2010) 1142-1149

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2.4. Physical Activity

The self-completed Western Australian Child and Ado-

lescent Physical Activity and Nutrition Survey (CAPA-

NS) questionnaire was used to assess physical activity

[17]. The CAPANS consists of 24 questions and was

first successfully used in a sample of 2274 children aged

7 to 16 years in 2003 [18]. The CAPANS asks children

to select the type of physical activity (from a compre-

hensive list of activities) they usually do in a typical

week; and then to record the number of times they did

the activity and the time spent on that activity. The total

time spent on physical activity per week was calculated

by totalling the time children spent in moderate or vig-

orous activity per day and then dividing this figure by

seven to give an average for the week. The UK govern-

ment recommends children are physically active at a

moderate intensity for 60 minutes per day [11]. There-

fore the physical activity data was further classified into

whether or not children were meeting these recommen-

dations or not.

2.5. Diet

The Block food intake screener was used to assess diet

and the intake of fat, fibre, fruit and vegetables [19]. The

responses to the screener can then be used to estimate

the amount of fat and fruit and vegetables a child is co-

nsuming in their diet. Fat and fruit intake for each child

was then further classified as achieving the optimal co-

nsumption of fats (< 35% of calories consumed per day)

or fruit and vegetable (at least 5 portions per day) or not.

2.6. Body Mass Index (BMI)

The pupils estimated their own height and weight which

was then used to calculate each child’s BMI. UK spe-

cific BMI reference values and cut-points were then used

to classify each child as having normal weight or being

overweight or obese [20].

2.7. Statistical Analysis

Continuous outcomes such as minutes of vigorous activ-

ity per day were compared between areas using a two in-

dependent samples t-test. Binary outcomes e.g. achiev-

ing 60 minutes of physical activity per day, yes or no,

were compared between areas using a chi-squared test.

Multiple linear regression (for continuous outcomes) and

multiple logistic regression (for binary outcomes) was

used to adjust the area effect for the potential confound-

ing variables of ethnicity (white vs. none-white), sex

(boy or girl) and age (years) which were known to be

associated with physical activity [12,21,22]. Also ad-

justed for was receipt of free school meals (yes or no) as

a proxy measure for deprivation. The multiple regression

analyses also adjusted for potential clustering of pupils’

outcomes within the schools by calculating robust stan-

dard errors with the cluster option in STATA v11 [23].

This was an anonymous survey and we have no informa-

tion about whether or not the children completed the

survey twice in both winter and summer. Therefore the

majority of the statistical analyses were performed and

reported separately by season. A P-value of less than

0.05 was regarded as statistically significant.

3. RESULTS

Table 1 shows the overall response rate to the survey was

33% (1869/5716). The demographic characteristics of

the respondents, in both summer and winter samples, can

be seen in Table 2. There was some evidence of statisti-

cally significant differences in the social demographic

characteristics of the pupils between the two areas.

Table 3 shows that the proportions of children ach-

ieving the UK recommended guidelines of 60 minutes

moderate to vigorous physical activity per day, was hig-

her in summer compared to winter, 32.2% (322/1000) vs.

16.9% (147/869). There was no evidence of a difference

in proportions achieving the recommendations between

areas in summer or winter (with and without adjustment

for covariates, such as sex, age, ethnicity and receipt of

free school meals). Overall only 25% (469/1869), 95%

CI: 23% to 27%, of children met the target of 60 minutes

moderate to vigorous physical activity per day. Similar

findings were observed for the continuous outcome of

minutes of moderate to vigorous physical activity per

day. Children were observed (see Table 4) to be under-

taking more physical activity in summer than in winter,

but there was no statistical evidence of a difference be-

tween areas in summer or winter (with and without ad-

justment for covariates). Children in the SW were ob-

served to be undertaking less sedentary behaviour per

day than children in the NW, both in summer and winter

(Table 4), although only in summer was this difference

statistically significant (P = 0.003) and this difference

was not statistically significant after adjustment for co-

variates.

Optimal fruit and vegetable consumption, of five or

more portions per day, was higher in summer than win-

ter, 57% (566/1000) vs. 50% (429/866), see Table 3.

There was no evidence of a difference in consumption

between areas in winter (with and without adjustment for

covariates). However there was some evidence of a dif-

ference between areas in the summer, with the odds of

children in the SW having optimal fruit consumption

being 1.8 (95% CI: 1.38 to 2.32, P < 0.001) times that of

the odds of children in NW, but this difference was not

statistically significant after adjustment for covariates.

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Table 2. Demographic characteristics of sample by area and season.

Area

Total Northwest Southwest

Absolute

difference

Odds

Ratio

n % n % n % (SW-NW)SW/NW 95% CI P-value1

Winter

Sex Male 439 50.5% 33354.0% 10642.1% −11.9% 0.62 (0.46 to 0.83)< 0.001

Female 430 49.5% 28446.0% 14657.9%

Total 869 100.0% 617100.0%252100.0%

Ethnicity Non-white 338 38.9% 32252.2% 16 6.3% −45.9% 0.06 (0.04 to 0.11)< 0.001

White 531 61.1% 29547.8% 23693.7%

Total 869 100.0% 617100.0%252100.0%

Child in receipt No 701 80.9% 48578.6% 21686.4% 7.8% 1.73 (1.15 to 2.63)0.008

of free school Yes 166 19.1% 13221.4% 34 13.6%

meals Total 867 100.0% 617100.0%250100.0%

Summer

Sex Male 528 52.8% 37362.0% 15538.9% −23.1% 0.39 (0.30 to 0.51)< 0.001

Female 472 47.2% 22938.0% 24361.1%

Total 1000 100.0% 602100.0%398100.0%

Ethnicity Non-white 383 38.3% 36160.0% 22 5.5% −54.5% 0.04 (0.02 to 0.10)< 0.001

White 617 61.7% 24140.0% 37694.5%

Total 1000 100.0% 602100.0%398100.0%

Child in receipt No 826 82.7% 47378.6% 35388.9% 10.3% 2.19 (1.49 to 3.16)< 0.001

of free school Yes 173 17.3% 12921.4% 44 11.1%

meals Total 999 100.0% 602100.0%397100.0%

n Mean (SD) n Mean (SD)n Mean (SD)Difference 95% CI P-value2

Winter

Age (years) 869 13.0 (1.2) 61713.1 (1.2)25213.0 (1.3)−0.1 (−0.2 to 0.1)0.478

Summer

Age (years) 1000 13.2 (1.3) 60213.1 (1.3)39813.5 (1.3)0.4 (0.2 to 0.5) < 0.001

1. P-value from chi-squared test; 2. P-value from two independent samples t-test.

Optimal fat intake in diet, of consumption of < 35% of

daily calories with fat, was marginally lower in summer

than winter, 21.4% (214/1000) vs. 22.3% (193/864), see

Table 3; but there was no evidence of a difference in

consumption between areas in summer or winter (with

and without adjustment for covariates).

The proportion of children with a normal BMI was

higher in summer than winter, 78.9% (345/437) vs. 74.7%

(543/727), see Table 3. There was no evidence of a di-

fference in the proportions with a normal BMI between

areas in summer or winter before adjustment for covari-

ates. However, after adjustment there was some evi-

dence of a significant difference between areas, in both

the summer and winter, with children in the SW being

less likely to have a normal BMI (i.e., more likely to be

overweight) than children in the NW. Using the con-

tinuous BMI measurement (see Table 3) children in the

SW were observed to have a larger BMI than children in

the NW in both summer and winter surveys. However

this difference was only statistically significant in the

winter survey after adjustment for covariates. The con-

verse was true for the summer survey as the difference

between areas was only statistically significant before

adjustments for covariates and not after. Overall, 24%

(276/1164), 95% CI: 21% to 26%, of pupils were classi-

fied as overweight or obese.

4. DISCUSSION

The present findings of this study indicate that only 25%

(17% in winter, 32% in summer) of children aged 11-15

years were engaging in 60 minutes of moderate to vigoro-

us physical activity per day; 53% took five or more por-

tions of fruit and vegetables per day; 22% consumed the

recommended amount of fats, and 24% of pupils were

obese or overweight as classified by their BMI [24].

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Table 3. Binary physical activity, fruit intake, fat intake and BMI outcomes by area and season.

1. P-value from two independent samples t-test. 2. Adjusted for age, sex, ethnicity (white/non-white), receipt of free school meals (yes/no) and clustering by school.

Optimal fruit/vegatable intake is defined as the consumption of 5 or more portions per day. Optimal fat intake is defined as the consumption of < 35% of daily calories with fat. 1. P-value from chi-squared test;

2. Adjusted for age, sex, ethnicity (white/non-white), receipt of free school meals (yes/no) and clustering by school.

Table 4. Continuous physical activity and BMI outcomes by area and season.

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The physical activity results from the present study

are lower than two previous studies. An international

World Health Organisation [25] study reported that 45%

of 11 year olds and 38% of 15 year olds were achieving

the recommend levels of physical activity. More recently

a British Heart Foundation [12] survey reported that

41% of 11-15 year olds were meeting the physical activ-

ity target. Our current data also revealed that the mean

time spent in moderate to vigorous activity by these

children was 44 minutes per day which looks very low

when compared to the mean amount of time spent in se-

dentary behaviour (270 minutes per day). These seden-

tary figures are particularly worrying as physical inactiv-

ity was thought to contribute to almost two million

worldwide deaths [26]. If there is a tendency in self-re-

port surveys to over-estimate physical activity then the

figures reported in this study could well be an over esti-

mate of the true activity levels [27]. In these circum-

stances this could be a worrying indicator for activity

levels.

Since the early 1990’s [14] the UK Government has

encouraged the consumption of at least five portions of

fruit and vegetables per day and a total fat intake of less

than < 35% of calories consumed. The intake of fruit and

vegetables has been particularly promoted amongst yo-

ung children with free fruit schemes in UK schools [28].

Consumption of at least 5 portions in the present study

was around 53% (50% in winter, 57% in summer) this

was much higher than the 13% of children consuming the

recommended in the national health survey [15]. Intake

of fats in the data also uncovered that only around one in

four (22%) of the children were taking in the recom-

mended amount of fats in their diets, i.e., less than 35%

of calories consumed, indicating an over eating of fatty

foods.

On an epidemiological basis for young people to be

considered overweight they would need to have a BMI

greater than or equal to the 85th percentile or to be obese

it would need to be greater than or equal to the 95th per-

centile according to UK reference curves [20]. The mean

age of the participants in this study was 13.2 years, th-

erefore this would equate to a BMI score of overweight

for boys 20.65 kg/m2 and girls 21.74 kg/m2 [20]. The ch-

ildren in this study were found to have a mean self-rep-

orted BMI of 19.7 kg/m2, and 76% (888/1164) had a ‘no-

rmal’ BMI. If children were underreporting their weight,

and/or over reporting their height, then this would result

in a lower BMI. However, this study’s estimate of 24%

(25% in winter and 21% in summer) of children being

overweight or obese compares favourably with other re-

cent surveys [9].

The study has several strengths and limitations. We

had a large sample of over 1,800 children self-reporting

diet and physical activity. We believe that the particip-

ants in this study represented an ethnically diverse cross

section of the secondary school population that is bro-

adly similar to many comprehensive secondary schools

in England. The data was collected over the same period

of time in all schools which should account for any dif-

ferences in activity due to holiday periods or seasonality.

The generalisability of this study, to other schools and

areas in England, is likely to have been affected by the

low response rate of 33% (1869/5716). This study invol-

ved only four schools in two regions, and is not a rand-

om sample of pupils or schools, so therefore the results

must be interpreted cautiously and cannot be wholly re-

presentative of other schools in the NW and SW or ind-

eed England. The low response rate may have poten-

tially caused a bias in the estimated differences in outco-

mes between the various groups. Unfortunately as this

was an anonymous survey no information was collected

on the characteristics of the non-respondents to the ques-

tionnaire, therefore a comparison of respondents to non-

respondents cannot be made. Also since this was an an-

onymous survey we have no information on how many

children completed the survey twice both in the winter

and summer. So we cannot rule out that some bias may

have been introduced into the sample. However, 23.5%

of our survey participants were classified as obese which

is similar to previous estimates for English school chil-

dren aged 11-15 of 21%; although only 25% of our sam-

ple met the physical activity guidelines compared to

around 52% reported nationally [25]. Our sample ap-

peared to have similar levels for receipt of free school

meals (18% vs. 16.5%) compared to school roll informa-

tion.

We believe that the responders, to our survey, are mo-

re likely to be a well motivated group of students, who

are more likely to report higher levels of physical activ-

ity and better levels of diet and lower levels of BMI (due

to overestimating their height and underestimating their

weight). If this is so then our estimates are potentially

likely to be larger than the true values as we have a self-

selected sample of students who eat and exercise well.

The cross-sectional design is less robust than a longi-

tudinal study. So it must be clearly acknowledged that

the data represents merely a snap shot of information on

physical activity and diet. The diet questionnaire alth-

ough validated and piloted by the authors has mainly

been used in an adult non-UK population, which again

may have an effect.

Pragmatically, we used self report methods rather than

objective measures such as pedometers or accelerome-

ters to estimate physical activity. This may have resulted

S. E. Boyle et al. / Health 2 (2010) 1142-1149

1148

in an overestimate of activity particularly if this was a

well motivated group of students. However, the use of

objective measures, such as pedometers, is not without

problems as the use of these tools tends to alter the be-

haviour of people being observed and again may result

in an over estimate of activity. In general, the potential

‘bias’ of self-reporting survey methods for diet or PA is

of concern to any researcher and the over-reporting in

activity or under-reporting fat intake maybe a particular

worry in studies of children [29]. However, in previous

studies of children and PA the self-report survey shows

some promise of being a quality research instrument

with a young population [27] and remains the most

widely used measurement tool [30].

For practical reasons (since we had a large sample) we

used the self-reported CAPANS instrument to assess PA,

which has been shown to be reliable and valid measure

in children [17]. In several studies self-reported BMI in

children has shown that students tend to underestimate

their BMI. Those students who are overweight or obese

tend to underestimate their BMI to a greater extent than

normal weight students. However, further studies have

found that differences between self-reported and meas-

ured height and weight in young people were not statis-

tically significant and there was reasonable agreement

between actual and self-reported measurements [31,32].

In other studies, which found differences, they reported

that over 90% of adolescent participants estimated wei-

ght and height was in the correct BMI (Overweight/

obese or Normal) classification group [33].

5. CONCLUSIONS

The findings of this study indicate that only 25% of

children aged 11-15 years in the four English schools

were engaging in the recommended 60 minutes of mod-

erate to vigorous physical activity per day. This estimate

is considerably lower than several previous reports

which suggested that between 38% and 80% of children

were achieving the recommended physical activity

guidelines. This level of inactivity, observed in our sur-

vey, if sustained, could have serious future public health

consequences for England. This may lead to an in-

creased likelihood of being overweight in adulthood and

consequently more ill health, with increases in the inci-

dence of diabetes and coronary heart disease in adult life.

Although the proportion of children with a normal BMI

of 24% is similar to other UK studies the consumption of

too little fruit and too much fat indicates few of these

children at secondary school age are meeting the UK

government targets of 5 or more portions of fruit and

vegetables per day and less than 35% of daily calorie

intake made up of fat. More research is needed possibly

linking self report and that of an objective nature, to

measure activity and BMI, to confirm these findings.

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